The journey from despair to hope: an exploration of the phenomenon of psychological distress in women residing in British secure mental health services

What do we know about the experience of seclusion in a forensic setting? An integrative literature review

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.

Exploring the frequency, duration and experience of seclusion for women in a forensic mental health setting: a mixed-methods study protocol

INTRODUCTION

Seclusion use is high in forensic mental health settings and is associated with avoidable physical and psychological harm. The use of seclusion causes significant distress and trauma for those secluded and women in these settings are particularly vulnerable. This study protocol aims to identify factors associated with the use of seclusion and the experience of seclusion for women in forensic mental health settings.

METHODS AND ANALYSIS

This study will use a prospective mixed-methods design. Quantitative data on the frequency and duration of seclusion and potential explanatory demographic and clinical variables will be collected prospectively from consecutive medical records of women admitted to a forensic mental health service over a 2-year period. Data will be analysed using descriptive statistics and logistic regression techniques. Qualitative data will be collected from individual face-to-face semistructured interviews with women who have experienced seclusion about the reason for seclusion, whether they agreed with the reason for seclusion, their experience of the seclusion event and the seclusion environment and support provided while in seclusion using qualitative description methods. Data will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the University of Newcastle Human Research Ethics Committee (H-2019-0122) and organisational support granted from the participating forensic mental health service. Participation will be voluntary and written informed consent is required. Results will be disseminated via the first author's doctoral thesis, in peer-reviewed journals and at conferences. Results will inform recommendations for policy, and evidence for timely and specific interventions to support the reduction of seclusion for women in forensic mental health settings.

"Moving on" through the locked ward system for women with intellectual disabilities

Background

The move to community support for all people with intellectual disabilities is an aspiration with international significance. In this article, we draw on rich accounts from women with intellectual disabilities detained under the Mental Health Act (E&W) 1983 and staff at an National Health Service secure setting in England to explore how “moving on” is defined and perceived.

Methods

The study reports on an ethnographic study using the field‐notes and the 26 semi‐structured interviews with detained women and staff on three wards.

Results

We first explore staff conceptions of moving on, which include behavioural change and utilizing coping strategies. Then, we discuss the areas of analysis that women discussed: taking back responsibility, success in arranged relationships, acceptance of regime and resistance to progression.

Conclusion

The concepts of moving on were not determined by the women but by the service. We recommend further research which explores women's own rehabilitation requirements.

Sex, gender and the carceral: Female staff experiences of working in forensic care with sexual offenders

English high-secure hospitals have contained individuals deemed mentally disordered, and dangerous, since the mid-nineteenth century. With the development of gender sensitive services female patients have been moved out of these institutions into smaller secure settings. Female staff continue to work in high secure hospitals, but are often in a minority in these services. Little is known about how female staff experience the everyday world of work. This paper is based on in-depth interviews with female nurses employed in a unit caring for detained male sexual offenders with a diagnosis of personality disorder. It forms part of a much larger discourse-analytic study of nine patients, with a history of sexual offending, and eighteen mental health nurses, which focused on talk about pornography and criminality. The findings from this project have been previously reported in Mercer and Perkins (2014). This paper demonstrates how patriarchy remains an enduring cultural characteristic of caring for men detained under the Mental Health Act (1983, 2007) because of sexually violent crimes against women and children. It textures the ward environment and the relationships between people who work within it, constructing women as 'outsiders' and producing a masculine culture which leaves female staff feeling vulnerable and at risk. The analytic focus of the paper is concerned with exploring how women experience working in the male-dominated environment of a high-security Personality Disorder Unit (PDU). Three discursive repertoires are identified: the institutional space as male, the impact of working with men detained as a result of sexual offending, and the construction of therapeutic work as a 'job for the boys'. In this world, female staff, as a product of their gender, constructed themselves both as at risk and inviting risk.

Lived experience of working with female patients in a high-secure mental health setting

Women's secure hospitals are often considered to be stressful and demanding places to work, with these environments characterized as challenging and violent. However, the staff experience of working in this environment is not well represented in the literature. The present study is the first to examine the 'lived experience' of seven nurses working in the National High Secure Healthcare Service for Women. Interview transcripts were analysed with the use of interpretative phenomenological analysis, and the findings presented within four superordinate themes 'horror', 'balancing acts', 'emotional hard labour', and 'the ward as a community'. These themes all depict the challenges that participants experience in their work, the ways in which they cope with these challenges, and how they make sense of these experiences. A meta-theme of 'making sense by understanding why' is also presented, which represents the importance for participants to attempt to make sense of the tensions and challenges by formulating a fuller meaning. The findings suggest the importance of workforce development in terms of allowing sufficient protected time for reflection and formulation (e.g. within the format of group supervision or reflective practice), and for staff-support mechanisms (e.g. clinical supervision, counselling, debriefs) to be inbuilt into the ethos of a service, so as to provide proactive support for staff 'on the frontline'.

Meeting the needs of women in secure mental health: a conceptual framework for nurses

Within the wards of Britain’s high and medium secure mental health services, the needs of the female population differ significantly from those of their male counterparts. Although much smaller in number, the vast majority of female patients formally detained in secure services are young, Caucasian women, who are less likely to be prone to criminality and have a propensity to suffer from psychological distress. Many have experienced extensive trauma and exhibit both internally and externally driven violence. Drawn from the women’s own narratives and analysed using a descriptive phenomenological approach, the findings provide the basic structure for a new ‘humanistic conceptual framework for care’ which could be used by mental health practitioners to both inform and structure the daily provision of care and to better understand the physical and mental health needs of this unique patient group within secure mental health services.