James Tapp

The characteristics of sexual abuse in sport: a multidimensional scaling analysis of events described in media reports.

Abstract Most research on sexual abuse has been conducted within family settings (Fergusson & Mullen, 1999). In recent years, following several high profile convictions and scandals, research into sexual abuse has also encompassed institutional and community settings, such as sport and the church (Gallagher, 2000; Woolfe, Jaffe, Jette, & Poisson, 2003). Research into sexual abuse in sport, for example, began with both prevalence studies (Kirby & Greaves, 1996; Leahy, Pretty, & Tenenbaum, 2002) and qualitative analyses of the processes and experiences of athlete sexual abuse (Brackenridge, 1997; Cense & Brackenridge, 2001, Toftegaard‐Nielsen, 2001). From such work, descriptions of the modus operandi of abusers in sport, and the experiences and consequences for athlete victims, have been provided, informing both abuse prevention work and coach education. To date, however, no study has provided empirical support for multiple associations or identified patterns of sex offending in sport in ways that might allow comparisons with research‐generated models of offending outside sport. This paper reports on an analysis of 159 cases of criminally defined sexual abuse, reported in the print media over a period of 15 years. The main aim of the study was to identify the nature of sex offending in sport, focusing on the methods and locations of offenses. The data were analysed using multidimensional scaling (MDS) as a data reduction method in order to identify the underlying themes within the abuse and explore the inter‐relationships of behavior, victim, and context variables. The findings indicate that there are specific themes that can be identified within the perpetrator strategies that include “intimate,” “aggressive,” and “dominant” modes of interaction. The same patterns that are described here within the specific context of sport are consistent with themes that emerge from similar behavioral analyses of rapist (Bishopp, 2003; Canter & Heritage, 1990) and child molester groups (Canter, Hughes, & Kirby, 1998). These patterns show a correspondence to a broader behavioral model—the interpersonal circumplex (e.g., Leary, 1957). Implications for accreditation and continuing professional education of sport psychologists are noted

Psycho-educational groupwork for detained offender patients: understanding mental illness

Psycho-education for patients suffering from psychiatric disorders is seen as a key element in the goal of recovery. The present study examined the usefulness of a groupwork cognitive behavioural psycho-educational intervention for patients in a high-security hospital. Thirty-one patients with a primary diagnosis of mental illness completed a group patients entitled: ‘Understanding Mental Illness’ which promotes awareness of descriptions of illness and strategies for managing symptoms. The SCQ and CORE-OM were administered pre- and post-group, measures to monitor relapse and behavioural change were also included. Semi-structured interviews were conducted with participants and their feedback was examined using content analysis. Themes from interviews indicated that patients reported a number of benefits. Formal measures used as indices of ‘change’ failed to yield clear improvements in self-reported functioning. However, the majority of patients engaged in further psychological work, which is cautiously interpreted as a trend in the direction of openness to engagement.

What do the experts by experience tell us about 'what works' in high secure forensic inpatient hospital services?

The evidence base for ‘what works’ for patients detained in high secure hospitals has predominantly been established from a clinical perspective, with the voices of those at the centre of care, the expert by experience, absent. Neglecting this voice renders an important source of information for evidence-based practice inaccessible to outcome evaluators. Twelve high secure patients considered ‘ready’ to be discharged were interviewed to explore what in their view had helped or hindered their progress to this stage. Thematic analysis steps were applied to interviews and eight themes were generated that represented valued elements of high security: temporary suspension of responsibility, collaboration in care, learning from others, supportive alliances, specific interventions (medical and psychotherapeutic), a safe environment and opportunities for work. Narratives demonstrated the complementary and unique contribution of the patient experience in informing ‘what works’, and are discussed alongside existing theories relevant to promoting clinical change and risk reduction.

Group-work for offender patients on sex offending in a high security hospital: Investigating aspects of impact via qualitative analysis

Abstract Qualitative methods can improve the understanding of the dynamic group processes that occur during interventions with sex offenders and how these might impact upon outcomes. The current study presents themes from post-group interviews with 17 male offender patients referred for group-work on sex offending in a high security hospital. Individual interview transcripts were analysed thematically and five themes were generated: the impact of disclosing offending experiences; essential ingredients of group-work; peer processes; taking on an offender identity; and life after the group. Despite methodological differences between this study and other research, there is clear thematic narrative overlap in findings. This suggests some outcomes in common across interventions for sex offenders, and demonstrates the usefulness of including reflective narratives as a means of gathering information about the impact of group-work for patients with serious offence histories.

