Staff perspectives of a violence intervention program in a forensic mental health hospital: Identification of environmental enablers and barriers to program implementation

Abstract

Inpatient forensic mental health recovery often involves participation in offending behavior and mental health recovery-oriented psychological treatment programs. Various factors can impact a program's implementation into service, including environmental features of the hospital environment, such as its physical structure, routines, and the behavior of staff. Little research has explored staff perceptions of environmental features that enable or interfere with a program's implementation and therefore people's ability to participate in programs. Such research is necessary to ensure enablers are promoted and barriers are addressed to maximize treatment outcomes. The aim of this study was to explore staff perceptions of an intensive violence reduction program, the Life Minus Violence-Enhanced program, in a forensic mental health hospital, and elucidate environmental features that staff think may impact the program's delivery. Eight individual interviews with staff and senior clinical leaders were conducted over a 2-year period. Data were analyzed using reflexive thematic analysis. Nine major themes were identified. Results highlighted several environmental barriers that may impact the delivery of intervention programs and the ability of people in the hospital to participate. Importantly, findings suggest the need for programs to be valued by all staff, greater resourcing to be provided to ensure programs run effectively, and wider staff support to ensure new learning and skill development are supported outside of formal treatment sessions. Additionally, staff highlighted the need for a culture within the hospital that is supportive of intervention programs more broadly and integration of the program with other key rehabilitation and recovery activities.

Keywords

program implementation forensic mental health hospital psychological interventions barriers to engagement environmental characteristics

Recovery within forensic mental health services encompasses both mental health and offence-specific recovery. Mental health recovery is defined as “the process by which people living with mental illness are supported to recognize meaning and purpose in their lives through hope, optimism and empowerment” (Forensicare, 2021, p. 14). Offence-specific recovery can be defined as supporting people to desist from offending and lead safe and meaningful lives (Forensicare, 2021). Both dimensions of recovery are often enabled through participation in psychological treatment. Various psychological treatment programs have demonstrated efficacy in preventing violent re-offending, although the effects of these programs are modest, and many people desist from future violent behavior without taking part in these treatments (Gannon et al., 2019; Papalia et al., 2019). The Life Minus Violence-Enhanced program (LMV-E; Ireland et al., 2010) is a cognitive behavioral treatment program that has demonstrable efficacy in the reduction of aggressive behavior and improvements in emotional regulation, coping, and problem-solving (Daffern et al., 2018; Ireland et al., 2023). It includes many treatment components (e.g., relapse prevention, role play, etc.) that have previously been associated with reductions in violent recidivism (Papalia et al., 2019) and incorporates a minimum of 125 sessions delivered over 9 to 12 months. Topics covered include exploring barriers to change, reflecting on one's background, including offending, building skills in areas related to risk of reoffending and relapse prevention (Ireland & Ireland, 2019).

The implementation of intensive psychological treatment programs in mental health services can be challenging. For example, the implementation of dialectical behavioral therapy (DBT) programs has revealed various barriers including staff turnover, financing, availability of resources, and insufficient time (i.e., the organization failed to reduce staff responsibilities to compensate for new DBT commitments) (King et al., 2018; Toms et al., 2019). Common reasons for DBT programs cessation include a lack of management support, leadership or organization buy-in, lack of funding, and a lack of time allocated to deliver DBT or priority given to competing service demands (King et al., 2018; Toms et al., 2019). Conversely, enablers to the implementation of DBT programs include practitioner skills, readiness and attitudes, DBT training, communication across teams, team support, and perceived advantage to implementing DBT (King et al., 2018; Toms et al., 2019). A systematic review of barriers and facilitators to the implementation of programs in hospitals found similar results, and staff identified physical and structural resources, the culture, and having appropriate training or skills as barriers to program implementation (Geerligs et al., 2018). Psychological treatment programs need to be appropriately implemented into services so that facilitators can deliver the program effectively to participants within the service. Furthermore, implementation requires well-trained, motivated and well-prepared clinicians who have support from supervisors and managers (Muller-Isberner et al., 2017).

Both personal characteristics and environmental factors can impact patients’ engagement in and completion of psychological treatment programs (Doyle et al., 2017; Sturgess et al., 2016; Ward et al., 2004). For instance, as identified by participants of programs, the availability and accessibility of programs can play a role in their ability to engage in programs (Sturgess et al., 2016; Tetley et al., 2012). Ensuring patients have access to a variety of programs that are suitable to their needs and level of risk and delivered by trained and motivated staff can support treatment engagement (Sturgess et al., 2016). Perceived support, from unit staff, facilitators, and peers has also previously been identified by participants of programs as impacting their engagement and completion of treatment (Sturgess et al., 2016; Tetley et al., 2012). Staff can support participants with challenges within the program, support them to achieve their goals, and encourage participants’ participation (Sturgess et al., 2016). Feeling safe within the environment where the program is offered can also improve treatment engagement (Sturgess et al., 2016). Polaschek (2010) found that for some people who were completing a violence reduction program within a prison, fears for their safety precipitated their withdrawal from the program.

