Complexities in reflective practice facilitation in a forensic mental health setting

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma‐related harm and re‐traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer‐reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex‐specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.

There is limited evidence to inform effective screening practices for identifying fetal alcohol spectrum disorder (FASD) in forensic mental health settings. This study sought to explore the potential use of four FASD screening tools in a Canadian forensic mental health program. In total, 151 patient charts were screened using the FASD Screening and Referral Tool for Youth Probation Officers and the FASD Risk Assessment Questions Asubset of current patients (n = 41) also completed screening interviews using the FASD Brief Screen Checklist and Life History Screen. Based on passive ascertainment via chart review, we found six cases of confirmed/suspected FASD (4%), evidence of PAE in 7% of the sample, and signs of maternal alcohol use during childhood in 17% of cases. Across the entire sample and four screening tools, the proportion of potentially ‘positive’ FASD screens based on exploratory evaluation ranged from 10% to 33%. Exploratory screening outcomes varied considerably between tools. Findings highlight the need for additional research to identify rates of FASD in forensic mental health settings, and to develop evidence-based screening and assessment approaches, and practice guidelines, for this setting.

ABSTRACTBoredom is a problem in forensic mental health settings and is believed to increase levels of violence and be detrimental to health and recovery. There were 8 men in a forensic unit, all diagnosed with a psychotic disorder, that were interviewed regarding their experiences of boredom. A thematic analysis was used to identify emergent themes. These included: Mental health and motivation; Restrictive environment; Responsibilities; and Nothing to do. These findings provide a greater understanding of factors which may contribute to boredom within forensic settings and can guide occupational therapy interventions to address them.

INTRODUCTION: Safewards is a model developed for acute mental health settings designed to reduce conflict and containment; however, it requires adaptation to forensic mental health settings. To develop the Safewards Secure model, a model to assist forensic mental health services to reduce conflict and containment. A literature review was conducted to elicit possible modifiers and adjustments to the interventions. A Nominal Group Technique was then used to engage forensic mental health experts who had experience implementing Safewards (n = 12) to seek feedback about the suggestions and reach consensus on the Safewards Secure model and interventions. Data were thematically analysed. Experts reached consensus on all suggestions, however, did recommend minor additions and modifications. Two themes were also interpreted: Safewards Secure is just as much for staff as it is for consumers, and the proposed additions encourage more meaningful staff to consumer collaboration. This study identified key challenges experienced by nurses working in forensic mental health settings, however, these challenges were not seen as insurmountable. The Safewards Secure model offers prompts and suggestions to encourage reflection, collaboration and a humanistic approach to care in forensic mental health settings. Addressing reactions to offending behaviour and encouraging more collaboration might assist in ensuring a more person-centred approach to forensic mental health nursing care.

Forensic mental health (FMH) is described as a complex and challenging specialism to work in. The experiences of staff working within FMH settings have important influences on the quality of care provided to patients. This thesis explored the experiences of both multidisciplinary staff and clinical psychologists. A meta-synthesis of international qualitative studies was conducted to explore the experiences of staff working in FMH settings. Sixteen papers were synthesised, revealing five themes: 1) The impact of safety; 2) Psychological and emotional impacts; 3) Trying to maintain control; 4) The double-edged sword of support; and 5) A special insight into humanity. The findings point to the importance of understanding how staff manage the impacts of working in FMH settings in order to develop effective support systems. Eight clinical psychologists were individually interviewed to explore their lived experiences of compassion satisfaction when working in UK forensic mental health settings. Five themes were identified using interpretative phenomenological analysis: 1) The magnitude of trust; 2) Adjusting expectations; 3) Being both lock and key; 4) Needing time and resources; and 5) Variety and complexity. The results highlighted important distinctions in how compassion satisfaction can be experienced by clinical psychologists in this specialty, and what may influence these experiences. A critical appraisal of the process of carrying out the research was conducted. Issues regarding ethical approval, recruitment, and methodology were discussed, in addition to the impact of the study on the researcher.

In providing the care and control of individuals found Not Criminally Responsible on Account of Mental Disorder (NCRMD), forensic psychiatry attempts to balance the protection of society with the treatment of mental illness. A new approach in mental health care is the recovery model, which centers on the understanding that there should be a ‘recovery in’, not a ‘recovery from’ serious mental illness. In clinical practice, this means that treatment decisions should be made in collaboration with patients and include their personal circumstances, such as criminality and aspirations. Concepts that intersect with these goals are elements like choice, hope, personal responsibility, and empowerment. This paper examines the implementation of the recovery model in forensic mental health settings and provides an in-depth exploration and evaluation of the model as it is practiced at a forensic psychiatric outpatient clinic with individuals found NCRMD. Ten participants, including both individuals found NCRMD and psychiatric professionals, took part in semi-structured interviews. The paper examines the experiences, perceptions and challenges of implementing the recovery model in a forensic psychiatric setting and compares its strategies to the predominant risk-based forensic practices. The analysis suggests that it is difficult to implement the recovery model in a forensic setting without compromising either the recovery model or the risk management approach.
 Keywords: NCRMD, recovery model, risk management, outpatient setting, qualitative, forensic mental health

