This thesis explores the contribution of the Personal Concerns Inventory (PCI; Cox & Klinger, 2000) to the development of treatment engagement strategies with people with personality disorder (PD) in forensic settings. A systematic literature review of evaluated engagement strategies with offenders and people with PD showed little diversity in terms of strategies evaluated with PD, specifically psycho-education and goal-based interventions only (Chapter 2). Furthermore current literature focuses mainly on motivational interviewing (MI) in offenders as somewhat useful in increasing motivation to engage and change. However preliminary support for node-mapping and interactive activities has been found in a small number of studies. The distinct lack of strategies with PD is problematic considering the high treatment non-completion rates with this population and the case study in Chapter 3 discusses the complexity of working with patients with PD. It finds Dialectical Behaviour Therapy (DBT), which embeds motivational strategies in its programme, as improving not only treatment retention but also clinical outcomes, thereby offering further encouragement in focusing engagement strategies with PD. Consequently, a critique of the PCI was necessary in understanding the PCI as both a measure of motivation to change and a motivational intervention. This semi-structured interview demonstrates reasonable reliability and validity however the offender variants’ psychometric properties are weaker. The robust theoretical basis of the PCI and the consistent positive qualitative feedback from participants suggests value in evaluating the tool as a motivational intervention. Thus Chapter 5, an empirical study, evaluates the PCI followed by goal counselling as a motivational intervention with people with PD using a mixed-methods approach and a small number multiple baseline design. The quantitative results offer limited support for the effectiveness of the PCI or understanding of the process of change. However the qualitative data reflects that in existing PCI literature: participants perceived it as effective in focusing them on their goals and the relevance of treatment, thereby enhancing motivation. Therefore further investigations are needed to clarify discrepancies between participant perception and the outcome measure data in order to understand the extent to which the PCI enhances motivation. The final chapter summarises the thesis’ findings, the impact for research and clinical practice, the main limitations of this thesis, and makes recommendations for future research. Overall, the complex and idiosyncratic manifestation of a diagnosis of PD and the numerous external and internal factors affecting the engagement of people with PD recommend tailored assessment and intervention using a client-led approach.

This thesis explores the value of including protective factors in the violence risk assessment and risk management processes of forensic mental health services. More specifically it investigates whether assessment of protective factors improves predictive accuracy of violence risk assessment tools, and discusses the implications for clinical practice. The impact on patient motivation to change is also considered. A critique is presented of the Historical Clinical Risk-20 Version 3 (HCR-20V3; Douglas, Hart, Webster, & Belfrage, 2013), one of the most popular and widely used violence risk assessment tools. Despite its popularity and good measurable properties, the HCR-20V3 does not include an assessment of protective factors. A systematic review examined research investigating the predictive accuracy of the three violence risk assessment tools recommended for use in forensic mental health services in the National Health Service: HCR-20V3, the Structured Assessment of Protective Factors (SAPROF; de Vogel, de Ruiter, Bourman, & de Vries Robbé, 2012), and the Short Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicolls, & Desmarais, 2004). The SAPROF had superior predictive accuracy of absence of violence compared to the other measures; however, limited reliability and validity evidence was found for its use in English forensic inpatient settings. An empirical research project conducted a prospective validation study of the SAPROF, also reporting on the reliability and validity of the measure across a number of domains, and in relation to the HCR-20V3 and START. The SAPROF demonstrated better absence of violence risk predictive abilities than the HCR-20V3 and the START (presence of violence risk); combined use of the SAPROF and HCR-20V3 significantly increased predictive accuracy of presence of violence risk. Finally, a single case study explores the impact of collaborative risk assessment and management training on a patient’s motivation to engage in treatment and interventions to manage risk. Collaborative risk assessment had a positive impact on motivation; however it was not reliably or clinically significant. This thesis provides positive research evidence for the inclusion of protective factors in the violence risk assessment and management process.