One external factor that has been the focus of increasing empirical attention in secure forensic mental health and criminal justice settings is the social climate (previously considered through examinations of the related concept, ward atmosphere). Social climate has been shown to impact treatment engagement (Schalast et al., 2008) and is related to motivation for treatment and therapeutic alliance (Gaab et al., 2020; Johansson & Eklund, 2004). The social climate can also have important implications for engagement in rehabilitation programs (Doyle et al., 2017). Schalast et al. (2008) identified three important features of the social climate: therapeutic hold, patients’ cohesion/mutual support, and experienced safety. Therapeutic hold refers to the perceived level of support from staff provided to patients,’ such as perceived level of time and effort provided to patients, whereas patients’ cohesion and mutual support refers to the perceived level of support from other patients within the unit (Schalast et al., 2008; Tonkin et al., 2012). Experienced safety refers to the level of safety staff and patients feel from violence and aggression on the unit (Schalast et al., 2008; Tonkin et al., 2012).

Day et al. (2011) explored the social climate of a medium-security correctional facility offering intensive rehabilitation and found that positive perceptions of social climate were associated with higher levels of treatment engagement. In another study, patients of a highly secure hospital described the impacts of the social climate on therapeutic interventions and their engagement in programs (Mason & Adler, 2012). Participants in this study described that the culture within the environment contributed to feelings of disempowerment, feeling unable to be autonomous in their decisions, and feelings of distrust and helplessness, all of which can influence engagement in intervention programs (Mason & Adler, 2012). Ensuring programs are valued by staff, and ensuring patients feel supported and safe may enhance patients’ engagement in the programs. If staff members value the programs, they may help to support and motivate patients to engage and promote participation and change.

Forensic mental health hospitals offer a range of therapeutic programs that focus on different aspects of recovery, whether they are directed at mental health concerns or offending behavior (Forensicare, 2021; Glorney et al., 2010). In the state-run secure forensic mental health hospital in Victoria, Australia, the LMV-E program is run to address patients’ propensity for violence. Given the time and resource-intensive nature of therapeutic programs such as LMV-E, and their potential to prevent future violent behavior, it is important to ensure they are delivered in an environment that is supportive of change so that active participation is promoted. The author's previous work explores patients’ perspectives of the LMV-E program prior to their engagement in the program (Sondhu, Maharaj, Simsion, et al., n.d.) and following their completion of the program (Sondhu, Maharaj, Dunne, et al., n.d.). It is, furthermore, important to understand barriers and enablers to the implementation of psychological treatment programs in forensic mental health services from the perspective of staff members so that these can be reduced.

Against this background, this study aimed to explore staff perceptions of the LMV-E program and identify environmental enablers and barriers faced in implementation and program delivery. There is limited research on staff perceptions of therapeutic programs in forensic mental health hospitals. It is important to explore, from the perspectives of staff who make decisions regarding program adoption and implementation, what barriers and enablers they perceive as impacting program implementation and delivery. The barriers and enablers identified by these senior staff can be referred to as “external factors,” that is factors within the broader environment rather than “internal” program content or program process factors. These external factors are rarely studied. They are important to understand because they can influence implementation of the program and how it is supported and operated. These external factors are quite different from the content and process factors that facilitators and participants may focus on.

Method

Design

This qualitative study was guided by a phenomenological approach to capture the essence of staff experiences and thoughts about the LMV-E therapeutic program (Patton, 2014). At the time of the study, authors one, two, and three (MS, AD, and NM) were working within a university, independently from the forensic mental health hospital. Authors four and five (DS and MD) were working within the forensic mental health service, but not within the hospital, and independently from all participants in the current study.

Location

Thomas Embling Hospital is a secure forensic mental health hospital providing treatment and care for people who are found not guilty by reason of mental impairment or unfit to stand trial under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997, or people who are sentenced or remanded to prison and who are admitted under the Mental Health Act 2014 or the Sentencing Act 1991. The hospital comprises 136 beds for men and women across intensive, acute, sub-acute, extended rehabilitation, and transitional rehabilitation units (Forensicare, 2021).

Participants

Purposeful sampling was used to select participants according to the study's eligibility criteria (Palinkas et al., 2015). To be eligible to participate, staff must have (a) been involved in decisions regarding the operations of therapeutic programs, or provided oversight and support of programs, or involved in the clinical management of staff involved in the care and treatment of people in the hospital who are participants of the LMV-E program, (b) have the capacity to provide informed consent, and (c) have sufficient English skills to engage in conversation. Thirteen staff members were approached and eight consented to participate in the research (62% response rate). Staff members included senior clinical leaders, staff involved in supporting patients within the LMV-E program, and staff involved in the operations of the program. Participating staff were from various health disciplines, including psychology, psychiatry, nursing, and occupational therapy.

