Tolland 2019

THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY
2019, VOL. 30, NO. 4, 570–593

https://doi.org/10.1080/14789949.2019.1627387
A systematic review of effective therapeutic

interventions and management strategies for
challenging behaviour in women in forensic mental
health settings
Heather Tollanda, Tracey McKeeb, Sarah Cosgrovea, Emma Drysdalea,
Mark Gillespiea, Lesley Patersona and Catherine Tottenc
a
Forensic Mental Health & Learning Disabilities, NHS, Greater Glasgow & Clyde, Glasgow,
Scotland; bNHS Greater Glasgow & Clyde, Glasgow, Scotland; cNHS State Hospitals Board for
Scotland, Glasgow, Scotland
ABSTRACT
Women in secure forensic mental health care require therapy and care that is
responsive to their specific needs. Despite the policy recognition that women
require a distinct service, evidence based practice is not available for this
population. This review was undertaken in response to a clinical need within
a medium secure unit in Glasgow that was experiencing high levels of chal-
lenging behaviour, in a female ward. The review aimed to identify effective
strategies or interventions for the management of challenging behaviour in
women in secure services and, therefore, improve practice and patient care.
A synthesis of the findings from the 11 identified studies revealed variability in
the approaches used to support women in forensic services, including: beha-
vioural programmes; organisational change with a focus on staff training and
support; medication; ECT and mechanical restraint. The challenging beha-
viours assessed included self-harm; physical and verbal aggression; suicide
attempts and arson/fire setting. The majority of articles suggested some
improvement in aspects of challenging behaviour, however this was limited
by the lack of control groups and small sample sizes. Further investigation is
required to find out whether interventions identified in this review can sustain
a reduction in challenging behaviours in the long-term.
ARTICLE HISTORY Received 16 January 2019; Accepted 30 May 2019
KEYWORDS Forensic mental health; women; systematic review; challenging behaviour
Introduction
Women make up approximately 6% of forensic inpatients in Scotland
(Scottish Government, 2017). It is now recognised that, in UK forensic
services, female patients are a minority group cared for in services that
have been largely designed around their male counterparts and therefore
CONTACT Emma Drysdale emma.drysdale@ggc.scot.nhs.uk

© 2019 Informa UK Limited, trading as Taylor & Francis Group
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 571
require a service that provides them with high quality therapy tailored to
their specific complex needs. It cannot be assumed that conditions and
therapy that have been successful with men, would be suitable for
women (Walker, Logan, & Shaw, 2017).
Historically, women with complex needs have been treated in the highest
security facilities available, where the level of security was often beyond that
which was required (Adshead, Gwen & Morris, 1995; Aitken & Noble, 2001;
Howlett, 1994; Shaw, Davies, & Morey, 2001; Thomas et al., 2005; Thomson,
Bogue, Humphreys, & Johnstone, 2001). This was recognised following the
publication of policy documents and guidelines aimed at redesigning ser-
vices, including in the forensic estate, around the specific needs of women,
the reduction or withdrawal of female high secure beds and the increasing
provision of female specific services at lower levels of security (in Scotland)
(Department of Health, 2003; Forensic Network, 2004). It has been over
a decade since these policy recommendations were presented, yet we do
not seem to be further forward in meeting the needs of women in forensic
services (Parkes & Freshwater, 2015).
A history of physical and sexual abuse has been found to be greater in
the female forensic population than the male population, with depressive
symptoms and history of self-harm also more common for women (Maden
et al., 2006; Thomson et al., 2001). Whilst female patients may have encoun-
tered similar aversive backgrounds and consequent needs or difficulties to
male patients, the way they experience them and express them may be
different. It follows that working with female patients involves stresses and
risks different from those typically presented by male forensic patients
(Uppal & McMurran, 2009). Similarly while their index offences and forensic
histories are often less serious than those of male patients, female patients
may be frequently among the more difficult patients to manage due to
challenging behaviour that can often include self-harm and anger and
aggression towards fellow patients and staff (Bartlett & Somers, 2017;
Beryl, Davies, & Völlm, 2018).
It has been argued that female patients require less physical security than
males, but greater relational and procedural security (Aitken & Noble, 2001;
Bartlett & Somers, 2017; Compton-Dickinson, Odell-Miller, & Adlam, 2012). The
Department of Health (2003) state that gender sensitive mental health care can
be defined as mental health care informed by a knowledge and understanding
of gender differences in women and men and their inter-relationships with the
areas of: childhood and adult life experiences, day-to-day social, family and
economic realities, expression and experience of mental ill health, pathways
into services and treatment needs and responses. For example, women are
more likely to live in poverty and be primary carers than men, and also more
likely to self-harm than men (Maden et al., 2006). These differences should be
considered in the delivery of mental health services for women. Guidelines also
572 H. TOLLAND ET AL.
suggest that gender-specific services should be co-located within forensic

