Michael Doyle

International Perspectives on the Practical Application of Violence Risk Assessment: A Global Survey of 44 Countries

Mental health professionals are routinely called upon to assess the risk of violence presented by their patients. Prior surveys of risk assessment methods have been largely circumscribed to individual countries and have not compared the practices of different professional disciplines. Therefore, a Web-based survey was developed to examine methods of violence risk assessment across six continents, and to compare the perceived utility of these methods by psychologists, psychiatrists, and nurses. The survey was translated into nine languages and distributed to members of 59 national and international organizations. Surveys were completed by 2135 respondents from 44 countries. Respondents in all six continents reported using instruments to assess, manage, and monitor violence risk, with over half of risk assessments in the past 12 months conducted using such an instrument. Respondents in Asia and South America reported conducting fewer structured assessments, and psychologists reported using instruments more than psychiatrists or nurses. Feedback regarding outcomes was not common: respondents who conducted structured risk assessments reported receiving feedback on accuracy in under 40% of cases, and those who used instruments to develop management plans reported feedback on whether plans were implemented in under 50% of cases. When information on the latter was obtained, risk management plans were not implemented in over a third of cases. Results suggest that violence risk assessment is a global phenomenon, as is the use of instruments to assist in this task. Improved feedback following risk assessments and the development of risk management plans could improve the efficacy of health services.

Using social media for support and feedback by mental health service users: thematic analysis of a twitter conversation

BackgroundInternet based social media websites represent a growing space for interpersonal interaction. Research has been conducted in relation to the potential role of social media in the support of individuals with physical health conditions. However, limited research exists exploring such utilisation by individuals with experience of mental health problems. It could be proposed that access to wider support networks and knowledge could be beneficial for all users, although this positive interpretation has been challenged. The present study focusses on a specific discussion as a case study to assess the role of the website www.twitter.com as a medium for interpersonal communication by individuals with experience of mental disorder and possible source of feedback to mental health service providers.MethodAn electronic search was performed to identify material contributing to an online conversation entitled #dearmentalhealthprofessionals. Output from the search strategy was combined in such a way that repeated material was eliminated and all individual material anonymised. The remaining textual material was reviewed and combined in a thematic analysis to identify common themes of discussion.Results515 unique communications were identified relating to the specified conversation. The majority of the material related to four overarching thematic headings: The impact of diagnosis on personal identity and as a facilitator for accessing care; Balance of power between professional and service user; Therapeutic relationship and developing professional communication; and Support provision through medication, crisis planning, service provision and the wider society. Remaining material was identified as being direct expression of thanks, self-referential in its content relating to the on-going conversation or providing a link to external resources and further discussion.ConclusionsThe present study demonstrates the utility of online social media as both a discursive space in which individuals with experience of mental disorder may share information and develop understanding, and a medium of feedback to mental health service providers. Further research is required to establish potential individual benefit from the utilisation of such networks, its suitability as a means of service provision feedback and the potential role for, and user acceptability of, mental health service providers operating within the space.

Predicting Post-Discharge Community Violence in England and Wales Using the HCR-20V3

Structured guidelines are fundamental for risk assessment, formulation and decision-making in medium secure forensic psychiatric services in the UK. The most commonly used guideline for violence risk assessment in the UK is the HCR-20, so it is important that the new version of the HCR-20 (HCR-20V3) is validated in UK samples. The aims of this study were to investigate if the HCR-20V3 has satisfactory interrater reliability and predictive validity for community violence. A prospective confidential inquiry design was used. The HCR-20V3 demonstrated very good inter-rater reliability and significantly predicted community violence at six and twelve months post-discharge, with ROC AUCs of .73 and .70 respectively. Implications for future research and practice are discussed.

Personal recovery within forensic settings – Systematic review and meta‐synthesis of qualitative methods studies

BACKGROUND Many mental health services now explicitly aim to support personal recovery. Are there special ethical and practical considerations for application of this model in forensic mental health services? Is there, for example, any conflict in this context between personal empowerment and risk management? AIM Our aim was to develop a model of the personal recovery processes for people needing forensic mental health services. METHODS A systematic literature review was conducted and meta-synthesis applied to data from relevant papers. RESULTS Five studies were identified through the search process and combined through meta-synthesis. Three key overarching themes were synthesised: safety and security as a necessary base for the recovery process, the dynamics of hope and social networks in supporting the recovery process and work on identity as a changing feature in the recovery process. CONCLUSIONS The themes identified provide for theoretically informed and testable developments in care that could enhance the quality of recovery and rehabilitation for offender patients through explicitly enhancing personal sense of safety, understanding the patients sense of personal identity and their social networks and transitioning between institutional and community support.

Personal recovery within forensic settings - Systematic review and meta-synthesis of qualitative methods studies, Criminal Behaviour & Mental Health

BACKGROUND Many mental health services now explicitly aim to support personal recovery. Are there special ethical and practical considerations for application of this model in forensic mental health services? Is there, for example, any conflict in this context between personal empowerment and risk management? AIM Our aim was to develop a model of the personal recovery processes for people needing forensic mental health services. METHODS A systematic literature review was conducted and meta-synthesis applied to data from relevant papers. RESULTS Five studies were identified through the search process and combined through meta-synthesis. Three key overarching themes were synthesised: safety and security as a necessary base for the recovery process, the dynamics of hope and social networks in supporting the recovery process and work on identity as a changing feature in the recovery process. CONCLUSIONS The themes identified provide for theoretically informed and testable developments in care that could enhance the quality of recovery and rehabilitation for offender patients through explicitly enhancing personal sense of safety, understanding the patients sense of personal identity and their social networks and transitioning between institutional and community support.

