Support for the predictive validity of the multifactor offender readiness model (MORM): forensic patients' readiness and engagement with therapeutic groups.

BACKGROUND: Treatment non-engagement in forensic health settings has ethical and economic implications. The multifactor offender readiness model (MORM) provides a framework for assessing treatment readiness across person, programme and contexts. AIMS: To answer the following question: Are the internal factors of the MORM associated with likelihood of engagement in groups by patients in forensic mental health services? METHOD: In a retrospective design, associations were investigated between internal factors of the MORM, measured as part of assessment for group participation, and the outcomes of treatment refusal, treatment dropout and treatment completion. RESULTS: One hundred and eighteen male patients in a high security hospital consecutively referred for group treatment agreed to participate. Internal factors of the MORM associated with treatment refusals included: psychopathic cognition, negative self-evaluation/affect and effective goal-seeking strategies. Those associated with dropouts included emotional dysregulation, low competencies to engage and low levels of general distress. MORM factors associated with completion included: low motivation, ineffective goal-seeking strategies, absence of psychopathic cognition, high levels of general distress and competency to engage. CONCLUSIONS: Internal factors of the MORM could be useful contributors to decisions about treatment readiness for hospitalised male offender-patients. Up to one in three programmes offered were refused, so clinical use of the MORM to aid referral decisions could optimise the most constructive use of resources for every individual. Copyright © 2016 John Wiley & Sons, Ltd.

Everything moves on: referral trends to a leavers' group in a high secure hospital and trial leave progress of group graduates.

BACKGROUND: Moving on from high secure psychiatric care can be a complex and potentially stressful experience, which may hinder progression. A leavers' group in a UK high secure hospital is offered to support patients with this transition. AIMS: The aims of this study are to investigate characteristics of patients referred for the leavers' group and compare outcomes for leavers' group graduates with those for patients who never attended a leavers' group for any reason. METHODS: A retrospective quasi-experimental design was applied to data extracted from various records sources - within and outside the high security hospital. RESULTS: About one-fifth of patients who left the hospital on trial leave during the study were referred to the leavers' group (N = 109). Referred patients were significantly more likely to have either been admitted from another high-security hospital or transferred from prison for treatment and have a diagnosis of paranoid schizophrenia. Patients not referred had a significantly higher rate of previously refusing to participate in groups. There was a tendency for rate of return from trial leave for group graduates to be lower than that of patients who did not attend the leavers' group, but this just failed to reach statistical significance (rate ratio [RR] = 1.04; CI 0.97-1.11). CONCLUSIONS: A leavers' group appeared to be a valued therapy option for people who had spent a long time in high secure psychiatric care, or those who continued to require hospital treatment beyond prison tariffs. There was a low return rate from trial leave, which made the evaluation of this outcome difficult. A detailed study into both the reasons for return from trial leave and successes would provide further information on ideal preparation for moving on. Copyright © 2016 John Wiley & Sons, Ltd.

Risk assessments for dating violence in mid to late adolescence and early adulthood.

AIM: The objective of this paper is to review risk instruments that have been used in the assessment of the potential for violence within the dating relationships of young people. METHOD: A review of the dating violence literature was conducted to identify risk assessment approaches that have been used to predict harmful behaviour within the dating relationships of people aged between 15 and 30 years. Risk assessments were evaluated on recommended quality criteria: predictive validity, accuracy (sensitivity and specificity) and inter-rater reliability. RESULTS: Only five studies describing assessments that focused specifically on dating violence risk factors were selected for review. Three assessments encompassed dating behaviours by victims that have been associated with an increased risk of further victimisation. CONCLUSIONS: Drawing on this evidence, we conclude that young people appear to be at greater risk of encountering dating violence if they have experienced violence in earlier attachment relationships; if their skills for coping with conflict and responding to coercion are limited and if the presence of peer influences reinforces offence supportive attitudes. The reliability and validity of existing intimate partner violence risk assessments that conceptually overlap with elements of dating violence risk warrant investigation to inform risk assessment developments in this field and, building on this, possible interventions to minimise future harm. Copyright © 2016 John Wiley & Sons, Ltd.

Observer Ratings of Interpersonal Behavior as Predictors of Aggression and Self-Harm in a High-Security Sample of Male Forensic Inpatients.

Incidents of aggression and self-harm in forensic mental health inpatient settings present a significant challenge to practitioners in terms of safely managing and reducing the harm they cause. Research has been conducted to explore the possible predictors of these incidents and has identified a range of environmental, situational, and individual risk factors. However, despite the often interpersonal nature of the majority of aggressive incidents, few studies have investigated forensic inpatient interpersonal styles as predictors of aggression and even fewer have explored the potential interpersonal function of self-harming behaviors. The current study investigated the predictive validity of the Chart of Interpersonal Reactions in Closed Living Environments (CIRCLE) for incidents of verbal and physical aggression, and self-harm recorded from 204 high-secure forensic inpatients. Means comparisons, correlations, and receiver operating characteristics (ROC) were conducted on recorded incident data at 12, 24, and 48 months following baseline assessment using the CIRCLE. Dominant and coercive interpersonal styles were significant predictors of aggression, and a coercive interpersonal style was a significant predictor of self-harm, over the recorded time periods. When categorizing the inpatients on the basis of short- and long-term admissions, these findings were only replicated for inpatients with shorter lengths of stay. The findings support previous research which has demonstrated the benefits of assessing interpersonal style for the purposes of risk planning and management of forensic inpatients. The predictive value may be time-limited in terms of stage of admission.

Evaluation of anger management groups in a high-security hospital.

