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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.

The provision of psycho-educational groups for people diagnosed with schizophrenia is an important part of successful treatment. The value of such interventions is less clearly established in secure settings with no reports on women. Gender differences in the manifestation of schizophrenia highlight the importance of a gender-specific intervention. A 'Living with Mental Illness' group programme for women in a secure psychiatric setting is described and evaluated. Those who completed group treatments (n = 20; 63%) showed improved knowledge of schizophrenia, decreased fear of schizophrenia, greater insight and increased optimism and perceived control of the illness. They also showed increased hope and greater self-compassion. Pre-post group findings reflected improved ratings of compliance with drug treatments, appropriate behaviour and insight into risk. This was reflected in a decrease in risk behaviours, improved attendance at treatment sessions and a reduction in symptomatology. Group members also reported a positive group therapeutic alliance. FINDINGS are discussed in the context of gender-specific treatment, research, methodological issues characteristic of a real-world evaluations and the need to assess the long-term benefits of such treatment. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Psycho-educational groups for secure inpatients with schizophrenia need to address gender-specific differences in the manifestation of the condition. Such interventions as part of a broader treatment initiative can be associated with clinical improvement that is both illness specific and leads to improved engagement with care initiatives. The needs of patients who do not complete treatments needs to be regularly reassessed. Language: en

Female firesetters have been somewhat neglected in the research literature, and knowledge and practice is underdeveloped. A survey of the characteristics of firesetters admitted to a secure service for women and their firesetting behavior was undertaken to inform the development of assessment and intervention strategies for this group. The analysis of case records of 90 consecutive admissions revealed that 49 women had a history of firesetting. This group was more likely than other women admitted to the same facility to have a diagnosis of either personality disorder or schizophrenia and they were more impulsive. The firesetters did not differ from the other women in terms of symptomatology, need, or self-efficacy; no differences were found between the firesetters and those convicted of arson. Firesetters tended to act alone and select targets within or close to their place of residence. In view of the poor understanding of risk factors for firesetting in this group it is suggested that interventi...

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 behavioural and psychological effects on people with intellectual disabilities of transferring to an environment influenced by patient choice and low secure standards.Design/methodology/approach– Patients and staff transferring from a non-optimal environment to one driven by low secure standards compared the homeliness, ward climate and satisfaction with the two wards. Comparisons were made between the occurrences of risk behaviours on the two wards.Findings– The new environment was rated by staff as more homely while patients’ increased satisfaction with the new ward was reflected in social climate ratings of patient cohesion and experienced safety. The latter findings were reinforced by an objective reduction in risk behaviours in the new environment.Practical implications– Treatment interventions need to optimise research findings that attest to the influence of the environment on the behaviour of patients with intellectual disabilities.Originality/value– Findings highlight need to increase the focus on aspects of the built environment in planning the treatment of women in secure care.

Background There is an abundant literature on the unfavourable attitudes held by staff working in mental health care settings towards patients with borderline personality disorder. The aim of this study was to assess whether attendance at a training session about the neurobiological underpinnings of borderline personality disorder could improve knowledge and produce positive attitudinal change within staff members working in a low secure inpatient setting. Method Staff knowledge and attitudes (Mental Health Locus of Origin, Empathic Concern and Perspective Taking) were assessed at baseline, post-training attendance and at an eight-week follow up. Results Attendance at the training session was associated with significant increases in theoretical knowledge, Perspective Taking and Locus of Origin scores. However, there were no changes observed in Empathic Concern scores. Conclusion This research suggests that a relatively brief training session, that utilises the neurobiological framework, can be effective in facilitating knowledge and attitudinal change for those working with borderline personality disorder. The implications of the findings are discussed along with suggestions for further research.

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.

Purpose – The purpose of this paper is to describe how aggressive and violent incidents differ across specialist gender, security and mental health/learning disability pathways in specialist secure care.Design/methodology/approach – The paper uses a retrospective survey of routinely collected incident data from one 207‐bed UK independent sector provider of specialist medium and low secure mental health care for male and female adults with primary diagnosis of mental illness or intellectual disability.Findings – In total, 3,133 incidents involving 184/373 (49.3 per cent) patients were recorded (68.2 per cent other‐directed aggression, 31.8 per cent self‐harm). Most incidents occurred in the medium secure wards but more than half of the most severely rated self‐harm incidents occurred in low security. Men were disproportionately involved in incidents, but a small number of women were persistently involved in multiple acts. Incidents were most common in the intellectual disability pathway.Research limitation...