Spirituality has been increasingly acknowledged in nursing literature as an important element of holistic care provision. The literature to date has investigated the meaning of spirituality in Western cultures, predominantly through positivist methodologies. Spirituality in Middle Eastern countries remains under-researched, and this study aims to address this gap and to better understand this concept. The main aim was to understand and interpret patients’ perceptions, experiences, beliefs and practices associated with spirituality by exploring how spirituality is manifest in the lives of Jordanian End Stage Renal Failure (ESRF) patients. A hermeneutic phenomenological approach was adopted informed by the philosophy of Martin Heidegger (Heidegger, 1962). Participants (n=27) were recruited from four different dialysis units: in a public hospital, a private hospital, an educational hospital and a refugees’ hospital in Jordan. Data was collected through in-depth unstructured interviews. Analysis was guided by the tenets of hermeneutic phenomenology, namely: gaining an immediate sense of what was said both during and after each interview, transcribing data verbatim, translating interviews into the English language, intensive reading and re-reading, seeking meaning units by line-to-line coding, developing situated structures (how spirituality was manifest in each text) and developing a general structure from the individual situated structures (how the phenomenon ‘spirituality’ comes into being). The findings uncovered the phenomenon of spirituality and how the Jordanian ESRF patients experienced it during their illness. The nature of this phenomenon appeared to be complex and multifaceted. The three superordinate themes that emerged from analysis and interpretation of the participants’ accounts clustered around Religion, Relationships and Desperation. The study findings show how language, religion and culture were important elements and cannot be ignored in understanding Jordanian ESRF spirituality. The findings reveal that cultural issues such as losing employability, social stigma, social isolation and being tagged negatively are results of suffering from ESRF and are related to the meaningful way in which Jordanian ESRF patients viewed their spirituality. This has important implications for health care professionals. Should they use spirituality in care, there is a need to address wider issues such as stigma that patients face in society which impacts negatively upon individuals’ spirituality. In addition, findings show a specific and crucial characteristic of spirituality was the conflict between acceptance and rejection of the illness, and a sense of patients feeling that they are human and that life has not stopped. It is also evident that spirituality has played an important role in Nafs (inner self). It was part of the transforming process of Nafs from being Nafs Ammarah (evil inside) to Nafs Lawamah (blaming) to ultimately reach tranquil Nafs (peace and comfort). These were the core spiritual needs of participants, who expected that health care providers, family and community should have the essential skills to address these needs. The role of nurses within the dialysis team is essential in enhancing patients’ spirituality through spiritual and religious engagements. However, few participants highlighted the challenges in nurse-patient relationships, for example being in a busy unit, cultural boundaries, nurses’ characteristics, lack of knowledge, lack of awareness, unbalanced power in such relationships, lack of support, lack of respect, and a lack of attention and psychological care. All these elements may affect a nurse’s role in providing spiritual care. This research prompts us to look at the important role pre-dialysis nurses can play in improving and addressing spiritual needs, increasing awareness, and educating patients, family and the public about ESRF in its early stages. It also highlights the important role for religious leaders, Imams, and psychologists in enhancing an individual’s spirituality. The study argues that a “secular” concept of spirituality had no meaning for the participants in the study in the absence of religion. Spirituality is fundamentally part of religion and vice versa. The findings may have consequences for the use of spirituality in multi-cultural settings in Western countries. Additionally, findings highlight an important emphasis on the practice of spirituality, often underestimated in previous literature for Arab-Muslim Jordanian patients. The study findings contribute to the existing gap in knowledge regarding how Arab-Muslim Jordanian ESRF patients experience spirituality during their illness. It provides valuable insights into the importance of spirituality for this patient group and suggests how nurses, educators and policy makers might help address ESRF patients’ spirituality and spiritual needs in order to provide appropriate spiritual care. The study suggests the findings may have relevance beyond the Jordanian context in educating nurses on the importance of appreciating the religious dimension of spirituality. The study recommends further research in order to understand spirituality from the healthcare providers’ perspective.