Data collection

Questions in the interview guide were developed by the research team with reference to factors identified from the desistance and forensic recovery literature as being important factors for participants to make positive changes (Clarke et al., 2016; Dorkins & Adshead, 2011; King, 2013). Questions explored staff members’ perceptions and experiences of the LMV-E program's implementation and delivery at the hospital (see supplementary material for interview guide).

Data were collected over 2 years during the first two iterations of the LMV-E program. A member of the research team (MS) contacted eligible staff members at the hospital, and a written explanation was provided to each potential staff member participant. If the staff member indicated interest in participating, a time was organized to meet to further discuss the research. Following this and informed consent being provided, semi-structured interviews were conducted by the research team (MS and MD) using an online video conferencing platform. Interview duration ranged from 41 to 56 min (average 49 min). Interviews were audio-recorded with participant's consent. Audio-recorded interviews were transcribed verbatim, and recordings were deleted after transcription. Interview transcripts were de-identified by substituting names with codes to ensure confidentiality. Interview transcripts ranged in length from 11 to 17 pages (average 13 pages). Electronic data were stored on a secure university network.

Analysis

Data was analyzed using a reflexive thematic analysis approach (Braun & Clarke, 2006, 2021b). Coding of data utilized an inductive orientation, that is, meaning and themes were derived from the staff members perspectives rather than the use of existing theories or research. This approach was chosen as there is limited research in this area and we aimed to identify patterns across the staff members’ interviews (Braun & Clarke, 2021a). The framework outlines a six-phase guide: familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and final analysis and write-up (Braun & Clarke, 2006). Analysis involves moving back and forth between the stages and is a recursive process (Braun & Clarke, 2006). Data analysis involved transcribing, noting down initial ideas, generating initial codes across the entire data set, collating similar codes, developing and reviewing themes through discussion, identifying the essence of themes, and writing detailed analysis for each theme. Categories were reduced to major themes, and one level of abstraction was undertaken, through re-reading of transcripts and ongoing discussion between researchers. The story the data told was produced and supported using data extracts (quotes) for evidence to emphasize and substantiate findings.

Trustworthiness

Trustworthiness is the overarching process of checking that the study is conducted in a way that accurately represents the perspectives of participants and that results drawn from the data are valid. There are four components that can help to promote trustworthiness. These are confirmability (whether findings are impartial and objective), dependability (consistency and reliability of the research process over time), transferability (whether the study's findings can be applied to other groups), and credibility (confidence that research findings are accurate and reflect participants’ experiences) (Ahmed, 2024). To promote reflexivity and responsivity within the analytic process, and therefore, confirmability, potential biases due to researchers’ values or interpretations, along with emerging codes and conceptual categories were critically reviewed in research meetings and regular research supervision. The above-detailed methodology strengthened dependability of the data collection and analytical process. The primary author (MS) coded all data.

Consensus coding was also independently performed and checked on 50% of randomly selected transcripts by another author with experience in qualitative research (NM) for a collaborative analysis and to promote trustworthiness. There was little variability between codes and themes and any variability that did arise did not impact the meaning of themes. Any discrepancies were discussed and resolved by consensus.

To further strengthen the reflexive thematic analysis that was undertaken, Braun and Clarke's (2006, p. 96) 15-point checklist of criteria for good thematic analysis was reviewed and addressed. During the transcription process, the transcripts were reviewed for accuracy by having one member of the team (MS) review all transcripts against the audio recording. The coding process was thorough and comprehensive to allow for each data item to be given equal attention and themes were not generated from a few examples. Themes were also checked against each other and with the original data set so that they were consistent and distinctive. The analysis process, as described above, allowed for the data to be analyzed and not just described. Furthermore, the researchers reviewed the analysis so that it told a well-organized story about the topic and data, and a balance between the analytic narrative and illustrative extracts were provided. Overall, researchers ensured that each phase in the research process was allocated enough time so that the analysis was adequate, the researcher was active in the process and the language used was appropriate (see supplementary materials for further information).

Ethics

Ethical approval to conduct the research was granted by the Swinburne University of Technology Human Research Ethics Committee (reference: 20215444-6033).

Results

Nine themes were identified, and these were: LMV-E is an intensive program, the need for psychological interventions to be valued, the need for better resourcing for psychological interventions, the importance of integrating learnings from interventions onto the unit, the need for more psychological interventions, factors to consider when implementing intensive programs, such as LMV-E, patients’ engagement in psychological interventions, intervention programs require a multi-disciplinary team to facilitate, and forensic recovery requires greater focus. These are explored below and substantiated with illustrative quotes.

LMV-E is an intensive program

Many staff members described LMV-E as an intensive program and one of the longest-structured psychological group-based programs delivered at the hospital at the time. Because of the program's intensity, many of the people participating in the LMV-E program were not completing other psychological interventions. Due to the advanced nature of the program, some staff members reported that this excluded some people from taking part in the program because they would likely need additional support that could not be resourced (i.e., language barriers, cognitive difficulties).