services more generally to optimise staff support and minimise the possibility
of burnout (Forensic Network, 2004). Given the specific challenges of this
patient group, the impact on the staff working with them is also of interest.
A small number of studies have reported that female patients tend to be
responsible for more aggressive incidents than male patients (Larkin,
Murtagh, & Jones, 1988; Rasmussen & Levander, 1996); Daffern, Howells,
Ogloff, and Lee (2005). Urheim and VandenBos (2006) documented aggres-
sive and violent incidents over a ten year period, in a maximum security
forensic ward in Norway. Although women occupied only 24% of the beds,
they were responsible for 37% of the incidents. Despite the recognition of
female forensic patients having distinct needs, there is a lack of published
empirical evidence about specific interventions or management strategies
that reduce the challenging behaviour of women in forensic services.
This systematic review was proposed in response to a clinical need within
a female medium secure forensic ward in one Health Board in Scotland.
A small number of female patients had presented with challenging beha-
viour consistently over a period of five years, suggesting that existing
strategies and interventions had been unable to successfully manage
these behaviours. Recorded statistics of ward incidents during 2013 to
2017 reported 4781 incidents, with 58% of these occurring in the single
female ward and 43% occurring in the remaining male wards.
In response to this large number of incidents, this review was undertaken
to identify effective strategies or interventions for the management of
challenging behaviour in women in secure services and, therefore, improve
practice and patient care. A secondary aim was to review the impact of
strategies or interventions on the staff group caring for female forensic
patients.
Methods
Protocol and registration
Methods of the analysis and inclusion criteria were specified in advance and
documented in a protocol, published on the PROSPERO website (https://
www.crd.york.ac.uk/prospero/display_record.php?RecordID=81621) with
registration number CRD42017081621.
Eligibility criteria
Study characteristics
Types of studies. Preliminary literature searches indicated that very few, if
any, randomised controlled studies had been published in this area. This
may be due to the proportionately low numbers of females compared to

males in secure settings. Consequently, the following types of studies were
included: randomised control trials; qualitative studies; case control studies
and cohort studies.
Types of participants. The review included participants aged 18–65,

female, in a forensic inpatient setting; for example low, medium or high
security forensic mental health hospitals or IPCU. The sample included
forensic patients with a learning disability.1 Prisoners were excluded from
the review due to the lack of therapeutic focus in prisons. Studies with
mixed male and female participants were included if there was a separate
analysis by gender. Participants must have demonstrated at least one of the
following challenging behaviours: self-harm; violence; aggression.
Types of interventions. All therapeutic interventions and management

strategies that aimed to address challenging behaviours in women in secure
settings, were included in the review.
Types of outcome measures.

Primary outcome measure. The primary outcome of interest was
a reduction in the challenging behaviour of women following an
intervention.
Secondary outcome measures. We also considered the impact of the inter-
vention on staff, where data was available. This included staff sickness
levels/burnout and any other staff measures.
Report characteristics
Included studies were limited to those published in English between the
years 2006 to 2017. In 2003, the Department of Health, UK, published
a report that recommended gender specific mental health services, includ-
ing secure services and identified a number of areas that should be adapted
to meet the specific needs of women in mental health services. The mental
health (Care and treatment) (Scotland) act 2003 came into effect in 2005.
During this period of time, there was also an international recognition that
female offenders have complex issues (Bloom, Owen, & Covington, 2003;
Victoria Department of Justice, 2005). We limited our search to the years
2006 to 2017 as we would expect the principles from the noted policy
recommendations to be evident in practice by 2006.
Search
The search process is presented in Figure 1. Studies were identified by
searching electronic databases from January 2006 until November 2017.
Records identified through database Additional records identified through

Identification searching to November 2016 database searching November 2016 to
(n = 10478) November 2017 (n = 1828)
Records after duplicates removed

(n = 8089)
Screening
Records screened Records excluded

(n = 8089) (n = 7972)
Full-text articles assessed Full-text articles excluded,

for eligibility with reasons (n =97 )
Eligibility
(n = 117) Not forensic inpatients (31)

Not on effectiveness of
treatment/management (47)
Not on managing challenging behaviour (9)
Too old (1)
Male patients only (4)
Systematic review (2)
Poster (3)
Studies included in review

(n=20)
Included
Figure 1. PRISMA 2009 flow diagram.
The search was carried out in the following databases: Ovid MEDLINE(R)
<1946 to Present> including Epub Ahead of Print, In-Process & Other Non-
Indexed Citations and Ovid MEDLINE(R) Daily, OVID Embase, OVID Amed,
EBSCO Cinahl, EBSCO PsycInfo, EBSCO Psychology and Behavioral Sciences
Collection, Cochrane Library, ClinicalTrials.gov, The Campbell Library,
Published International Literature on Traumatic Stress (PILOTS) Database
and The British Library EThOS service.
The search strategy was developed by a Subject Specialist Librarian in
consultation with the review group. The strategy utilised a combination of
subject heading and keywords; the master strategy for OVID Medline can be
found in Appendix 1. The search strategy was adapted to each database as
required, to take account of differences in subject headings and search
tools.
Study selection
On completion of the initial search, each review author was given an equal
number of abstracts/titles to screen against the inclusion criteria. Each
author was partnered with another review author, and they also indepen-
dently screened their partner’s allocated abstracts/titles. The pair of review
authors then compared the eligible papers they identified. Any disagree-
ments were discussed and resolved as a pair through accessing the full text
or consulting with all group members for clarification. Those papers con-
sidered to be potentially eligible were then accessed in full text. Each pair of
authors were then allocated a set of full text papers (previously unseen by
them) to assess against the eligibility criteria. Each pair assessed full text
papers independently and then discussed any differences. When a paper
was excluded a reason was recorded.
Data collection process

A data extraction form was developed based on the Cochrane data collec-
tion form for intervention reviews: RCTs and non-RCTs. It was piloted by
each of the authors on a randomly selected study and refined accordingly.
This was then used to record required data from each of the selected
papers. Each eligible study had data extracted by two reviewers indepen-
dently to ensure accuracy. Any disagreements were resolved via discussion.
Risk of bias in individual studies

