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The evidence base for 'what works' for patients detained in high secure hospitals has predominantly been established from a clinical perspective, with the voices of those at the centre of care, the expert by experience, absent. Neglecting this voice renders an important source of information for evidence-based practice inaccessible to outcome evaluators. Twelve high secure patients considered 'ready' to be discharged were interviewed to explore what in their view had helped or hindered their progress to this stage. Thematic analysis steps were applied to interviews and eight themes were generated that represented valued elements of high security: temporary suspension of responsibility, collaboration in care, learning from others, supportive alliances, specific interventions (medical and psy-chotherapeutic), a safe environment and opportunities for work. Narratives demonstrated the complementary and unique contribution of the patient experience in informing 'what works', and are discussed alongside existing theories relevant to promoting clinical change and risk reduction.

Purpose. Further to evidence of the successful application of cognitive skills programmes with offenders in HM prison service, the Enhanced Thinking Skills (ETS) training course is now delivered in various secure forensic hospitals, and its usefulness with an offender patient population merits examination. Our aim was to evaluate the impact of ETS using measures designed to capture change in key areas targeted by the course, and a more global measure of mental well-being.Methods. Offender patients (N ¼ 83) referred for ETS between 2001 and 2006 via a wider groupwork service within a high security hospital were administered questionnaires before and after the training course, which was minimally adjusted to meet the needs of the patient population. Attendance rates, including 'drop-out' (completion of 10 or less sessions) were recorded. Demographics by subgroup (completers vs. non-completers), and the clinical significance of any changes endorsed by participants post-group were examined.Results. ETS completers were significantly more likely than non-completers to endorse changes in thinking style (e.g. a reduction in post-course scores). Significant differences were observed at both the group and individual level in the direction of less externalization of blame, a slight increase in tolerance of frustration, an increase in social conformity, and improvement in critical reasoning skills. Furthermore there was a reduction in the endorsement of aggressive solutions to social problems.Conclusions. These findings demonstrate a significant short-term impact of the course for mentally disordered offenders with regards change in aspects of their thinking style and enhancement of their social problem solving skills. This profile lends some support to the provision of ETS within secure hospital settings.

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High secure forensic inpatient hospitals serve important functions in the detention and rehabilitation of people with serious mental health needs who present as a risk to society.Establishing whether services are effective in restoring mental health and reducing risk is an important task, but one that has not been systematically undertaken. A systematic review of outcome evidence from this setting was therefore conducted to establish its scope and quality.Evidence was found from twenty-two studies for nine different interventions targeting multiple and overlapping outcomes, which included recidivism, mental health, aggression, social functioning and quality of life. Studies were commonly assessed as being at a potentially high risk of bias from validity threats. The 'best' available evidence was for medication, psychoeducation and third-wave cognitive-behavioural interventions. Clinical implications are tentatively offered given the narrow focus of the review on high security. Directions for the high secure services research agenda are more definitively proposed.

SummaryViolence between people is a complex social phenomenon involving both social and individual psychological variables. Prevention of violence includes attention to risk factors for violence; but also the provision of interventions for those who have been violent to others. This article explores the evidence that failures of the mentalising process are a risk factor for acts of violence, especially in mental health service users; and describes the implementation of potential therapeutic programmes that seek to improve mentalising in individuals who pose a risk of serious violence to others.

Purpose – 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. Design/methodology/approach – 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. Findings – 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. Research limitations/implications – 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. Practical implications – 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. Originality/value – 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.