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Title: Forensic service users' experiences of adversity and psychological interventions in secure care
Author: Cartwright, Jessica
ISNI:       0000 0004 9354 6044
Awarding Body: Cardiff University
Current Institution: Cardiff University
Date of Award: 2020
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The present thesis recognises that capturing service users’ experiences can add insightful information to research and clinical practice. This thesis acknowledges that this collaborative approach can be often underrepresented and particularly in forensic psychiatric settings, where care and treatment are often determined by legal requirements, received on an involuntary basis and where coercive measures may be used. This thesis offers two papers which explored forensic service users’ perspectives. The first paper considered how forensic service users may be expected to engage in psychological treatments as part of their care and treatment plans, and consequently, individuals may comply without feeling personally motivated or invested. Most of the evidence for psychological interventions in forensic psychiatric care is based on quantitative data, which provides tentative and limited evidence to support its effectiveness. The first paper reviewed forensic service users’ perspectives on such interventions, and aimed to inform clinicians and services providing such treatments. Paper one followed a meta-ethnography approach to synthesise the findings from 11 qualitative papers. This synthesis described six super-ordinate themes that reflect which aspects of psychological interventions service users found both valuable and not so valuable. The synthesis demonstrated that many individuals comply with these treatments as they believe this is expected of them, perhaps because it is the only way to move towards discharge, or because they have no other choice. Whilst a collaborative approach was recognised as valuable, this can be a challenge to establish in forensic practice and a good therapeutic relationship is pivotal. The results indicated that interventions should be tailored to each individuals’ abilities and that many prefer a gradual approach to ease them into the therapeutic process. Service users reported positive changes from engaging in psychological interventions, including increased emotional regulatory skills, 6 interpersonal skills and personal growth, which enabled them to think more positively about the future. It is recommended that these findings should be used in conjunction with the quantitative evidence available and further research is still needed in this area. The second paper also considered service users’ perspectives, but from a trauma-informed approach. It recognised that forensic service users have often had experiences of adversity and trauma throughout their lives, and research increasingly shows a strong relationship between these experiences, mental health difficulties and offending behaviours. Services are encouraged to adopt a collaborative stance, however, the literature in this area lacks forensic service users’ perspectives. Paper two aimed to address this through interviewing forensic service users about their past adverse experiences and how they make sense of these, particularly in relation to their detention in secure care. This paper captured the voices of eight service users, six of whom are male, detained in medium and low secure wards. Four super-ordinate themes are discussed from an interpretative phenomenological analysis (IPA) and relate to: service users’ experiences of living amongst adversity; managing these adversities throughout their lives; relating their pasts to their detention in secure care; and how the past still impacts them in the present. Individuals described previously feeling isolated and let down by others, and therefore, they used destructive ways to internalise and externalise their distress. There were differences between how individuals related these past experiences to their detention, with some individuals being more aware of this relationship than others. It seemed that individuals’ insight to this relationship was part of a process, which was facilitated by staff input. Service users also tended to use avoidant strategies to cope with their pasts and this was evident in some of the interviews. This paper related these findings to attachment theory from a developmental trauma perspective and proposed the adoption of trauma-informed care in forensic services. 7 Some aspects of paper one and paper two can be related. For instance, they both acknowledged that service users have interpersonal difficulties and that services can adapt their approaches to minimise the impact of these and to enhance trusting and collaborative relationships. Although limitations of each paper are acknowledged, they both provided clinical implications for forensic psychiatric services. Paper one provided implications for clinicians offering psychological interventions and also for the wider systems, as the importance of collaboration, positive relationships and transparent communication can be considered necessary throughout the services. Paper two also provided implications for service delivery and supports the notion of trauma informed care. It highlighted that staff should be aware of the impact and consequences of adverse experiences, for both the service users and for themselves when supporting service users. It also referred to the psychological interventions discussed in paper one, which acknowledge the impact of past adverse experiences. Future research is recommended for both papers. Both papers have been written in line with the standards of the Journal of Forensic Psychiatry and Psychology but as per doctorate guidelines, a word limit of 8000 is used for each (Appendix A).
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (D.Clin.Psy.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: BF Psychology