Our research programmes and approach

Conducted by: Josie Broyd, Lindsay Dewa, Jonathan Hafferty & Rita Hira

Oxehealth is a contact-free optical sensory which allows hospitals to monitor vital health data on patients without disruption to their daily activities. Quantitative and qualitative data will be collected to:

• Capture staff and patient views on the technology and its effects on safety, patient wellbeing, physical health and other factors on the wards
• Study the role of the technology in addressing patient safety incidents including violence against staff and patients, self-harm, general violence and physical health of patients by review of aggregate and individual incidents
• Examine the quality of life, sleep quality and mood in forensic inpatients using Oxehealth technology.

Conducted by: Josephine Broyd, David Murphy, Jonathan Hafferty, Freya Walker & Laura Gröger

A previous study of 100 admissions to Broadmoor Hospital (Lumsden et al. 1998) found a high prevalence of central nervous system trauma (CNS) in the population.

An association between CNS trauma and violent offending was also found. Since that study’s publication, the patient population at Broadmoor has changed dramatically, with the hospital reducing in size (a new hospital being built) and tending to accept only the most unwell patients in the secure hospitals and prison estate.

A recent investigation of the general levels of intellectual functioning of admissions to Broadmoor hospital over the last fifty years has also suggested that general levels of intellectual functioning have fallen by at least one standard deviation and are likely to be a reflection of increasing complexity and co-morbidity of admissions (Murphy et al., 2021). This project, therefore, aims to evaluate the history of traumatic brain injury of 200 consecutive recent admissions to Broadmoor and its associations with the risk of violence and engagement with psychological services.

This service evaluation will identify areas of unmet clinical need and facilitate in the allocation of resources to manage those with a significant head injury in the high secure service patient population. This project will be part of a larger working group focusing on neuropsychology.

Conducted by: Rita Hira, Josie Broyd, Emily Morley, Maryam Halaoui, Alex Lewis, Jonathan Hafferty, Mary Davoren.

In 2019 patients moved out of the older Victorian-style building, into the newly designed Broadmoor Hospital. The research team has evaluated the security, therapeutic and physical impact of the new build on both patients and staff, over the course of three years. We evaluated if the core outcomes which the redevelopment was designed to improve (patient care, physical health, quality of life, risk, and safety and comfort), changed after patients and staff moved to the new hospital building. We compared outcomes collected via clinical records and questionnaires, at various points pre and post-Hospital Move.

Find more about the new hospital.

Conducted by: Simon Draycott, Rita Hira and Andreas Kappes (External; City, University of London)

In collaboration with City University of London, this study utilises well-validated experimental paradigms (commonly used to understand the behaviours of people with Borderline Personality Disorder) to understand how staff members who provide treatment engage with this group.

Including information associated with trust and their likelihood to update their beliefs related to themselves and others.

There is potential to extend the study to delusions and other areas.

The research proposal is currently being drafted.

Conducted by: Simon Draycott

This qualitative study will explore the perceptions of the therapeutic relationship between patients of Broadmoor Hospital, and their services.

Conducted by: Azizah Attard, John Wakelam, Jonathan Hafferty, Josephine Broyd

This study is evaluating the long-term outcome of the use of Olanzapine long-acting injection (OLAI) in a high secure setting.

OLAI is not often used in the community due to the associated post-injection syndrome requiring a prolonged observation period following depot administration, which is not feasible in such settings. Such monitoring is standard in high security and therefore we have the unique opportunity to evaluate its use over 10 years in Broadmoor.

The reasons for starting OLAI, stopping OLAI, peak doses and any safety concerns with OLAI in this patient population will be evaluated.

Conducted by: Rita Hira, Josie Broyd, Estelle Moore, Jonathan Hafferty, James Tapp.

This evaluation assessed the impact of the redeveloped Broadmoor Hospital environment on staff members’ experience of providing and patients’ experience of receiving High Secure Care. As a part of the larger Move to Improve project run by Dr James Tapp, we looked at interviews with patients and staff on how they felt the redevelopment contributed to outcomes.

