University of Birmingham Admitting offenders with antisocial personality disorder to a medium secure unit : a qualitative examination of multidisciplinary team decision- making McRae, Leon DOI: 10.1080/14789949.2012.752518 License: Other (please specify with Rights Statement) Document Version Publisher's PDF, also known as Version of record Citation for published version (Harvard): McRae, L 2013, 'Admitting offenders with antisocial personality disorder to a medium secure unit : a qualitative examination of multidisciplinary team decision-making', International Journal of Law and Psychiatry, vol. 24, no. 2, pp. 215-232. https://doi.org/10.1080/14789949.2012.752518 Link to publication on Research at Birmingham portal Publisher Rights Statement: Copyright © 2013 The Author(s). Published by Taylor & Francis This is an Open Access article. 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Mar. 2023 This article was downloaded by: [University of Birmingham] On: 17 April 2013, At: 06:07 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Forensic Psychiatry & Psychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rjfp20 Admitting offenders with antisocial personality disorder to a medium secure unit: a qualitative examination of multidisciplinary team decision- making Leon McRae a a Birmingham Law School, University of Birmingham, Birmingham, UK Version of record first published: 14 Dec 2012. To cite this article: Leon McRae (2013): Admitting offenders with antisocial personality disorder to a medium secure unit: a qualitative examination of multidisciplinary team decision-making, Journal of Forensic Psychiatry & Psychology, 24:2, 215-232 To link to this article: http://dx.doi.org/10.1080/14789949.2012.752518 PLEASE SCROLL DOWN FOR ARTICLE For full terms and conditions of use, see: http://www.tandfonline.com/page/ terms-and-conditions esp. Part II. Intellectual property and access and license types, § 11. (c) Open Access Content The use of Taylor & Francis Open articles and Taylor & Francis Open Select articles for commercial purposes is strictly prohibited. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. 3 1 0 2 ril p A 7 1 7 0 6: 0 at ] m a h g n mi r Bi f o y sit r e v ni U [ y b d e d a o nl w o D TheJournalofForensicPsychiatry&Psychology,2013 Vol.24,No.2,215–232,http://dx.doi.org/10.1080/14789949.2012.752518 Admitting offenders with antisocial personality disorder to a medium secure unit: a qualitative examination of multidisciplinary team decision-making Leon McRae* Birmingham LawSchool, University of Birmingham,Birmingham, UK 13 (Received 23July 2012;final version received20November2012) 0 2 ril This paper reports on the results of a qualitative study funded by the p A Economic and Social Research Council (ESRC) looking at multidisciplin- 7 ary team decisions to admit sentenced offenders with antisocial personality 1 7 disorder to a medium secure unit. The aim of the study was to examine 6:0 admission decision-making from a multidisciplinary perspective, and to 0 explore the interprofessional dynamics and contextual pressures informing at those decisions. The primary method of data collection was 12 semi-struc- m] tured interviews with a convenience sample of various multidisciplinary a staff involved in pre-admission assessment and post-assessment decision- h g making. Data was then coded according to the dialectic of competitive and n mi cooperative goal seeking within groups. The findings suggest that, whilst Bir both forms of goal seeking inform admission decisions, the presence of f significant resource pressures will lead to decisional solidarity among the y o multidisciplinary team. When minor professional disagreements arise, they sit are resolved by the group leader, the Responsible Clinician, in order to er maximise group productivity. It is argued that the discursive-limiting effect niv of resource pressures on group decision-making may weaken the morale of U certain front linestaff,if notundermine institutional purpose. [ by Keywords: medium secure unit; antisocial personality disorder; decision- d making; responsibleclinician; competition; collaboration e d a o nl w Introduction o D Forensic medium secure units are often called upon by referrers to admit sentenced offenders with antisocial personality disorder (ASPD) in need of specialistcareandtreatment(Grounds,Melzer,Fryers,&Brugha,2004a).Whilst we now know a great deal about the therapeutic challenges that such offenders can present to professionals once admitted to specialist services, we know little aboutthediscretionaryprofessionaljudgmentsthatleadtoanofferofadmission. NICE Guidelines (2010) recommend that only offenders who are ‘seeking treatment’ be considered for hospital admission; however, the motivation of the *Email: [email protected] (cid:1)2012Taylor&Francis 216 L. McRae offender is likely to form only part of the complex story of admission deci- sion-making. It is well known, for instance, that offenders serving fixed sen- tences are occasionally transferred to medium secure units at the behest of the Secretary of State upon reaching their earliest date of release (Morris Gibbon, & Duggan, 2007). There are also various contextual and relational factors that may impact on admission decisions, over which the willing offender has little or no control. These factors include the availability of beds, operating exclu- sion criteria, quality of relationship with referrers, unit ethos (Grounds et al., 2004b) and the less empirically tested phenomenon of ‘different attitudes and perceptions’ among multidisciplinary team staff (Ministry of Justice, 2009, p. 146). Whilst only Psychiatrists have the power to make admission recom- 3 mendations following the diagnosis of a mental disorder (section 12(2) of the 1 0 Mental Health Act 1983), the admission decision itself may be informed by 2 ril complex interactions between multidisciplinary staff involved in pre-admission p assessment and post-assessment deliberations. A 7 The probable complexity of admission decision-making is reflected in a 1 7 vast and important sociological literature, much of which is beyond the scope 0 6: of this paper. For current purposes, this literature can effectively be summa- at 0 rised into two separate models. The first model is a development of continental ] philosophy post-Marx, and posits that group decisions should be seen as a m a product of the potential for individuals within those groups to positively or h ng negatively influence one another. Within groups acting on competitive profes- mi sional strategies, decision-making power is not held by any individual within r Bi the group, such the Responsible Clinician (RC); rather, ‘[p]ower only exists of when it is put into action’ (Foucault, 1982, p. 219). The impact of this on mul- y sit tidisciplinary working is often defensiveness, unclear professional boundaries er and responsibilities, and lack of solidarity (Glover-Thomas, 2007). v ni The second model, deriving from the Anglo-American sociological tradi- U [ tion, posits that group members are primarily motivated by the achievement of y b collective goals consistent with their group mandate. For instance, members of ed the multidisciplinary forensic team may have the goal of admitting suitable d a offenders with ASPD for treatment to reduce reoffending rates. To increase the o nl chances of goal success, medical decision-making groups will recognise the w o primacy of solidarity over self-interest (Nugus, Greenfield, Travaglia, D Westbrook, & Braithwaite, 2010; Parsons, 1989). If, or when, low-level decisional conflict threatens to undermine the group’s productivity, the group leader will intervene to direct its decision. Talcott Parsons (1963) posits four means by which the leader will guide her team to a collective decision: (1) Persuasion (intentional channel, positive sanction): why it would be a ‘good thing’ to agree with the group leader; (2) Activation of commitments (intentional channel, negative sanction): why it would be ‘wrong’ for individual members to disagree with the group leader; The Journal of Forensic Psychiatry & Psychology 217 (3) Inducement (situational channel, positive sanction): the offering of ‘situ- ation advantages’, such as money; and (4) Deterrence (situational channel, negative sanction): the use of negative sanctions. Parsons (1965) reminds us that the usual leader of psychiatric decision- making teams is the Psychiatrist, for it is she who historically became the locus of care-based decisions when an individual’s mental difficulties extended beyond the capabilities of the family. Historical legitimacy is now reflected in the preponderance of Psychiatrists in charge of the patient’s overall care (the RC role), and her authority to make medical recommendations under the Men- 3 tal Health Act 1983. It is also reflected in the preference of empirical research- 1 0 ers to examine psychiatric admission decision-making from the perspective of 2 ril the Psychiatrist’s decision frame alone. Most notable among those researchers p are Grounds et al. (2004b). A 7 Covering 98% of the medium secure bed estate, grounds and colleagues 1 7 found that ‘a complex range of contextual factors impinge on admission deci- 6:0 sions’ (p. 48). One of these, Psychiatrists stressed, was that the multidisciplin- at 0 ary team must achieve ‘a clear and shared view of what [they are] trying to ] achieve’ before an individual is admitted (p. 40). The implication that it would m a be the Psychiatrist (group leader) who would resolve group conflict in this situ- h ng ation has been confirmed elsewhere: mi r Bi I think you could direct [the decision] one way or another … I could … in quite of an influential way, because of the position that I have, not because of who I am y but of whatI am.