BACKGROUND: Anger management programmes for offenders typically aim to improve the management of emotion associated with aggressive and antisocial behaviour. Such programmes have been quite extensively evaluated in prison and probation settings, but there is less published research in forensic mental health settings. AIM: This study aimed to evaluate anger management groups in a high-security hospital. METHOD: Eighty-six patients were referred for a 20-session anger management intervention. Outcomes were self-reported experiences of anger and changes in institutionally documented incidents of aggression. Incident rates were retrospectively reviewed for all group graduates, where data were available, including a comparison group of graduates who acted as their own controls. RESULTS: Group graduates reported sustained reductions in feelings of anger and positive changes in their use of aggression in reaction to provocation. Some reduction in incidents of physical aggression was noted when group completers were compared with non-completers. Incidents of verbal aggression were observed to increase for graduates. There was also a trend towards improvement when treated men were compared with men on the waiting list. CONCLUSIONS: Our findings contribute to the growing evidence for anger management groups for aggressive men, although the low-base rate of incidents, typical of such a containing and therapeutic hospital setting, rendered the analysis of behavioural outcomes difficult. IMPLICATIONS FOR PRACTICE AND RESEARCH: Anger management sessions for male forensic psychiatric patients can be effective in reducing incidents of physical aggression in response to provocation. Evaluation of treatments for anger is particularly difficult in secure and protective settings, where the aim is to keep incidents of actual physical aggression to a minimum. Further research of this kind is needed to test the value of self-reported reduction in angry feelings as an indicator of clinically useful progress.

Working with women prisoners who seriously harm themselves: ratings of staff expressed emotion (EE).

BACKGROUND: Prison staff are repeatedly exposed to prisoners' suicidal behaviours; this may impair their capacity to care. Expressed emotion (EE), as a descriptor of the 'emotional climate' between people, has been associated with challenging behaviour in closed environments, but not previously applied to working alliances in a prison. AIMS: To investigate the feasibility of rating EE between staff and suicidal women in prison; to test the hypothesis that most such staff-inmate alliances would be rated high EE. METHODS: All regular staff on two small UK prison units with high suicidal behaviour rates were invited to participate. An audiotaped five-minute speech sample (FMSS) about work with one nominated suicidal prisoner was embedded in a longer research interview, then rated by two trained raters, independent of the interview process and the prison. RESULTS: Seven prison officers and 8 clinically qualified staff completed interviews; 3 refused, but 17 others were not interviewed, reasons including not having worked long enough with any one such prisoner. Participants and non-participants had similar relevant backgrounds. Contrary to our hypothesis, EE ratings were generally 'low'. As predicted, critical comments were directed at high frequency oppositional behaviour. CONCLUSIONS: EE assessments with prison staff are feasible, but our sample was small and turnover of prisoners high, so the study needs replication. Attributions about problem behaviour to illness, and/or traumatic life experience, tend to confirm generally supportive working relationships in this sample.

The relationship between insight and social rank appraisals in people with schizophrenia.

OBJECTIVE: The relationship between insight and appraisals of social rank in people with schizophrenia was examined. METHOD: Seventy people with schizophrenia completed self-report measures of insight and social rank. Two points of comparison were used for social rank appraisal: (1) the person's mental health worker; and (2) the general population. RESULTS: Greater awareness of illness was associated with lower social rank appraisals when the participants compared themselves to the general population (r = -.25, p = .04). Social rank appraisals and duration of illness predicted 14.5% of the variance in insight scores. CONCLUSIONS: The relationship between insight and depressive reactions in people diagnosed with schizophrenia may be modulated by social rank appraisal.

Prevalence and denial of sexual abuse in a male psychiatric inpatient population.

While the link between sexual abuse and psychiatric morbidity is well established, there are only a few studies that have investigated the prevalence of sexual abuse in male psychiatric populations and these studies have typically employed designs that ignore methodological issues specific to male sexual abuse. The present study aims to contribute to this research using as methodologically sound approach as possible. Seventy-four male inpatients were interviewed using a questionnaire (J. N. Briere, 1992) about childhood sexual experiences. Approximately one third reported incidents that met this study's criteria for sexual abuse. Many of these men did not label such experiences as "sexual abuse." The results suggest that mental health professionals need to be aware that many of their male patients may have a history of sexual abuse and that potential minimization or denial of it is a barrier to disclosure.

The voice of detainees in a high security setting on services for people with personality disorder.

BACKGROUND: British government Home and Health Departments have been consulting widely about service development for people with ' dangerous severe personality disorder' (DSPD). There has, however, been no consultation with service users, nor is there any user view literature in this area. METHODS: All people detained in one high security hospital under the legal classification of psychopathic disorder were eligible but those on the admission or intensive care wards were not approached. Views of service were elicited using a purpose designed semi-structured interview. The principal researcher was independent of all clinical teams. Confidentiality about patients' views was assured. AIMS: To establish views on services from one subgroup of people nominated by the government department as having 'DSPD'. RESULTS: Sixty-one of 89 agreed to interview. With security a given, about half expressed a preference for a high security hospital setting, 20% prison and 25% elsewhere, generally medium secure hospitals. Participants most valued caring, understanding and 'experience' among staff. An ideal service was considered to be one within small, domestic living units, providing group and individual therapies. Some found living with people with mental illness difficult, but some specified not wanting segregated units. Views were affected by gender and comorbidity. CONCLUSIONS: As the sample were all in hospital, the emphasis on treatment may reflect a placement bias. All but five participants, however, had had experience of both health and criminal justice services, so were well placed to talk with authority about preferences.