While this study is currently being finalised, out results show many factors which the hospital anticipated to change did, some which did not, and participants give insight into how they interacted with the environment.

A psychometric evaluation of the State-Trait Anger Expression Inventory-2 for UK adult male forensic psychiatric inpatients

Conducted by:

Gilderthorp, N., Wilson, C., & Tapp, J. (2019).

Published in: International Journal of Forensic Mental Health, 1-11

Recent reviews of clinical assessments used in the forensic mental health field have identified a need for psychometric evaluations to support their use. The current study tested the 6-factor structure of the State-Trait Anger Expression Inventory- 2 (STAXI-2) in a sample of 128 adult male forensic inpatients in the UK, as a reduction in the experience and expression of anger is a frequently targeted outcome for this group. Scale reliability indices and convergent validity were also investigated.

Confirmatory factor analysis of the study sample responses suggested a poor fit with the six factors reported in the STAXI-2 validation study.

Reliability indices (average variance estimation, composite reliability, alpha) of the STAXI-2 scales indicated “acceptable” internal consistency, specifically for State and Trait Anger and Anger Expression-In scales.

Scale coherence was further supported by associations with theoretically related self-report and observer-rated anger assessments. The findings offer support for the use of the STAXI-2 with people in forensic mental health services, but research into whether revisions to the assessment might improve its construct validity with this population is recommended. Based on this study samples reported levels of anger and normative comparisons, and impression management considerations are advised when administering the STAXI-2.

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

Conducted by: 

Fuller, J., Tapp, J., & Draycott, S. (2019).

Published in: Criminal Behaviour and Mental Health, 29(2), 111-121

Background

Motivation and readiness to change are important drives for forensic patients accessing interventions. It is thought that guilt and shame influence these drives, but to date, their relationship has not been empirically tested.

Aims and hypotheses

The aim of this study is to investigate associations between guilt, shame, and treatment motivation and readiness in a sample of men in a secure hospital. It was hypothesised that guilt would be positively correlated, and shame negatively correlated, with treatment motivation and readiness.

Methods

Sixty-six adult male patients detained in a secure hospital completed the assessments of experiences of guilt, shame, motivation, and readiness for treatment. Clinician-rated readiness ratings were also collected.

Results

Shame proneness showed no significant association with motivation for change or treatment readiness. Guilt proneness and offence-related shame were positively correlated with treatment readiness. Offence-related guilt was positively correlated with both motivation and readiness. Regression modelling indicated offence-related guilt had a significant level of explanatory power.

Conclusions and implications for practice

This first study of the impact of guilt and shame on motivation and readiness for change among offender hospital inpatients found that offence-related guilt may be helpful but did not replicate the potential disadvantage of shame. Further research would be warranted into whether the “newness” or the extent of shame may be more important than shame more generally. Given the probable importance of offence-related guilt, we recommend that guilt attribution is assessed in offender patients to optimise nature and timing of treatment.

A psychometric evaluation of the Defence Style Questionnaire-40 in a UK forensic patient population

Conducted by:

Tapp, J., Cottle, L., Christmas, M., Stratton, R., Gannon, T., & Moore, E. (2017).

Published in: The Journal of Forensic Psychology and Psychiatry, 1-20

Psychological defence mechanisms have been considered important personality processes in the onset, maintenance and recovery of mental disorders.

More recently, their application to understanding presenting problems and as potential outcome indicators for forensic patients has been recommended.

However, to date, there have been no investigations into the reliability and factor structure of defence mechanism assessments for this population.

The current study investigated the factor structure, internal consistency and test-retest reliability of the Defence Style Questionnaire-40 (DSQ) for 160 adult male UK forensic patients.

The three-factor model of defences proposed by the DSQ-40 developers was not confirmed in the study sample. Reliability indices of the three factors indicated that the Immature factor was the most ‘acceptable’ in terms of internal consistency.

Test-retest reliability coefficients ranged from .70 to .91. A revised three-factor structure that closely corresponds to the original validation study is recommended following an exploratory factor analysis.

