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Abstract High secure services treat patients who may have very complex clinical needs under conditions of security. Until very recently such services were run and managed on the periphery of the structures and accountability arrangements put in place for the rest of the NHS, becoming isolated from modern thinking and evidence‐based therapeutic practice. A high percentage of patients in the high secure system were assessed as no longer requiring that level of security.Following an inquiry at Ashworth hospital which reported in 1999, steps were taken to bring these services into the mainstream of the NHS, to decentralise further the commissioning and performance management and to develop the capacity and capability to enable discharge of patients to lower levels of security. New partnerships and new relationships have resulted in an NHS Plan target of 400 patients discharged from high security.The inclusion of high security services within Health & Offender Partnerships creates a framework for managing proposed and ongoing changes. High security services are a necessary part of our mental health system and should be valued and developed. This paper outlines how quality improvements will be enabled and embedded.

The purpose of this paper is to derive from an on-going, innovative, project to explore the concept, and application, of “recovery” in the care and clinical management of patients detained in one UK high-security hospital.

Utilising a qualitative, action research, methodology the aim was to involve forensic mental health nurses in a collaborative, client-centred approach to identification and resolution of dilemmas in the process of planning care for offender-patients.

In this context the authors identify constraints and contradictions involved in employing recovery principles in institutions critics refer to as part of the disciplinary apparatus of psychiatric and social control; where the taken for granted lives, and relations, of an incarcerated population are measured by the calendar, not the clock.

Protective practices remain highly relevant in high-secure practice. Safety, an important value for all can by and large be achieved through recovery approaches. The humanistic elements of recovery can offer up safe and useful methods of deploying the mental health nurse on the ward. Many nurses have the prerequisite approach but there remains a wide scope to enhance those skills. Many see the approach as axiomatic though nurse education often prepares nurses with a biomedical view of the ward.

Currently, philosophical tenets of recovery are enshrined in contemporary health policy and professional directives but, as yet, have not been translated into high-secure settings. Drawing on preliminary findings, attention is given to the value of socially situated approaches in challenging historic dominance of a medical model.

It is concluded that recovery could be a forerunner of reforms necessary for the continued relevance of high-secure care into the twenty-first century.

This research is located in high-secure setting. The social situation is marked by the extent of the isolation involved. A value is in this situation. First it is akin to the isolation of the tribe utilised by many anthropologists for their ability to adopt the “social laboratory” status to test out theories of behaviour in industrial society. The authors urge others to utilise this research in this way. Second, the situation represents the locus of so many of societies dilemmas, paradoxes and fears that moral issues morph from what is the mundane in wider society. In this way humanistic approaches are tested via action research with nurses in some rigouous ways.

The purpose of this paper is to describe service users’ perspectives on the difference between high secure long-stay forensic psychiatric services in the Netherlands and high secure forensic psychiatric care in England. These perspectives are relevant in considering the benefits of a similar long-stay service in England.

A current in-patient detained in a high secure hospital in England and other mental health service users and carers with experience in forensic-psychiatric settings were asked to watch a documentary on a Dutch high secure long-stay service. Then they were invited to make comparisons between this service and high secure care in England. These perspectives were gained in the context of their membership of the Service User Reference Group of an externally funded study on long-stay in forensic-psychiatric settings in England.

The small group of participants highlighted the importance of relational security, meaningful occupation, autonomy, positive therapeutic relationships with staff and a homely environment for those with lengthy admissions and perceived these to be better met in the Dutch service. These factors might contribute to improved quality of life that services should strive to achieve, especially for those with prolonged admissions.

Perspectives of service users with lived experience of long-stay in forensic settings are important in informing service developments. Lessons can be learnt from initiatives to improve the quality of life in long-stay services in other countries and consideration be given on how to best manage this unique group.

To the authors’ knowledge this is the first study asking service users about their view on forensic services in other countries. The findings suggest that service users have valuable contributions to make to aid service developments and should be involved in similar such exercises in the future.

The “outcomes revolution” in healthcare has yet to impact strongly on secure intellectual disability (ID) services in the UK. The purpose of this paper is to review the service-level outcome studies that exist for this population, and to explore some of the challenges of conducting such research. It further describes some illustrative routine outcome data from the National High Secure Learning Disability Service.

Routinely collected outcome measures (length of stay; violent incidents; Emotional Problem Scale (EPS) Behaviour Rating Scale and EPS Self-Report Inventory) were analysed for two overlapping cohorts of patients resident in the high-secure service between 2008 and 2013.

The median length of stay of those discharged during the study period (n=27) was around 9.9 years (range one to 40 years). A significant proportion (25 per cent) of discharges resulted in an eventual return to high security. There did not appear to be a treatment effect over two to three years using staff-rated global clinical measures, but patient-rated clinical measures did reduce. Violent incidents also reduced significantly over a longer period of four years in treatment.

There are identified challenges to research design and outcome measurement which need to be addressed in any future cross-service studies.

There are relatively few published outcome studies from forensic ID services. None of the studies have used clinical measures of changes or patient-rated outcome measures.

The authors offer up an example of recovery in a high-secure setting. The purpose of this paper is to highlight how an individual account of recovery and the academic literature offer up related and important perspectives that have serious clinical utility.

First the context is outlined. The biographical account is then deployed to describe the experience of being detained in an English high-secure facility using recovery as a framework for elucidation. This is often referred to in recovery as accessing the views of the “expert by experience”. In a thematic way this author details his understanding of recovery, what worked and what did not. This account is then contrasted with the academic literature and research at the same site. Social anthropology acts as the theoretical backdrop. This debate informs some clinical implications and issues for practice.

