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.     

Outcome measurement in forensic mental health research: an evaluation

Abstract

Measuring change resulting from healthcare interventions is critical to evaluating their usefulness. The choice of outcome measure is an important part of such evaluations and is driven by assumptions about what is likely to change and how best to capture this. Despite its importance, forensic mental health has paid little attention to determining which are the best measures of outcome. This study used a panel of relevant professionals to (i) assess the relative importance of different areas of potential outcome measurement and (ii) evaluate specific instruments used currently as outcome measures in forensic mental health research. Although a wide range of potential outcomes were endorsed as appropriate, few corresponding instruments have been used consistently. Only three psychiatric instruments deemed by our panel as feasible, relevant and psychometrically adequate have been used in five or more studies (the Beck Depression Inventory; the Brief Psychiatric Rating Scale, and the Symptom Checklist-90–Revised). Significant measurement gaps were noted in areas such as social and emotional functioning. Although instruments exist that could capture most areas, none were sufficiently developed for routine use as outcomes. Further research to develop robust, sensitive and diverse outcome measures is needed. This is an essential precursor to extending the evidence base for forensic mental health interventions.     

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.     

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.     

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.     

A model process for forensic mental health screening and evaluation

This article describes an operational definition and a model process for forensic mental health examinations developed on the bases of field research, reviews of literature and other documentary materials, and a survey of forensic mental health programs. Forensic mental health screening and evaluation is defined as the process conducted by mental health personnel, at the direction of criminal justice authorities, for the purposes of delineating, acquiring, and providing information about the mental condition of client-offenders that is useful in decision making in the criminal justice system. The proposed model encompasses 14 pragmatically oriented steps within three major structural components of the examination process—delineation, acquisition, and provision—in a manner that places the entire process in the functional context of the criminal justice and mental health systems. The definition and model are aimed at practitioners, program evaluators, and policy makers to be used as a starting point for the establishment of standards against which the practices and policies relating to forensic mental health screening and evaluation can be compared and improved.The preparation of this article was supported in part by a grant (No. 79-NI-AX-0070) by the National Institute of Justice. The views expressed are those of the author and do not necessarily reflect the positions of the National Institute of Justice or the National Center for State Courts. The author thanks his colleagues for their assistance and advice during the study upon which this article is based, as well their critical reviews of earlier documents related to this work. The comments and suggestions of Amiran Elwork and an anonymous reviewer are also gratefully acknowledged.     

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.     

Distinguishing between forensic science and forensic pseudoscience: Testing of validity and reliability,and approaches to forensic voice comparison

In this paper it is argued that one should not attempt to directly assess whether a forensic analysis technique is scientifically acceptable. Rather one should first specify what one considers to be appropriate principles governing acceptable practice, then consider any particular approach in light of those principles. This paper focuses on one principle: the validity and reliability of an approach should be empirically tested under conditions reflecting those of the case under investigation using test data drawn from the relevant population. Versions of this principle have been key elements in several reports on forensic science, including forensic voice comparison, published over the last four-and-a-half decades. The aural–spectrographic approach to forensic voice comparison (also known as “voiceprint” or “voicegram” examination) and the currently widely practiced auditory–acoustic–phonetic approach are considered in light of this principle (these two approaches do not appear to be mutually exclusive). Approaches based on data, quantitative measurements, and statistical models are also considered in light of this principle.     

AIDS-related dementia and competency to stand trial: a potential abuse of the forensic mental health system?

Public health officials, hospital administrators, forensic directors, jail wardens, judges, prosecutors, and defense attorneys must confront the issue: how should cases of individuals with AIDS dementia be treated when they are found to be permanently incompetent to stand trial? Although charges are sometimes dismissed in advanced cases of dementia, the more common pattern involves placement of the defendant in a public facility while awaiting trial. The refusal of some state facilities to accept these patients raises a host of legal, moral, and medical questions that virtually every urban state's forensic system will have to consider in the near future.     

Implementing violence and incident reporting measures on a forensic mental health unit

The assessment of risk and prediction of violence in mental health units can play a large role in creating a safer environment for both the staff and the patients. Nurses in forensic units are in a unique position in regards to assessment of violence as they spend a great deal of time with the patients. Nurses on a forensic mental health unit scored the Brøset Violence Checklist (BVC) twice daily for 12 weeks for all patients either resident on or admitted to the unit (N?=?46). The Staff Observation Aggression Scale-Revised (SOAS-R) was used to report any adverse incidents (N?=?51). Data were examined at the both the item and scale level. Main results showed the area under the curve values of the BVC score, slide rule, and the sum of BVC and slide rule score in turn demonstrated strong predictive accuracy for inpatient aggression (0.68–0.73). Through logistic regression analyses the BVC uniquely predicted inpatient aggression but adding the slide rule did not improve prediction. Predictive accuracy was found across three diagnostic groups – dementia, psychosis and substance use disorders. These results provide further support on the predictive accuracy of the BVC for short-term violence in forensic mental health settings.     

