Impact - Ijranss-1. Ijranss - Length of Stay Reporting in Forensic Secure Care Can Be Augmented by An Overarching Framework To Map Patient Journey in Mentally Disordered Offender Pathway For

IMPACT: International Journal of Research in Applied,
Natural and Social Sciences (IMPACT: IJRANSS)

ISSN (P): 2347–4580; ISSN (E): 2321–8851
Vol. 9, Issue 9, Sep 2021, 1–38
© Impact Journals
LENGTH OF STAY REPORTING IN FORENSIC SECURE CARE CAN BE AUGMENTED

BY AN OVERARCHING FRAMEWORK TO MAP PATIENT JOURNEY IN MENTALLY
DISORDERED OFFENDER PATHWAY FOR OPTIMAL RESULTS – PART II
Dr Surya Prasad N1 & Dr Sarangapani Nivarthi2

1
Research Scholar, CCT Forensic Psychiatry, PG Dip Health Management, UK
2
Research Scholar, Jain Business School, Jain University, Bengaluru, India
Received: 19 Sep 2021 Accepted: 20 Aug 2021 Published: 21 Aug 2021
ABSTRACT
Single episode admissions in Forensic Psychiatric care have enquired into ‘Length of Stay’ in Hospitals, with different
methods of calculating this, and the determining factors from patient data per se were reported in paper I. There is a
growing recognition of the negative effects of environmental factors, interpersonal dynamics and the prolonged restrictive
stay in secure care as detrimental to patient recovery. Effectiveness of treatment interventions for mental disorders and
risk reduction has been lately reviewed and is a growing ground for research. Effective Patient and Carer reengagement,
facilitating social return and successful collaboration between agencies and services are now recognized to enable
successful discharge from secure care hospitals in addition to reducing recidivism.
In this paper (Paper II), literature review identified 7key components impacting Length of Stay which we describe
as secondary factors and integrate them into a proposed framework for reporting Length of Stay.
KEYWORDS: Continuity of Care, Improving Outcomes, Mentally Disordered Offender, Pathway, Accommodation
Model, Framework, Transitions, Key components of Length of Stay, Key determinants of Length of Stay,Treatment
effectiveness, Secure Care, Forensic Psychiatry
INTRODUCTION
Studies have so far used ‘Length of Stay’ in Secure Care hospitals as a proxy for reporting various outcomes of secure care
delivery (clinical, recidivism and financial). Our thematic appreciation of literature on the key components that determine
experience and outcomes; which in turn affects Length of Stay in secure care pathway, showed the following themes of
research:
• Chronic illness care and recovery
• Patient and Carer autonomy and self-efficacy in managing their conditions and risks to the public.
• Effectiveness of interventions
• Evidence Based Medicine and Evidence Based Systemic Practise
• Evaluation of therapeutic relationship and therapeutic environments
• Challenges to smooth transitions of care upward/downward/sideways or by Age and Gender
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2 Dr Surya Prasad N & Dr Sarangapani Nivarthi
• Continuity of care / Collaborative outcomes achieved by co working of agencies and services
It is important to consider variables related to the time before the current treatment, treatment-related variables,
and variables related to the follow-up to identify patients at risk of criminal recidivism after discharge from forensic
treatment (CS, n = 249) (Probst et al., 2020).There is significant literature on the rise regarding the 7 key themes identified
in our review, but is currently not integrated into Length of Stay studies. The first European study on external factors
impacting long term care in forensic psychiatry involved a SWOT analysis of regional representatives for long-term
forensic care. They identified Care & Treatment pathways (admission criteria, discharge pathways & community
integration), Resources (funding, facilities & quality staff), Legal frameworks & Systemic Factors, and Sharing Expertise
(collaboration, standards & guidelines, & research) as the critical factors (Connell et al., 2019). Moreover, some of these
determinants are difficult to evaluate quantitatively and establish its causative association with LoS. In this paper (Paper
II), we endeavour to bring these 7 themes into a framework under study for LoS (See Table 2 in the end).
BACKGROUND
In Paper I, we provided a thematic analysis of factors identified from key Length of Stay studies in secure care. The
published literature focuses on patient data per se for a given episode of admission. The 7 themes were: sociodemographic
factors, criminal history, psychiatric history, index offence, clinical variables, treatment variables and risk variables (Paper
I - Table 1. Factors prolonging, reducing or having ambivalent reporting outcomes on LoS). A rapid review (Vollm et al.,
2017) and machine learning (Kirchebner et al., 2020) model both pointed to the nature (homicidal and sexual) and severity
of index offence as the key determinants among other potential factors (we provided a thematic analysis of these 7 themes
in Paper I) driving Length of Stay per admission episode. Individuals admitted in the secure care system in earlier years
had slower rates of discharge compared to more recent admissions. Patients having comorbid substance use or personality
disorder or neurological disorder or having committed a severe violent offence increased their stay duration in hospital
(CRS, n = 2533, over 25 years) (Penney et al., 2018).Methods described to reduce LoS in secure care hospitals compiled
from Nagtegaal et al., 2011 & Huband et al., 2018 include:
• Willingness to grant conditional discharge
• Extend the maximum duration legally allowed for conditional discharge
• Improve supervision & aftercare programmes on leaving secure hospital settings
• Empower & support general psychiatric services to receive ex-forensic patients earlier in care
• Design, staffing provision and activities for longer stay patients have a significant impact on social environment
reducing adverse behaviours and thus facilitating discharge
However, the above data is focusing on the patient data per se in the given episode of admission, and is not able to
capture the contextual, historic and settings factors, softly but probably significantly contributing to overall time spent in
secure care pathway and the meaningful outcomes achieved. There is a growing recognition to triage, prioritise and focus
interventions in chronic care models that considers the environment and stage of treatment. Some are advocating that
Forensic treatment planning should prioritize forensic outcomes, such as restoration of trial competence or mitigation of
violence risk, as the first steps in a continuum of care that eventually leads to the patient's ability to resolve forensic issues
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Length of Stay Reporting in Forensic Secure Care can be Augmented by an Overarching Framework to 3
Map Patient Journey in Mentally Disordered Offender Pathway for Optimal Results – Part II
and return to the community for recovery-oriented care (Schaufenbil et al., 2015). A lack of clear treatment standards that
address all aspects of forensic care can lead to inefficient or inappropriate interventions and contribute to institutional
violence; therefore, forensic interventions should be prioritised in secure care settings(Warburton, 2015).We conceived a
model of throughput across providers in an interdependent manner (indicating that slack at one point can lead to congestion
at another), possibly challenging the culture and boundaries of current practices, and hence advocated for a need
prioritised, evidence-based provision, of tiered service across providers (Figure 4, Paper I).
METHOD
This Literature Review has attempted to gather a representative broad view of developments in Mental Illness, Recovery,
Risk Reduction, LoS, Experiences (patient, carer and professional stakeholders) and Recidivism (prioritised references
have often included comparative reporting from developed world countries where specialised services for Forensic
Psychiatry and continuity of care exists) in order to find significant links across Services and Disciplines, and prioritised
evidence in the below order (Figure 1)
I = Interview, IPA – Interpretive Phenomenological Analysis, Q = Questionnaire, FG = Focus Groups

Figure 1: Studies included in Review.
RESULTS
Chronic Illness Care and Recovery
Chronic conditions account for 7/10 of primary care presentations (Veale 2003 as cited in Cal et., al, 2015) and resilience
plays an important role in the process of illness and outcomes of health (SR, n = 12) (Cal et al., 2015). However, resilience
is in turn made of several other personal attributes and these are already strained in patients with mental illness. About 24%
of pretrial prisoners have chronic health problems (Wermink et al., 2016) but most are younger age adults in comparison to
the general population where chronic illness is mostly related to increasing age. About 1/3 of mental illnessis treatment
resistant (multiple systematic reviews), ~ 55% of secure care patients receive antipsychotic polypharmacy (CSS, n = 142)
(Farrell & Brink, 2020)and ~ 50% of patients with major psychiatric disorders are non-compliant to prescribed
psychotropic medication (SR & MA, n = 46) (Semahegn et., al, 2020). Interestingly, the non-compliance estimate in
children & adolescents with severe mental illness is also > 50% (Edgcomb & Zima, 2018). In contrast, non-compliance to
medication in medical chronic diseases is 40 – 50% (Kleinsinger, 2018). A Swedish National registry study of postmortem

toxicological analysis showed 46% adherence to prescribed medications with ~70% for antidepressants and ~ 21% for
cardiovascular drugs (Forsman et al., 2018). Fixed dose combination, dosing frequency, reminders, refills, pill-counts,
depot injections have all shown improved adherence to medications.
Health literacy improves adherence to treatment by ~ 16%, higher reported effect size by subjective measures, and
the effect size is even higher in disadvantaged groups (Miller, 2016). Insight into mental illness has a complex
interrelationship with disease characteristics and health outcomes (Lysaker et al., 2018). Unawareness of illness/symptoms
(anosognosia/lack of insight) is common in neurological and psychiatric conditions especially with neurovascular or brain
injury damage and secondary neurodegenerative changes of functional mental disorders (David et al., 2012). Please refer to
(Thirioux et al., 2020) for a detailed discussion on insight (into mental illness, index offence, offending behaviour,
remorse, empathy, Theory of Mind, reflection, metacognition etc) as the interrelated concepts are all crucial determinants
of compliance to medications and engagement in psychosocial interventions for illness and risks, impacting on the duration
of secure care delivery.
Patient experience and engagement in the improvement of chronic care needs changes at the macro (systems),
meso (organizational) and micro level (patients’ involvement in their own care and how to manage deep-rooted
expectations and ideas about who does what and how) (Granström, 2021). Chronic illness care requires therapeutic
relationship (patient perspective on their illness, transference, individualised care plans), effective team dynamics
(appreciation of roles & boundaries, interpersonal behaviours & attitudes, openness to ambivalence), and focus on wider
system (disease prevention & health promotion, empowering patients & carers, developing services, & effective
interagency/department liaison). In forensic psychiatry, mismatch between healthcare providers’ and patients’ beliefs and
expectations, may undermine collaborative care. Reflective practice directed at understanding personal and system
responses to chronically ill patients may optimise collaborative care (Campbell & McGauley, 2005).
An Australian study of patient working party on recovery experiences in forensic psychiatry showed denial,
despair, hope, acceptance, willingness, responsible action and a meaningful life contributing in a community as the key
steps to recovery (I, MM, DS) (Davey & Dempsey, 2012). Patient’s perception of recovery in forensic mental is about their
experience of connectedness, treatment, sense of self, past experiences, freedom, hope and health. The adoption of a
recovery tool ‘My Shared pathway’ was examined in UK where patients described care in secure hospitals as a journey,
their vulnerabilities in it, their relationships with staff, loss and hope (SR, TA & IPA, n = 11 for SR & n = 6 for IPA)
(Clarke, 2014). Patients identified 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
(SR & TA, n = 5) (Shepherd et al., 2015). Patients described knowing what they needed in order to recover: to find
meaning in existence, to be treated as a person given the impersonal context, and to be empowered in their restricted life (I
& TA, n = 11) (Marklund et al., 2019).
Coproduction is considered as central to delivering person-centred care (National Institute for Health and Care
Excellence, 2016 as cited in Webb et., al, 2021), defined as a process of multidisciplinary collaboration between patients,
staff and stakeholders as equal partners with complementing knowledge (Webb et., al, 2021). There are several best
practice examples for collaborative and coproduced care (ex: QNFMHS aggregated annual reports in England and Wales)

Since addiction is a major problem in secure care pathway, both causative and maintenance, for mental illness and
recidivism; this area of patient experience was measured in Addiction services in Canada. It identified patient-centred care,
treatment effectiveness, staff behaviour, availability and coordination of care, and communication as the key patient
requirements (Q, FA, n = 1222) (Currie et al., 2020). Treating substance misusing patients involuntarily, led to their lower
health and social functioning, and they sought discharge against medical advice twice as frequently as voluntarily admitted
substance misusing patients, and their treatment against their wish is not sustainable (CRS, n = 608) (Habermeyer et al.,
2018). Patients needed specific work assistance in each aspect of a Norwegian recovery model rather than each domain of
recovery sorting itself out (CCS, MM, n = 20 patients & 141 staff) (Hauso et al., 2021).
Patient and Carer Autonomy and Self-Efficacy in Managing their Conditions and Risks to the Public
In General Psychiatry detentions, patients' perceived autonomy and participation in decisions for themselves, their feeling
of whether or not they are being cared for, and their sense of identity were expressed both positively and negatively when
detained (SR & TA, n = 5) (Katsakou & Priebe, 2007). Patients had ambiguous experiences in their judicial trajectory (I &
TA, n = 11) (Aga et al., 2017). They experienced barriers to admission, felt without a voice, passive in the decision-making
process with little support during transitions and the indeterminate duration of care trajectories, contributed to overall
negative lived experiences. The balance between a criminal justice and mental health approach in forensic mental health
care is questioned (I & TA, n = 23) (De Pau et al., 2020). In order to answer some of this negativity of patients in secure
care, their perceptions of coercion, fairness and legitimacy impacting their level of treatment engagement, risk for adversity
and progress in recovery is being investigated (MM, n = 120+) (Simpson et al., 2020).
Coercion in psychiatric care may seem intuitive due to compulsory admissions needing treatment and care for severe
mental illness, likely impact on capacity to make decisions, risks to self and others; however, up to three-quarters of psychiatric
patients, including individuals with serious illnesses such as schizophrenia or bipolar disorder may have capacity to make medical
decisions in the context of their illness, have capacity to judge risk-reward situations, and to adequately decide about the
important treatment outcomes, and most are able to make rational decisions about their healthcare. Decisional capacity
impairments in psychotic patients are temporal, identifiable, and responsive to interventions directed towards simplifying
information, encouraging training and shared decision making (Meta-review, n = 11 SR)(Calcedo-Barba et al., 2020).There are
many types of coercive measures in psychiatric practice – covert, oral medication, physical restraint, chemical restraint,
mechanical restraint, and seclusion. Covert measures can range from subtle suggestions to alarms, special observations,
medications mixed in food etc and are difficult to measure. The other overt measure rates differ across countries, and mechanical
restraint and seclusion are banned in some countries. The data measured are heterogenous and not all categories are reported,
making comparisons difficult. If the coercive practice in one domain is lower, practices in other domains are usually higher.
However, most countries have measured their coercive practices in psychiatry. The range of practices is shown in Table 1 below.
(Q) (Horvath et al., 2018), (SR, n = 13) (Steinert et al., 2009),(SR, n = 48)(Muir‐Cochrane et al., 2020)
Table 1: Range of Coercive Measures Across Countries as a Percentage of Psychiatric Admissions

Oral Any coercive measure
Covert Physical Chemical Mechanical
Coerced Seclusion (excluding covert and
Measures Restraint Restraint Restraint
Medication oral medication)
X - 70% Unknown 2.5% - 7.3% 2.7% - 7.6% 1.2% - 8% 0.03% - 15.6% 8% - 36.3%