Recovery can be a highly relevant concept in a high-secure context. The author found that the biographical account of the “patient” can offer the observer some insights for practice. The authors noted that the collective themes of previous research where consistent to this account. The authors found the use of recovery principles helped the person receiving care fulfil his potential. Nevertheless, forensic recovery implies a forensic past. This complicates recovery and placed limits on the own use of the principles.

The authors argue that recovery is highly relevant to the context and particularly important to people who are often stigmatized for multiple reasons including their, “illness”, their “crime”, and their social situation. The paper implies that forensic recovery is more problematic than mainstream recovery. Key events mark out issues.

This is the first co-produced paper surrounding recovery in high-secure care.

There is a dearth of research exploring pathways to episodes of deliberate self‐harm (DSH) within mentally ill men in high‐secure hospitals. This study aims to explore pathway(s) to episodes of self‐harm experienced by this group over the course of their life.

A total of seven men with a history of repetitive DSH participated in audio‐taped semi‐structured interviews. Transcribed interviews were analysed using grounded theory methods.

Two pathways to episodes of DSH emerged and were termed: the relief, and the response to mental health problems pathways. Participation within a dyadic suicide pact emerged as an unexpected theme.

There were a number of limitations within this study. Participants did not describe DSH episodes, which occurred within the high‐secure hospital and it was unclear as to the stage of their illness or whether co‐morbid difficulties were present during the episodes of DSH. Further research is required to substantiate the two pathways to episodes of DSH found within this study.

The present study offers a theoretical framework for clinicians working with mentally ill men within high‐secure hospitals, who have a history of DSH and identifies the need to carefully assess each individual episode of DSH.

This study is the first to explore pathways to episodes of self‐harm as experienced by mentally ill men within a high‐secure hospital by interviewing patients directly.

The evidence base for what works with forensic patients in high-security inpatient settings has typically focused on outcome research and not included clinical expertise from practice-based experience, which is an important facet of evidence-based practice. The purpose of this paper is to establish whether experts with clinical and/or research experience in this setting could reach consensus on elements of high-security hospital services that would be essential to the rehabilitation of forensic patients.

A three-round Delphi survey was conducted to achieve this aim. Experts were invited to rate agreement with elements of practice and interventions derived from existing research evidence and patient perspectives on what worked. Experts were also invited to propose elements of hospital treatment based on their individual knowledge and experience.

In the first round 54 experts reached consensus on 27 (out of 39) elements that included physical (e.g. use of CCTV), procedural (e.g. managing restricted items) and relational practices (e.g. promoting therapeutic alliances), and to a lesser extent-specific medical, psychological and social interventions. In total, 16 additional elements were also proposed by experts. In round 2 experts (n=45) were unable to reach a consensus on how essential each of the described practices were. In round 3 (n=35), where group consensus feedback from round 2 was provided, consensus was still not reached.

Patient case complexity, interventions with overlapping outcomes and a chequered evidence base history for this population are offered as explanations for this finding alongside limitations with the Delphi method.

Based on the consensus for essential elements derived from research evidence and patient experience, high-secure hospital services might consider those practices and interventions that experts agreed were therapeutic options for reducing risk of offending, improving interpersonal skills and therapeutic interactions with patients, and mental health restoration.

The study triangulates what works research evidence from this type of forensic setting and is the first to use a Delphi survey in an attempt to collate this information.

Dialectical behaviour therapy (DBT) (Linehan, 1993) is a comprehensive psychological treatment that was first developed for suicidal individuals with a diagnosis of borderline personality disorder. The model has successfully been used to address violence and aggression in a forensic setting (Evershed et al, 2003). The National High Secure Learning Disability Service (NHSLDS) piloted an adapted DBT programme suitable for men with mild learning/intellectual disabilities in 2004, and the programme has been developed over a period of six years. This paper describes the rationale for development of the programme, how the programme has evolved, the major modifications to mainstream DBT that it incorporates, and the challenges that remain.

Discharge preparation from high to medium levels of security has received little attention from researchers to date, but is a critical stage in a patient's pathway. This paper aims to capture the perspectives of patients who are preparing to move on from high to medium security.

Nine patients who were in the “discharge preparation” stage of their pathway were interviewed to capture their perspectives on the process. Interview transcripts were analysed using thematic analysis.

Nine themes were identified as representing the patient interviews: trust and support, feeling empowered, journey of self-acceptance, skilling-up, getting to know the Medium Secure Unit (MSU), feeling disempowered and unvalued, issues with the system, anxiety about endings, and stigma and society.

This paper gives voice to patients across clinical directorates at a UK high secure hospital regarding their perspectives on what has helped and hindered their discharge preparation. It presents some new findings, and recommended good practice, which should be of use to clinicians and managers who wish to enhance discharge preparation interventions for patients within high secure services.

This paper seeks to explain the reasons for use of a therapeutic community for personality disorder in a high secure intellectual disability service.

The paper describes the rationale for, and early experiences of, a therapeutic community intervention for people with mild intellectual disability and personality disorder in a high secure setting.

No empirical findings are reported. Evaluation is being undertaken and will be reported in due course.

The therapeutic community approach has not been applied in forensic intellectual disability before, and this paper therefore describes an original and, in many ways, radical intervention.