Various risk of bias tools were used to assess the methodological quality on
the studies including the following: The Downs and Black tool (Downs &
Black, 1998) the CASP (Critical Appraisal Skills Programme) checklist; The
Checklist for Case Series (10 items) from the Joanna Briggs Institute; the
CASP Cohort checklist and the 10 item tool for Case Studies from the Centre
for Evidence Based Management. Further detail is provided in the protocol
registered on PROSPERO.
Synthesis of results
A narrative/descriptive synthesis of the identified studies was adopted due
to the variety of study designs.
Results
Study selection
A PRISMA flow diagram was used to demonstrate the number of papers
initially identified by the search strategies, the number excluded after
screening for eligibility and the final number of papers included in the
review (Figure 1).
Characteristics of included studies

The characteristics and outcomes of all the studies included in this review are
summarised in Table 1. The majority of studies were conducted in the UK (n = 8).
The remaining studies were located in Ireland (n = 1), the United States (n = 1)
and Denmark (n = 1). Studies took place across eleven medium secure units
(including one learning disabilities ward), one low secure unit, one high secure
unit, one unit that included medium, low and rehabilitation wards and two
studies that did not state a level of security. Sample sizes were low, encompass-
ing 235 participants across 11 studies. Of these studies, the lowest sample size
was one participant (2,25,8), with 70 as the largest sample size (7). The majority of
participants were female forensic patients (n = 173), while the remaining parti-
cipants were members of staff (n = 12) and male forensic patients (n = 50). Four
of the studies employed a case study design, including three single case study
designs and one case series design that described three separate cases. The
remaining study designs included a retrospective chart review study and six pre/
post test designs (one quasi-experimental waiting list controlled study; one pre/
post organisational change and one prospective single cohort).
The primary diagnosis for participants in the majority of studies was
schizophrenia and schizoaffective disorder (1,4,5,6,7,11) and/or personality
disorder (3,5,7,8,11). For the three remaining studies the primary diagnosis
was learning disability (2,9,10).
A range of challenging behaviours were assessed across the studies
including: self-harm (n = 6); violent attitudes (n = 1); disruptive behaviour
and social function (n = 1); physical aggression (n = 5); verbal aggression
(n = 2); disturbed behaviour (n = 1); psychotic aggression (n = 1); predatory
aggression (n = 1); impulsive aggression(n = 1); suicide attempts/suicidal
behaviour (n = 3); staff assault; not responding to medication (n = 1), sex
offences (n = 1) arson/fire setting (n = 2).
Various types of interventions were used across the studies including:
behavioural programmes (n = 4); mindfulness group programme (n = 1)
organisational change with a focus on staff training and support (n = 1);
medication (n = 2); ECT (n = 1) and mechanical restraint (n = 1).
Quality of included studies

The majority of papers scored moderate on quality, as detailed in Table 1. This
is discussed in further detail under the ‘Descriptive Data Synthesis’ section.
Descriptive data synthesis

Medication was adopted as an intervention in two studies (4, 8). Clozapine
was used in both of these studies, with one study controlling for psychosis.
Table 1. Summary of included studies.
Country and Type of Intervention or Type of Challenging Quality tool used and
Study Forensic Setting Design Sample size Management Strategy Behaviour Assessed Results score
1. Jotangia, Rees- UK. Quasi-experimental 38 (all female) R&R2MHP – structured, Disruptive behaviour No significant difference between Downs and Black. Scored
Jones, Six secure waiting list manualized CBT treatment and control group in measures 15/32. Moderate
Gudjonsson, forensic controlled study; program related to challenging behaviour. Only quality
and Young facilities (5 acceptability and significant differences observed Locus
(2015). medium efficacy study of Control and Rational Problem-
secure and Solving Style.
one low
secure)
2. Lamza (2006). UK. High secure Single case study 1 (female) Behavioural – based on Physical, verbal Significant reduction in number of Critical Appraisal of
Applied Behavioural aggression and self- physically aggressive assaults on staff a Case Study Tool.
Analysis model harm until the patient went on an outing. Agreement with 5/10
Following the outing, the number of items on checklist.
assaults towards staff increased. Model Moderate quality
was then used inconsistently and
incidents of challenging behaviour
fluctuated.
3. Long, Collins, UK. Before and after – 20 (12 staff, 8 female Organisational change Disturbed behaviour Decrease in self-injury, damaging Downs and Black. Scored
MacDonald, Medium secure impact on patients) including: staff support property, provocative or insulting 21/32. Good quality
Johnston, and learning organisation and education; training behaviour and total weight 3 incidents.
Hardy (2008). disabilities in RAID; service user However physical aggression increased.
ward involvement
4. Skoretz and United States. Multiple case study 3 (all female) Medication – Psychotic aggression, Decrease in impulsive aggression when Critical Appraisal
Tang (2016) Female forensic (3) methylphenidate and predatory aggression, methylphenidate was taken in addition Checklist for Case
unit, does not clozapine impulsive aggression to clozapine. Series. Agreement
specify level with 4/10 Checklist
of security items. Moderate
quality
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY
5. Carr (2012) UK. Does not Single Case Study 1 (female) Mechanical Restraint Self-harm, suicide Reduced incidents of challenging Critical Appraisal of
level of attempts, staff assault behaviour, patient reported feeling less a Case Study.
security anxious, staff reported patient more Agreement with 4/10
engaged in activities and easier to checklist items.
577
manage. Moderate quality.

