Group treatment in a male low secure mental health service: a treatment description and descriptive evaluation
| Date | 06 May 2014 |
| DOI | https://doi.org/10.1108/JFP-01-2013-0006 |
| Published date | 06 May 2014 |
| Pages | 139-155 |
| Author | Claire Nagi,Jason Davies,Laura Shine |
| Subject Matter | Health & social care,Criminology & forensic psychology,Forensic practice |
Group treatment in a male low secure
mental health service: a treatment
description and descriptive evaluation
Claire Nagi, Jason Davies and Laura Shine
Dr Claire Nagi is a Chartered
Forensic Psychologist, based
at Abertawe Bro Morgannwg
University Health Board,
Swansea, UK and a Senior
Lecturer in Forensic
Psychology at the Applied
Psychology Department,
Cardiff Metropolitan University.
Dr Laura Shine is a Psychiatrist,
based at Abertawe Bro
Morgannwg University Health
Board, Swansea, UK.
Dr Jason Davies is a
Consultant Clinical Forensic
Psychologist, based at
Abertawe Bro Morgannwg
University Health Board and
CHIRAL, School of Medicine,
University of Swansea,
Swansea, UK.
Abstract
Purpose – The purpose of this paper is to describe the development, content and structure of an intensive
group-based intervention designed to address a range of needs common to individuals within low secure
forensic mental health settings. Additionally,the feasibility, acceptability, resource implications and levels of
participation and understanding are evaluated.
Design/methodology/approach – This paper describes the development, content and structure of an
intensive group-based intervention designed to address a range of needs common to individuals within low
secure forensic mental health settings. Additionally, the feasibility, acceptability, resource implications and
levels of participation and understanding are evaluated.
Findings – Analysis showed that the intervention was well received by staff and participants and that those
with low self-report knowledge at the start showed large improvements. Recorded levels of participation and
understanding were lower than expected.
Research limitations/implications – Group-based interventions in low secure settings canbe developed
from existing “what works”information. Such treatments can feasibly be delivered although participants
may need support – something which is not reported in many intervention studies. Research is now needed
to assess the impact of the General Treatment& Recovery Programme (GTRP) intervention on participants.
Originality/value – The development of treatment programmes for offending behaviour within low secure
forensic mental health settings is still in its infancy. This paper outlines and describes the development of
such an intervention, namely the GTRP.
Keywords Recidivism, Low secure, Offender treatment, Outcome, What works
Paper type Research paper
Low secure mental health settings provide “intensive, comprehensive, multidisciplinary
treatment [y] for patients who demonstrate disturbed behaviour in the context of a serious
mental disorder and who require the provision of security [y] underpinned by the principles of
rehabilitation and risk management” (Pereira and Clinton, 2002, p. 4). Estimates suggest that
there are over 1,500 individuals detained in the approximately 140 low secure units in the UK
(Pereira et al., 2006). Some of these individuals form part of the larger number of around 4,000
mentally disordered offenders (MDOs) subject to restriction orders in hospitals in England and
Wales (Ministry of Justice, 2010). Given that low secure services act as the final staging post
before reintegration back into the community (Prins, 2005), specialist interventions designed to
address mental health needs, offending behaviour and risk in this population are important for
rehabilitation, community integration and long-term risk management.
At present, group interventions are used in secure mental health services to address a range of
offending behaviour needs (e.g. Davies and Oldfield, 2009) many of which are based on
programmes developed for prison populations. However there is limited outcome evidence
for “mainstream offender-based treatment programmes” when applied to forensic inpatient
DOI 10.1108/JFP-01-2013-0006 VOL. 16 NO. 2 2014, pp. 139-155, CEmerald Group Publishing Limited, ISSN 2050-8794
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JOURNAL OF FORENSIC PRACTICE
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populations (Blackburn, 2004; Nagi and Davies, 2010a). This has led some to develop
specialised programmes or adaptations of existing interventions for MDOs who have engaged in
specific forms of offending (e.g. violence). However the evidence for their use is still being
developed (e.g. Braham et al., 2008; Ireland, 2007). Other offending behaviours such as those
considered “general offending” (e.g. burglary, theft, drug and car crime) have not be subject
to specific interventions to date despite the comparative high rate of such offences (compared
to sexual or violent assault) amongst those in secure settings. Instead, treatment for “general
offending” has tended to focus on wider criminogenic factors such as cognitive skills (i.e.