In General Psychiatry, patients’ experience of coercive measures depends upon the provision of information, contact
and interaction with staff, adequacy of communication with professional, humane treatment, respect, staff support, debriefing,
quality of the working and physical environment, and some individual and treatment variables (SR & TA, n = 34) (Aguilera-
Serrano et al., 2017). Physical restraint is more common in intensive care environments. The likelihood of physical injuries in
restraint process is 0.8 - 4%, commonest cause of death is cardiac arrest by chest compression or strangulation, and pulmonary
thromboembolism(SR, n = 67) (Kersting et al., 2019). Seclusion episodes are more common with female patients, younger age of
patient, and early in admission, in addition to behaviours leading to seclusion episodes (CRS, n = 990) (Cullen et al., 2016).
In Forensic psychiatry, 70% of patients report experiencing coercion to take medication and this was influenced
by their attitude towards medication and the degree of insight into illness, to a lesser extent by symptom severity (Q)
(Horvath et al., 2018). Theyexperience5 times more overt coercion in comparison to general psychiatry counterparts
(seclusion, mechanical restraint, room confinement or involuntary medication). The long duration of coercive measures in
forensic psychiatry probably reflects their risk of violence (CRS, CCS & FA, n of secure care = 1,049, n of general
psychiatry = 115,011) (Flammer et al., 2020). While implementing the guidelines of the Committee for Prevention of
Torture, although the total number and duration of coercive measures showed a reducing trend, a few patients were not
responsive to deescalating interventions, increasing the average measures of the institute due to outlier effects (CRS, n =
1000) (Lau et al., 2020). Factors affecting coercive practice in secure care when studied with a machine learning model, as
many as 569 potential predictor variables were initially identified but the key determinants were: Threat of violence,
(actual) violence toward others, the application of direct coercive measures during past psychiatric inpatient treatments,
poor impulse control, uncooperativeness, hostility, total PANSS-score at admission, prescription of haloperidol during
inpatient treatment, daily cumulative olanzapine equivalent antipsychotic dosage at discharge, and the legal prognosis
estimated by a team of licensed forensic psychiatrists (CCS, n = 131 cases & 227 controls) (Günther et al., 2020).
Patients preferred intermittent observation, time out and PRN medication over other intrusive methods and they
least preferred locked-door seclusion and coerced IM medication. Staff disapproval for more coercive measures increased
with experience and male staff were more involved and showed higher approval in coercive methods(Q, MM, n = 2587)
(Whittington et al., 2009). Personal opinions seem to be a major factor when choosing one method over the other and the
measure that is most familiar to the staff is what is preferred (Laiho et al, 2016). Patients don’t perceive seclusion or
mechanical restraint differently but they prefer a choice (RCT, n = 102) (Bergk et al., 2011).
Most patients accept the need for involuntary treatment but mostly express negative feelings, although some
described positive effects of safety and security, protection, trust, helpfulness and a decrease of stimulation. It depends on
their age and gender, and their adaptation to the illness and treatment system (Soininen et al, 2016). Restrictive practices in
secure care are experienced by patients from an individual, institutional and systemic level. Restrictiveness was subjective
and included such disparate elements as limited leave and grounds access, ownership of personal belongings and staff
attitudes. The patients could perceive these interventions as caring or custodial (SR & TA, n = 50) (Tomlin et al., 2018). In
the UK, restrictions on autonomy of patients in different levels of security using Forensic Restrictiveness Questionnaire
(FRQ) was negatively correlated with quality of life and ward climate. Patients described the antecedent conditions, the
restrictive phenomena, how they these were enacted, how the restriction was subjectively experienced and, the
consequences of these restrictions. These patient experiences encourage us to rethink the unintended effects of placing
individuals within secure hospitals (I & TA, n = 18) (Tomlin et al., 2019).

Patients describe seclusion mostly negatively as fear, neglect, abuse, and power struggle (I & IPA, n = 7) (Askew
et al., 2019a). They express being vulnerable, disconnected and having a negative impact on their mental health (SR, n = 8)
(Askew et al., 2019b). Even a year later, they describe memories of helplessness, tension, fear, and rage over the seclusion
episode. However, 58% reported some positive effects such as contact with staff helping them in alleviating distress (RCT,
Q, n = 102) (Steinert et al., 2013). The nature of interpersonal relationships between both parties (staff and patients) and
their views on acceptability and justifiability, shapes their perception of care and treatment during their use (MM, I & TA)
(Johnson, 2013). Patients rate the quality of support and seclusion environment lower than staff (Q, n = 268) (Lundqvist &
Schroder, 2015). Seclusion rooms are designed poorly (SR) (Kaar et al., 2017). Recornect in Netherlands is an IT
interfaced wall screen in seclusion room that helps to calm the patient and maintain engagement(McCarthy et al., 2017).
Forensic mental health professionals should be aware of the relationship between perceived institutional
restriction and psychopathology because it might influence treatment course and outcome (Q, n = 184) (Franke et al.,
2019). Patients sometimes abscond from leave/escape from unit and several patient characteristics and socio-environmental
factors underlying these events have been summarised (Bowers et., al 1998, 1999 as cited in Hearn et., al, 2013).
Technologies such as CCTV, motion sensors and GPS tracking raise ethical concerns, patient objections and cost
effectiveness considerations but have the potential to improve recovery outcomes and reduce length of stay (Tully et al.,
2015)
Families of violent patients with illness feel traumatised even if they were not living with the patient. (CSS, n =
116) (Hanzawa et al., 2013). They describe raised levels of stress because of violence, dual stigma (offence and mental
illness), disintegration of family relationships, public exposure due to media attention, and confrontation with the judicial
system, these leading to isolation without help. They need psychosocial supports and timely access to clear and plain
language information. Their strengths can be harnessed to help the patient (SR, n = 6) (Rowaert et al., 2016). They are
ambivalent towards the judicial system, feel thatprison is an inappropriate place for MDO’s, peg their hopes on mental
health support and were fighting a losing battle, but were hopeful (I, n = 24) (Rowaert et al., 2017). In UK Secure care,
theyemphasise the importance of communication and improving their knowledge of services, as methods of meaningful
inclusion in treatment and recovery (FG, n = 2) (Sampson et al., 2019).
In a Swiss secure clinic, healthcare professionals felt that family was strength but most were broken families, not
possible to trust; and they get in the way of patient's care. They felt that it was important to achieve a balance and control
over the family; otherwise, family-oriented work would be impossible (I) (Hörberg et al., 2015). QNFMHS CCQI, quality
network in Forensic psychiatry in England and Wales have produced a carer’s toolkit addressing the carers needs and
requirements in secure care pathway (RCPsych, 2018).
Commonly used risk assessment tools identify low risk individuals with high accuracy but their predictive validity
is moderate at best. The number needed to detain is 2-4 and number safely discharged was 4-18 (SR & MA, n = 68) (Fazel
et al., 2012). Shared decision making and Collaborative care in the area of risk assessment and management needs further
research to identify the issues, barriers and complexities in implementing this aspect of care (Markham, 2020).
Effectiveness of Interventions
There are many knowledge gaps in forensic psychiatry and there is high risk of bias in the primary studies in secure care
(SR, n = 38) (Howner et al., 2018). The European Psychiatric Association summarised the practices and effectiveness of

treatments in Forensic Psychiatry currently (Völlm et al., 2018). The relative risks are typically increased for all violent
outcomes in most diagnosed psychiatric disorders compared with people without psychiatric disorders, with increased odds
in the range of 2–4. Absolute rates of violent crime over 5–10 years are typically below 5% in people with mental illness
(x2, excluding personality disorders, schizophrenia, and substance misuse), which increases to 6–10% in personality
disorders and schizophrenia spectrum disorders (x3), and to more than 10% in substance misuse (x4) (SR & MA) (Whiting
et al., 2020).Forensic Treatment Evaluation instrument in Netherlands showed that higher risk patients can show more
treatment progress than lower risk patients (Q & FA, n = 240) (van der Veeken et al., 2018) and points to the need for
careful secure care selection of patients to benefit from interventions.
Regarding occupation, patients expressed the need to have control over decision-making, help with motivation
and support, and generating suggestions alongside as helping them (FG & TA, n = 26 patients in 5 groups) (Craik et al.,
2010). The evidence base supporting occupational therapy in forensic mental health setting is relatively weak and
consensus needs to be achieved about defining specific interventions, and then scientifically evaluating their intended
outcomes (SR) (O’Connell & Farnworth, 2007).
There is a shortage of knowledge on the effectiveness of pharmacological treatment specifically to forensic issues
within forensic psychiatry (SR, n = 10) (Howner et al., 2020). Patients who have a history of serious violence are more
likely to show higher levels (in terms of frequency and severity) of aggressive and violent behaviour as compared to
patients who do not have such a history. Patients with a history of violence have a greater frequency of lifetime domestic
violence, a greater lifetime propensity to misuse substances, a higher number of compulsory admissions, lifetime substance
use disorders, early age at the first contact with mental health services, and have a longer illness duration. Verbal
aggression is significantly associated with aggression against objects, and this with physical aggression, in this progressive
order of aggression in most cases. About ⅟4 of aggressive incidents is related to psychosis and ⅟5 to being under the
influence of alcohol. Violence is frequently impulsive (92.4%). Victims of violence were more frequently the patients’
parents or partners (28.0% and 24.6% respectively), followed by clinical staff (6.8%), patients’ friends (6.8%), other
relatives (6.8%), other patients (2.5%), or others (24.6%).A large majority of patients (88.8%) recognize their acts as
violent, while the remaining 11.2% deny the violent nature of the offenses, and⅟4 of the violent patients are arrested for the
violent offenses. Social acceptability of the patients is inversely related to violence to a modest extent. About ⅟5 of patients
with a violent history are readmitted to hospital within a year (twice those with mental illness without a violent history).
Patients on enhanced close monitoring and intensive care in residential settings, that prevents substance abuse, show lower
levels of violence when compared to patients living independently in the community.Violence in severe mental illness
significantly shapes public stigma, increases discrimination, and places a heavy burden on family and carers (CCS, n =
247) (Barlati et al., 2019). Clozapine, olanzapine and risperidone have a weak effect on violence reduction (SR, n = 10)
(Reisegger et al., 2021).
However, the prevalence estimate of Treatment resistant (TR) Schizophrenia is ~ ⅓ (Mørup et al., 2020), TR
Depression is ⅓ (MA) (Jaffe et al., 2019), TR Anxiety Disorders is ⅓ (MA) (Bystritsky, 2006) and developmental
disorders can mostly only achieve a reasonable QoL. Co-morbidities also make treatment more resistant such as Bipolar
Affective Disorder is associated in ~⅟2 the patients with an anxiety disorder (MA) (Nabavi et al., 2015) etc. Substance
misuse is present in more than a ⅓ of secure care patient, more than ½ of secure care patients have had prior contact with

primary care and mental health services. Inadequate response is defined as less than 20% - 50% reduction in symptoms
depending upon the diagnosis. Treatment resistance in pharmacologic interventions is defined as more than 6 – 8 weeks of
failed treatment, unsuccessful response to 2 medications of different class, and hence a degree of improvement to lead a
reasonable QoL is described by some as the goal, rather than absence of symptoms (Demyttenaere, 2019). However,
patients wish for symptom remission. As a consequence of the above discussion, given that patients reaching secure care
have a combination of these risk factors, the prevalence of treatment resistant conditions could well be > ⅓ (no identified
study on this issue). However, personality disorders as main diagnoses and comorbid personality disorders were associated
with prolonged inpatient treatment in forensic psychiatry care. Substance dependence in addition to a personality disorder
was an aggravating factor. Comorbid somatic disorders affected treatment duration of patients diagnosed with a psychotic
disorder (CRS, n = 364) (Werner et al., 2014).
The prevalence of metabolic syndrome in secure care patients is about the same as for psychotic patients in the
community i.e., ~ ⅟4 and ~ 3/4 are overweight or obese (SR, n = 32) (Ma et al., 2020). Almost all patients in secure care are
on antipsychotic medications (even those with non-psychotic primary diagnosis) and ~ ⅟2 on multiple antipsychotics. The
association is stronger in those with longer stay, depot medication and on clozapine (CSS, n = 172) (Farrell & Brink,
2020). However, psychotic patients in general psychiatry are on more antipsychotic medications than in forensic psychiatry
and the forensic patients differ from general psychiatry patients with psychosis, having more megalomanic ideations,
animosity, affect flattening, weak will, social passivity, apathy, uncooperative behaviour, and poor impulse control (Vasic
et al., 2017). Despite the increase in this risk, a 20-year cumulative mortality for schizophrenia without antipsychotics to
schizophrenia with antipsychotics is 46% and 25% respectively, thus net weighting on the beneficial side (CRS, n = 62,
250) (Taipale et al., 2020).
Thereporting of adverse effects of psychotherapy has failed to progress in trials of psychological therapies (Parry
et al., 2016). A meta-analysis of psychological interventions in in-patient forensic mental health showed small effect size
for increasing insight into mental illness, ameliorating symptoms, improving problem solving ability, reducing pro-
criminal attitudes, & improving ward behaviour, a medium effect size was found for increasing knowledge of their mental
illness. Very little research has so far been undertaken to evaluate the more commonly offered interventions (SR &MA, n =
28) (McIntosh et al., 2021). Commonly offered group interventions in HSU in UK included anger/aggression, offence-
specific, enhancing insight and understanding of mental illness, thinking skills/problem solving, substance misuse, self-
harm, relationships, self-esteem and well-being, relapse prevention, and moving on (SR, n = 28) (Sturgeon et al., 2018).
Individual psychological interventions in secure care include CBT, DBT, MBT, psycho education, schema-focused
therapy and solution-focused brief therapy, IPT and psychosocial interventions as psycho educational strategies, non-
directive counselling, supportive interactions and tangible assistance (SR, n = 9) (MacInnes & Masino, 2019). Patients
completing forensic psychotherapy report the importance of trust and acceptance in therapeutic relationship, and changes
in the domains of perception of self and interpersonal functioning as well as changes in problematic behaviours (I & TA, n
= 10) (Yakeley & Wood, 2011)
The major predictors of recidivism are the same for MDO’s as they are for non-MDO’s, with criminal history
variables dominating over clinical variables in effect size on reoffending (MA) (Bonta et al., 1998). A model for central
risk factors with 8 domains was introduced by Bonta. The Big four: Antisocial – cognitions, personality, behaviour and

associates, and the moderate four – substance abuse, leisure, education/employment, family/marital. The Big four are more
predictive than other clinical variables for general and violent recidivism in MDO’s (MA) (Bonta et al., 2014). However,
only half of the C8 predict general recidivism in sex offenders and further loses relevance in older sex offenders (CRS, n =
650) (Wilpert et al., 2018). Incarceration in prison irrespective of sentence length or community sanctions are both
associated with slightly increased rates of recidivism and lower risk offenders are negatively influenced by prison settings
(SR & MA, n = 50) (Gendreau et al., 1999).
After discharge from secure care, the suicide rates are ~3.25/1,000/year, crude reoffending rates are 4.5/1,000/year
and readmission rates are 7.2/1,000/year (Fazel et al., 2016). Substance abuse increases the hazard ratio for
rehospitalisation, death and violent recidivism by a factor of x 1.3 – 2 (Fazel, Wolf et.,al, 2016). The SMR from suicide is
~ 18 times the general population and SMR for all-cause death is x 2.2 the general population (CRS, n = 966) (Takeda et
al., 2019). The 3-year recidivism rate is ~ 17% after discharge from secure care and can vary with region. Those who have
committed severe prior violence are less likely to reoffend (CS, n = 1,800) (Charette et al., 2015). A 10-yr follow up study
demonstrated general recidivism in ~ ⅓ and violent recidivism in ⅟6 (CRS & Q, N = 125) (Krona et al., 2016). This is in
comparison to 39% of released inmates reoffending in a year, 50% within 2 years and 75% within 9 years. More recent
data suggests the annual reoffending rates are ~ 30%, with higher rates among those serving shorter prison time (MoJ UK,
2010). A recent matched case control study of three groups, (1) forensic examination without court treatment order: (2)
forensic examination with court treatment order: (3) matched general offenders showed that reoffending, severe offending,
and recurrent offending was 1 > 2 > 3 (Bengtson et., al, 2019).There is a reported 10 – 24% reduction in re-offending rates
from delivering Offending Behaviour Programmes (OBP) depending on the type of programme, age and gender of the
offender, and the risk of re-offending (SR) (Samele, 2008). Accredited OBP should have an integrated model of evaluation
that focuses on the climate of program delivery, cost-effectiveness, integrity, and the treatment outcomes in the short and
long term. Recidivism is only an outcome in the long term (Friendship et al., 2003). As an example, the Ministry of Justice
in UK provides for 14 community and 21 custodial programmes for offenders currently in England (Ministry of Justice,
2021). There has also been a move to offer OBP’s in secure care settings as part of the psychological intervention’s
pathway. These factors imply that although the predictors of violence among MDO’s and non-MDO’s are the same, the
outcomes after forensic treatment and risk management interventions in hospitals and other institutions reduce recidivism
when compared to matched no-intervention offender groups, and also matched prison intervention groups. Psychological
treatments for adult violent offenders in correctional and forensic mental health settings are effective in preventing
community recidivism and institutional (hospital/prison) misconduct but their combinations with other interventions and
the appropriate offender groups need further research (SR & MA, n = 27) (Papalia et al., 2019).
Neuro-cognitive Deficits or Impairment (NCD/NCI) occurs in all mental disorders and across all age groups of
mental illness. NCI can occur in any of the 6 key domains of higher cognitive functioning; IQ being a part of it. There are a
wide range of tools and rating scales to undertake these assessments. Mental illness is commonly associated with NCD (all
cases) and Neurological soft signs NSS (75%), both of which contribute to the illness burden in addition to
psychopathology. However, these aspects are currently not integrated into regular psychiatric care. IQ is also affected in
mental illness (70% with low (<10 IQ points), moderate (<20 IQ points) and severe (>30IQ points) in the ratio 1:2:1
among those with lowered IQ from premorbid IQ of ~ 95). Level of insight and aggressive behaviour is also related to an
extent with NCD’s. Hence endeavouring to evaluate NCD/NSS/IQ/pre-morbid IQ in a long-term care patient, contrasting it

