Health and social care services for women offenders: current provision and a future model of care

Secure provision for women in both the Criminal Justice System and the Health Service has evolved in the last decade, in line with emerging gender-specific policy. Notable gains have been the approach to self-harm in prison and a reduction in the inappropriately high levels of secure hospital care. Although treatment pilots in UK settings are in progress, much practice remains poorly described and insufficiently evaluated. Recent strategic initiatives by both the Ministry of Justice and the Department of Health, as well as the commissioning changes that have followed the Health and Social Care Act 2012, provide a basis for reconsideration and a further paradigm shift. Suggestions for a reinvigorated model of gender-sensitive provision are made, relying on principles of resilience and autonomy.     

A systematic review of effective therapeutic interventions and management strategies for challenging behaviour in women in forensic mental health settings

Women in secure forensic mental health care require therapy and care that is responsive to their specific needs. Despite the policy recognition that women require a distinct service, evidence based practice is not available for this population. This review was undertaken in response to a clinical need within a medium secure unit in Glasgow that was experiencing high levels of challenging behaviour, in a female ward. The review aimed to identify effective strategies or interventions for the management of challenging behaviour in women in secure services and, therefore, improve practice and patient care. A synthesis of the findings from the 11 identified studies revealed variability in the approaches used to support women in forensic services, including: behavioural programmes; organisational change with a focus on staff training and support; medication; ECT and mechanical restraint. The challenging behaviours assessed included self-harm; physical and verbal aggression; suicide attempts and arson/fire setting. The majority of articles suggested some improvement in aspects of challenging behaviour, however this was limited by the lack of control groups and small sample sizes. Further investigation is required to find out whether interventions identified in this review can sustain a reduction in challenging behaviours in the long-term.     

Characteristics that predict firesetting in male and female mentally disordered offenders

Few studies have adequately explored the characteristics of male and female mentally disordered firesetters and compared these to those of non-firesetting mentally disordered offenders. Furthermore, there is a paucity of research examining the characteristics which can predict repeat firesetting within this population. The current study aimed to examine similarities and differences in the characteristics of (1) male and female mentally disordered firesetters, (2) male and female mentally disordered firesetters compared to non-firesetting offenders, and (3) one-time and repeat firesetters. Furthermore, the ability of these characteristics to predict offence status (i.e. firesetter or non-firesetter) and repeat firesetting was explored. Information was collected from patient hospital records for 77 (43 firesetters, 34 non-firesetters) mentally disordered offenders; including sociodemographic, family and personal background, psychiatric, and offence history factors. The findings suggest that mentally disordered firesetters are similar to their non-firesetting counterparts on key characteristics; however, firesetters are more likely to have an expressed interest in fire/explosives and a diagnosis of a schizophrenic disorder and female firesetters are more likely to have a higher number of firesetting incidents than males. Furthermore, findings suggest that fire interest is the largest predictor of repeat firesetting. Clinical implications in terms of treatment and risk assessment are discussed.     

A qualitative exploration of the experience of restorative approaches in a forensic mental health setting

Restorative justice (RJ) is an intervention gaining worldwide recognition in criminal justice systems and other settings. There is a growing evidence base demonstrating positive outcomes in a number of domains, but we found no previous research focussed upon the use of RJ in a forensic mental health setting. This study used a constructivist grounded theory analysis of semi-structured interviews to explore and develop a deeper understanding of RJ practices interventions in such a setting. Ten participants including RJ facilitators, patients and mental health staff took part in research interviews. Restorative interventions were found to be congruent with models of mental health and offender recovery. Processing emotions, developing thinking and coherent narrative, and immediacy are found to be key components of the intervention. The emergent model highlights the role of containment and a high level of facilitator skill when working with a complex, vulnerable and potentially unstable client group.     