The findings are compared with previous reliability and factor analytic evaluations of the DSQ-40, and recommendations for its use with forensic patients are discussed.

Substance misuse in personality disorder and schizophrenia: findings and clinical implications from a high secure hospital

Conducted by:

Cappai, A., Wells, J., Tapp, J., Perkins, D., Manners, A., Ferrito, M., Gupta, N., Das, M. (2017)

Published in: The Journal of Forensic Practice, 19(3): 217-226 

Purpose

Substance misuse (SMU) is widely prevalent in mentally disordered offenders and is linked with violence and offending behaviour. There is, however, a scarcity of literature dedicated to investigating SMU and its clinical correlates in relation to patients detained within high secure hospital settings. The purpose of this paper is to investigate the extent and severity of SMU and corresponding treatment needs in patients with a primary diagnosis of personality disorder (PD) in comparison with mental illness (MI) in a high secure hospital.

Methodology and approach

The responsible clinicians of all patients (n=240) detained in a high secure hospital were asked to record information using a SMU screening questionnaire over a ten-month period. Details requested included substance type, history of past use and assessment and treatment needs. Data were recorded and then analysed: descriptive statistics were conducted to report historical use of substances, cross-tabulations and χ2 analysis explored the relationship between SMU and treatment status and diagnosis and offending behaviour and a means comparison analysis was employed to explore the length of stay and treatment of SMU.

Findings

• A total of 230 questionnaires were returned (95 per cent of the patient population).
• A history of SMU was reported in 88.6 per cent of the sample, with alcohol and cannabis misuse being the most prevalent.
• At least one substance had been abused by 74.3 per cent of the sample.
• In two-thirds of the sample, SMU was linked with the onset of mental health problems and symptom exacerbation, including violence.
• Patients with a diagnosis of MI as compared with PD were more likely to have used substances (93.3 per cent compared to 81.9 per cent) and were more likely to need treatment for SMU (64.3 per cent compared to 36.8 per cent).
• In those with an MI diagnosis, SMU was more likely to be linked with violence and index offence (74.3 per cent compared to 59.0 per cent).

Practical implications

SMU is significantly prevalent in high-risk mentally disordered offenders and is linked to the onset of mental health problems and offending. Patients with schizophrenia have a higher prevalence of SMU than PD and are likely to be more in need of treatment. Violence and offending are more likely to be related to SMU in schizophrenia than in PD.

Value of the study

This study substantiates existing evidence that SMU contributes to mental health problems and criminogenic behaviour. Furthermore, the study reports new findings that characterize differences in the relationship of SMU to offending in schizophrenia and PD in forensic psychiatric patients presenting to a high secure hospital.

Long-term patterns in interpersonal behaviour amongst psychopathic patients in secure inpatient treatment: A follow-up study

Conducted by: Draycott S, Short R, Kirkpatrick T.

Published in: Personal Ment Health. 2015 May;9(2):124-32.
Epub 2015 Jan 26. PMID: 25622564.

Psychopathy is a disorder that is partly defined by with maladaptive interpersonal behaviour and has significant effects on treatment outcomes. A previous study (Draycott et al., ) found that higher levels of psychopathy led to a specific interpersonal 'trajectory' amongst patients in a secure psychiatric treatment programme during the first 9 months of their admission. In that programme, more psychopathic patients became increasingly dominant over time, and less psychopathic patients became increasingly hostile. This study is a longer-term follow-up and extension of that study, extending the window of observation to 33 months of treatment. It was found that the more psychopathic patients' increased dominance returned to baseline levels by 33 months, as did the less psychopathic patients' increased hostility. This suggests that treatment for this group is not idiopathic but leaves unanswered the question as to what these divergent trajectories represent.

