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Purpose In the UK, the mental health treatment requirement (MHTR) order for offenders on probation has been underused. A MHTR service was established to assess the effectiveness of a partnership between a probation service, a link worker charity and an independent mental healthcare provider. Short-term structured cognitive behavioural interventions were delivered by psychology graduates with relevant work experience and training. Training for the judiciary on the MHTR and the new service led to a significant increase in the use of MHTR orders. The paper aims to discuss these issues. Design/methodology/approach A total of 56 (of 76 MHTR offenders) completed treatment in the first 12 months. A single cohort pre-post follow-up design was used to evaluate change in the following domains: mental health and wellbeing; coping skills; social adjustment; and criminal justice outcomes. Mental health treatment interventions were delivered under supervision by two psychology graduates who had relevant work experience and who were trained in short term, structured, cognitive behavioural (CBT) interventions. Findings Clinically significant changes were obtained on measures of anxiety and depression, and on measures of social problem solving, emotional regulation and self-efficacy. Ratings of work and social adjustment and pre-post ratings of dynamic criminogenic risk factors also improved. This new initiative has addressed the moral argument for equality of access to mental health services for offenders given a community order. Originality/value While the current initiative represents one of a number of models designed to increase the collaboration between the criminal justice and the mental health systems, this is the first within the UK to deliver a therapeutic response at the point of sentencing for offenders with mental health problems. The significant increase in the provision of MHTR community orders in the first year of the project has been associated with a decrease in the number of psychiatric reports requested that are time consuming and do not lead to a rapid treatment.

BackgroundThe engagement of service users in their treatment within secure settings is a priority, in terms of outcome of treatment, recidivism, and cost efficiency. The present study was designed to assess the effectiveness of a treatment preparatory group for women newly admitted to a medium secure setting.MethodA matched subject pre-test-post-test design was used to evaluate a group program utilising cognitive behavioural and psycho-education components with the aim of developing service users engagement in treatment and overall coping strategies.ResultsTreatment completers (N=25) were matched with a group of women who did not participate in the program (N=25). Clinically significant changes in treatment completers were apparent on ratings of treatment readiness, participation in treatment, hope, self-efficacy, insight and interpersonal relationships. Furthermore, completers were found to attend more therapy sessions post group, compared with those who did not engage in the program, and were rated as having key strengths in terms of insight, attitudes, relationships, coping and treatability.ConclusionA treatment preparatory group that focused on psycho-education, orientation to therapy and coping skills was instrumental in motivating engagement in women newly admitted to medium secure care.

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.

Reducing the use of seclusion to deal with challenging behaviour is a priority in secure services for women. This study describes the concurrent introduction of a series of initiatives based on recovery principles and the full involvement of patients in their risk management plans.Following change implementation, the first 19 patients who had completed one year of treatment were matched with 19 patients who had completed their first year of treatment before change.A significant decline in both the number of seclusions and risk behaviour post-change was complemented by improved staff ratings of institutional behaviour, increased treatment engagement and a reduction in time spent in medium security. Staff and patients differed in terms of their ratings of the most effective strategies introduced. Patients favoured the Relational Security item of increased individual engagement and timetabled Behaviour Chain Analysis sessions. Staff viewed on ward training and use of de-escalation techniques as most effective.Findings confirm results from mixed gender forensic mental health samples that seclusion can be successfully reduced without an increase in patient violence or alternative coercive strategies. Limitations of the study are discussed along with the need for future evaluations to address issues of fidelity and utilise vigorously designed case studies.