…proportion of people with… acquired brain injuries or other sort of functional cognitive deficits that makes it more challenging and need for sort of more adaptation… which then again becomes a resource issue. – Staff member 8

The LMV-E program was perceived as a more advanced program and a progression from previous interventions offered, and therefore some staff members reported the need for people to engage in preparatory programs prior to engaging in LMV-E. However, staff members were unsure of what programs people needed to engage in prior to LMV-E or what the next steps were after they had finished. There was, therefore, uncertainty around the LMV-E programs fit within the hospital. Some staff members reported that the LMV-E program would not be suitable for some people at the hospital, given its long duration and focus on violence, and therefore, expressed the need for other offence programs to be offered within the hospital.

A program like this was very, very much needed… I just don’t know what the steppingstones are for it. – Staff member 6

The need for psychological interventions to be valued

Many staff members felt that the LMV-E program needed to be better integrated into the units and valued more by staff members at the hospital. Staff members spoke about the separation between learnings from the group and other activities in their unit. Some staff members spoke about the culture of the hospital and reported that offence-specific programs were not seen as a priority and therefore the LMV-E program did not fit within the culture and day-to-day activities of staff. Some staff members described time spent “persuading” other staff of the value of the program and ensuring staff saw it as a priority.

it's a significant investment in time, both staff time and also resources and of course patient time. So that took some persuading. – Staff member 4

Some staff members described a need for a change within the hospital environment that ensured offence-specific programs were valued. Some staff members noted that providing program training and education to staff may increase staff perceptions of the value of programs.

You need to work simultaneously on messaging for the senior people and bringing them on board, but at the same time with frontline staff and patients. – Staff member 4

Many staff members reported the importance of having senior staff support interventions and that this would help to make programs a priority within the hospital. Staff members reported that having senior staff support and commitment to the program would assist in creating more systematic awareness of the utility of programs.

If you don’t have that at the top, well then you’re not going to fund the programs in the services at the coal face. – Staff member 7

Some staff members identified that the delivery of mental health and offence-specific programs were within the hospital's model of care, which outlines how the hospital will deliver its services. However, although the delivery of intervention programs is within the model of care, staff members said that for interventions to be valued and prioritized, they needed to be further embedded in hospital processes. This included processes such as key performance indicators, accreditation, and Dangerousness, Understanding, Recovery, and Urgency Manual ratings (a structured tool used to aid decision making around admission, transfer, and discharge in forensic mental health services) (Kennedy et al., 2010).

…therapeutic programs and its priority and its importance needs to be elevated… much more central to what we’re doing and not just seen as an add on. – Staff member 5

The need for better resourcing for psychological interventions

Most staff members reported that intervention programs were not well resourced. Staff members described that intervention programs are time consuming and that it was not just time spent delivering the program, but also the time training, preparing for group sessions, and organizing pre- and post-program tasks. Some staff members identified that the hospital did not have enough therapeutic spaces for group programs and that the lack of equipment (such as technology) can sometimes be a barrier to the delivery of intervention programs.

…resourcing to sort of training and provision of training and not just for facilitators but as I was talking about earlier sort of for you know, the whole process of referrals and doing pre-group and post-group assessments, liaising with units… – Staff member 8

Many staff members reported that the LMV-E program was under-resourced. Some stated that resourcing was not looked at in-depth prior to the program's implementation. However, some staff members reported that given the LMV-E program was running for the first time, there were unforeseen challenges and sometimes programs needed to commence to understand the resources required.

We probably could have done better to address the resources. It's a bit of a conundrum though, because sometimes the message is systematically, run the thing and demonstrate the resources that you need as you run it. – Staff member 7

One barrier identified in the implementation of the LMV-E program was finding staff to deliver the program. Some staff members reported that treating staff delivered the LMV-E program in addition to their usual responsibilities and acknowledged their commitment and motivation to implement LMV-E. It was reported that resources were taken from the hospital units to support LMV-E and that this impacted the ability of the unit to provide psychology services to other people on the unit. Many staff members reported that the LMV-E program was mostly driven by psychologists but that a multi-disciplinary approach to delivery may improve outcomes and reduce burden on psychology staff who, as a consequence of facilitating LMV-E, were less available to meet the other needs of patients on the units.

…if you’re taking resources for the group, I think they need to be separate from the unit. It's almost like you can’t, you know, take it from Peter and give it to Paul. – Staff member 2

Many staff members reported receiving feedback from facilitators around the difficulties in delivering LMV-E. This included challenges in managing competing demands, which included the facilitation of the LMV-E program (including pre- and post-program tasks) and their unit work, the time-consuming nature of the program, and feeling burnt out.

…the staff expressed considerable disappointment that it seemed to be going on like in a vacuum, that no one much cared, including the patients… there wasn’t the sort of follow-on flow that you’d expect. – Staff member 4

Some staff members reported the need for designated staff to run intervention programs at the hospital and ensure facilitators are appropriately trained. They reported that having designated program staff would mean resources are not taken from the unit and can allow for facilitation of groups across the hospital. Some staff members reported that some programs are typically unit-based (rather than being offered across the hospital irrespective of where the person is housed), or that facilitators chose programs specific to the needs of the unit that they were a part of and, therefore, are not available to all patients in the hospital. Some staff members also spoke about the disruptions that staffing changes can have on intervention programs delivery.

