Journal of Psychiatric
Intensive Care
Journal of Psychiatric Intensive Care
Vol.7 No.1:17 26
doi:10.1017/S1742646410000099
Ó NAPICU 2011
Original Article
Women referred for medium secure inpatient care: a population
study over a six-year period
Clive Long1, Louise Hall1, Lorraine Craig1, Ursula Mochty1, Clive R. Hollin2
1
St Andrews Healthcare; 2University of Leicester
Abstract
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.
Keywords
Women; medium secure; forensic; risk
INTRODUCTION
Despite the trend toward an overall increase in
the number of forensic and medium secure
beds nationally (Priebe et al., 2005) little attention has been paid to trends in the characteristics of female patients admitted to medium
secure facilities. The improvement of prison
mental health care has led to more mental illness
being ‘found’ in prison populations (Hill, 2006).
Bartlett (2006) noted that the absence of both
longitudinal cohort studies and case register
data for medium security made it hard to
Correspondence to: Dr C.G. Long, St Andrews Healthcare, Billing
Road, Northampton, NN1 5DG. Tel: 01604 616307; Fax: 01604
616410; E-mail: clong@standrew.co.uk
First published online date: 06/07/2010
Ó NAPICU 2010:7:17 26
describe women in secure services ‘even in
crude terms’.
A telephone survey of medium secure units
in England and Wales found that 342 of 1836
beds were occupied by women (Hassell &
Bartlett, 2001). In a subsequent study of a sample of 31 of the 342 women it was found that:
most were mentally ill; arson was the most common index offence; one-third had offences
involving violence to others; two-thirds had histories of deliberate self-harm and of child sexual
or physical abuse; and one-third had been
admitted without a conviction for an index
offence (Bartlett, 2006). These findings echo
those of a comprehensive survey of the characteristics of women in medium secure facilities
reported by Coid et al. (2000a). In a subsequent
cluster analysis of the diagnoses of 471 women
17
Long C et al
admitted to 7 UK regional services, Coid et al.
(2000b) found: three subgroups with personality
disorder as their primary psychopathology; three
subgroups with major mental illness; and one
subgroup with organic brain syndrome. However, these studies reflect the characteristics of
patients admitted to medium security between
1988 and 1994 and therefore may not be representative of current populations in the light of
changing service provision and admission practice (Hill, 2006). Ricketts et al. (2001) reported
an analysis of 504 admissions to a regional secure
unit between 1983 and 1999 which included 91
(18.1%) women. This figure represented a
decline in the admission of women from 31%
of the service user population to 8% over the
duration of the study. Ricketts et al. (2001)
speculated that the decline may be related
to other trends, including the admission of
more serious offenders and a reluctance to admit
vulnerable women to male dominated environments.
The responsivity principle, which refers to
the responsivity of the care provider, has been
relatively neglected despite the widespread
adoption of the Risk and Needs principles in
the criminal justice system (Ogloff & Davis
2004). General responsivity refers to the delivery of a multi model treatment programme
that is cognitive behavioural in nature and skills
based. Such a programme for female psychiatric
populations in medium secure settings has been
described by Long et al. (2008). Specific
responsivity, however, includes a variety of factors that match the patient’s attribution and
motivation to engage in treatment to the content and pace of therapy (Gudjonsson & Young,
2007). It is this principle that necessitates regular
monitoring of the characteristics of the treatment population in order to match interventions to the patients readiness to engage with
therapy (Howells & Day, 2007). In this light,
the current study provides a clinical profile of
the patient group, admitted between 2002 and
2008, to an independent (charitable trust) proIn the London Medium Secure (MSU) vider of medium secure mental health care for
Benchmarking Study, Bartlett et al. (2007) noted women. This profile provides complementary
that 9.6% of the 781 inpatients in medium or low data from the independent sector in order to
secure settings were women. Twenty-five per chart change over time and inform the process
cent of these women were not offenders, mental of planning future gender specific treatment serillness led to their admission in 9 out of 10 cases, vices. In this regard, the analysis follows the best
and women were more likely than men to be practice model for a medium secure women’s
admitted with a diagnosis of personality disorder. service previously described (Long et al.,
One-third of the women had committed serious 2008), in which components of a psychosocial
violence (homicide, attempted murder and treatment programme were determined by anagrievous bodily harm) and 13% had committed lysis of the changing characteristics of the serarson. The MSU female population gave a pro- vice user population.
file similar to that of a high secure hospital sample. Bartlett et al. (2007) also noted a significant
variation in the availability and quality of data METHOD
available from the seven London forensic units
Sample
included in their study.