(Continued)
578
Table 1. (Continued).
Country and Type of Intervention or Type of Challenging Quality tool used and
Study Forensic Setting Design Sample size Management Strategy Behaviour Assessed Results score
6. Kristensen, Denmark. Retrospective chart 8 (6 male, 2 female) ECT Self-harm, suicidal Psychotic symptoms accompanied by Critical Appraisal of
Brandt- Medium review/cohort behaviour, assualt, not serious assault, all but one had an a Case Study.
Christensen, secure study responding to excellent or good symptomatic and Agreement with 7/10
Ockelmann, medication behavioural response to ECT. Half went checklist items.
and on to maintenance ECT. No adverse Moderate quality
Jørgensen effects documented.
(2012)
H. TOLLAND ET AL.
7. Long (2011a) UK. Medium Prospective single 70 (all female) Treatment was Self harm, suicidal Clinically significant reduction in risk Cohort Checklist. Agreed
secure cohort pre test/ psychosocial behaviour, physical behaviours (physical aggression with 10/12 Checklist
post test design underpinned by RAID assaults, physical against self/people/objects/verbal items. Good quality
training aggression against aggression).
objects, verbal
aggression
8. Rutledge et al Ireland. Medium Single Case Study 1 female Medication – clozapine Self harm, planned Reduced aspects of challenging behaviour Critical Appraisal of
(2007) secure aggression, arson and improved patient’s subjective a Case Study.
distress, but not planned aggressive Agreement with 7
acts so not full rehabilitation and checklist items.
transfer to community. Moderate quality
9. Novaco and UK. Includes low Controlled before 50 (6 females) 1:1 CBT anger treatment Violence, sex offences, Reduction in aggressive behaviour Downs and Black. Scored
Taylor (2015) and medium and after study programme fire setting including hitting, punching or kicking. 15/32. Moderate
secure beds quality
10. Chilvers, UK. Medium Repeated measures 14 (all female) Mindfulness group Aggressive incidents Incidents of observations, physical Downs and Black. Scored
Thomas, and secure with one interventions and seclusion decreased 15/32. Moderate
Stanbury independent from start to end of the group. quality
(2011) variable
11. Long et al. UK. Medium Controlled before 44 females (29 CBT group adapted from Self harm, grievous and When compared with non completers, Downs and Black. Scored
(2011b) secure and after study completers; 15 non DBT skills training actual bodily harm, there was a significant reduction in 15/32. Moderate
completers) major violence, assault reported feelings of anxiety, suicidality, quality
guilt and hostility; significant reduction
in self harm, suicide attempts and
physical assaults. There was no change
in risk behaviours for non completers.
The patient in the single case study (8) had bipolar personality disorder,
whereas the three patients in the series of case studies had been diagnosed
with schizophrenia (4). Both studies monitored the effect of medication on
a number of outcomes with variation in length of monitoring period for
each case study: 12 weeks (n = 2), 13 months (n = 1) and 24 months (n = 1).
One study found that clozapine with methylphenidate reduced impulsive
aggression in all cases (4). The study involving a woman with BPD found
that clozapine reduced the number of days in seclusion, her subjective
experience of distressing symptoms and the need for high nursing levels,
however there was no impact on planned pre-meditated aggression.
There was a focus on organisational change and staff support/education
in one study (3) that involved staff training in Reinforce Appropriate (beha-
viour) Implode Disruptive (Behaviour) (RAID). RAID is a 3 day training course
developed in the UK for tackling disturbed and challenging behaviour. Staff
were also trained on gender-specific issues, person-centred planning, dual
diagnosis issues, running therapeutic groups and use of an adapted beha-
viour chain analysis. Organisational change also included implementing
reflective practice group sessions and service user involvement. Outcomes
of work environment, burnout and job satisfaction were measured six
months prior and six months post organisational change. Self-injury and
aggression were assessed using the disturbed behaviour list three months
prior and four months after organisational change. A reduction was found in
self-injury, damaging property and provocative and insulting behaviour,
however physical aggression increased. A significant increase in job satisfac-
tion and an improvement in burnout was reported. A significant difference
was also found between the mean ward disturbance score pre and post
organisational change. It is not known whether there would have been
lasting change in the longer-term and whether these changes could be
maintained long-term.
The RAID approach and behavioural chain analysis was also the focus of
the treatment approach in another study (7) by the same author. There was
an examination of the relationship between changes in risk profiles and
engagement in treatment. Risk comparisons were made between the first
and last six months in treatment. Significant reductions were found for total
risk behaviours following discharge and clinically significant reductions in
self-injurious behaviours and suicide attempts, physical assaults and aggres-
sion and verbal aggression. There was also an increased engagement in
treatment activities between the first and last six months in care. Although
the reduction in risk was paralleled with engagement in treatment, it cannot
be claimed that treatment caused risk reduction or vice versa.
Behavioural programmes were the focus of four studies, with one
Reasoning and Rehabilitation Cognitive programme (1), a CBT group pro-
gramme adapted from DBT skills training (11), an Applied Behavioural
Analysis (ABA) approach (2) and an individual anger management course (9).
The ABA programme was implemented by a small number of nurses who
attended training with one patient who was causing significant disruption in
the unit. The Reasoning and Rehabilitation Cognitive Programme was deliv-
ered to 38 female patients in total, a treatment group of 18 patients and
treatment as usual control group of 20 patients, and consisted of sixteen
sessions lasting ninety minutes each. One of the studies (1) reported
a significant change pre and post treatment in locus of control and problem
solving orientation, however no significant results were found for outcomes
relating to challenging behaviour. The case study (2) found that challenging
behaviour fluctuated throughout the duration of the programme and there
were issues with sustaining the behavioural approach due to staff absence.
Another cognitive behavioural programme based on DBT skills training (11)
was delivered weekly to 44 female patients, (with 29 participants complet-
ing the study) over a period of 10 months. Outcome measures were taken
3 months pre and post treatment. Results showed a reduction in self-
reported feelings of guilt, anxiety, suicidality and hostility. In addition,
a reduction in self-injurious behaviour, suicide attempts and physical
assaults was found for those who completed the course. As noted by the
authors, findings are limited by the small sample size and lack of control
group. All of these studies lacked a significant follow-up period.
An anger management programme (9) delivered on a one to one basis
was delivered over 9 weeks, and outcomes were measured from case file
notes 12 months prior to treatment and 12 months following treatment to
those patients who remained inpatients. The authors found a significant
reduction in physical assault incidents in the 12 month period following
treatment compared to the 12 months prior to treatment. The inclusion of
only 6 female participants compared to 44 male participants is problematic
when assessing the impact of this intervention for female patients.
A mindfulness group programme (10) that consisted of 30 minute weekly
groups was delivered to 15 women with learning disabilities on the same
ward over a 6 month period. Awareness training about mindfulness was also
made available to all ward staff, of which 82% attended. The mean number
of observations, seclusions and physical interventions were measured across
the 3 time points of pre treatment, mid treatment and post treatment with
a reduction in all 3 outcomes over the monitoring period. Similar to the
previous studies, findings must be interpreted with caution as the study was
underpowered.
The impact of Electroconvulsive Therapy (ECT) for patients with schizo-
phrenia who displayed challenging behaviour was assessed in one study
through a retrospective chart review. Two participants (of eight in total)
were female, with one receiving five courses of ECT over four years (46
treatments) and was now receiving maintenance ECT, while the other
female participant received three courses of ECT (62 treatments) which

