Week 9

Question 1

What was the historical approach to individuals with mental illness in the UK?

Answer 1

They were kept in large asylums, later called psychiatry hospitals.

Question 2

What was the main issue with high-security special hospitals?

Answer 2

Patients were often far from home, and transitioning to the community was challenging.

Question 3

What did the Glancy Report (1974) and Butler Report (1975) advocate?

Answer 3

The need for regionally based Medium Secure Units (MSUs) for treatment nearer to patients’ homes with lesser security.
* Following a similar reasoning the opening of Low Secure Units (LSUs)

Question 4

What type of patients are managed in High Security Units?

Answer 4

Patients in an acute stage of mental illness.

Question 5

What is the purpose of Medium and Low Secure Units?

Answer 5

To manage patients with long-standing illnesses who respond poorly to treatment and provide a gradual reduction in security levels.

Question 6

What the reed report says?

Answer 6

the level of control and security should be the least restictive possible

Question 7

Why is risk assessment critical in forensic mental health services?

Answer 7

To ensure ward safety, public protection, and patient care in the least restrictive environment.

Question 8

What are the most severe outcomes mental health services aim to prevent?

Answer 8

Service users’ homicide or suicide.

Question 9

what is the main focus of interest in forensic secure care?

Answer 9

the risk of violence

Question 10

Define “violence” in the context of secure care.

Answer 10

Actual, attempted, or threatened harm to a person, including fear-inducing behavior.

Question 11

How is sexual violence defined?

Answer 11

Actual, attempted, or threatened non-consensual sexual contact.

Question 12

Structured Professional Judgement (SPJ)

List the seven steps in the SPJ process.

Answer 12

1. Gather information.
2. Identify presence of risk factors.
3. Assess relevance.
4. Formulate understanding.
5. Develop scenarios.
6. Plan management strategies.
7. Provide final opinions.

a method that combines professional judgment with empirically validated tools to assess and manage risk.

Question 13

What is the purpose of the HCR-20 framework?

Answer 13

To support decision-making about an individual’s risk of violence and facilitate risk-reduction strategies.

Question 14

How is the HCR-20 used in practice?

Answer 14

As professional guidelines that integrate research and clinical judgment, not just as a checklist.

Question 15

what is the administration step 1 for HCR-20?

Answer 15

aim is to have as much info as possible.
–>file records (criminal,clinical,education/employment, social)
–>interview with subject
–> talking with informants (victims, family etc..)

Question 16

what is the HCR-20 administrative step 2?

Answer 16

o Rating process for risk factors (No, Possibly or Partially, and Yes)
o Document evidence both for and against the presence of risk factors
* Y/N/P/O
Historical –LIFETIME, refer to areas of past functioning, behaviors, and experiences
Clinical –RECENT (1-6 months) problems with…
focus on recent or current psychosocial, mental health, and behavioural functioning
Regular re-evaluation
Risk Management –FUTURE (between now and next evaluation) problems with…
factors refer to areas of future functioning, psychosocial adjustment, living situation, and use of professional plans (institution or community).

Question 17

What is step 3 HCR-20?

Answer 17

Relevance of Risk Factors - determine which of the risk factors rated as present or partially present may play a causal role in violence, at the individual level.

Consider the extent to which risk factors have acted as:
Motivators (i.e., increase the perceived benefit of violence)
** Disinhibitors** (i.e., decrease the perceived cost of violence),
Destabilizers (i.e., impair decision making).

Question 18

what is step 4 in HCR-20?

Answer 18

Risk Formulation- Must provide a solid understanding of why a person has acted violently in the past, and why they may do so in the future. –>drive a management of the risks
Such an understanding is necessary to manage future violence, and hence how best to reduce the risk

• 5 P’s model used

5Ps model (see Weerasekera, 1996)
problem (that is, risk of what?)
predisposing (or vulnerability) factors
precipitating factors (or triggers to harm)
perpetuating (or maintenance) factors
protective factors

Question 19

what’s step 5 in HCR-20?

Answer 19

Risk Scenarios- Develop informed, reasoned projections (i.e., linked to and derived from case facts) about future behaviors and the contexts that may lead to a certain violent outcome.
* Repeat (engages in the same type of violence, for similar reasons, as past violence)
* Twist (change in the nature of violence- victim selection or use of weapons)
* Escalation (worst-case scenario is one in which the severity of violence becomes worse over time)
* Optimistic (best-case scenario, the severity of violence decreases

Question 20

What’s step 6 of HCR-20?

Answer 20

Management Planning
Address risk factors taking into account – formulation and scenarios.
Management includes a range of risk reduction strategies at the disposal of agencies or persons responsible for the supervision of an individual

Question 21

what’s step 7 of HCR-20?

Answer 21

Conclusory Opinions- Summarize concerns about risk level and prioritization of services

Question 22

What is the key concept behind risk and security in secure mental health settings?

Answer 22

Security and therapy are complementary, not mutually exclusive.
Safety is crucial in delivering treatment.

Question 23

What makes secure mental health settings complex for staff?

Answer 23

They require balancing care and security.
Staff must manage serious risks and address tensions between safety and therapy.

Question 24

What are the three core elements of security in secure mental health services?

Answer 24

Physical Security
Procedural Security
Relational Security

Question 25

What is the purpose of physical security?

Answer 25

• prevent:
  – unauthorised leave, including escape
  – unauthorised ingress of people and/or contraband items
• Examples:
  Perimeter fences or walls.
  Secure entry/exit points.
  Resilient doors, windows, ceilings, and locks.
  Alarms and CCTV.