Secondary traumatic stress in police officers investigating childhood sexual abuse

Conducted by:

Hurrell, A.-K., Draycott, S. and Andrews, L. (2018)

Published:

Policing: An International Journal, Vol. 41 No. 5, pp. 636-650

Purpose

Previous research has indicated that helping professionals working with traumatised individuals are susceptible to adverse effects which can be recognised as secondary traumatic stress (STS). The purpose of this paper is to explore STS in police officer’s investigating childhood sexual abuse (CSA) in the UK.

Methodology and approach

This study employed a cross-sectional, quantitative design. An online questionnaire was completed by 101 Child Abuse Investigation Unit (CAIU) police officers in England and Wales. STS, coping strategies, anxiety, depression and demographic information were collected for all participants.

Findings

It was indicated that increased exposure to CSA, measured by number of interviews in the past six months, was associated with higher levels of STS. Positive coping strategies, negative coping strategies, anxiety and depression all had a strong, positive relationship with STS.

Research limitations and implications

This paper is a first step to understanding STS in CAIU police officers in England and Wales. This area of research remains under-developed and would benefit from further attention in the future.

Originality and value

This is the first known study of its kind in the UK.

Predictive power of the DASA-IV: Variations in rating method and timescales

Conducted by:

Nqwaku M, Draycott S, Aldridge-Waddon L, Bush EL, Tsirimokou A, Jones D, Puzzo I.

Published in: Int J Ment Health Nurs. 2018 Dec;27(6):1661-1672

Epub 2018 May 10. PMID: 29749085.

About the study

This project evaluated:

• The predictive validity of the dynamic appraisal of situational aggression - inpatient version (DASA-IV)
• In a high-secure psychiatric hospital
• In the UK over 24 hours and over a single nursing shift.

Methodology and approach

DASA-IV scores from three sequential nursing shifts over a 24-hour period were compared with the mean (average of three scores across the 24-hour period) and peak (highest of the three scores across the 24-hour period) scores across these shifts.

In addition, scores from a single nursing shift were used to predict aggressive incidents over each of the following three shifts.

The DASA-IV was completed by nursing staff during handover meetings, rating 43 male psychiatric inpatients over a period of 6 months.

Data was compared to incident reports recorded over the same period. Receiver operating characteristic (ROC) curves and generalized estimating equations assessed the predictive ability of various DASA-IV scores over 24-hour and single-shift timescales.

Scores from the DASA-IV based on a single shift had moderate predictive ability for aggressive incidents occurring the next calendar day, whereas scores based on all three shifts had excellent predictive ability. DASA-IV scores from a single shift showed moderate predictive ability for each of the following three shifts.

The DASA-IV has excellent predictive ability for aggressive incidents within a secure setting when data are summarized over a 24-hour period, as opposed to when a single rating is taken. In addition, it has moderate value for predicting incidents over even shorter timescales.

How do forensic inpatients’ interpersonal sensitivity to dominance and perceptions of staff coercion impact upon anger and rates of aggression?

Conducted by:

Holley, J., Tapp, J. and Draycott, S. (2021)

Published in: The Journal of Forensic Practice, Vol. 23 No. 2, pp. 90-105

Purpose

Coercive practices – which are used as means to manage violent/aggressive behaviour in secure forensic settings – have come under scrutiny in recent years due to their paradoxical effects on provoking further service user aggression and violence.

Previous research has found relationships between increased service user aggression with both service users’ interpersonal styles and perceptions of staff coercion (i.e. staff limit setting).

This paper aims to investigate whether forensic service users’ levels of interpersonal sensitivity to dominance increase levels of self-reported anger and rates of aggression towards staff through perceptions of staff coercion.

Methodology and approach

In a cross-sectional quantitative study design, 70 service users were recruited from one high and two medium secure forensic hospitals. Standardised measures were completed by service users and recorded incident data was collected within the past year. Correlation and mediation analyses were run to investigate the relationship between study variables.

Findings

A significant relationship was found between service users’ interpersonal sensitivity to dominance and self-reported rates of anger, whereas forensic service users’ who had higher levels of interpersonal sensitivity to others’ dominance were likely to report higher rates of anger. No significant relationships were found between all other study variables.

