Therapeutic alliance in forensic mental health: coercion, consent and recovery

Unleashing compassionate care: canine-assisted intervention as a promising harm reduction approach to prisonization in Canada and its relevance to forensic psychiatry

In recent years, there has been a global advancement in the offering of canine-assisted interventions (CAI) in prisons. However, these programs have focused primarily on the benefits to the dogs involved and not on the impact on the participants. The authors of this perspective study have been running a CAI program with therapy dogs, called PAWSitive Support, in a Canadian federal prison since 2016. Thoughts from the program facilitators and interviews with prison staff indicate that the program, and specifically the therapy dogs, provides a unique and integrated source of comfort, support, and love for participants. These benefits are consistent with those seen in CAI programs outside of prisons. Unique to the prison setting appears to be an improvement in participant-staff relations. The therapy dogs have helped participants to experience comfort and consequently express their emotions. This seems to contribute to their recognition of support within the prison system and specifically developing trust with staff. Additionally, the dogs have helped to create an experience of the feeling of love within the prison, interpreted as the feeling of being cared for, which is rare for this population. The authors suggest that the integration of a therapy dog intervention in prison could be a novel harm reduction strategy to address issues related to prisonization and associated mental health concerns, including substance use. This consideration can offer unique insight into the field of forensic psychiatry about providing compassionate care to patients.

Positive and negative syndrome scale in forensic patients with schizophrenia spectrum disorders: a systematic review and meta-analysis

Among forensic patients with schizophrenia spectrum disorders, the association between symptomatology and violence is still not entirely clear in literature, especially because symptoms shift both during the acute phase of the illness and after. The aims were to investigate the level of symptomatology in forensic patients and to evaluate if there are differences in the level of symptoms between forensic and non-forensic patients. According to PRISMA guidelines, a systematic search was performed in PubMed, Web of Science, and ProQuest, using the following key words: "forensic" AND "Positive and Negative Syndrome Scale" OR "PANSS". A total of 27 studies were included in the systematic review, while only 23 studies in the meta-analysis. The overall sample included a total of 1702 participants, most commonly male and inpatients in forensic settings. We found that studies with an entirely male sample had significantly lower Positive PANSS ratings than studies with mixed samples. Although both forensic and non-forensic patients were affected by mild psychopathological symptoms, forensic patients presented higher ratings in all four PANSS scales. This meta-analysis shows that forensic patients reported a mild level of symptomatology, as assessed with the PANSS, and therefore might be considered as patients in partial remission. Among patients with schizophrenia, the association between symptoms and violence is very complex: many factors might be considered as key mediators and thus should be taken into account to explain this association. Further studies are needed.Trial registration all materials and data can be found on the OSF framework: https://osf.io/5ceja (date of registration: 8 September 2021).

Prospective cohort study of the evaluation of patient benefit from the redevelopment of a complete national forensic mental health service: the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST) protocol

INTRODUCTION

Secure forensic mental health services are low volume, high cost services. They offer care and treatment to mentally disordered offenders who pose a high risk of serious violence to others. It is therefore incumbent on these services to systematically evaluate the outcomes of the care and treatment they deliver to ensure patient benefit in multiple domains. These should include physical and mental health outcomes, as well as offending related outcomes. The aim of Dundrum Forensic Redevelopment Evaluation Study (D-FOREST) is to complete a structured evaluation study of a complete national forensic mental health service, at the time of redevelopment of the National Forensic Mental Health Service for the Ireland.

METHODS AND ANALYSIS

D-FOREST is a multisite, prospective observational cohort study. The study uses a combination of baseline and repeated measures, to evaluate patient benefit from admissions to forensic settings. Patients will be rated for physical health, mental health, offending behaviours and other recovery measures relevant to the forensic hospital setting at admission to the hospital and 6 monthly thereafter.Lagged causal model analysis will be used to assess the existence and significance of potential directed relationships between the baseline measures of symptomatology of schizophrenia and violence risk and final outcome namely length of stay. Time intervals including length of stay will be measured by median and 95% CI using Kaplan-Meier and Cox regression analyses and survival analyses. Patient related measures will be rated as changes from baseline using general estimating equations for repeated measures, analysis of variance, analysis of covariance or logistic regression.