Purpose – The purpose of this paper is to assess the antecedent behaviours and consequences of firesetting for women in a secure psychiatric setting along with treatment engagement factors. To explore predictions made about emotionally expressive subtype firesetters by the multi-trajectory theory of adult firesetting (M-TTAF). Design/methodology/approach – In total, 75 individual firesetting episodes involving 25 female multiple firesetters were assessed using the St Andrew's Fire and Arson Risk Instrument. Assessments were made of treatment readiness, firesetting related self-efficacy, insight and barriers to change. Findings – Findings support the relationship between recidivist firesetting and the psychological features of psychosis, personality disorder and substance misuse. The reported association of firesetting with suicidal thoughts, depression, interpersonal problems, anger/revenge motivation and lack of planning supports the view that behaviour is used to manage distressing life experience and as a “cry for help”. However, in a quarter of incidents there was an intention to harm others and evidence of premeditation in twelve percent. A small but significant minority lacked insight into their behaviour, were not ready for treatment and had low firesetting related self-efficacy. Predictions made by the M-TTAF about likely clinical features and motivators of emotionally expressive firesetters were largely supported. Originality/value – The study highlights the importance of a detailed and specific risk assessment of firesetting that leads to identification of individual risk factors and an individualised treatment approach. This is of particular importance given the complex problems presented by women in secure settings and by the diversity of the conditions associated with fires set by each individual.

Purpose – The purpose of this paper is to assess the effectiveness of a gender-specific group treatment programme for personality disordered (PD) women in a medium secure psychiatric setting. Design/methodology/approach – In all, 56 consecutive admissions with a primary diagnosis of personality disorder (mostly borderline type) and co-morbidity were assessed according to their participation in, and benefit from, a core set of five manualised group treatments that focused on social and interpersonal deficits, instability of mood and problematic substance use. A single cohort pre-test post-test comparison design was used with evaluation based on global change over an amalgam of self-report group specific outcome measures. Findings – In all, 70 per cent of patients attended three or more core groups, with attendance for each group ranging from 85 to 53 per cent. Between 65 and 77 per cent of patients showed a significant improvement on pre-group psychometrics. Patients who achieved a significant positive change in one group tended to do so in others. In all, 85 per cent of patients who completed two or more groups had overall positive direction of change scores. Those who benefited from treatment engaged more quickly, were more likely to have been admitted from hospital, to have previously engaged in therapy and to score lower on measures of impulsivity and personality pathology. Research limitations/implications – In a clinically representative study the absence of a control group limits the extent to which observed changes can be attributed to described interventions. Practical implications – Findings reflect the importance of providing a broad clinical approach to changing cognitive behavioural functioning with PD patients in secure settings. They also highlight the need to improve ways of engaging patients at an earlier stage of hospital stay and of increasing the acceptability and uptake of relevant group treatments. Further evidence-informed service developments are needed to meet these challenges. Originality/value – The study adds to a small literature on the clinical impact of a gender-specific group treatment programme for PD women in secure settings.

Purpose – The purpose of this paper is to explore the incidence of obesity and its complications in secure psychiatric settings; and to assess changes in body mass index (BMI). Design/methodology/approach – Electronic patient records were used to determine levels of obesity and weight change over a three-year period. BMI levels were related to status, medication and patient characteristics. Findings – The incidence of obesity (34 per cent) in the sample (n=351) was higher than in the general population. One-third of patients were on medication for hyperlipidaemia and 10 per cent were diagnosed with type II diabetes. Patients on regular antipsychotic drugs and sodium valproate and who were less active had higher BMIs. Gender differences over a three-year period showed a tendency for women's weight to continue to increase which may be linked to lower levels of engagement in activities of moderate or vigorous intensity. Originality/value – Previous surveys using secure psychiatric populations have been point in time reviews. The current study tracks changes over a three-year time period and related this to a range of interventions.

A group psychoeducation programme for women in medium security was piloted. The programme aimed to increase participants’ knowledge about emotionally unstable personality disorder, decrease feelings of stigma, increase hope and motivate engagement in treatment. Treatment completers showed significant improvements on selected measures while non-completers did not. The implications of the findings are discussed along with suggestions for further research.