had little impact on her mental state. However the fourth course of
twenty sessions resulted in a change to behaviour to the extent that
the patient’s planned transfer to a high secure facility from medium
secure did not proceed and instead the patient was transferred to shel-
tered accommodation where she continued with maintenance ECT.
Patients were not followed up to assess the impact of maintenance ECT
on challenging behaviour. Although this study included eight patients,
only two patients were female, limiting the transferability of findings to
other settings.
Mechanical restraint (body belt with cuffs, leather wrist/waist restraint)
was applied in one case study with a female patient diagnosed with
schizophrenia and personality disorder who had been engaging in life
threatening deliberate self-harm, suicide attempts and staff assault. A case
file review revealed that incidents of challenging behaviour reduced, the
patient felt less anxious, more engaged in activities and was easier to
manage. The assessment period of the intervention lasted only five weeks,
limiting any claims that can be made on the longer-term impact of this
approach.
Discussion
To our knowledge this is the first study to systematically evaluate the
effectiveness of interventions and management strategies concerned with
challenging behaviour of women in forensic services. A significant gap in
the literature was identified, reflecting the little attention that has been
given to women in forensic services despite the increased recognition that
female forensic patients have distinct needs.
A number of interventions described in the articles showed promising
results and may have the potential to reduce challenging behaviour in this
population, for example, mindfulness, staff training and some behavioural
approaches. This review provides initial support for these interventions,
however claims cannot be made about their effectiveness until future
research has been carried out.
Limitations of this review must be taken into account. This review was
limited to articles written in English and interventions that took place in
secure forensic care. A broader search strategy that included general adult
mental health and prison settings may have identified other evidence
based interventions for challenging behaviour, however the forensic set-
ting has unique environmental challenges including the need to balance
security requirements with a therapeutic approach. It follows that inter-
ventions in other settings would not be applicable to the forensic inpa-
tient population.
Methodological quality
Methodological limitations across the studies presented difficulties for
answering the review question. The case studies tested different interven-
tions and therefore were not comparable. However, the varied interventions
may reflect the different needs of the patients involved. The majority of
studies did not make clear the theoretical basis for specific interventions, in
terms of how they responded to the distinct needs of women that have
been identified in the literature (Maden et al., 2006; Ribeiro, Tully, &
Fotiadou, 2015; Thomson et al., 2001). Although a number of studies men-
tioned ‘gender-specific’, it was not always clear how this was operationalised
in the intervention.
As previously noted, small sample sizes make generalisations beyond the
individual articles problematic. A number of articles described single case
studies, which may reflect small numbers of female patients being respon-
sible for the largest proportion of challenging behaviour. It follows that
many of the studies were underpowered and are unable to include compar-
able control groups in their evaluation design. Additionally, women in
forensic services are a minority and any empirical research is therefore likely
to encounter challenges with including substantial numbers of women as
participants.
Measurements of challenging behaviour were varied, and included mea-
sures of attitudes. A change in attitude does not necessarily translate to
a change in challenging behaviours. Positive changes in challenging beha-
viour that were demonstrated did not appear to be consistent, and there
was not significant follow-up periods. We also failed to indentify effective
management strategies from any of the included articles.
Recommendations and conclusions

This review demonstrated that there are existing interventions being deliv-
ered to female patients in forensic mental health settings with the aim of
reducing challenging behaviour, however the number of published studies
available appears to be proportionally low when compared to the number
of existing female units in the UK (Harty, Somers, & Bartlett, 2012; Mental
Welfare Commission, 2017). It is not known whether this is due to interven-
tions being implemented for women, and then not evaluated or published,
or whether it is due to a lack of interventions being delivered to women
generally in this setting.
The variability in interventions adopted across the published studies
suggests that work in this area remains in the early stages of development.
This review evidenced some encouraging results in terms of reductions in
challenging behaviour. The behavioural programmes described, offered
mixed results in terms of their impact on challenging behaviour, with a CBT

