Sexually Violent Predator Evaluations: Empirical Evidence,Strategies for Professionals,and Research Directions

Several states have passed civil commitment laws that allow the precautionary detention of sex offenders who have completed their criminal sentences. Over 2,500 sex offenders have been committed across states with such statutes and several thousand more sex offenders have been evaluated. Most statutes call for an evaluation of risk by a mental health professional and, although each state statute is worded differently, three main elements common to sexually violent predator evaluations are used to guide evaluators: mental abnormality, volitional capacity, and likelihood of future sexual violence. The current article presents empirical evidence for the main tenants of these forensic evaluations, provides recommendations for evaluators in light of current limitations of evidence, and offers suggestions for future research in this area of forensic assessment.     

Feedback on Forensic Mental Health Assessments in a Juvenile Court Clinic Certification Program

Public-sector mental health systems have set forth specialized practice competencies for forensic mental health clinicians conducting court-ordered examinations. This study examined a sample of feedback letters to clinicians who submitted mid-training and final reports for review as part of the requirements for certification as a juvenile court clinician. The most common feedback points were insufficient/irrelevant historical data, problems with clarity/organization of the report, problems with interview/mental status examination, and problems with competency to stand trial data/opinions. Clinicians had fewer deficiencies in their final report compared to their mid-training report, supporting the perspective that forensic training and supervision is associated with better quality reports.     

Community-based forensic child and adolescent mental health services in England,Scotland and Wales: a national mapping exercise

Aim: We sought to ascertain the current nature of specialist community mental health provision for young people presenting with risk of harm to others or involvement with the youth justice system in England, Wales and Scotland. Methods: Questionnaire-based survey. Results: Fifty-five services were contacted, 48 responded and 35 of these were found to be providing some form of community mental health provision to high-risk young people. Thirteen services provided comprehensive community forensic child and adolescent mental health (FCAMH) services, whilst the remainder offered more ad hoc clinical input. Amongst the comprehensive FCAMH services, staffing, function, commissioning arrangements and population served varied widely. Conclusions: There is patchy geographical provision of comprehensive community FCAMH services across England, Scotland and Wales with heterogeneous commissioning arrangements, staffing and function. Development of a national commissioning strategy for community FCAMH services is required to ensure that the complex needs of high-risk young people are adequately addressed.     

Comparison of HoNOS and HoNOS-Secure in a forensic mental health hospital

The Health of the Nation Outcome Scale (HoNOS) is a widely used tool for monitoring consumer outcomes within mental health services. However, concern about its suitability in forensic mental health settings led to the development of a forensic version of this tool (HoNOS-Secure). To date, no direct comparison of these versions has appeared in the empirical literature. In the present study, a cohort of forensic mental health consumers was rated using the HoNOS and HoNOS-Secure. Pearson correlations were generated to compare the tools at a total score and item level. Logistic regression was employed to evaluate how well these tools categorise patients on a range of measurable outcomes. HoNOS scores were also compared against civil mental health consumers to evaluate differences between these populations. The HoNOS/HoNOS-Secure correlated strongly at the total score level, but demonstrated variable correlations at the item level. Logistic regression suggested that the HoNOS-Secure ‘clinical and social functioning scale’ adds little to the HoNOS in a forensic setting; however, the HoNOS-Secure ‘security scale’ added significant benefit to both versions. Results remained stable when re-evaluated over time. Forensic and civil mental health patients were found to demonstrate the same degree of psychopathology at the point of admission; however, they differed at review and discharge collection occasions. Implications for clinical practice and policy are explored.     

Three faces of justice: Competing ethical paradigms in forensic psychiatry

Respect for justice has traditionally been an essential principle of health care ethics. However, many bioethical accounts of justice focus only on distributive justice, and how resources for health care should be allocated. In this article, I will argue that the practice of forensic mental health care requires clinicians to engage with justice in three additional and different ways: justice as liberty and fairness; retributive justice and protection of the vulnerable; and justice as the promotion of virtue. I will argue that British forensic psychiatry favours retributive and protective justice; in contrast to a libertarian approach to forensic practice in the United States. I discuss how respect for justice as support for virtue complements therapeutic work with offenders, which aims at the development of pro‐social character. I will conclude that without respect for justice as virtue, there is a danger that clinical forensic psychiatry risks doing harm to patients and bringing the profession into disrepute.     