This ethnographic study explores how a research team navigated power dynamics while developing patient-oriented research practices in a high-secure forensic mental health care setting. Data were collected through team meetings, interviews, and field notes. The study explored how power was understood and addressed at individual, interpersonal, and structural levels. The three themes and six subthemes focused on the importance of acknowledging power within the system, power given to the project through community support, and power held by researchers. Researchers learned to navigate strict policies, procedures, and practices within the forensic environment, focusing on building trust with staff while ensuring patient autonomy and engagement. Equitable communication, particularly with patients, was critical in garnering support for patient-oriented research, often requiring the use of accessible language. Lastly, reflexivity allowed the research team to critically reflect on their biases and positionalities, fostering power-balanced relationships essential for authentic engagement. Findings suggest that addressing power imbalances early and often, and building on the support of staff champions, are key considerations for conducting patient-oriented research in forensic mental health settings.

High levels of service user satisfaction are viewed as a reliable indicator of a service providing good care and treatment. There has been limited research looking into levels of satisfaction in forensic mental health settings with most work focused on staff satisfaction in these settings. This study examined service users' levels of satisfaction with a forensic mental health service in the United Kingdom. The service covered two sites; one a purpose-built secure unit and the other based in an old cottage hospital. Thirty-nine in-patients completed a 60-item validated forensic satisfaction scale. The scale measured seven domains of satisfaction as well as reporting an overall satisfaction score. The results indicated the service users were reasonably satisfied with the care and treatment they received. The domains of rehabilitation, safety, staff interaction and overall care showed the highest level of satisfaction. The high rehabilitation satisfaction score demonstrated the importance of meaningful activities for users accessing forensic services and may have been influenced by the security measures on the wards. The high safety domain score indicated respondents felt safe and secure within the wards and were likely to be influenced by positive interpersonal interactions. Good staff interaction was also an important factor in helping service users feel safe on the wards. These interactions are likely to be associated with longer periods of admission in secure services allowing therapeutic relationships to develop. Financial advice/support was the one domain that recorded negative satisfaction levels. Financial literacy training may help develop money management skills.

In this paper, we present an account of the nature of relational security and the need for robust, comprehensive and consistent implementation within secure and forensic mental health settings in England and Wales. Within this, we review and critique the See Think Act framework of relational security and consider how it may be further developed. We conclude by making a series of evidence-based recommendations for improving the quality of relational security as it is deployed within secure and forensic mental health settings.

To examine empirical literature on user involvement in collaboration between patients and nurses. The scope of the review was limited to structured violence risk management interventions in forensic mental health settings. Violence in forensic mental health settings represents a significant problem for patients and staff. Structured violence risk management interventions in forensic mental health have been reported to ignore patient participation, despite the growing attention on user involvement in clinical practice. A systematic review. Searches were conducted in six databases: the Cochrane Systematic Reviews, MEDLINE, CINAHL, ProQuest, ScienceDirect and PsycINFO. Papers were assessed according to a predetermined set of inclusion and exclusion criteria. After searches of the reference lists of retrieved articles were conducted, only three papers met the inclusion criteria. This review has shown that empirical research on the topic of risk management interventions in which patients are involved is scarce. There is barely any research evidence of the clinical effect of user involvement approaches on violence risk management in forensic mental health practice. Therefore, we suggest that clinicians may learn from positive experiences concerning user involvement in general psychiatry and carefully adapt and test them out in the forensic treatment context.

The aim of the study was to investigate why registered nurses seek forensic mental health employment and explore their initial impressions of this setting. Explanatory sequential mixed methods. Registered nurses employed in a forensic mental health hospital completed an online survey about their reasons for seeking work in forensic mental health and their transition into the setting. To fully explore findings, semi-structured interviews were conducted with a sub-group of survey respondents. Descriptive statistics were used to analyse survey data, and thematic analysis was used to analyse the interviews. Sixty-nine respondents completed the survey, and 11 interviews were conducted. Prior interest in forensic mental health and encouragement from hospital staff were considered important influences in seeking forensic mental health employment. New knowledge, changes in clinical responsibility, exposure to patients' background offences and security processes overwhelmed some participants initially. However, participants reported that the initial challenges of their transition revealed opportunities to develop genuine connections with patients. This study provides a new understanding of the reasons why nurses seek employment in forensic mental health and the challenges and opportunities experienced when first working in this setting. Such professional and personal elements need to be considered by organizations to strengthen recruitment strategies and support future nurses' transition into forensic mental health settings. This study provides new knowledge about recruiting and supporting nurses' transition into forensic mental health employment. As such, it informs policymakers, clinical services and managers about strategies needed to attract and retain this workforce. No public or patient involvement.

