Consensus-based guidelines to support psychologists in identifying and formulating traumatic brain injuries within forensic settings.

Traumatic Brain Injury (TBI) is prevalent within forensic mental health services, yet it is not routinely screened for or identified during admission. Despite the under-resourcing of neuropsychology in these settings, pockets of best practice likely exist but have not been fully integrated into research evidence base. This study aimed to explore how Practitioner Psychologists identify and formulate TBI in forensic mental health and to develop a set of good practice guidelines for psychologists working with TBI patients in these settings.

A Delphi study design was used, which recruited an expert panel of UK based Practitioner Psychologists working in forensic settings with patients who had experienced a TBI (n=13). Following the initial interview round each of the experts proposed three guidelines, and further potential guidelines were extracted from the analysis of the interview transcripts. This approach necessitated identifying relevant experiences discussed in the interviews that were not explicitly presented as recommendations. An analytical framework for this purpose was developed that utilised a critical realist approach to thematic analysis. The framework was structured around the three critical realist concepts: experiences, events, and causes, which correspond to data, codes, and themes, respectively. The initial interview, framework development and data extraction was then followed by two consecutive rounds of Delphi surveys.

The study reached consensus on 29 guidelines, with over 90% agreement among experts, identifying them as "important or essential" considerations for Practitioner Psychologists working with TBI populations in forensic mental health.

The findings underscored the pressing need to address the growing recognition of TBI as a silent epidemic in forensic settings. While trauma-focused models have been adopted, there is a critical need to incorporate a trauma-neuro informed approach. The guidelines from this study offer a basis for training and supporting Practitioner Psychologists in these settings, enabling better care for individuals with TBI and facilitating access to expert neuropsychological input. This includes practice-based recommendation for holistic assessment, formulation and risk assessment. The possibility of a distinct neuropsychological normative population in forensic services was discussed alongside the ethical issues apparent in using inaccurate norming data during forensic assessment. The study also highlighted the need to reassess neuropsychological training in DClinPsy courses, addressing gaps in foundational knowledge necessary for effective practice in forensic services.

As a limitation, participants were recruited via the BPS’s Division of Clinical Psychology, the Faculty for Forensic Clinical Psychology, and the Specialist Register of Clinical Neuropsychologists. This method may have resulted in sample homogeneity, as not all psychologists are affiliated with these groups. The potential bias, reflected in geographic location and experience, suggests a skew towards those working in medium and high secure services, which could limit the diversity of experience and the comprehensiveness and applicability of the guidelines.