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.

People with mental disorder account for a disproportionately large amount of smokers, and the problem is greatest in inpatient settings. 'Stop smoking' services should be tailored to the needs of individual patient groups. It is important therefore to investigate factors relevant to different groups in order to inform future quit smoking interventions. We compared 50 patients and 50 staff in a secure mental health hospital on measures of smoking and smoking motives, nicotine dependence, craving, previous cessation attempts, motivation to quit and quit smoking-related self-efficacy. Patients were significantly more dependent on nicotine with higher levels of craving; were more likely to smoke to cope with stress, for something to do when bored, for enjoyment and pleasure; and reported significantly less readiness to quit smoking. Staff were more likely to cite health concerns as reasons for quitting. Future pre-intervention work with inpatients should focus on increasing their readiness to quit smoking. Once motivation is increased, interventions should include advice on reducing cravings, finding alternative methods for coping with stress and boredom and achieving enjoyment and pleasure from alternative sources.

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.

PurposeThis study aims to explore whether female psychiatric homicide offenders form a distinct group when compared to women who have committed other types of serious violent offences.Design/methodology/approachA range of background and psychological characteristics for 13 homicide and 13 non‐homicide offenders, matched by date of birth, were compared. In addition, change in psychological and behavioural presentation after 12 months stay at a registered charity trust hospital in England was considered.FindingsThe findings indicate that the two groups were broadly similar, although the non‐homicide violent offenders had somewhat more troubled backgrounds. The two groups responded similarly to treatment, although the homicide offenders displayed significantly fewer aggressive risk behaviours whilst in care.Practical implicationsIt is concluded that the two groups present with similar needs, with indications of greater treatment need for polynomial substance misuse for the non‐homicide group.Originality/valueThis is the first study to compare directly these two specific groups of violent female offenders, considering both static background variables, and behaviour whilst in security.

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.

PurposeThe purpose of this paper is to review issues of relevance to practitioners using group cognitive behavioural therapy (CBT) with women in secure settings.Design/methodology/approachThe extant literature on CBT as applied to women in secure settings is reviewed to highlight best practice. Aspects of best practice are illustrated with examples from a women's medium secure service.FindingsObstacles include the characteristics of the patient group, treatment non compliance and an environment that accepts the primacy of security over treatment. Environmental and need factors amenable to intervention are highlighted in addition to CBT specific considerations that include the timing and intensiveness of treatment, content and delivery of therapy, treatment readiness and use of the group process. The use of a manualised CBT group treatment aid attempts to ensure treatment integrity is associated, and which is associated with treatment outcome. A focus on the social and environmental factors that attribute to the therapeutic milieu is vital to treatment generalisation, as is harnessing the therapeutic potential of the built environment. Finally, treatment evaluation imposes a structure that can facilitate progress in treatment.Originality/valueThere is comparatively little work on CBT group treatments for women in secure settings. Attempts to synthesise best practice initiatives in this area are helpful in guiding treatment developments.

Women in secure setting represent a group for whom gender sensitive treatments are only emergent. Service users are viewed as participants in treatment developments. However, the opinions of forensic patients have, in contrast to other service users, been under researched.To identify service users' views of the constituents of an effective therapeutic milieu for women in secure settings and to help identify the extent to which services need to be specifically tailored for women.A qualitative service user-led participatory research approach was used. Two focus groups with service users from low and medium secure settings discussed the ingredients of an effective therapeutic milieu based on their experience of gender-specific treatment. Group transcripts were subjected to thematic analysis.Themes identified covered interpersonal relationships; treatment programming; service user empowerment; the ward as a place of safety; and hope for the future. Participants did not highlight gender-specific issues despite this being implicit in focus group questions.Findings echo themes from other psychiatric settings and provide a much needed consensus between service providers and users on which to base healthcare planning. The elucidation of gender-specific factors in effective therapeutic milieus requires more focussed research.