Enhanced Thinking Skills, Reasoning and Rehabilitation) and social problem solving (e.g. Think
First; McGuire, 2005 and Stop and Think!; McMurran et al., 2001; McMurran and McGuire,
2005).
In addition to criminogenic need, a range of other factors require attention within forensic mental
health settings. From a traditional risk/harm reduction viewpoint these have sometimes been
identified as specific responsivity factors, i.e. they need to be addressed because they may
interfere with treatment or impact on motivation when addressing criminogenic factors (Andrews
and Bonta, 2010). Whilst some evidence suggests that affect, for example, may be important
to address in order to maximise engagement with interventions (Howells and Day, 2006), it is
becoming more widely accepted that factors such as emotion regulation and management,
mental health/wellbeing and dysfunctional coping (e.g. substance misuse) may be important in
their own right in the pathway to offending.
It has been noted that the focus on cognitive skills programmes has resulted in very little
emphasis or consideration of emotion in offender decision making and behaviour (Ward and
Nee, 2009). The empirical evidence demonstrates the role of strong emotions in the offence
chains for both violent and sexual offending (Howells et al., 2004; Polaschek et al., 2001) and
that offenders struggle to experience and accurately label their emotional states (Day et al.,
2008b). Consequently, psychological interventions designed to increase emotional awareness
and emotional regulation may have an important role in offender treatment (Day et al., 2006,
2008a; Ward and Nee, 2009) although further research is needed to establish the criminogenic
status of negative emotional states (Day, 2009). In the wider context, mood states and problems
with emotional regulation are also known to be important factors in mental health problems and
substance misuse (Moses and Barlow, 2006; Axelrod et al., 2011). Therefore the need to
address affective determinants to engagement and wider emotional regulation problems are
likely to be an important treatment component when working with MDOs.
The treatment needs associated with mental health and recovery are also important
considerations for low secure settings. The stress-vulnerability model of schizophrenia (Zubin
and Spring, 1977) suggests that the severity and cause of symptoms are determined by three
different factors: biology, vulnerability and stress/coping skills. Research indicates that whilst
70 per cent of patients show improvement in psychotic symptoms with neuroleptic drugs, many
still experience distressing and recurrent symptoms (Curson et al., 1988). Since major mental
illness is a modest risk factor of violence, psychological treatment addressing stress and
vulnerability factors for mental health issues should be incorporated into interventions designed
to address offending in mentally disordered populations. In addition, it is well documented that
there are high rates of historic substance misuse among MDOs detained in forensic settings and
that substance misuse is associated with serious violent offending in these populations (D’Silva
and Ferriter, 2003; Oddie and Davies, 2009; Quayle et al., 1998; Ritchie et al., 2003). Substance
misuse is the strongest predictor of relapse and reoffending following discharge in mentally
disordered populations (Scott et al., 2004), with offenders most likely to seriously reoffend being
those with significant substance misuse prior to the original offence (Norris, 1984). Other studies
have found significant co-morbidity between Axis I and Axis II disorders among offenders (Rotter
et al., 2002), highlighting the requirement for treatment targets to be tailored towards personality
pathology among offenders, as well as major mental illness.
There is growing support for the argument that interventions should also emphasise the
importance of protective factors and strengths (Andrews and Bonta, 2010; Ward and Maruna,
2007), in addition to addressing identified problems and needs. One approach that has been
used is the development of “good life” plans which take into account factors including an
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