The Health of the Nation Outcome Scale (HoNOS) is a widely used tool for monitoring consumer outcomes within mental health services. However, concern about its suitability in forensic mental health settings led to the development of a forensic version of this tool (HoNOS-Secure). To date, no direct comparison of these versions has appeared in the empirical literature. In the present study, a cohort of forensic mental health consumers was rated using the HoNOS and HoNOS-Secure. Pearson correlations were generated to compare the tools at a total score and item level. Logistic regression was employed to evaluate how well these tools categorise patients on a range of measurable outcomes. HoNOS scores were also compared against civil mental health consumers to evaluate differences between these populations. The HoNOS/HoNOS-Secure correlated strongly at the total score level, but demonstrated variable correlations at the item level. Logistic regression suggested that the HoNOS-Secure ‘clinical and social functioning scale’ adds little to the HoNOS in a forensic setting; however, the HoNOS-Secure ‘security scale’ added significant benefit to both versions. Results remained stable when re-evaluated over time. Forensic and civil mental health patients were found to demonstrate the same degree of psychopathology at the point of admission; however, they differed at review and discharge collection occasions. Implications for clinical practice and policy are explored.

We (both author and reader) will explore the need to develop a practicable evaluative human rights-based approach to the care, treatment and discharge of forensic mental health patients. It can be argued that patients in secure and forensic services are potentially the most marginalised and extensively stigmatised of all patient cohorts, and that the extent to which they are discriminated against should not be underestimated. We will consider the concept of right-based practice in secure and forensic mental health settings, and how the quality of practice can be strengthened. We will ground our exploration in the lived experiences of secure and forensic mental health patients and seek through the lens of lived experience to envisage what could constitute fairer and more supportive systems of care.

Pharmacotherapy is a front-line intervention used to address complex health concerns among forensic system consumers. Many are prescribed a polypharmacy pharmacotherapy regimen, though this may pose significant risks to physical health and well-being. Forensic consumers also have evidence of behavioral health concerns that may impact preferred treatment and prescribing practices. We examined the relationship between ACEs, suicide, self-harm, and inpatient aggression with psychotropic polypharmacy using retrospective data extracted from medical records from a US forensic mental health facility (N = 182). Nearly all participants (98.5%) prescribed any medication (72%) received a psychotropic polypharmacy regimen. ACEs were common, impacting 75.8% of the sample. ACEs, self-harm, and inpatient aggression, though not suicide attempts, were positively predictive of psychotropic polypharmacy in a series of regression analyses. Mediation analyses explored the interplay between ACEs, specific behavioral concerns, and psychotropic polypharmacy, though only models involving self-harm were significant. Implications for trauma-informed practice include an emphasis on consumer choice, empowerment, collaboration, and autonomy. Future research should investigate implementation of trauma-informed practices in forensic mental health settings and the effectiveness of nonpharmacological interventions that can be used to reduce dependence on psychotropic medications when managing forensic consumers’ health concerns.

Purpose – The efficacy of cognitive-behavioural therapy (CBT) for schizophrenia in community and general psychiatric settings has been widely investigated and its practice recommended in primary and secondary care. In secure forensic mental health services the evidence is less established. The purpose of this paper is to evaluate the effectiveness of group CBT for schizophrenia in a high secure hospital. Design/methodology/approach – In all, 27 male forensic patients completed a manualised CBT group and were compared on primary and secondary outcomes to patients receiving treatment as usual (TAU). Primary outcomes were positive and negative symptoms as measured by the Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms (SANS) and the Psychotic Symptom Rating Scales (PSYRATS). A secondary outcome was interpersonal functioning as measured by the Inventory of Interpersonal Problems (IIP-64). Findings – CBT participants showed improvement on negative symptoms; affective flattening, alogia, anhedonia and avolition; in comparison to participants in TAU. CBT participants also showed reductions in delusions and hallucinations on the SAPS but not the PSYRATS. TAU participants improved on positive symptoms as measured by the PSYRATS. CBT participants showed reductions in overall interpersonal problems, and most notably in being socially inhibited and self-sacrificing. No iatrogenic effects of treatment were found; improvements in depression anxiety and stress were reported by group completers, which contrasted to experiences of the TAU group. Research limitations/implications – Absence of random allocation to CBP or TAU groups retains the risk of recruitment bias. Findings are preliminary given the sample size. Multiple outcome assessments increase risk of a type I error. Practical implications – CBT for schizophrenia can be effective with clients in secure forensic mental health settings. Improvements in negative symptoms and interpersonal functioning appear to be particular gains. Self-report measures might be subject to specific demand characteristics in such settings. Originality/value – The evaluation includes a comparator group in a high secure setting, which is typically absent in reported evidence for this population (Blackburn, 2004). The study also investigated changes in interpersonal functioning, which has previously been noted as an important but absent outcome in CBT for psychosis (Haddock et al., 2009). Iatrogenic outcomes were also considered in the evaluation to ensure no adverse effects were experienced from treatment.