PurposeThe aim of this paper is to investigate reasons for treatment non‐attendance for dual diagnosis women in secure psychiatric settings.Design/methodology/approachA semi structured interview was used to investigate patients' reasons for session non attendance on the day of non participation across four wards. Reasons for non attendance were grouped using the mulifactorial offender readiness model (MORM) categories of affective, volitional, behavioural, cognitive and external. Assignment of responses to categories was undertaken by a two person team and inter rater reliability was assessed.FindingsPatients' rates of attendance varied by ward and level of security (low vs medium); and diagnosis. Systematic enquiry about the reasons for non attendance led to increased session attendance. Reasons for non attendance were cognitive reflecting negative evaluations of treatment and treatment outcomes. Psychological therapies and educational sessions were deemed the most important along with one‐to‐one clinician appointments.Originality/valueIssues of treatment engagement and the timing of treatment interventions are major issues in the care of secure psychiatric patients, particularly those with a primary diagnosis of personality disorder. Findings highlight the importance of systematic enquiry about reasons for non attendance and suggest potential interventions designed to improve engagement.

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.

Accessible summary • Factors predicting length of stay in a women's secure service were analyzed. • Patients were divided into short- and long-stay groups. • Longer stay patients differed in terms of symptomatology, personality scale scores and need. Shorter stay patients engaged more in treatment. Abstract Attempts to understand determinates of length of stay in secure settings has been given increased impetus by minimum standard setting and payment by results initiatives. Factors predictive of length of stay in the extant literature include, index offence, previous engagement in therapy, symptomatology, personality pathology and need. These factors were assessed for their predictive validity in a sample of 70 consecutive admissions to a women's medium secure service. Patients were divided into short- and long-stay groups A loglinear analysis of intake variables indicated that the highest order interaction (duration of stay × diagnosis × index offence/previous engagement in therapy) was significant. Analysis of dynamic variables indicated that longer stays were associated with total symptomatology, paranoid pathological personality scale scores and Camberwell Assessment of Need Forensic Version need items of psychotic symptoms and psychological distress. Short-stay patients showed higher levels of therapy engagement. Findings are confirmatory of some of the key variables to be considered when estimating length of stay and when planning treatment.

Accessible summary This article addresses the need for more appropriate sexual health assessment materials for use with women with a learning disability. It gives a summary of other assessment measures that have been developed and why they are not suitable for women with a learning disability. It describes the development of a new assessment measure that can be used to assess the sexual knowledge needs of women in secure settings, with a learning disability. This research is important because it acknowledges that people with a learning disability have the same rights as others with regard to information about sexual health matters. As such people with a learning disability should be asked the questions about the sexual knowledge in an easy and straightforward way that allows them to discuss concerns. Summary Little research has been published on the need for sexual education for women in secure psychiatric facilities when patients present with a combination of learning disability, mental illness and personality disorder. The development of a brief, feasible, gender-specific sexual knowledge questionnaire is described, which has validity and reliability and which is comprehensible by 95% of adults. Results of a pilot study show significant sexual knowledge deficits in learning disability and mentally ill women along with risk and vulnerability factors. Ways of addressing these issues are discussed.

Nutrition screening is the first-line approach to addressing the nutritional needs of service users and has been recommended as best practice by several authoritative and regulatory bodies. A simple and comprehensive screening tool, the St Andrew's Nutrition Screening Instrument (SANSI), was developed for use in an inpatient secure psychiatric setting. The aim of this study was to test the screening tool for reliability and validity. This study identified SANSI as reliable and valid for use in secure psychiatric settings for adolescents and adults. This should give confidence to regulatory and commissioning organizations, that the nutritional risk for patients in an organization which serves a diverse mental health population is being correctly identified, raising staff awareness and allowing appropriate action to be planned.

Alcohol consumption has increased in the United Kingdom in recent years. Many people now consume in excess of the recommended NHS guidelines and may be at risk of developing problems related to alcohol. Important factors that influence alcohol consumption are drinking motives and anxiety. In the current study, drinking motives and state and trait anxiety were assessed in low-, moderate- and high-risk drinkers. State and trait anxiety were related to high scores on coping and conformity motives in low- and moderate-risk drinkers. State anxiety is related to coping motives in high-risk drinkers. The findings support an indirect relationship between anxiety and alcohol use. Implications for the prevention and treatment of alcohol abuse in moderate- and high-risk drinkers are discussed.

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.