Risk Formulation: What are We Doing and Why?

In this short article, a critical look is taken at practice and process surrounding the use of formulation in relation to violence risk assessment within a forensic context. The historical background to the adoption of formulation as a component within clinical risk assessment and management is outlined, and questions are highlighted in relation to the paucity of research evaluating the approach. Despite potential limitations in terms of evidence base, it is noted that the use of risk formulation has risen in popularity, which, in view of the high stakes that characterize the forensic mental health context, may be an issue that merits debate. Central issues are discussed, and broad questions that may be useful to explore in future research are suggested.

Suicide risk in primary care patients diagnosed with a personality disorder: a nested case control study

BackgroundPersonality disorder (PD) is associated with elevated suicide risk, but the level of risk in primary care settings is unknown. We assessed whether PD among primary care patients is linked with a greater elevation in risk as compared with other psychiatric diagnoses, and whether the association is modified by gender, age, type of PD, and comorbid alcohol misuse.MethodsUsing data from the UK Clinical Practice Research Datalink, 2384 suicides were matched to 46,899 living controls by gender, age, and registered practice. Prevalence of PD, other mental disorders, and alcohol misuse was calculated for cases and controls separately and conditional logistic regression models were used to estimate exposure odds ratios. We also fitted gender interaction terms and formally tested their significance, and estimated gender age-specific effects.ResultsWe found a 20-fold increase in suicide risk for patients with PD versus no recorded psychiatric disorder, and a four-fold increase versus all other psychiatric illnesses combined. Borderline PD and PD with comorbid alcohol misuse were associated with a 37- and 45-fold increased risk, respectively, compared with those with no psychiatric disorders. Relative risks were higher for female than for male patients with PD. Significant risks associated with PD diagnosis were identified across all age ranges, although the greatest elevations were in the younger age ranges, 16–39 years.ConclusionsThe large elevation in suicide risk among patients diagnosed with PD and comorbid alcohol misuse is a particular concern. GPs have a potentially key role to play in intervening with patients diagnosed with PD, particularly in the presence of comorbid alcohol misuse, which may help reduce suicide risk. This would mean working with specialist care, agreed clinical pathways and availability of services for comorbidities such as alcohol misuse, as well as opportunities for GPs to develop specific clinical skills.

Discharges to prison from medium secure psychiatric units in England and Wales

BACKGROUND Early findings from a national study of discharges from 32 National Health Service medium secure units revealed that nearly twice as many patients than expected were discharged back to prison. AIMS To compare the characteristics of those discharged back to prison with those discharged to the community, and consider the implications for ongoing care and risk. METHOD Prospective cohort follow-up design. All forensic patients discharged from 32 medium secure units across England and Wales over a 12-month period were identified. Those discharged to prison were compared with those who were discharged to the community. RESULTS Nearly half of the individuals discharged to prison were diagnosed with a serious mental illness and over a third with schizophrenia. They were a higher risk, more likely to have a personality disorder, more symptomatic and less motivated than those discharged to the community. CONCLUSIONS Findings suggest that alternative models of prison mental healthcare should be considered to reduce risks to the patient and the public.

The effectiveness of an enhanced thinking skills programme in offenders with antisocial personality traits

Although evidence is emerging that enhanced thinking skills (ETS) interventions are effective in reducing recidivism in prisoners, there is limited evidence supporting the effectiveness of ETS improving behaviour and functioning in prisoners with antisocial personality disorder (ASPD) traits. This study investigated the effectiveness of a group ETS programme in improving antisocial attitudes, anger regulation and social problem-solving skills in offenders with traits diagnostic of ASPD. A controlled trial was conducted comparing ETS programme with treatment as usual (TAU). Outcome measures were the Antisocial Personality Questionnaire, the Novaco Anger Scale and the Social Problem-Solving Inventory-Short Form. Significant improvements in the ETS group on all of the outcome measures were evident, when compared to TAU group. This study provides evidence that cognitive skills programmes based on ETS improve functioning in offenders with traits diagnostic of ASPD. The ETS programmes may be a therapeutic option when working with this historically difficult to treat group. However, further research is required that includes a randomised design, more objective behavioural outcome measures and a longer follow-up period.

Exploratory trial of schema-focussed therapy in a forensic personality disordered population

Abstract The management of needs and risks in personality disordered offender populations has become a focus for health and criminal justice services in the UK. Recent studies demonstrate the effectiveness of schema focussed therapy (SFT) for patients with borderline personality disorder. This study was an exploratory trial of the feasibility of implementing SFT in a population of patients with personality disorder in a high secure hospital in England. Preliminary evaluations of the effects of SFT were conducted to investigate whether those receiving SFT demonstrated significant improvements on measures of anger, impulsiveness, schemata and interpersonal style. No significant effects were evident although there was a significant increase in defectiveness/shame schema in the SFT group. Lack of effectiveness of SFT is likely due to the preliminary nature of this study. Future trials of SFT need to ensure comprehensive therapist preparation, control of TAU, bigger samples, address attrition and provide more intensive therapy.