This thesis provides a broad and diverse investigation into the field of traumatic responses in mentally disordered perpetrators of homicide and group treatment for such offenders. A range of methods including a systematic review, a single case study and a primary phenomenological investigation were used to explore issues in the field. Following an introduction in Chapter 1, Chapter 2 reviews trauma responses in homicide offenders. The results indicate that trauma reactions among homicide offenders as a direct result of the offence are highly prevalent which has implications for potential interventions. The existing literature is obstructed by weak studies using suboptimal scientific designs and future research is recommended. In Chapter 3 a single case study explores a homicide offender’s progress in a group treatment. The group therapy under investigation adopts a recovery oriented approach, addressing both criminogenic need and the well-being of the offender. The impact of the treatment is determined using a range of psychometric measures. The results indicate improvements in the targeted areas with clinically significant change demonstrated. Chapter 4 explores the lived experience of a group treatment for homicide using the principles of Interpretive Phenomenological Analysis. Three areas were discussed: (1) the Group (2) Recovery and (3) Risk. Recurrent themes reflected the importance of shifting narratives and hope for the future in both domains of recovery and risk, lending support to the utilisation of narrative approaches in Index Offence work. The results have implications for clinical practice and are discussed in the context of directions for further research. Chapter 5 evaluates the Inventory of Complicated Grief which was used as an assessment measure in Chapter 3. Finally, Chapter 6 provides a discussion and close to the thesis drawing together the implications of the research.

No description available.

The importance of family caregiver involvement in (secure) mental health services has been increasingly recognised and there is a wide consensus that family caregivers should be seen by clinicians as partners in the care of patients (Harvey & Ramsay, 2004). Mental health carers however, especially those caring for relatives who are subject to compulsory care and treatment, often feel overlooked and marginalised, caring in complex circumstances with little or no support. This thesis focuses specifically on the views and experiences of parents of adult children in forensic mental health services. A structured review and synthesis of qualitative studies was undertaken to develop insight into the perceived level of involvement in care, from the perspective of family members of mental health service users. The review also examines family carers’ relationships and engagement with mental health professionals. This highlighted that the practices of some professionals contribute to the distress experienced by caregivers in this marginalised group. The empirical research study, employed a qualitative design conducted within the framework of IPA, and explored what it is like for parents with an adult son or daughter with mental illness and offending background detained in a regional medium secure unit. Findings indicated that parents’ experiences were characterised by a strained relationship with mental health services, accompanied by practical difficulties in getting help in the first place, and conflicting emotions felt in response to their unwell family member’s continued detention in the forensic care setting. Following on from this, a case study describes brief family psycho-education in secure care and illustrates how staff in forensic services can collaborate with parents more empathetically and effectively. Afterwards, the Family Relations Test, an instrument that assesses affective relations from the child’s perspective is critically reviewed. The utility of this tool in clinical practice is remarked upon. In the concluding chapter, the ways in which service delivery and research can be influenced by ‘giving a voice’ to parents of forensic clients is explored, and implications of the findings are discussed with reference to the current recognition of family and social inclusion.