Criminal law and mentally ill offenders in comparative perspective

Abstract

In this stick we compare legal arrangements dealing with mentally disordered offenders in the criminal law systems ct Belgium, Canada, Germany, the Netherlands, Norway, Sweden, and the United Kingdom. To describe relevant diffesenoes and similarities in the arrangemeats, we used a checklist containing antral aspects of adjudication, assessment and treatment of mentally ill offenders. These aspects concern: (1) the legal classifications of mental illnesses that can lead to exclusion of criminal responsibility: (2) the acceptance of diminished capacity as a partial excuse; (3) the possibilities for imposing security measures of compulsory treatment instead of or next to criminal punishment; (4) the conditions for their imposition in terms of seriousness of crimes committed and dangerousness of offenders; (5) the available hospitals or special clinics for executing security measures; (6) the role and task of forensic mental health professionals in assessing the offender's state of mind and in advising compulsory treatment; (7) the rules for duration, prolongation and termination of the measures. The findings of this comparative analysis are evaluated in light of legal protection for mentally disordered offenders.     

Stigma and discrimination in mentally disordered offender patients – a comparison with a non-forensic population

High levels of stigma and discrimination are reported by individuals with mental health problems. Aim: To assess self-reported levels of stigma and discrimination in forensic psychiatric patients, with psychotic illness, compared with general adult psychiatric patients with psychosis. Hypothesis: Individuals with a history of violent offending, as well as severe mental illness, report more stigma and discrimination, than non offender patients, as a result of them being perceived as dangerous and unpredictable. Method: Experiences of stigma and discrimination were compared in 32 forensic and 32 non-forensic general psychiatric patients, with schizophrenia or schizoaffective disorder, using the Stigma and Discrimination Scale (DISC). Results: Stigma and discrimination were widely reported by all patients, particularly affecting relationships with family, intimate relationships and friendships. No significant difference emerged between the forensic and non-forensic patients, in experienced or anticipated stigma. Conclusions: We suggest that the lower level of psycho pathology, longer inpatient stays and intensive rehabilitation for forensic patients may reduce the extent to which these patients experience stigma and discrimination.     

‘Cashing In’ on curiosity and spectacle: the forensic patient and news media

Health and social care professionals are gatekeepers to, and custodians of, confidential service user information. In the United Kingdom (UK), police investigations have unveiled cases of payments being made to public service officials by journalists in return for service user information. The purpose of this discussion is to investigate such cases in the context of high-security forensic care. This paper provides a discussion drawing upon two UK-based case studies of prosecutions of public service workers relating to the sale of confidential information. The analysis presented here illuminates upon the salient and connected issues at work that have led to the transgression of legal obligations and professional responsibilities/principles of confidentiality. A fuller reading of the context in which these transgressions occur, and motivations that exist, may well serve to inform policy, training, guidance or vigilance in relation to the preserving of service user information in the future.     

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.     

Finding a voice – the feasibility and impact of setting up a community choir in a forensic secure setting

This study reports on the feasibility and impact of running a choir for forensic psychiatric inpatients, staff and members of the local community, within the confines of a medium secure psychiatric unit. The choir ran between October and December 2013. Eight weekly workshops and a final concert performance were evaluated through participant observation and focus groups held with the participants. Between 12 and 16 male and female patients attended each workshop and the final concert. All participating patients had received a diagnosis of schizophrenia, schizo-affective disorder or personality disorder, all had committed serious violent or sexual offences and all were legally detained and receiving treatment in a forensic medium or low secure ward, under the Mental Health Act (England and Wales). Considerable benefits were reported by patients, as well as by the participating community choir members and staff. Primary benefits reported by patients included the following: improved happiness and well-being; increased confidence and self-esteem; greater emotional connectedness and reduced sense of stigma. Participating staff also reported increased feelings of well-being and happiness, greater tolerance and more positive perceptions of the functioning and capabilities of forensic psychiatric patients. The longer term benefits of music participation on the mental health and social functioning of forensic psychiatric patients require further investigation.     

