Aggression control therapy for violent forensic psychiatric patients: method and clinical practice

Aggression control therapy is based on Goldstein, Gibbs, and Glick's aggression replacement training and was developed for violent forensic psychiatric in- and outpatients (adolescents and adults) with a (oppositional-defiant) conduct disorder or an antisocial personality disorder. First, the conditions for promoting "treatment integrity" are examined. Then, target groups, framework, and procedure are described in detail, followed by the most important clinical findings during the period 2002 to 2006. Finally, new programme developments are mentioned, with aggression control therapy as a starting point.     

The precarious practice of forensic psychiatric risk assessments

The development of forensic psychiatric risk assessments is discussed from a clinical point of view using the example of Sweden. A central task in forensic psychiatry has traditionally been to identify dangerous, mentally disordered subjects considered to be prone to commit violent acts. Over time, “dangerousness” has been reworded into “risk”. Nevertheless, such assessments have generally been based on the psychiatric factors characterising the individual patient, while group interaction, situational factors, or social and cultural circumstances, such as the availability of alcohol and drugs, have been largely overlooked. That risk assessments have a focused on people with a diagnosis of “mental disorder” and been used as grounds for coercive measures and integrity violations has somehow been accepted as a matter of course in the public and political debate. Even the basic question whether offenders with a mental disorder are really more prone to criminal recidivism than other offenders seems to have been treated light-handedly and dealt with merely by epidemiological comparisons between groups of persons with broad ranges of psychosocial vulnerability and the general population. Legal texts, instructions and guidelines from the authorities in charge are often vague and general, while actors in the judicial system seem to put their trust in psychiatric opinions. The exchange of professional opinions, general public expectations, and judicial decision processes poses a huge risk for misunderstandings based on divergent expectations and uses of terminology.     

The clinical picture and forensic psychiatric evaluation of psychogenic states in minor victims

Two groups of adolescent victims of sexual assault were studied, conformities of psychogenic state occurrence were analysed, age characteristics of their clinical course and dynamics were studied. Problems of forensic psychiatric evaluation of mental state of adolescent victims at different stages of judicially significant situation were developed.     

The impact of forced forensic psychiatric confinement on composition and structure in the personal networks of personality-disordered forensic psychiatric patients

This study explored to what extent the composition and structure of personal networks of personality-disordered forensic psychiatric patients changed before and after forced confinement in a forensic psychiatric centre. Semi-structured in-depth interviews with 36 patients and selected members of their networks were examined. During forensic psychiatric treatment, patients reported a decrease in network size, in the number of high-risk network members, and in the number of social ties between these high-risk network members. Personal relationships were of shorter duration, with lower levels of contact frequency and reciprocity. No changes were observed in the patients’ companionship, practical and emotional support networks. During forensic psychiatric treatment, patients reported some new relationships, especially with persons outside the forensic psychiatric centre. Information on compositional and structural personal network factors over time helps forensic mental health professionals to properly assess and manage the important dynamic social network conditions associated with recidivism.     

Psychological assessment of forensic psychiatric outpatients

The 1960s decrease in long-term residential mental health care resulted in former psychiatric patients being admitted to correctional and forensic psychiatric facilities. Although psychologists face challenges in managing and treating this displaced population, assessment data plays a pivotal role in the determination of appropriate aftercare for the mentally ill parolee. This article discusses the assessment protocol utilized by the Forensic Conditional Release Program (CONREP) in California, summarizes data from these patients, and uses case excerpts to illustrate the potential value of assessment with a forensic psychiatric (outpatient) population. Special emphasis is given to the use of the MMPI-2 and Rorschach.     