Question 26

What is the purpose of procedural security?

Answer 26

• Prohibition of items that could increase risk for violence, security breach, substance misuse or other unwanted behaviours.
• example: sharp implements, weapons, glass items, lighters/matches, alcohol, drugs and IT equipment including mobile phones, laptops
• How? By searching patients, visitors, and environments for contraband.
  Supervising and restricting visitors.

Question 27

What is Relational security?

Answer 27

Refers to the detailed understanding of those who receive secure care, including their individual risk signals and behaviours, and to the possession of the skills required to prevent and manage violence and aggression

Question 28

How does relational security guide decision-making?

Answer 28

By understanding patient triggers and conducting risk assessments.
Example: Deciding between encouraging positive activities and prioritizing safety.

Question 29

Why are serious incidents in secure mental health services impactful?

Answer 29

Devastating consequences for patients, staff, and the community.
Undermines the safety, reputation, and trust in the service.
Often rooted in poor relational security.

Question 30

What is relational security?

Answer 30

The knowledge and understanding of a patient and their environment.
Translating this understanding into appropriate responses and care.
Safe, professional, therapeutic, and purposeful relationships with understood boundaries.

**more dynamic **

Question 31

What are the four key factors and subgroups influencing relational security?

Answer 31

1. Team (boundaries, therapy)
2. other patients (patient mix, patient dynamic)
3. inside world (physical environment, personal world)
4. Outside world (outward connections, visitors)

Question 32

What are examples of maintaining boundaries in relational security?

Answer 32

Identifying negotiable and non-negotiable boundaries.
Communicating boundaries clearly to patients.
Recognizing and affirming when patients respect boundaries.
Discussing personal and team boundaries openly.

Question 33

How does therapy support relational security?

Answer 33

Considering how it would feel to be a patient
Engaging with patients proactively
Exampling great behaviour – to patients and colleagues
Involving patients in planning their own care
Making certain that patient care plans have clearly stated health outcomes as well as management plans
Making sure therapies and activities reflect health outcomes
Planning how to manage transition and change (near future also)

Question 34

How does patient mix impact ward safety?

Answer 34

Requires understanding the risks and characteristics of the patient population.
Impacts ward dynamics when patients arrive or leave.
Requires alertness to needed adjustments in the mix.

Question 35

What does recognizing the “personal world” of patients involve?

Answer 35

Seeing patients as people with good and bad days.
Treating them as adults, not children.
Knowing their histories, risks, and triggers.
Talking sensitively about triggers and planning responses togethe

Question 36

How can the physical environment support positive patient engagement?

Answer 36

Creating opportunities for social interaction.
Designing spaces for observation and engagement.
Minimizing noise and overcrowding.
Providing access to fresh air.

Question 37

What are key considerations for managing visitors?

Answer 37

Assessing risks to patients and visitors.
Preparing for and supervising visits.
Encouraging positive visits that aid recovery.
Detecting and acting on suspicious behavior.

Question 38

What is crucial when developing outward connection plans for patients?

Answer 38

Clear management plans for leave.
Clear rules and consequences for breaches (e.g., escaping or absconding).
Monitoring unusual behaviors that signal planning to escape.

Question 39

What are the three intervention categories for managing aggression and violence risk?

Answer 39

Psychosocial: E.g., understanding triggers and relational security.
Physical: E.g., environmental management or restraints.
Pharmacological: E.g., rapid tranquillization.

Question 40

What is the primary focus of violence prevention interventions?

Answer 40

Predicting risks through assessments.
Preventing escalation with de-escalation, observation, and reduced stimulation.

Question 41

What are secondary interventions for imminent violence?

Answer 41

Plans to stop imminent aggression

Question 42

What are tertiary interventions for managing violence?

Answer 42

Minimizing harm once violence occurs, e.g., seclusion or rapid tranquillization.

Question 43

What are the NICE (2015) recommendations for managing violence?

Answer 43

Prediction through risk assessment.
Prevention using de-escalation, observation, and environment management.
Continued management through pharmacological or physical interventions.

Question 44

What is the definition of de-escalation?

Answer 44

Gradual resolution of a potentially violent situation using empathy, respect, and non-confrontational limit-setting.

Question 45

What techniques are used in de-escalation?

Answer 45

Distraction and removing stimuli.
Calm and respectful communication.
Using non-threatening body language and neutral expressions.

Question 46

What should restrictive interventions aim to do?

Answer 46

Be proportionate to the risk and duration.
Be the least restrictive option.
Avoid punishment, humiliation, or establishing dominance.
–>* take account of the service user’s preferences, if known and it is possible to do so
* take account of the service user’s physical health, degree of frailty and developmental age.

Question 47

What is manual restraint?

Answer 47

A skilled, hands-on technique to safely immobilize a service user, preventing harm to themselves or others.

Question 48

What is mechanical restraint?

Answer 48

Use of equipment like restraining belts to restrict movement, applied by trained professionals.

Question 49

What is rapid tranquillization?

Answer 49

dministering medication by intramuscular or intravenous routes for urgent sedation when oral options are not possible.

Question 50

What is seclusion, and what is its purpose?

Answer 50

Supervised confinement of a patient in a room (which may be locked).
Aims to contain severely disturbed behavior likely to harm others.

Question 51

What is the difference between short-term and long-term seclusion?

Answer 51

Short-term: Typically lasts one day, monitored until the patient calms down.
Long-term: May occur if patients fail to comply with treatments or require ongoing seclusion.