Cognitive-behavioural therapy for schizophrenia in a forensic mental health setting

– The efficacy of cognitive-behavioural therapy (CBT) for schizophrenia in community and general psychiatric settings has been widely investigated and its practice recommended in primary and secondary care. In secure forensic mental health services the evidence is less established. The purpose of this paper is to evaluate the effectiveness of group CBT for schizophrenia in a high secure hospital. , – In all, 27 male forensic patients completed a manualised CBT group and were compared on primary and secondary outcomes to patients receiving treatment as usual (TAU). Primary outcomes were positive and negative symptoms as measured by the Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms (SANS) and the Psychotic Symptom Rating Scales (PSYRATS). A secondary outcome was interpersonal functioning as measured by the Inventory of Interpersonal Problems (IIP-64). , – CBT participants showed improvement on negative symptoms; affective flattening, alogia, anhedonia and avolition; in comparison to participants in TAU. CBT participants also showed reductions in delusions and hallucinations on the SAPS but not the PSYRATS. TAU participants improved on positive symptoms as measured by the PSYRATS. CBT participants showed reductions in overall interpersonal problems, and most notably in being socially inhibited and self-sacrificing. No iatrogenic effects of treatment were found; improvements in depression anxiety and stress were reported by group completers, which contrasted to experiences of the TAU group. , – Absence of random allocation to CBP or TAU groups retains the risk of recruitment bias. Findings are preliminary given the sample size. Multiple outcome assessments increase risk of a type I error. , – CBT for schizophrenia can be effective with clients in secure forensic mental health settings. Improvements in negative symptoms and interpersonal functioning appear to be particular gains. Self-report measures might be subject to specific demand characteristics in such settings. , – The evaluation includes a comparator group in a high secure setting, which is typically absent in reported evidence for this population (Blackburn, 2004). The study also investigated changes in interpersonal functioning, which has previously been noted as an important but absent outcome in CBT for psychosis (Haddock et al., 2009). Iatrogenic outcomes were also considered in the evaluation to ensure no adverse effects were experienced from treatment.

A Critical Analysis of Clinical Evidence from High Secure Forensic Inpatient Services

High-secure forensic inpatient hospitals serve important functions in the detention and rehabilitation of people with serious mental health needs who present as a risk to society. Establishing whether services are effective in restoring mental health and reducing risk is an important task, but one that has not been systematically undertaken. A systematic review of outcome evidence from this setting was therefore conducted to establish its scope and quality. Evidence was found from 22 studies for nine different interventions targeting multiple and overlapping outcomes, which included recidivism, mental health, aggression, social functioning and quality of life. Studies were commonly assessed as being at a potentially high risk of bias from validity threats. The ‘best’ available evidence was for medication, psychoeducation and third-wave cognitive-behavioral interventions. Clinical implications are tentatively offered given the narrow focus of the review on high security. Directions for the high-secure services research agenda are more definitively proposed.

Evaluation of anger management groups in a high‐security hospital

BACKGROUND Anger management programmes for offenders typically aim to improve the management of emotion associated with aggressive and antisocial behaviour. Such programmes have been quite extensively evaluated in prison and probation settings, but there is less published research in forensic mental health settings. AIM This study aimed to evaluate anger management groups in a high-security hospital. METHOD Eighty-six patients were referred for a 20-session anger management intervention. Outcomes were self-reported experiences of anger and changes in institutionally documented incidents of aggression. Incident rates were retrospectively reviewed for all group graduates, where data were available, including a comparison group of graduates who acted as their own controls. RESULTS Group graduates reported sustained reductions in feelings of anger and positive changes in their use of aggression in reaction to provocation. Some reduction in incidents of physical aggression was noted when group completers were compared with non-completers. Incidents of verbal aggression were observed to increase for graduates. There was also a trend towards improvement when treated men were compared with men on the waiting list. CONCLUSIONS Our findings contribute to the growing evidence for anger management groups for aggressive men, although the low-base rate of incidents, typical of such a containing and therapeutic hospital setting, rendered the analysis of behavioural outcomes difficult. IMPLICATIONS FOR PRACTICE AND RESEARCH Anger management sessions for male forensic psychiatric patients can be effective in reducing incidents of physical aggression in response to provocation. Evaluation of treatments for anger is particularly difficult in secure and protective settings, where the aim is to keep incidents of actual physical aggression to a minimum. Further research of this kind is needed to test the value of self-reported reduction in angry feelings as an indicator of clinically useful progress.