Sixty-five service users, consecutive admissions
Most studies of secure settings have not over a 6-year period to a women’s medium
undertaken a separate gender analysis (e.g. secure service (St Andrew’s Healthcare, NorthDolan & Lawson (2001); Coid & Dunn ampton UK), formed the sample. In this period
(2004); Wheatley et al., (2004); Chowdhury et only six referred patients were not admitted:
al., (2005)). The need to map womens’ secure four because of bed availability and two because
hospital services in terms of patient population of problems with ‘patient mix’. The admission
and service needs is pressing, as knowledge of criteria for the women’s unit are: 1) Age
the characteristics of the population enables 19 60 years at the time of assessment; 2) Meetthe adaptation of treatment to the precise needs ing criteria for detention under the Mental
of the patient group.
Health Act 1983; 3) Presenting disturbed and
18
Ó NAPICU 2010:7:17 26
Women referred for medium-secure inpatient care
challenging behaviour that could be appropriately and safely managed in medium secure
conditions.
Pre-admission assessment visits to referring
organisations were by multidisciplinary teams,
with either a consultant psychiatrist or psychologist and members of senior nursing staff.
Information was gathered from care staff, the
service user and care records. A structured
assessment schedule was used to ensure consistent and detailed collation of relevant
information. The assessment included sociodemographic details, with diagnosis, reason for
referral, forensic history, risk behaviours, length
of time in hospital/prison, legal status, current
level of nursing observation, ground leave status, and degree of security of current placement.
The Health of the Nation Outcome Scale: Secure (HoNOS Secure; Sugarman & Walker,
2004) and the Camberwell Assessment of
Need Forensic Version (CANFOR; Thomas
et al., 2003) were also completed as baseline
measures against which to assess progress.
Design
During the course of the study period
(2002 2008) a single ward was replaced by
two new units (in 2006), increasing capacity
from 13 to 28 beds. Data relating to the
medium secure population at three (26 month)
time periods are reported in terms of: source
of admission, Mental Health Act (1983) section,
demographic and personal characteristics
including age, ethnicity, marital status, children,
intelligence quotient (IQ), past abuse, diagnosis,
forensic histories, risk profiles and risk behaviours. IQ classifications were based on pre- or
post-admission assessment using either the
Weschler Adult Intelligence Scale (WAIS III;
Weschler, 1999a) or the Weschler Abbreviated
Scale of Intelligence (WASI; Weschler,
1999b). Diagnoses reported are those arrived
at (or confirmed by) the unit consultant psychiatrist three months after admission. Although a
minority of patients had more than two ICD10 (World Health Organisation, 1992) diagnoses, the secondary diagnosis reported was as
identified by the psychiatrist or was the most
clinically significant secondary condition.
Ó NAPICU 2010:7:17 26
Risk categorisation (high ¼ re-occurrence
very likely; medium ¼ re-occurrence possible;
low ¼ reoccurrence unlikely despite previous
presence of risk indicators) for self-harm, aggression, suicide, aggression, fire setting, sexual
assault, sexually inappropriate behaviour is that
agreed at three-month post-admission by the
multidisciplinary team, based on current behaviour and informed by routinely administered
HoNOS secure ratings A G and Historical,
Clinical Risk 20 (HCR-20; Webster et al.,
1997) assessments. The Overt Aggression Scale
(OAS; Yudofsky et al., 1986) categories of physical aggression were used to describe disturbed
behaviour. Data has been analysed in terms of
whole sample (N ¼ 65) and in terms of their distribution over three (26 month) time periods,
with 14 women overlapping two time periods.
There were 19 patients admitted in time period
1, 17 patients admitted in time period 2, and a
further 29 patients admitted in time period 3
which coincided with the expansion in bed provision. Given the numbers involved, selected
descriptive statistics were favoured over other
statistical analysis (Baer, 1977).
RESULTS
Source of admission and section
Between February 2002 and July 2008, there
were 65 first admissions to the women’s
medium secure service. Most patients were
admitted under hospital orders (44.6%), followed by civil section (23.1%); 20% of patients
were admitted as sentenced prisoners and
12.3% were admitted from court pre-sentence.
The majority of the cohort (93.8%) had had
one or more previous psychiatric admissions.