Associations between ward climate and patient characteristics in a secure forensic mental health service

Ward climate is associated with patient satisfaction and, potentially, with improved outcomes but increased understanding of its relationship with individual patient characteristics is required. We investigated relationships between patient (N?=?63) gender, perceived risk, risk behaviour, therapeutic engagement (session attendance), psychopathology and ward climate in a forensic psychiatric hospital. Lower security levels were significantly associated with better patient cohesion (PC), experienced safety (ES) and therapeutic hold (TH). Female gender predicted PC and ES. Higher perceived risk was associated with lower PC after controlling for security level and gender. Diagnosis of personality disorder or psychosis was associated with higher ES. Lower levels of engagement predicted greater TH. The relationship between patient characteristics and ward climate in forensic settings is complex. Prospective studies are needed to further establish determinants of ward climate, particularly those aspects of patient risk that are associated with poorer PC.     

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.

     

Unlocking the potential of forensic traces: Analytical approaches to generate investigative leads

Forensic investigation involves gathering the information necessary to understand the criminal events as well as linking objects or individuals to an item, location or other individual(s) for investigative purposes. For years techniques such as presumptive chemical tests, DNA profiling or fingermark analysis have been of great value to this process. However, these techniques have their limitations, whether it is a lack of confidence in the results obtained due to cross-reactivity, subjectivity and low sensitivity; or because they are dependent on holding reference samples in a pre-existing database. There is currently a need to devise new ways to gather as much information as possible from a single trace, particularly from biological traces commonly encountered in forensic casework. This review outlines the most recent advancements in the forensic analysis of biological fluids, fingermarks and hair. Special emphasis is placed on analytical methods that can expand the information obtained from the trace beyond what is achieved in the usual practices. Special attention is paid to those methods that accurately determine the nature of the sample, as well as how long it has been at the crime scene, along with individualising information regarding the donor source of the trace.     

Perceptions and use of videoconferencing in forensic mental health assessments: A survey of evaluators and legal personnel

ABSTRACT

The use of videoconferencing (VC) to conduct forensic mental health assessments (FMHA) is increasing. Yet, little is known about its acceptability among clinicians or legal professionals. In Study 1 (N?=?156), forensic evaluators were asked about their use of VC, reasons for its use, and opinions about the validity, usefulness, ethics, and legality of its use. An estimated one-third of evaluators have used VC in the past. Although evaluators overall expressed moderate concern over the ethics and legality of use, prior experience appeared to mitigate concerns. Younger practitioners were also more open to using VC. Reduced costs for courts was the most frequently endorsed benefit associated with VC, while restricted ability to administer psychological testing and potential technological problems were seen as the biggest disadvantages. In Study 2 (N?=?27), attorneys and judges were surveyed about frequency with which they encounter VC for FMHA and their perceptions about the validity of those assessments. Findings indicated legal personnel expressed rather negative views without having much first-hand experience of VC, including concerns about establishing rapport and technical difficulties. These studies have implications for whether VC will be adopted more frequently in FMHA.     

Macroscopic assessment of environmental trace evidence dynamics in forensic settings

Environmental trace evidence offers useful circumstantial intelligence to link persons and scenes of forensic interest. An increasing empirical research base is dedicated towards understanding the transfer and persistence dynamics of environmental indicators including pollen, soils, and diatoms, within a diverse range of experimental frameworks. This paper presents two discrete studies exploring transfer and persistence of soils and sediments on footwear and diatomaceous earth adhered to clothing in forensically pertinent scenarios. Variables including sediment type, foot position, clothing type, and body positioning were also explored throughout. Both experiments incorporated a field-based methodology during the sampling effort. Photographs were collected of an initial transfer sample and of a retained assemblage following hours, days, and up to one-week of wear, facilitating macroscopic assessment of trace evidence dynamics. All images were processed using accessible, open-source software before spatial analysis of evidence distribution within and temporal assessment (% retention) upon each evidential surface. The results highlighted consistent loss of transferred sediment from footwear with significantly greater retention of loamy clay soil than dune sand which was absent beyond 24 h of wear. Loss was not influenced by wearer gait but was more rapid from those areas of the shoe sole in direct contact with the ground. Diatomaceous earth was retrieved from all three clothing types tested after one week – significant losses of material occurred before 48 h with a consistent assemblage identified beyond this. Denim was significantly more effective than acrylic and fleece for diatomaceous earth retention and significantly more material was lost from clothing worn on the lower body. These findings highlight the value of using visual environmental markers and a macroscopic analytical approach during the investigation of environmental trace dynamics. The methodology offers a novel, non-destructive assessment of soil and diatom transfer and persistence, complementing more extensive laboratory-based examinations to ensure the development of a well-rounded research base within the forensic sciences.