ETHICS AND DISSEMINATION

The study has received approval from the Research Ethics and Effectiveness Committee of the National Forensic Mental Health Service, Ireland. Results will be made available to the funder and to forensic psychiatry researchers via international conferences and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05074732.

Online video games and patient-staff power relations. A qualitative study of care and custody in forensic psychiatry

WHAT IS KNOWN ON THE SUBJECT?: Frontline forensic mental health staff often face challenges when providing recovery-orientated care, as they must balance between caring for the forensic psychiatric patient and at the same time ensuring safety and security for all other patients and staff at the ward. Research shows that balancing between care and custody in everyday clinical practice is possible, but more practical nursing studies showing ways of balancing power relations are needed to guide clinical practice. Online video games are increasingly recognized as promising new tools to promote social relations, establish competencies and re-articulate power relations in therapeutic environments. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides insights into how using online video gaming interventions may influence the establishment of social power relations of staff and forensic psychiatric patients. It adds to existing research by providing a conceptual way to study and understand how mental health nurses may balance between care and custody, delivering care to accommodate patients' needs without compromising safety and security at the ward. This study answers a call in current research by providing qualified knowledge regarding the use of online video gaming to build and sustain therapeutic relations in mental health care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our paper suggests that balancing between care and custody is possible by using online video gaming interventions in forensic psychiatry. It moreover provides practice-close knowledge that may inspire and guide clinical mental health nurses to further develop online video gaming interventions in mental health care for the benefit of their patients. ABSTRACT: Introduction In recovery-oriented care, forensic psychiatric nurses must engage in care relationships with forensic psychiatric patients (FPs) whilst focussing on ward security. Online video games (OVGs) may provide a platform for negotiating power and social relations. Studies showing how OVG interventions may influence power balances in forensic psychiatric care are needed to guide clinical practice. Aim Our aim was to study how power relations were articulated between FPs and staff in an OVG intervention in a Danish forensic psychiatric ward. Method Data consist of three months of observational data and interviews with three staff members and six patients. We used sociologist Pierre Bourdieu's framework of field, power and capital to analyze data. Results The OVG intervention consisted of two power fields, "in-game" and "over-game." In-game concerned the practice of gaming. Over-game described the organization of the gaming intervention. Specific logics, skills and symbolic capitals drove power in each field. Discussion Power in-game was open to FPs and staff, leading to symmetric power relations. Power over-game was open to staff only, resulting in asymmetrical power relations. Implications for practice Online video game interventions may facilitate power balancing in forensic psychiatry. These insights may guide the development of new OVG interventions for patients and nurses in mental health care.

Privacy and safety: Issues of dual compliance in high-secure and other forensic psychiatric hospitals

Health care organizations are obligated to provide safe and effective treatment to their patients and also protect the safety of their workers. This paper analyzes the tensions arising from legislative regimes that, respectively, protect privacy and workplace safety, using a large, tertiary high-secure forensic psychiatric hospital in Ontario, Canada, as an example. In Ontario, the Personal Health Information Protection Act (PHIPA) prohibits personal health information (PHI) from being disclosed to individuals who fall outside the "circle of care," including nonclinical employees who have direct involvement with patients and may be at risk of violence. PHIPA permits the disclosure of information where there is a risk of violence, but the statute's scheme for privacy protection was not designed to address, and may not be compatible with, the operations and requirements of high-secure forensic and other psychiatric hospitals. At the same time, the Occupational Health and Safety Act (OHSA) creates a regulatory framework that sets health and safety standards, including an employer's duty to disclose the risk of violence. OHSA prosecutions and proceedings demonstrate how these duties have been enforced against psychiatric hospitals. We examine this regulatory backdrop, explaining that PHIPA provides little guidance to psychiatric hospitals, where the risk of violence is elevated. We also discuss issues of dual compliance that arise from a hospital's legal obligations under PHIPA and OHSA. Finally, we turn to the ongoing clinical and operational challenges, suggesting strategies for increasing staff safety. These include strengthening the therapeutic alliance and providing patients with the option of consenting to disclosure of PHI to those outside the circle of care.