Approximately one-third (33.8%) were admitted from another medium secure unit, 26.1%
came from prison, and 21.5% were transferred
from a high secure hospital. The remaining
patients came from non-secure and low secure
NHS (10.8%) and independent (7.7%) facilities.
Table 1 shows the source of admission and sections of the Mental Health Act (1983) under
which service users were admitted across the
three time periods together with age and level
of cognitive functioning (IQ).
19
Long C et al
Table 1. Pre-admission information over three time periods (2002 2008)
Time period 1
4.2.02 3.4.04
(n ¼ 19)
Time period 2
4.4.04 3.6.06
(n ¼ 17)
Time period 3
4.6.06 3.8.08
(n ¼ 29)
Source of admission
High secure
Medium secure
Prison
Non and low secure
N (%)
6 (31.6%)
8 (42.1%)
1 (5.3%)
4 (21.1%)
N (%)
6 (35.3%)
5 (29.4%)
2 (11.8%)
4 (23.5%)
N (%)
2 (6.9%)
9 (31.0%)
14 (48.3%)
4 (13.8%)
Mental Health Act (1983) section
on admission
Section 37 or 37/41
Pre- and sentenced (38, 48, 49, 47 &
45a)
Civil section (2 or 3)
Age [average (SD)]
N (%)
N (%)
N (%)
IQ Range
70 79 borderline
80 89 low average
90 109 average
110 119 high average
120 129 superior
11 (57.9%)
0 (0.0%)
7 (41.2%)
5 (29.4%)
11 (37.9%)
16 (55.2%)
8 (42.1%)
33 (SD ¼ 7)
5 (29.4%)
33 (SD ¼ 8)
2 (6.9%)
32 (SD ¼ 10)
N (%)
0 (0.0%)
9 (47.4%)
8 (42.1%)
2 (10.5%)
0 (0.0%)
N (%)
1 (5.9%)
9 (52.9%)
4 (23.5%)
2 (11.8%)
1 (5.9%)
N (%)
15 (51.7%)
6 (20.7%)
4 (13.8%)
4 (13.8%)
0 (0.0%)
Demographic and personal
characteristics of participants
The mean age of the women at admission was
31 years (SD ¼ 8.55; range ¼ 19 49). Of the
65 service users, 60 were white (92.3%), one
was black african (1.5%) and four were of mixed
heritage (6.2%). The majority of service users
were single (78.5%) and 16 (24.6%) had children they were in contact with via phone,
mail or visit. Most of the service users had a
self-reported history of emotional, physical
and/or sexual abuse (84.6%).
Length of stay
There were 27 (41.5%) of the cohort who
remained as inpatients in July 2008. The mean
duration of admission for those service users
who had been discharged (N ¼ 38) was 623.4
days (SD ¼ 299.1; range ¼ 45 1134).
nosed with borderline disorder; 18 (27.7%)
had a primary diagnosis of schizophrenia or
schizoaffective disorder and 5 (7.7%) had a
primary diagnosis of affective disorder. Post
traumatic stress disorder was a secondary diagnosis in 9 cases (13.8%). Table 2 shows the
primary and secondary diagnoses for patients
admitted according to the three time periods.
Although only ten women (15.4%) were
given a formal diagnosis of alcohol or substance
dependence or misuse, 57 patients (87.7%) had
a documented history of alcohol and/substance
misuse with substance/alcohol misuse identified
as a current risk on their initial risk assessment.
Table 3 shows the past history of substance
abuse and main drug of choice (self-defined).
Individuals were classified as either single substance users or polydrug users if they concurrently and regularly used three or more drugs
of abuse (Wheatley, 1998). While only three
patients were formally diagnosed with an eating
disorder, symptoms of an eating disorder were
described in 17 (26.2%) patients’ case notes.