(Psychiatrist inGrounds Howes, &Gelsthorpe, 2003,p.129) sit r e v The problem with this view is that it presupposes that prototypical leadership ni U qualities are more influential than other complex relational phenomena, such as [ y the use of subversive strategies by group members (competition), in explaining b d admission decisions. Tickle counters that the potential for staff to ‘disagree e d when making such decisions’ means that our current understanding of the deci- a o nl sional processes underlying prison transfers is inadequate. Indeed, Grounds w et al. conclude that further research with a ‘more varied sample base, particu- o D larly including other medium secure unit staff, would be merited’ (2004b, p. 48). The current study responds to this call by examining decisions to admit offenders with ASPD from various feeder prisons to a medium secure unit for treatment (under section 47 of the Mental Health Act 1983) from a variety of professional perspectives. Aims of the study were to determine whether cooperative or competitive strategies characterised multidisciplinary team decision-making, and to generate moderatum generalisations for use by future researchers wishing to explore the complexity of forensic decisions. 218 L. McRae Working method The study took place on a specialist ward for male personality disordered offenders in a medium secure unit located within the auspices of the Nottinghamshire Healthcare NHS Trust. The decision to conduct the study in the field of personality disorder was mediated by two factors. First, the uncer- tainties surrounding the responsiveness of ASPD to treatment, and the potential for fractious behaviours by those with the disorder, has been shown to compli- cate admission decision-making (Grounds et al., 2004b). Second, a complimen- tary aim of the study was to examine the rehabilitative effects of treatment, if any, once admission had taken place. The results of this inquiry are presented in a separate paper, and require an alternative theoretical framework. 3 To explore the identified themes of cooperation, competition and leadership 1 20 in the decisional forum, multiple methods of data collection were employed. ril The primary method was semi-structured interviews with 12 members of the p A multidisciplinary team: Psychiatrists (n=2; cited as 1a and 2a, respectively), 17 Nurses (n=6; 1b to 6b), Psychologists (n=2; 1c and 2c), Occupational Thera- 7 pists (n=2; 1d and 2d). Each interview took place in a private room, and 0 6: lasted between 20 and 75min (providing over 10h of data). 0 at The essential prerequisites for inclusion in the study were that the profes- m] sional be involved in pre-admission assessment and post-assessment delibera- a h tions. To avoid what Becker (1967) has described as the assumption of a g n ‘hierarchy of credibility’ within ‘ranked groups’, all members of the multidisci- mi r plinary team conducting pre-admission assessments and post-assessment delib- Bi erations were invited to participate, irrespective of seniority or grade. Since no f y o generalisations were apparent on the basis of professional seniority, the author sit only refers the reader to the profession of the respondent. ver The aims of the semi-structured interviews were, first, to identify the ni impact of contextual factors on discretionary decisions taken by multidisciplin- U y [ ary staff to admit offenders with ASPD for treatment; and, second, to pursue d b the more sensitive inquiry of whether members of the team, including the RC de (Psychiatrist), were generating cooperation in decision-making through the use a o of strategies. Whilst the RC, as group leader, may secure the cooperation of nl w his or her team through the use of explicit, Parsonian-type strategies, it was o D anticipated that non-leaders would be more likely to rely to subversive strate- gies to secure compliance in the event of disagreement. Clearly, this sort of inquiry would not have been usefully served by participant observation or ethnographic methods. Staff were selected for participation on the basis of availability (conve- nience sampling), and the giving of informed consent. All respondents gave their consent for interviews to be audio taped. Interview content was then tran- scribed, and a thematic content analysis