Practitioners working within forensic environments will be acutely aware of the diverse risks, complex treatment needs and unique responsivity issues found within the multifaceted marginal group of sexual offenders. Deviant sexual fantasy (DSF) is considered to be important in the assessment and treatment of sexual offenders. Despite the recent growth in research, conclusions remain inconsistent on the significance of fantasy in offending behaviour. Furthermore, the underlying structural components of fantasy remain relatively unexplored. The aim of this thesis was to explore the forensic relevance of the fantasy phenomenon predominantly related to sexual offending populations. This was done by investigating the cognitive components of fantasy in regards to the intersection between fantasy, cognition, personality and self-representation (the latter constructs being considered as reflections of individual internal mental models). Chapter one provided a context to the thesis by presenting an argument that fantasy is forensically relevant in terms of implicit beliefs (offence supportive), cognitions (cognitive distortions, offence supportive beliefs) and personality organisation and functioning (e.g. coping mechanisms). Chapter two detailed a literature review following a systematic approach, exploring the role of fantasy within sexual offending behaviour. Sixteen studies were included in the review. An associative relationship was found between offence supportive fantasy and sex offending behaviour. Personality (among others) was identified as one of the moderating factors within this relationship. However, key methodological limitations with the included studies were discussed. Chapter three utilised a case study approach to consider the complexities of assessment and treatment for a medium risk internet sexual offender (ST). This chapter explored ST’s vulnerabilities in depth (low self-esteem, interpersonal difficulties, emotional dysregulation, rigid cognitive style) and provided a comprehensive assessment and formulation of risk (fantasy experiences reinforce offence supportive attitudes and cognitive distortions). Results suggested that fantasy could be mapped onto personality, organisation and functioning. ST’s fantasy life was considered a latent variable that only became an acute and dynamic risk factor when combined with his distorted attitudes. Chapter four detailed a critique of the MCMI-III. Specific emphasis was placed on assessing the utility of the measure within forensic settings and how this could supplement assessment of fantasy experiences. The tool was found to be psychometrically stable, however it was suggested that use with a sex offender population is approached with caution. Chapter five investigated associations between personality, fantasy proneness and sexual fantasies, in addition to exploring the function and structural components of sexual fantasy. An anonymous electronic questionnaire (containing several psychometric questionnaires e.g. IPIP-50, WSFQ, CEQ) was presented online for a period of 12 weeks. 259 males participated in the study. Links to fantasy proneness, certain personality markers (e.g. agreeableness, intellect/imagination) and early abusive experiences were found. Static fantasy experiences were associated with conscientiousness. Behavioural expression of fantasy was associated with extraversion. ‘Vividness’ of sexual fantasy was explained by the following themes: 1) Boundaries of imagination 2) Context 3) Structure of fantasy and, 4) Fantasy-Reality distinction. Finally, chapter six provides a conclusion to the thesis by summarising the main findings, with particular emphasis on how findings relate more directly to the fantasy phenomenon. The main suppositions and recommendations are as follows: • Fantasies prime self-other associations. Thus, indirect measures of fantasy may be useful and allow the cognitive mapping of fantasy. • A tiered definition of offence related fantasy is recommended pertaining to frequency, vividness, level of intrusion and the risk relevance. • Control (and disintegration of), coping and cognitive capabilities are implicated as important concepts for fantasy prone individuals. To a certain point, offence related fantasy may act as a protective factor for some individuals, until the fantasy can no longer satiate their needs. • The temporal ordering of fantasy function is important in determining risk relevance pertaining to protective factors (emotional regulation), risk inducing factors (priming offender identity) and high risk situations. • Fantasy generation is a skill; the more involvement an individual has with their internal world the more adept they will be at generating complex fantasy experiences and, in turn, the more enmeshed fantasy and reality can become. • Grounding techniques and acceptance commitment therapy may be a useful treatment recommendation for individuals that experience offence related fantasy. Discussion is augmented within contemporary theoretical perspectives in order to consider clinical implications. Limitations of the current thesis and recommendations for future research are also outlined.

This thesis sought to explore the effectiveness of CBT based anger management interventions with offenders. This was achieved in part through a random control trial on a sample of 24 community based male offenders, screened for dysfunctional anger. Statistical analysis revealed significant post-intervention reductions for both Groups in the reported anger symptoms and a substantial overall treatment effect noted (r = .89). The intervention used in the RCT was adapted to provide treatment for a female offender (N=1). An in-depth formulation of the case study facilitated the adaptation of the programme for the female offender. The case study was assessed at baseline, after the intervention and after a period of follow-up. The results obtained indicated clinically significant changes which seemed to justify the formal adaption of the programme. A psychometric critique also delved in the suitability of using the Anger Disorder Scales (Di Giuseppe & Tafrate, 2004) as the main measure of anger in the research and case study. Its reliability and validity and its strengths in terms of developing in-depth formulation of offenders’ anger dysfunction were discussed. The research and case study used psychometric measures to assess the efficacy of interventions. Thus, to compensate for the reliance on self-reported measures, the systematic review and meta-analysis explored the effectiveness of CBT based interventions by analysing long-term behavioural changes of interventions as measured through general and violent recidivism. All the included studies (n=14) were submitted to a quality assessment prior to extracting the required information. An overall risk reduction of 23% was estimated for general recidivism (k = 7; n = 1836; RR = .77; 95% CI .61 to .96) and 28% for violent recidivism (k = 7; n = 1888; RR = .72; 95% CI .55 to .93) following treatment. Furthermore the risk reduction for general recidivism increased to 42% (k = 6; n = 703; RR = .58; 95% CI .39 to .87) and increased to 56% for violent recidivism (k = 6; n = 1029; RR = .44; 95% CI .27 to .71) for those offenders completing treatment compared to treatment drop-outs. The magnitude of effect in the included studies also compared lower intensity programmes such as anger management with more intensive violence prevention programmes. Conclusions of this meta-analysis were discussed in terms of the economic viability of interventions and magnitude of treatment effects.