Diagnoses
Of the 65 patients there were 58 (89.2%) diagnosed with a personality disorder as either a
primary or secondary diagnosis using ICD-10
(World Health Organisation, 1992). Of the 45 Forensic histories
primary or secondary diagnoses of personality Most of the cohort (61; 93.8%) had a forensic
disorder, the majority (41; 63.1%) were diag- history with one or more convictions, and all
20
Ó NAPICU 2010:7:17 26
Women referred for medium-secure inpatient care
Table 2. Primary and secondary psychiatric diagnosis for patients admitted over three time periods (2002 2008)
Time period 1
4.2.02 3.4.04
n¼19
Time period 2
4.4.04 3.6.06
n¼17
Time period 3
4.6.06 3.8.08
n¼29
Primary diagnosis
Borderline personality disorder
Other personality disorders
Schizophrenia
Schizoaffective disorder
Bipolar affective disorder
Affective disorder
N (%)
8 (42.1%)
2 (10.5%)
5 (26.3%)
2 (10.5%)
1 (5.3%)
1 (5.3%)
N (%)
9 (52.9%)
2 (11.8%)
3 (17.7%)
2 (11.8%)
1 (5.9%)
0 (0%)
N (%)
19 (65.5%)
2 (6.9%)
4 (13.8%)
2 (6.9%)
1 (3.4%)
1 (3.4%)
Secondary diagnosis
Substance dependence abstinent in a
protected environment
Borderline personality disorder
Other personality disorders
Substance dependence syndrome
PTSD
Affective disorder
Eating disorder
Dissociative identity disorder
N (%)
10 (52.6%)
N (%)
4 (23.5%)
N (%)
8 (27.6%)
4
1
2
0
1
0
0
2
4
3
3
1
0
0
3
2
6
6
2
1
1
(21.1%)
(5.3%)
(10.5%)
(0.0%)
(5.3%)
(0.0%)
(0.0%)
(11.8%)
(23.5%)
(17.7%)
(17.7%)
(5.9%)
(0%)
(0.0%)
(10.3%)
(6.9%)
(20.7%)
(20.7%)
(6.9%)
(3.4%)
(3.4%)
Table 3. Pre-admission alcohol/drug abuse history over three time periods (2002 2008)
Time period 1
4.2.02 3.4.04
n ¼ 19
Time period 2
4.4.04 3.6.06
n ¼ 17
Time period 3
4.6.06 3.8.08
n ¼ 29
Previous alcohol/drug abuse
Single substance use
Polysubstance use
Total
N (%)
6 (31.6%)
10 (52.6%)
16 (84.2%)
N (%)
6 (35.3%)
10 (58.8%)
16 (94.1%)
N (%)
8 (27.6%)
17 (58.6%)
25 (86.2%)
Main substance of abuse
Alcohol
Heroin
Crack cocaine
Cannabis
Ecstasy
N (%)
10 (62.5%)
3 (18.8%)
1 (6.3%)
2 (12.5%)
0 (0%)
N (%)
10 (62.5%)
3 (18.8%)
2 (12.5%)
1 (6.3%)
0 (0.0%)
N (%)
14 (56.0%)
7 (28.0%)
5 (20.0%)
2 (8.0%)
1 (4.0%)
but ten women had an index offence that had
led to their admission to St Andrew’s Healthcare. In terms of the type of index offence,
over one-half were either charged with or convicted of a violent offence (39; 60%), ranging
from threats to kill and affray, to murder and
manslaughter. Of these violent index offences,
43.6% were classed as ‘major’ violence following the criteria of Coid et al. (2000b) and
56.4% as serious offences against the person.
The most prevalent index offence after violence
was arson with 14 (21.5%) of the cohort either
being charged with or convicted of arson. A
similar pattern to current offences can be seen
with previous convictions. Almost two-thirds
Ó NAPICU 2010:7:17 26
of the cohort had been previously convicted
of a serious offence against the person (60%);
35.4% had been previously convicted of arson;
30.8% had been convicted of a ‘major’ violent
offence. Fifteen members of the cohort
(23.1%) had previously worked in the sex
industry. Table 4 shows the index offences and
average number of previous convictions of
admissions over three time periods.
Risk profiles
All but two members of the cohort had histories
of deliberate self-harm in their case notes. Three
months after their admission, 61 women
21
Long C et al
Table 4. Index offences and prior conviction histories of patients admitted over three time periods (2002 2008)
Time period 1
4.2.02 3.4.04
(n¼19)
Time period 2
4.4.04 3.6.06
(n¼17)
Time period 3
4.6.06 3.8.08
(n¼29)
Index offence
None
Major violence (murder, manslaughter,
attempted murder, grievous bodily harm
(GBH))
Serious offences against person (ABH,
threats, wounding, affray, weapons)
Acquisitive offences
Arson
N (%)
5 (26.3%)
5 (26.3%)
N (%)
3 (17.7%)
5 (29.4%)
N (%)
2 (6.9%)
7 (24.1%)
7 (36.8%)
7 (41.2%)
8 (27.6%)
0 (0.0%)
2 (10.5%)
0 (0.0%)
2 (11.8%)
2 (6.9%)
10 (34.5%)
Previous convictions
N (Av. no. of convictions
per patient)
6 (0.32)
N (Av. no. of convictions
per patient)
7 (0.36)
N (Av. no. of convictions
per patient)
14 (0.32)
15 (0.79)
21 (0.73)
53 (1.24)
11 (0.58)
8 (0.42)
11 (0.45)
6 (0.21)
36 (0.85)
15 (0.45)
Major violence (murder, manslaughter,
attempted murder, GBH)
Serious offences against person (ABH,
threats, wounding, affray, weapons)
Acquisitive offences (incl. criminal damage)
Arson
(93.8%) had risk of self-harm rated as medium
(‘recurrence possible’) or high (‘recurrence
very likely’) by the multidisciplinary team; and
56 (86.2%) were rated as medium or high risk
of suicide. The majority of women (62;
95.4%) were assessed as being of medium or
high risk of committing physical assault.
Although only 23 (35.4%) had a previous conviction for arson, 46 (70.8%) of the cohort
were identified as being at medium or high
risk of deliberate fire-setting. While only a small
number, 5 (7.7%) were rated as being at risk of
committing sexual assault, almost one-half of
the cohort, (49.2%) were rated as being at risk
of behaving in a sexually inappropriate manner.
order as a consistent diagnostic category in
addition to mental illness, together with a significant past history of violence, self-harm, arson
and substance misuse. The current sample
resembles, in terms of presenting problems, the
profile of female patients in a high secure hospital as described a decade ago by Bland et al.
(1999). This similarity may in part reflect the
migration of this population over the past decade from high to medium secure conditions
(Dent, 2006). The study population, however,
most closely resembles the subgroup of women
admitted to secure facilities that have borderline
personality disorder as their primary psychopathology (Coid et al. 2000b). In Coid et al.’s
(2000b) sample the largest personality disorTable 5 shows the incidence of outward dered subgroup had a primary diagnosis of bor(assaults on people or property) and inward- derline personality disorder with a proportion
directed aggression (self-harm) for all patients having an additional diagnosis of schizophrenia
resident over the three time periods together or paranoid psychosis. Coid et al.’s (2000b)
with the use of prevention and management of group was, as with the current sample, overaggression and violence (PMAV) procedures whelmingly Caucasian, UK-born and single;
(including safe patient restraint) and seclusion.
three-quarters had been admitted as a result of
criminal behaviours, particularly arson, and
there was a high prevalence of co-morbid alcoDISCUSSION
hol/drug dependence or abuse. The borderline
Analysis of the first 65 admissions to an inde- sub-group also had extensive criminal histories
pendent sector provider of a female pathway and were more likely than the other six clusters
of care, beginning with a medium secure facil- or sub-groups to have had a previous psychiatric
ity, reveals a population with personality dis- admission (Coid et al., 2000b).
22
Ó NAPICU 2010:7:17 26
Women referred for medium-secure inpatient care
Table 5. Violent behaviour and use of PMAV and seclusion during three time periods (2002 2008)
Time period 1
4.2.02 3.4.04
Time period 2
4.4.04 3.6.06
Time period 3
4.6.06 3.8.08
Assaults on people
Assaults on property
Self harm
N (Av. no. of incidents per
patient)
86 (4.5)
22 (1.2)
310 (16.3)
N (Av. no. of incidents per
patient)
28 (1.7)
43 (2.5)
190 (11.2)
N (Av. no. of incidents per
patient)
263 (9.1)
311 (10.7)
531 (18.3)
Incidents of PMAV and
seclusion
PMAV
Seclusion
N (Av. no. of incidents per
patient)
71 (3.7)
42 (2.2)
N (Av. no. of incidents per
patient)
81 (4.8)
45 (2.7)
N (Av. no. of incidents per
patient)
384 (13.2)
249 (8.6)
Violent behaviour
The current population shows some differences to the (mostly) NHS medium secure samples described by Bartlett (2006) and Bartlett et
al. (2007). Specifically, although a similar percentage had a prior history of abuse, in contrast
to Bartlett (2006) all but two service users had a
forensic history. Further, a higher proportion of
the current sample were classified as having
committed serious violence than in the London
medium secure benchmarking study (Bartlett
et al., 2007). In contrast to Bartlett (2006), violence (49.2%) rather than arson (21.5%) was the
most common index offence. In terms of legal
status, this cohort is significantly different from
a geographically similar, though mixed gender,
regional secure unit (Ricketts et al., 2001), particularly in terms of a much higher rate of S37
and S37/41 admissions.
