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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.

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.

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.

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.

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.