Linking the past and the present: service users’ perspectives of how adverse experiences relate to their admission to forensic mental health services

Purpose This study aimed to explore how forensic mental health service users make sense of their past adverse experiences. Secondly, it aimed to explore whether service users considered their adverse experiences to be related to their current stay in a forensic mental health setting. Design/methodology/approach Interpretative phenomenological analysis was used to analyse interviews with eight service users in low and medium secure care. Six of the participants were male and two were female. Findings Four super-ordinate themes emerged from the data: “Living amongst adversity”; “Managing adverse experiences”; “Making sense of going into secure care”; and “Coping with the past in the present”. All participants referred to multiple adverse experiences throughout their lives and used harmful coping strategies to manage these. Individual differences in how they related their past experiences to their detention in secure care were evident. Practical implications Author guidelines state that this section is optional. Implications for clinical practice are discussed at length in the discussion section. Originality/value This study offers an insight into the way in which forensic mental health service users make sense of their past traumas in relation to their current admission to secure services. To the best of the authors’ knowledge, no research has previously addressed this from the perspective of service users.

A rapid evidence assessment of psychological treatment approaches for stalking behaviour

Purpose This paper aims to provide practitioners with a brief but comprehensive review of the current evidence base for psychological treatment approaches used in the UK that may be useful for stalking therapies. Design/methodology/approach A rapid evidence assessment was conducted on papers (post the UK Protection from Harassment Act, 1997) that discuss treatments of stalking (with or without a conviction) and associated offences/disorders. Therapies reviewed were Acceptance and Commitment Therapy, Cognitive Analytic Therapy, Cognitive Behavioural Therapy, Dialectical Behaviour Therapy and Schema Therapy. Searches for Mentalization-Based Therapy and Psychodynamic Therapy in relation to stalking were also performed but yielded no results that met inclusion criteria. Findings There is currently a severely limited evidence base for the efficacy of the psychological treatment of stalking behaviours. Some interventions show promise although a multifaceted, formulation-based approach is likely to be required. Practical implications Future research would benefit from robust studies focused on stalking with long-term efficacy follow-ups. Originality/value To the best of the authors’ knowledge, this is the first rapid evidence review of psychological treatments that directly address stalking behaviour.

The use of a guided peer review assessment for investigative interviewers of child witnesses

Purpose Investigative interviewers assess their colleagues' interviews (‘peer review’) as a necessary part of their practice, and for their self-development. Yet, there is little guidance around what the process involves and how they might do it. Research suggests that effective peer review is supported by using guidance material. The goal of the present work was to describe the use of such a guide by a group of professionals who regularly conduct investigative interviews with children, to share what was learned with other professionals seeking to create a formalized peer review process. Design/methodology/approach Sixty US child witness interviewers completed a guided peer review assessment of an anonymous interview, as an assignment at the conclusion of an 18-hour training program that focused on developing their interviewing skills. They consented to the use of their learning data in research, and the research was approved by the university's research ethics board. Peer reviews were coded for the extent to which they used the guide to support their evaluations, and the overall quality of the review to assess the utility of the guide in supporting them to conduct effective assessments. Findings In general, the guide and instructions for providing feedback were moderately effective in supporting the peer assessments, but results suggested specific training in how to deliver peer review would be useful. Practical implications Through this process, the authors identified components that would be helpful to further increase the efficacy of peer review. Originality/value The aim of this work was to spark a greater conversation among practitioners and academics about professionalizing the peer review process and aiding interviewers to develop peer review tools that would support their continued growth. The authors conclude with five key tips for professionals that stem from the experiences creating and evaluating the guide in combination with existing literature and three areas for future investigation.

Developing a measure to assess clinicians’ ability to reflect on key staff–patient dynamics in forensic settings

Purpose Relational dynamics between patients and staff in forensic settings can be complicated and demanding for both sides. Reflective practice groups (RPGs) bring clinicians together to reflect on these dynamics. To date, evaluation of RPGs has lacked quantitative focus and a suitable quantitative tool. Therefore, a self-report tool was designed. This paper aims to pilot The Relational Aspects of CarE (TRACE) scale with clinicians in a high-secure hospital and investigate its psychometric properties. Design/methodology/approach A multi-professional sample of 80 clinicians were recruited, completing TRACE and attitudes to personality disorder questionnaire (APDQ). Exploratory factor analysis (EFA) determined factor structure and internal consistency of TRACE. A subset was selected to measure test–retest reliability. TRACE was cross-validated against the APDQ. Findings EFA found five factors underlying the 20 TRACE items: “awareness of common responses,” “discussing and normalising feelings;” “utilising feelings,” “wish to care” and “awareness of complicated affects.” This factor structure is complex, but items clustered logically to key areas originally used to generate items. Internal consistency (α = 0.66, 95% confidence interval (CI) = 0.55–0.76) demonstrated borderline acceptability. TRACE demonstrated good test–retest reliability (intra-class correlation = 0.94, 95% CI = 0.78–0.98) and face validity. TRACE indicated a slight negative correlation with APDQ. A larger data set is needed to substantiate these preliminary findings. Practical implications Early indications suggested TRACE was valid and reliable, suitable to measure the effectiveness of reflective practice. Originality/value The TRACE was a distinctive measure that filled a methodological gap in the literature.

