Reith Lectures: Gwen Adshead - 4 Questions about Violence

Individual
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      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :   POLITICAL 

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Is there such a thing as Evil?	What is the relationship between trauma and violence?
Is violence normal^?	Can we change violent minds?

BBC Radio 4: Lecture 1 - Is there such a thing as Evil?

^'normal' -isation.

A citation of Hodges' model IN "Excellence in forensic psychiatry services..."

McLaughlin, P., Brady, P., Carabellese, F., Carabellese, F., Parente, L., Uhrskov Sorensen, L., . . . Kennedy, H. (2023). Excellence in forensic psychiatry services: International survey of qualities and correlates. BJPsych Open, 9(6), E193. doi:10.1192/bjo.2023.578

Background

Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development.

Aims

To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security.

Method

A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire.

Results

Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score.

Conclusions

Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

<>

As the second citation  for Hodges' model from ResearchGate this month, I hope this is a trend. If I can assist any researchers, please let me know. 

While welcome, I'm not interested in being a co-author; if I can help your understanding and application of Hodges' model this is what counts.

Delighted to add McLaughlin et al. to the bibliography.

Many thanks to Harry G. Kennedy and team.

Book - "Criminal: How Our Prisons Are Failing Us All"

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GROUP

LIFE CHANCES LIFE SKILLS (mental) health learning disability acquired brain injury post traumatic disorder ...	Personalised medicine: "If you use substance 'x' or this class of drugs, then there is a 'y' probability that 'z' will happen." ... ... future ...? Traumatic Brain Injury Screening
Collective Life Chances Society ...? Life Skills 'fit' for 21st C. EDUCATION EDUCATION EDUCATION Pre-School! Pre-School!! Pre-School!!! equity Social Justice

I heard Angela Kirwin being interviewed about her book on Times Radio earlier today.

Prisons have changed. Haven't they? Prison reform 'happened'. It is a fact of history after all - Elizabeth Fry et al.? At least according to Social and Economic History GCSE in the 1970s.

Mental asylums changed. They have closed. 

Prisons have (apparently) changed markedly since the 19th - 20th century.

With the 'asylum system' of institutionalised 'care' they share a few things in common..

The 'estate' was Victorian (Winwick Hospital is long gone - leaking, cockroach infested, red carpet at the main entrance - with frequent reference to custodial care and how to change - challenge this.).

Now community care, or care in the community (take your pick) holds sway. 

We are a fifth of the way into the 21st century - can you believe it?

Decades from now will they look at the prison system now and see it as archaic as we see the 'lunatic asylums' pre-20th century (terrible for much of the 20th in fact), and yet we often forget the rationale for their original establishment?

From a mental health perspective what do the social determinants (of health) mean?

Mechanistically speaking, it seems determinism is very much doing its work - too many enter the political system and it's not the one - to represent the community in Parliament.

I've viewed Hodges' model as a resource to highlight parity of esteem at an individual level (physical AND mental health).

Increasing in relevance, I can see its utility in the pursuit of collective parity of esteem.

The most troubling commonality here: care in the community is unfinished. It sort of got started. It fledged, but never took flight.

There were many compassionate, caring, professional staff in the asylums. Exceptional role models. They saw the theory - practice gap. Pointing it out. Aptitude - Attitude. They were the heart in the Victorian shell, even as science struggled (and still does) with the ghost in the machine.

Historically speaking the ‘workhouse’ is closer than we think.

The UK rightly lauds its National Health Service, created in 1948. The Poor Law was also abolished in 1948 (Hillam and Bone, 1999).

Prisons, mental health care, preventive health, health education and community care .. so much still to do.

This sounds an interesting new book too! :-)

Hillam, Christine., and J.M. Bone. THE POOR LAW AND AFTER: workhouse hospitals and public welfare. Liverpool: Liverpool Medical History Society, 1999. ISSN 1364-999x

A State of Fear - Dangerous Minds

Books ...

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SOCIOLOGY : POLITICAL

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group

Dangerous Minds
	A State of Fear

My source:

Ditum, S. (2021) An eye-opening journey into dangerous minds, Saturday Review, The Times, June 12, p.14.

Aaronovitch, DF. (2021) A covidiot's guide to paranoia, Saturday Review, The Times, June 12, p.15.

