This book is essentially a report of a research project. The project is a survey of approximately 20% of the patients who had been in one of the special hospitals for a year or more at the time of the study. It concerns 296 patients, 241 men and 55 women. The aim was to provide a demographic, criminological, psychiatric and behavioural description of each patient. Data on each subject were collected from the case notes, an interview with the patient, a nursing representative, the patient's consultant, and lastly the research team made their own separate assessment of each patient's diagnosis, treatment and security needs.While there is a brief account of the administrative and philosophical background against which this study of psychiatric treatment in secure circumstances was conducted, and the method is clearly described, most of the book is taken up by a very detailed account of the findings. There are more than 100 tables of results. This style of presentation is unusual in a book, and indeed would not be commonplace in a scientific paper. Authors of such works tend to be asked to present their work rather more succinctly.The book really reads like the results chapters of a thesis or like a final report to a funding body. As such, it might be expected to be rather poor value for its price of £75.00 and also to be rather dull and repetitive. It is repetitive but I did not find it dull. Subject-matter of this kind cannot be dull. The detailed account of the severity and intractability of the problems presented by these patients will be of interest to psychiatrists with responsibility for the care of those with major psychiatric disorders, and will be essential reading for those involved in planning. While the article is on the whole densely written, with little comment, there are some telling observations, e.g. on page 62: 'It is easy to say that patients do not require maximum security. It is much more difficult to find a placement that meets their extensive therapeutic needs more successfully than their current placement' and on page 66: 'for almost 95% of psychotic patients the clinical team can see no likelihood of improvement over the next 5 years. In other words the question of placement for most of these patients will have to take account of Criminal Behaviour and Mental Health, 7, 95-105 1997 © Whurr Publishers Ltd 95
Within more conventional discourse amongst health-care professionals, 'deliberate self-harm' is largely conceived in pejorative terms. Unlike other so-called 'pathological' behaviour for which the 'sick' are not held wholly responsible, this particular behavioural mosaic carries within its very conception quite different connotations of 'intentionality'. This project constituted a retrospective survey of the phenomenon amongst patients resident within a British special hospital, over a 6-month period, in 1987, prior to the establishment of a unit for disturbed females in November of that same year. It illustrated that the scale, and nature, of the problem was comparable to any of the other much-publicized accounts that have emerged from other custodial establishments. It is the contention, here, that patient characteristics alone are an insufficient explanation for the level of self-harm that prevails and that significant, alternative considerations are available. It is intended that this paper should contribute to the evaluation of the clients' predicament, and the institutional management of their self-harm, within an environment such as a special hospital in the hope that a clearer understanding, and strategy, may be elaborated.
Psychiatric nurses who are key workers or primary nurses within special hospitals are well placed to comment on their patients' needs and the benefits, and shortfalls, of trying to meet these within a maximum-security environment. In this survey, nurse respondents gave information on two groups of special-hospital clients, though they themselves were unaware of any group differentiation. Those who were not seen as requiring continued care within maximum security, as judged by other team investigators, were conceptualized by the researcher as 'leavers'. The survey revealed that in relation to those continuing to require maximum security--the 'stayers'--'leavers' retained exceptionally high levels of deficits related to their potential for community reintegration. Deficits in cognitive, social and life skills were as prevalent among those considered to need lower levels of security, and closer contact with the community, as those remaining within the special-hospital service. It also became clear that the effective management of special-hospital residents demanded a necessary conflict of interests: client-centred flexibility within the constraints of secure custody. There were also inconsistent features between the hospitals, as was shown in the differential provision of parole for patients. Only the survey sample from Broadmoor had access to this important resource. The conclusion is that, with the special hospitals' unequivocal commitment to maintain security, not all treatment and security needs of patients are appropriately met. Certain opportunities should, perhaps, be provided within new, alternative facilities.
This article attempts to define and describe self-mutilation and offers an introductory view of its nursing management. Most importantly it enjoins nurses to self-consciously appraise their practice in this area and develop an unconditional acceptance of the validity of such unconventional behaviour.
Traditionally, supervision among health professionals was a somewhat esoteric forum for a privileged few practitioners who would examine clinical case material in order to elicit and improve their therapeutic skills. Today's professional climate demands a supervisory process, beyond such a purist model, which examines virtually all areas of professional activity. This article does not argue for or against the retention of a purist model of clinical supervision but examines some of the hazards of an alternative framework.
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