Are guilt and shame in male forensic patients associated with treatment motivation and readiness?

BACKGROUND: Motivation and readiness to change are important drives for forensic patients accessing interventions. It is thought that guilt and shame influence these drives, but to date, their relationship has not been empirically tested. AIMS AND HYPOTHESES: The aim of this study is to investigate associations between guilt, shame, and treatment motivation and readiness in a sample of men in a secure hospital. It was hypothesised that guilt would be positively correlated, and shame negatively correlated, with treatment motivation and readiness. METHODS: Sixty-six adult male patients detained in a secure hospital completed the assessments of experiences of guilt, shame, motivation, and readiness for treatment. Clinician-rated readiness ratings were also collected. RESULTS: Shame proneness showed no significant association with motivation for change or treatment readiness. Guilt proneness and offence-related shame were positively correlated with treatment readiness. Offence-related guilt was positively correlated with both motivation and readiness. Regression modelling indicated offence-related guilt had a significant level of explanatory power. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This first study of the impact of guilt and shame on motivation and readiness for change among offender hospital inpatients found that offence-related guilt may be helpful but did not replicate the potential disadvantage of shame. Further research would be warranted into whether the "newness" or the extent of shame may be more important than shame more generally. Given the probable importance of offence-related guilt, we recommend that guilt attribution is assessed in offender patients to optimise nature and timing of treatment.

Support for the predictive validity of the multifactor offender readiness model (MORM): forensic patients' readiness and engagement with therapeutic groups.

BACKGROUND: Treatment non-engagement in forensic health settings has ethical and economic implications. The multifactor offender readiness model (MORM) provides a framework for assessing treatment readiness across person, programme and contexts. AIMS: To answer the following question: Are the internal factors of the MORM associated with likelihood of engagement in groups by patients in forensic mental health services? METHOD: In a retrospective design, associations were investigated between internal factors of the MORM, measured as part of assessment for group participation, and the outcomes of treatment refusal, treatment dropout and treatment completion. RESULTS: One hundred and eighteen male patients in a high security hospital consecutively referred for group treatment agreed to participate. Internal factors of the MORM associated with treatment refusals included: psychopathic cognition, negative self-evaluation/affect and effective goal-seeking strategies. Those associated with dropouts included emotional dysregulation, low competencies to engage and low levels of general distress. MORM factors associated with completion included: low motivation, ineffective goal-seeking strategies, absence of psychopathic cognition, high levels of general distress and competency to engage. CONCLUSIONS: Internal factors of the MORM could be useful contributors to decisions about treatment readiness for hospitalised male offender-patients. Up to one in three programmes offered were refused, so clinical use of the MORM to aid referral decisions could optimise the most constructive use of resources for every individual. Copyright © 2016 John Wiley & Sons, Ltd.

Everything moves on: referral trends to a leavers' group in a high secure hospital and trial leave progress of group graduates.

BACKGROUND: Moving on from high secure psychiatric care can be a complex and potentially stressful experience, which may hinder progression. A leavers' group in a UK high secure hospital is offered to support patients with this transition. AIMS: The aims of this study are to investigate characteristics of patients referred for the leavers' group and compare outcomes for leavers' group graduates with those for patients who never attended a leavers' group for any reason. METHODS: A retrospective quasi-experimental design was applied to data extracted from various records sources - within and outside the high security hospital. RESULTS: About one-fifth of patients who left the hospital on trial leave during the study were referred to the leavers' group (N = 109). Referred patients were significantly more likely to have either been admitted from another high-security hospital or transferred from prison for treatment and have a diagnosis of paranoid schizophrenia. Patients not referred had a significantly higher rate of previously refusing to participate in groups. There was a tendency for rate of return from trial leave for group graduates to be lower than that of patients who did not attend the leavers' group, but this just failed to reach statistical significance (rate ratio [RR] = 1.04; CI 0.97-1.11). CONCLUSIONS: A leavers' group appeared to be a valued therapy option for people who had spent a long time in high secure psychiatric care, or those who continued to require hospital treatment beyond prison tariffs. There was a low return rate from trial leave, which made the evaluation of this outcome difficult. A detailed study into both the reasons for return from trial leave and successes would provide further information on ideal preparation for moving on. Copyright © 2016 John Wiley & Sons, Ltd.

Risk assessments for dating violence in mid to late adolescence and early adulthood.

AIM: The objective of this paper is to review risk instruments that have been used in the assessment of the potential for violence within the dating relationships of young people. METHOD: A review of the dating violence literature was conducted to identify risk assessment approaches that have been used to predict harmful behaviour within the dating relationships of people aged between 15 and 30 years. Risk assessments were evaluated on recommended quality criteria: predictive validity, accuracy (sensitivity and specificity) and inter-rater reliability. RESULTS: Only five studies describing assessments that focused specifically on dating violence risk factors were selected for review. Three assessments encompassed dating behaviours by victims that have been associated with an increased risk of further victimisation. CONCLUSIONS: Drawing on this evidence, we conclude that young people appear to be at greater risk of encountering dating violence if they have experienced violence in earlier attachment relationships; if their skills for coping with conflict and responding to coercion are limited and if the presence of peer influences reinforces offence supportive attitudes. The reliability and validity of existing intimate partner violence risk assessments that conceptually overlap with elements of dating violence risk warrant investigation to inform risk assessment developments in this field and, building on this, possible interventions to minimise future harm. Copyright © 2016 John Wiley & Sons, Ltd.

Observer Ratings of Interpersonal Behavior as Predictors of Aggression and Self-Harm in a High-Security Sample of Male Forensic Inpatients.

Incidents of aggression and self-harm in forensic mental health inpatient settings present a significant challenge to practitioners in terms of safely managing and reducing the harm they cause. Research has been conducted to explore the possible predictors of these incidents and has identified a range of environmental, situational, and individual risk factors. However, despite the often interpersonal nature of the majority of aggressive incidents, few studies have investigated forensic inpatient interpersonal styles as predictors of aggression and even fewer have explored the potential interpersonal function of self-harming behaviors. The current study investigated the predictive validity of the Chart of Interpersonal Reactions in Closed Living Environments (CIRCLE) for incidents of verbal and physical aggression, and self-harm recorded from 204 high-secure forensic inpatients. Means comparisons, correlations, and receiver operating characteristics (ROC) were conducted on recorded incident data at 12, 24, and 48 months following baseline assessment using the CIRCLE. Dominant and coercive interpersonal styles were significant predictors of aggression, and a coercive interpersonal style was a significant predictor of self-harm, over the recorded time periods. When categorizing the inpatients on the basis of short- and long-term admissions, these findings were only replicated for inpatients with shorter lengths of stay. The findings support previous research which has demonstrated the benefits of assessing interpersonal style for the purposes of risk planning and management of forensic inpatients. The predictive value may be time-limited in terms of stage of admission.

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.