with psychopathology PANSS, understanding the overall burden to the patient’s ADL and instrumental-ADL, relation to
aggressive behaviour and the level of functional handicap that poses on him/her, would provide pragmatic perspectives on
the extent of achievable recovery. This will inform the patient’s and attending professional team’s best judgements on
rehabilitation pathway in Rehabilitation Psychiatry and Forensic Psychiatry (see our other paper “Role Of Neurocognitive
Impairment in Patients With Chronic Mental Illness – Relevance To Patients In Rehabilitation Psychiatry And Forensic
Secure Care”.
Experts felt that there is some convergence and some divergence of what constitutes efficacious treatment (what is
given by professionals to patients) and similarly, of care (what is received by the patient) and what is a collaborative mix
(DS, n = 54) (Tapp et al., 2016). Nurses generally have a more negative perception of people diagnosed with a personality
disorder and this negativity is focused more towards managing the behaviours rather than on treatment efficacy and clinical
outcomes. This is more so in lower & medium security than in HSU (Q, n = 600) (Mason, Hall et., al, 2010). There is a
significant nurse to other groups and other multidisciplinary intergroup variations on diagnostic labelling which would
result in different perspectives on management of patients in these settings (Q, n = 600) (Mason, Caulfield et al., 2010).
Evidence for staffing levels and patient outcomes in mental healthcare specifying staff numbers and ratios is
particularly weak. There is a stronger argument for an increase in registered nurse numbers and a richer skill mix. More
attention was needed to training, staff wellbeing and attitudes, especially given that there are a wide range of settings where
patient interventions are offered (SR) (Lawes et al., n.d.). However, another study reporting the implementation of a safe-
ward policy demonstrates that Staffing levels on acute mental health wards appeared crucial in the implementation of a
restraint minimization project. Both staff and service users implicate insufficient staffing for deficiencies in the relational
elements of care. Organisations and policy makers ought to address environmental, contextual and resourcing factors,
rather than identify problems exclusively in terms of perceived aberrant behaviour of staff or service users (I & MM, n =
130 staff and 32 patients) (McKeown et al., 2019).
ID secure care services identified their outcome domains as effectiveness (severity of clinical symptoms), patient
safety (offending behaviours) and patient and carer experience (reactive and restrictive interventions, quality of life and
patient satisfaction) (SR & TA, n = 60) (Morrissey et al., 2017). However, a survey of the outcome domains showed that ~
85% of their focus was only on half of the effectiveness elements of care (DS, n = 15) (Morrissey, Langdon, et al., 2017).
Secure services only offer religious service support to patients when the patients’ religious tendencies are not part
of their mental illness(I) (Nissen et al., 2019). Daily patient education programmes improved patient QoL & patient
satisfaction, although discharge rates or time to discharge did not show significant changes in the 1-year study period (Q, n
= 22) (Schofield, 2019).An expert user group identified research priorities in forensic mental health as physical health,
future plans and moving on, and causes of illness and crime (DS, n = 27) (Aboaja et al., 2020).
Forensic psychiatry patients have different types of stories describing their offence and its meaning in their lives.
Illness narratives can be utilized therapeutically because they may construct patients’ identity, experiences, and their
situation; and they seek explanations and meanings for their plight (I & TA) (Askola et al., 2015). Patients at different
stages in their treatment need a variety of approaches. At first, they need more information about their situation in addition
to being treated humanely. Later, they find it hard to work through their criminal offence and it aroused negative feelings.
Their identity is constantly explored and they are particularly stigmatized. Not all forensic psychiatric patients experience

personal recovery, but each patient can rehabilitate within the scope of his or her own resources (I & TA, n = 8) (Askola et
al., 2016). There are up ~25% in HSU and ~ 18% in MSU of Long Stay patients with a variation of 0 – 50% in MSU. On
mapping their characteristics, it was found that this category of patients showed a 4x4 structure of
attribution/outlook/approach/readiness for change vs Static or Dynamic acceptance/Static or Dynamic resistance. Patients’
perceptions of their situation differ in their attribution (internal/external), outlook (positive/negative), approach
(active/passive) and readiness for change (CRS, I, MM, DS) (Vollm et al., 2015).
Evidence Based Medicine and Evidence Based Systemic Practise
Hodgins violence typology for schizophrenia patients is a useful model of 4 groups - first offender, early starter, late
starter, late late starter has again received importance through a recent study. It found that early starters: late starters: late
late starters is 2:2:1. The first group had more offending history, hospital admissions and higher life adversities; the second
group had equivocal health and offending needs but were less severe, and the third group had less of both needs but a
higher chance of using illegal drugs. The study confirmed another observation that offender characteristics are more
important in violence typology associated with mental disorder. This would suggest that the Length of stay for group 1 >
LoS for group 2 > LoS for group 3(CRS, n = 71) (Lau et al., 2020). HoNOS-Secure, forensic outcome tool developed in
England and Wales showed an apparent lack of change over 15 months masking a more complex picture, where initial
decline in ratings was succeeded by significant improvement. Results suggest that it is challenging to measure clinical and
risk-related medium-term outcomes (n = 180) (Dickens et al., 2010). QNFMHS as part of CCQI (Quality Network for
secure care in England & Wales) peer reviews LSU & MSU units. A case control study of 38 LSU’s, a year after peer
reporting, showed no change in quality of physical environment and facilities of the service. However, staff reported
feeling safer after review report introduction but with more burn out. There was no change in clinical outcomes or patient
satisfaction or violent incidents (CCS, n = 38) (Aimola et al., 2018).
The use of Measurement Based Care (MBC) has the potential to improve the accuracy of diagnoses and improve
the outcomes of care (Aboraya et al., 2018). A similar approach is suggested for behavioural health (Lewis et al., 2019).
Forensic psychiatry is described as being ideally suited for incorporating this practice (Glancy et al., 2021). Structured
professional Judgement tools are already in use in secure care services for risk assessment, formulation and management.
There are several clinical assessment tools in individual disciplines of secure care (Ex: CAMCOG, RBANS, IPDE,
MOHOST, PANSS, AIMS etc). There are also ward climate and culture assessments in addition to several QoL, and
outcomes measures which could be reported and quantified. We suggest that with the new age IT options, Natural
Language Program with AI integration, use of IoT, Blockchain technology © has the potential to enable implementation of
EBM and EBP, and taking on the heavy-duty administrative effort of several reports needed in Forensic Psychiatry
(psychology report, psychiatric report, nursing report, OT report, Medications management, court reports, tribunal reports,
MAPPA reports, ministry reports, CPA report, leave applications etc). There are also several assessment reports, clinical
tools by discipline, outcomes measurements, effectiveness measurements, climate/environment measurements etc which
also consumes lot of time and effort and partially, is the reason for limited uptake in practise.
Our practice suggests that there clearly is a felt need for this; but whether ethical considerations and available
technology currently has answers to these problems is not known (Thieme et al., 2020). Personal wireless devices collect
and integrate patients' personal physiological data, and then transmit the data to the backend of the network for related

diagnostics using Internet of Things and Body Area Network, already in use in elderly care homes(Deng et al., 2017).The
ethics of autonomy, beneficience and non-maleficience and Justice is explored by Cockerill, 2020.Blockchain technology
is being trialled in the cybersecurity of healthcare data. Acceptability to such interventions is not known, and barriers and
facilitators to implementation need to be worked through (SR, n = 33) (Simblett et al., 2018). Nursing staff in secure care
feel that it could help early identification of aggression, but are concerned about user acceptance and impact on their
mental health, along with workload concerns from real time monitoring (FG & TA, n = 25) (Greer et al., 2019). See Table
1 in the end for a model range of descriptions and potential measures of data that could plausibly be used for analytics.
Evaluation of Therapeutic Relationship and Therapeutic Environments
Nursing documentational descriptions involve complex interactions between patient and staff that were linked to specific
circumstances surrounding the patient. These antecedents, combined with the aggression incident itself, created stereotypic
representations of patients as deviant, unpredictable and dangerous and they solely focused on the patient's behaviour. Such
response would be counterproductive to managing aggression (QS, CRS) (Berring et al., 2015). Documenting the
motivation for aggression (irritable, instrumental or defensive) would better inform risk management (CRS, n = 2649
incidents) (Winje et al., 2017). Use of FESAI (Forensic Early Warning Signs of Aggression lnventory) for early joint
detection by nursing staff and patient of impending aggression reduced aggressive incidents significantly, more so for PD
and Substance abusing patients than psychotic patients (CCS, n = 168 patients) (Albertus & Fluttert, 2010). In the UK,
modified OAS (Overt Aggression Scale) is especially used in neuro-behavioural units to assess response to treatments and
identify a predefined set of antecedents to inform formulation and interventions. Incidents in mental healthcare are
triggered when users experience staff behaviour as custodial rather than caring and when they feel ignored. Patients
identified that their mental illness and the negative aspects of the treatment environment affected the incidents (SR, n = 13)
(Gudde et al., 2015). In secure care settings with a mixed forensic and civil section detained patients, 90% of the violent
incidents are committed by the latter (CRS, n = 840 incidents) (Kuivalainen et al., 2013). Individuals with an ASD have
disproportionately higher number of incompatibilities with other patients compared to those patients without an ASD, and
experience higher and longer periods of seclusions (MA, n = 8) (Murphy et., al, 2017).Social climate in secure settings is
defined by therapeutic relationship, care and treatment orientation; the secure base working in an environment created by -
patient group, staff group, physical environment and system level factors (SR & TA, n = 20) (Doyle et al., 2017). Both
social climate and sense of community predict incidents of disruptive behaviour as shown on a high secure ward (Puzzo et
al., 2018). Some of the models and tools for social climate on secure care ward includes Safe ward model, EssenCES, See
Think Act, Ward Atmosphere Scale and Forensic Restrictiveness Questionnaire.
Adult safeguarding procedures in England revealed histories of trauma, multi‐factorial abuse; living with fear and
stigma as well as mental distress; the effects of “psychiatric disqualification” and individual blaming needing to be
addressed (MM, I, chats, n = 793) (Carr et al., 2019). Patient Safety in in-patient mental health settings is related to
interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication
safety, unauthorised leave, clinical decision making, falls, and infection prevention and control (SR & TA, n = 364)
(Thibaut et al., 2019). MDT staff interviews on secure wards pointed to environment, policies and practices, teamwork and
support; staff experience and knowledge; and patient factors (I & TA, n = 88) (Marshall et al., 2019).

Suicidal patients in general psychiatry services described connection, protection and control as vital to their
experiences of safety (SR, n = 20) (Berg et al., 2017). Majority of suicides in secure care had schizophrenia with chronic
treatment-resistant illnesses, and had committed proportionally more violent offences, had a history of serious self-injury
but no recognized clear depressive episodes (CRS, n = 14) (Ramsay et al., 2001). A comparison of suicide rates between
prison and secure care setting in Germany revealed that there is no difference in the incidence @ ~ 130/100,000 residents.
The level of mental distress is high in long term detainees (Otte et., al. 2017 as cited in Voulgaris et., al, 2018). Patients
who commit suicide in forensic hospitals are, in comparison to the prison system, more likely to have committed a violent
offense and have a prior history of suicide attempts. The duration from admission into the institution to the suicide event is
shorter in the prison group. Also, younger people committed suicide earlier during their stay in a forensic psychiatric
hospital or prison (CRS, FA, n = 519) (Voulgaris et al., 2018).The first international expert consensus study to identify
research priorities in patient safety in mental health identified a. Patient contributions to their own safety b. The patient
perspective on medication safety c. Perspectives on safety culture in patients who self-harm d. Good self-driven
individualised safety planning e. Safety plans and safety improvement f. Factors in allowing reduction in restrictive
practice including restraint and seclusion; from a set of 117 priorities obtained from systematic reviews (DS & I, n = 56)
(Dewa et al., 2018).
Patient’s perception of care quality increases when they are relocated to a new building with evidence-based
healthcare environment design, and this view persists even three years later, especially for the seclusion room environment
(I, n = 58) (Wijk et., al, 2019). Secure care Hospital design can positively influence patient experience (Mclaughlan et al.,
2020). Even staff members felt that person-centred and psychosocial interventions improve after relocation (I, n = staff in 3
secure hospitals) (Degl’ Innocenti et., al, 2019). An Italian study on an acute psychiatric ward demonstrated that the
average noise level on the ward is ~ twice the WHO recommended levels (Berglund et al., 2000) for patients (Camuccio et
al., 2019). An initial investigation of excessive sleepiness in some psychotic patients suggests the need for further research
to disentangle directions of effect amongst sleepiness, mood, activity, psychotropic medication and psychotic symptoms,
and investigate possible interventions for excessive sleepiness in psychosis (CCS, n = 60) (Reeve et al., 2021). The
relationship between patient characteristics and ward climate in forensic settings is complex. Lower security levels are
better for patient cohesion (PC), experienced safety (ES) and therapeutic hold (TH). Female gender is conducive for PC
and ES. Higher perceived risk is associated with lower PC. Diagnosis of personality disorder or psychosis is associated
with higher ES. Lower levels of engagement predict greater TH (n = 63) (Dickens et al., 2014). Given that smoking has
been banned in secure settings, ⅓ of patients interviewed were angry and ⅔ reported gaining weight (Q & FG, n = 21)
(Hehir et al., 2012).However, staff felt it easier to provide patient care with this ban and they reported lesser patient
aggression (Q, n = 111) (Hehir et al., 2013).
BME’s are overrepresented in Secure care in UK and their care was found to be more coercive and less needs
fulfilling and discriminatory (DoH, 2005 as cited in Rahul Bhattacharya et al., 2010, pp. 222–231). There is a call to shift
from cultural competency to ethnographically informed formulation where patients’ lived experiences in their psychosocial
and cultural contexts need to be understood and the information used in treatment planning (Kleinman & Benson, 2006 as
cited in Rahul Bhattacharya et al., 2010, pp. 222–231).
Sexual dysfunction with long-term psychotropic use is prevalent in 30 – 80% of patients (Montejo et., al, 2018).
On interviewing experts from European Forensic Psychiatry, it was found that no country had a national policy on patient