Profile of forensic state patients at a psychiatric unit in KwaZulu Natal,South Africa: demographic,clinical and forensic factors

State patients are mentally ill offenders whose charges involved serious offences. Research on association between psychiatric morbidity and offences is important however data from Southern Africa is limited. To examine the demographic, clinical and forensic characteristics of state patients, and to evaluate the determinants of offending by an investigation of the association between mental illness and other variables (offence, comorbidity). Retrospective record review of state patients admitted to a forensic unit in KwaZulu-Natal from the 1 June 2013 to the 31 May 2016. Most patients were male (n = 90, 98.90%), single (n = 89, 97.8%), unemployed (n = 89, 97.80%) and had a diagnosis of intellectual disability (n = 33, 36.26%). Majority of participants had comorbid diagnoses (n = 70, 76.92%) and most of them (n = 52, 57.14%) had substance use disorder. Forty (43.96%) patients had past forensic history and 18 (72.5%) were non-adherent with treatment. Offences were predominantly against persons (n = 80, 87.91%), and rape was the most common offence (n = 50, 54.95%). Findings regarding diagnosis and offence were not consistent with the literature and suggest the need to explore the differences further. A better understanding of the association between mental health and crime in resource restrained settings may assist in developing appropriate prevention and rehabilitation programmes.     

Forty-five revolutions per minute: a qualitative study of Hybrid Order use in forensic psychiatric practice

Psychiatrists who recommend a Hybrid Order (Section 45A) as a disposal option at the point of sentencing accept that the convicted individual, as well as being mentally disordered and in need of treatment, is also culpable and deserving of criminal punishment. Ethical and clinical concerns have typically limited its clinical use. However, in 2015 the Court of Appeal specified in R v Vowles and others that the Hybrid Order disposal should be considered first in terms of potential mental health disposals. This judgement sets a high threshold for the use of the hospital order which has been the bedrock of inpatient forensic psychiatric practice since 1983. This study sought to explore the attitudes of consultant forensic psychiatrists towards the use of the Hybrid Order in the wake of the Vowles judgement. We interviewed 12 consultant forensic psychiatrists with longstanding experience of psychiatric sentencing recommendations. We found that the majority of consultants considered the Hybrid Order to be a valuable disposal option when used under specific circumstances. However, significant concerns were raised about its use in those with an enduring psychotic illness. Community aftercare arrangements for Hybrid Order disposals were viewed as inferior to community aftercare arrangements for Section 37/41 patients.     

Substance use disorders in forensic psychiatric patients

There is a lack of detailed information on the role of substance use disorders (SUD) as a substantial factor in offences and treatment in forensic psychiatric patients. The aim of this study was to get a better understanding of these specifics. Clinical records of 193 male patients admitted to a Dutch forensic psychiatric hospital were scrutinized on anamnestic, diagnostic and risk assessment data. One of the central findings was that the prevalence of SUDs was high. Patients with an SUD had a more extensive criminal history, unstable and deviant lifestyle and higher risk of violent behavior than patients without a substance use disorder. No differences were found in duration of treatment, aggressive incidents and leave. Another important finding was that a distinction could be made between patients with substance use as a primary criminogenic risk factor and patients with substance use as a secondary risk factor. Although substance use is identified as a general risk factor, this study supports the idea of sub categorization of patients with an SUD and emphasizes the need for a different treatment approach. Further study is needed to identify specific treatment approaches, based on more differentiated profiles of these patients.     

Alexithymia in Dutch violent forensic psychiatric outpatients

Abstract

Until now alexithymia has not been investigated in Dutch low-educated offenders who are known for their violent behaviour. We therefore investigated a sample of aggressive forensic psychiatric outpatients, who are characterized by emotional dysregulation in conflict situations. For that purpose we used a Dutch questionnaire, the Bermond-Vorst Alexithymia Questionnaire (BVAQ; Vorst & Bermond, 2001), which we also administered in a sample of secondary vocational students for a comparison. Unfortunately, the five-factor structure of the BVAQ could not be confirmed in both samples, but in the patient sample the test-retest reliability of the total score turned out to be moderate, and meaningful correlations were found with measures of relevant personality domains and problem behaviours. When both samples were compared, patients were found to display significantly higher total scores on the BVAQ than the secondary vocational students, when controlled for age. Therefore, we concluded that alexithymia may contribute to the aggressive behaviour of violent forensic psychiatric outpatients. However, patients as well as students had much higher total scores on the BVAQ than found by Vorst and Bermond (2001) in a sample of Dutch psychology students. This indicates that alexithymia as measured by the BVAQ is also inversely related to educational level and perhaps to intelligence.