Images:

https://www.waterstones.com/book/dangerous-minds/dr-taj-nathan//9781529392913

https://blackwells.co.uk/bookshop/product/A-State-of-Fear-by-Laura-Dodsworth-author/9781780667201

RCGP Secure Environments Group 8th Health & Justice Summit: Communities of Practice in Secure Care

 

October 12-13, 2021 

Crowne Plaza Newcastle, Stephenson Quarter, Hawthorn Square, Forth Street, Newcastle upon Tyne, NE1 3SA

To address the complex health and social care needs of people resident in custodial settings, effective partnership work is required not only between health partners and the prison service but also with health and justice policymakers. PHE 2018-2019 Annual Health & Justice Review

Prisons and other secure settings can provide a unique opportunity to address a wide variety of health needs. These can range from infectious diseases such as HIV, hepatitis and tuberculosis as well as mental health issues, substance misuse disorders and long-term conditions.

‘Prison Health’ should be considered ‘Public Health’ as the vast majority of prisoners return to the community, and the investment in healthcare in these settings provides a wider overall benefit. The mission of this Summit is to share models of good practice, innovations in healthcare delivery and advances in treatment in order to best utilise the opportunity we have for our patients and for our society.

Following on from the highly successful 7th RCGP Secure environments summit in November 2019, and the 1st Virtual RCGP Health and Justice Summit in November 2020 the RCGP Secure Environments Group & Convenzis are very excited to share details of the 8th Annual RCGP Secure Environments Summit taking place on Tuesday the 12th and Wednesday 13th of October 2021 in central Newcastle.

This as always is ran with various key partners, this includes: Ethypharm, Mountain Healthcare, Spectrum Healthcare, Nottinghamshire Healthcare, Ashworth Hospital, Mersey Care, Merck Sharp & Dohme, Inclusion (Part of Midlands Partnership NHS Foundation Trust), Oxford Immunotec, SLD Training, Essex Partnerships, Public Health Wales and West London NHS Trust.

In recognition of the significant progress and collective contribution of our attendees, partners and sponsors, we are titling the 8th Summit:

Compassion, collaboration and continuity through the gate

We are now considering the next the next decade, and we look forward to receiving content on the following themes including:

• Clinical practice and teamwork
• Guidance, Research and analysis
• Innovation and technology
• Leadership and culture

As in previous years, the event will be held in partnership with a range of sector-leading strategic partners, more updates on this year’s partners will be disclosed soon.

Registration for the day is now open, and we look forward to seeing some familiar faces and new delegates across both days.

===

Having attended previously (in person) the knowledge and insights gained have proved invaluable working in Adult Community Mental Health Team, Early Intervention and START - Specialist Triage Assessment Referral and Treatment Team. So if you work in prison health, secure, forensic and related health, social and community services the potential gains should be even greater. The time invested also contributed to my revalidation. I plan to attend and possibly present Hodges' model.

6th Health and Justice Summit: safety with continuity i

Whilst I am using Hodges' model (h2cm) to 

reflect on the 1st day of this event no 

endorsement should be inferred...

My exposure to forensic - prison nursing is trivial in contrast to the emotions, policy, issues, contention and hence importance that just the word 'prison' provokes. This statement can can be summarised in one point that was made this afternoon. That is, how any duty of care to prisoners must be balanced with the public's perception* of what should and should not be done. The word important is a moot one when the the aim is to stress the risk of being forgotten. Prison health is surely in danger of being lost within the Russian doll of mental health. Mental health that was (still is?) also the Cinderella service of health care? I refer to history in celebration since while there was mention of pressure of staff, long shifts, not feeling valued, heightened risk there was no shroud waving. Attending today was refreshing in the expressed passion, pride and enthusiasm that I heard; even while some of slides showing older and newer prison interiors and rooms - cells - were sobering (as they are supposed to be*).

My forensic experience is limited to time as a student nurse, making numbers up, on Ward 17 at Winwick. Visiting a medium secure unit to liaise and 'communicate' about the National Programme for IT and co-writing a paper on the Hodges' model in forensic settings. I have long wondered about the model being used educationally with groups in primary care, looking at stress and vulnerability, resilience, staying well ... and perhaps more selectively with this population. A strength here is the model's use: explicit - explained and shared or used implicitly guiding the 'teacher' or (more properly?) facilitator. We invest in 'life story' interventions for people with dementia. What about the 'life stories' of prisoners? It not the matter of their life story, but their lack of understanding of that story? What tools are there to help make sense of their 'health career' the life chances encountered and experienced in their lives?

The keynotes this morning emphasised the facts and figures of the physical health of prisoners with severe mental illnesses [SMI] and the work of Equally Well. Amid many health problems the focus is upon obesity and smoking cessation.