of the anonymised data was under- taken. Consideration was given to the use of a statistical package (such as NVivo), but manual analysis was deemed to be sufficiently robust for the The Journal of Forensic Psychiatry & Psychology 219 sample size. Moreover, computer-assisted analysis is not free of bias, because ‘themes have to be coded in the first place’ (Grounds et al., 2004b). A further method of data collection was systematic and detailed analysis of 34 patient medical records (for which patient consent was received). The records provided useful qualitative data on pre-admission assessments and writ- ten recommendations by staff of the perceived suitability of respective patients for admission and treatment. Further, Supplementary, data was achieved by three methods. First, informal conversations with four members of staff (three Nurses and one Health Support Worker); second, formal observation of a pre- admission assessment interview with an offender in prison, conducted by the RC (Psychiatrist), a Nurse and an Occupational Therapist; and, third, for- 3 mal observation of a pre-admission assessment exercise with the aforemen- 01 tioned offender. In all cases, contemporaneous ‘field’ notes were taken. The 2 ril decision not to use an audio tape for these observations was taken to reduce p the chances of contrived group dynamics (Pope & Mays, 1995). A 7 The study’s working method was approved by an NHS ethics committee 1 7 and the researcher’s academic institution. Remaining limitations may include 6:0 the study’s single site design and relatively small sample size. Melzer, Tom, at 0 Brugha, and Fryers, contend that individual unit characteristics can have ‘pow- ] erful effects on admissions, and thus generalising from local studies can be haz- m a ardous’ (2004, p. 8). However, it is submitted that it is more hazardous to h ng divorce decisional phenomena from their interrelational context in an effort to mi creategeneralisabledata aboutdiscretionary decisions.Complexrelationalinter- r Bi actions are only ever intelligible from the standpoint of a specific location. Fur- of thermore, researchers who pursue data collection beyond the point of data ersity staaktuinragtipolnacienewviitthaibnlytheantcinosutnittuetrio‘nre(pLeytiatlilve&dBisacrutlsestito,n2s0’10o,fpd.e8c9is1io).nTalhedyfinnadminigcss v ni below demonstrate that single site research has an important role to play in the U [ development of moderatum generalisations (those linked to the broad features y b of theresearch) ofuse for futureresearchers pursuing (multisite) research. d e d a o wnl Pre-admission assessment: the operation of exclusion criteria o D Once an offender has been identified through referral, it is commonplace for him to receive a full multidisciplinary assessment in prison. The first assess- ment is usually undertaken by a section 12 (of the Mental Health Act 1983) approved Psychiatrist with experience in the diagnosis of mental disorder. The outcome of this assessment normally determines whether further assessments take place: If I thought that someone [with ASPD] wasn’t suitable, I wouldn’t ask the rest of the team to see them … And there are usually very good reasons when someone is excluded right at the beginning … But most get the full assessment. (Psychiatrist 1a) 220 L. McRae One ‘very good reason’ to suspend further assessment is if the offender says ‘there’s nothing about them which needs to change’ (Nurse 6b). Unmotivated patients are a drain on professional resources and a disturbance to the therapeu- tic ethos of the ward. A further exclusion criterion is applied in respect of offenders who receive a comorbid diagnosis of ASPD and schizophrenia. Even if the psychosis is in remission, most psychotic patients find ‘the stress of the treatment is actually quite damaging’ (Psychiatrist 2a). This particular finding compares with previous research (Grounds et al., 2004b), in which it was high- lighted that many national units had effectively become psychosis only ser- vices. The reason for the discrepancy is likely to be different treatment emphases between the two disorders: psychotherapeutic approaches used for 3 the treatment of ASPD may be incongruent with the ‘fundamental and charac- 1 0 teristic distortions of thinking and perception, and by inappropriate or blunted 2 ril affect’ common to sufferers of schizophrenia (WHO, 1992, p. 54). p A third criterion operates to exclude offenders displaying hostile or assaul- A 7 tive behaviour. By comparison, if the offender had a mental illness, hostility 1 7 would usually be ‘one reason why you would consider admitting [them]’ (Psy- 0 6: chiatrist in Grounds et al., 2004b, p. 37). The different