Background: Understanding patient experiences of detention under mental health legislation is crucial to efforts to reform policy and practice.

Aims: To synthesise qualitative evidence on patients' experiences of assessment and detention under mental health legislation.

Method: Five bibliographic databases were searched, supplemented by reference list screening and citation tracking. Studies were included if they reported on patient experiences of assessment or detention under mental health legislation; reported on patients aged 18 years or older; collected data using qualitative methods; and were reported in peer-reviewed journals. Findings were analysed and synthesised using thematic synthesis.

Results: The review included 56 papers. Themes were generally consistent across studies and related to information and involvement in care, the environment and relationships with staff, as well as the impact of detention on feelings of self-worth and emotional state. The emotional impact of detention and views of its appropriateness varied, but a frequent theme was fear and distress during detention, including in relation to the use of force and restraint. Where staff were perceived as striving to form caring and collaborative relationships with patients despite the coercive nature of treatment, and when clear information was delivered, the negative impact of involuntary care seemed to be reduced.

Conclusions: Findings suggest that involuntary in-patient care is often frightening and distressing, but certain factors were identified that can help reduce negative experiences. Coproduction models may be fruitful in developing new ways of working on in-patient wards that provide more voice to patients and staff, and physical and social environments that are more conducive to recovery.

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Patients' experiences of assessment and detention under mental health legislation: systematic review and qualitative meta-synthesis

Background: Forensic psychiatric services provide care for those with mental disorders and offending behaviour. Concerns have been expressed that patients may stay for too long in too high levels of security. The economic burden of these services is high, and they are highly restrictive for patients. There is no agreed standard for ‘long stay’; we defined a length of stay exceeding 5 years in medium secure care, 10 years in high secure care or 15 years in a combination of both settings as long stay.

Objectives: To (1) estimate the number of long-stay patients in secure settings; (2) describe patients’ characteristics, needs and care pathways and the reasons for their prolonged stay; (3) identify patients’ perceptions of their treatment and quality of life; and (4) explore stakeholders’ views on long stay.

Design: A mixed-methods approach, including a cross-sectional survey (on 1 April 2013) of all patients in participating units to identify long-stay patients [work package (WP) 1], file reviews and consultant questionnaires for long-stay patients (WP2), interviews with patients (WP3) and focus groups with other stakeholders (WP4).

Setting: All three high secure hospitals and 23 medium secure units (16 NHS and 9 independent providers) in England.

Participants: Information was gathered on all patients in participating units (WP1), from which 401 long-stay patients were identified (WP2), 40 patients (WP3), 17 international and 31 UK experts were interviewed and three focus groups were held (WP4).

Results: Approximately 23.5% of high secure patients and 18% of medium secure patients were long-stay patients. We estimated that there are currently about 730 forensic long-stay patients in England. The source of a patient’s admission and the current section of the Mental Health Act [Great Britain. Mental Health Act 1983 (as Amended by the Mental Health Act 2007). London: The Stationery Office; 2007] under which they were admitted predicted long-stay status. Long-stay patients had complex pathways, moving ‘around’ between settings rather than moving forward. They were most likely to be detained under a hospital order with restrictions (section 37/41) and to have disturbed backgrounds with previous psychiatric admissions, self-harm and significant offending histories. The most common diagnosis was schizophrenia, but 47% had been diagnosed with personality disorder. Only 50% had current formal psychological therapies. The rates of violent incidents within institutions and seclusion were high, and a large proportion had unsuccessful referrals to less secure settings. Most patients had some contact with their families. We identified five classes of patients within the long-stay sample with different characteristics. Patients differed in their attribution of reasons for long stay (internal/external), outlook (positive/negative), approach (active/passive) and readiness for change. Other countries have successfully developed specific long-stay services; however, UK experts were reluctant to accept the reality of long stay and that the medical model of ‘cure’ does not work with this group.

Limitations: We did not conduct file reviews on non-long-stay patients; therefore, we cannot say which factors differentiate between long-stay patients and non-long-stay patients. 

Conclusions: The number of long-stay patients in England is high, resulting in high resource use. Significant barriers were identified in developing designated long-stay services. Without a national strategy, these issues are likely to remain.

Future work: To compare long-stay patients and non-long-stay patients. To evaluate new service models specifically designed for long-stay patients.

Study registration: The National Institute for Health Research (NIHR) Clinical Research Network Portfolio 129376.

Funding: The NIHR Health Services and Delivery Research programme

A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

Aims and method Recent policy guidelines published by the Department of Health highlight the need to develop gender-sensitive psychiatric services. However, very little is currently known about the specific characteristics and needs of female patients entering acute psychiatric wards, particularly psychiatric intensive care units. This article aims to review the current literature on what is known about this group of patients. PubMed, Embase and PsycINFO were systematically searched using a number of key terms. Results A total of 27 articles were obtained. The findings were divided into four categories: admission characteristics, treatment needs, risk management and outcomes after discharge. Gender differences were found in diagnosis and presentation. Clinical implications The differences observed in the reviewed studies suggest that women may have different assessment and treatment needs, and ultimately, different philosophies of care. A dearth of studies in this area indicates that if services are to develop in line with government policies, more research is needed.

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Women in acute psychiatric units, their characteristics and needs: a review.

https://www.pure.ed.ac.uk/ws/files/41921429/DoyleEtalAVB2017SocialClimate.pdf

Social climate in forensic mental health settings: A systematic review of qualitative studies

BackgroundShared decision-making (SDM) is supposed to position patient and expert knowledge more equal, in which will have an impact on how mental health-care professionals relate to their patients...

https://journals.sagepub.com/doi/pdf/10.1177/2377960817752159

Shared Decision-Making-Balancing Between Power and Responsibility as Mental Health-Care Professionals in a Therapeutic Milieu.

Background: Women in secure setting represent a group for whom gender sensitive treatments are only emergent. Service users are viewed as participants in treatment developments. However, the opinions of forensic patients have, in contrast to other service users, been under researched.Aims: To identify service users' views of the constituents of an effective therapeutic milieu for women in secure settings and to help identify the extent to which services need to be specifically tailored for women.Method: A qualitative service user-led participatory research approach was used. Two focus groups with service users from low and medium secure settings discussed the ingredients of an effective therapeutic milieu based on their experience of gender-specific treatment. Group transcripts were subjected to thematic analysis.Results: Themes identified covered interpersonal relationships; treatment programming; service user empowerment; the ward as a place of safety; and hope for the future. Participants did not highl...

M. Thomas

Papers

Effective therapeutic milieus in secure services for women: the service user perspective.