IntroductionEnsuring safety in secure psychiatric units for women is dependent on a clear rationale and structure underpinning risk management. The reinforcement of positive behaviour needs to be balanced by contingencies to prevent ineffective behaviours being reinforced. The use of a Risk Stage System is based on the notion of equality of contingency for similar risk behaviour.MethodSecure ward staff and women patients completed service structured interviews to determine their view of the Risk Stage System in terms of its perceived value in risk management and recovery.ResultsStaff and patients with previous experience of the Risk Status System positively evaluated it. Patients in medium security currently subject to the system were divided on the issue of whether it helped in focussing on recovery and keeping patients and staff safe.Discussion & ConclusionsThe division between staff and patients’ opinion indicates the need to thoroughly engage patients in the risk management process, to arrive at a shared understanding of boundaries and to consistently implement agreed procedures.

A group therapy programme to develop social confidence in women in secure settings addresses issues of interpersonal functioning using principles of behaviour management. This complement to Reinforce Appropriate Implode Disruptive (RAID) milieu approach produced encouraging results on measures that reflect interpersonal confidence.

For young people, the transition from adolescent to adult services is particularly problematic. This may be particularly difficult for female service users.The aim of this study is to gain a fuller account of the experience of young people during transition from adolescent services to adult services and to add to the knowledge around the transitional process.This study used a qualitative analysis of female adolescents' experience of transition to adult secure services. A four-layer coding structure grouped responses by time frame.The results were consistent with previous research indicating that adolescents are sensitive to the behaviour of others throughout the transition process. Particularly, strong themes were the negative impact of aggression from other patients, the importance of relationships with staff and other patients, and the need for informed involvement in all aspects of the transition process.An increase in positive statements regarding the post-transition experience suggests that moves have been positive although this could be explained by admission to settings of lower security. The discussion highlights the importance of moving beyond procedural issues of transition to a focus on the social and culture gaps that appear to divide CAMHS and AMHS.

BackgroundInterpersonal effectiveness and social competence are central issues in treatment engagement and recovery for women with a diagnosis of personality disorder or schizophrenia in secure psychiatric settings.AimsTo assess the effectiveness of a manualized group cognitive behavioural treatment for women admitted to a secure inpatient unit.MethodThirty four patients were divided into treatment completers and non completers on the basis of rates of attendance. Pre-post measures covered interpersonal problems, self efficacy, company, relationships and risk behaviours.ResultsCompleters show significant pre-post changes on all measures, in contrast to non completers. Completers were younger and more likely to have experienced psychotherapy in the past.ConclusionsResults provide confirmatory evidence for the value of training in interpersonal and communication skills training for women in secure care. The failure of one third of patients to complete treatment raises issues about the timing and applicability of treatment for some patients.

While eating disorder symptomatology may be part of a broader picture of challenging behaviour for women admitted to secure care, little is known of the nature and incidence of such conditions. A survey of 131 women admitted to a secure psychiatric facility found 25 to have a recognized eating disorder, most with a diagnosis of eating disorders not otherwise specified (EDNOS) or binge eating disorder. However, few staff had experience of working with such patients and most expressed a need for training and support with such cases. The clinical and training implications of these findings are discussed.

A matched pair design was used to compare women admitted to a medium-secure psychiatric facility from prison and from the mental health service. Findings confirmed a number of hypothesised differences between the two groups: Prison admissions took longer to engage in treatment; had more unmet needs and continued to pose a greater risk of self-injury. The majority of both groups have significant substance misuse problems that require psychotherapeutic input. Findings support previous work showing significant levels of unmet need among prisoners and the urgent need for therapeutic input to address the deficiencies of offender rehabilitation programmes.