approaches can, again, 0 at be explained by divergent treatment approaches between disorders: psychother- ] apeutic treatment aimed at reducing antisocial behaviours can only be effective m a with the cooperation of the patient, whereas the absence of cooperation is no h ng bar to the compulsory administration of psychotropic medication for the mi treatment of symptoms related to a patient’s mental illness (section 63 of the r Bi Mental Health Act 1983; B v Croydon Health Authority (1995) Fam 133). of In most cases, however, the offender will not present as manifestly aggres- y sit sive during initial interview. Therefore, to reach informed decisions about his er suitability for medium security, further multidisciplinary assessment will be v ni required. One important indicator of aggressive tendencies will be the presence [U of severe psychopathic traits (Hart, 1998). These will be identified through y b qualitative assessment by the Nursing team, and a Psychologist applying the ed Hare’s Psychopathy Checklist (PCL-R). A formal score of 25 or above (out of d a 40) on the PCL-R would be cause for concern. A Nurse (1b) explains: o nl w o Psychopaths set other people up as well; they’re behind the scenes … And D they’re quite charismatic, you see … And they cause a lot of difficulties within the staff team because they’ll target people, and they’ll befriend people, and people will feel quite positive about them, and others feel quite negative. And they actually createthat scenario.And itoften results inviolence … A final exclusion criterion is the presence of learning disabilities. The extent of any functional difficulties is assessed by a Psychologist using the Wechsler Adult Intelligence Scale (WAIS). The WAIS defines intelligence or I.Q., as ‘The global capacity of a person to act purposefully, to think rationally, and to deal effectively with his/her environment’ (Wechsler, 1939, p. 229). An I.Q. The Journal of Forensic Psychiatry & Psychology 221 score of below 75 would not satisfactorily reflect these qualities for the purposes of admission and treatment. Excluding those with low I.Q. helps maintain therapeutic conditions on the ward, and ensure the safety and well- being of vulnerable individuals: [They’re] quite vulnerable, and it’s frustrating for other patients … They often take more training, but they get it in the end … They can frustrate the patient group…[T]hereneedstobeafacility forpeoplewhoareborderline withsimilar programmes, butwith slower,more individual practising. (Psychiatrist 1a) A further justification for applying threshold scores is that they help engender consistency and predictability into the decisional forum. Consider, for instance: 3 1 0 2 I don’t think [the Responsible Clinician] would let someone come in who was ril really highly dangerous, posing lots of risks, high PCL-R, no motivation. I don’t Ap think he’d entertain them,andneither wouldwe.(Nurse 2b) 7 1 7 What this does not mean, however, is that the multidisciplinary team always 0 6: agrees with the RC. Whilst collaborative processes characterised many, if not 0 at all, of the decisions reached by the team, the findings suggest that admission m] decisions taken by the RC can be heavily influenced by the use of subversive ha strategies by members of her team. This confirms that discretionary decisions g n explaining the admission of offenders with ASPD to hospital are best explored mi from a multidisciplinary perspective. r Bi f o y The pre-admission meeting: collaborative decision-making? rsit Following pre-admission assessment, ‘[we] come back [to the ward] and do e v the pre-admission meeting, when the team decide whether the person can be ni U managed in a medium secure unit (Nurse 3b). Within this relational context, [ y members of the multidisciplinary team provided two general accounts of b d decision-making. The first was that admission decisions took place within a e d collaborative framework, but were ultimately the province of the RC: a o nl w I think as far as the various disciplines are concerned, everyone has an opinion. o D But,ultimately,itwillbeguidedbywhattheRCwillsay.Wedoourbestbysay- ing,wethinkthispersonshouldbebroughtin,orthispersonshouldn’tbebrought in,butifyoudobringhimin,thenthesearethethingsyouneedtowatchoutfor. Ithinkthat’sthebestwecandointhatsituation.(Psychologist1c) ‘The Psychiatrists just make that decision, I think. But you can put your recom- mendations inyourreport, andthat’sall youcando,really’. (Nurse3b) The second, more nuanced, view was that decisions were taken by the RC, but, in the event of substantial disagreement, members of the team involved in the front line patient management cast the deciding vote: