Gillian Mezey

Perceptions, experiences and meanings of recovery in forensic psychiatric patients

The ‘Recovery Approach’ is widely regarded as the guiding principle for mental health service delivery in the UK. However, it is not clear whether this approach has any relevance, or is applicable to mentally disordered offender patients, who are almost invariably detained against their will and whose capacity to exert choice and control over their treatment must therefore be severely restricted. This study set out to explore definitions, experiences, and perceptions of recovery in patients with severe mental illness, currently detained in medium secure psychiatric provision. Most patients defined recovery as getting rid of symptoms and feeling better about themselves. Medication and psychological work, relationships with staff and patients and being in a secure setting were all cited as being important in bringing about recovery. The stigma associated with being an offender, as well as having a serious mental illness, was perceived as a factor holding back recovery, particularly in relation to discharge and independent living in the community. Core recovery concepts of hope, self-acceptance, and autonomy are more problematic and appear to be less meaningful to individuals, who are detained for serious and violent offences. The recovery approach may need to be modified for use in forensic psychiatric services.

One size fits all: or horses for courses? Recovery-based care in specialist mental health services

IntroductionThe ‘recovery approach’ to the management of severe mental health problems has become a guiding vision of service provision amongst many practitioners, researchers, and policy makers as well as service users.MethodThis qualitative pilot study explored the meaning of ‘recovery’ with users of three specialist mental health services (eating disorders, dual diagnosis, and forensic) in 18 semi-structured interviews.ResultsThe relevance of themes identified in mainstream recovery literature was confirmed; however, the interpretation and relative weight of these themes appeared to be affected by factors that were specific to the diagnosis and treatment context. ‘Clinical’ recovery themes were also seen as important, as were aspects of care that reflect core human values, such as kindness.

Development and preliminary validation of a measure of social inclusion for use in people with mental health problems: The SInQUE

Background: Social exclusion can be both a cause and a consequence of mental health problems. Socially inclusive practice by mental health professionals can mitigate against the stigmatizing and excluding effects of severe mental illness. Aim: To develop and test the validity of a measure of social inclusion for individuals with severe mental illness – the Social Inclusion Questionnaire User Experience (SInQUE). Method: The domains of the SInQUE were chosen to reflect the domains of social inclusion identified in the Poverty and Social Exclusion Survey. Patients with severe mental illness were recruited from rehabilitation, general and forensic psychiatric services and were asked to complete the questionnaire in an individual interview with a researcher. Results: Sixty six patients with schizophrenia and schizoaffective disorder completed the SInQUE, alongside measures of psychiatric symptoms, needs and quality of life, to assess its acceptability, and concurrent and construct (convergent and discriminant) validity. The SInQUE took 45 minutes to complete and was found to have good concurrent and discriminant validity. Convergent validity was established for two domains: social integration and productivity. Conclusion: Preliminary findings suggest that the SInQUE may be a useful tool for assessing and monitoring social inclusion in individuals with severe mental illness. It has construct and concurrent validity with measures of unmet need and quality of life in this group. Further testing of the reliability of the SInQUE on a larger population is indicated.

Choice and social inclusion in forensic psychiatry: acknowledging mixed messages and double think

Social exclusion can be both a cause and a consequence of mental health problems and efforts to promote socially inclusive practice are likely to benefit both the individual mental health service user and society (CSIP, 2007; Department of Health, 1999b; Department of Health, 2004; Payne, 2006; Social Exclusion Unit, 2002a). The ‘recovery approach’ to mental health care delivery (Anthony, 1993) is designed to increase social inclusion and participation by increasing patients’ sense of autonomy, confidence and motivation to engage in economic, social and cultural life within the society in which they live (Burchardt, Le Grand, & Piachaud, 1999; Gordon et al., 2000). Social inclusion requires individuals to be able to exert choice and to have the confidence and self-esteem necessary to engage fully in the community in which they live. Rather than having treatment dictated to them by health professionals, patients or ‘users’ are now considered to be experts in their own condition, who provide a different, but essentially equal, contribution towards the understanding and management of their mental disorder (Department of Health, 2001; Department of Health, 2005). Health professionals are therefore expected to negotiate decisions about treatment and care, with the individual ‘user’ being encouraged to take the lead and to make ‘personal choices’ about their life and illness, as well as the level of risk they are prepared to take (Department of Health, 1999a; Department of Health, 2004; General Medical Council, 2006). The government’s increasing commitment to choice and empowerment and social inclusion in mental health care provision can be difficult to reconcile, however, with its equally committed stance with regard to public protection within an increasingly risk-adverse society. Resolving this tension can be particularly difficult to finesse within forensic psychiatric practice. Mentally disordered offenders tend to have experienced disproportionately high levels of social exclusion, even before entering mental health care (Thomson et al., 1997). Young men from ethnic minorities, with high rates of childhood deprivation, abuse, institutionalisation, previous convictions, low educational and vocational attainment, homelessness, are disproportionately represented. Many of them are socially isolated, with absent or severely fragmented social networks. Few of them have experience of mature, intimate and non-abusive relationships, many are detained The Journal of Forensic Psychiatry & Psychology Vol. 20, No. 4, August 2009, 503–507

Tackling the problem of teenage pregnancy in looked-after children: a peer mentoring approach

ABSTRACT Teenage pregnancy is associated with adverse health and social outcomes, even after adjusting for prior disadvantage, and is recognized as a major public health issue. Rates of teenage pregnancy in the UK are among the highest in Europe. Interventions introduced in the past decade to address the problem, such as improved sex and relationships education in schools, have been accompanied by a fall in teenage pregnancy rates in the UK. However, this decline has not been mirrored among looked‐after children. In this paper, we discuss why this may be the case. We suggest that a system of peer mentoring, involving a young person, whose experience of life post‐care has been positive, may be an effective approach to tackling the problem of pregnancy in this group. Peer mentoring has the potential to assist young people in developing self‐esteem, confidence and in making choices regarding their education, personal development and relationships.

Characteristics of adolescents placed under section 136 Mental Health Act 1983

Mental Health Act 1983 section136 allows a non-medically trained professional to deprive individual liberty on mere suspicion of a mental disorder, based on ‘disorderly’ behaviour in the community. This study describes the characteristics, presentation and outcomes of adolescents, subjected to s.136. Socio-demographic, psychiatric and s.136 data were collected from 40 adolescents and consecutive same-sex adults placed on s.136 over a three year period in a London Mental Health Trust. Categorical variables were compared using Pearson χ2 analysis (or Fishers Exact test, where indicated). Twice as many female as male adolescents were brought in on s.136. Adolescents were found with higher rates of institutionalisation, abuse, criminal histories and more likely to be brought in due to self-harm. Despite evidence of vulnerability and psychiatric problems, about half were admitted to hospital following assessment. Further research to address the needs and improve service provision for this group is indicated.

Finding a voice – the feasibility and impact of setting up a community choir in a forensic secure setting

This study reports on the feasibility and impact of running a choir for forensic psychiatric inpatients, staff and members of the local community, within the confines of a medium secure psychiatric unit. The choir ran between October and December 2013. Eight weekly workshops and a final concert performance were evaluated through participant observation and focus groups held with the participants. Between 12 and 16 male and female patients attended each workshop and the final concert. All participating patients had received a diagnosis of schizophrenia, schizo-affective disorder or personality disorder, all had committed serious violent or sexual offences and all were legally detained and receiving treatment in a forensic medium or low secure ward, under the Mental Health Act (England and Wales). Considerable benefits were reported by patients, as well as by the participating community choir members and staff. Primary benefits reported by patients included the following: improved happiness and well-being; increased confidence and self-esteem; greater emotional connectedness and reduced sense of stigma. Participating staff also reported increased feelings of well-being and happiness, greater tolerance and more positive perceptions of the functioning and capabilities of forensic psychiatric patients. The longer term benefits of music participation on the mental health and social functioning of forensic psychiatric patients require further investigation.

Never ever? Characteristics, outcomes and motivations of patients who abscond or escape: a 5-year review of escapes and absconds from two medium and low secure forensic units

BACKGROUNDnAbsconds and escapes by psychiatric patients from secure forensic psychiatric settings create public anxiety and are poorly understood.nnnAIMSnTo describe secure hospital patients who escape from within the secure perimeter or abscond, and test for differences between these groups.nnnMETHODnEscapes and absconds between 2008 and 2012 from the medium and low secure forensic psychiatric inpatient units of two London National Health Service Trusts were identified through the Trusts databases. Demographic, offending, mental health and incident data were extracted from records for each.nnnRESULTSnSeventy-seven incidents, involving 54 patients, were identified over the five years. These were 13 escapes involving 12 patients, representing a rate of 0.04 per 1000 bed days, and 64 absconds involving 42 patients, a rate of 0.26 per 1000 bed days; 15 (28%) patients were absent without leave more than once. Over half of the patients came back voluntarily within 24 hours of leaving. Over 50% of them had drunk alcohol or taken drugs while away from the unit. Escapees were more likely to be transferred prisoners and to have planned their escape, less likely to return to the unit voluntarily and away longer than patients who absconded. Offending was rare during unauthorised leave--just three offences among the 77 incidents; self-harm was more likely. Motives for absconding included: wanting freedom or drink or drugs, family worries and/or dissatisfaction with aspects of treatment.nnnCONCLUSIONSnEscapes or absconding from secure healthcare units have different characteristics, but may best be prevented by convergent strategies. Relational security is likely to be as important for foiling plans for the former as it is for reducing boredom, building strong family support and managing substance misuse in the latter.

Developing and piloting a peer mentoring intervention to reduce teenage pregnancy in looked-after children and care leavers: an exploratory randomised controlled trial

BACKGROUNDnLooked-after children (LAC) are at greater risk of teenage pregnancy than non-LAC, which is associated with adverse health and social consequences. Existing interventions have failed to reduce rates of teenage pregnancy in LAC. Peer mentoring is proposed as a means of addressing many of the factors associated with the increased risk of teenage pregnancy in this group.nnnOBJECTIVEnTo develop a peer mentoring intervention to reduce teenage pregnancy in LAC.nnnDESIGNnPhase I and II randomised controlled trial of a peer mentoring intervention for LAC; scoping exercise and literature search; national surveys of social care professionals and LAC; and focus groups and interviews with social care professionals, mentors and mentees.nnnSETTINGnThree local authorities (LAs) in England.nnnPARTICIPANTSnLAC aged 14-18 years (mentees/care as usual) and 19-25 years (mentors).nnnINTERVENTIONnRecruitment and training of mentors; randomisation and matching of mentors to mentees; and 1-year individual peer mentoring.nnnMAIN OUTCOME MEASURESnnnnPRIMARY OUTCOMEnpregnancy in LAC aged 14-18 years.nnnSECONDARY OUTCOMESnsexual attitudes, behaviour and knowledge; psychological health; help-seeking behaviour; locus of control; and attachment style. A health economic evaluation was also carried out.nnnRESULTSnIn total, 54% of target recruitment was reached for the exploratory trial and 13 out of 20 mentors (65%) and 19 out of 30 LAC aged 14-18 years (63%) (recruited during Phases I and II) were retained in the research. The training programme was acceptable and could be manualised and replicated. Recruitment and retention difficulties were attributed to systemic problems and LA lack of research infrastructure and lack of additional funding to support and sustain such an intervention. Mentees appeared to value the intervention but had difficulty in meeting weekly as required. Only one in four of the relationships continued for the full year. A future Phase III trial would require the intervention to be modified to include provision of group and individual peer mentoring; internal management of the project, with support from an external agency such as a charity or the voluntary sector; funds to cover LA research costs, including the appointment of a dedicated project co-ordinator; a reduction in the lower age for mentee recruitment and an increase in the mentor recruitment age to 21 years; and the introduction of a more formal recruitment and support structure for mentors.nnnCONCLUSIONSnGiven the problems identified and described in mounting this intervention, a new development phase followed by a small-scale exploratory trial incorporating these changes would be necessary before proceeding to a Phase III trial.nnnFUNDINGnThis project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 85. See the NIHR Journals Library website for further project information.

Social exclusion in adult informal carers: A systematic narrative review of the experiences of informal carers of people with dementia and mental illness

Social exclusion has a negative impact on quality of life. People living with dementia or mental health disorders as well as informal carers have been separately described as socially excluded. The objective of this systematic narrative review was to examine the extent to which social exclusion experienced by adult informal carers of people living with dementia or severe mental health disorders has been identified and described in research literature. It synthesised qualitative and quantitative evidence and included the perspectives of carers themselves and of professionals. Eight electronic databases (1997-2017) were searched. Five relevant studies published between 2010 and 2016 were identified. All were qualitative and used interviews and focus groups. Study quality was variable and most were European. Two focused on carers of people living with dementia and three on carers of people with mental health disorders. Four investigated carers perspectives and experiences of social exclusion directly (total of 137 carer participants, predominantly parents, spouses and adult children), while the fifth focused on the perceptions of 65 participants working in health and social care. Stigma, financial difficulties and social isolation were highlighted in four studies and the challenges for carers in engaging in leisure activities were described in the fifth. Most conceptualised social exclusion as a form of stigma, or as resulting from stigma. One presented social exclusion as an element of carer burden. Two explicitly discussed the negative effects of social exclusion on carers. The dearth of research and the lack of specificity about social exclusion in carers was surprising. Future research should investigate aspects of social exclusion that may adversely affect carer wellbeing.