We need to make sure that we have resources devoted to someone coordinating, holding programs, ensuring the facilitators are trained. – Staff member 3

Most staff members spoke about the competing demands that facilitators faced when running an intervention program and working on a unit. Staff members described that facilitators need the support of the unit to be able to run group programs. It was identified that many staff members at the hospital wanted to run programs but were burdened by other tasks. Some staff members said that some staff within the hospital had too many tasks assigned to their role which led to feeling burnt out.

…people just subsuming the additional work that's required and that being an expectation, which may be how it's perceived. – Staff member 7

The importance of integrating learnings from interventions onto the unit

Most staff members described the importance of integrating learnings from psychological interventions onto the unit to help people consolidate new knowledge and skills, and that learnings from the program should not be viewed as separate from the unit's treatment activities. Some staff members reported that greater unit staff awareness of programs, and better communication and recording of information about patient's engagement in programs, strategies they were learning, skills, or homework tasks to practice, was needed for this integration to occur.

…but then you go back to your unit, back to your normal life, and therefore… there's not an ongoing reinforcement learning. – Staff member 4

Some staff members reported a need for better communication between LMV-E facilitators and unit staff, with ideas around providing written information about program participation for staff on units. An increase in communication was viewed as helpful for improving patient's program engagement, integrating learnings from the program, managing any risks, and supporting people taking part in the program. Staff members reported that facilitators would communicate with unit staff when the program was going to go through challenging content. Some staff members reported that there was no expectation for unit staff to help people implement or rehearse what was being introduced in the group.

I think a bit more collaboration… even for the patients it’ll be helpful because somebody's following up with the work… the learnings could be better too for the patients. – Staff member 2

Staff members also described the importance of better communication with unit staff to improve patient's engagement in the program. For example, staff members described feedback surrounding little support from the unit, where the program was not seen as a priority and appointments were scheduled at times the group was running.

Everything should work around the program; the program shouldn’t have to work around everything. – Staff member 4

The need for more psychological interventions

Most staff members reported the need for psychological interventions at the hospital. This included more programs targeting different offending risk factors, more programs that complement each other, and the need for more challenging and advanced interventions. Some staff members also spoke about the need for psychological interventions to fit the needs of people in the hospital and for programs to adhere to the risk-needs-responsivity principles. Staff members noted that few psychological intervention programs were currently run at the hospital, which meant limited opportunity for people to commence and engage in group interventions. Some staff members reported that group intervention programs did not consistently run within the hospital or programs were faced with many disruptions during their delivery.

…we’ve got a fair bit of work to do to sort of have a sort of compendium or suite of programs that really fully complement one another. – Staff member 8

Most staff members reported that there are few programs on offer at the hospital that address offending behavior. Staff members reported previous difficulties in implementing offence-specific group programs, with a lack of resourcing towards offence-specific programs being a contributing factor. Some staff members reported that most offence-specific work is addressed in individual therapy. Most staff members acknowledged that addressing offending behavior is necessary for recovery and that it is important to consider how people address risk factors related to their offending during their time at the hospital.

…violence and offending programs, it was certainly a glaring issue for us, a lot of one-to-one work was done… but I don’t think we’ve ever had a consistent group-based program. – Staff member 3

Most staff members reported that psychological interventions are helpful, important and were supportive of interventions. Some staff members identified that group work is important to undertake so that people can learn from and help other people in the group. Staff members saw engagement in programs as a positive component in working towards recovery.

I think there's a lot to be learned in a group program from you know consumers learning from other consumers rather than doing it one to one. – Staff member 3

Most staff members had positive perceptions about the program and its utility. This included perceptions around the program having good evidence, receiving positive feedback about the content, and an overall perception that the program was effective. Many staff members thought the program was appropriate for some of the people at the hospital and met their needs in reducing risk. In meeting the needs of people, some staff members expressed that the LMV-E program was consistent with the aims of the hospital, that is, to reduce risk factors for people with a history of violence and aid forensic recovery.

a good, pretty thorough program with the right treatment dosage that met the needs of a core of our consumers. – Staff member 8

Factors to consider when implementing intensive programs, such as LMV-e

Staff members described several factors to consider when implementing intensive programs, such as LMV-E. This included ensuring appropriate resources are allocated (both physical resources, such as having an appropriate therapeutic space and materials, and appropriate staffing), ensuring facilitators are trained and supported, the importance of having more facilitators (three facilitators was identified as being helpful) for programs with longer duration and a contingency plan for when facilitators are away, considering the duration and timing of the program, systematic support for the program (including ‘buy in’ from people and senior staff members), the need for broader support of the program, and evaluating the program to ensure it is suitable and meeting the needs of patients.