skills programme based on DBT training offering promising results (11).
Mindfulness group programmes also warrant further investigation as one
study (10) showed a decrease in the number of observations, seclusions and
physical interventions following the delivery of a mindfulness programme.
We acknowledge that there were also positive results demonstrated from
case studies, including mechanical restraint, ECT and medication. Case
studies are useful for revealing new ways in which to treat a patient, how-
ever further research is needed to assess whether any of the interventions in
the case studies would be effective for larger numbers in this population. It
is difficult to make any conclusions about the effectiveness of medication for
challenging behaviour based on the findings, due to the small number of
participants involved, the differences in diagnosis, co morbidities and the
varied doses of medication and monitoring period.
The lack of a theoretical basis for the majority of studies highlights a need
to understand how ‘gender-specific’ practice recommended by policy, trans-
lates into practice. The DoH (2003, p. 38) state that secure services for
women should offer a ‘a safe, validating and self-affirming environment
that will enable women to begin to heal and recover from severe abuse
and trauma that they may have experienced as children, adolescents and
adults (both outside and within the mental health system).’ This suggests
that the environment may be the most important consideration for female
forensic patients, over and above any specific intervention. Three of the
studies included in the review reported positive outcomes following staff
adopting a consistent approach. For example, the article that described
a mindfulness intervention, noted how ward staff were provided with
awareness sessions about mindfulness and participated in the mindfulness
sessions with patients. In the study that described the single case study of
a woman in a high secure hospital, six nurses were trained in a specific
approach (integrated applied behavioural analysis) and they found that
challenging behaviour reduced following the delivery of this approach.
This consistent, predictable approach has also been cited as important for
a ‘therapeutic milieu’ (Mahoney, Palyo, Napier, & Giordano, 2009) and
‘trauma informed care’ (Sweeney, Clement, Filson, & Kennedy, 2016; NHS
Education for Scotland, 2017). Patients in forensic settings value a consistent
approach from familiar staff who they can trust (Clarkson, Murphy, Coldwell,
& Dawson, 2009).
In order for all staff to be working in line with a specific model or
approach consistently, staff training may be required, in the specific
approach being adopted. For example, this may be training in mind-
fulness, RAID training or trauma informed care. It is perhaps surprising
that few of the studies included staff training as part of the intervention,
considering that this has been recommended in policy. For example, the
Department of Health (2003) stated that due to the high incidence of

victimisation of women in mental health services, and the likelihood of
retraumatisation, mental health staff require training to handle these
issues appropriately. Due to the high proportion of women in forensic
mental health services with a history of abuse, this seems even more
pertinent in this setting. Strong leadership, and staff characteristics are
also likely to be vital for ensuring that staff trust any new way of
working.
Despite an intention to look at the impact of interventions on staff
outcomes as well as patient outcomes, only one paper provided evidence
for staff outcomes (3). We might have expected to identify more studies
that included staff outcomes related to stress and burnout, given that this
is an issue for forensic staff (Dickinson & Wright, 2008). We would recom-
mend that future research focus on these staff outcomes (in addition to
patient outcomes) to ensure that interventions are beneficial for both
patients and staff. There was also an absence of qualitative accounts
from patients themselves, in the articles reviewed. Evaluating the
strengths and gaps in services from the perspectives of female patients
has the potential to offer a voice to this ‘hidden’ population and create
a more person centred model of care (Carlin, Gudjonsson, & Yates, 2005;
Scottish Government, 2009; 2012).
Despite the noted difficulties of the small numbers in this population,
attempts should be made to increase sample sizes in future studies. This
may involve evaluating interventions across a number of different sites,
possibly at a national level to ensure that greater numbers of participants
are available and comparable control groups can be included in the evalua-
tion. It should be reiterated that we cannot claim that these interventions
are effective in reducing challenging behaviour and much uncertainty
remains about the most appropriate intervention for women in this popula-
tion, however, without additional research we are unable to refute the
results and so these interventions should be considered for further
investigation.
Notes
1. For the purposes of this review we will refer to development/intellectual/
learning disability as learning disability to maintain a consistent terminology.
2. Numbers refer to the number the study has been allocated in Table 1.
Acknowledgments
The authors would like to thank Dr Brian Gillatt and Professor Lindsay Thomson for
their expert guidance and feedback on drafts of this review.
Disclosure statement
No potential conflict of interest was reported by the authors.
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Appendix 1 - Master strategy for OVID Medline

Database: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid
MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present>
Search Strategy:
(1) Self Mutilation/ (3213)

