Extreme Stress Events in a Forensic Hospital Setting: Prevalence, Impact, and Protective Factors in Staff.

The current research explored the prevalence of stressful events in a forensic hospital setting, and their impact on staff. A systematic review of the literature on responses following exposure to extreme stress comprised 46 articles. This was followed by a Delphi study of professionals based in a forensic hospital (n = 43) to explore views on the factors that affect responses to extreme stress. This comprised three rounds to build consensus. Finally, a study of forensic hospital staff was conducted (n = 153, 47% male) to capture current trauma symptoms. The systematic review indicated three superordinate themes: outcomes adversely impacting staff and patients; personal characteristics moderating the impact of events; and organisational and interpersonal support moderating the impact of events. The Delphi supported these themes and noted the importance of factors external to the workplace and internal factors, such as self-blame. The final study demonstrated how a fifth of the workforce showed at least some trauma symptomology. Those who experienced less burnout reported lower trauma symptoms, while staff who experienced higher levels of secondary trauma at work reported higher levels of trauma symptoms. A higher level of resilience was related to lower levels of trauma symptomology. Findings are discussed in relation to the importance of recognising trauma in staff and implementing strategies to reduce and/or buffer the impact of stress on wellbeing. In doing so, the research presents a new model for consideration and development, the Impact and Amelioration of extreme stress events Model (IA-Model).

Staff Beliefs Toward Self-Injurious Behavior in Patients: A Study of Secure Services.

ABSTRACT: Staff beliefs toward patient self-harm in secure forensic services are explored, capturing forensic nurses and other clinical staff from four secure units from one National Health Service trust, comprising high through low and forensic learning disability. One hundred fifty-five respondents took part (overall completion rate: 61%). The Theory-Driven Measure of Self-Injurious Behavior and the Suicide Competency Assessment Form were completed. It was predicted that higher competency and increased levels of training would associate with beliefs toward patient self-harm. Beliefs differed in accordance to location; perceiving self-injurious behavior as planned and within patient control was endorsed more in high-security settings by forensic nurses, with nurses in high security also more likely to endorse the perception that patients engaging in such behaviors were able to cope and felt valued. Competence and training experience were identified as factors of relevance. The study offers suggestions for future research, including a focus on capturing the environment, exploring "endorsed beliefs" as opposed to "negative attitudes," and proposing the concept of "professional exposure to self-harm" as an important variable.

Understanding Factors Relevant to Self-Injurious Behavior in a High-Risk Secure Psychiatric Sample: Developing the Theory-Driven Measure of Self-Injurious Behavior Engagement.

ABSTRACT: A measure for the assessment of self-injurious behavior is developed. Commencing with a Delphi composed of 33 experts: detached experts (academics), experts by exposure (staff), and experts by experience (patients), the Theory-driven Measure of Self-Injurious Behavior Engagement is outlined. This is then examined in two samples: high-secure psychiatric male patients (n = 76) and high-secure psychiatric nursing staff (n = 100; 50 men, 50 women). We predicted that all components of the Theory of Planned Behavior and the capacity, belongingness, and burdensomeness elements of the Interpersonal Psychological Theory of Suicidal Behavior would be confirmed as important inclusions. Results initially showed the importance of including intention, perceived behavioral control, affect, capacity, and burdensomeness. The role of environmental and individual factors, such as coping, was captured as additional variables of value. However, the structure of items differed between patients and staff. Being valued consistently represented a core consideration, as did capacity and affect. Directions for future research are indicated.

Psychopathy and trauma: Exploring a potential association.

This research presents a series of linked studies exploring the association between psychopathy and trauma. It comprises a systematic review (n = 58), followed by an expert Delphi (n = 19), and patient file trawl using a male forensic psychiatric patient sample (n = 66). An association between psychopathy and developmental trauma was predicted. It was further predicted that different types of trauma would be associated with different subtypes of psychopathy and that the severity of trauma would be important. The systematic review identified the following core themes: presence of Post-Traumatic Stress Disorder and/or symptoms; trauma type; trauma/abuse variables; and sex differences. The ensuing Delphi study indicated the specific variant of psychopathy to be important, with secondary psychopathy particularly relevant. The final study found that the severity of developmental trauma related differentially to primary and secondary psychopathy. Implications and directions for future research are discussed, most notably with regards to the conceptualisation of psychopathy.