I think you need leadership… you need organization support and you need leadership for it to be sustained. – Staff member 3

Many staff members identified that COVID-19 had ongoing impacts at the hospital and was a factor that likely needed to be considered with programs going forward. This included impacting the running of the LMV-E program and other intervention programs, as well as staff feeling fatigued from the changes and challenges of COVID-19.

I’d say it's been one of the most challenging times that I’ve ever experienced to run a group program. – Staff member 8

Patients’ engagement in psychological interventions

Engagement in psychological interventions was considered problematic. Staff members reported that there was little uptake of the LMV-E program, which was consistent with participation in other psychological interventions offered at the hospital. Some staff members described staff as often trying to motivate people to engage in the LMV-E program and other interventions. Factors identified for the limited uptake of psychological interventions included unsettled or unstable mental state of people in hospital, a reluctance of people to do more challenging programs, concerns around the duration of programs, and the impact that the program might have on involvement in other commitments or programs.

I would say there's a few patients doing a lot, and majority of our patients are doing very little. – Staff member 5

Leave (permission to leave the hospital for a certain reason) was also seen as a potential barrier to participation in psychological treatment programs. Some staff members reported that leave from the hospital was prioritized over attendance at psychological treatment programs. Some staff members described the importance of fitting leave around programs and not setting them up to compete against each other. Additionally, it was reported that leave should be used therapeutically, that is, integrating learnings from programs with leave. Some reported that progression to leave was seen as a sign of recovery.

How do we fit leave in with other programs to make sure that people are attending the opportunities that we actually already have available for them? – Staff member 1

Intervention programs require a multi-disciplinary team to facilitate

The consensus from staff members was that various disciplines at the hospital (i.e., psychiatry, psychology, nursing, social work, occupational therapy) tend to operate in independently. Intervention programs at the hospital were mostly seen as being the responsibility of psychologists. Many staff members described the need for intervention programs to be run by a multi-disciplinary team of facilitators.

We are very disciplined connected and specific. – Staff member 1

Many staff members reported that the psychology department spent much of their time conducting risk assessments and less time undertaking intervention work. Some staff members described changes being implemented around sharing the role of risk assessments amongst other disciplines. Staff members also described psychology staff as having a large workload and it being unclear on what tasks to prioritize.

If you look at the way psychology time is spent at the moment, it's only a relatively small proportion that is actually engaged in direct clinical work. There's a lot of time spent in meetings, there's a lot of other time doing other things that's not sitting with the patient. – Staff member 7

Forensic recovery requires greater focus

Some staff members reported that the hospital prioritizes mental health recovery rather than forensic recovery. Staff members described that many staff within the hospital were clinically trained and, therefore, there was a focus on mental health. Few staff members were forensically trained and therefore offence specific work was not often the core activity at the hospital. There was, therefore, a tension between staff skillset and the clinical activities that needed to be undertaken at the forensic mental health hospital, resulting in offence-specific programs and forensic recovery not being prioritized.

So there's a tension in the hospital… because the staff are primarily mental health professionals, there's a strong focus on mental health treatment… and there's not as much investment in the need to directly address factors that perpetuate things like violence in the patient group. – Staff member 4

Staff members noted that all staff within the hospital should be aware of risks factors for offending to support patient care and planning. Nevertheless, some staff members reported that some staff within the hospital were not comfortable talking about offending or risks. Factors that contributed to this included: a junior workforce, poor staff retention where trained and experienced staff were leaving, and reduced education and training around forensic work.

We’ve gone backwards in staff feeling comfortable in being able to talk about any offending or any risk with patients. – Staff member 5

Discussion

The primary aim of the present study was to explore staff perceptions of the LMV-E program and external factors that may enable or impede the program's implementation and delivery at a forensic mental health hospital. Nine key themes were identified, and these are discussed below.

Perceptions about the LMV-E program

Most staff members described positive perceptions of the LMV-E program and the need for offence-specific interventions at the hospital. However, they also reported that offence-specific programs did not align with the prevailing culture within the hospital, which created some resistance from staff in supporting the program. They identified that many people within the hospital would benefit from the LMV-E program. Staff members described LMV-E as the most intensive structured psychological group-based program delivered at the hospital. Because of the program's intensity, staff members described the need for people to engage in other programs prior to LMV-E. Previously identified by participants of programs, perceiving treatment as too difficult can be a barrier to treatment engagement and precipitate program withdrawal (Sturgess et al., 2016). Motivational interviewing is a preparatory intervention that has demonstrated support in correctional settings in enhancing retention and engagement in therapy and improving motivation for change (McMurran, 2009). People benefit from having certain skills and competencies (such as literacy, behavioral, and verbal skills) prior to entering therapy, different from those that they may learn and acquire during therapy (Ward et al., 2004). Despite staff members acknowledging that engaging in other less intensive programs prior to LMV-E may be beneficial, there was some uncertainty as to what programs may prepare patients for LMV-E participation. Further consideration is likely needed to determine what skills or competencies people require to benefit from intensive offence-specific programs in forensic mental health hospitals to ensure outcomes are maximized. Generally, cognitive ability should be evaluated to ensure they would be able to appropriately engage in the LMV-E program, and people should have basic communication and social skills (Ward et al., 2004).