Validation of a patient-reported measure of social support provided by nurses in breast cancer care (SuPP-N): based on a cross-sectional patient survey in 83 German hospitals

OBJECTIVES

To validate the patient-reported measure of Social Support Perceived by Patients Scale-Nurses (SuPP-N).

DESIGN/SETTING

A secondary data analysis based on a cross-sectional breast cancer patient survey in 83 German hospitals. Patients were asked to give written informed consent before they were discharged. If they agreed to participate, the questionnaire was sent via mail to their home address after discharge.

PARTICIPANTS

Of 5583 eligible patients, 4841 consented to participate in the study and 4217 returned completed questionnaires (response rate: 75.5 %). For the data analysis n=3954 respondents were included. On average, participants were 60 years old and mostly in cancer stages I and II.

PRIMARY AND SECONDARY OUTCOME MEASURES

Perceived social support was assessed with a three-item patient-reported scale (SuPP-N). Convergent validity and criterion-related validity were tested using the following constructs: trust in nurses, trust in the treatment team (Wake Forest Physician Trust Scale, adapted), quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire), processes organisation, availability of nurses.

RESULTS

The structural equation model (SEM) assuming a one-dimensional structure of the instrument showed acceptable goodness of fit (root mean square error of approximation=0.04, Comparative Fit Index=0.96 and Tucker-Lewis Index=0.96; factor loadings ≥0.83). Hypothesis-consistent correlations with trust in nurses (beta=0.615; p<0.01) and trust in the treatment team (beta=0.264; p<0.01) proved convergent validity. Criterion-related validity was proved by its association with patients' quality of life (beta=-0.138; p<0.01), processes organisation (beta=-0.107; p<0.01) and the availability of nurses (beta=0.654; p<0.01).

CONCLUSION

The results of the SEM identify potential important factors to foster social support by nurses in cancer care. In patient surveys, the SuPP-N can be used efficiently to measure patient-reported social support provided by nurses. The use of the scale can contribute to gain a better understanding of the relevance of social support provided by nurses for patients and to detect possible deficits and derive measures with the aim of improving the patient-nurse interaction.

Strong Associations Between Childhood Victimization and Community Violence in Male Forensic Mental Health Patients

Background: Childhood abuse and neglect increase the risk of both mental disorders and violent behavior. Associations between child relational adversities and violent behavior have not been extensively investigated in forensic mental health settings. We asked whether the extent of child adversities predicts the extent of violence in the community in forensic mental health patients. Methods: We included 52 male patients at a medium security forensic mental health ward, with diagnoses of predominantly paranoid schizophrenia and other schizophrenia and psychotic disorders. Seventy-five percent had comorbid substance abuse. We extracted information on six types of child adversities based on clinicians' administrations of the Historical Clinical Risk Management 20 version 3 (HCR 20) scale and summary notes in electronic patient journals. These same sources were used to extract information on war trauma and interpersonal violence in the community. We established cumulative scales for exposure to number of types of child adversities and number of incidents of community violence. Results: Physical and emotional abuse, emotional and physical neglect, and bullying were associated with higher levels of community violence. We observed a linear, significant increase in the frequency of community violence with cumulative numbers of child adversity types. Conclusions: Cumulative exposure to child adversities may be associated with higher degrees of violence in forensic mental health patients, with the most violent patients having the most extensive exposures to adversities. An enhanced focus on child adversities in risk assessment and management of violence may be considered in forensic inpatient settings.