Practical implications

The findings from this study contradict previous research where coercive practices may not necessarily increase rates of aggression towards staff but, in the context of service users’ interpersonal sensitivities to dominance, it may be more useful to consider the way in which coercive practices are implemented.

Originality and value

There is a gap in the literature, which looks at the way in which forensic service users perceive coercive practices in relation to their interpersonal sensitivities and whether this too has an impact on service user aggression.

Purpose

This paper aims to describe the process and outcomes of restorative justice (RJ) between a detained patient with autism and a person he harmed.

Conducted by:

Tapp, J., Moore, E., Stephenson, M. and Cull, D. (2020)

The image has been changed in my mind: a case of restorative justice in a forensic mental health setting.

Published in: The Journal of Forensic Practice, Vol. 22 No. 4, pp. 213-222. 

Methodology and approach

A single case study design was used to provide an in-depth description of a restorative justice referral.

Findings

Restorative outcomes that align with the theories of restorative justice, in particular trauma processing and emotional reconnection, were observed by restorative justice practitioners and reported by participants. The person harmed reported a 'safer' memory of the offence.

Research limitations

The absence of outcome assessments limits the findings to observational data and self-reported experiences from participants. A triangulated outcome approach is recommended.

Practical implications

Restorative justice practices can safely be applied within a secure hospital environment. The restorative justice process can also be followed by a person with difficulties in social and emotional processing.

Originality

The restorative justice process provides a safe framework within which forensic mental health services can respond to the needs of victims, which are not routinely addressed in standard clinical practice, and in worst-case scenarios, may even be overlooked.

Wechsler Adult Intelligence Scale full-scale IQ of male admissions to a high secure psychiatric hospital over six decades

Conducted by:

Murphy, D., Mitchell, J., Morley, E., Vacher, J., & Puzzo, I (2021)

Published in:

International Journal of Forensic Mental Health.

About the study

The present study describes the Wechsler Adult Intelligence Scale (WAIS) full scale IQ (FIQ) of admissions to one UK High Secure Psychiatric Care hospital.

WAIS IV comparative data and the FIQ of admissions from the 1960s to the 2010s are presented (n = 639).

Findings

Results suggest 75% of current admissions have FIQs within the ‘low average’ and ‘extremely low’ classifications, with significant discrepancies between composite scales being common and processing speed being the most compromised area of cognitive functioning.

A one standard deviation decline in FIQs of admissions since the 1960s to the 2010s is also present. The results are discussed in terms of the changing clinical presentations of admissions, along with research and clinical implications.

Psychotropic medication prescribing in people with autism spectrum disorders with and without psychiatric comorbidity

Conducted by:

McCarthy, E., Ross, C. & Murphy, D. (2021).

Published in:

BJ Psych Advances.

About the study

Autism spectrum disorders (ASDs) are a group of lifelong neurodevelopmental disorders characterised by difficulties in social interactions and social communication, and restricted and repetitive behaviours.

Relative to the general population, individuals with ASDs are likely to be overrepresented in secure psychiatric care and custodial settings.

Outcomes vary and can be problematic in the context of co-occurring intellectual disability, psychiatric disorder and challenging behaviours.

To date, there is little in the way of specialised clinical guidance on the prescription of psychotropic medicines for individuals with ASDs, particularly information on any differences in efficacy and/or tolerability of specific medications.

This review summarises the key research to date on the prescription of psychotropic medication in ASD with and without comorbid psychiatric or neurodevelopmental disorders, within the context of the existing clinical guidance. Some critical analysis is provided to aid clinicians in following a safe, effective and individualised approach to prescribing for people with ASDs.

Examining the relationship between neuropsychological functioning assessed during admission to a high secure psychiatric care hospital and vulnerability to long-term segregation

Conducted by:

McMichael, I., Tiley, O., Broyd, J. & Murphy, D. (2020).

Published in:

Journal of Forensic Practice.