blems being apparent in childhood that potentially may be related. The patient population
in the most recent time period also displayed a
higher average number of assaults on people,
associated with a very high incidence of the
use of PMAV and seclusion as a management
strategy. While these factors may be aspects of
the complex psychopathology of women
admitted from prison to mental health facilities
(Bartlett, 2006), they have implications for
medium secure services both in terms of assessment and treatment.
First, less attention and resources have been
devoted to the assessment and treatment of prisoners’ mental health needs, so that their mental
health needs have been under-estimated
(Rutherford & Taylor, 2004), and few prisoners
receive psychiatric treatment (Singleton et al.,
Findings from the current study chart a 1998). As Bartlett et al. (2007) noted, there is
change in the referral and acceptance pattern a need for a thorough review of the emerging
of patients admitted over the last 2 years since demands on forensic services from the criminal
the opening of two new purpose built medium justice system, particularly in the light of the
secure wards. An expected decline in special Department of Health’s Offender Health Strathospital referrals (Dent, 2006) and in Section 3 egy (Department of Health, 2009).
patients had been paralleled by an increase in
prison transfers: the prison transfers are assoSecond, a changing psychopathology, risk
ciated with drug-related offending (Councell, and IQ profile will necessitate continual adjust2003), with substance misuse being identified ments to psychosocial treatment programming.
as the most pressing mental health problem in The relationship between a diagnosis of personfemale inmates (Blitz et al., 2006; Loughran & ality disorder and childhood physical and sexual
Seewoonerain, 2005). Of particular interest, abuse has been noted (Hassell & Bartlett, 2001).
however, is the association between prison In the current sample the very high incidence of
transfers and a lower level of cognitive func- personality disorder, mostly of the borderline/
tioning. The association between low IQ and emotionally unstable type, plus comorbidity
arson is evident (Dickens et al., 2008; Enayati highlights the therapeutic challenge presented
et al., 2008), with lifelong, temperamental pro- by this population, one-third of whom were
Ó NAPICU 2010:7:17 26
23
Long C et al
referred for specialist treatment from other
medium secure facilities. Further, although a
diagnosis of schizophrenia occurs in only a small
subgroup of borderline patients, such women
require special techniques of management
(Coid et al., 2000b).
coming them. These internal treatment readiness conditions include cognitive, affective,
behavioural readiness, volitional and identify
factors (Howells & Day, 2007) and are of particular significance in personality disordered
populations where the establishment of a therapeutic alliance is particularly problematic (LiveWhile multi-disciplinary team risk assess- sey, 2001). Central to this process is the
ments of newly admitted patients are subjective instillation of hope (Hillbrand & Young, 2008)
and possibly conservative, the majority of the along with validation of the patient’s struggle
cohort were assessed as being concomitantly to help build a therapeutic alliance and the resihigh-risk of both self-harm/suicide and physical lience to persist with treatment (Linehan, 1993).
assault, reinforcing the need for thorough risk
assessment, and a treatment focus on the develIn practical terms, a further consideration is
opment of more effective coping skills, particu- the need to regularly adjust a gender specific
larly emotional regulation (Linehan, 1993; Long treatment programme to meet the need of indiet al., 2008). Although only four of this sample viduals with lower levels of intellectual funcwere in an ongoing marital relationship, almost tioning. This consideration has led to the
one-quarter had children they were in contact review of all written group and handout materwith and elements of identity, such as being ial in terms of its comprehensibility (Flesch,
someone’s mother partner or sibling, need to 1948), and changes in the methods of group
be recognised and nurtured as appropriate treatment delivery. An increased emphasis on
(Hassell & Bartlett, 2001).
interventions to ensure generalisation of the
use of coping skills outside treatment situations
Low levels of treatment engagement are has also been emphasised (Osnes & Lieblein,
endemic in both offender treatment pro- 2003).