(2) Self-Injurious Behavior/ (6471)
(3) Exposure to Violence/ or Workplace Violence/ or Violence/ (29790)
(4) Aggression/ (31882)
(5) Physical Abuse/ (124)
(6) agonistic behavior/ or bullying/ (4130)
(7) Sexual Harassment/ (1444)
(8) Pica/ (1153)
(9) Human Coprophagia/ (33)
(10) Racism/ (1224)
(11) Crime Victims/ (7471)
(12) (self harm* or self injur*).mp. [mp=title, abstract, original title, name of sub-
stance word, subject heading word, keyword heading word, protocol supple-
mentary concept word, rare disease supplementary concept word, unique
identifier] (10594)
(13) sexual* disinhibit*.mp. [mp=title, abstract, original title, name of substance
word, subject heading word, keyword heading word, protocol supplementary
concept word, rare disease supplementary concept word, unique identifier]
(117)
(14) (pagophagia or trichophagia or papyrophagia or metallophagia or lithophagia
or geophagia or hyalophagia or coprophagia).mp. [mp=title, abstract, original
title, name of substance word, subject heading word, keyword heading word,
protocol supplementary concept word, rare disease supplementary concept
word, unique identifier] (612)
(15) ((verbal* adj3 abus*) or swear* or expletive* or obscenit*).mp. [mp=title,
abstract, original title, name of substance word, subject heading word, key-
word heading word, protocol supplementary concept word, rare disease sup-
plementary concept word, unique identifier] (1233)
(16) ((disrupt* or extreme* or problem* or unacceptable* or inappropriate* or
abusive or distress* or threat* or challeng* or intimidat* or bully* or violen*
or aggress* or conflict* or sexual* or dangerous* or hostil* or antisocial) adj3
(behavio* or action* or conduct)).mp. [mp=title, abstract, original title, name of
substance word, subject heading word, keyword heading word, protocol
supplementary concept word, rare disease supplementary concept word,
unique identifier] (159029)
(17) (assault* or hitting).mp. [mp=title, abstract, original title, name of substance
(14309)
(18) victim*.mp. [mp=title, abstract, original title, name of substance word, subject
heading word, keyword heading word, protocol supplementary concept word,
rare disease supplementary concept word, unique identifier] (48067)
(19) violen*.mp. [mp=title, abstract, original title, name of substance word, subject
(20) 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16
or 17 or 18 or 19 (286736)
(21) forensic psychiatry/ or “commitment of mentally ill"/ (14202)
(22) Hospitals, Psychiatric/ (24983)
(23) Psychiatric Department, Hospital/ (6343)
(24) Inpatients/ (17388)
(25) Hospitalization/ (90577)
(26) exp Mental Disorders/ (1170827)
(27) Mental Health/ (30061)
(28) exp Intellectual Disability/ (92151)
(29) mentally disabled persons/ or mentally ill persons/ (9343)
(30) mentally disordered offender*.mp. [mp=title, abstract, original title, name of
(31) ((mental* or learning or intellectual*) adj3 (disab* or disorder* or handicap* or
retard* or deficien* or impair* or ill* or disease*)).mp. [mp=title, abstract,
original title, name of substance word, subject heading word, keyword head-
ing word, protocol supplementary concept word, rare disease supplementary
concept word, unique identifier] (318034)
(32) ((compulsory or involuntary or civil) adj3 (admi* or treat* or commit* or
detention or detain*)).mp. [mp=title, abstract, original title, name of substance
(3139)
(33) ((high or medium or low) adj3 secur*).mp. [mp=title, abstract, original title,
name of substance word, subject heading word, keyword heading word,
(34) ((forensic or secure) adj3 (patient* or inpatient* or client* or unit* or service* or
department* or clinic* or hospital* or ward*)).mp. [mp=title, abstract, original
(35) (section* or hospitali* or inpatient*).mp. [mp=title, abstract, original title, name
of substance word, subject heading word, keyword heading word, protocol
(36) 24 or 25 or 35 (1017417)
(37) 26 or 27 or 28 or 29 or 31 (1282285)
(38) 36 and 37 (111937)
(39) 21 or 22 or 23 or 30 or 32 or 33 or 34 or 38 (152257)
(40) Women/ (15272)
(41) Female/ (8019970)
(42) wom?n.mp. [mp=title, abstract, original title, name of substance word, subject
(43) female*.mp. [mp=title, abstract, original title, name of substance word, subject
(44) girl*.mp. [mp=title, abstract, original title, name of substance word, subject
(45) 40 or 41 or 42 or 43 or 44 (8296212)
(46) exp Drug Therapy/ (1251611)
(47) exp Psychotherapy/ (183146)
(48) complementary therapies/ or exp mind-body therapies/ or exp biofeedback,
psychology/ or exp breathing exercises/ or hypnosis/ or “imagery (psychother-
apy)"/ or laughter therapy/ or meditation/ or mental healing/ or exp psycho-
drama/ or psychophysiology/ or relaxation therapy/ or tai ji/ or therapeutic
touch/ or yoga/ or exp sensory art therapies/ or exp acoustic stimulation/ or
exp aromatherapy/ or exp art therapy/ or exp color therapy/ or exp dance
therapy/ or exp music therapy/ or exp play therapy/ (113963)
(49) animal assisted therapy/ or equine-assisted therapy/ (324)
(50) bibliotherapy/ or exercise therapy/ or occupational therapy/ or recreation
therapy/ (45894)
(51) exp Milieu Therapy/ (3032)
(52) (sensory adj (integration or room* or therap*)).mp. [mp=title, abstract, original
(53) comfort room*.mp. [mp=title, abstract, original title, name of substance word,
subject heading word, keyword heading word, protocol supplementary con-
cept word, rare disease supplementary concept word, unique identifier] (10)
(54) (positive behavi* adj3 support*).mp. [mp=title, abstract, original title, name of
(55) trauma informed.mp. [mp=title, abstract, original title, name of substance
(348)
(56) Allied Health Personnel/ (11104)
(57) Physical Therapy Modalities/ or Physical Therapy Specialty/ (35621)
(58) Physical Therapists/ (886)
(59) language therapy/ or speech therapy/ (7445)
(60) “speech and language therap*”.mp. [mp=title, abstract, original title, name of
(61) Nutritionists/ (780)
(62) Patient Education as Topic/ (81924)
(63) ((patient* or service user* or client*) adj3 (educat* or learn*)).mp. [mp=title,
(64) (physio* or tai chi or yoga or meditat* or psychodrama or psychophysiology or