Some staff members described the need for better communication and coordination between LMV-E facilitators and unit staff. Some staff members described instances where appointments conflicted with LMV-E session times. Importantly, some staff members identified that leave was often a barrier to attendance at intervention programs, where at times people were choosing leave from the hospital instead of attending psychological interventions. Development of an LMV-E program schedule that is distributed to relevant unit staff and respected by all staff may boost attendance by minimizing the clashes between program sessions and other appointments or leave. This may help to ensure that violence treatment programs are prioritized. If a conflict does occur, patients need to be supported to re-arrange other commitments so that they can benefit from all rehabilitative and social or personal activities. Strong communication between treatment program facilitators and unit staff may also lead to improvements in staff understanding of the content of the program, which can help to elevate its importance, as well as staff understanding of their role in supporting people within the hospital to undertake the program. If unit staff have a better understanding of the program, this may help program participants feel supported and to be encouraged on their unit to utilize strategies and practice and consolidate skill development. Previous research in implementing DBT programs has found that communication across teams is important for the program's success (Toms et al., 2019). Doyle et al.'s (2017) systematic review of the social climate in forensic mental health settings considered studies that explored both patient and staff perspectives. Amongst other factors, the review outlined the importance of the unit culture and staff interest and encouragement in supporting patients’ recovery. Additionally, a meta-analysis by Papalia et al. (2019) found greater reductions in violent recidivism when intervention programs were delivered in a designated treatment unit as these units may provide greater opportunities and support for group participants to practice strategies in a change supportive and safe environment.

Intervention programs at the hospital

Staff members reported previous difficulties in implementing offending group programs within the hospital, with a lack of resources being a contributing factor. Issues with resourcing the LMV-E program were seen as a barrier to the delivery of the program. Ensuring people have access to a range of intervention programs that address mental health difficulties, targeting specific risk factors for offending, and promoting recovery, are critical for recovery. However, if offence-specific programs, such as the LMV-E program, are not resourced appropriately this can be a barrier to its effective delivery, which is consistent with prior research. A Delphi study, which included 76 clients and 55 clinicians, identified a range of barriers and enablers to treatment engagement. The study found that therapy staff shortages and difficulties with accessing appropriate treatment were barriers to engagement (Tetley et al., 2012). Furthermore, Sturgess et al.'s (2016) systematic review of reasons for completion and noncompletion of treatment highlighted that the availability of appropriate treatment programs can be a barrier to engagement. In a mixed-methods analysis of barriers to the implementation of DBT programs in mental health services, 68 participants completed an online survey (King et al., 2018). The study found that barriers to the implementation of programs included staff turnover, financing, and the availability of resources. A critical literature review of the implementation of DBT programs in mental health services also highlighted resourcing, such as, staff having adequate time, appropriate finances, and therapeutic spaces as a barrier to program implementation (Toms et al., 2019). These findings are consistent with findings in the current study, which identified that resourcing was a barrier to the delivery of the LMV-E program.

Staff members described low uptake of psychological interventions by people in the hospital, particularly the LMV-E program, and attributed this to patients’ low motivation. Patients have previously identified that uncertainty around length of hospital stay, and a sense of control can impact motivation levels (Doyle et al., 2017; Mason & Adler, 2012). Whilst internal motivation may be low, previous research has demonstrated that external motivation, such as support and encouragement from staff, can help to motivate people to engage in treatment (Mason & Adler, 2012; O'Brien & Daffern, 2017), and internal motivation can be continuously improved during treatment.

Resourcing considerations with intervention programs

Most staff members identified staff and space resourcing issues. Intervention programs were typically “added on” to staff members’ responsibilities, which meant that they were often strained, and some were experiencing burnout. These findings are consistent with a qualitative study by Gale et al. (2018), which interviewed psychologists involved in providing treatment and found that staff shortages, limited funding, and staff feeling overburdened by competing demands negatively impacted the delivery of treatment programs, such as omitting modules or reducing the number of sessions. Additional research has found that a common barrier to the implementation of DBT programs includes the organization failing to reduce staff responsibilities to compensate for new commitments (Toms et al., 2019). Accordingly, to support engagement in therapy and maximize treatment outcomes, it is critical that staff are enabled smaller caseloads or provided with other contingencies so that they have the time to deliver the program effectively (Toms et al., 2019). Additionally, it is important that staff are well trained, experienced and supported (both facilitators and unit staff), and appropriate, dedicated spaces to deliver the program are made available (Muller-Isberner et al., 2017; Tetley et al., 2012).