Coping, mental health, and subjective well-being among mental health staff working in secure forensic psychiatric settings: Results from a workplace health assessment.

Given raised rates of patient suicide and violence in secure psychiatric facilities, staff in such settings are arguably at increased risk for burnout and reduced mental health. The present article responds to the recent U.K. National Institute for Health and Care Excellence (NICE) call to assess workforce well-being. This article held the following aims: (1) to quantify existing levels of mental health (i.e., depression, anxiety, distress, and posttraumatic stress) and subjective well-being (i.e., job satisfaction, life satisfaction, and four domains of burnout) and (2) to evaluate Coping Self-Efficacy (CSE) and Need for Affect (NFA) as factors associated with staff mental health and subjective well-being. We conducted a voluntary cross-sectional health needs assessment of forensic mental health staff (N = 170) between 2017 and 2018 from one National Health Service (NHS) Trust. Descriptive findings suggest staff possessed nonclinical average ranges of mental health symptoms. Subjective well-being findings showed burnout was relatively low, whereas job and life satisfaction were modest. Regression models demonstrated that (a) thought/emotion stopping beliefs were negatively associated with psychological exhaustion; (b) social support beliefs were positively associated with life satisfaction and job enthusiasm; (c) NFA Avoidance was linked with poor mental health and burnout, and; (d) NFA Approach was positively associated with two health subjective well-being indicators. Overall, assessment results suggest NHS forensic mental health staff reported relatively good health. Cognitive- and emotion-focused coping beliefs demonstrate promise as content for prevention programming. Using Emotional Labor Theory, we offer psychological services-based recommendations for future prevention programming and research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Predicting security incidents in high secure male psychiatric care.

PURPOSE: The contribution of environmental and organisational factors in predicting security incidents within a high secure male psychiatric setting is considered using a series of connected studies; a systematic literature review comprising 41 studies and five inquiries (Study 1) to identify core themes of likely importance; application of these themes to incident data through assessment of the ward culture, as perceived by 73 male psychiatric patients and 157 staff (Study 2); and detailed examination of noted relevant factors in the form of interpersonal style, meaningful activity and physical environmental characteristics in a study comprising 62 patients and 151 staff (Study 3). It was predicted that security incidents would be identified through inclusion of environmental and organisational factors. RESULTS: The systematic review demonstrated the importance of accounting for staff characteristics, patient interactions, physical environment and meaningful activity. The subsequent study noted the importance of only specific aspects of the social environment, with the final study demonstrating that incidents were associated with controlling interpersonal styles of staff, lower perceived fairness, and less involvement in off-ward activities. Perception of fair treatment and off-ward activities mediated the staff interpersonal style and security incident relationship. CONCLUSIONS: The research proposes a preliminary framework - the McKenna Framework for understanding Incidents in Secure Settings (M-FISS) - to explain the occurrence of security incidents in secure psychiatric care.

Initial development of the Psychopathic Processing and Personality Assessment (PAPA) across populations.

Three studies describe development of the Psychopathic Processing and Personality Assessment (PAPA). Study one outlines a literature review and Expert Delphi (n=32) to develop the initial PAPA. Study two validates the PAPA with 431 participants (121 male prisoners and 310 university students: 154 men, 156 women), also using the Levenson Self Report Psychopathy scale and a measure of cognitive schema and affect. Study three refined the PAPA, employing it with 50 male students and 40 male forensic psychiatric patients using clinical (interview) assessments of psychopathy: the Psychopathy Checklist - Screening Version and the Affect, Cognitive and Lifestyle assessment. The PAPA comprised four factors; dissocial tendencies; emotional detachment; disregard for others; and lack of sensitivity to emotion. It positively correlated with existing psychopathy measures. Variations across PAPA subscales were noted across samples when associated with clinical measures of psychopathy. Support for the validity of the PAPA was indicated across samples. Directions for research and application are outlined.

Predicting hospital aggression in secure psychiatric care.

