Currently there are 15,914 people sectioned under the Mental Health Act (1983) in mental health hospitals across England. A proportion of those (n=4800, 29%) are currently supported within secure forensic mental health hospitals. Many people within this setting self-report additional complexities such as Adverse Childhood Experiences (ACE), substance misuse and trauma. This may also predispose individuals to other issues such as Foetal Alcohol Syndrome Disorder (FASD). The combination of those issues may also present further complexities which are termed co-morbidities. Those co-morbidities may also lead to stigma and contribute to the wider public health agenda.
The aim of this study was to explore if there is a relationship between trauma, mental health, substance misuse and FASD within the secure forensic mental health setting, and to understand the implications of this upon the facilitators and barriers in an individual’s treatment journey. The study also aims to review the effect of resilience upon an individual experiencing trauma.
The overall aim was achieved by the following:
• A literature review was undertaken to identify the gaps in the literature in relation to trauma, mental health, substance misuse and FASD in a secure forensic hospital setting.
• A systematic review of the international literature identified and synthesised available qualitative evidence of professional perspectives on any relationship between trauma, mental health, substance misuse and FASD for people aged over 14+ years within a criminal justice setting.
• Further exploration of the themes emerging from the literature review and the systematic review informed a exaination of the categorical data of patients residing in a secure forensic mental health setting.
• Exploration of the themes from the literature review and the systematic review informed thirteen semi-structured interviews which were conducted with people currently residing in a secure forensic mental health setting.
• The findings of the above methods were then triangulated using convergence methods to identify how to improve the outcomes for individuals 18+ within the secure forensic mental health setting.
The literature review identified professional perspectives on the relationship of the variables between trauma, mental health, substance misuse and FASD.
The systematic review sifted 18,761 papers of which six qualitative articles were further synthesised as they focused on the professional perspectives on the relationship between trauma, mental health, substance misuse and FASD in clinical settings. There was limited evidence found of a relationship of the variables between trauma, mental health, substance misuse and FASD.
A categorical data analysis synthesised n=168 data records and this identified evidence of a relationship between trauma and mental health diagnosis (n=101, 62%) and a relationship of the variables between trauma, mental health, and substance misuse (n=87, 53%). The association between mental health disorder and substance misuse disorder was considered to be extremely statistically significant (Chi squared equals 114.333 with 1 degree of freedom). The two-tailed P value is < 0.0001. The association between trauma and substance misuse disorder is considered be statistically significant (Chi squared equals 6.442 with 1 degree of freedom. The two-tailed P value is less than 0.0111).
Interviews with participants residing in a secure forensic mental health setting in a North East secure forensic hospital found that all participants had experienced Adverse Childhood Experiences (ACEs) and all had self-reported trauma with n=12 using substances problematically. No participants identified FASD.
Barriers identified from the triangulation process include a) limited knowledge of FASD and how to assess for its presence in society generally and within the forensic setting, b) limited knowledge of Adverse Childhood Experiences in health and social care prevention services, and c) inconsistent responses to complex needs in health and social care provision whichhas led to stigma, d) People in the clinical setting had built levels of resilience and learned to adapt and cope with adversities.
The quantitative elements of this thesis suggest a relationship between trauma, mental health and substance misuse and no empirical evidence to relate trauma with FASD in forensic settings. The study concluded the following recommendations would improve outcomes: Good listening skills, embedded research, Use of Trauma Informed Care (TIC) and positive language should be introduced across secure forensic services. It also concluded that embedded research may be an effective way to balance power.
|Date of Award
|23 Jun 2023
|Judith Eberhardt (Supervisor), Dorothy Newbury-Birch (Supervisor) & Azrini Wahidin (Supervisor)