grammes and in patients with personality disorder (Howells & Day 2007). The likely lack
In summary, the changing nature of the
of ‘preparedness’ for psychiatric intervention patient group admitted to medium secure facilby patients admitted from prison to medium se- ities poses an evolving challenge in terms of
cure facilities highlights the need for greater both risk management and ‘preparedness’ for
emphasis, following stabilisation, on motiva- psychosocial treatment. A treatment programme
tional and therapeutic alliance building work based on these considerations is described in
(to achieve a state of readiness to engage in Long et al. (2008) and is currently under evalutreatment (Ward et al., 2004)). The responsivity ation.
principle suggests the need to adapt treatment
interventions to the characteristics of the forensic population being treated if treatment outcomes are to be optimised. Given that the References
causes of low engagement tend to be within Baer, D.M. (1977) Perhaps it would be better not to know
the person rather than being related to situeverything. Journal of Applied Behaviour Analysis. 10:
ational or programme factors this point is parti167 172.
cularly important (Howells & Day, 2007). In Bartlett, A. (2006) Second Expert Paper: social division & difference:
the current setting, this has led to ward-based
women. NHS National Programme on Forensic Mental Health
psychoeducational/motivational/goal
setting
Research & Development, London. www.nfmph.org.uk
group sessions as a prelude to engagement in a Bartlett, A., Johns, A., Fiander, M. and Jhawar, H. (2007)
manual-driven group treatment programme
Report of the London Forensic Unit’s Benchmarking Study. Lon(Long et al., 2008). ‘Getting the most from
don: NHS.
your treatment’ sessions target key internal fac- Bland, J., Mezey, G. and Dolan, B. (1999) Special women,
tors relevant to treatment engagement along
special needs: descriptive study of female special hospital
patients. Journal of Forensic Psychiatry. 10: 34 45.
with common obstacles and strategies for over24
Ó NAPICU 2010:7:17 26
Women referred for medium-secure inpatient care
Blitz, C.L., Wolff, N. and Paap, K. (2006) Availability of
behavioural health treatment for women in prison. Psychiatric
Services. 57: 356 360.
Chowdhury, N.A., Whittle, N., McCarthy, K., Bailey, S.
and Harrington, R. (2005) Ethnicity and its relevance in a
7-year admission cohort to an English national adolescent
medium secure health service unit. Criminal Behaviour in
Mental Health. 15: 261 272.
Coid, J. and Dunn, W. (2004) Forensic psychiatry assessments
and admissions from East London, 1987 1994. Journal of
Forensic Psychiatry & Psychology. 15: 76 95.
Coid, J., Kahtan, N., Gault, S. and Jarman, B. (2000a)
Women admitted to secure forensic psychiatric services I:
comparison of women & men. Journal of Forensic Psychiatry.
11: 275 295.
Coid, J., Kahtan, N., Gault, S. and Jarman, B. (2000b)
Women admitted to secure forensic psychiatry services II:
identification of categories using cluster analysis. Journal of
Forensic Psychiatry. 11: 296 315.
Councell, R. (2003) The Prison Population in 2002: A Statistical
Review. Findings 228. London: Home Office.
Dent, E. (2006) The safer sex. Health Service Journal. 116:
24 26.
Department of Health (2009) Improving Health, Supporting
Justice: The national delivery plan of the health and criminal justice
programme board. London: Department of Health.
Dickens, G., Sugarman, P., Ahmad, F., Edgar, S., Hofberg, K. and Tewari, S. (2008) Characteristics of low IQ
arsonists at psychiatric assessment. Medicine, Science & the
Law. 48: 217 220.
Dolan, M. and Lawson, A. (2001) Characteristics and outcomes of patients admitted to a psychiatric intensive care
unit in a medium secure unit. Psychiatric Bulletin. 25:
296 299.
Enayati, J., Grann, M., Lubbe, S. and Fazel, S. (2008) Psychiatric morbidity in arsonists referred for forensic psychiatric
assessment in Sweden. The Journal of Forensic Psychiatry and
Psychology. 19: 139 147.
Flesch, R. (1948) A new readability yardstick. Journal of
Applied Psychology. 32: 221 233.
Gudjonsson, G. and Young, S. (2007) The role and scope of
forensic clinical psychology in secure unit provisions: a proposed service model for psychological therapies. The Journal
of Forensic Psychiatry & Psychology. 18: 534 556.
Hassell, Y. and Bartlett, A. (2001) The changing climate for
women patients in medium secure psychiatric units. Psychiatric Bulletin. 25: 340 342.
Hill, S.A. (2006) The future of medium secure forensic psychiatry in Britain: a survey. Medicine, Science & the Law. 46:
245 247.
