14 October 2020

This is day four of the #ELFTResearch & Innovation Awareness Week. Across the whole of ELFT, important and groundbreaking research projects are underway all the time.

Potentially, everyone has a part to play in improving healthcare, and conducting or taking part in research is part of that.  

Dr Mark Freestone is Reader in Mental Health and Director of Postgraduate Taught Programmes in the Wolfson Institute and an Honorary Senior Research Fellow here at ELFT.

Here he describes the relationship between academic research and the real lived experience of healthcare, with a focus on violence reduction and mental health.

Forensic medium secure services in the UK are a scarce but essential resource providing care for those in the criminal justice system with severe mental disorder.

The intersection between academic research and practical lived experience is something ELFT seeks to foster and develop, in order to help make life better for everyone in all of our communities. 

How fruitful is it for you to have quite a direct and ongoing relationship with ELFT?

I worked for ELFT for four years in the forensic directorate myself and think back on that experience very fondly.

Not only did my work in ELFT, together with my experience in high-security prisons and hospitals, fundamentally shape my ideas about how mental health research for forensic service users should be directed, but my relationships with clinicians drive my sense of what research should prioritise to support NHS providers ‘on the ground’.

ELFT developed a violence reduction programme through their Quality Improvement (QI) processes, and now I am collaborating with senior service managers to fund a trial of this intervention.

This trial is important because it allows us to say that the programme can have generalisable impact outside the Trust: if it’s shown to be effective, it would then be portable to any psychiatric service in the UK.

This shows how applied research can help bring clinical knowledge and good practice into a much wider context.

ELFT has fostered a unique and important relationship between clinicians and academics. How can it help develop and enhance the careers of our clinical staff within ELFT who may not have chosen to take an academic route?

When I finished my PhD I was unsure whether I wanted to become an academic or go into clinical training.

I felt very fortunate that a research qualification allowed me such a high degree of flexibility in terms of working as a medical researcher where I could continue to work with clinicians and other practitioners.

But I could also make a sustainable contribution to practice by investigating and evaluating interventions and programmes, particularly for patients with a forensic history.

On the basis of research work by myself and my colleagues, mental health services for offenders and ex-offenders have changed considerably in the past 14 years.

It gives you a real sense of satisfaction that you can make changes to practice nationally or even internationally.

Anyone who enjoys unpicking the details of why things happen in a certain way, and wants to make a difference can get involved in research.

Clinicians – in my experience – often make great researchers, even if they don’t feel they have the skills.

Universities have people who can handle the technical parts of data gathering and analysis but new ideas are the most important driving force in research.

It is often assumed that 'research' is something left to the academics - the profs and the doctors! Why is this not true?

As academics, we do have a role to play in facilitating research, but ultimately we don’t know as well as people who work in clinical services what the real priorities are.

Some of my most successful projects have been conducted with people – most from ELFT in fact – who have no academic or research training background but want to find out something about the way their services work and need help designing a study that is rigorous and will have real impact.

We need more clinicians to come forward with ideas for research projects so that we’re able to develop it together.

The idea that research is just something for researchers and academics does more harm than good.

In the long run, how can this collaborative ethos between clinicians and academics help strengthen not just the safety and quality of life of people in our care, but the wider community also?

For me these things are inter-linked.

As anyone who has worked in community forensic services or rehabilitation knows, the decisions that clinicians make there have real implications for the local community.

The way for us to approach this is to focus our energies on determining the causes of some behaviours so that we can prevent them from happening again. 

This might seem like a strange thing to say; after all, don’t we do this anyway?

But in fact in most cases we don’t: most of the research that still informs practice, is stuck in identifying general predictive factors.

Identifying and proving causality is complicated and resource-intensive, but now we have machine learning techniques to aid us we do not need to rely so much on randomised controlled trials to understand ‘what works for whom in what conditions.' (1, 2) 

We simply need good data from services and a clear theoretical understanding of the underlying causes of these behaviours. 

While it is a myth that people diagnosed with mental illness are any more 'dangerous' than people not given this label, studies show that often, people convicted of serious offences are not diagnosed, so do not get the help they need. 

How important is the gathering of empirical data to help develop our understanding?    

The work from the Prisoner Cohort Study has been hugely influential in allowing us to establish that a simple diagnosis of mental illness is not a very helpful piece of information in risk management.

Rather, to manage risk effectively and match the right treatment to the right person we need to know whether or not someone has active symptoms of their illness and whether those have been treated.

Even more importantly -  whether those active symptoms occur simultaneously with that person demonstrating aggressive behaviours(3).

In other words, we are able to hone in on the causal link between symptoms and behaviour to an extent that other risk management studies had not previously been able to do; and we could then use our methodology to cross-check the findings with other datasets (4, 5).

We have been working on using the Prisoner Cohort Study to model acute risk factors. That is, risk factors that occur within the hours or even minutes preceding an incident (6) and currently we are using the data to explore other behaviours, again from a causal viewpoint.

It’s a fantastically rich resource to be able to work with.


1. Constantinou, A. C., Freestone, M., Marsh, W., & Coid, J. (2015). Causal inference for violence risk management and decision support in forensic psychiatry. Decision Support Systems, 80, 42–55. https://doi.org/10.1016/j.dss.2015.09.006

2. Constantinou, A. C., Freestone, M., Marsh W., Fenton, N., & Coid, J.W. (2015). Risk assessment and risk management of violent reoffending among prisoners. Expert Systems with Applications, 42(21): 7511-7529.

3. Keers. R. Ullrich, S., DeStavola, B. & Coid, J. (2013) Association of Violence With Emergence of Persecutory Delusions in Untreated Schizophrenia. American Journal of Psychiatry 2014 171:3, 332-339

4. Coid JW, Ullrich S, Kallis C, et  al. The relationship between delusions and violence: findings from the East London first episode psychosis study. JAMA Psychiatry. 2013;70:465–471.

5. Ullrich S, Keers R, Coid JW. Delusions, anger, and serious violence: new findings from the MacArthur Violence Risk Assessment Study. Schizophr Bull. 2014 Sep;40(5):1174-81. doi: 10.1093/schbul/sbt126. Epub 2013 Sep 18. PMID: 24048345; PMCID: PMC4133660.

6. Freestone, M. C., Ullrich, S., & Coid, J. W. (2017). External Trigger Factors for Violent Offending: Findings From the U.K. Prisoner Cohort Study. Criminal Justice and Behavior44(11), 1389–1412. https://doi.org/10.1177/0093854817713237

To find out more about how to get involved in research at ELFT visit the webpage Getting Involved in Research.

You can contact ELFT’s R&I team for more informationelft.researchoffice@nhs.net