Setting

Secure forensic mental health and learning disability services provide care and treatment for adults with conditions such as ‘mental illness, personality disorder and neurodevelopmental disorders including learning disabilities and autism’ (NHS England 2018). The risk of harm to others and the risk of patients escaping cannot be managed safely in other settings and patients are ordinarily detained under the Mental Health Act 2007 – or the Mental Health (Care and Treatment) (Scotland) Act 2003.

Patients in these services often have a history of adverse childhood experiences, complex trauma and exposure to violence (Price and Maguire 2016), alongside chronic health conditions often linked to a history of criminal behaviour and offences. Forensic mental health settings typically have high rates of psychosis, anxiety and depression among patients and high rates of stress and burnout among staff (Dickinson and Wright 2008).

People living in secure forensic settings experience high levels of isolation and may be particularly ‘starved’ of touch. They are separated from family, friends and pets and, since the coronavirus disease 2019 pandemic, live in an environment where staff still wear face masks. A person-centred, recovery-oriented and trauma-informed approach to care is beneficial for patients in these settings (Price and Maguire 2016, Marshall and Adams 2018).

Implementation

The service’s nurse consultant (physical health) – who is the first author of this article – obtained support from the head of forensics and criminal justice services – who is the second author of this article – for the introduction of seated chair massage therapy and for funding to be trained and accredited in seated chair massage. Support was then secured from the wider multidisciplinary team. Seated chair massage was discussed with patients in the service user involvement group and advertised through posters in all seven forensic wards.

Ten-minute seated chair massage sessions were made available on each ward. Any patient or staff member was eligible to sign up for a seated chair massage on their ward. The massages were available to all staff – not only clinical staff such as nurses and doctors but also non-clinical staff such as administrative staff and housekeepers.

On the day of their planned massage, patients underwent a dynamic risk assessment carried out by the nurse in charge of the ward. The aim was to ensure that patients were in a settled mental health state, that there were no risk factors present that could trigger an adverse emotional reaction, and that patients would therefore be able to safely partake in the massage. Before their massage, patients also received a careful explanation of what it would entail and were given an opportunity to ask questions and consider whether they thought the massage would be beneficial for them.

The nurse consultant delivered the massages in April and May 2022. Each massage lasted ten minutes, used a standard routine and was provided in a private room with a second member of staff present. In total, 62 massages were provided across the seven forensic wards.

Data collection

Data were collected using a survey designed by the nurse consultant. Surveys enable the capturing of quantifiable data that can be easily assimilated and presented in a variety of formats (Polit and Beck 2021). Furthermore, a short and simple survey is expected to generate a greater response rate than more time-consuming data collection methods such as interviews.

Anyone who had received a massage was given a paper questionnaire by ward staff, rather than by the nurse consultant, to reduce bias and ensure participants felt able to provide honest feedback. Ward staff would have been aware of any literacy issues patients may have and, when needed, offered support to complete the questionnaire.

The questionnaire contained ten questions (Box 1). Six were closed questions answered by ‘yes’ or ‘no’ (questions 1, 2, 4, 5, 6 and 7). Question 3 offered a list of six body areas that participants could choose from to indicate where they had felt the most benefit from the massage. Question 8 offered a list of 14 descriptors that participants could choose from to articulate how they felt immediately after the massage. In questions 3 and 8, participants could circle as many responses as they wanted. Two open-ended questions (questions 9 and 10) were included to generate qualitative data in the form of free-text responses.

Ethical considerations

This was a service evaluation so ethical approval was not necessary. The clinical audit coordinator from the quality assurance and effectiveness team, contacted before data collection, explained that there were no formal protocols for gathering feedback of that nature. The responsible clinicians – that is, the mental health professionals in charge of patients’ care and treatment while they are detained – gave approval for patients to be offered a seated chair massage on the proviso that the dynamic risk assessment carried out by the nurse in charge of the ward would reveal no concerns regarding patients’ mental health state on the day. Questionnaires were anonymous to protect people’s privacy and confidentiality and encourage honest responses.

