Accountability and psychiatric disorders: How do forensic psychiatric professionals think?

Swedish penal law does not exculpate on the grounds of diminished accountability; persons judged to suffer from severe mental disorder are sentenced to forensic psychiatric care instead of prison. Re-introduction of accountability as a condition for legal responsibility has been advocated, not least by forensic psychiatric professionals. To investigate how professionals in forensic psychiatry would assess degree of accountability based on psychiatric diagnoses and case vignettes, 30 psychiatrists, 30 psychologists, 45 nurses, and 45 ward attendants from five forensic psychiatric clinics were interviewed. They were asked (i) to judge to which degree (on a dimensional scale from 1 to 5) each of 12 psychiatric diagnoses might affect accountability, (ii) to assess accountability from five case vignettes, and (iii) to list further factors they regarded as relevant for their assessment of accountability. All informants accepted to provide a dimensional assessment of accountability on this basis and consistently found most types of mental disorders to reduce accountability, especially psychotic disorders and dementia. Other factors thought to be relevant were substance abuse, social network, personality traits, social stress, and level of education.     

Sexsomnia – a forensic psychiatric challenge – a case report

In rare penal cases, a defendant makes a claim that he or she was asleep at the time of an alleged crime. This article discusses a case of alleged sexsomnia where a man claimed that he had been asleep during a sexual encounter (rape) with a woman. The question that often arises during an investigation and in court is how complex a behaviour is someone able to perform and still be asleep? To assist the court in answering this question, forensic psychiatric experts may be appointed. But the experts were not present during the act and must therefore consider each case on the basis of the available information and existing research. This paper provides a brief overview of the research regarding sexsomnia. It will also discuss what kind of information is important to elaborate in these cases in order to clarify the premises for the experts’ conclusions to the court.     

Improving caregiver attendance at forensic service users’ psychiatric clinic appointments

In Singapore, families play an important role caring for mentally disordered offenders. They are particularly important in cases where courts oblige psychiatric assessment, because they provide corroborating information not otherwise volunteered. However, their attendance is generally low. Our quality improvement project sought to increase caregiver attendance at outpatient visits. We followed WHO guidelines for quality improvement, determined the root cause of poor attendance, and devised three Plan–Do–Study–Act cycles over six weeks in late 2013. We followed their impact for 12 months. Case managers and medical social workers implemented three strategies to address issues of poor communication and awareness, which led to poor attendance. Prior to our project, caregivers attended 47% of outpatient visits. Following the implementation of our strategies, rates rose to 70%, sustained over the 12 following months. The entire case management department adopted our strategies. Simple changes to standard operating procedures improved the rate of caregiver attendance at follow-up appointments.     

Individuals’ experiences of sexual offending therapy in a forensic psychiatric setting

There is a paucity of research exploring individuals’ experiences of sexual offending therapy, particularly in forensic psychiatric settings. This study qualitatively explored the perspectives of six male medium-secure patients regarding the treatment programme they completed to address their sexual offending behaviour. Thematic analysis of interviews generated two themes: the experience of transition through the programme and the experience of engagement. The importance of gaining service-user feedback and the implications for programme design and delivery are discussed.     

De Clérambault's Syndrome (Erotomania) and claims of psychiatric malpractice

De Clérambault's Syndrome or Erotomania was originally described as a delusional disorder in which a woman believes that an older man of higher social status is passionately in love with her. The patient's relentless pursuit of the delusional love object, often with escalating intrusiveness, may eventually involve threats or overt acts of retaliation, in response to repeated rejection, unrequited love, or alleged betrayal. Cases from the literature are reviewed in which the delusional romantic attachment involves the patient's psychiatrist or another medical specialist. The authors present a case involving a patient suffering from erotomania who develops a delusional fixation on her psychiatrist and, after her advances are repeatedly rejected, sues him for malpractice, alleging she had a sexual relationship with him in the course of treatment. The implications of the litigious paranoid, who uses the legal system to act out delusional concerns and retaliatory fantasies, are discussed. This is the first known case of an erotomanic patient claiming malpractice on the grounds that her psychiatrist had a sexual relationship with her.     

Prisoners with psychosis in England and Wales: diversion to psychiatric inpatient services?

The prevalence of psychosis among prisoners in England and Wales is ten times that in the household population and UK government policy is that prisoners should receive equivalent care to those in the community. This study investigated the implications of policy to divert more from the criminal justice system for psychiatric treatment. Psychotic prisoners were compared with psychotic persons in households and with other prisoners in two surveys of psychiatric morbidity in representative samples of the UK population. Psychotic prisoners were younger, more from ethnic minorities, with comorbid anxiety, substance misuse, ASPD, and childhood behavioural problems compared to psychotic persons in households. Less than a third had received previous inpatient treatment. Psychotic prisoners had similar criminal histories and higher psychopathy scores than non-psychopathic prisoners. Diversion is unfeasible without improved screening for psychosis and increasing bed numbers at higher levels of security to accommodate more patients who would pose high risk to the public. Future research should investigate why UK psychiatric services fail to identify psychotic prisoners and provide aftercare.     