Hillbrand, M. and Young, J.L. (2008) Instilling hope in forensic treatment: the antidote to despair and desperation. The
Ó NAPICU 2010:7:17 26
Journal of the American Academy of Psychiatry & the Law. 36:
90 94.
Howells, K. and Day, A. (2007) Readiness for treatment in
high risk offenders with personality disorders. Psychology,
Crime & Law. 13: 47 56.
Linehan, M. (1993) Cognitive-Behavioural Treatment of Borderline
Personality Disorder. New York: Guildford Press.
Livesey, W.J. (ed) (2001) Handbook of Personality Disorders: theory, research & treatment. pp 570 600. New York: Guilford
Press.
Long, C.G., Fulton, B. and Hollin, C.R. (2008) The
development of a ‘best practice’ service for women in a
medium secure psychiatric setting: treatment components
and evaluation. Clinical Psychology and Psychotherapy. 15:
304 319.
Loughran, M. and Seewoonarain, K. (2005) Characteristics
of need and risk among women prisoners referred to inreach
mental health services. British Journal of Forensic Practice. 7(3):
12 21.
Ogloff, J.R.P. and Davis, M.R. (2004) Advances in offender
assessment and rehabilitation: contributions of the risk-needsresponsivity approach. Psychology, Crime & Law. 10:
229 242.
Osnes, P.G. and Lieblein, T. (2003) An explicit technology
of generalisation. The Behaviour Analyst Today. 3: 40 45.
Priebe, S., Badesconyi, A., Fioritti, A., Hansson, L.,
Kilian, R., Torres-Gonzales, F., Turner, T. and
Wiersma, D. (2005) Reinstutionalisation in mental health
care: comparison of data on service provision from six European countries. British Medical Journal. 330: 123 126.
Ricketts, D., Carnell, H., Davies, S., Kaul, A. and
Duggan, C. (2001) First admissions to a regional secure
unit over a sixteen year period: changes in demographic
and service characteristics. The Journal of Forensic Psychiatry.
12: 78 89.
Rutherford, H. and Taylor, P.J. (2004) Transfer of women
offenders with mental disorder from prison to hospital. Journal of Forensic Psychiatry & Psychology. 15: 108 123.
Singleton, M., Meltzer, H., Gatward, R., Coid, J. and
Deasy, D. (1998) Psychiatric morbidity among prisoners in England and Wales: The Report of a Survey carried out in 1997 by the
Social Survey Division of the Office of National Statistics on behalf
of the Department of Health. London: The Stationery Office.
Sugarman, P. and Walker, L. (2004) Health of the Nation
Outcome Scales for Users of Secure Services. London: Royal College of Psychiatrists Research Unit.
Thomas, S., Harty, M.A., Parrott, J., McCrone, P.,
Slade, M. and Thorneycroft, G. (2003) Camberwell Assessment of Needs Forensic Version. London: Gaskell.
Ward, T., Day, A., Howells, K. and Birgden, A. (2004)
The multifactor offender readiness model. Aggression and
Violent Behaviour. 9: 645 673.
25
Long C et al
Webster, C.O., Douglas, K.S., Eaves, D. and Hart, S.D.
(1997) HCR-20: Assessing Risk for Violence, Version 2. Burnaby, British Columbia: Simon Fraser University.
Wheatley, M., Waine, J., Spence, K. and Hollin, C.R.
(2004) Characteristics of 80 adolescents referred for secure
inpatient care. Clinical Psychology & Psychotherapy. 11: 83 89.
Weschler, D. (1999a) Weschler Adult Intelligence Scale
Third
UK Edition (WAIS-III UK). Administration and scoring manual.
PsychCorp.
World Health Organisation (1992) The ICD-10 Classification
of Mental and Behavioural Disorders. Geneva: World Health
Organisation.
Weschler, D. (1999b) Weschler Abbreviated Scale of Intelligence
(WASI). PsychCorp.
Yudofsky, S.C., Silver, J.M., Jackson, W., Endicott, J.
and Williams, D. (1986) The Overt Aggression Scale for
the objective rating of verbal and physical aggression. American Journal of Psychiatry. 143: 35 39.
Wheatley, M. (1998) The prevalence and relevance of substance use in detained patients. The Journal of Forensic Psychiatry. 9: 114 129.
26
Ó NAPICU 2010:7:17 26