The elements of therapeutic security

Secure forensic hospitals and services can always be described in terms of the elements of therapeutic security (Kennedy Reference Kennedy2002): environmental or physical security; relational security (quantitative and qualitative); procedural security; and the specialist management and governance arrangements necessary to facilitate and sustain these (Box 3).

Specialist management and governance

Management and governance structures and processes should be organised to maintain the elements of therapeutic security according to quality standards and excellence, compliance with national and international standards, sustainability over time and resilience. This should include clarity regarding management of resources, lines of reporting and responsibility. There should be processes for the weekly monitoring and benchmarking of admission, transfer and discharge decisions according to predetermined criteria. There should be processes for ensuring compliance with legal and policy requirements. There should be maintenance of inter-agency relationships and boundaries.

Incident reporting and collation with other forms of information relevant to risks and threats should be systematised for risk management, therapeutic security and organisational learning. Formal and systemic assessment of risks relevant to decisions about levels of leave and privileges is central to the prevention of absconding and contraband, while at the same time ensuring that therapeutic risks are taken to achieve timely movement to less secure placements. Particular care is required regarding child visits.

Resilience in a forensic model of care is the ability to cope with new demands, opportunities and difficulties through planning and preparation, to recover from setbacks and serious adverse events (homicides, riots, hostage incidents, arson, absconding and coordinated escapes, boundary breaches, epidemic outbreaks, surges in demand for services). One formulation identifies four elements of organisational resilience as preventive control (defensive consistency), mindful action (defensive flexibility), performance optimisation (progressive consistency) and adaptive innovation (progressive flexibility) (Denyer Reference Denyer2017). Resilience in a clinical service is closely aligned to the concept of excellence, since it relies on prioritising training, practice and innovation. Resilience requires the ability to respond quickly to new and unanticipated challenges, for example the COVID-19 pandemic (Lemieux Reference Lemieux, Dumais Michaud and Damasse2020), by adopting practices from international experience, by innovation and improvisation, using continuous evaluation and design principles and working flexibly and responsively. Expert medical and clinical leadership is essential for such resilience and innovation and to motivate teams for such flexible working. Professional, non-clinical management is necessary to support clinical leadership.

The standard model

Secure forensic hospitals can be organised according to principles of therapeutic security in a variety of ways. Very small services have relatively little choice in how they are organised; larger services can have more choice; and a minimum size may be necessary for critical mass to enable the delivery of specialist treatment programmes. The most common design is stratified therapeutic security, in which distinctions are made between high security, medium security and low security (Fig. 1). This allows an efficient allocation of human resources so that there are high staff:patient ratios (high quantitative relational therapeutic security) in acute, subacute and intensive care wards, with progressively lower ratios in medium secure and pre-discharge wards. This system of stratification of risk and matching relational security (Müller-Isberner Reference Müller-Isberner, Webster and Gretenkord2007; Pillay Reference Pillay, Oliver and Butler2008) may intersect with stratification of ward security, from acute and subacute wards, to medium-term medium secure and slow-stream secure or long-term wards and finally to rehabilitation and pre-discharge wards (see ‘Pathways governance and management’ below). Special considerations arise concerning the provision of secure forensic services for women, for adolescents and for special needs groups.

FIG 1 Stratified therapeutic security, the most common model of therapeutic security in secure forensic hospitals. PY, per year.

Sustainable levels of service

Any forensic hospital, service or system is liable to silt up if the numbers discharged in a given time period cannot keep pace with demand for admissions. This can be expressed in various ways. Bed occupancy should generally be managed at about 85% to cope with seasonal or other surges in demand. In practice many secure forensic hospitals run at 100% occupancy. Occupancy above 100% will reduce relational therapeutic security and is unsafe. Average length of stay in a ward or a hospital can be calculated in various ways. Operational research shows that length of stay is a mixed exponential function. This can be approximated by thinking in terms of half-lives rather than mean length of stay. The median length of stay is a rough but useful approximation (Priest Reference Priest, Fineberg and Merson1995). In practice a mixed exponential function means that there will always be some patients who require much shorter and much longer lengths of stay. Although the majority may be discharged back to the community or the criminal justice system, unless there is provision for those requiring much longer lengths of stay, admission capacity will quickly be lost as new long-stay patients accumulate.