Dr Alan Cohen from Equally Well, reported on surveys and analysis of national QOF data comparing the prevalence of people with SMI in ten long-term conditions. As per the summit website: “The physical health of those with a severe mental illness is held up as one of the last significant health inequalities. This presentation will explore some of the data that underpins that inequality. This will describe how it can be used to enhance services, through the development of a national learning network. Equally Well.”

There are plans for an evaluation phase of the work and other audits. Dr Cohen almost had me ask a question, with regards to some people having three health problems across least and most deprived populations. How can this be explained?

The second keynote c/o Stephen Watkins confirmed (for me) the history of mental health beds (below) and how ongoing studies and graphs can illustrate processes across prisons. How long do prisoners have to wait for mental health transfer and remission? Diagnoses, across gender, ethnicity and outcomes were also presented.

Today @NHSBenchmarking presented results from our national review of prison mental health transfers and remission. Findings include delays in the pathway in some areas, over representation of BAME groups, variations in prisoner location, & low remission rates

— Stephen Watkins (@SteveWatkinsNHS) January 31, 2019

Stephen Watkins NHS Benchmarking

Stephen Watkins NHS Benchmarking

I will post soon on the workshops I attended. As is often found with satellite sessions the choice is difficult at times.

Tomorrow I must ask someone about 'social care' input. I have had cause to liaise with palliative care and local hospices recently, dementia and cancers. A question concerning a very literal form of 'in-reach' was asked for me. With four people to follow up with tomorrow, great organisation and day 2 to follow it will be a 'breeze' getting out of bed - even if that breeze is chilly...

individual

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humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

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group

	primary care
::: Society: SOCIAL (care): Family interface :::::: :::	Prison Health --------------  INTERFACE ------------- Prison Service

individual

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INTERPERSONAL : SCIENCES

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SOCIOLOGY : POLITICAL

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group

personal autonomy	OPEN door CLOSED door Mechanistic: 'Lock' 'Up' Ability to step on the grass
Family involement (What do they know?)	prison experience in-validates the 'person' narrows - restrains - autonomy

Reflective exercises: define 'continuity' as per Hodges' model?

What is the bandwidth of autonomy across the domains of Hodges' model?

Contrast the return to society of prisoners and service veterans?

RCGP’s 6th Health & Justice Summit: Safety through Continuity

Perhaps I will see you in Liverpool, UK later this week? 
I will be taking notes and look forward to reporting here.

A 2-day summit organised by the RCGP Secure Environments Group in partnership with, Broadmoor, Ashworth, and Rampton high secure hospitals, Spectrum, Care UK, NHS England, Martindale Pharma, Nottinghamshire Healthcare NHS Foundation Trust, Betsi Cadwaladr University Health Board, HMP Berwyn, West London NHS Trust, Mersey Care NHS Trust.

Following on from our successful event in Glasgow in 2017, we are now focusing on ‘Continuity of Care – safety through continuity’ as this year’s theme. We recognise the need to embolden the links between primary and secondary care for people resident in secure settings and are looking to showcase examples of good practice on how we can improve on care transition to the community.

The first day will broadly address physical health in secure mental health environments, and the second day will address the health needs of people in other custodial environments such as prisons, immigration removal centres and YOI’s.

If you are registered as a delegate for the event, please register which workshop you would like to attend via the link below:

www.convenzis.co.uk/6th-health-justice-summit-safety-through-continuity-registration/

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n.b. There are two papers listed in the bibliography (please see the sidebar) that show how h2cm is applicable to this specialist field.

Forensic Architecture (Care Forensics?)

individual

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	forensic adjective: forensic relating to or denoting the application of scientific methods and techniques to the investigation of crime. "forensic evidence" relating to courts of law. noun plural noun: forensics; noun: forensic 1. scientific tests or techniques used in connection with the detection of crime.

See also:
ICA London, 7 March - 6 May, Counter Investigations: Forensic Architecture.

My source:
Rowan Moore, Forensic Architecture: detail behind the devilry. The Observer Sun 25 Feb 2018

FROM: the couch TO: the courtroom | c/o BBC Radio 4

INDIVIDUAL

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humanistic --------------------------------------- mechanistic 
 subjective --------------------------------------- objective

SOCIOLOGY : POLITICAL

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Inc. community - GROUP - the State  

Pain Individual   Vulnerability Psychological Trauma - Shock Therapy    Recovery     Closure motivation? - Catharsis - outcome? Psychoanalysts uncover truth Hidden Psychical Material Emotion  PTSD Forensic Psychiatry - Experts PURPOSES	Pain Events - Time True - Memories - False Accounts - Re-Living Rationality   Logic (Objective) Truth Analytic processes Physical Trauma - Shock PROCESS
From: War  Psychological  To: Domestic Trauma  'trauma' as a human and medical idea Reparation (psychological AND legal)? Public expectations Community Public Values PRACTICE	Magistrates uncover truth Law  Courts  Justice Adversarial System Closure - Compensation Victims of crime Psychiatric Reports Unconscious Responsibility POLICY

From the Couch to the Courtroom BBC Radio 4: 17 April 2017
Helena Kennedy QC asks if our legal system is becoming too influenced by the culture of psychotherapy.