The Perspective of Forensic Inpatients With Psychotic Disorders on Protective Factors Against Risk of Violent Behavior

Background: Little is known about the opinions of forensic inpatients with psychotic disorders like schizophrenia on factors likely to prevent or decrease future violent behavior. Aims: To understand the perspectives of forensic inpatients with psychotic disorders on protective factors against risk of violent behavior and compare them to factors identified by professional staff. Method: Using the Structured Assessment of Protective Factors (SAPROF) checklist for self-appraisal of violence risk, we conducted semi-structured interviews with 32 inpatients of the Medical Treatment and Supervision Act Ward and compared the results with those of professionals. Results: Inpatients scored higher in the SAPROF total score, the motivational factors of "life goals" and "motivation for treatment," and the protective level in general. Inpatients scored themselves lower in risk level than professionals. The degree of agreement between service users' and professionals' evaluations was low for all categories except external factors. Inpatients prioritized "life goals," "self-control," and "medication" as the top three key strengths currently preventing violent behavior, whereas the professionals selected "life goals" less often. The top three important future goals for preventing future violence selected by inpatients were "work," "intimate relationships," and "life goals," with the former two being selected significantly less often by the professionals. Conclusions: This is the first study to shed light on Japanese forensic inpatients' perspectives about preventing future violent behavior. Despite professionals' underestimation, inpatients viewed themselves as having high motivation for treatment and positive life goals. Inpatients prioritized personal values such as life goals, work, and intimate relationships, whereas professionals prioritized understanding, treating, and observing the disease. Our findings are consistent with past reports on patients' and clinicians' perspectives. Awareness of such gaps in perceptions can help build fruitful therapeutic alliances. We discuss the implications in terms of treatment, how to address the gap therapeutically, and how to design treatment accordingly. Directions for future research are also discussed.

The relationship between the therapeutic alliance and client variables in individual treatment for schizophrenia spectrum disorders and early psychosis: Narrative review

Given the high rates of treatment disengagement and medication nonadherence in individuals with schizophrenia spectrum disorders and early psychosis, fostering a strong alliance in treatment is critical. Moreover, the role of the therapeutic alliance extends beyond that in traditional psychotherapy because of the multifaceted nature of treatment. Thus, this review provides a comprehensive discussion of the relationship between the alliance and client variables across various provider types and individual treatments. This review summarizes existing research on (a) client correlates/predictors of the therapeutic alliance and on (b) the relationship between the alliance and client treatment outcomes in individual treatment for schizophrenia spectrum disorders and early psychosis. Parallel literature searches were conducted using PubMed and PsycINFO databases, which yielded 1202 potential studies with 84 studies meeting inclusion criteria. With regard to correlates/predictors, the existing evidence suggests that better insight, medication adherence, social support, and recovery variables were related to better client-rated alliance. Better medication adherence and recovery variables as well as less severe symptoms were related to better provider-rated alliance. In terms of alliance-outcome relationships, evidence suggests that a strong provider-rated alliance was predictive of improved functioning and medication and treatment adherence. There was some limited evidence that better client-rated alliance was related to improved recovery outcomes. Despite mixed results and heterogeneity among studies, this review suggests that a strong alliance can be beneficial in individual schizophrenia treatment. Thus, training and supervision of providers should emphasize developing a positive alliance, particularly with clients for whom developing an alliance may be difficult.

Client predictors of the therapeutic alliance in individual resiliency training for first episode psychosis

Individuals experiencing their first episode of psychosis (FEP) are often reluctant to seek treatment, and are difficult to engage and retain in mental health services. The therapeutic alliance (TA), or the affective and collaborative bond between therapist and client, is predictive of better treatment outcomes for clients with FEP; thus, it is important to understand the predictors of the TA in order to determine how best to foster a positive alliance with these individuals. The primary aim of the present study was to examine whether baseline client characteristics, including severity of symptoms, social functioning, and insight, were associated with the TA. The exploratory aim was to examine associations between demographic variables (age, race, and gender) and the TA. The present study included a subsample of participants (n = 134) who received Individual Resiliency Training (IRT) as part of the NAVIGATE treatment in the Recovery After An Initial Schizophrenia Episode Early Treatment Program study. Four trained research assistants rated the TA from early audiotaped sessions of IRT. Multilevel modeling was utilized given the nested data structure. Results indicated that more severe positive and less severe negative symptoms were significantly and uniquely associated with a better therapeutic alliance, as was female gender. The findings suggest that client symptom profiles should be considered when developing a TA with FEP clients.