Triage and pathways management

Forensic psychiatrists typically act as gatekeepers for secure forensic hospitals to ensure that patients are detained in no greater or more restrictive a level of therapeutic security than is necessary and for no longer than is necessary. Structured professional judgement instruments based on validated criteria are increasingly used as decision support structures by admissions panels and other governance structures for gatekeeping and individual goal setting. This includes reports to mental health review boards. These instruments guide but do not bind the clinician and the decision maker. Such instruments should be patient focused not institution centred, rating according to the patient's characteristics and situation, not seeking to match the patient to an institutional characteristic. They should be calibrated in meaningful units of reliable change (high-, medium- or low-security needs) or difference and validated against real world operational differences (high, medium or low secure) and changes (moves between levels of care or security) (Glancy Reference Glancy, Choptiany and Jones2021; Kennedy Reference Kennedy, O'Reilly and Davoren2019b; Shinkfield Reference Shinkfield and Ogloff2014).

In many jurisdictions the courts decide on committal to a forensic hospital or forensic psychiatry service on the basis of expert evidence, first regarding mental disorder, then fitness to stand trial or responsibility, then according to the need for treatment and the level of therapeutic security required. Forensic psychiatrists have an essential role in relation to each of these steps. Although the courts should be independent in the exercise of their powers, an effective secure forensic hospital service requires there to be some degree of consistency in decision-making by the courts and predictability in the numbers and triaging for admission from year to year (supplementary Box 1, available online at https://dx.doi.org/10.1192/bja.2021.34.) (Chow Reference Chow and Priebe2016; Gupta Reference Gupta, Akyuz and Baldwin2018; NHS Digital Reference NHS Digital2017; Salize Reference Salize and Dressing2007). It follows that when planning a model of care, the ability to admit numbers of this order is essential, it must be sustainable over time and should include surge capacity. Modelling future needs should take account of annual admission rates and case mix (need for therapeutic security) and likely length of stay in half-lives and the effects of alternatives such as community treatment orders (Davoren Reference Davoren, Byrne and O'Connell2015a; Gibbons Reference Gibbons and McCarthy2015).

Admission rates and bed capacity may be driven by differences in population density, deprivation and social cohesion scores. Differences in case mix are also relevant, although the increasing use of measures of need for therapeutic security demonstrates consistent results in most high secure hospitals (Eckert Reference Eckert, Schel and Kennedy2017; Williams Reference Williams, Senanayke and Ross2020) but not in all jurisdictions (Habets Reference Habets, Jeandarme and Kennedy2019). Consistency has been shown in medium secure hospitals, in prison and court triage assessments for all levels.

Specialist forensic psychiatry assessment is required to ensure appropriate admissions to secure hospitals, and this should be supported by use of validated structured professional judgement tools (Glancy Reference Glancy, Choptiany and Jones2021). Similarly, the decision to move from high to medium to low security, from acute to subacute to medium or low security and the community is heavily influenced by risk assessment using modern instruments for which there is objective validation, such as the 20-item Historical, Clinical and Risk Management guidelines (HCR-20) and the Dangerousness Understanding, Recovery and Urgency Manual (DUNDRUM) toolkit (Adams Reference Adams, Thomas and Mackinnon2018; Davoren Reference Abidin, Davoren and Naughton2013; Wharewera-Mika Reference Wharewera-Mika, Cooper and Wiki2020). A regular clinical audit of the appropriateness of admissions using a validated instrument such as the DUNDRUM-1 triage security instrument (Freestone Reference Freestone, Bull and Brown2015; Habets Reference Habets, Jeandarme and Kennedy2019; Williams Reference Williams, Senanayke and Ross2020) would assist in ensuring sustainability.

Progress along the pathway from admission and subacute to medium secure and pre-discharge wards is based on routine assessment of risk of violence (Abidin Reference Abidin, Davoren and Naughton2013; Dolan Reference Dolan and Blattner2010; Müller-Isberner Reference Müller-Isberner, Webster and Gretenkord2007; Pillay Reference Pillay, Oliver and Butler2008) and suicide (Abidin Reference Abidin, Davoren and Naughton2013) using structured professional judgement instruments. In intensive care, acute and subacute settings, daily short-term assessments such as the Dynamic Assessment of Situational Aggression (DASA) and the Brøset Violence Checklist (BVC) are used (Maguire Reference Maguire, Daffern and Bowe2019). Equally important is the use of repeated measures of treatment programme completion and forensic recovery (Davoren Reference Davoren, Abidin and Naughton2013, Reference Davoren, Hennessy and Conway2015b; McCullough Reference McCullough, Stanley and Smith2020) to inform individual care planning and reports to mental health review boards.