Essential elements of treatment and care in high secure forensic inpatient services: an expert consensus study

Purpose – The evidence base for what works with forensic patients in high-security inpatient settings has typically focused on outcome research and not included clinical expertise from practice-based experience, which is an important facet of evidence-based practice. The purpose of this paper is to establish whether experts with clinical and/or research experience in this setting could reach consensus on elements of high-security hospital services that would be essential to the rehabilitation of forensic patients. Design/methodology/approach – A three-round Delphi survey was conducted to achieve this aim. Experts were invited to rate agreement with elements of practice and interventions derived from existing research evidence and patient perspectives on what worked. Experts were also invited to propose elements of hospital treatment based on their individual knowledge and experience. Findings – In the first round 54 experts reached consensus on 27 (out of 39) elements that included physical (e.g. use of CCTV), procedural (e.g. managing restricted items) and relational practices (e.g. promoting therapeutic alliances), and to a lesser extent-specific medical, psychological and social interventions. In total, 16 additional elements were also proposed by experts. In round 2 experts (n=45) were unable to reach a consensus on how essential each of the described practices were. In round 3 (n=35), where group consensus feedback from round 2 was provided, consensus was still not reached. Research limitations/implications – Patient case complexity, interventions with overlapping outcomes and a chequered evidence base history for this population are offered as explanations for this finding alongside limitations with the Delphi method. Practical implications – Based on the consensus for essential elements derived from research evidence and patient experience, high-secure hospital services might consider those practices and interventions that experts agreed were therapeutic options for reducing risk of offending, improving interpersonal skills and therapeutic interactions with patients, and mental health restoration. Originality/value – The study triangulates what works research evidence from this type of forensic setting and is the first to use a Delphi survey in an attempt to collate this information.

Mentalisation-based therapy (MBT) in a high-secure hospital setting: expert by experience feedback on participation

Abstract Evidence for mentalisation-based therapy (MBT) is increasing in relation to the treatment of personality disorder. Individuals with personality disorder are over-represented in inpatient, forensic and forensic inpatient mental health services. This study explores MBT within a forensic setting as an intervention designed to moderate deficits linked to violence and to improve adaptive coping. Interpretative phenomenological analysis was conducted on interviews with four patients who completed MBT at a high-secure hospital. Findings suggest that MBT-enhanced participants’ mentalising which had a positive impact upon their capacity to manage their behaviour and emotions. MBT further enabled participants to process past experiences of violence and develop some degree of empathy for others, which led to a trend in abstinence from risk behaviours. Findings contribute a secure inpatient perspective on the experience of MBT and to MBT clinical outcomes.

A psychometric evaluation of the Defence Style Questionnaire-40 in a UK forensic patient population

Abstract Psychological defence mechanisms have been considered important personality processes in the onset, maintenance and recovery of mental disorders. More recently, their application to understanding presenting problems and as potential outcome indicators for forensic patients has been recommended. However, to date there have been no investigations into the reliability and factor structure of defence mechanism assessments for this population. The current study investigated the factor structure, internal consistency and test-retest reliability of the Defence Style Questionnaire-40 (DSQ) for 160 adult male UK forensic patients. The three-factor model of defences proposed by the DSQ-40 developers was not confirmed in the study sample. Reliability indices of the three factors indicated that the Immature factor was the most ‘acceptable’ in terms of internal consistency. Test-retest reliability coefficients ranged from .70 to .91. A revised three-factor structure that closely corresponds to the original validation study is recommended following an exploratory factor analysis. The findings are compared with previous reliability and factor analytic evaluations of the DSQ-40, and recommendations for its use with forensic patients are discussed.