BACKGROUND: Risk assessment instruments have become a preferred means for predicting future aggression, claiming to predict long-term aggression risk. AIMS: To investigate the predictive value over 12 months and 4 years of two commonly applied instruments (Historical, Clinical and Risk Management - 20 (HCR-20) and Violence Risk Appraisal Guide (VRAG)). METHOD: Participants were adult male psychiatric patients detained in a high secure hospital. All had a diagnosis of personality disorder. The focus was on aggression in hospital. RESULTS: The actuarial risk assessment (VRAG) was generally performing better than the structured risk assessment (HCR-20), although neither approach performed particularly well overall. Any value in their predictive potential appeared focused on the longer time period under study (4 years) and was specific to certain types of aggression. CONCLUSIONS: The value of these instruments for assessing aggression in hospital among patients with personality disorder in a high secure psychiatric setting is considered. DECLARATION OF INTEREST: J.L.I., C.A.M. and J.K. are employed by the trust where the data were collected. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Exploration of emotion regulation experiences associated with borderline personality features in a non-clinical sample.

BACKGROUND: Emotion dysregulation is a core feature associated with borderline personality features (BPF). Little research has explored how individuals with high levels of BPF regulate their emotions. This study aimed to explore how individuals with high versus low levels of BPF compare on the strategies they use to regulate emotions and in their experiences of emotion regulation. METHODS: Twenty-nine university students were recruited and assessed for the presence of BPF using self-report questionnaires. Each participant took part in a semi-structured interview about their experiences of emotion regulation. All interview transcripts then underwent thematic analysis. In addition chi square analyses were conducted to explore the association between level of BPF (High vs Low) and each qualitative theme identified. RESULTS: Findings indicated similarities in the types of emotion regulation strategies used by the high and low-BPF groups. However, the groups differed in their experiences and thought processes surrounding emotion regulation. High-BPF participants were found to describe a need to communicate negative emotions with others and demonstrated difficulty maintaining attention on positive experiences. In addition there was a trend towards High-BPF participants demonstrating less forward-planning in emotion regulation. CONCLUSIONS: This study provides insights into some of the unique aspects of emotion regulation in individuals with high BPF that may make emotion regulation attempts less successful.

Sleep and its association with aggression among prisoners: Quantity or quality?

OBJECTIVE: The current paper aims to examine the association between self-reported sleep quality and quantity and how these relate to aggression motivation and hostile cognition in a male prisoner sample. The cognitive component of sleep, namely perception, is consequently a variable of particular interest and one neglected by previous research. METHODS: Two independent studies are presented. The first comprised 95 adult male prisoners who completed a sleep quality index along with measures of implicit and explicit aggression. The second study extended this to consider aggression motivation and hostile attribution biases using a sample of 141 young male adult prisoners. RESULTS: In study one, sleep quantity and indicators of sleep quality were found not to associate with aggression whereas the perception of poor sleep did; those perceiving poor sleep quality were more likely than those perceiving good sleep to report they had perpetrated aggression in the previous week and to report higher levels of implicit aggression. Study two found that while increased indicators of poor sleep quality were associated with lower prosocial attribution tendencies and higher levels of reactive and proactive aggression, sleep quantity was not associated. The perception of poor quality sleep was important; those perceiving poor sleep were more likely to report higher levels of reactive and proactive aggression than those reporting good sleep. CONCLUSIONS: Collectively the studies highlight the importance of accounting for the perception of sleep quality as an important cognitive component in understanding the association between sleep and aggression.

Initial development of an implicit and explicit approach to assess psychopathy.

Four studies outline the ACL (Affective, Cognitive and Lifestyle) assessment, a new means of assessing psychopathy capturing implicit and explicit functioning. Studies 1 and 2 comprised students (Study 1, n=42, 14 men, 28 women; Study 2, n=50 men), Study 3 comprised 80 young prisoners (men) and Study 4, 40 forensic psychiatric patients (men). It was predicted that the ACL affective, cognitive and interpersonal components would positively correlate with the interpersonal factor of another measure of psychopathy (PCL-SV), whereas the ACL Lifestyle component would correlate with the criminal history/lifestyle component of the PCL-SV. Evidence for internal reliability for the ACL was noted. The ACL correlated as expected with the PCL-SV although variation across samples was noted. Implicit affect and specific aspects of cognition positively correlated with increased psychopathy on the PCL-SV. Implicit affect correlated differently across samples. Findings are discussed regarding implications. Directions for future research are indicated.

Personality structure among prisoners: how valid is the five-factor model, and can it offer support for Eysenck's theory of criminality?