Pathways governance and management

An admissions panel should act as gatekeeper and should then actively prioritise the waiting list for admission to the secure forensic hospital (Flynn Reference Flynn, O'Neill and Kennedy2011; Freestone Reference Freestone, Bull and Brown2015; Williams Reference Williams, Senanayke and Ross2020).

Acute and subacute admission wards must remain capable of providing a sustainable level of admissions per year. An intensive care ward is necessary to minimise the use of seclusion, restraint and forced medication. It also prevents the disruption of the therapeutic milieu and patient safety on other wards. High staff:patient ratios and specialist skills (relational therapeutic security) are required for the prevention and management of violence and aggression, including dynamic risk assessment, de-escalation and the proportionate use of restrictive and intrusive interventions (Kennedy Reference Kennedy, Mullaney and McKenna2020).

Medium-term medium secure wards for those recovering from acute symptoms should orient towards psychoeducation and psychological treatments for relapse prevention, recovery from substance misuse and reducing the risk of future offending, with an emphasis on reducing also the seriousness of any future offending.

Slow-stream secure or long-term wards are necessary to accommodate those who do not benefit from interventions sufficiently to progress towards less secure or community placements. The emphasis should be on building rapport and trust while providing quality of life for self-actualisation and self-transcendence (Eckert Reference Eckert, Schel and Kennedy2017).

Pre-discharge wards provide rehabilitation for those in transition from the secure hospital to community places. The progressive use of accompanied, unaccompanied and overnight leave typically is regarded as necessary before conditional discharge. Leave is often a hazard for bringing drugs and other contraband back into the therapeutically secure environment. Limiting communication with other parts of the secure campus may be necessary at this stage. The emphasis is on occupational therapy and rehabilitation, self-medication, self-maintenance of abstinence and relapse prevention. Family work is often critical at this or earlier stages along the pathway.

A governance structure should act as gatekeeper and pathways manager for passage between the subacute ward and the medium-term medium secure ward; and between the medium-term medium secure ward and the pre-discharge ward that leads on to the community.

Specialist pathways

Women generally make up 10–15% of patients in secure forensic hospitals, and for safety reasons require single-sex wards (Mezey Reference Mezey, Hassell and Bartlett2005), although many activities can be integrated with male patients. A minimum number of wards is required to avoid mixing acutely unwell and high-risk patients with recovering and pre-discharge patients all in the one ward (Harty Reference Harty, Somers and Bartlett2012).

A similar pathways design can be used for patients with intellectual or developmental disorders, acquired brain injury, older patients and other specialist needs.

Secure hospital provision for forensic child and adolescent patients necessitates further modifications. Special attention is required to ensure appropriate transitions from forensic child and adolescent to adult forensic psychiatry services, including processes, experience and outcomes (Livanou Reference Livanou, D'Souza and Lane2021).

Active management of length of stay

This basic model (Fig. 1) supposes that a male secure hospital pathway of about 110 beds would, subject to the governance of a medically led admissions panel and subject to interactions with the courts, admit 60 patients per year from remand or sentenced prisons, of whom 45 would have a managed length of stay of approximately 3 months before returning to the criminal justice system or stepping down via the courts to community mental health teams; the remaining 15 would spend a further 12 months in a subacute ward. A worked example of further active management of length of stay is given in supplementary Box 2.

Community forensic residences

Those who are on periods of trial leave in the community, or are conditionally discharged for supervision in the community, may be placed in residential settings that also have a stratified system of therapeutic security, with minimal if any physical security but varying levels of relational and procedural security. Staffing may vary from 24 h nurse care to social care at varying levels, with frequent contact with the supervising community forensic mental health team. Patients may progress from higher to lower levels of support and supervision over time, until they settle in independent living or find the level of support necessary to remain stable and achieve their personal optimum recovery goals in a forensic context (Adams Reference Adams, Thomas and Mackinnon2018; Davoren Reference Davoren, Byrne and O'Connell2015a). Patients may be reintegrated into community mental health teams at the point of transition into the community (an integrated model), remain in a forensic psychiatry service in the community (a parallel model) or reintegrate some time after transition to the community (Coid Reference Coid, Hickey and Yang2007; Sharma Reference Sharma, Dunn and O'Toole2015).

