Assessing protective factors to prevent post-discharge violent behaviour: Towards an assets-based approach for clinical risk management.

Medium secure forensic psychiatric units (MSUs) in the UK aim to be recovery-oriented to enable discharge to community-based services. Risk assessments are key to discharge planning, but clinical practice tends to focus on risk factors for violence rather than protective factors associated with a decrease in risk. The aims of this study were to investigate the reliability and validity of the Structured Assessment of Protective Factors (SAPROF) as a useful measure to support an assets-based approach when planning discharge from MSUs. A prospective cohort follow-up design was chosen for this study using a confidential inquiry design to ensure a total sample of all discharges. All forensic patients discharged from 32 NHS MSUs over a 12-month period were assessed at discharge and followed-up at six and 12 months post discharge. The occurrence and frequency of post-discharge violence were compared with discharge SAPROF scores. The inter-rater reliability between SAPROF raters was very high and the SAPROF significantly predicted community violence and scores were strongly correlated with violence frequency. The higher the SAPROF score the higher the protection against violence and the risk significantly diminished. Assessing protective factors is essential to identify assets and prevent violence with a focus on what makes somebody safe. This study supports the use of the SAPROF to inform discharge planning. Cultivating protective factors is likely to be motivating for patients and the SAPROF can provide an objective, reliable measure of internal, motivational and external assets that reduce risk and support defensible decision making at discharge.

Predicting time to recall in patients conditionally released from a secure forensic hospital: A survival analysis.

BACKGROUND: The recall of conditionally discharged forensic patients in England is a formal order from the Ministry of Justice under the Mental Health Act (1983) which has the power to revoke conditional release and direct readmission to hospital. Recall has significant implications for the individual and for hospital services, but despite this, little is known about predictors of recall for forensic patients. METHODS: We examined the rate of recall for 101 patients conditionally discharged from medium secure forensic inpatient services between 2007 and 2013. Demographic, clinical, and forensic factors were examined as possible predictors of time to recall using Cox regression survival techniques. RESULTS: Conditionally discharged patients were followed for an average of 811 days, during which 45 (44.5%) were recalled to hospital. Younger age (HR 1.89; 95% CI 1.02-3.49; p = 0.04), non-white ethnicity (HR 3.44; 95% CI 1.45-8.13), substance abuse history (HR 2.52; 95% CI 1.17-5.43), early violence (HR 1.90; 95% CI 1.03-3.50), early childhood maladjustment (HR 1.92; 95% CI 1.01-3.68), treatment with a depot medication (HR 2.17; 95% CI 1.14-4.11), being known to mental health services (HR 3.44; 95% CI 1.06-11.16), and a psychiatric admission prior to the index admission (HR 2.44; 95% CI 1.08-5.52) were significantly associated with a shorter time to recall. Treatment with clozapine reduced the risk of recall to hospital (HR 0.40; 95% CI 0.20-0.79). CONCLUSIONS: Time to recall can be predicted by a range of factors that are readily available to clinical teams. Further research is required to determine if targeted interventions can modify the likelihood or time to recall for conditionally released forensic patients.

Predictors of Mental Health Review Tribunal (MHRT) outcome in a forensic inpatient population: a prospective cohort study.

BACKGROUND: Previous studies have investigated factors associated with outcome at Mental Health Review Tribunals (MHRTs) in forensic psychiatric patients; however, dynamic variables such as treatment compliance and substance misuse have scarcely been examined, particularly in UK samples. We aimed to determine whether dynamic factors related to behaviour, cooperation with treatment, and activities on the ward were prospectively associated with outcome at MHRT. METHODS: At baseline, demographic, clinical, behavioural, and treatment-related factors were ascertained via electronic medical records and census forms completed by the patient's clinical team. Data on MHRTs (i.e., number attended, responsible clinician's recommendation, and outcome) were collected at a 2-year follow-up. Logistic regression analyses were performed to determine factors associated with outcome among those who attended a MHRT within the follow-up period. Of the 135 forensic inpatients examined at baseline, 79 patients (59%) attended a MHRT during the 2-year follow-up period and therefore comprised the study sample. Of these 79 patients included in the current study, 28 (35%) were subsequently discharged. RESULTS: In univariable analyses, unescorted community leave, responsible clinician's recommendation of discharge, and restricted Mental Health Act section were associated with a greater likelihood of discharge at MHRT; whilst inpatient aggression, a recent episode of acute illness, higher total score on the Historical Clinical Risk - 20 (HCR-20), higher HCR-20 clinical and risk scores, and agitated behaviour were negatively associated with discharge (p < 0.05). In multivariable analyses, HCR-20 clinical scale scores and physical violence independently predicted outcome at tribunal after controlling for other dynamic variables. CONCLUSION: By identifying dynamic factors associated with discharge at tribunal, the results have important implications for forensic psychiatric patients and their clinical teams. Our findings suggest that by reducing levels of agitated behaviour, verbal aggression, and physical violence on the ward, achieving unescorted community leave, and targeting specific items on the HCR-20 risk assessment tool, patients may be able to improve their changes of discharge at a MHRT.

Admitting offenders with antisocial personality disorder to a medium secure unit: a qualitative examination of multidisciplinary team decision-making.

This paper reports on the results of a qualitative study funded by the Economic and Social Research Council (ESRC) looking at multidisciplinary team decisions to admit sentenced offenders with antisocial personality disorder to a medium secure unit. The aim of the study was to examine admission decision-making from a multidisciplinary perspective, and to explore the interprofessional dynamics and contextual pressures informing those decisions. The primary method of data collection was 12 semi-structured interviews with a convenience sample of various multidisciplinary staff involved in pre-admission assessment and post-assessment decision-making. Data was then coded according to the dialectic of competitive and cooperative goal seeking within groups. The findings suggest that, whilst both forms of goal seeking inform admission decisions, the presence of significant resource pressures will lead to decisional solidarity among the multidisciplinary team. When minor professional disagreements arise, they are resolved by the group leader, the Responsible Clinician, in order to maximise group productivity. It is argued that the discursive-limiting effect of resource pressures on group decision-making may weaken the morale of certain front line staff, if not undermine institutional purpose.