Treatment progress in medium security hospital settings for women: changes in symptoms, personality and service need from admission to discharge.

BACKGROUND: Service evaluations of medium secure hospital facilities for women are underrepresented in the extant literature. HYPOTHESIS: That positive changes in symptoms, personality traits and service need would be evident between admission and discharge among women in a medium security hospital service. METHODS: A pre-test/post-test design was used, with comparisons made between admission and pre-discharge points on a variety of measures of psychiatric symptoms and personality traits. RESULTS: There were significant improvements in mood according to Beck Depression Inventory scores, mood and other symptoms of mental disorder and distress as measured by the Brief Psychiatric Rating Scale and the Modified Post Traumatic Stress Disorder Symptom Scale, personality traits recorded using the Millon Clinical Multiaxial Inventory III and service need as measured by the Camberwell Assessment of Need, Forensic Version. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Significant positive change during treatment, in all clinical areas, is encouraging given poor outcomes for women reported in other research. Findings cannot, however, be unequivocally attributed to the treatments given. Further work is needed to improve early engagement and tailor treatment more specifically to the needs of a heterogeneous population.

Developing an assessment of fire-setting to guide treatment in secure settings: the St Andrew's Fire and Arson Risk Instrument (SAFARI).

BACKGROUND: Arson and fire-setting are highly prevalent among patients in secure psychiatric settings but there is an absence of valid and reliable assessment instruments and no evidence of a significant approach to intervention. AIMS: To develop a semi-structured interview assessment specifically for fire-setting to augment structured assessments of risk and need. METHOD: The extant literature was used to frame interview questions relating to the antecedents, behaviour and consequences necessary to formulate a functional analysis. Questions also covered readiness to change, fire-setting self-efficacy, the probability of future fire-setting, barriers to change, and understanding of fire-setting behaviour. The assessment concludes with indications for assessment and a treatment action plan. The inventory was piloted with a sample of women in secure care and was assessed for comprehensibility, reliability and validity. RESULTS: Staff rated the St Andrews Fire and Risk Instrument (SAFARI) as acceptable to patients and easy to administer. SAFARI was found to be comprehensible by over 95% of the general population, to have good acceptance, high internal reliability, substantial test-retest reliability and validity. CONCLUSIONS: SAFARI helps to provide a clear explanation of fire-setting in terms of the complex interplay of antecedents and consequences and facilitates the design of an individually tailored treatment programme in sympathy with a cognitive-behavioural approach. Further studies are needed to verify the reliability and validity of SAFARI with male populations and across settings.

Treatment of chronic anorexia nervosa: a 4-year follow-up of adult patients treated in an acute inpatient setting.

Despite evidence from a number of long-term follow-up studies of anorexia nervosa that nearly 50% of patients eventually make a full recovery, controlled trials of psychotherapy for anorexia nervosa are lacking. Those with severe and enduring problems represent a considerable therapeutic challenge. Thirty-four consecutive adult referrals to the inpatient treatment unit who fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for anorexia nervosa were examined pre-admission, post-discharge and 4 years after admission. Characteristics of remitted and non-remitted patients were examined. Secondary analyses considered the differences between patients with anorexia nervosa, restricting type and anorexia nervosa binging/purging type. The findings highlight a number of differences between patients with anorexia nervosa (restricting type) versus anorexia nervosa (binging/purging type) as well as remitted versus non-remitted patients. The use of a comprehensive battery of assessments found that resolution of eating disorder symptomatology was paralleled by improvements in emotional and psychological distress and improvement in body image perception and coping skills. Better results were obtained for those who had continuity of care on an outpatient basis. This pattern is particularly significant given the more 'chronic' nature of the sample that were older, with a higher incidence of binge-eating and purging than previous samples. Results provide some encouragement for the treatment of those adults with anorexia nervosa who typically have less favourable outcomes.

Dealing with Feelings: the effectiveness of cognitive behavioural group treatment for women in secure settings.