Psychological and the physical health impacts of forensic workplace trauma

Purpose Health-care professionals working in inpatient forensic mental health settings are exposed to a range of traumatic and distressing incidents with impacts discussed variously as “burnout”, “compassion fatigue”, “secondary trauma stress” and “vicarious traumatisation”. This study aims to explore the short- and long-term psychological and physical health effects of trauma exposure in the workplace for frontline staff in a forensic setting. Design/methodology/approach Semi-structured interviews were conducted with 14 nursing staff members working in the male personality disorders care stream in a Medium Secure Hospital. Findings Thematic analysis yielded five themes: categories of trauma; how well-being is impacted; ways of coping and managing; protective factors; and systemic factors, with sub-themes within each of the superordinate themes. Practical implications The findings demonstrate that some staff members were affected both physically and psychologically as a result of trauma-focused work whereas other staff members were unaffected. The psychological and physical health effects were broadly short-term; however, long-term effects on staff member’s social networks and desensitisation to working conditions were observed. A broad range of coping methods were identified that supported staff member’s well-being, which included both individual and organisational factors. Staff member’s health is impacted by exposure to workplace trauma either directly or indirectly through exposure to material, and there is a greater need to support staff members after routine organisational provisions are complete. Staff should receive education and training on the possible health effects associated with exposure to potentially traumatic material and events. Originality/value This research has further contributed to understanding the staff needs of nursing staff members working with the forensic personality disorder patients within a secure hospital setting. This research has identified the following service developments: the need for ongoing support particularly after organisational provisions are complete; further prospects to engage in psychological formulations; greater opportunities for informal supervision forums; staff training to understand the potential health impact associated with trauma-focused work; supervisors being appropriately trained and supported to elicit impacts of trauma-focused work on staff members; and additional opportunities to discuss well-being or monitor well-being.

Intensive intervention and risk management services (IIRMS) three years on: what we need to do better in the offender personality disorder pathway

Purpose This is a discussion paper describing the reflections of clinical leads within well-established intensive intervention and risk management services (IIRMS). IIRMS has developed in the past five years, with a small number of services leading in the development of a psychologically informed case management approach to working with individuals released from prison on probation licence, who have a history of high risk, high harm violent convictions linked to pervasive psychological and interpersonal problems. Design/methodology/approach Clinical leads of three services considered a period of 23 months up to December 2019, in which the outcomes for all individuals on their caseload at that time were reviewed. Reflections on the themes included the reasons for a premature return to prison and emerging themes for those who appeared to be successfully resettled. Findings Approximately one-third of the individuals were returned to prison, and for most, this occurred within the first 18 months of release. There was considerable unanimity between clinical leads regarding the themes, and problems with relative youth, substance misuse, relationship difficulties, managing transitions and complacency featured. There were four themes identified in those who appeared to have settled successfully in the community. Practical implications The identified themes provide key learning that will be enshrined in an updated version of the guidance for all IIRMS, with the overall aim of reaching out and engaging with a group of individuals who are most at risk of exclusion from services. Originality/value Although there are limitations associated with the informal approach of this paper, the reflections of the clinical leads have provided a valuable addition to the very limited empirical literature in this field.

The positive aspects of fire use: a grounded theory of the experiences of non-criminalised fire users

Purpose Psychological research on fire has focussed primarily on its misuse in the form of arson and firesetting, which reflects a tradition in forensic psychology for focussing on risk and pathological behaviour. However, this is inconsistent with the strengths-based approach because it fails to account for positive aspects of fire and law-abiding/ healthy interactions with fire. This study aims to explore the psychology of non-criminalised forms of fire use. It is predicated on a novel, dimensional, conceptualisation of fire-related behaviour – the continuum of fire use (CoFU; Horsley, 2020, 2021). Design/methodology/approach Semi-structured interviews were conducted with 12 adults who use fire in law-abiding forms. Data were analysed using techniques informed by grounded theory. Steps were taken to ensure reliability and validity, including a Cohen’s Kappa calculation, which indicated an agreement level of 0.8 between two raters. Findings Four core themes were identified relating to the benefits of fire on psychological well-being, namely, immediate gratification; hope and empowerment; self-concept and emotional security. Research limitations/implications Drawing on findings from this study, a theoretical framework of the psychology of non-criminalised fire use is presented. This is a preliminary conceptualisation and more work is needed to address this under-researched topic. Practical implications The findings can inform the work of forensic practitioners. They highlight the importance of considering service users' positive interactions with fire, alongside maladaptive/ criminal use. This has implications for the assessment of fire setters, as well as rehabilitative approaches. Social implications It is argued in this paper that a society-wide approach is key to firesetting reduction. More specifically, findings can inform the development and refinement of early intervention programmes, which focus on supporting young people to develop a healthy relationship with fire. Originality/value To the best of the authors’ knowledge, this study is the first to explore the psychology of non-criminalised forms of fire use. It is predicated on a novel, dimensional, conceptualisation of fire-related behaviour – the continuum of fire use (CoFU; Horsley, 2020, 2021a, 2021b).