sexuality in secure care, although many had local policies or shared practices. Progressive approaches were evident in 9/14
countries, and practices in UK appeared most prohibiting and excluding (QS & I) (Tiwana et al., 2016). Disgust is a
common experience for healthcare professionals, yet it is not talked about. Professionals cope with it usually by the
defence of empathy (SR, n = 11) (Hadjittofi et al., 2020).
It was observed that specialist knowledge and skills for forensic nursing were not documented inn literature. In
order to achieve specialty status, nurses have to consolidate their role in the containment and care of patients, they have to
return to the nurse–patient relationship as the foundation of psychiatric nursing practice, then, within that relationship,
nurses must expand their practice to include dealing with offence issues (SR and TA) (Martin, 2001). Staff burn-out in
secure care is mostly due to interprofessional conflicts, workload, and lack of involvement in decision-making (SR)
(Dickinson & Wright, 2008).Forensic patients were more likely to give negative feedback on mental healthcare services
than non-forensic patients. The service’s level of security-impacted patient’s willingness to engage with giving feedback
(Q & MM, TA, n = 906) (Mottershead et al., 2019).
In frustration, some patients abscond from the ward. In general psychiatry, the patients attributed this to stigma,
mixed experiences with caregivers, poor resources and services, and mental illness symptoms (I, n = 10) (Kaggwa et al.,
2021). In secure care, half of the patients return voluntarily within 24 hours of leaving. Over 50% of them had drunk
alcohol or taken drugs while away from the unit. Escapees were more likely to be transferred prisoners and to have planned
their escape, less likely to return to the unit voluntarily, and were away for longer. Offending was rare during unauthorised
leave. Motives for absconding included: wanting freedom or drink or drugs, family worries and/or dissatisfaction with
aspects of treatment (CRS, n = 77 incidents of absconsion) (Mezey et al., 2015). Between this study and Wilkie et al.,
2014, 30-50% were repeat absconders. Improvements in therapeutic communication between patients and clinical teams
could be helpful. Patients want to find relief, to regain power and control over their lives and/or to address unmet needs
(SR, n = 8) (Voss & Bartlett, 2019).
Challenges to Smooth Transitions of Care Upward/Downward/Sideways or By Age and Gender
Persons with severe mental illness are responsible for ~5.3% of all violent crimes (Walsh et al., 2002). This includes ~ 35 –
50 homicides/ year by SMI patients in England and wales (~ 10% of all homicides per year) (38 years homicides registry
study) (Taylor & Gunn, 1999). Repeat homicide by released prisoners is ~ 7.3% and grave offence is ~ 20% (CIRN, n.d.).
However, in comparison, the pooled estimate for homicide recidivism in schizophrenia is 2.9% given that they have
received treatment interventions (Golenkov et al., 2014) and violent recidivism is ~ 40% (Fazel & Wolf, 2016). Severe
violence in SMI is mostly towards family and familiar people, except in psychopathy. There were many previous studies
that reported 3 – 10fold increased risk of homicide in schizophrenia patients compared to normal population, but a meta-
regression study attributed this mainly to comorbid substance abuse; stating that schizophrenia patients have no more risk
of homicide than the general population (Fazel et al., 2009). However, despite these findings, the public response and
professional pathways to reintegrate offender patients into the community is significantly more risk averse and slower.
Offenders in custodial or hospital settings need to adapt their masculinity differently in relation to the setting and
transitions between these settings brings to focus this required transition. In hospital, they need to primarily focus on illness
and recovery, whilst in prison they have to learn to desist (CCS, T, n = 20) (Haddow, 2013). Secure care patients reoffend
violently more often than normally sentenced individuals, suggesting the need for continua of services, independently of

medicolegal status. It is dependent on male sex, younger age, pre-index violent crime, personality disorder (vs.
schizophrenia spectrum and other psychiatric disorder), substance use disorder, and 5+ hospital admissions (CCS, FA, n =
1062) (Bengtson et al., 2019).
Patients felt that suspension of responsibility, collaboration in care, learning from others, supportive alliances,
specific interventions (medical and psychotherapeutic), a safe environment and opportunities for work is what enables
them to reach discharge (I & TA, n = 12) (Tapp et al., 2013). Loneliness for the secure-unit patients was a more unpleasant
experience and more associated with difficulties in forming close attachments (CCS, TA, n = 61) (Murphy, 2000). There is
an ongoing study on effectiveness of social network coaching on post discharge outcomes (Q, RCT, n = 105) (Swinkels et
al., 2020).
Transitions in adolescents involve emotional and developmental readiness to moving onto adult-oriented settings
(I & TA, n = 34) (Livanou et al., 2021).On being discharged from hospital, adolescents feel the need for close connection
to at least one person, to receive practical help with regard to finances, work and housing; and to be able to experience
pleasure and joy in their lives (I & TA, n = 25) (Van Hecke et al., 2019). Life after discharge for most young adults from
secure services was characterised by close friends and a high quality of life, but also by substance abuse, professional
support, debts, and delinquency. Because of persistent problems, residential treatment and aftercare should focus more on
patients' long-term needs (Q & FA, n = 46) (Janssen-de Ruijter et al., 2019). On release from prison, female adolescents
with more resilience displayed higher QoL and less offending, while more support was associated with higher QoL only;
thus, demonstrating the importance of internal and external resources as can be achieved by a Good Lives Model (Q & FA,
n = 49) (Van Damme et al., 2021). A qualitative analysis of female adolescents' experience of transition to adult secure
services showed that they are sensitive to the behaviour of others throughout the transition process (negative impact of
aggression from other patients, relationships with staff and other patients, and the need for informed involvement) (Q &
TA) (Wheatley et al., 2013).
Older Mentally ill offenders feel better in prison rather than secure care settings but wanted to live independently,
despite previous failed attempts (I & IPA, n = 8) (De Smet et al., 2014). During side-ways transition, patients find the
uncertainties hard to bear and are concerned about tangible and practical issues (I & IPA, n = 17) (Parkes et al., 2014).
When stepping down in secure care, they relate to feeling free, one step at a time, having to prove oneself, and being open
to assistance that comes in many forms. They describe the need to be connected throughout the process for successful
transition (I & TA, n = 5) (Kinney, 2011). Some patient feel that transitional housing is a good trial opportunity. They
could improve their social participation, self-esteem/efficacy, community integration and renewal of daily living skills,
community living skills, cultivate self-confidence and grow their personal resilience (I & IPA, n = 6) (Heard et al., 2019).
Offender patients found incompetent to stand trial were patients with chronic mental illness, had lesser charges on
index offence, were more disturbed in presentation during early part of admission, and took a longer time to restore
competency to stand trial. They also had lower Global Assessment of Functioning and lower IQ on admission. Their LoS
in secure care was also eventually longer (CRS, n = 71) (Colwell & Gianesini, 2011). Important aspects influencing the
patients' transition to the community as described by providers were a well-planned care plan, together with a suitable non-
institutional dwelling (see Figure 2 for an author conceptualised model of accommodation arrangements) and a tailored
occupation. They also felt that having a well-functioning and trusting social network and a good relationship with a contact

person/advocate is helpful. They also need to be able to manage their own finances (FG & TA, n = 12) (Gustafsson et al.,
2011). Consultants felt that those patients who had residual psychopathology, risk, personality traits, those who were more
institutionalised and their anxiety struggled in transitions. Lack of suitable facilities and media attention were judged to be
less important (CRS, I, MM, DS) (Vollm et al., 2015). The successful rehabilitation of people through forensic inpatient
services relies ultimately on there being places and support available for them to return to in the community (gov.scot,
2021).A range of accommodations and supports will help locate the offender patients in appropriate environments as in
Figure 2 and allow feasible discharge plans; helping reduce LoS in the secure care pathway and potentially discharge some
Long Stay patients.
Figure 2: © Range of Accommodation Arrangements to Suit Various Offender Patient Groups.
Continuity of Care/ Collaborative Outcomes Achieved by Coworking of Agencies and Services
Quality of mental health care in prison estates were found to be related to working effectively in MDT’s, having good
communication, balancing care with security, and an expressed positive staff-prisoner relationship. They identified
numerous shortfalls in service provision across the prison estate and called for reform with mental health as a key priority
(TA, n = 42 inspectorate reports) (Glorney et al., 2020). ID prisoners on release reported unsettling conditions on return to
community (I, n = 9) (Chiu et al., 2019) (I, n = 38) (Murphy et al., 2017).There are more typical criminogenic needs among
those with early onset crime. Those with crime onset after mental illness show fewer criminogenic needs and have better
outcomes on release, than those who had crime onset before mental illness. Individuals with no prior contact with mental
health or criminal justice have higher functioning prior to their crime and have a lower risk of reoffending (CRS, n = 1800)
(Crocker et al., 2018).
About 3/4 of forensic patients have a prior general psychiatry admission, ⅟4 of general psychiatry patients with
schizophrenia have offending history, and ⅟5 of general psychiatry patients with schizophrenia are at some point admitted
to forensic psychiatry units. The authors recommended risk targeted management interventions in general psychiatry for
this subgroup of patients (CRS, n = 232) (Hodgins & Müller-Isberner, 2004). On comparing general psychiatry and
forensic psychiatry schizophrenia patients over 2 years follow up, general patients displayed higher levels of positive and
negative symptoms than forensic patients, and more of them engaged in aggressive behaviour towards others. Aggressive
behaviour was associated with positive symptoms and Antisocial Personality Disorder. Rates of readmission were similar

for the two groups. The forensic approach that includes assessing and managing risk of violence as well as treating
symptoms of schizophrenia led to better outcome than that of general psychiatry (CCS, n = 248) (Hodgins et al., 2007). A
5-month follow up of acute psychiatry patients after discharge showed that 25% were violent and the factors underlying
violence were the same as is in a representative forensic patient group (Doyle et al., 2011).The evolution of specialisation
in all areas of occupation, is also relevant to the field of Forensic Psychiatry. The interface with General Psychiatry has its
tensions but with cooperation and communication, patients’ continuity of care can be optimised (Khosla et al., 2014).
A retrospective cohort study over 15 years in Sweden, of discharged forensic patients identified that ~ ⅓ have
schizophrenia spectrum disorders, ⅟4 have personality disorder,1/6 substance abuse as primary diagnosis and ⅟4 have other
primary diagnoses. Substance abuse increased the hazard ratio of rehospitalisation, death and violent recidivism by a factor
1/
of x 1.3 – 2. The mean age of discharge is ~ 36years, ~ ⅓ die at a mean age of 52 (suicide ~ 1/4, accidental death 6 and
2
cardiovascular deaths are the commonest cause), ⅔ are re-hospitalised within an average time of 5.3 years and /5 violently
reoffend over a mean time of 4.2 years (retrospective cohort, n = 6520)(Fazel, Wolf, et al., 2016). In contrast, another study
found that men died ~ 15 years and women 25 years earlier than normal population but found no increased rates of suicide
or accidental deaths in their 20-year cohort study. They instead identified respiratory/cancer and cardiovascular events as
the main cause in their cohort’s premature death (Rees & Thomson, 2020). This discussion demonstrates the need for long
term mental, physical and risk management care (in whatever service models available in a country) over at-least 10 – 15
years following discharge from forensic secure care hospitals. In general psychiatry, there is no evidence of patient benefit
from current CTO outcome studies. In addition, it increases readmission rates, length of stay in hospital, the duration of
compulsory treatment, while minimally reducing the patients becoming victims of crime (Metareview, n = 53) (Rugkåsa,
2016).Childhood adversity is known in ~ 80% of secure care patients with physical abuse being the commonest (CRS & Q,
n = 422) (Karatzias et al., 2019). It also demonstrates that violence and mental illness history usually commences by mid
adolescence for many, as these offender patients graduate from criminal justice or mental health or both sets of services
before landing in forensic psychiatry hospitals. Efforts to provide early interventions in both these groups could potentially
alter the trajectory and length of stay for offender patients.
Most LoS studies report per admission episode only and not the up/down/side transitions of patient stay in
hospital and the periods of community restrictions and treatments a patient receives. These are also important so as to
evaluate interventions, triage interventions for right-place right-intervention strategy, minimise duplication, identify
treatment resistance factors, improve patient motivation and engagement in interventions, and reduce restrictions earlier by
identifying continuity. An Independent Forensic Mental Health Review in Scotland provides information on the Forensic
Network reporting of mean length of stay durations. This for a high security patient turns out to be HSU (6yrs) +MSU
(2.75 yrs) +LSU (4.3yrs) = 13 years. They found that if actions are not taken to address the issues of hospital and
accommodation capacity, and the impact it is having on people moving through the system, the system is in danger of
grinding to a halt. People must have access to the care and treatment they need in the correct level of security. There are
two areas that require immediate attention: the pressure on medium secure beds and delays in the discharge process that are
creating a bottleneck of people waiting to leave low secure service. In all, they made 21 recommendations across services
and agencies to improve coworking among agencies and services (gov.scot, 2021).
There is a lack of evidence for the effectiveness of interventions for PD and related recidivism in prison, hospital
or community settings. However, there is a global trend to consider non-institutional care to this group considering holistic

approaches to target trauma and relationship building, early identification and sentence planning, and the importance of
workforce development and relationships (SR) (Skett & Lewis, 2019) in whatever settings the offender finds
himself/herself in. There is ample evidence that higher PCL-R score, presence of ASPD with or without primary functional
mental illness has higher, earlier and more severe reoffending for both general psychiatry and forensic psychiatry patients
(n = 136) (Shepherd et al., 2016). Improving the clinical and risk management factors on HCR-20 in forensic psychiatry
admissions does not reduce the risk of reoffending in patients with psychopathy (n = 40) (Mastromanno et al., 2017). There
is also no published literature on how to effectively deliver mental health care in Probation (SR, n = 44) (Brooker et al.,
2020) and this group of offender shave very high-risk for completed suicide - reasons for this include drug overdose,
mental health problems, and poor physical health. They suggest good quality partnership working between probation and
mental health services, in addition to appropriate investment in services(SR, n = 13) (Sirdifield et al., 2020).
Norwegian Knowledge Centre for Health Services collated the first set of international data on Patient Experience
in healthcare based on OECD and WHO requirements. Patient satisfaction in General Psychiatry is related to the extent of
improvement in mental health, food provided, and patients with prior admission; showed greater satisfaction, and those
who were secluded & experienced poor therapeutic alliance, showed lower satisfaction (CSS, n = 270) (Zendjidjian et al.,
2014). In Australia, the move is towards patient-centred care, redesigning systems architecture, shift from activity-based
funding to results/outcomes-based funding and redistribution of resources from downstream to upstream mental health
interventions to live contributing lives, and participate as fully as possible, as members of thriving communities (NR)
(National Mental Health Commission, 2014). The only independent correlates of low satisfaction in mental healthcare were
schizophrenia diagnosis and low psychiatrist to patient ratio, and they recommended examining expectations formed by
previous experience of treatment, service-related knowledge, stigma and patients’ disempowerment, and power imbalance
(CSS, n = 8250) (Krupchanka et al., 2017). It is also related to insight, satisfaction with physical health, self-efficacy,
family support, and social anhedonia (QS, n = 125) (Ratner et al., 2018). A study using ~ 75 different PREM tools in
mental health with a massive 1932 items; showed that the key experience measures were interpersonal relationships
(22.6%), respect and dignity (19.3%), access and care coordination (14.9%), drug therapy (14.1%), information (9.6%),
psychological care (6.8%), care environment (6.1%) & patient satisfaction (6.7%) (SR, n = 86) (Fernandes et al., 2020).
Patient experience work is insufficiently embedded in most mental health trusts and there is a need to gather, analyse and
interpret this data and triangulate it with outcomes and safety data (CSS & MM, n ~ 270 +, 47 hospital sites + conference)
(Weich et al., 2020). It has been emphasised that quality improvement is applicable to corporate, strategic and support
services, in addition to clinical services, in order to influence the clinical realm (Shah & Fitzgerald, 2018).
The role of language proficiency is insufficiently acknowledged as it is very important in mental health care (SR,
n = 26) (Bauer & Alegría, 2010). This brings into focus the important role of translation and interpreter services, advocacy
groups for patients and carers, easy read and watch communication-material provided by key organisations such as national
professional bodies and voluntary organisations representing the interests of the patients and carers; and the role of expert
user groups in shaping consensus decisions on recruitment, planning, design and delivery of secure care services.
Professionals’ practice is subject to bias: both Implicit (Sukhera & Watling, 2018) and Explicit (Clarke, 2018). Patient
reported experiences when analysed for content over 12 years found that multiple interactions affect patient experience and
perceived care quality and the care provided by an individual clinician cannot be separated from the wider healthcare team
(QA & TA) (Baines et al., 2019).