This thesis explores the role of complex psychological trauma (CPT) and violence within male adult offenders. It aims to investigate the impact of CPT in better understanding the trauma-violence relationship. Chapter 1 provides an introduction to the topic of CPT and violence. Chapter 2 is a systematic review that investigates the prevalence of CPT in violent males and reviews the existing evidence for the trauma-violence relationship. This review provides some evidence for the trauma-violence relationship, finding that CPT correlated with violent outcomes. Physical neglect correctly classified violent offenders by offence status, whilst physical abuse, emotional abuse and sexual abuse were also found to be associated with violent offending. The findings regarding CPT predicting violent offending were mixed, whilst a higher percentage of studies supported the trauma- violence notion, a minority number of studies did not. The evidence for CPT predicting violent behaviour in custody was more consistently shown across studies assessing this outcome. The role of mediating and moderating factors in the trauma-violence relationship were also investigated, finding that psychopathy, age, substance misuse, genetic factors, and positive criminal thinking styles and attitudes accounted for some variances. Following this review, Chapter 3 includes a Thematic Analysis (TA) investigating forensic nursing staff’s perceptions of the impact of CPT on forensic male offenders with a diagnosis of personality disorder, particularly with regards to violent behaviour whilst detained in a mental health high-secure hospital. Nursing staff’s experiences of managing patient distress and violence were also explored. The findings illustrate that nursing staff believed patient distress and violent behaviour were associated with CPT experiences, suggesting that the impact of CPT on attachment, biological, cognitive and affective aspects of functioning during development, served to account for the difficulties that patients faced in adulthood and increased the likelihood of violence. On-going prevention strategies were found to be most important and more effective than short-term risk management steps. The management of patient distress in the context of the therapeutic relationship was illustrated as a significant component for promoting recovery and successfully managing challenging behaviours. Aspects of the secure environment that imitated abuse experiences were also perceived to significantly contribute to the occurrence of violent behaviour. Change with regards to transitioning and progressing through the system was identified to evoke trauma-related fears of moving on. The fear of moving on and its association with trauma experiences was explored in a single case study of a male violent offender with personality disorder, which is presented in Chapter 4. This chapter aimed to identify and outline the offender’s fears about transitioning from a high-secure hospital to a medium-secure unit (MSU), and understanding the factors that contributed to and maintained the client’s fears. The client’s fears were found to relate to previous-trauma related experiences, although interpersonal violence and trauma experiences in the prison environment were found to be a deep rooted aspect of the client’s concerns about moving on. Whilst the client feared being vulnerable to abuse, threat and further ‘persecution’, the fear of being unable to manage his behaviour (e.g. aggression) in response to this and cope with such potential experiences outside of the high-secure environment and subsequent consequences of not being able to cope (arrest and transfer to prison), was perceived to be a more frightening prospect. Upon exploring fears of moving on, the client’s existing cognitive-behavioural relapse prevention (RP) plan was reviewed in assisting the client to revisit skills and coping strategies that can be used to prepare and avoid high-risk situations. This work contributed to understanding the ways to best support the client in making a successful transition to a MSU. Key considerations and recommendations are made at the end of the chapter with regards to the case. Following this, Chapter 5 outlines a critique of the Coping Inventory for Stressful Situations (CISS; Endler & Parker, 1999), which was used in Chapter 4 as it provides a measure of coping with stressful, distressing or painful situations. The CISS is examined with regards to its purpose, reliability and validity in terms of its research uses. Chapter 6 provides a discussion of the thesis findings, outlining the implications of the research and providing recommendations for future research.

The impact of delusional thinking on the violent behaviour of individuals with psychiatric diagnoses has been explored using a variety of investigative methods. The notion that delusions play a role in an individual’s violent offending has been broadly upheld within the work of this thesis. The nature or function of delusions in this process appears to be affected by a range of mediating and moderating factors. The complexity of these was illustrated during the conduction of a case study. Advances in the understanding of mental disorder as a continuum, alongside the developments of risk assessment and management approaches, seem to provide the potential for an optimum vantage point to formulate the true role of delusions in the cognitive process. Future research should avoid utilising the overarching themes of psychiatric diagnoses or sets of symptoms to explore violence and should focus on considering the functions of individual symptoms or characteristics, as many of these overlap with other clinical and nonclinical populations.