aromatherap* or biofeedback or hypno* or imagery or acoustic stimulation or
bibliotherap* or (breath* adj3 (exercis* or technique*))).mp. [mp=title, abstract,
(65) dieti?ian*.mp. [mp=title, abstract, original title, name of substance word, sub-
ject heading word, keyword heading word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier] (6512)
(66) (allied health profession* or AHP or AHPs).mp. [mp=title, abstract, original title,
(67) ((drug* or psycho* or mental* or pet* or cat* or dog* or equine or horse* or
animal* or danc* or exercis* or sport* or music* or art* or occupational* or
recreation* or complementary or relaxation or laugh* or movement or envir-
onment* or milieu or alternative or dialectical or cognitive or physical* or diet*
or speech or language or mind-body or touch or sensory or colo?r or play) adj3
(therap* or treat* or intervention*)).mp. [mp=title, abstract, original title, name
of substance word, subject heading word, keyword heading word, protocol
(68) 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59
or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 (3272449)
(69) Police/ (4377)
(70) Criminal Law/ (5473)
(71) Law Enforcement/ (3287)
(72) Patient Participation/ (22546)
(73) Noise/ (19289)
(74) Crowding/ (2772)
(75) “Hospital Design and Construction"/ (9827)
(76) health facility environment/ or patients' rooms/ (6542)
(77) Diagnosis-Related Groups/ (10946)
(78) “Attitude of Health Personnel"/ (108883)
(79) Health Knowledge, Attitudes, Practice/ (96046)
(80) Staff Development/ (8577)
(81) Clinical Competence/ (79268)
(82) Organizational Culture/ (15884)
(83) relational security.mp. [mp=title, abstract, original title, name of substance
(15)
(84) ((rapid* adj3 tranquili*) or (intramuscular adj3 sedat*)).mp. [mp=title, abstract,
(85) Restraint, Physical/ (11646)
(86) Immobilization/ (13160)
(87) Patient Isolation/ (3628)
(88) (de-escalat* or deescalat*).mp. [mp=title, abstract, original title, name of sub-

identifier] (1352)
(89) professional-patient relations/ or nurse-patient relations/ or physician-patient
relations/ (127913)
(90) Leadership/ (37702)
(91) (clinical adj3 leader*).mp. [mp=title, abstract, original title, name of substance
(1687)
(92) criminal*.mp. [mp=title, abstract, original title, name of substance word, sub-
ject heading word, keyword heading word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier] (27788)
(93) ((organi?ation* or staff* or unit* or service* or department* or clinic* or
hospital* or ward* or social or profession*) adj3 (culture* or climate* or
value* or environment*)).mp. [mp=title, abstract, original title, name of sub-
identifier] (167250)
(94) (limit* or boundar*).mp. [mp=title, abstract, original title, name of substance
(1454731)
(95) (seclu* or time out* or observation* or ((manual* or mechanical* or emergency
or physical* or chemical*) adj3 restrain*)).mp. [mp=title, abstract, original title,
(96) (behavio?r adj3 manag*).mp. [mp=title, abstract, original title, name of sub-
identifier] (3190)
(97) (containment adj3 control*).mp. [mp=title, abstract, original title, name of
(98) (prosecut* adj3 (patient* or service user* or client*)).mp. [mp=title, abstract,
(99) ((engagement or participat*) adj3 (patient* or service user* or client*)).mp.
[mp=title, abstract, original title, name of substance word, subject heading
word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier] (44636)
(100) servicescape*.mp. [mp=title, abstract, original title, name of substance word,
cept word, rare disease supplementary concept word, unique identifier] (5)
(101) ((nois* or loud* or crowd* or busy* or design* or architect* or accommodation)
adj3 (unit* or service* or department* or clinic* or hospital* or ward* or
room*)).mp. [mp=title, abstract, original title, name of substance word, subject

(102) ((patient* or service user* or client*) adj3 (mix or characteristic* or factor* or
diagnosis)).mp. [mp=title, abstract, original title, name of substance word,
cept word, rare disease supplementary concept word, unique identifier]
(191779)
(103) ((client* or patient* or service user*) adj3 (relationship* or bond* or rapport* or
trust*)).mp. [mp=title, abstract, original title, name of substance word, subject
(104) ((staff* or doctor* or physician* or nurse* or clinician* or therapist* or psychol-
ogist* or profession* or psychiatrist or physio* or dieti?ian*) adj3 (training* or
skill* or attitude* or support or gender mix or number* or debrief* or reflective
practice or clinical supervis* or post incident or proactive)).mp. [mp=title,
(105) 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 or 77 or 78 or 79 or 80 or 81 or 82
or 83 or 84 or 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 or
96 or 97 or 98 or 99 or 100 or 101 or 102 or 103 or 104 (3065055)
(106) 68 or 105 (5863199)
(107) 20 and 39 and 45 and 106 (4758)
(108) limit 107 to english language (4365)
(109) limit 108 to yr="2006 -Current” (2482)

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THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY

2019, VOL. 30, NO. 4, 570–593

A systematic review of eﬀective therapeutic

ARTICLE HISTORY Received 16 January 2019; Accepted 30 May 2019

KEYWORDS Forensic mental health; women; systematic review; challenging behaviour

CONTACT Emma Drysdale emma.drysdale@ggc.scot.nhs.uk

suggest that gender-speciﬁc services should be co-located within forensic

may be due to the proportionately low numbers of females compared to

Types of participants. The review included participants aged 18–65,

Types of interventions. All therapeutic interventions and management

Types of outcome measures.

Records identified through database Additional records identified through

Records after duplicates removed

Records screened Records excluded

Full-text articles assessed Full-text articles excluded,

(n = 117) Not forensic inpatients (31)

Studies included in review

Figure 1. PRISMA 2009 ﬂow diagram.

Data collection process

Risk of bias in individual studies

Characteristics of included studies

Quality of included studies

Descriptive data synthesis

manage. Moderate quality.

female participant received three courses of ECT (62 treatments) which

Recommendations and conclusions

mixed results in terms of their impact on challenging behaviour, with a CBT

Department of Health (2003) stated that due to the high incidence of

Appendix 1 - Master strategy for OVID Medline

(1) Self Mutilation/ (3213)

(64) (physio* or tai chi or yoga or meditat* or psychodrama or psychophysiology or

(88) (de-escalat* or deescalat*).mp. [mp=title, abstract, original title, name of sub-

room*)).mp. [mp=title, abstract, original title, name of substance word, subject

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