Benefits

The findings of this service evaluation point towards an overwhelmingly positive impact of introducing seated chair massage therapy in the authors’ workplace. The literature outlines many potential benefits of massage therapy in forensic mental health settings, which are detailed in Box 2. Of particular interest is the idea that massage therapy can help tackle issues of equity and social justice in healthcare provision by giving patients access to a treatment option they may not otherwise have access to (Singer and Adams 2014, Sharp et al 2018). Another thought-provoking idea is that massage therapy offered to both patients and staff may act as a ‘leveller’, subtly softening the power imbalance between staff and patients (Livingston et al 2012, Marshall and Adams 2018). The authors have observed this ‘levelling effect’ in their workplace, where the patients know that seated chair massage is available to anyone on the ward and ‘take turns’ with staff to receive it.

Barriers

There are numerous potential barriers to massage therapy in forensic mental health settings mentioned in the literature (Box 3), including a lack of senior support, negative perceptions or attitudes among staff (Fire 1994, Sharp et al 2018) and judgemental attitudes or focus on patients’ historical criminal offences (Livingston et al 2012, Dhaliwal and Hirst 2016, Marshall and Adams 2018). A full exploration of these potential barriers is beyond the scope of this article, which will now focus on the barriers that can be grouped under the heading ‘the taboo of touch’.

Taboo of touch

Massage involves touch, which by definition involves physical contact and is, arguably, one of the most powerful components of non-verbal communication (Ramsden et al 2006). The use of touch is culturally specific and can be misinterpreted by the recipient. Touch can be ‘instrumental’ and task-oriented or ‘expressive’ and communication-oriented (Gleeson and Higgins 2009). In nursing, examples of instrumental touch include taking a manual pulse reading or cleaning a wound, and examples of expressive touch include giving a handshake or a hug.

Historically, psychiatric nurses believed they should touch their patients ‘sparingly, if at all’ (Hilliard 1995). In forensic inpatient settings, touch has long been something of a taboo (Gleeson and Higgins 2009). Ramsden et al (2006) noted that touch which appears to be considered appropriate in some mental health settings may still be considered ‘inappropriate within the no-touch forensic setting’, where there may be concerns that it can cause flashbacks of past violence or abuse or prompt accusations of inappropriate touching. Ramsden et al’s (2006) book chapter is entitled ‘Something dangerous: touch in forensic practice’, which anecdotally demonstrates that the taboo of touch in forensic inpatient settings still exists.

Two publications about massage therapy in psychiatric hospitals in the 1990s documented that ward staff expressed concerns around flashbacks and adverse emotional reactions in patients who may have previously experienced physical trauma or abuse (Fire 1994, Hilliard 1995). However, both authors laid such concerns to rest, concluding that massage therapy offered a positive experience that could appropriately meet an ‘unfulfilled need for safe touch’ (Hilliard 1995). Hilliard carried out more than 700 seated chair massages in a US psychiatric hospital with ‘no untoward reactions’ (Hilliard 1995).

Singer and Adams (2014) described massage therapy as a ‘bounded and safe’ touch experience that could be ‘validating and positive’. However, people with unresolved trauma may be deeply anxious about touch and uncertain what is safe, positive or appropriate touch (Ramsden et al 2006). Touch is an integral part of nursing practice but must be used sensitively, respecting people’s preferences and personal space, particularly in mental health settings (Gleeson and Higgins 2009). Mental health nurses are taught to use touch with great care and sensitivity, respecting each patient’s uniqueness, needs, wishes and dignity, particularly when working with people who may have a history of physical trauma or abuse (Ramsden et al 2006).

Touch should always be consensual and necessary, and it should be explained in advance to help ensure the recipient experiences it as safe and appropriate. Careful explanation of any procedure or intervention involving touch can help to prevent people with a history of physical or sexual abuse from experiencing flashbacks or adverse emotional reactions. Carefully explaining a proposed massage session to the intended recipient is essential so that they can decide whether they think it could be a positive experience for them and whether they wish to receive it.

In this service evaluation, no patients experienced flashbacks or adverse emotional reactions and no patients responded inappropriately, either during or after the seated chair massage. This led the authors to conclude that seated chair massage is a low-risk and boundaried complementary therapy intervention that is appropriate in forensic mental health settings. The findings of this service evaluation challenge the view that these settings are essentially ‘no touch’ environments.

Limitations

The service evaluation did not distinguish between patients and staff. Furthermore, the experiences of those who chose not to complete the questionnaire remain unknown. It has been suggested that many questions in the questionnaire had been framed positively, which could have influenced responses. A further limitation is that the service evaluation did not explore whether the benefits lasted beyond the immediate post-massage period. Further investigation is needed, notably to determine whether massage has benefits in the longer term.