In evidence-based practice, tools to measure work environment of healthcare professions (SR, n = 37) (Maassen et
al., 2020), nursing cultural competence (SR, n = 44) (Osmancevic et al., 2021), Quality & Satisfaction in mental health
(SR, n = 34) (Sanchez-Balcells et al., 2018) show that certain tools meet psychometric properties but they need to be
suitably modified and developed further with consensus. QoL evaluation using a suitable instrument from the available
multitude of scales can be useful in demonstrating the impact of mental illnesses and the possible benefits of therapeutic
interventions in psychiatric care (SR, n = 159) (Berlim & Fleck, 2003).The negative impact of stigma in secure care on
patient transition to the community showed that access to care and community resources, and completing identity work
necessary for moral and social community inclusion, were hindered (SR & TA, n = 7) (MacMillan, 2016). In the
community, they are stigmatised and not properly understood by non-specialists when they engage with primary care teams
(I & IPA, n = 11) (Campbell, 2008). They may receive insufficient support in the community from staff that are
overworked and under resourced (Q & TA, n = 80) (Coffey & Coleman, 2001). A national community sample of
healthcare workers describe the poly-problems of MDO’s suggesting the need for an integrated and comprehensive
approach, which is challenged by the fragmented and diverse ideologies of the behavioural health, criminal justice, and
social service systems. This diverse range of problems needs the healthcare professionals to have knowledge of many
different problems, expertise to respond to them, and an understanding of how these problems interact when they co-occur
(Wolff et al., 2013). There will be various such challenges for the discharged secure care patients to face in order to remain
well and safe in the community.
DISCUSSION
The 7 key themes identified show possible significant relationship with Length of Stay, as both upstream and downstream
systems/services/Interventions feed into LoS in a given admission episode (Paper II), in addition to factors underlying
secure care stay per episode of admission (Paper I). The evidence suggests needing to consider macro, meso, micro, static,
dynamic and continuity level factors in considering goals and outcomes. There is a need to design a consensus framework
(for example EPA forensic guidelines 2018) and evaluate these outcomes with the ability to allow devolved
implementation, but within the framework. The QNFMHS in England and Wales have aggregated annual reports for
LSU/MSU with defined standards in 14 categories of physical, procedural & relational security, safeguarding, patient
focus, family & friends, environment & facilities, admission, treatment & recovery, medication, leave & discharge,
physical healthcare, workforce and governance. The peer review provides benchmarking and balancing practices across
secure care hospitals. However, these 14 categories in the QNFMHS reporting standards are different, albeit with some
overlap, to the research evidence on Length of Stay (Paper I & II). The Hoeven Outcome Monitoring method in
Netherlands, currently in evaluation is a tool with emphasis on macro, meso and micro factors but relate to an episode of
admission (Keune et al., 2016). MDT consideration of the whole care pathway is required to address increased length-of-
stay (again in reference to an episode of admission). Further research is required to support development of evidence-based
standards that can be applicable in various regions of the world and improve outcomes for patients at risk of increased
length-of-stay in forensic services (Connell et al., 2019).
We have endeavoured to provide a sample representation of key determinants of Length of Stay (primary 10 and
secondary 20 factors) in the entirety of the offender patient care pathway, with some examples of what to observe and
measure or gather evidence for, in Table 2 below.

CONCLUSIONS
We have endeavoured to bring together the relevant discussions on how long a patient stays in secure care in the entirety of
offender patient care pathway in these two papers ‘Length Of Stay Reporting In Forensic Secure Care Can Be Augmented
By An Overarching Framework To Map Patient Journey In Mentally Disordered Offender Pathway For Optimal Results-
Paper I & II’. Paper I describes factors in a single episode of admission and Paper II identifies other secondary factors
demonstrated to impact Length of Stay indirectly through various outcomes. These factors for many patients starting at
High secure care begins from adverse trauma in childhood, with early onset substance use and criminal justice involvement
by mid adolescence, early general psychiatry admission, graduation to high secure unit and step down for ~ 13 years to be
discharged into the community at an average age of 36 years. They need follow up from services for 10 – 15 years
thereafter and die in the community at a mean age of ~ 52 years. This summarises the life-long need and challenges to
patient/carer autonomy/experience for this complex-needs offender patient group with severe violent offence history.
In order to empathise with the offender patient/family who traverse the secure care pathway, we provide an
imaginary fully informed offender patient narrative on their journey through this pathway in our other paper to follow - A
Review Of Patients’ Experiences Amidst Other Stakeholder Views In Forensic Psychiatry. We endeavoured to identify the
role of chronic illness and neurodegenerative changes across the spectrum of psychiatric disorders that would have a
significant impact on the potential for psychiatric and risk rehabilitation in our fourth paper awaiting publishing titled ‘Role
Of Neurocognitive Impairment In Patients With Chronic Mental Illness – Relevance To Patients In Rehabilitation
Psychiatry And Forensic Secure Care’.
We hope that these four papers together capture the most relevant perspectives and challenges in determining
Length of Stay in secure care pathway in any country.
CONFLICT OF INTEREST DECLARATION
There is a certain degree of overlap between Paper II and the paper ‘A Review Of Patients’ Experiences Amidst Other
Stakeholder Views In Forensic Psychiatry’, awaiting publication. However, the purpose of the narrative is different in these
papers, and in addition, have their own independent description and evidence base.
ACKNOWLEDGEMENTS
We acknowledge and thank the providers for our combined experiences. First Author has worked in General and Forensic
Psychiatry in England and Scotland, UK. In this regard, a note of appreciation and gratitude to Mersey Care NHSFT
Forensic Psychiatry Clinicians, UK. Second Author has had Australian and other National comparative reporting
experience for businesses, policies, and CSR.

Table 2: © Summary 10 and 20 Factors Determining Length of Stay in Secure Care
REFERENCES
1. Aboaja, A., Forsyth, B., Bates, H., & Wood, R. (2020). Involving service users to identify research priorities in a
UK forensic mental health service. BJPsych Bulletin, 1–6. https://doi.org/10.1192/bjb.2020.131
2. Aboraya, A., Nasrallah, H. A., Elswick, D. E., Ahmed, E., Estephan, N., Aboraya, D., Berzingi, S., Chumbers, J.,
Berzingi, S., Justice, J., Zafar, J., & Dohar, S. (2018). Measurement-based Care in Psychiatry-Past, Present, and
Future. Innovations in clinical neuroscience, 15(11-12), 13–26.
3. Aguilera-Serrano, C., Guzman-Parra, J., Garcia-Sanchez, J. A., Moreno-Küstner, B., & Mayoral-Cleries, F.
(2017). Variables Associated With the Subjective Experience of Coercive Measures in Psychiatric Inpatients: A
Systematic Review. The Canadian Journal of Psychiatry, 63(2), 129–144. sagepub.
https://doi.org/10.1177/0706743717738491
4. Aimola, L., Jasim, S., Tripathi, N., Bassett, P., Quirk, A., Worrall, A., Tucker, S., Holder, S., & Crawford, M. J.
(2018). Impact of a peer-review network on the quality of inpatient low secure mental health services: cluster
randomised control trial. BMC Health Services Research, 18(1). https://doi.org/10.1186/s12913-018-3797-z
5. Albertus, F., & Fluttert, J. (2010). Management of Inpatient Aggression in Forensic Mental Health Nursing The
application of the Early Recognition Method (pp. 50–51). Gildeprint Drukkerijen - Enschede.
http://www.antoniocasella.eu/archipsy/Fluttert_2010.pdf
6. Askew, L., Fisher, P., & Beazley, P. (2019a). What are adult psychiatric inpatients’ experience of seclusion: A
systematic review of qualitative studies. Journal of Psychiatric and Mental Health Nursing, 26(7-8), 274–285.
https://doi.org/10.1111/jpm.12537

7. Askew, L., Fisher, P., & Beazley, P. (2019b). Being in a Seclusion Room: The Forensic Psychiatric Inpatients’
Perspective. Journal of Psychiatric and Mental Health Nursing, 27(3). https://doi.org/10.1111/jpm.12576
8. Askola, R. A., Louheranta, O., Paavilainen, E., Åstedt-Kurki, P., Soininen, P., Putkonen, H., & Nikkonen, M.
(2015). Forensic Psychiatric Patients’ Narratives of Their Offense. Issues in Mental Health Nursing, 36(3), 162–
170. https://doi.org/10.3109/01612840.2014.969391
9. Askola, R., Nikkonen, M., Paavilainen, E., Soininen, P., Putkonen, H., & Louheranta, O. (2016). Forensic
Psychiatric Patients’ Perspectives on Their Care: A Narrative View. Perspectives in Psychiatric Care, 54(1), 64–
73. researchgate. https://doi.org/10.1111/ppc.12201
10. Baines, R., Donovan, J., Regan de Bere, S., Archer, J., & Jones, R. (2019). Comparing psychiatric care
experiences shared online with validated questionnaires; do they include the same content? Pearl.plymouth.ac.uk.
https://pearl.plymouth.ac.uk/handle/10026.1/13736
11. Bauer, A. M., & Alegría, M. (2010). Impact of Patient Language Proficiency and Interpreter Service Use on the
Quality of Psychiatric Care: A Systematic Review. Psychiatric Services, 61(8), 765–773.
https://doi.org/10.1176/ps.2010.61.8.765
12. Bengtson, S., Lund, J., Ibsen, M., & Långström, N. (2019). Long-Term Violent Reoffending Following Forensic
Psychiatric Treatment: Comparing Forensic Psychiatric Examinees and General Offender Controls. Frontiers in
Psychiatry, 10(715). https://doi.org/10.3389/fpsyt.2019.00715
13. Bergk, J., Einsiedler, B., Flammer, E., & Steinert, T. (2011). A Randomized Controlled Comparison of Seclusion
and Mechanical Restraint in Inpatient Settings. Psychiatric Services, 62(11), 1310–1317.
https://doi.org/10.1176/ps.62.11.pss6211_1310
14. Berg, S. H., Rørtveit, K., & Aase, K. (2017). Suicidal patients’ experiences regarding their safety during
psychiatric in-patient care: a systematic review of qualitative studies. BMC Health Services Research, 17(1).
https://doi.org/10.1186/s12913-017-2023-8
15. Berlim, M. T., & Fleck, M. P. A. (2003). “Quality of life”: a brand new concept for research and practice in
psychiatry. Revista Brasileira de Psiquiatria, 25(4), 249–252. https://doi.org/10.1590/s1516-44462003000400013
16. Berring, L. L., Pedersen, L., & Buus, N. (2015). Discourses of aggression in forensic mental health: a critical
discourse analysis of mental health nursing staff records. Nursing Inquiry, 22(4), 296–305.
https://doi.org/10.1111/nin.12113
17. Bonta, J., Law, M., & Hanson, K. (1998). The prediction of criminal and violent recidivism among mentally
disordered offenders: A meta-analysis. Psychological Bulletin, 123(2), 123–142. https://doi.org/10.1037/0033-
2909.123.2.123
18. Bonta, J., Blais, J., & Wilson, H. A. (2014). A theoretically informed meta-analysis of the risk for general and
violent recidivism for mentally disordered offenders. Aggression and Violent Behavior, 19(3), 278–287.
https://doi.org/10.1016/j.avb.2014.04.014

19. Bystritsky, A. (2006). Treatment-resistant anxiety disorders. Molecular Psychiatry, 11(9), 805–814.
https://doi.org/10.1038/sj.mp.4001852
20. Cal, S. F., S , L. R. de, Glustak, M. E., & Santiago, M. B. (2015). Resilience in chronic diseases: A systematic
review. Cogent Psychology, 2(1). https://doi.org/10.1080/23311908.2015.1024928
21. Campbell, C., & McGauley, G. (2005). Doctor-patient relationships in chronic illness: insights from forensic
psychiatry. BMJ, 330(7492), 667–670. https://doi.org/10.1136/bmj.330.7492.667
22. Campbell, C. W. (2008). “But what can a Psychiatrist do about my Bowel?!” Borderline Personality Disorder in
Primary Care: A Qualitative Analysis of Patient Experience..Edinburgh Research Association.
https://era.ed.ac.uk/handle/1842/3298
23. Camuccio, C. A., Sanavia, M., Cutrone, F., Marella, I., Gregio, M., Cabbia, C., Cocchio, S., & Baldo, V. (2019).
Noise Levels in an Acute Psychiatric Unit: An Exploratory Observational Study. Issues in Mental Health Nursing,
40(6), 493–502. https://doi.org/10.1080/01612840.2018.1557301
24. Carr, S., Hafford Letchfield, T., Faulkner, A., Megele, C., Gould, D., Khisa, C., Cohen, R., & Holley, J. (2019).
“Keeping Control”: A user led exploratory study of mental health service user experiences of targeted violence
and abuse in the context of adult safeguarding in England. Health & Social Care in the Community, 27(5).
https://doi.org/10.1111/hsc.12806
25. Chiu, P., Triantafyllopoulou, P., & Murphy, G. (2019). Life after release from prison: The experience of
ex offenders with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 33(4).
https://doi.org/10.1111/jar.12661
26. Clarke, C. (2014). “My shared pathway”: the experience of users of a low secure service.
https://eprints.soton.ac.uk/370353/
27. Clarke, Jessica, Explicit Bias (November 19, 2018). Northwestern University Law Review, Vol. 113, p. 505
(2018), Vanderbilt Law Research Paper No. 18-47, Available at SSRN: https://ssrn.com/abstract=3213998
28. Coffey, M., & Coleman, M. (2001). The relationship between support and stress in forensic community mental
health nursing. Journal of Advanced Nursing, 34(3), 397–407. https://doi.org/10.1046/j.1365-2648.2001.01770.x
29. Colwell, L. H., & Gianesini, J. (2011). Demographic, criminogenic, and psychiatric factors that predict
competency restoration. The journal of the American Academy of Psychiatry and the Law, 39(3), 297–306.
30. Craik, C., Bryant, W., Ryan, A., Barclay, S., Brooke, N., Mason, A., & Russell, P. (2010). A qualitative study of
service user experiences of occupation in forensic mental health. Australian Occupational Therapy Journal,
57(5), 339–344. https://doi.org/10.1111/j.1440-1630.2010.00857.x
31. Crocker, A. G., Martin, M. S., Leclair, M. C., Nicholls, T. L., & Seto, M. C. (2018). Expanding the early and late
starter model of criminal justice involvement for forensic mental health clients. Law and Human Behavior, 42(1),
83–93. https://doi.org/10.1037/lhb0000269