BACKGROUND: Women in secure psychiatric settings have gender specific treatment needs. The current study examined the feasibility of a Dealing with Feelings Skills Group training for dual diagnosis women admitted to a medium secure setting. METHOD: A pre-test--post-test design was used to evaluate a group programme adapted from dialectical behaviour therapy skills training. RESULTS: Most patients had a primary diagnosis of personality disorder. Treatment completers (n = 29) were compared with non-completers (n = 15). Clinically significant changes in treatment completers were apparent on coping response measures of positive reappraisal, problem solving and alternative rewards; on measures of anxiety and suicidality; on self-reported ability to engage in activities to reduce negative mood and to recognize mood changes. Self-harming and aggressive behaviours also reduced in the 3 months following group treatment. CONCLUSION: An adapted coping skills component of DBT benefit many dual diagnosis patients: issues related to treatment drop-out and failure to benefit are discussed.

Assessing comorbid substance use in detained psychiatric patients: issues and instruments for evaluating treatment outcome.

This review assesses the issues involved in the selection and treatment of patients comorbid for mental illness and substance misuse being treated in secure psychiatric facilities. It includes those individuals who have a history of offending and whose placement is the result of severe behavioral disturbance. The relevant issues in the assessment and treatment of these patients are reviewed and a battery of tests is suggested on the basis of their usefulness with this population in terms of their brevity, ease of administration, and for their value in planning treatment, providing motivational feedback, and monitoring change. The paucity of assessment tools developed specifically for this patient population is highlighted.

The development of a 'best practice' service for women in a medium-secure psychiatric setting: treatment components and evaluation.

The inadequacy of inpatient facilities for women with severe psychiatric and co-morbid difficulties has been repeatedly documented. The establishment of effective therapeutic programmes for women in medium psychiatric facilities is also in their infancy, and little research has been undertaken. This article describes the development of a 'best practice' psychological treatment programme for women with a dual diagnosis. Emphasis is placed on the need to develop further intensive gender-specific services using an established model for effective therapeutic service development. In addition to a detailed description of the group therapy programme, staff training initiatives, methods for ensuring treatment integrity and a methodology for service evaluation is given.

Screening for incontinence in a secure psychiatric service for women.

Incontinence is associated with mental illness and neuroleptic medications but diagnosis and treatment is often poor or non-existent. Problems of incontinence are compounded in secure psychiatric services for women by poor health, obesity, and a sedentary lifestyle. Addressing the physical health of this group necessitates a more accurate picture of the nature, incidence, and management of incontinence. A point-in-time survey of 108 women who agreed to be interviewed (93%) covered presence, frequency, and nature of incontinence, and information on management case note data was used to gather demographic and previous medical history, comparisons were made between patients with and without problems of incontinence. Findings indicate a problem of incontinence in 48% of women with a dominance of problems of stress and urge enuresis. Of modifiable factors that contribute to enuresis, the current study highlighted the contribution of obesity, smoking and clozapine medication. A further finding was the preference for managing rather than treating problems of incontinence. Actions to improve the detection and treatment of this problem are described.

Usefulness of the CANFOR-S for measuring needs among mentally disordered offenders resident in medium or low secure hospital services in the UK: a pilot evaluation.

BACKGROUND: The short form of the forensic version of the Camberwell Assessment of Needs (CANFOR-S) (Thomas et al., 2003) is of potential value in all clinical forensic settings, but so far reported mainly with high security hospital patients. AIMS: To conduct a pilot study of the feasibility of using the CANFOR-S in medium and low security hospital units and to report preliminary findings there. METHODS: Thirty-six of 38 patients on one medium secure ward for women, one low secure ward for women and one low secure ward for men, all in the same hospital, agreed to participate in the study. Staff and patients completed the CANFOR-S as part of a larger formal assessment package. RESULTS: All the women and 18 of the 20 men completed the CANFOR-S. It was found to be easy and quick (25 minutes) to use, and acceptable. Staff and patient ratings were similar on all but one item: needs with regard to safety to others, with staff consistently rating more. Men and women were similar in number of needs, but had different needs profiles. Those in medium security were generally more needy than those in low security. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The CANFOR-S is feasible for clinical practice, with results perceived as useful in treatment planning by patients and staff. More widespread use could improve service planning.