Understanding prolific self-harm in her majesty’s women’s estate prisons, in England

Purpose The purpose of this paper is to outline qualitative research into what influences, maintains and reduces prolific self-harm within women’s prisons across England. Design/methodology/approach Semi-structured interviews were conducted with participants who were identified as engaging in prolific self-harm. Thematic analysis was applied to two data sets, and analyses were combined to generate final themes. Findings Six overarching themes were identified which served to explain what influences the repetitive nature of prolific self-harm and also what helps to reduce it. The themes were reasons for self-harm, trauma, being in prison, support, other support and interventions: management and rehabilitative. Research limitations/implications Owing to the sensitive nature of the research a stringent exclusion criteria was applied which limited the data sample from the original pool. Variance in detail was observed from the interviewer transcripts. The data sample was not large enough to examine the influence of protected characteristics. Practical implications Responsivity in the support offered by staff is critical to a reduction in repetitive harm. A re-focus on staff training, plus support mechanisms for staff supporting people in women’s prisons who self-harm prolifically has been recommended. Originality/value This paper has focussed specifically on prolific self-harm within women’s prisons. This has not been an area that has been investigated separately to the general self-harm literature in prisons. This paper provides insight into factors which influence, maintain and reduce prolific-self harm in women residing in prison.

From research to practice: a multifaceted and dimensional approach to psychopathy

Purpose This paper aims to evaluate trends in research and clinical practice that may contribute to the limited utility of assessment and treatment modalities designed to capture and address psychopathy. It identifies a lack of consistency between the academic understanding of psychopathy and how the construct is applied in clinical contexts. The authors provide clarity and direction for a more effective application of the psychopathy construct in practical contexts. Design/methodology/approach This review first examines the etiology of important limitations to psychopathy research and practical application, and proposes the adoption of the most recent empirical conceptualization of the construct into practical contexts. It then evaluates the current functionality of psychopathy in practical contexts. The review ultimately proposes a method for designing intervention practices based on the model used in the development of dialectical behavior therapy (DBT) for borderline personality disorder, which will improve the practical utility of the construct. Findings The present review provides evidence that a multifaceted and dimensional perspective of psychopathy will improve the practical utility of the construct and help move the field forward. It suggests that considering independent components of the psychopathy construct along a continuous scale, as with DBT, will contribute to improvements in assessments and treatments that target psychopathy. Practical implications The current review applies relevant research to a model for developing an intervention modality particularly in forensic or correctional settings where individuals high in psychopathy are often seen. The implications outlined provide a framework that could impact practice and assessment in forensic contexts moving forward. Originality/value Previous research has not concisely outlined problems concerning the link between psychopathy research and how the construct is applied in practical settings. Few researchers have proposed plausible solutions that could improve the utility of the construct in such settings.

The impact of inequality on mental illness: thematic analysis on clinical notes

Purpose The concept of inequality can be described as not being treated equally to everyone else in society. While previous studies have explored the concept of inequality and its impact on mental illness, these have been primarily quantitative. The details of experiences and potential impacts of inequalities by patients prior to admission into secure care have not been investigated comprehensively using a qualitative approach, which will identify individualised factors that may contribute to the development of mental ill-health. This study aims to explore whether those with multiple disadvantages are at greater risk of developing mental illness. Design/methodology/approach A qualitative study of patients’ clinical notes upon admission to a secure in-patient facility was conducted using a thematic analytical approach to investigate the key inequalities reported by patients with mental health problems. The topic of inequality was examined by assessing the clinical notes of 21 patients who were under treatment at the time of the study. Findings The majority of patients experienced multiple inequalities which impacted negatively on their mental health status. Three main themes that were identified were – a disrupted living environment, disturbed childhood and the importance of support. The thematic analysis has shown that the majority of the patients were exposed to numerous societal disadvantages in association with challenging life events in their early years and these have impacted significantly on their subsequent well-being. Practical implications When assessing the background to mental illness, it is important to gain a deep understanding of many inequalities that patients have faced prior to them developing their condition and, in particular, how these have combined to initiate the clinical manifestation. The study highlights the importance of raising awareness of how being treated unfairly, whether based on protected or non-protected characteristics, can contribute towards people becoming disadvantaged in society and ultimately making them more vulnerable to the development of mental health difficulties. Results of the study may inform the future use of inequalities as an integral component in the development of trauma-informed care. Originality/value This is the first study, to the authors’ knowledge, to consider intersectionality and admission to mental health units by adopting qualitative approach, specifically by reviewing patients’ clinical notes.