The effects of psychiatric and “biological” labels on lay sentencing and punishment decisions

Objectives

This research, using focal concerns perspective on sentencing, examines how and why psychiatric labels, and having diagnoses biologically “labeled,” affect sentencing beliefs. Dimensions of public stigma toward psychiatric illnesses are hypothesized to mediate sentencing views.

Methods

This is a 2?×?2 partially-crossed, between-subjects multifactorial experiment with a lay sample (n=?1213), presenting mediation analyses.

Results

Four psychiatric labels (Attention Deficit Hyperactivity Disorder, behavioral-variant Frontotemporal Dementia, High Functioning Autism, Borderline Intellectual Disability) led to significant beneficial effects on sentencing (less prison/rehabilitation support) as mediated by decreased stigmatization regarding lack of treatability, social acceptance, and personal responsibility. One biological “label” (Pedophilic Disorder) was mediated by decreased stigmatization (dangerousness), resulting in less prison support.

Conclusions

Data support effects of psychiatric labeling on sentencing under focal concerns. As no psychiatric labels resulted in increased discriminatory sentencing and, instead, led to decreased discriminatory sentencing behavior, psychiatric labeling may reduce punitiveness and bolster non-punitive sentencing beliefs. Biological labeling, aside from Pedophilic Disorder, may not affect sentencing.

     

When doctors divulge: is there a "threat from within" to psychiatric confidentiality?

Psychiatrists, as a profession, have always asserted the central importance of confidentiality. The American Psychiatric Association (APA), in its recently released "Guidelines on Confidentiality," reaffirms this position. In an age of progressive erosion of the traditional psychiatrist-patient confidentiality, the threat to confidentiality is invariably perceived as exogenous, emanating from external sources such as the legal system, third-party payers, and peer review organizations. In rare instances, there appears to be a threat from within, when the psychiatrist (or nonpsychiatrist physician dealing with a psychiatric patient) deliberately chooses to divulge the patient's confidential communications in the absence of any clearcut legal requirement to do so (and against the express wishes of the patient). Four case examples of these unusual breaches of confidentiality are presented. The author concludes that although significant assaults on patient confidentiality are occurring from without, it is quite rare for such violations to come from within the profession itself.     

Transfers of mentally disordered adolescents from custodial settings to psychiatric hospital in England and Wales 2004–2014

This article has used data provided by the Ministry of Justice to track changes in the number of adolescents under the age of 18 transferred from secure custodial institutions, who have required transfer to psychiatric hospital using Section 47 and Section 48 of the Mental Health Act. During the period 2004–2014 there were large reductions in the population of young people detained in custody in England and Wales. The number of young people requiring hospital transfer fell during this period but to a much lesser degree. The possible reasons for this are discussed and include the increased complexity of young people in custody and the increased availability of secure psychiatric beds.     

Who’s going to leave? An examination of absconding events by forensic inpatients in a psychiatric hospital

Absconding is a potentially risky event that has wide reaching consequences both for the institution and greater community; however, few studies have examined the characteristics of clients who abscond, their motivations, and details about their absconding event, especially within a forensic context. The purpose of this research was to determine if risk factors could be identified that might predict absconding behavior. A retrospective chart review was conducted of all reported absconding events between 1 January 2012 and 31 August 2015 by clients on forensic units in a public psychiatric hospital in Ontario, Canada. In addition, these clients were matched with a comparison group. Categories of motivations for absconding including goal-directed, frustration/boredom, symptomatic/disorganized, and impulsive/opportunistic were identified. The best indicator of a client’s risk for absconding was having experienced a stressful, significant event in the two weeks prior to the absconding event. Additionally, total scores on the HCR-20 and the presence of a co-occurring substance use disorder differentiated the absconders from the comparison group. This research contributes to our knowledge base regarding absconding events by forensic psychiatric patients and highlights specific targets for clinical staff in assessing risk for absconding and managing privileges leading to more effective care planning.     

The clinician–patient working alliance: is it a significant predictor of psychiatric medication adherence in a sample of recently released parolees?

Persistent psychiatric symptoms can serve as a major barrier to the successful reintegration of parolees with mental illness. Thus, it is important to identify factors that might impact their mental health recovery, such as low adherence to their treatment regimen. The strength of the clinician/patient working alliance has been found to be significantly associated with psychiatric medication adherence in prior research, but this relationship has not been assessed in a parolee population. Logistic regression analysis was used to determine if patient-rated working alliance was a significant predictor of low psychiatric medication adherence while taking into account alcohol/illegal drug use, age, and ethnicity in a sample of recently released parolees with mental illness (N = 49). Patient-rated working alliance, age, and ethnicity were not significant predictors of low adherence. Alcohol/illegal drug use during the follow-up period was associated with a significantly increased likelihood of meeting the criteria for low medication adherence (OR = 8.36; 95% CI = 1.60, 43.66). While working alliance was not found to be a significant predictor of medication adherence in this study, further research is needed to examine how substance misuse impacts the clinician–patient working alliance in this population.