PurposeThe purpose of this paper is to describe the architectural design considerations and effects of moving patients from an adapted Victorian medium secure unit to a purpose built facility.Design/methodology/approachPatients and staff views of the old and new unit environments were compared in terms of homeliness, architectural features, ward atmosphere (WAS) and patient satisfaction.FindingsThe new unit was rated as more homely. The change of environment did not increase risk behaviours and was associated with a reduction in symptomatology.Research limitations/implicationsLimitations of the study include the small‐sample size and choice of measure of WAS. More research is needed into the constituents of “planned” environments where the physical environment is the primary intervention.Practical implicationsThese include the need for close collaboration among architects, clinicians and patients in order to maximise the therapeutic benefit of the built environment.Originality/valueThis paper contributes to a small literature that “bridges” architectural, psychiatric and environmental domains.

Despite widespread work on the process of safeguarding vulnerable adults, there is a relative absence of research in secure psychiatric settings where reliance is placed on external community safeguarding teams. This study analyses safeguarding incidents over a three‐year period in a medium secure psychiatric setting for women. It focuses on incident type, the characteristics of victims and perpetrators and safeguarding processes, including protection strategies. The action implications of the findings are discussed with reference to the unique feature of the patient population and setting and the extant research literature.

Accessible summary • Progress in treatment for women in medium secure conditions is dependent on reducing patients risk to self and others. • A method of managing and reducing risk behaviours is described. • In this study risk reduction has been paralleled by increased engagement in treatment activities. • The implications for treatment and further research are discussed. Abstract The treatment and risk management programmes in a women's medium secure service are described. Changes in risk profiles and its relationship to treatment engagement are examined in a cohort of women during their stay in a medium secure service. Findings show that clinically significant reductions in risk behaviours were paralleled by increases in treatment engagement. The clinical healthcare implications of these findings are discussed along with the need for further research.

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.

In this study we demonstrate how the Health of the Nation Outcomes Scales for secure and forensic service users (HoNOS‐secure) tracks risk and recovery in men with mental illness and men with learning disability in a secure care pathway. Total and individual HoNOS‐secure item ratings made by multi‐disciplinary teams across the course of a period of admission (mean 15 months) for 180 men were examined. There was significant positive change on the clinical and risk‐related scales of HoNOS‐secure for patients in the learning disability care pathway (N = 48) between initial and final ratings. In the mental health care pathway (N = 132 patients) an apparent lack of change masked a more complex picture, where initial decline in HoNOS‐secure ratings was succeeded by significant improvement. Results suggest that it is challenging to measure clinical and risk‐related medium‐term clinical outcomes objectively for these patients, particularly in relation to core issues of treatment of mental disorder, and reduction of both problem behaviour and risk to others. However, it is important that practitioners continue to strive to demonstrate the benefits of care and treatment through appropriate outcomes measures.

Background: The treatment of substance abuse in secure settings needs to be informed by gender specific considerations. Aim: To assess the effectiveness of a manualised CBT substance abuse treatment programme designed for women in medium security. Method: Assessment of pre–post changes following treatment using substance-specific and other outcome indicators. Results: Positive outcomes were identified for treatment completers (n = 23) in terms of improved substance-related self-efficacy, lower perceived costs and greater benefits of change. These differences, which were not evident in the non-completer group (n = 11), were paralleled by positive clinical changes on subscale of the BPRS, CANFOR needs and increased general self-efficacy. Conclusions: Treatment was successful in engaging two-thirds of patients to complete treatment in readiness for conditions of lower security and potential exposure to alcohol and other drugs. Differences between completers and non-completers raise issues about the timing an...

Female forensic mental health patients are a highly selected group who present exceptional clinical and behavioral challenges along with highly complex treatment needs. St. Andrew's Healthcare Women's Service offers a ‘best practice’ psychosocial treatment program in conditions of medium security. The outcomes of 60 women residents between 2003 to 2008 are described in terms of risk, behavior, symptomatology, and social functioning using HoNOS-secure. The instrument was sensitive to change in this population, including the security scale, which captured highly significant clinical improvements. Some of the challenges associated with measuring outcomes for this group are discussed. The needs of women in secure services can be effectively addressed, enabling movement to less secure settings and further improvement.