Purpose

This paper aims to examine the relationship between neuropsychological functioning as assessed following admission to a high secure psychiatric care (HSPC) hospital and subsequent time spent in long-term segregation (LTS). Evidence from forensic populations suggests neuropsychological functioning difficulties can increase vulnerability to interpersonal violence. However, the impact of this relationship on restrictive interventions used in these settings is poorly understood.

Methodology and approach

This study quantitatively examined the neuropsychological profiles of 80 male HSPC patients as assessed during routine admission assessments, comparing data against any subsequent LTS duration during a one-year period, and a non-LTS control (n = 27).

Findings

The analysis found individuals who were willing and able to complete a routine neuropsychological admissions assessment spent significantly less time in LTS than those unable to complete the assessment.

Performance within a test of novel problem solving (Key Search Test) was significantly worse in the LTS group than controls.

Performance within a visual memory task (Immediate Recall section of the Rey Complex Figure Test) significantly correlated with LTS duration.

Additional findings suggest the absence of self-reported planning difficulties as measured by a Dysexecutive Questionnaire (DEX) negatively correlated with LTS duration, while self-reported restlessness was positively correlated with LTS.

Practical implications

This has implications for early assessment of LTS risk and potential use of cognitive interventions to reduce the use of restrictive practices.

Originality and value

The results suggest some aspects of neuropsychological performance as assessed during admission to a HSPC hospital appear to be related to subsequent time spent in LTS.

Autism: Implications for high secure psychiatric care and move towards best practice

Conducted by:

Murphy, D. (2020)

Published in:

Research in Developmental Disabilities

Aims

To explore the role of high secure psychiatric care (HSPC) in the assessment and management of individuals with an Autism Spectrum Disorder (ASD) using published studies and clinical experience. Key areas of exploration include the prevalence of ASD within HSPC, some autism-specific issues including clinical and cognitive characteristics, psychopathy and emotional regulation, presence of incompatibilities and use of seclusion, as well as experiences of being detained in HSPC. Developing best practices and a specialist ASD service in HSPC is also discussed.

Method

A discussion of available literature, supported by clinical experience.

Conclusions

Although individuals with an ASD admitted to HSPC comprise a small group, they are likely to be overrepresented relative to the general prevalence of ASD in the population and present with specific issues.

While individuals report a generally positive experience of HSPC, therapeutic outcomes are variable and the factors influencing them are poorly understood.

Staff knowledge and application of ASD theory and practice appears to have a significant influence on outcomes.

Implications

Although best practices concerning ASD secure services will continue to be improved and developed, the role of HSPC in the assessment and management of some individuals with an ASD who present with complex needs and high-risk behaviours remains clear.

Autism spectrum disorders in high secure psychiatric care: A review of literature, future research and clinical directions

Conducted by:

Murphy, D. & Allely, C. (2019)

Published in:

Advances in Autism

Purpose

The purpose of this paper is to review available literature targeting the assessment and management of individuals with an autism spectrum disorder (ASD) admitted to high secure psychiatric care (HSPC).

Key areas of examination include:

• The prevalence of ASD in HSPC
• How individuals with an ASD differ from other patient groups in clinical and cognitive characteristics
• The views of staff regarding patients with an ASD
• An exploration of the experiences and quality of life of patients with an ASD, as well as treatment and interventions.

Findings

Although individuals with an ASD comprise a relatively small proportion of the total HSPC cohort, they appear to be overrepresented relative to the general population prevalence. Several research projects suggest that individuals with an ASD present with difficulties and needs different to other patient groups, as well as being viewed by staff as potentially vulnerable and requiring a different care approach. Individuals with an ASD report both positive and negative aspects of life in HSPC.

Practical implications

Suggestions are made with regard to how individuals with an ASD might be better managed in HSPC. Following the spirit of various pieces of government legislation such as the Autism Act (2009) and the Equalities Act (2010), the role of a specialist ASD HSPC service is proposed.

Originality and value

This paper provides a detailed review of the research to date exploring the assessment and management of individuals with an ASD detained in HSPC. It outlines key research findings, highlights limitations with it and provides a personal perspective on future research and clinical targets.