Current issues in state mental health forensic programs

The major current issues facing state and local forensic mental health programs are presented in this paper. Debates over forensic patients' rights and the insanity defense are discussed, together with many administrative problems such as the pros and cons of correctional versus mental health system program control and payment incentives for treatment. The authors cite the differing goals of correctional and mental health systems, i.e., security and treatment, as reasons for difficulties in developing needed collaboration. Guidelines are suggested to address such important issues as mixing civil with criminal patients, developing units for special populations, defining patients who can respond to treatment, and follow-up after discharge.     

Quality of criminal responsibility reports submitted to the Hawaii judiciary

This paper is the third in a series of research reports on quality of forensic mental health evaluations submitted to the Hawaii judiciary. Previous studies examined quality of reports assessing competency to stand trial (CST) and post-acquittal conditional release, in felony defendants undergoing court-ordered examinations. Utilizing a 44-item quality coding instrument, this study examined quality of criminal responsibility reports in a sample of 150 forensic mental health evaluations conducted between 2006 and 2010 by court-appointed panels. Raters attained high levels of agreement in training and quality coding. Similar to the previous studies, overall quality of reports was mediocre, falling below the .80 quality criterion score for report elements, regardless of evaluator professional identification or employment status. Level of agreement between evaluators and judicial sanity determinations was “fair” using Cicchetti's (1994) standards for interpretation of intra-class correlations. Level of agreement was lower than previously published findings for CST reports and better than conditional release reports. Reasons for mediocre report quality and “fair” inter-rater agreement are discussed, including the fact that criminal responsibility evaluations are complex, retrospective in nature, and involve significant degrees of inference. In contrast to CST evaluations, assessment of criminal responsibility involves a mental state at the time of the offense evaluation. Threats to reliability in forensic reports are discussed. Suggestions for improvement of report quality are proffered, including standardization of procedures and report format and use of forensic assessment instruments.     

Medicolegal death investigator workplace safety hazards: A scoping review of the literature

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.     

The Criminogenic,Clinical, and Social Problems of Forensic and Civil Psychiatric Patients

Forensic psychiatric patients consume an increasing proportion of mental health resources in Canada and the United States. To inform mental health policy and practice, we compared the criminogenic, clinical, and social problems of forensic patients to those of civilly committed psychiatric patients in two Canadian studies. We predicted that forensic patients would score higher on criminogenic problems and lower on clinical and social problems than civil patients in two studies: one comparing 83 forensic and 189 civil inpatients on a clinician-completed form, the Resident Assessment Instrument--Mental Health, at an urban mental health center, and the second comparing 423 forensic and 178 civil patients assessed at different times using the Patient Problem Survey. The two studies were quite similar in their findings, despite differences in their samples, measures, and data collection methods. In both studies, forensic patients were similar to or lower than civil psychiatric patients in all criminogenic, clinical, and social problems. We conclude that forensic mental health services would benefit greatly by drawing from knowledge accumulated in the general psychiatric literature. This finding also supports the idea that many forensic patients can be appropriately diverted to nonforensic mental health services.     

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)     

A tale of two cultures: examining patient-centered care in a forensic mental health hospital

Several questions remain unanswered regarding the extent to which the principles and practices of patient-centered care are achievable in the context of a forensic mental health hospital. This study examined patient-centered care from the perspectives of patients and providers in a forensic mental health hospital. Patient-centered care was assessed using several measures of complementary constructs. Interviews were conducted with 30 patients and surveys were completed by 28 service providers in a forensic mental health hospital. Patients and providers shared similar views of the therapeutic milieu and recovery orientation of services; however, providers were more likely to perceive the hospital as being potentially unsafe. Overall, the findings indicated that characteristics of patient-centered care may be found within a forensic mental health hospital. The principles of patient-centered care can be integrated into service delivery in forensic mental health hospitals, though special attention to providers' perceptions of safety is needed.     