32. Cullen, A. E., Bowers, L., Khondoker, M., Pettit, S., Achilla, E., Koeser, L., Moylan, L., Baker, J., Quirk, A., Sethi,
F., Stewart, D., McCrone, P., & Tulloch, A. D. (2016). Factors associated with use of psychiatric intensive care
and seclusion in adult inpatient mental health services. Epidemiology and Psychiatric Sciences, 27(1), 51–61.
https://doi.org/10.1017/s2045796016000731
33. Currie, S. R., Liu, P., Adamyk-Simpson, J., & Stanich, J. (2020). Validation of a Comprehensive Patient
Experience Survey for Addiction and Mental Health that was Co-designed with Service Users. Community Mental
Health Journal, 56(4), 735–743. https://doi.org/10.1007/s10597-019-00534-1
34. Davey, I., & Dempsey, J. (2012). Working with complexity: a map for recovery in forensic psychiatry. New
Paradigm, Spring/Summer 2012, 20–23. https://www.mhrt.nsw.gov.au/.
https://www.mhrt.nsw.gov.au/files/mhrt/pdf/RecoveryinForensicPsychiatry.pdf
35. David, A. S., Bedford, N., Wiffen, B., & Gilleen, J. (2012). Failures of metacognition and lack of insight in
neuropsychiatric disorders. Philosophical Transactions of the Royal Society B: Biological Sciences, 367(1594),
1379–1390. https://doi.org/10.1098/rstb.2012.0002
36. Degl’ Innocenti, A., Wijk, H., Kullgren, A., & Alexiou, E. (2019). The Influence of Evidence-Based Design on Staff
Perceptions of a Supportive Environment for Person-Centered Care in Forensic Psychiatry. Journal of Forensic
Nursing, 16(3), E23–E30. https://doi.org/10.1097/jfn.0000000000000261
37. Demyttenaere, K. (2019). What is treatment resistance in psychiatry? A “difficult to treat” concept. World
Psychiatry, 18(3), 354–355. https://doi.org/10.1002/wps.20677
38. De Pau, M., Mertens, A., Bourmorck, D., Vanderplasschen, W., Nicaise, P., & Vander Laenen, F. (2020).
Crushed by the Belgian system: Lived experiences of forensic care trajectories by persons labelled as not
criminally responsible. International Journal of Law and Psychiatry, 68, 101539.
https://doi.org/10.1016/j.ijlp.2019.101539
39. De Smet, S., Van Hecke, N., Verté, D., Broekaert, E., Ryan, D., & Vandevelde, S. (2014). Treatment and Control:
A Qualitative Study of Older Mentally Ill Offenders’ Perceptions on Their Detention and Care Trajectory.
International Journal of Offender Therapy and Comparative Criminology, 59(9), 964–985.
https://doi.org/10.1177/0306624x14521129
40. Dewa, L. H., Murray, K., Thibaut, B., Ramtale, S. C., Adam, S., Darzi, A., & Archer, S. (2018). Identifying
research priorities for patient safety in mental health: an international expert Delphi study. BMJ Open, 8(3),
e021361. https://doi.org/10.1136/bmjopen-2017-021361
41. Dickens, G. L., Suesse, M., Snyman, P., & Picchioni, M. (2014). Associations between ward climate and patient
characteristics in a secure forensic mental health service. The Journal of Forensic Psychiatry & Psychology,
25(2), 195–211. https://doi.org/10.1080/14789949.2014.903505
42. Dickens, G., Sugarman, P., Picchioni, M., & Long, C. (2010). HoNOS Secure: tracking risk and recovery for
men in secure care. The British Journal of Forensic Practice, 12(4), 36–46.
https://doi.org/10.5042/bjfp.2010.0613

43. Dickinson, T., & Wright, K. M. (2008). Stress and burnout in forensic mental health nursing: a literature review.
British Journal of Nursing, 17(2), 82–87. https://doi.org/10.12968/bjon.2008.17.2.28133
44. Doyle, P., Quayle, E., & Newman, E. (2017). Social climate in forensic mental health settings: A systematic
review of qualitative studies. Aggression and Violent Behavior, 36, 118–136.
45. Doyle, P., Quayle, E., & Newman, E. (2017). Social climate in forensic mental health settings: A systematic
review of qualitative studies. Aggression and Violent Behavior, 36, 118–136.
46. Edgcomb, J. B., & Zima, B. (2018). Medication Adherence Among Children and Adolescents with Severe Mental
Illness: A Systematic Review and Meta-Analysis. Journal of Child and Adolescent Psychopharmacology, 28(8),
508–520. https://doi.org/10.1089/cap.2018.0040
47. Farrell, C., & Brink, J. (2020). The Prevalence and Factors Associated With Antipsychotic Polypharmacy in a
Forensic Psychiatric Sample. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00263
48. Fazel, S., Gulati, G., Linsell, L., Geddes, J. R., & Grann, M. (2009). Schizophrenia and Violence: Systematic
Review and Meta-Analysis. PLoS Medicine, 6(8), e1000120. https://doi.org/10.1371/journal.pmed.1000120
49. Fazel, S., Singh, J. P., Doll, H., & Grann, M. (2012). Use of risk assessment instruments to predict violence and
antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis. BMJ,
345(jul24 2), e4692–e4692. https://doi.org/10.1136/bmj.e4692
50. Fazel, S., Fimińska, Z., Cocks, C., & Coid, J. (2016). Patient outcomes following discharge from secure
psychiatric hospitals: Systematic review and meta-analysis. British Journal of Psychiatry, 208(1), 17–25.
https://doi.org/10.1192/bjp.bp.114.149997
51. Fazel, S., Wolf, A., Fimińska, Z., & Larsson, H. (2016). Mortality, Rehospitalisation and Violent Crime in
Forensic Psychiatric Patients Discharged from Hospital: Rates and Risk Factors. PLOS ONE, 11(5), e0155906.
https://doi.org/10.1371/journal.pone.0155906
52. Flammer, E., Frank, U., & Steinert, T. (2020). Freedom Restrictive Coercive Measures in Forensic Psychiatry.
Frontiers in Psychiatry, 11(146). https://doi.org/10.3389/fpsyt.2020.00146
53. Forsman, J., Taipale, H., Masterman, T., Tiihonen, J., & Tanskanen, A. (2018). Comparison of dispensed
medications and forensic-toxicological findings to assess pharmacotherapy in the Swedish population 2006 to
2013. Pharmacoepidemiology and Drug Safety, 27(10), 1112–1122. https://doi.org/10.1002/pds.4426
54. Franke, I., Büsselmann, M., Streb, J., & Dudeck, M. (2019). Perceived Institutional Restraint Is Associated With
Psychological Distress in Forensic Psychiatric Inpatients. Frontiers in Psychiatry, 10.
https://doi.org/10.3389/fpsyt.2019.00410
55. Friendship, C., Falshaw, L., & Beech, A. R. (2003). Measuring the real impact of accredited offending behaviour
programmes. Legal and Criminological Psychology, 8(1), 115–127.

56. Glancy, G., Choptiany, M., Jones, R., & Chatterjee, S. (2021). Measurement-based care in forensic psychiatry.
International Journal of Law and Psychiatry, 74, 101650. https://doi.org/10.1016/j.ijlp.2020.101650
57. Glorney, E., Ullah, H., & Brooker, C. (2020). Standards of Mental Health Care in Prisons in England and Wales:
A Qualitative Study of Reports from Her Majesty’s Inspectorate of Prisons. International Journal of Forensic
Mental Health, 19(3), 1–14. https://doi.org/10.1080/14999013.2020.1743389
58. Golenkov, A., Nielssen, O., & Large, M. (2014). Systematic review and meta-analysis of homicide recidivism and
Schizophrenia. BMC Psychiatry, 14(1). https://doi.org/10.1186/1471-244x-14-46
59. gov.scot. (2021, February 26). Independent Forensic Mental Health Review: final report - gov.scot.
Www.gov.scot; Crown Copyright. https://www.gov.scot/publications/independent-forensic-mental-health-review-
final-report/pages/8/
60. Granström, E. (2021). From patient to person: perspectives on the role of quality data, patient experience and
patient involvement in the improvement of chronic care. In openarchive.ki.se. Inst för lärande, informatik,
management och etik / Dept of Learning, Informatics, Management and Ethics.
https://openarchive.ki.se/xmlui/handle/10616/47493
61. Greer, B., Newbery, K., Cella, M., & Wykes, T. (2019). Predicting Inpatient Aggression in Forensic Services
Using Remote Monitoring Technology: Qualitative Study of Staff Perspectives. Journal of Medical Internet
Research, 21(9), e15620. https://doi.org/10.2196/15620
62. Günther, M. P., Kirchebner, J., & Lau, S. (2020). Identifying Direct Coercion in a High Risk Subgroup of
Offender Patients With Schizophrenia via Machine Learning Algorithms. Frontiers in Psychiatry, 11.
63. Gudde, C., Vatne, S., Olsø, T., & Whittington, R. (2015). Service users’ experiences and views of aggressive
situations in mental health care: a systematic review and thematic synthesis of qualitative studies. Journal of
Multidisciplinary Healthcare, 8, 449. https://doi.org/10.2147/jmdh.s89486
64. Gustafsson, E., Holm, M., & Flensner, G. (2011). Rehabilitation between institutional and non-institutional
forensic psychiatric care: important influences on the transition process. Journal of Psychiatric and Mental
Health Nursing, 19(8), 729–737. https://doi.org/10.1111/j.1365-2850.2011.01852.x
65. Haddow, C. (2013). Patient and prisoner experiences: major mental illness and masculinity in the context of
violent offending behaviour. https://era.ed.ac.uk/handle/1842/9751
66. Hadjittofi, M., Gleeson, K., & Arber, A. (2020). The experience of disgust by healthcare professionals: A
literature review. International Journal of Nursing Studies, 110, 103720.
https://doi.org/10.1016/j.ijnurstu.2020.103720
67. Hanzawa, S., Bae, J.-K., Bae, Y. J., Chae, M., Tanaka, H., Nakane, H., Ohta, Y., Zhao, X., Iizuka, H., & Nakane,
Y. (2013). Psychological impact on caregivers traumatized by the violent behavior of a family member with
schizophrenia. Asian Journal of Psychiatry, 6(1), 46–51. https://doi.org/10.1016/j.ajp.2012.08.009

68. Hauso, G. E. Y., Alsaker, K., & Senneseth, M. (2021). Service user involvement in a secure setting before and
after the implementation of recovery oriented practice: A quasi experimental study. Journal of Advanced
Nursing. https://doi.org/10.1111/jan.14841
69. Heard, C. P., Scott, J., Tetzlaff, A., & Lumley, H. (2019). Transitional housing in forensic mental health:
considering consumer lived experience. Health & Justice, 7(1). https://doi.org/10.1186/s40352-019-0091-z
70. Hearn, D. (2013). Tracking patients on leave from a secure setting. Mental Health Practice, 16(6), 17–21.
https://doi.org/10.7748/mhp2013.03.16.6.17.e813
71. Hehir, A. M., Indig, D., Prosser, S., & Archer, V. A. (2012). Evaluation of a smoke-free forensic hospital:
Patients’ perspectives on issues and benefits. Drug and Alcohol Review, 31(5), 672–677.
https://doi.org/10.1111/j.1465-3362.2012.00456.x
72. Hehir, A. M., Indig, D., Prosser, S., & Archer, V. A. (2013). Implementation of a smoke-free policy in a high
secure mental health inpatient facility: staff survey to describe experience and attitudes. BMC Public Health,
13(1). https://doi.org/10.1186/1471-2458-13-315
73. Hodgins, S., & Müller-Isberner, R. (2004). Preventing crime by people with schizophrenic disorders: the role of
psychiatric services. British Journal of Psychiatry, 185(3), 245–250. https://doi.org/10.1192/bjp.185.3.245
74. Hodgins, S., Müller-Isberner, R., Freese, R., Tiihonen, J., Repo-Tiihonen, E., Eronen, M., Eaves, D., Hart, S.,
Webster, C., Levander, S., Tuninger, E., Ross, D., Vartiainen, H., & Kronstrand, R. (2007). A Comparison of
General Adult and Forensic Patients with Schizophrenia Living in the Community. International Journal of
Forensic Mental Health, 6(1), 63–75. https://doi.org/10.1080/14999013.2007.10471250
75. Horvath, J., Steinert, T., & Jaeger, S. (2018). Antipsychotic treatment of psychotic disorders in forensic
psychiatry: Patients’ perception of coercion and its predictors. International Journal of Law and Psychiatry, 57,
113–121. https://doi.org/10.1016/j.ijlp.2018.02.004
76. Howner, K., Andiné, P., Bertilsson, G., Hultcrantz, M., Lindström, E., Mowafi, F., Snellman, A., & Hofvander, B.
(2018). Mapping Systematic Reviews on Forensic Psychiatric Care: A Systematic Review Identifying Knowledge
Gaps. Frontiers in Psychiatry, 9(452). https://doi.org/10.3389/fpsyt.2018.00452
77. Howner, K., Andiné, P., Engberg, G., Ekström, E. H., Lindström, E., Nilsson, M., Radovic, S., & Hultcrantz, M.
(2020). Pharmacological Treatment in Forensic Psychiatry—A Systematic Review. Frontiers in Psychiatry,
10(963). https://doi.org/10.3389/fpsyt.2019.00963
78. Huband, N., Furtado, V., Schel, S., Eckert, M., Cheung, N., Bulten, E., & Völlm, B. (2018). Characteristics and
Needs of Long-Stay Forensic Psychiatric Inpatients: A Rapid Review of the Literature. International Journal of
Forensic Mental Health, 17(1), 45–60. https://doi.org/10.1080/14999013.2017.1405124
79. Hörberg, U., Benzein, E., Erlingsson, C., & Syrén, S. (2015). Engaging with Families Is a Challenge: Beliefs
among Healthcare Professionals in Forensic Psychiatric Care. Nursing Research and Practice, 2015, 1–10.
https://doi.org/10.1155/2015/843717

80. Janssen-de Ruijter, E. A. W., Mulder, E. A., Bongers, I. L., Omlo, L., & van Nieuwenhuizen, Ch. (2019). Looking
into the crystal ball: quality of life, delinquency, and problems experienced by young male adults after discharge
from a secure residential care setting in the Netherlands. Child and Adolescent Psychiatry and Mental Health,
13(1). https://doi.org/10.1186/s13034-019-0305-0
81. Johnson, D. (2013). Staff and patient experiences of seclusion and special observations in high secure care.
https://livrepository.liverpool.ac.uk/3062910/1/27657410.pdf
82. Kaar, S. J., Walker, H., Sethi, F., & McIvor, R. (2017). The function and design of seclusion rooms in clinical
settings. Journal of Psychiatric Intensive Care, 13(2), 83–91. https://doi.org/10.20299/jpi.2017.007
83. Kaggwa, M. M., Acai, A., Rukundo, G. Z., Harms, S., & Ashaba, S. (2021). Patients’ Perspectives on the
Experience of Absconding From a Psychiatric Hospital: a Qualitative Study. BMC Psychiatry in Review.
https://doi.org/10.21203/rs.3.rs-402597/v1
84. Karatzias, T., Shevlin, M., Pitcairn, J., Thomson, L., Mahoney, A., & Hyland, P. (2019). Childhood adversity and
psychosis in detained inpatients from medium to high secured units: Results from the Scottish census survey.
Child Abuse & Neglect, 96, 104094. https://doi.org/10.1016/j.chiabu.2019.104094
85. Katsakou, C., & Priebe, S. (2007). Patient’s experiences of involuntary hospital admission and treatment: A
review of qualitative studies. Epidemiologia E Psichiatria Sociale, 16(2), 172–178.
https://doi.org/10.1017/s1121189x00004802
86. Kersting, X. A. K., Hirsch, S., & Steinert, T. (2019). Physical Harm and Death in the Context of Coercive
Measures in Psychiatric Patients: A Systematic Review. Frontiers in Psychiatry, 10.
87. Khosla, V., Davison, P., Gordon, H., & Joseph, V. (2014). The interface between general and forensic psychiatry:
the present day. Advances in Psychiatric Treatment, 20(5), 359–365. https://doi.org/10.1192/apt.bp.109.007336
88. Kinney, P. J. (2011). Exploring connectedness: The meaning of transition experiences for patients within a
forensic psychiatric service (p. ii). http://www.op.ac.nz/assets/OPRES/a12fc62cce/Kinney-Exploring-
connectedness-2011.pdf
89. Kirchebner, J., Günther, M., Sonnweber, M. et al. Factors and predictors of length of stay in offenders diagnosed
with schizophrenia - a machine-learning-based approach. BMC Psychiatry 20, 201 (2020).
https://doi.org/10.1186/s12888-020-02612-1
90. Kleinsinger F. (2018). The Unmet Challenge of Medication Nonadherence. The Permanente journal, 22, 18–033.
https://doi.org/10.7812/TPP/18-033
91. Krupchanka, D., Khalifeh, H., Abdulmalik, J., Ardila-Gómez, S., Armiya’u, A. Y., Banjac, V., Baranov, A.,
Bezborodovs, N., Brecic, P., Čavajda, Z., de Girolamo, G., Denisenko, M., Dickens, H. A., Dujmovic, J., Ergovic
Novotny, D., Fedotov, I., Fernández, M. A., Frankova, I., Gasparovic, M., & Giurgi-Oncu, C. (2017). Satisfaction
with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries. Social Psychiatry
and Psychiatric Epidemiology, 52(8), 989–1003. https://doi.org/10.1007/s00127-017-1366-0