The need to map women’s secure hospital services in terms of patient population and service needs over time is acknowledged given: the increase in forensic and medium secure beds nationally; and limited gender specific analysis in previous studies. Data is presented relating to 65 consecutive admissions (over a 6-year period) to a women’s medium secure unit at three (14-month) time periods. Trends noted in population statistics include a decline in special hospital referrals and an increased proportion of prison referrals with an index offence of arson in the past two years in association with a lower level of cognitive functioning, and a higher level of assaultative behaviour. In accord with the responsivity principle (Ogloff & Davis, 2004) the implications for treatment and service planning for this changing population are discussed.

An evaluation of the Extra Care Area (ECA) in a medium secure psychiatric facility for women is described. A retrospective case note audit over an 18 month period concluded that the ECA was used infrequently for the most disturbed service users who had previously been frequently secluded. Ongoing self harm and aggression in ECA was a feature of some cases raising the possibility that admission may be counter productive for some, particularly when it is combined with a lack of occupational stimulation. Service users valued the opportunity for reflection in a low stimulus environment and there were no repeat admissions. A number of initiatives to improve multidisciplinary care planning, documentation, therapeutic engagement and service user involvement to reduce risk have been actioned. Of particular importance is the need to begin ‘discharge planning’ at the first point of entry to avoid prolonged stays, isolation from peers and dependence on both individual staff attention and a special status living arrangement.

The nutrition and eating habits of women in a secure psychiatric service were surveyed using in vivo participation, observation and self‐report procedures. It was predicted that high levels of obesity were partly related to unhealthy eating preferences, over‐consumption of food and environmental factors that supported an unhealthy lifestyle. The results indicated an obesogenic environment in which patients made unhealthy food choices to supplement meals. Post‐survey initiatives have led to increased satisfaction with a healthier and more palatable diet and proactive attempts to help patients engage with a therapeutic and healthier lifestyle to address obesity. The importance of environmental change, education and motivational strategies to engage patients is highlighted.

There is a large evidence base that demonstrates the efficacy of abbreviated progressive muscle relaxation (PMR) in the treatment of a wide variety of psychiatric and somatoform or psychosomatic disorders. A review of literature published in the last decade suggests that, in recent years, abbreviated PMR has been used primarily as an adjunctive therapy for people with a range of physical health problems. Doubts remain about its applicability to schizophrenic and severely emotionally and behaviourally disturbed populations within secure mental health settings. This article describes the development and evaluation of a relaxation training programme using abbreviated PMR techniques for female service users detained in conditions of medium security. More rigorous experimental evaluation is necessary to draw firm conclusions but preliminary results are positive and suggest that a group relaxation training programme that teaches abbreviated PMR techniques could be a useful intervention for this client group.

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 effects of organisational change on a medium secure ward for women with developmental disabilities are examined. Intervention followed the BAITS model (Milne et al, 2003) in focusing on behavioural analysis, intervention, training and support as a way of amalgamating psychological perspectives to address problems and promote positive attitude change. The positive benefits of this programme are described in terms of pre‐ and post‐changes in the perceived work environment, job satisfaction and burn‐out, and levels of disturbed behaviour. The implications of these findings are discussed in terms of promoting positive evidence‐based practices in secure developmental disability services.

Self‐reported quality of life (QOL) was examined in a cohort of detained psychiatric in‐patients. Two patient groups, categorised as high and low on the Lehman Quality of Life Interview (QOLI) in terms of their ‘satisfaction with life in general’, were compared. A model of satisfaction with life derived from a logistic regression analysis contained three measures: (high) QOLI satisfaction rating for living situation, (low) suicidality and (high) motivation and energy. The practical implications of these findings are discussed in terms of assessment, symptom relief and environmental change.

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. Copyright © 2008 John Wiley & Sons, Ltd.

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.

Although smoking is a major health problem among forensic psychiatric inpatient populations, a multitude of factors (motivational, environmental, procedural and psychiatric) militate against effective treatment. Despite this, few studies have reported on the use of population‐appropriate treatment approaches. This pilot study reports the results of group and individual treatments involving combination nicotine replacement therapy (NRT), motivational enhancement therapy (MET) and cognitive behavioural treatment. The importance of selecting patients with some skills in emotional regulation is highlighted, along with ways of reducing institutional obstacles to change and maximising environmental support for quit attempts.