The observation of mental disorder and dangerousness in arsonists: a contemporary appraisal of changes in Dutch forensic mental health cases

In the Netherlands pre-trial forensic mental health assessments are conducted to examine whether a mental disorder was present at the time of the offence that affected the free will of a person, in which case criminal accountability is considered diminished or absent. This study aims to investigate societal changes over time in forensic mental health recommendations in arson cases. Seventy-two reports of male arsonists assessed in 1950–2010 were included in this study, 36 arsonists were assessed in the first time period (1950–1979) and 36 in the second period (1980–2010). Results show an association between DSM classification and the conclusion on criminal accountability only in the first period and an association between recidivism risk and the forensic mental health recommendation only in the later period. It is concluded that mental disorder was of greater influence on the conclusion on accountability in the first time period, whilst dangerousness played a more important role on the forensic mental health recommendation in the later time period. Our findings reflect a shift from paternalistic principles to principles of risk control and show that societal changes influence the field of forensic mental health.     

Barriers to the operation of mental health legislation in Australian emergency departments: a qualitative analysis

This study aimed to describe the perceived barriers faced by emergency clinicians in utilising mental health legislation in Australian hospital emergency departments. A semi-structured interview methodology was used to assess what barriers emergency department doctors and nurses perceive in the operation of mental health legislation. Key findings from the interview data were drawn in accordance with the most commonly represented themes. A total of 36 interviews were conducted with 20 members of the Australasian College for Emergency Medicine and 16 members of the College for Emergency Nursing Australasia representing the various Australian jurisdictions. Most concerning to clinicians were the effects of access block and overcrowding on the appropriate use of mental health legislation, and the substandard medical care that mental health patients received as a result of long periods in the emergency department. Many respondents were concerned about the lack of applicability of mental health legislation to the emergency department environment, variation in legislation between States and Territories causing problems for clinicians working interstate, and a lack of knowledge and training in mental health legislation. Many felt that clarification of legislative issues around duty of care and intoxicated or violent patients was required. The authors conclude that access block has detrimental effects on emergency mental health care as it does in other areas of emergency medicine. Consideration should be given to uniform national mental health legislation to better serve the needs of people with mental health emergencies.     

Saleem Shah

This article describes the important ways in which Saleem Shah contributed to the improvement of delivery of forensic mental health services in state mental health systems throughout the nation. In addition, it describes his impact on the development of forensic mental health law, policy, and services internationally, especially in China and the former Soviet Union.     

EMPIRICAL ANALYSIS OF REFERRAL ISSUES AND “ULTIMATE ISSUE” RECOMMENDATIONS FOR PARENTS IN CHILD PROTECTION CASES*

Mental health professionals frequently respond to requests for clinical information on parents in child protection cases; however, little data exist on the issues precipitating requests or on the controversial practice of offering “ultimate issue” recommendations in forensic clinical reports. We investigated 243 requests for clinical information on parents and 204 clinician reports submitted for use in child abuse and neglect proceedings in a large, urban juvenile court system. We coded 56 objective and qualitative characteristics regarding referral questions, pending legal issues, and four levels of recommendations. We found that the most common referral questions related to service planning, parenting ability, and/or parents' mental health functioning, and the most common pending legal issues were selection or change of a permanency goal and visitation arrangements. Levels of recommendations varied with type of legal decision, in that clinicians always offered direct recommendations for narrow, statute‐based issues (e.g., termination of rights, adoption) and less so for other issues. Community‐based evaluators were more likely to offer direct recommendations than court‐based clinicians. Based on the findings, we offer practice recommendations and directions for further research in forensic parenting assessment.     

