Impact case study database

Three core strands capture the SAIP impact:

1. Therapeutic intervention and professional training

It had been recognised by clinicians that the existing literature “…failed to address the specific needs…” of high-risk patients with long standing histories of severe mental illness and trauma [B]. FRG developed a therapy programme for perpetrators (Life Minus Violence Enhanced – LMV-E; Ireland J.L., Ireland, C. A) based on the following FRG research findings:

• Importance of treating aggression motivation and not typology [6];

• Need to capture a wide range of emotions in high-risk populations [3, 6];

• Role of hostile attribution and aggravating factors (e.g. lack of sleep) [6];

• Need to address implicit processing [4].

Implemented continuously across the impact period, these elements were new to aggression intervention. FRG acquired an NHS R&D grant for its evaluation, which demonstrated clinical gains [1]. Since 2013, LMV-E has been delivered to 60 high risk violent patients in the Mersey Care NHS Foundation Trust [B], with 90% consequently progressing positively. LMV-E has been singled out by the patient care teams who reported “…marked improvements in the patients who have attended the intervention…” and as enabling the progress of patients from high security to medium security [B]. LMV is now the preferred aggression intervention procedure across the Youth Offender Prison Estate [A].

Since August 2013 those using LMV-E include Birmingham Solihull Trust, Ty Llywelyn Medium Secure Hospital, Primrose Unit, HMP Foston Hall, Newton Lodge Hospital, Cairstairs, Rainsbrook Secure Training Centre, Cygnet, Priory, Elysium, Cheswold Park Hospital, Coastal Child and Adult Therapeutic Services (CCATS) and Northern Ireland Mental Health Forensic Services [C, D, E]. It forms part of the Prison Service Personality Disorder Pathway for men [D]. Over 250 children have received the therapy through CCATS, Julie Kershaw, Services Manager at CCATS reported that many patients are now able to understand the functions of their behaviour and better manage their emotions. This has enabled participants to learn management strategies to reduce relapse and go on to employment, college and university [C].

Since August 2013 over 200 specialist mental health/secure staff have been trained in LMV and underpinning FRG research [3, 4, 6], with a further 190 trained in components [B]. This includes 50 professionals from New South Wales Police, Australia (2013 and 2015). LMV is currently being implemented in a psychiatric service in Australia [F]. Dr Nikki Loft reported that LMV-E was valuable in “…empowering them [the patients] with skills and insights into their behaviour and how to manage in less violent and more prosocial ways” when it was implemented in an inpatient setting in South London. Dr Loft now plans to implement the LMV-E program in her new role at the Thomas Embling Hospital in Melbourne, Australia [F]. A survey of services attending LMV training between 2013 to 2019 [I] noted between 500 and 700 violent clients had received the therapy, with 75% of clients being positively affected. All services identified FRG research to have positively impacted on practice, citing the FRG research on aggression motivation (70%), emotions (60%), information processing (50%) and implicit processing (40%). Confidence in working clinically with aggressive individuals was noted by 85% of attendees [I]. Since August 2013 there have been at least four annual professional training events capturing the aggression research conducted by FRG [3, 4, 5, 6] (each n = 25 to 30 practitioners).

The practitioners who took part in the training reported that their practice was now more informed as a result. The interventions and skills provided to practitioners have shown direct benefits to patients in a variety of settings. One respondent reported that the training gave them “…a range of tools to help individuals better understand themselves and motivations/reactions” [I]. Julie Kershaw, Service Manager at CCATS also noted that the programme had given their clients practical skills and tools that helped them to manage themselves appropriately and prevent relapsing or reoffending [C]. Implementation at Ty Llewelyn Medium Secure Hospital resulted in participants being able to “…recognise their emotions more effectively and the circumstances in which they may become aggressive.” [E1]

2. Crisis intervention (e.g. hostage-taking, roof-top protests, barricades) and negotiator training

The research from FRG emphasised the:

• Importance of understanding perpetrator motivation [6].

• Importance of perceived staff fairness in resolution;

• Importance of developing rapport and accounting for mental health/personality [6];

In 2014 FRG redeveloped a Crisis Negotiation Package (CNP) to incorporate their research [6], including negotiator training (Ireland, C. A.). A funded PhD (2015) explored security incidents, noting the importance of motivation, communication and meaningful activities in incident reduction. Based on this research FRG proposed and published a new theoretical model of understanding security incidents, consolidating the earlier FRG research on the importance of environment and systems [2].

The CNP is the only NHS crisis package in existence and has been applied successfully to crisis incidents, leading to resolution and safe hostage recovery [G]. It has been used in community incidents, involving Merseyside and Lancashire Police, and is the only package adopted by Mersey Care NHS Foundation Trust. Since 2014, crisis profiles, based on FRG research [6], are recorded for all patients in high secure services in Mersey Care NHS Foundation Trust, capturing over 200 patients and shared across all four high security services in Britain [G]. Since 2014, over 130 specialist NHS, private health and police staff have been trained in the CNP by the FRG [G, H].

3. Policy and service development

The SAIP have informed development of national and international policy on patient-to-patient aggression. Ireland, J. L, authored the first NHS policy on this [H3], which is revised every three years to include new FRG research [2, I]. FRG has made a material contribution to the content by noting bullying as a significant issue [2] that is environmentally driven, and that being an aggressor, or a victim, is not mutually exclusive. These findings have been built directly into the electronic recording system for Mersey Care NHS Foundation Trust, where all bullying incidents are now logged, capturing elements of the FRG research.

Ireland, J. L. also authored the design of the Commissioning for Quality and Innovation (CQUIN, NHS) indicator on patient safety [H3] in high secure services. Ward alterations were made to all high secure psychiatric hospitals in England (n = 3; housing around 700 high risk individuals), with Ireland, J. L designing and evaluating these changes based on the psychological theory underpinned by FRG research [2]. The CQUIN ran until 2017, with the final evaluation report produced in 2018 [H3].