An evaluation of the effectiveness of positive behavioural support within a medium secure mental health forensic service

A number of recent influential reports recommend the use of proactive and preventative approaches such as Positive Behavioural Support (PBS) in the management of challenging behaviours. Although evidence supporting the use of PBS is mainly drawn from studies of learning disability and child populations, it is recognised that PBS could have a much wider utility. In this study, PBS was implemented in a medium secure forensic mental health service, a novel context. Impact was evaluated using an adapted version of the Checklist of Challenging Behaviour at baseline and then at 3 monthly intervals for a year. Significant reductions were observed in aggression frequency, management difficulty and severity and other challenging behaviour frequency and management difficulty. Reductions in challenging behaviour were still evident after six months for the full group and twelve months for the sub-group with the exception of other challenging behaviour management difficulty. In contrast, no such significant differences were found for a control group. This study indicated that PBS was an effective intervention in the management of challenging behaviour in this forensic mental health context.     

Correctional outcomes of offenders with mental disorders

While there is now a considerable literature on the extent of mental disorder (MD) within correctional settings, there is much less research on the correctional outcomes of offenders with a mental disorder (OMDs). This study contributes to that knowledge base by comparing the profiles and institutional and community outcomes of federally-sentenced Canadian offenders with, and without, a MD and examines the correctional response to their management. Results showed that OMDs had higher risk and need ratings and were more likely to be serving their current sentence for a violent offense. Outcomes for OMDs were poorer as reflected by higher rates of institutional charges and transfers to segregation, and higher rates of recidivism on release. This difference holds for the recidivism analysis, even when variables related to risk are controlled. The results demonstrate the complex needs of OMDs and points to the requirement for correctional agencies to provide specialized interventions that address both their mental health and criminogenic needs. Future research is required to examine whether type of diagnosis, particularly the degree of antisocial orientation, contribute to these poorer outcomes.     

Problems of female patients in a secure psychiatric hospital

Abstract

The problems experienced by a sample of 30 female offender-patients in a secure psychiatric hospital were surveyed using the Behavioral Coding System (BCS). Common problems are emotional difficulties, antisocial behaviors, auditory hallucinations, and self-injury. Problem profiles derived from medical records, key workers' reports, and patients' self reports differed. The survey revealed the necessity of revising the BCS better to identify relevant concerns in this particular population.     

A prospective comparative evaluation of a Criminal Justice Liaison and Diversion Service in Belfast

There is continued interest in the planning, development and implementation of services designed to identify detainees with mental illness and connect them to health and social services. However, currently, little is known about how best to configure, organise and deliver these services. The study employed a prospective follow-up design with a comparator group to describe and evaluate a police mental health liaison service based in Belfast. Participants were recruited from two neighbouring police stations, only one of which provided a mental health liaison service. Outcomes including mental health status, drug and alcohol misuse, risk-related behaviour and ‘administrative’ outcomes were assessed at the time of arrest and six months later. The service was successful in identifying and assessing detainees, though there appeared to be similar between-group levels of mental health problems over time. Results highlight a need to develop firmer linkages and pathways between criminal justice liaison/diversion services and routine health and social services.     

Sexual offenders with serious mental illness: prevention, risk, and clinical concerns

Individuals with serious and persistent mental illness who have also engaged in illegal sexual behavior present a unique challenge for our legal and clinical systems. Frequently, these individuals may engage in problematic sexual behaviors which result in hospitalization rather than incarceration, and an overburdened and resource-deficient public community mental health system is ill-equipped to address the seriousness of these sexual behaviors. We have a rather limited understanding of how prevention programs, intervention strategies, and risk assessment would work with this population. Here we evaluate data from a sample of 245 inpatient psychiatric sexual offenders in a forensic mental health setting and compare these with what information has already been presented in some of the literature. Through an examination of seriously mentally ill sexual offenders and their clinical presentation, legal history, and risk management concerns, we illustrate a variety of tertiary prevention needs. Future directions in the area of prevention and risk management for seriously mentally ill sexual offenders are also discussed.     