Some alternative possible organisations of pathways and processes within secure forensic hospitals will be mentioned towards the end of this section.

Variants of the standard model of care

Much depends on the size of the population served. In many jurisdictions, forensic mental health services are organised to serve population aggregates of 3–5 million. In the provinces of Canada, the states of Australia and the Länder (federal states) of Germany this allows a single integrated service to provide high, medium and low levels of therapeutic security on a single campus, with seamless movement of patients between levels according to individual need and measured outcomes (described below as the ‘four recoveries’). A critical mass can also be achieved to enable not only stratification according to levels of therapeutic security and risk, but also specialised pathways in parallel groups such as women (typically 10–15% of forensic patients), patients with intellectual and developmental disorders, patients for whom complex needs arise mainly from personality disorders, and other small specialist groups (elderly patients, patients with acquired brain injury, long-term/slow-stream patients).

Very small services (20–30 beds) may not be able to stratify (supplementary Fig. 1(a)). When patients are admitted, treated and discharged all in the same ward, this may be viable for very short-term crisis admissions but is disruptive for other patients on the ward engaged in medium-term treatments and rehabilitation. Larger hospitals or campuses may have several such wards still acting independently (supplementary Fig. 1(b)), mixing acute, subacute, medium term and pre-discharge together in each ward, with no stratification of risk or treatment and recovery stages, and no specialist wards. There may be arbitrary variation between wards according to local clinician preferences. In the alternative, a multi-ward hospital may have an admission ward, then multiple small specialist wards (supplementary Fig. 1(c)) that again mix patients at different levels of risk and different stages of treatment and recovery. The standard model of stratified therapeutic security for approximately 100 beds (supplementary Fig. 1(d)) has been described above.

Services covering very large populations (15–20 million) may opt to provide highly specialised (tier 4) high-security hospitals that are separate from medium secure and low secure hospitals (serving 2–5 million) (supplementary Fig. 1(e)). Each of these may then have stratified pathways within the campus and in some cases (supplementary Fig. 1(f)) parallel pathways for special groups such as those with complex needs or neurodevelopmental disorders. This requires strong central governance (supplementary Fig. 1(g)) to ensure that patients do not suffer excessive delays when ready to move between services and between levels of therapeutic security.

These contrasting models may be compared according to criteria such as ability to match patient needs with proportionate therapeutic security levels over time, consistency for all patients, transparency of pathways, safety for patients and staff, and placement based on individual and population need (supplementary Table 1).

Prison screening, court liaison and diversion

In-reach services for remand prisons (‘jails’ in North America) work best when closely integrated with court liaison and diversion services for those awaiting trial (O'Neill Reference O'Neill, Smith and Caddow2016; Simpson Reference Simpson and Jones2018). Systematic screening of all those received at such a prison should lead seamlessly to court liaison, diversion to community mental health services or referral to a forensic hospital at an appropriate level of therapeutic security. This is an essential protection for the rights of the mentally ill, particularly when imprisonment can be related to mental health service strain at community and tier 2 level (O'Reilly Reference O'Reilly, Donohoe and O'Sullivan2019b). Specialist units in remand prisons may offer enhanced care while individuals are awaiting assessment or transfer to a community mental health team, tier 2 psychiatric hospital or forensic hospital.

‘Sentenced prisons’ and continuity of care

For prisoners requiring psychiatric follow-up while serving their sentence (those in ‘sentenced prisons’), a system of psychiatric continuity of care and monitoring is necessary. This should also work best when closely integrated with the forensic mental health service and secure forensic hospital and community services (Doyle Reference Doyle, Coid and Archer-Power2014). Specialist units within prisons may offer enhanced support for those returned from periods of treatment in a forensic hospital or for those with psychiatric or psychological needs not requiring transfer to a forensic hospital.

Community forensic teams

Patients conditionally discharged following a finding of not criminally responsible who have successfully completed medium- or longer-term treatment in a secure forensic hospital are most often placed in specialist community residences with high, medium or low levels of staff support and structures. These patients are often followed both therapeutically and from the point of view of monitoring and supervision by community forensic mental health teams. These may also be integrated with probation, parole and other voluntary sector agencies. This sort of forensic mental health pathway can be described as ‘parallel’ to general adult and community mental health services. It is in the interests of recovery and de-stigmatisation that reintegration into mainstream services should always remain as medium- or longer-term goal.