The potential of Hodges' model as a generic conceptual framework has always been demonstrable through the distinction between the individual and the State. In this Radio 4 programme it is well worth also considering the diametric (potential) opposition of the person and their mental health (and therefore their physical state) as in applying the law in all aspects of healthcare and human welfare.

There are two references in the bibliography (sidebar) on the role of Hodges' model in forensic contexts.

Rooms with a View (and without) ...

There are times ... when to understand body, mind - and the things that people do to themselves and others - we need to consider the four care domains.

Then we can appeal to the fifth. ...

'Problem patients?' 1 - Wimps and space to care

I responded to a mail list discussion around 'problem patients' which began with the following main points:

• a relatively new nurse
• surprise that a significant minority of (my) patients are pathological wimps;
• even prior to seeing them they can often easily be spotted by examining their medical records;
• for example, I frequently notice that wimps have an obscene (and often downright odd) amount of special meal requests;
• current nursing philosophy encourages nurses to be endlessly supportive of wimps. i.e. to follow the often demonstrably wrong idea that "the patient is always right.";
• IMO nurses who claim they benefit such patients using the current model of appeasement based care are co-dependent personality types who enjoy feeling needed more than they enjoy actually helping people.

My first response is copied below with some additional points a further post will follow:

Patients are always a challenge in that they come in lots of 'varieties'. This is why we recognise the need for individualised, person-centred care. One variety is physical trauma laden to which the full-complement of the multidisciplinary team must respond. These patients and *their* crises bring out the best in us in terms of the skills and knowledge, team work they force us to exercise.

Among the plethora of other varieties there are those who are viewed as 'problems'. Like the Pepsi ad of decades ago they are variously and pejoratively described as -

multiattendin, attentionseekin, patiencesappin, bedblockin,
buzzabuzz-buzzin, heartsinkin, timewastin,
symptomfindin, carenumbin
.... patients!

If I receive referral information or heads up information on diagnosis of a 'tci' (to come in) that suggests the above is on the way, has arrived or worse "is on your caseload" - what do I do?

• Brace myself for impact?
• Go off sick (suffering loss of job satisfaction)?
• Become purely task or disease focussed, give up on effecting +ve change and improved outcome?
• Share collective anecdotes in the office - staff changing as a way to cope, de-stress, inject some humour?

OR do I -

• Avoid labelling them, or use these labels in a re-constructive way?
• Ask why are they 'who' they are?
• Gaze into their 'life history' and help them learn from it?
• Refuse to make gross assumptions, even based on previous experience with client - patient?
• Look at the individual wholistically - socially, educationally, behaviourally?
• Believe you can still make a difference (be the fly-half you can be and play ball)?
• Side step being tripped by foibles, behaviours and blatant displays of -ve obstructive ...... attitude that offend 'me'?
• Enter their space and do my utmost to find room for manoeuvre (this is the hardest test)?
• Speak to my manager(s) very tersely about protecting 'me' as a scarce resource and shout "OK where the hell is the gate keeper!"
• Or, as a nurse do you boldly go and seek out new strengths and new opportunities in the same way that Kirk, McCoy, Spock et al. (2264) go and seek New Life, New Civilizations...?

You may have an impossible lock to pick (in its most severe form this has become known as 'personality disorder'), but the nursing challenge is there in all its personal and professional glory. Address this personal - under-the-skin - slant - seek supervision. Be aware of the pit that some people fall into. The trap for some people with life chances they may have completely:

missed, never had, were stolen, denied,
took for granted, spurned,
totally - wasted.

Around the pit is the zone of judgement, but beware it is a singularity (no perspective) and very slippery.

• Otherwise go do your job: Nurse.

Nurse Philosophy list

Reference:

Kirk, McCoy, Spock et al. (2264) The Caring Imperative, To Boldly Go..., Four Quadrant Galactic Care Journal, Integrated Galactic Care Publishing Inc. itess-cube: 1701u-care4mesafelyandnicely