Demographic and clinical characteristics of 1092 consecutive police custody mental health referrals

The 43 police forces in England and Wales have made over 13 million arrests in the last decade. Yet, despite this high volume criminal justice system activity, and evidence of substantial health morbidity across the criminal justice pathway, mental health services in police custody have only been patchily developed, and the literature in this area is limited. Referrals (n = 1092) to a pilot mental health service operating across two police stations in a London borough were examined over an 18-month period in 2012/2013. The referred group had high levels of mental health and substance misuse problems (including acute mental illness, intoxication and withdrawal), self-harm, suicide risk and vulnerability (including intellectual disability), with some important gender differences. Although this work has limitations, the findings are broadly consistent with the small existing literature and they confirm the need for services that are sufficiently resourced to meet the presenting needs.     

Understanding how sexual offenders compare across psychiatric and correctional settings: examination of Canadian mentally ill sexual offenders

Abstract

Much of what is known about sexual offenders is based on correctional samples and then applied across settings based on the assumption that this group is homogeneous. In this study, 149 files were compared, including 108 cases from the forensic mental health system (FMH) and 41 cases from the correctional system (COR). Although many similarities were observed between the FMH and COR groups, the results also revealed important differences. The FMH group was characterised by more frequent hospitalisations, higher rates of major mental illness and single status. The COR group was characterised by a history of physical and sexual abuse, family history of addictions, more intrusive sexual offences and higher rates of offending. These results highlight different profiles for sexual offenders in forensic mental health and correctional settings and challenge us to consider the implications for assessment, treatment and risk management of this unique group of sexual offenders.     

Executive functioning profiles of adult and juvenile male sexual offenders: A systematic review

Evidence regarding biological correlates of sexual offending, which might enhance the understanding, research, and treatment of these offenders, is rather emerging or in the embryonic stage. In this study, our main objective is to identify specific executive functioning (EF) processes that are commonly impaired in sexual offenders, and to further determine whether these differ as a function of offender subtypes. A search is conducted in ProQuest, Criminal Justice Abstract, EBSCOhost, and Social Science Citation Index electronic journal databases for studies published spanning the period 1990–2015. Google Scholar and Google search engines were also searched and the reference lists of the retrieved papers were searched for additional papers. A total of 1303 papers were retained for consideration. After removing duplicates, and subjecting the retrieved papers to inclusion and exclusion criteria, 24 papers (19 published and 5 unpublished) were deemed appropriate for the review. While several EF processes have been investigated, the available evidence implicates deficits in cognitive flexibility and inhibition of interference as commonly reported among adult male sexual offenders. This finding may be due to the sensitivity of tests of cognitive flexibility (e.g. the Wisconsin Card Sorting Test) and inhibition of interference (e.g. the Stroop Test) to frontal lobe lesions, and also because these tests are among the most frequently administered EF tests as revealed by this study. Juvenile sexual offenders, however, exhibit no distinct EF profiles. The findings of the study, implications for treatment, and recommendations for future studies are succinctly discussed.     

Music therapy for improving mental health problems of offenders in correctional settings: systematic review and meta-analysis

Objectives

The aim of this review was to assess the effectiveness of music therapy on improving the mental health of offenders in correctional settings.

Methods

Multiple databases and journals were searched to identify randomized controlled trials and quasi-randomized controlled trials of music therapy for offenders in correctional settings.

Results

Five studies (n?=?409; predominantly male) were included in random-effects meta-analyses. Music therapy was effective for promoting offenders’ self-esteem (Hedges’ g?=?0.55, p?<?0.001) and social functioning (g?=?0.35, p?<?0.05). Effects on anxiety and depression depended on the number of sessions. For both outcomes, the studies with 20 or more sessions had larger effects than the study that had fewer than 20 sessions, and this difference was statistically significant (Q?=?11.88, df?=?1, p?<?0.001, anxiety; Q?=?9.16, df?=?1, p?=?0.002, depression). No significant effects were found on behavior management or between different music therapy approaches.

Conclusions

Music therapy may be helpful for offenders to improve mental health. Future studies should consider including offenders of both genders, using larger sample sizes, and examining long-term effects. Publication bias may be an issue for this review given the small number of studies and the small sample sizes.

     

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.