Patients admitted to acute or subacute wards in a secure forensic hospital then diverted from the criminal justice system to community mental health services can best be thought of as following a pathway that is integrated between forensic and general adult mental health services.

Continuity of care and responsibility

A number of models for continuity of care can be compared. There may be one consultant psychiatrist-led team per ward. This pleases nurses, who have to service only one ward round a week and can expect consistency. However, consultant forensic psychiatrists and other members of the multidisciplinary team will need to have wider horizons of clinical activity to maintain their expertise, including prison, community and court work. A more common solution is to operate wards in clusters – for example acute with subacute and intensive care; medium-term medium secure wards; pre-discharge and community. Two consultants will then follow their patients along a coherent part of the pathway, while also taking a role in the gatekeeping and transfer processes. With ward managers and senior allied health professionals, consistency can be expected in the planning of care and treatment according to individual and aggregated patient needs and treatment goals. For patients, changes of primary nurse, key worker and consultant at intervals of 1 or 2 years represent a process of learning to develop and cultivate professional and supportive relationships with appropriate boundaries (Tighe Reference Tighe and Gudjonsson2012) that avoid excessive personal dependence. This is essential for successful supervision in the community over periods of years.

There is much evidence that each discipline contributes qualitatively different elements to the individual care and treatment plan, but there is only opinion evidence Murphy (Reference Murphy2002) that multidisciplinary teams in secure forensic hospitals or the community as shared decision makers contribute measurable benefit for improved risk assessment or management, shortened length of stay or improved patient satisfaction. Multidisciplinary teams impose administrative burdens on time and reduce available face-to-face time for direct patient therapeutic contact. Transdisciplinary ways of working (all members of a team carrying out the same tasks) can lead to confusion regarding boundaries, competencies and clinical responsibility.

Treatment resources

Identifying and quantifying treatment resources and activity is the first part of the logic model relating inputs to outputs (health gains). The Quality Network for Forensic Mental Health Services (QNFMHS) set as a standard that every patient should have 25 h a week of structured activities (Aimola Reference Aimola, Jasim and Tripathi2016). In the absence of better evidence regarding the relationship between ‘dose’ in hours of face-to-face time with a therapist and response in terms of reduction in risk and the seriousness of risk and reduction in length of stay, a reasonable goal is to deliver 5 h a week of face-to-face interventions in mental health, substance misuse, problem behaviours (criminogenic need) and formal family therapy. The remaining 20 h should be taken up with activities of daily living and education, occupation and creativity focusing on quality of life (O'Flynn Reference O'Flynn, O'Regan and O'Reilly2018), self-actualisation (Roychowdhury Reference Roychowdhury2011) and self-transcendence (Wharewera-Mika Reference Wharewera-Mika, Cooper and Wiki2020).

A potential failing of unwritten models of care for in-patient treatment in forensic settings is not delivering measured hours of face-to-face talking therapies by appropriately qualified therapists (Duggan Reference Duggan2011). A model of care must set a standard for delivery of effective treatments. The standard set must be quantified and the delivery must be quantifiable. If one whole-time therapist can deliver 20 h a week of face-to-face therapy with patients, then to deliver 5 h a week of individual face-to-face therapy for 100 patients would require 25 whole-time equivalents with appropriate skills. If face-to-face time is made up of 3 h of one-to-one sessions and a 2 h group session involving eight patients and two therapists, this would require 17.5 whole-time equivalents for 100 patients. Further staff planning is required to ensure that therapists can deliver appropriately tiered therapies, scheduling for availability of treatment rooms and coordination with other daily and weekly routines. This should be an explicit part of the model of care.

Individual care and treatment plans are typically drafted very soon after admission and are regularly revised in the light of reassessment and progress at least every 6 months, typically before a legal review of detention. These can be used at the individual level and at the aggregated level to assess need for general and specific treatment programmes. A governance system is required to ensure that resources are systematically brought to bear to meet these treatment needs. This can take the form of a practical booking system for patients, therapists and rooms. This quantified resource, ‘dose’ or input is the first part of the ‘logic model’ of the model of care.