BACKGROUND: Research with offenders has tended to use a categorical system of diagnosis or a three-factor model. There is growing evidence among non-offending groups that a five-factor model (FFM), which is more holistic and emphasises strengths as well as limitations, may be more clinically useful. AIM: The purpose of this study was to test the validity of the FFM of personality in a sample of adult male prisoners. It was predicted that they would show higher scores for extraversion (E) and lower scores for emotional stability (ES) [the equivalent of higher neuroticism (N)], that E would be predicted by prison experience and age and that the FFM would be confirmed as a better fit to the data over Eysenck's three-factor [P(psychoticism)EN] model. METHODS: Two independent samples of adult male prisoners were asked to complete the International Personality Item Pool while locked in their cells over the lunchtime period. Parallel and confirmatory factor analyses were used to test the hypotheses. RESULTS: There was a 65 and 75% response rate across the independent samples, resulting in samples of 259 and 183, respectively. Overall, more positive personality traits were evidenced across both samples. E was not predicted by prison experience or age, with increased ES related to increased age in only one sample. The best-fitting model comprised five factors, but represented a variant of the FFM. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The value of applying broad conceptualisations of personality to special samples is discussed, with the importance of accounting for positive, as well as negative, traits acknowledged. The presence of increased positive traits in comparison to negative traits is not in keeping with Eysenck's original personality theory of criminal behaviour, with the study highlighting value in accounting more for environmental factors.

Intra-group aggression among prisoners: bullying intensity and exploration of victim-perpetrator mutuality.

A new multiple indicator method of assessing bullying behaviour is employed (Direct and Indirect Prisoner behaviour Checklist - Scaled version [DIPC-SCALED]) with 605 adult prisoners (487 men and 118 women). The study explores if the DIPC-SCALED is a reliable method comprising of identifiable aggression factors; if prisoners can be classified into groups based on behavioural frequency; and if there is evidence for mutual victim/perpetrator groups. The DIPC-SCALED proved reliable, comprising of a number of aggression factors. Prisoners could be classified into groups based on behavioural frequency with one-fifth classified into an "intense" perpetrator and/or victim group. Evidence for mutual perpetrator/victims was found. Results are discussed with regards to the method used and the value in accounting for behavioural frequency in group classification.

Coping style and distress in newly incarcerated male adolescents.

PURPOSE: To research relations between coping style and well-being in adolescent prisoners; previous research suggests that the stress of incarceration may be moderated by coping style in adult prisoners. METHODS: This research examined links between coping style and distress in 133 male adolescent prisoners on two occasions over a six-week period shortly after the commencement of their imprisonment. RESULTS: Anxiety and depression both declined over this period, with T1-T2 depression reduction negatively associated with T1 emotion-based coping and positively associated with T1 detachment. Emotion coping declined over the six weeks, whereas detachment coping increased. These changes were associated with improved depression and anxiety scores. CONCLUSIONS: Detachment and low emotional expression may assist incarcerated adolescents to adapt more positively to the initial period of imprisonment, and prisoners may adopt these more effective coping styles over time. These findings are explained in terms of adaptation to stressors specific to the prison environment.

Coping style and psychological health among adolescent prisoners: a study of young and juvenile offenders.

The current study explores the role of coping styles as a predictor of poor psychological health among adolescent offenders. It presents the first study to compare young and juvenile offenders. Two hundred and three male offenders took part: 108 young (18-21 years) and 95 juvenile (15-17 years) offenders. All completed the General Health Questionnaire (GHQ-28) and a revised version of the Coping Styles Questionnaire (CSQ-3). Young offenders reported using emotional, avoidant and detached coping styles more than juveniles. They also reported more overall psychological distress than juveniles, with a trend to report increased depression, anxiety and insomnia. For both young and juvenile offenders, emotional coping predicted increased psychological distress. This was consistent across different symptoms (i.e. somatic, anxiety and insomnia, social dysfunction and severe depression). For young offenders, rational coping predicted a decrease in overall distress and was found across all symptoms. For juveniles, although detached coping predicted a decrease in overall psychological distress, across symptoms it only predicted social dysfunction. Increased rational coping was also found to predict decreased depression for juveniles. The study highlights differences between young and juvenile offenders regarding coping styles and how this relates to psychological distress. It highlights the complexities of trying to understand the coping-health relationship in a prison setting and asks if such settings are increasing the potential for adolescents to over-use coping styles that may not be the most effective.