Gender differences in violent offending: results from a multicentre comparison study in Dutch forensic psychiatry

ABSTRACT

The past two decades, a disproportionate growth of females entering the criminal justice system and forensic mental health services has been observed worldwide. However, there is a lack of knowledge on the background of women who are convicted for violent offenses. What is their criminal history, what are their motives for offending and in which way do they differ from men convicted for violent offenses? In this study, criminal histories and the offenses for which they were admitted to forensic care were analyzed of 218 women and 218 men who have been treated between 1984 and 2014 with a mandatory treatment order in one of four Dutch forensic psychiatric settings admitting both men and women. It is concluded that there are important differences in violent offending between male and female patients. Most importantly, female violence was more often directed towards their close environment, like their children, and driven by relational frustration. Furthermore, female patients received lower punishments compared to male patients and were more often considered to be diminished accountable for their offenses due to a mental illness.     

The use of telepsychiatry within forensic practice: a literature review on the use of videolink – a ten-year follow-up

In the last decade, telepsychiatry – the use of telecommunications technologies to deliver psychiatric services from a distance – has been increasingly utilised in many areas of mental health care. Since the review by Khalifa and colleagues in 2007 the body of literature relevant to the forensic applications of telepsychiatry has grown substantially, albeit not by much in the United Kingdom. In the current review, we aim to provide an update summary of the literature published since 2007 to determine the effectiveness and feasibility of increasing telepsychiatry utilisation in forensic practice. The literature reviewed provides some encouraging evidence that telepsychiatry is a reliable, effective and highly acceptable method for delivering mental health care in forensic settings. There are also a number of papers that indicate the use of telepsychiatry may be cost effective for health providers in the longer term. Further research is required to consider the potential legal and ethical implications of using telepsychiatry in forensic settings.     

Describing the feasibility of using case management in a specialist forensic substance misuse intervention for UK veterans: a case study

Veterans with mental health problems are a high-risk group for substance misuse difficulties and are over-represented in forensic settings. Yet, there are few substance misuse services available for this population. Evidence suggests that case management can provide effective interventions for veterans with substance misuse problems. However, there is little research to show its effectiveness in the UK. The present study reported on the implementation and preliminary outcomes of the Veterans Forensic Substance Misuses Service (VFSMS), piloted within a prison setting, to demonstrate the feasibility of the service. The VFSMS operated in four stages: Assessing needs, developing case management plans, providing bespoke support and developing discharge plans. Case studies were used to demonstrate this process, with measures of alcohol use and recovery showing outcomes for each case. Findings from three case studies suggested that case management was a feasible approach, with a range of interventions being used, including substance misuse and mental health services, plus housing and employment services. Outcome measures suggested that alcohol and substance misuse recovery improved following the VFSMS intervention. While the scope of the findings is limited, they suggested that case management is a feasible substance misuse intervention, with preliminary findings showing improvements in substance misuse outcomes.     

Head banging as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Introduction: ‘Head banging’ is a common form of self-harm, linked to numerous negative outcomes including significant brain damage. However, little research has investigated head banging behaviour and its correlates in clinical populations. Method: Head banging episodes were identified from the incident records (n = 5417) of two inpatient forensic services (one intellectual disability and one mental health), using relevant search terms. Rates were compared between individual patients, by gender, diagnosis and level of security. Incident accounts were analysed qualitatively using thematic analysis. Results: Head banging incidents occurred approximately every 3 days in each service, with 229 incidents recorded in 1 year. Individual patient rates varied widely, ranging from 1 to 38 incidents within 1 year. Women, and patients in higher levels of therapeutic security, were significantly more likely to engage in head banging. Qualitative incident reports indicated that head banging was associated with mental distress, anger and psychotic experiences. Discussion: Head banging occurs frequently in forensic services, and has documented associations with traumatic brain injury in affected individuals, thus negatively impacting progress through the care pathway and treatment outcomes. Further research should investigate short- and long-term management strategies and treatment approaches, in order to minimise harm.