92. Kuivalainen, S., Vehviläinen-Julkunen, K., Putkonen, A., Louheranta, O., & Tiihonen, J. (2013). Violent
behaviour in a forensic psychiatric hospital in Finland: an analysis of violence incident reports. Journal of
Psychiatric and Mental Health Nursing, 21(3), 214–218. https://doi.org/10.1111/jpm.12074
93. Laiho T., Hottinen A., Lindberg N., Sailas E. (2016) Staff Attitudes Towards Seclusion and Restraint in Forensic
Settings. In: Völlm B., Nedopil N. (eds) The Use of Coercive Measures in Forensic Psychiatric Care. Springer,
Cham. https://doi.org/10.1007/978-3-319-26748-7_12
94. Lau, S., Brackmann, N., Mokros, A., & Habermeyer, E. (2020). Aims to Reduce Coercive Measures in Forensic
Inpatient Treatment: A 9-Year Observational Study. Frontiers in Psychiatry, 11.
95. Lawes, A., Marcus, E., & Pilling, S. (n.d.). What staffing structures of mental health services are associated with
improved patient outcomes? A rapid review. National Collaborating Centre for Mental Health. Retrieved April
29, 2021, from
http://allcatsrgrey.org.uk/wp/download/governance/clinical_governance_2/NCCMH_Literature_Review_Mental_
Health_Final_2.pdf
96. Lewis, C. C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A.,
Douglas, S., Simon, G., & Kroenke, K. (2019). Implementing Measurement-Based Care in Behavioral Health: A
Review. JAMA psychiatry, 76(3), 324–335. https://doi.org/10.1001/jamapsychiatry.2018.3329
97. Livanou, M., D’Souza, S., Lane, R., La Plante, B., & Singh, S. P. (2021). Challenges and Facilitators During
Transitions from Adolescent Medium Secure Units to Adult Services in England: Interviews with Mental
Healthcare Professionals. Administration and Policy in Mental Health and Mental Health Services Research.
https://doi.org/10.1007/s10488-021-01115-9
98. Lundqvist, L.-O., & Schröder, A. (2015). Patient and Staff Views of Quality in Forensic Psychiatric Inpatient
Care. Journal of Forensic Nursing, 11(1), 51–58. https://doi.org/10.1097/jfn.0000000000000060
99. Lysaker, P. H., Pattison, M. L., Leonhardt, B. L., Phelps, S., & Vohs, J. L. (2018). Insight in schizophrenia
spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and
emerging treatments. World Psychiatry, 17(1), 12–23. https://doi.org/10.1002/wps.20508
100. Ma, T.,Mackinnon, T., & Dean, K. (2020). The prevalence of cardiometabolic disease in people with psychotic
disorders in secure settings – a systematic review. The Journal of Forensic Psychiatry & Psychology, 32(2), 281–
307. https://doi.org/10.1080/14789949.2020.1859588
101. Maassen, S. M., Weggelaar Jansen, A. M. J. W., Brekelmans, G., Vermeulen, H., & van Oostveen, C. J. (2020).
Psychometric evaluation of instruments measuring the work environment of healthcare professionals in hospitals:
a systematic literature review. International Journal for Quality in Health Care, 32(8), 545–557.
https://doi.org/10.1093/intqhc/mzaa072
102. MacInnes, D., & Masino, S. (2019). Psychological and psychosocial interventions offered to forensic mental
health inpatients: a systematic review. BMJ Open, 9(3), e024351. https://doi.org/10.1136/bmjopen-2018-024351.

103. MacMillan, Z. (2016). How stigma is a barrier for people with mental illness transitioning from forensic or
correctional institutions into the community: a systematic review. In library2.smu.ca.
https://library2.smu.ca/handle/01/26704
104. Markham, S. (2020). Collaborative risk assessment in secure and forensic mental health settings in the UK.
General Psychiatry, 33(5), e100291. https://doi.org/10.1136/gpsych-2020-100291
105. Marklund, L., Wahlroos, T., Looi, G. E., & Gabrielsson, S. (2019). “I know what I need to recover”: Patients’
experiences and perceptions of forensic psychiatric inpatient care. International Journal of Mental Health
Nursing, 29(2), 235–243. https://doi.org/10.1111/inm.12667
106. Marshall, L. A., Adams, E. A., & Stuckey, M. I. (2019). Relationships, experience, and support: staff perception of
safety in a forensic mental health facility. The Journal of Forensic Psychiatry & Psychology, 30(5), 824–835.
https://doi.org/10.1080/14789949.2019.1642368
107. Martin, T. (2001). Something special: forensic psychiatric nursing. Journal of Psychiatric and Mental Health
Nursing, 8(1), 25–32. https://doi.org/10.1111/j.1365-2850.2001.00349.x
108. Mason, T., Caulfield, M., Hall, R., & Melling, K. (2010). Perceptions of Diagnostic Labels in Forensic
Psychiatric Practice: A Survey of Differences between Nurses and Other Disciplines. Issues in Mental Health
Nursing, 31(5), 336–344. https://doi.org/10.3109/01612840903398727
109. Mason, T., Hall, R., Caulfield, M., & Melling, K. (2010). Forensic nurses’ perceptions of labels of mental illness
and personality disorder: clinical versus management issues. Journal of Psychiatric and Mental Health Nursing,
17(2), 131–140. https://doi.org/10.1111/j.1365-2850.2009.01483.x
110. Mastromanno, B., Brookstein, D. M., Ogloff, J. R. P., Campbell, R., Chu, C. M., & Daffern, M. (2017). Assessing
change in dynamic risk factors in forensic psychiatric inpatients: relationship with psychopathy and recidivism.
The Journal of Forensic Psychiatry & Psychology, 29(2), 323–336.
https://doi.org/10.1080/14789949.2017.1377277
111. McCarthy, L., Garrett, G., Bennett, G., Sims, P., Vujkovic, D., & Taylor, N. (2017). Using technology to enhance
the therapeutic impact on seclusion. Repository.nottinghamshirehealthcare.nhs.uk.
https://repository.nottinghamshirehealthcare.nhs.uk/handle/123456789/2808
112. McIntosh, L. G., Janes, S., O’Rourke, S., & Thomson, L. D. G. (2021). Effectiveness of psychological and
psychosocial interventions for forensic mental health inpatients: A meta-analysis. Aggression and Violent
Behavior, 58, 101551. https://doi.org/10.1016/j.avb.2021.101551
113. McKeown, M., Thomson, G., Scholes, A., Jones, F., Baker, J., Downe, S., Price, O., Greenwood, P., Whittington,
R., & Duxbury, J. (2019). “Catching your tail and firefighting”: The impact of staffing levels on restraint
minimization efforts. Journal of Psychiatric and Mental Health Nursing, 26(5-6), 131–141.
https://doi.org/10.1111/jpm.12532

114. Mclaughlan, R., Lyon, C., & Jaskolska, D. (2020). Architecture as change-agent? Looking for innovation in
contemporary forensic psychiatric hospital design. Medical Humanities. https://doi.org/10.1136/medhum-2020-
011887
115. Mezey, G., Durkin, C., Dodge, L., & White, S. (2015). Never ever? Characteristics, outcomes and motivations of
patients who abscond or escape: A 5-year review of escapes and absconds from two medium and low secure
forensic units. Criminal Behaviour and Mental Health, 25(5), 440–450. https://doi.org/10.1002/cbm.1982
116. Miller, T. A. (2016). Health literacy and adherence to medical treatment in chronic and acute illness: A meta-
analysis. Patient Education and Counseling, 99(7), 1079–1086. https://doi.org/10.1016/j.pec.2016.01.020
117. Ministry of Justice. (2021). CORRECTIONAL SERVICES ACCREDITATION AND ADVICE PANEL (CSAAP)
Currently Accredited Programmes ACCREDITED FOR DELIVERY IN THE COMMUNITY Becoming New Me +
(BNM+). CSAAP Secretariat.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/960097/Descrip
tions_of_Accredited_Programmes_-_Final_-_210209.pdf
118. Montejo, A. L., Montejo, L., & Baldwin, D. S. (2018). The impact of severe mental disorders and psychotropic
medications on sexual health and its implications for clinical management. World Psychiatry, 17(1), 3–11.
https://doi.org/10.1002/wps.20509
119. Morrissey, C., Geach, N., Alexander, R., Chester, V., Devapriam, J., Duggan, C., Langdon, P. E., Lindsay, B.,
McCarthy, J., & Walker, D.-M. (2017). Researching outcomes from forensic services for people with intellectual
or developmental disabilities: a systematic review, evidence synthesis and expert and patient/carer consultation.
Health Services and Delivery Research, 5(3), 1–102. https://doi.org/10.3310/hsdr05030
120. Morrissey, C., Langdon, P. E., Geach, N., Chester, V., Ferriter, M., Lindsay, W. R., McCarthy, J., Devapriam, J.,
Walker, D.-M., Duggan, C., & Alexander, R. (2017). A systematic review and synthesis of outcome domains for
use within forensic services for people with intellectual disabilities. BJPsych Open, 3(1), 41–56. cambridgecore.
https://doi.org/10.1192/bjpo.bp.116.003616
121. Mottershead, T., Khalifa, N., & Völlm, B. (2019). A mixed-methods examination of patient feedback within
forensic and non-forensic mental healthcare services. The Journal of Forensic Psychiatry & Psychology, 31(1),
106–122. https://doi.org/10.1080/14789949.2019.1680726
122. Mørup, M. F., Kymes, S. M., & Oudin Åström, D. (2020). A modelling approach to estimate the prevalence of
treatment-resistant schizophrenia in the United States. PLOS ONE, 15(6), e0234121.
https://doi.org/10.1371/journal.pone.0234121
123. Muir Cochrane, E., Grimmer, K., Gerace, A., Bastiampillai, T., & Oster, C. (2020). Prevalence of the use of
chemical restraint in the management of challenging behaviours associated with adult mental health conditions:
A meta synthesis. Journal of Psychiatric and Mental Health Nursing, 27(4). https://doi.org/10.1111/jpm.12585
124. Murphy, D. (2000). An Exploration of the Concept of Loneliness in Forensic Psychiatry. Medicine, Science and
the Law, 40(1), 33–38. https://doi.org/10.1177/002580240004000108

125. Murphy, D., Bush, E.-L. and Puzzo, I. (2017), "Incompatibilities and seclusion of patients with an autism
spectrum disorder detained in high-secure psychiatric care", Journal of Intellectual Disabilities and Offending
Behaviour, Vol. 8 No. 4, pp. 188-200. https://doi.org/10.1108/JIDOB-05-2017-0007
126. Nabavi, B., Mitchell, A. J., & Nutt, D. (2015). A Lifetime Prevalence of Comorbidity Between Bipolar Affective
Disorder and Anxiety Disorders: A Meta-analysis of 52 Interview-based Studies of Psychiatric Population.
EBioMedicine, 2(10), 1405–1419. https://doi.org/10.1016/j.ebiom.2015.09.006
127. Nagtegaal, M.H., van der Horst,R.P.& Schönberger, H.J.M. (2011). <i style="mso-bidi-font-
style:normal">Length of stay in forensicpsychiatric hospitals [Dutchwith English summary]. Meppel,
Netherlands: Boom Juridische Unitgevers (RoyalBoom Publishers).
128. O’Connell, M., & Farnworth, L. (2007). Occupational Therapy in Forensic Psychiatry: A Review of the
Literature and a Call for a United and International Response. British Journal of Occupational Therapy, 70(5),
184–191. https://doi.org/10.1177/030802260707000502
129. Osmancevic, S., Schoberer, D., Lohrmann, C., & Großschädl, F. (2021). Psychometric properties of instruments
used to measure the cultural competence of nurses: A systematic review. International Journal of Nursing
Studies, 113, 103789. https://doi.org/10.1016/j.ijnurstu.2020.103789
130. Papalia, N., Spivak, B., Daffern, M., & Ogloff, J. R. P. (2019). A meta analytic review of the efficacy of
psychological treatments for violent offenders in correctional and forensic mental health settings. Clinical
Psychology: Science and Practice, 26(2), e12282. https://doi.org/10.1111/cpsp.12282
131. Parkes, J. H., Pyer, M., Ward, A., Doyle, C., & Dickens, G. L. (2014). “Going into the unknown”: Experiences of
male patients in secure settings during environmental transition. International Journal of Mental Health
Nursing, 24(1), 2–10. https://doi.org/10.1111/inm.12088
132. Parry, G. D., Crawford, M. J., & Duggan, C. (2016). Iatrogenic harm from psychological therapies – time to
move on. British Journal of Psychiatry, 208(3), 210–212. https://doi.org/10.1192/bjp.bp.115.163618
133. Puzzo, I., Aldridge-Waddon, L., Bush, E., & Farr, C. (2018). The Relationship Between Ward Social Climate,
Ward Sense of Community, and Incidents of Disruptive Behavior: A Study of a High Secure Psychiatric Sample.
International Journal of Forensic Mental Health, 18(2), 153–163.
https://doi.org/10.1080/14999013.2018.1532972
134. Rahul Bhattacharya, Cross, S., & Dinesh Bhugra. (2010). Clinical Topics in Cultural Psychiatry (pp. 222–231).
Cambridge University Press.
135. Ramsay, L., Gray, C., & White, T. (2001). A Review of Suicide within the State Hospital, Carstairs 1972–
1996. Medicine, Science and the Law, 41(2), 97–101. https://doi.org/10.1177/002580240104100202
136. RCPsych. (2018, March 27). QNFMHS publications and resources. RC PSYCH ROYAL COLLEGE of
PSYCHIATRISTS. https://www.rcpsych.ac.uk/improving-care/ccqi/quality-networks-accreditation/forensic-
mental-health-services/publications-and-resources