Measuring therapeutic relationship in the care of patients with haemophilia: A scoping review

OBJECTIVE

We conducted a scoping review of the tools used to measure therapeutic relationship in patients with haemophilia.

BACKGROUND

Haemophilia is an inherited bleeding disorder caused by a deficiency of a clotting factor in the blood. Therapeutic relationship is foundational to the management of patients with chronic diseases like haemophilia. A reliable and valid measurement tool for assessing therapeutic relationship is needed to evaluate the quality of care received by these patients, and to rigorously study the association between therapeutic relationship and the outcomes of treatment.

METHODS

We adopted the Arksey and O'Malley framework for scoping studies. The following electronic databases were searched for studies that measured a construct related to therapeutic relationships in haemophilia care: MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus. We inventoried these studies, identified the measurement tools used, and described each tool by purpose, content, measurement properties and target population. We identified gaps in the current evidence and directions for future research.

RESULTS

There were 253 unique records retrieved in the search, and twenty studies were deemed relevant. Ten measurement tools were identified. None of the tools measured therapeutic relationship as a single entity; however, six tools measured constructs considered part of patient-provider relationship (eg trust, communication, working alliance). There has been little validation testing of these tools in haemophilia patient populations.

CONCLUSIONS

There is a need for a validated tool for measuring therapeutic relationship in the care of patients with haemophilia. This review provides a foundation for future research in this area.

Victimization and Vulnerability: A Study of Incarceration, Interpersonal Trauma, and Patient-Physician Trust

Despite the critical importance of patient-physician trust, it may be compromised among vulnerable patients, such as (1) incarcerated patients and (2) those patients who have been victims of trauma. The purpose of this study was to examine patient-physician trust among forensic and civilian psychiatric inpatient populations and to explore whether it varied based on a patient's history of incarceration and/or victimization. A trust survey (WFPTS) and a trauma instrument (LEC-5) were administered to 93 patients hospitalized on forensic and civilian psychiatric hospital units in a large, urban public hospital. Results showed no difference in patient-physician trust between incarcerated and civilian patients. Similarly, there was no effect of a history of physical assault or sexual assault on ratings of patient-physician trust. However, the hospitalized civilian and forensic patients who reported being the victim of weapons assault had significantly lower patient-physician trust scores than their counterparts.

Psychodynamic Treatment of the Criminal Offender: Making the Case for Longer-Term Treatment in a Longer-Term Setting

In recent years, prisons and jails have become de facto psychiatric hospitals, responsible for the care and treatment of individuals with serious mental illness. Historically, cognitive-behaviorally informed therapeutic approaches have been the treatment of choice among mental health practitioners in correctional settings. However, inmate-clients often present with complex diagnostic issues that are arguably better served by long-term treatment options, such as psychodynamic psychotherapy. We first review the nature of psychotherapy in the correctional setting, as well as treatment barriers and challenges faced by both mental health providers and inmate-clients. We then review treatment studies that examine the efficacy of various therapeutic techniques in correctional/forensic contexts. Finally, we argue that, due to the complex nature of psychopathology, average length of time incarcerated, and treatment issues that arise in this multifaceted and challenging setting, mental health treatment providers should consider providing psychodynamic treatment modalities when working with incarcerated individuals. We also argue that more research is needed to examine the efficacy of these treatment approaches with inmate-clients.

Colleague and patient appraisal of consultant psychiatrists and the effects of patient detention on appraisal scores

Aims and method This paper aims to review colleague and patient feedback from the 10-year period of the operation of the Royal College of Psychiatrists' 360-degree appraisal system, specifically: (1) examine the overall distribution of ratings; (2) examine the effect of working primarily with detained patients on patient feedback, represented by forensic psychiatrists; and (3) look for a relationship between colleague and patient ratings. Results Data were analysed for 977 participating psychiatrists. Both colleagues and patients rated psychiatrists overall with high scores. Less than 1% were identified as low scorers, although there was no relationship between those identified by colleagues or patients. Colleague and patient feedback scores varied little between subspecialties including forensic consultants. Clinical implications Psychiatrists in all subspecialties obtained high scores from colleagues and staff. Working with detained patients appeared to have little effect on patient ratings.