Incorporating psychological interventions at the hospital

Staff members described factors they thought were important in promoting and elevating the value of psychological interventions at the hospital. This included having senior staff support for programs, incorporating programs into hospital processes, better integration of learnings onto the unit, and elevating the importance of forensic recovery within the hospital. If offence-specific programs are not prioritized, this can create an environmental barrier to offence-specific program delivery and impact people's engagement in the program. Previous research has demonstrated that the social climate and culture can impact the programs delivery at a service (Day et al., 2011; King et al., 2018; Mason & Adler, 2012; Toms et al., 2019). The social climate can be influenced by organizational structure, staff attitudes and characteristics, and external environmental factors (such as the training of staff) (Doyle et al., 2017). Therefore, the wider hospital environment likely plays an important role in ensuring intervention programs are delivered effectively. Ensuring programs are accepted and valued by staff may have implications for program engagement, that is, if staff members value the programs, they may help to motivate people to engage and promote learnings from group-based psychological treatment programs. As identified from the perspectives of patients, support from staff can help to support program engagement and recovery (Doyle et al., 2017; Mason & Adler, 2012; Sturgess et al., 2016). An assessment of the social climate may help to identify areas for improvement to promote external treatment readiness factors that may increase engagement in programs. Staff members described the need for senior staff support for offence-specific programs, the importance of integrating learnings on units and better incorporating offence-specific programs within hospital processes, which may in turn help to reduce barriers in delivering the LMV-E program.

Limitations

The current study highlights some important experiences and perceptions of intervention programs at a forensic mental health hospital. These findings, however, should be considered within the context of the following limitations. Information power refers to the level of information the sample holds, where the sample holds more information fewer participants are needed (Malterud et al., 2016). There have been few studies of barriers and enablers to program implementation in forensic mental health hospitals and therefore the current study was broad and open in its focus. However, the study had a small sample size and therefore, the information power in the current study may not be sufficient to fully garner all issues pertaining to the implementation of programs in forensic mental health services and this is a limitation (Malterud et al., 2016). The current study did, however, have a specific participant sample and purposeful sampling was used to promote information power. Furthermore, the experiences and perceptions of staff in this study may differ from those of staff working in other forensic mental health services, so care should be taken before assuming staff in other settings also hold these opinions. Forensic mental health hospitals may vary according to characteristics of the physical environment, such as design and security levels, and staff characteristics, such as the number, experience, and qualifications of staff. As such, there may be different environmental influences on programs and patients’ responses to these intervention programs. It may be beneficial for future research to explore perceptions of the impact of external characteristics in different hospital settings to expand research in this area. Additionally, some staff members described the experiences of other staff members, which may have impacted reliability due to their subjective interpretation of what others purportedly said. For example, some staff members in the current study spoke about the experiences of the facilitators delivering the program and participants within the LMV-E program. Future research, which is currently underway, will explore the perceptions of facilitators of the LMV-E program, and the experiences of the participants within the LMV-E program (Sondhu, Maharaj, Simsion, et al., n.d.), to gain a first-hand understanding of their experiences.

Conclusion

There are several important findings from this study that have potential implications for the implementation and delivery of intervention programs at forensic mental health hospitals. Importantly, this research provides insight into barriers within the forensic mental health hospital environment that may impact patient treatment engagement. This included the need for more programs to be offered so that people have access to programs that meet their needs, clarity around when programs should be undertaken, and appropriate resourcing of intervention programs, particularly staffing and therapeutic rooms. The findings also highlight the importance of an organizational culture that is supportive of intervention programs and the need for strong integration, communication, and understanding of programs within the wider hospital environment. Overall, this study highlights the importance of exploring staff member perspectives to gather in-depth information to examine characteristics within the environment of a forensic mental health hospital that may impact the delivery of an intervention program.

Supplemental Material

sj-docx-1-fmh-10.1177_14999013251316592 - Supplemental material for Staff perspectives of a violence intervention program in a forensic mental health hospital: Identification of environmental enablers and barriers to program implementation

Supplemental material, sj-docx-1-fmh-10.1177_14999013251316592 for Staff perspectives of a violence intervention program in a forensic mental health hospital: Identification of environmental enablers and barriers to program implementation by Monique K Sondhu, Ashley L Dunne, Natasha Maharaj, Daniel D Simsion and Michael Daffern in International Journal of Forensic Mental Health

Footnotes

Acknowledgments

We are grateful for the support and assistance provided by staff and program facilitators at Thomas Embling Hospital. Thank you to Dr. Niki Loft for his support with the research.

Funding

The first author received an Australian Government Research Training Program Scholarship.

Declaration of conflicting interests

At the time of data collection, one of the authors (DS) was employed at Thomas Embling Hospital and involved in the delivery of the LMV-E program. He was not involved in data collection or analysis, and he did not have access to participants’ identifiable interview transcripts. DS contributed to the development of the study's aims and methods, helped to interpret the study findings, and reviewed the manuscript.

Data availability statement

The data that support the findings of this study are not publicly available due to ethical restrictions.

ORCID iD

Monique K. Sondhu

Supplemental material

Supplemental material for this article is available online.

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