137. Reeve, S., Sheaves, B., & Freeman, D. (2021). Excessive sleepiness in patients with psychosis: An initial
investigation. PLOS ONE, 16(1), e0245301. https://doi.org/10.1371/journal.pone.0245301
138. Rees, C., & Thomson, L. (2020). Exploration of morbidity, suicide and all-cause mortality in a Scottish forensic
cohort over 20 years. BJPsych Open, 6(4). https://doi.org/10.1192/bjo.2020.40
139. Rowaert, S., Vandevelde, S., Lemmens, G., & Audenaert, K. (2017). How family members of mentally ill offenders
experience the internment measure and (forensic) psychiatric treatment in Belgium: A qualitative
study. International Journal of Law and Psychiatry, 54, 76–82. https://doi.org/10.1016/j.ijlp.2017.05.003
140. Rowaert, S., Vandevelde, S., Lemmens, G., Vanderplasschen, W., Vander Beken, T., Vander Laenen, F., &
Audenaert, K. (2016). The role and experiences of family members during the rehabilitation of mentally ill
offenders. International Journal of Rehabilitation Research, 39(1), 11–19.
https://doi.org/10.1097/mrr.0000000000000152
141. Samele, C. (2008). A review of the use of offending behaviour programmes for people with mental health
problems. In Sainsbury Centre for Mental Health. A review of the use of offending behaviour programmes for
...https://www.patientlibrary.net › tempgen
142. Sampson, S., Foster, S., Majid, S., & Völlm, B. (2019). Carers of Long-Stay Patients’ Perspectives of Secure
Forensic Care: An Exploratory Qualitative Study. International Journal of Forensic Mental Health, 18(4), 305–
315. https://doi.org/10.1080/14999013.2018.1552635
143. Sanchez-Balcells, S., Callarisa Roca, M., Rodriguez-Zunino, N., Puig-Llobet, M., Lluch-Canut, M.-T., & Roldan-
Merino, J. F. (2018). Psychometric properties of instruments measuring quality and satisfaction in mental health:
A systematic review. Journal of Advanced Nursing, 74(11), 2497–2510. https://doi.org/10.1111/jan.13813
144. Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2020). Psychotropic medication
non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review
and meta-analysis. Systematic Reviews, 9(1). https://doi.org/10.1186/s13643-020-1274-3
145. Shepherd, S. M., Campbell, R. E., & Ogloff, J. R. P. (2016). Psychopathy, Antisocial Personality Disorder, and
Reconviction in an Australian Sample of Forensic Patients. International Journal of Offender Therapy and
Comparative Criminology, 62(3), 609–628. https://doi.org/10.1177/0306624x16653193
146. Simblett, S., Greer, B., Matcham, F., Curtis, H., Polhemus, A., Ferrão, J., Gamble, P., & Wykes, T. (2018).
Barriers to and Facilitators of Engagement With Remote Measurement Technology for Managing Health:
Systematic Review and Content Analysis of Findings. Journal of Medical Internet Research, 20(7), e10480.
https://doi.org/10.2196/10480
147. Simpson, A. I. F., Boldt, I., Penney, S., Jones, R., Kidd, S., Nakhost, A., & Wilkie, T. (2020). Perceptions of
procedural justice and coercion among forensic psychiatric patients: a study protocol for a prospective, mixed-
methods investigation. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-02629-6
148. Sirdifield, C., Brooker, C., & Marples, R. (2020). Suicide and probation: A systematic review of the
literature. Forensic Science International: Mind and Law, 1, 100012. https://doi.org/10.1016/j.fsiml.2020.100012

149. Skett, S., & Lewis, C. (2019). Development of the Offender Personality Disorder Pathway: A summary of the
underpinning evidence. Probation Journal, 66(2), 167–180. https://doi.org/10.1177/0264550519832370
150. Soininen P., Kontio R., Joffe G., Putkonen H. (2016) Patient Experience of Coercive Measures. In: Völlm B.,
Nedopil N. (eds) The Use of Coercive Measures in Forensic Psychiatric Care. Springer, Cham.
https://doi.org/10.1007/978-3-319-26748-7_14
151. Steinert, T., Lepping, P., Bernhardsgrütter, R., Conca, A., Hatling, T., Janssen, W., Keski-Valkama, A., Mayoral,
F., & Whittington, R. (2009). Incidence of seclusion and restraint in psychiatric hospitals: a literature review and
survey of international trends. Social Psychiatry and Psychiatric Epidemiology, 45(9), 889–897.
https://doi.org/10.1007/s00127-009-0132-3
152. Steinert, T., Birk, M., Flammer, E., & Bergk, J. (2013). Subjective Distress After Seclusion or Mechanical
Restraint: One-Year Follow-Up of a Randomized Controlled Study. Psychiatric Services, 64(10), 1012–1017.
https://doi.org/10.1176/appi.ps.201200315
153. Sturgeon, M., Tyler, N., & Gannon, T. A. (2018). A systematic review of group work interventions in UK high
secure hospitals. Aggression and Violent Behavior, 38, 53–75. https://doi.org/10.1016/j.avb.2017.11.004
154. Sukhera, J., & Watling, C. (2018). A Framework for Integrating Implicit Bias Recognition Into Health
Professions Education. Academic Medicine, 93(1), 35–40. https://doi.org/10.1097/acm.0000000000001819
155. Swinkels, L. T. A., van der Pol, T. M., Popma, A., ter Harmsel, J. F., & Dekker, J. J. M. (2020). Improving mental
wellbeing of forensic psychiatric outpatients through the addition of an informal social network intervention to
treatment as usual: a randomized controlled trial. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-
02819-2
156. Taipale, H., Tanskanen, A., Mehtälä, J., Vattulainen, P., Correll, C. U., & Tiihonen, J. (2020). 20 year
follow up study of physical morbidity and mortality in relationship to antipsychotic treatment in a nationwide
cohort of 62,250 patients with schizophrenia (FIN20). World Psychiatry, 19(1), 61–68.
https://doi.org/10.1002/wps.20699
157. Tapp, J., Warren, F., Fife-Schaw, C., Perkins, D., & Moore, E. (2013). What do the experts by experience tell us
about “what works” in high secure forensic inpatient hospital services?. The Journal of Forensic Psychiatry &
Psychology, 24(2), 160–178. https://doi.org/10.1080/14789949.2012.760642
158. Tapp, J., Warren, F., Fife-Schaw, C., Perkins, D., & Moore, E. (2016). Essential elements of treatment and care
in high secure forensic inpatient services: an expert consensus study. Journal of Forensic Practice, 18(3), 189–
203. https://doi.org/10.1108/jfp-07-2015-0041
159. Thibaut, B., Dewa, L. H., Ramtale, S. C., D’Lima, D., Adam, S., Ashrafian, H., Darzi, A., & Archer, S. (2019).
Patient safety in inpatient mental health settings: a systematic review. BMJ Open, 9(12), e030230.
https://doi.org/10.1136/bmjopen-2019-030230
160. Thieme, A., Belgrave, D., & Doherty, G. (2020). Machine Learning in Mental Health. ACM Transactions on
Computer-Human Interaction, 27(5), 1–53. https://doi.org/10.1145/3398069

161. Thirioux, B., Harika-Germaneau, G., Langbour, N., & Jaafari, N. (2020). The Relation Between Empathy and
Insight in Psychiatric Disorders: Phenomenological, Etiological, and Neuro-Functional Mechanisms. Frontiers
in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00966
162. Tiwana, R., McDonald, S., & Völlm, B. (2016). Policies on sexual expression in forensic psychiatric settings in
different European countries. International Journal of Mental Health Systems, 10(5).
https://doi.org/10.1186/s13033-016-0037-y
163. Tomlin, J., Bartlett, P., & Völlm, B. (2018). Experiences of restrictiveness in forensic psychiatric care: Systematic
review and concept analysis. International Journal of Law and Psychiatry, 57, 31–41.
https://doi.org/10.1016/j.ijlp.2017.12.006
164. Tomlin, J., Egan, V., Bartlett, P., & Völlm, B. (2019). What Do Patients Find Restrictive About Forensic Mental
Health Services? A Qualitative Study. International Journal of Forensic Mental Health, 19(1), 1–13.
https://doi.org/10.1080/14999013.2019.1623955
165. Tully, J., Larkin, F., & Fahy, T. (2015). New technologies in the management of risk and violence in forensic
settings. CNS Spectrums, 20(3), 287–294. https://doi.org/10.1017/s1092852915000279
166. Van Damme, L., Fortune, C.-A., Hoeve, M., Vanderplasschen, W., & Colins, O. F. (2021). The Role of Personal
Resilience and Interpersonal Support in Building Fulfilling and Prosocial Lives: Examining the Good Lives
Model among Young Women Four Years after Youth Detention. International Journal of Offender Therapy and
Comparative Criminology, 0306624X2199405. https://doi.org/10.1177/0306624x21994055
167. van der Veeken, F. C. A., Lucieer, J., & Bogaerts, S. (2018). Forensic psychiatric treatment evaluation: The
clinical evaluation of treatment progress with repeated forensic routine outcome monitoring
measures. International Journal of Law and Psychiatry, 57, 9–16. sciencedirect.
https://doi.org/10.1016/j.ijlp.2017.12.002
168. Van Hecke, N., Vanderplasschen, W., Van Damme, L., & Vandevelde, S. (2019). The bumpy road to change: a
retrospective qualitative study on formerly detained adolescents’ trajectories towards better lives. Child and
Adolescent Psychiatry and Mental Health, 13(1). https://doi.org/10.1186/s13034-019-0271-6
169. Vasic, N., Segmiller, F., Rees, F., Jäger, M., Becker, T., Ormanns, N., Otte, S., Streb, J., & Dudeck, M. (2017).
Psychopharmacologic treatment of in-patients with schizophrenia: comparing forensic and general psychiatry.
The Journal of Forensic Psychiatry & Psychology, 29(1), 1–15. https://doi.org/10.1080/14789949.2017.1332773
170. Völlm B, Edworthy R, Holley J, et al. A mixed-methods study exploring the characteristics and needs of long-stay
patients in high and medium secure settings in England: implications for service organisation. NIHR Journals
Library, Southampton (UK); 2017.
171. Völlm, B., Majid, S., & Edworthy, R. (2018). English vs Dutch high secure hospitals: service user
perspectives. The Journal of Forensic Practice, 20(2), 112–121. https://doi.org/10.1108/jfp-12-2016-0054

172. Vollm, B., Majid, S., Edworthy, R., Holley, J., Talbot, E., Weaver, T., Duggan, C., & McDonald, R. (2015).
Characteristics and Needs of Long-stay Patients in High and Medium Secure Forensic-Psychiatric Care:
Implications for Service Organisation - Summary Report. In . https://www.ncbi.nlm.nih.gov/books/NBK424827/
173. Voss, I., & Bartlett, R. (2019). Seeking freedom: A systematic review and thematic synthesis of the literature on
patients’ experience of absconding from hospital. Journal of Psychiatric and Mental Health Nursing, 26(9-10),
289–300. https://doi.org/10.1111/jpm.12551
174. Voulgaris, A., Kose, N., Konrad, N., & Opitz-Welke, A. (2018). Prison Suicide in Comparison to Suicide Events in
Forensic Psychiatric Hospitals in Germany. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00398
175. Walsh, E., Buchanan, A., & Fahy, T. (2002). Violence and schizophrenia: Examining the evidence. British
Journal of Psychiatry, 180(06), 490–495. https://doi.org/10.1192/bjp.180.6.490
176. Webb E, Girardi A, Stewart I (2021) Exploring coproduction of patient care in a secure mental health
setting. Nursing Times [online]; 117: 4, 34-38.
177. Weich, Scott, Fenton, Sarah-jane, Staniszewska, Sophie, Canaway, Alastair, Crepaz-keay, David, Larkin,
Michael, Madan, Jason, Mockford, Carole, Bhui, Kamaldeep, Newton, Elizabeth, Croft, Charlotte, Foye,
Una, Cairns, Aimee, Ormerod, Emma, Jeffreys, Stephen and Griffiths, Frances (2020). Using patient experience
data to support improvements in inpatient mental health care: the EURIPIDES multimethod study. Health
Services and Delivery Research, 8 (21), pp. 1-338.
178. Wheatley, M. D., Long, C. G. L., & Dolley, O. (2013). Transitions of females from adolescent secure to adult
secure services: A qualitative pilot project. Journal of Mental Health, 22(3), 207–217.
https://doi.org/10.3109/09638237.2012.705921
179. Whittington, R., Bowers, L., Nolan, P., Simpson, A., & Neil, L. (2009). Approval Ratings of Inpatient Coercive
Interventions in a National Sample of Mental Health Service Users and Staff in England. Psychiatric
Services, 60(6), 792–798. https://doi.org/10.1176/ps.2009.60.6.792
180. Wijk, H., Degl’ Innocenti, A., Kullgren, A., & Alexiou, E. (2019). Evidence-Based Design Has a Sustainable
Positive Effect on Patients’ Perceptions of Quality of Care in Forensic Psychiatry: A 3-Year Follow-Up
Study. Journal of Forensic Nursing, 15(1), 60–68. https://doi.org/10.1097/jfn.0000000000000226
181. Wilkie, T., Penney, S. R., Fernane, S., & Simpson, A. I. F. (2014). Characteristics and motivations of absconders
from forensic mental health services: a case-control study. BMC Psychiatry, 14(1). https://doi.org/10.1186/1471-
244x-14-91
182. Wing, J. (n.d.). Severe Mental Illness. Retrieved May 8, 2021, from
https://www.birmingham.ac.uk/Documents/college-mds/haps/projects/HCNA/HCNAVol2chap13sh6L.pdf
183. Winje, M., van Mastrigt, S., Gjestad, R., Urheim, R., & Rypdal, K. (2017). Staff members’ evaluation of
inpatients’ motivation for aggression – the roles of staff restrictions and aggression severity. The Journal of
Forensic Psychiatry & Psychology, 29(3), 419–433. https://doi.org/10.1080/14789949.2017.1410563

184. Wolff, N., Frueh, B. C., Huening, J., Shi, J., Epperson, M. W., Morgan, R., & Fisher, W. (2013). Practice informs
the next generation of behavioral health and criminal justice interventions. International Journal of Law and
Psychiatry, 36(1), 1–10. https://doi.org/10.1016/j.ijlp.2012.11.001
185. Yakeley, J., & Wood, H. (2011). Patients’ experiences of forensic psychotherapy. Psychoanalytic
Psychotherapy, 25(1), 105–114. https://doi.org/10.1080/02668734.2010.519160
186. Zendjidjian, X. Y., Auquier, P., Lançon, C., Loundou, A., Parola, N., Faugère, M., & Boyer, L. (2014).
Determinants of patient satisfaction with hospital health care in psychiatry: results based on the SATISPSY-22
questionnaire. Patient Preference and Adherence, 8, 1457–1464. https://doi.org/10.2147/PPA.S67641

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IMPACT: International Journal of Research in Applied,

Natural and Social Sciences (IMPACT: IJRANSS)

LENGTH OF STAY REPORTING IN FORENSIC SECURE CARE CAN BE AUGMENTED

Dr Surya Prasad N1 & Dr Sarangapani Nivarthi2

Received: 19 Sep 2021 Accepted: 20 Aug 2021 Published: 21 Aug 2021

• Chronic illness care and recovery

• Evidence Based Medicine and Evidence Based Systemic Practise

• Evaluation of therapeutic relationship and therapeutic environments

• Challenges to smooth transitions of care upward/downward/sideways or by Age and Gender

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

• Continuity of care / Collaborative outcomes achieved by co working of agencies and services

• Willingness to grant conditional discharge

• Extend the maximum duration legally allowed for conditional discharge

• Improve supervision & aftercare programmes on leaving secure hospital settings

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

I = Interview, IPA – Interpretive Phenomenological Analysis, Q = Questionnaire, FG = Focus Groups

Chronic Illness Care and Recovery

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Table 1: Range of Coercive Measures Across Countries as a Percentage of Psychiatric Admissions

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

Evidence Based Medicine and Evidence Based Systemic Practise

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Evaluation of Therapeutic Relationship and Therapeutic Environments

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Challenges to Smooth Transitions of Care Upward/Downward/Sideways or By Age and Gender

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Figure 2: © Range of Accommodation Arrangements to Suit Various Offender Patient Groups.

Continuity of Care/ Collaborative Outcomes Achieved by Coworking of Agencies and Services

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

CONFLICT OF INTEREST DECLARATION

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

Table 2: © Summary 10 and 20 Factors Determining Length of Stay in Secure Care

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Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us

Impact Factor(JCC): 5.8648 – This article can be downloaded from www.impactjournals.us

NAAS Rating: 3.00 – Articles can be sent to editor@impactjournals.us