Therapeutic alliance in mental health nursing: an evolutionary concept analysis

The concept of therapeutic alliance is relevant in contemporary mental health care, as the consumer-led recovery movement promotes the development of collaborative relationships, and is focussed on the consumer's individual concept of wellbeing. An evolutionary concept analysis was undertaken to establish a contemporary interpretation of therapeutic alliance for mental health nursing. The CINAHL, Scopus and PsycINFO databases were searched for articles (n = 322), with 52 deemed appropriate for analysis. Therapeutic alliance is characterised by mutual partnerships between nurses and consumers, and is dependent on a humanistic healthcare culture. Therapeutic alliance is associated with enhanced consumer outcomes and experiences with care.

Recovery and concordance in a secure forensic psychiatry hospital - the self rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales

BACKGROUND

Detention in a secure forensic psychiatric hospital may inhibit engagement and recovery. Having validated the clinician rated DUNDRUM-3 (programme completion) and DUNDRUM-4 (recovery) in a forensic hospital, we set out to draft and validate scales measuring the same programme completion and recovery items that patients could use to self-rate. Based on previous work, we hypothesised that self-rating scores might be predictors of objective progress including conditional discharge. We hypothesised also that the difference between patients' and clinicians' ratings of progress in treatment and other factors relevant to readiness for discharge (concordance) would diminish as patients neared discharge. We hypothesised also that this difference in matched scores would predict objective progress including conditional discharge.

METHOD

In a prospective naturalistic observational cohort study in a forensic hospital, we examined whether scores on the self-rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales or differences between clinician and patient ratings on the same scales (concordance) would predict moves between levels of therapeutic security and conditional discharge over the next twelve months.

RESULTS

Both scales stratified along the recovery pathway of the hospital, but clinician ratings matched the level of therapeutic security more accurately than self ratings. The clinician rated scales predicted moves to less secure units and to more secure units and predicted conditional discharge but the self-rated scores did not. The difference between clinician and self-rated scores (concordance) predicted positive and negative moves and conditional discharge, but this was not always an independent predictor as shown by regression analysis. In regression analysis the DUNDRUM-3 predicted moves to less secure places though the HCR-20 C & R score dominated the model. Moves back to more secure places were predicted by lack of concordance on the DUNDRUM-4. Conditional discharge was predicted predominantly by the DUNDRUM-3.

CONCLUSIONS

Patients accurately self-rate relative to other patients however their absolute ratings were consistently lower (better) than clinicians' ratings and were less accurate predictors of outcomes including conditional discharge. Quantifying concordance is a useful part of the recovery process and predicts outcomes but self-ratings are not accurate predictors.

Assessment of trust in physician: a systematic review of measures

Over the last decades, trust in physician has gained in importance. Studies have shown that trust in physician is associated with positive health behaviors in patients. However, the validity of empirical findings fundamentally depends on the quality of the measures in use. Our aim was to provide an overview of trust in physician measures and to evaluate the methodological quality of the psychometric studies and the quality of psychometric properties of identified measures. We conducted an electronic search in three databases (Medline, EMBASE and PsycInfo). The secondary search strategy included reference and citation tracking of included full texts and consultation of experts in the field. Retrieved records were screened independently by two reviewers. Full texts that reported on testing of psychometric properties of trust in physician measures were included in the review. Study characteristics and psychometric properties were extracted. We evaluated the quality of design, methods and reporting of studies with the COnsensus based Standards for the selection of health status Measurement INstruments (COSMIN) checklist. The quality of psychometric properties was assessed with Terwee's 2007 quality criteria. After screening 3284 records and assessing 169 full texts for eligibility, fourteen studies on seven trust in physician measures were included. Most of the studies were conducted in the USA and used English measures. All but one measure were generic. Sample sizes range from 25 to 1199 participants, recruited in very heterogeneous settings. Quality assessments revealed several flaws in the methodological quality of studies. COSMIN scores were mainly fair or poor. The overall quality of measures' psychometric properties was intermediate. Several trust in physician measures have been developed over the last years, but further psychometric evaluation of these measures is strongly recommended. The methodological quality of psychometric property studies could be improved by adhering to quality criteria like the COSMIN checklist.

Prospective study of factors influencing conditional discharge from a forensic hospital: the DUNDRUM-3 programme completion and DUNDRUM-4 recovery structured professional judgement instruments and risk

BACKGROUND

We set out to examine whether structured professional judgement instruments DUNDRUM-3 programme completion (D-3) and DUNDRUM-4 recovery (D-4) scales along with measures of risk, mental state and global function could distinguish between those forensic patients detained in a secure forensic hospital (not guilty by reason of insanity or unfit to stand trial) who were subsequently discharged by a mental health review board. We also examined the interaction between these measures and risk, need for therapeutic security and eventual conditional discharge.

METHODS

A naturalistic observational cohort study was carried out for 56 patients newly eligible for conditional discharge. Patients were rated using the D-3, D-4 and other scales including HCR-20, S-RAMM, START, SAPROF, PANSS and GAF and then observed over a period of twenty three months during which they were considered for conditional discharge by an independent Mental Health Review Board.

RESULTS

The D-3 distinguished which patients were subsequently discharged by the Mental Health Review board (AUC = 0.902, p < 0.001) as did the D-4 (AUC = 0.848, p < 0.001). Item to outcome analysis showed each item of the D-3 and D-4 scales performed significantly better than random. The HCR-20 also distinguished those later discharged (AUC = 0.838, p < 0.001) as did the S-RAMM, START, SAPROF, PANSS and GAF. The D-3 and D-4 scores remained significantly lower (better) for those discharged even when corrected for the HCR-20 total score. Item to outcome analyses and logistic regression analysis showed that the strongest antecedents of discharge were the GAF and the DUNDRUM-3 programme completion scores.

CONCLUSIONS

Structured professional judgement instruments should improve the quality, consistency and transparency of clinical recommendations and decision making at mental health review boards. Further research is required to determine whether the DUNDRUM-3 programme completion and DUNDRUM-4 recovery instruments predict those who are or are not recalled or re-offend after conditional discharge.

Working alliance, interpersonal trust and perceived coercion in mental health review hearings

Background

There is some evidence that when mental health commitment hearings are held in accordance with therapeutic jurisprudence principles they are perceived as less coercive, and more just in their procedures leading to improved treatment adherence and fewer hospital readmissions. This suggests an effect of the hearing on therapeutic relationships. We compared working alliance and interpersonal trust in clinicians and forensic patients, whose continued detentions were reviewed by two different legal review bodies according to their legal category.

Methods

The hearings were rated as positive or negative by patients and treating psychiatrists using the MacArthur scales for perceived coercion, perceived procedural justice (legal and medical) and for the impact of the hearing. We rated Global assessment of Function (GAF), Positive and Negative Symptom Scale (PANSS), Working Alliance Inventory (WAI) and Interpersonal Trust in Physician (ITP) scales six months before the hearing and repeated the WAI and ITP two weeks before and two weeks after the hearing, for 75 of 83 patients in a forensic medium and high secure hospital.

Results

Psychiatrists agreed with patients regarding the rating of hearings. Patients rated civil hearings (MHTs) more negatively than hearings under insanity legislation (MHRBs). Those reviewed by MHTs had lower scores for WAI and ITP. However, post-hearing WAI and ITP scores were not different from baseline and pre-hearing scores. Using the receiver operating characteristic, baseline WAI and ITP scores predicted how patients would rate the hearings, as did baseline GAF and PANSS scores.

Conclusions

There was no evidence that positively perceived hearings improved WAI or ITP, but some evidence showed that negatively perceived hearings worsened them. Concentrating on functional recovery and symptom remission remains the best strategy for improved therapeutic relationships.