Background Engaging patients in treatment in secure settings is a major challenge. Engagement is associated with a shorter length of stay, whereas treatment non-completion is associated with an increased risk of recidivism. Aims The aims of this study were to assess differences between high and low treatment attendees in a women's medium secure unit and to compare progress over the course of their stay. Methods Sixty consecutive admissions to a women's medium secure unit were classified into high and low treatment attendee groups. The two groups were compared in terms of risk behaviours and psychometric measures of symptomatology, impulsivity and personality. Results High treatment attendees had a shortened length of stay, showed less disturbed behaviour and made more progress in terms of a reduction in symptoms overall and traumatic stress symptoms specifically. Low treatment attendees were more likely to have a diagnosis of schizophrenia/schizotypal illness than personality disorder, less likely to be impulsive and more likely to have scores indicative of severe disorder on the personality subscales of the Millon Clinical Multiaxial Inventory—III. Conclusion Attendance at groups in this medium security unit had clear advantages for patients and potential cost savings for services and the community, but we found a subgroup of women who found it difficult to attend. Given the small sample size, we advocate replication, but our findings suggest the following: Implications for practice development of motivational interventions to help patients make a therapeutic alliance more accurate assessment of treatment readiness, to avoid mistimed interventions that are counterproductive more effective deployment of milieu therapeutic approaches to stabilise behaviour at an early stage of hospitalisation abandonment of a ‘one size fits all’ approach to groups for mixed patient populations. More ‘customised’ approaches would allow more appropriate ‘pacing’ of treatment and adaptations of interventions according to need during the treatment course. Copyright © 2012 John Wiley & Sons, Ltd.

Problem-solving interventions are a feature of overall medium secure treatment programmes. However, despite the relevance of such treatment to personality disorder there are few descriptions of such interventions for women. Beneficial effects for women who completed social problem-solving group treatment were evident on a number of psychometric assessments. A treatment non-completion rate of one-third raises questions of both acceptability and timing of cognitive behavioural interventions.

Background: There have been few assessments of women with substance misuse problem in secure psychiatric settings. Aims: The aim is to describe the characteristics and psychometric test performance of women admitted to a medium secure hospital. Method: Consecutive admission was classified into risk-relevant categories using case note data. Responses to psychometric measures of dependence, substance-related problems, self-efficacy, motivation for change, craving and coping were assessed. Results: Forty-four out of 55 consecutive admissions had a risk-relevant pattern of substance use before admission. Analysis of psychometric test performance produced two groups of patients differentiated according to self-efficacy, craving and belief in the benefits of change. Conclusions: Although further work needs to be done in assessing the applicability of specific psychometrics to specialist populations, findings reinforce the importance of matching treatment interventions to stages of readiness to change.

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.

Engaging patients in treatment in secure settings is a major challenge. Engagement is associated with a shorter length of stay, whereas treatment non-completion is associated with an increased risk of recidivism.The aims of this study were to assess differences between high and low treatment attendees in a women's medium secure unit and to compare progress over the course of their stay.Sixty consecutive admissions to a women's medium secure unit were classified into high and low treatment attendee groups. The two groups were compared in terms of risk behaviours and psychometric measures of symptomatology, impulsivity and personality.High treatment attendees had a shortened length of stay, showed less disturbed behaviour and made more progress in terms of a reduction in symptoms overall and traumatic stress symptoms specifically. Low treatment attendees were more likely to have a diagnosis of schizophrenia/schizotypal illness than personality disorder, less likely to be impulsive and more likely to have scores indicative of severe disorder on the personality subscales of the Millon Clinical Multiaxial Inventory-III.Attendance at groups in this medium security unit had clear advantages for patients and potential cost savings for services and the community, but we found a subgroup of women who found it difficult to attend. Given the small sample size, we advocate replication, but our findings suggest the following: Implications for practice development of motivational interventions to help patients make a therapeutic alliance more accurate assessment of treatment readiness, to avoid mistimed interventions that are counterproductive more effective deployment of milieu therapeutic approaches to stabilise behaviour at an early stage of hospitalisation abandonment of a 'one size fits all' approach to groups for mixed patient populations. More 'customised' approaches would allow more appropriate 'pacing' of treatment and adaptations of interventions according to need during the treatment course.

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.