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.     

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.     

Mental disorder in violent women in secure settings: Potential relevance to risk for future violence

The relevance to women of common violence risk factors identified in men has in many instances yet to be established. Consequently, there is a reluctance to accept without question the application to women of practices relating to violence risk assessment and management developed from research into men. This study examines mental disorder in women who are violent in order comment on its relevance to the practice of violence risk assessment and management. A sample of 95 violent women in high secure prison and forensic psychiatric care were assessed. Structured assessments of Axis I and II mental disorders and psychopathy were undertaken on all women and conviction histories were recorded. Very high levels of psychiatric morbidity were noted and patterns in comorbidity were detected. Among Axis I conditions, psychotic disorders and disorders of mood co-occurred at a very high rate. Among the Axis II conditions, dimensional ratings of borderline personality disorder (PD) correlated with dimensional ratings of avoidant, dependent and paranoid PDs while ratings of antisocial PD correlated with those of narcissistic, histrionic and obsessive–compulsive PDs. Women who had been incarcerated for a major violent offence were four times more likely to have a diagnosis of borderline PD than women whose index offence was one of minor violence. A number of the findings reported are in contrast to those reported in similar studies of men. Findings suggest that practitioners are right to question the application to women of knowledge derived from research into men. The practice of violence risk assessment and management with women should emphasise the development of individual risk formulations and responding to psychiatric comorbidity should be the rule rather than the exception with this population.     

Characteristics and personality profiles of first 100 patients admitted to a secure forensic adolescent hospital

Bluebird House is a mixed-gender adolescent medium-secure forensic unit. There is a paucity of data available about this unique patient group. We aimed to explore the demographic, clinical and personality characteristics of the first 100 patients admitted to a mixed-gender adolescent medium-secure forensic unit. We used a retrospective cross-sectional study of the first 100 consecutive patients admitted to Bluebird House. Demographic and clinical data were collected from the medical notes including the Millon Adolescent Clinical Inventory. The first 100 young people admitted to an adolescent medium-secure unit have had very high incident rates, particularly amongst the females. Incident rate was correlated with a history of sexual assault in female patients. The males were more likely to have been referred from custody and more likely to have a diagnosis of psychosis or autism. We describe similarities and differences to the first 100 admissions admitted to the first secure psychiatric unit for adolescents in Manchester over 20 years ago.     

Using the National Diabetes Audit to improve the care of diabetes in secure hospital in-patient settings in the UK

To examine the ability of two forensic units, one high secure and one medium secure, to meet the NICE (National Institute for Health and Care Excellence) standards of care for diabetes. We applied the National Diabetes Audit programme, which uses as standards the NICE guidelines, to assess the quality of care provided for patients in two forensic units. Of the 500 patients, 200 in high secure and 300 in medium secure, 88 (17.6%) had type 2 diabetes. None had Type 1 diabetes. Of those with Type 2 diabetes, the care of 74 (84%) met all 8 NICE recommended standards. Glucose levels were lower in the medium/low secure unit compared to the higher security environment. Whilst achievement of process-based outcomes was higher than those reported nationally, achieving clinical outcomes was more challenging. High-quality diabetic care can be provided for patients in forensic units. Benchmarking physical health outcomes against national criteria in mental health inpatients is a potential method of improving outcomes.     

Assessing change in dynamic risk factors in forensic psychiatric inpatients: relationship with psychopathy and recidivism

This study explored change in dynamic risk for violence using the Clinical and Risk Management subscales of the Historical Clinical and Risk Management-20 version 3 (HCR-20 v3) and sought to determine whether change was associated with violent recidivism. The association between the magnitude of change and psychopathy was also assessed. Participants were 40 male (n = 32) and female (n = 8) forensic psychiatric inpatients discharged from a secure forensic mental health service. Results showed that participants significantly improved on the HCR-20v3 Clinical subscale but significantly worsened on the Risk Management subscale. Psychopathy was unrelated to change in Clinical and Risk Management subscales. The hypothesis that changes in dynamic risk would predict recidivism over and above total pre-treatment risk (HCR-20v3 Total score) and psychopathy was not supported. These results suggest that improvements in mental state risk factors alone are insufficient with regard to lowering violence risk.     

Characteristics of female patients admitted to an adolescent secure forensic psychiatric hospital

Bluebird House is the only mixed gender NHS secure forensic psychiatric hospital for adolescents in the South of England. It has admitted more than 30 female patients since the service opened in 2008. The admission criteria are that patients must be detained under the Mental Health Act and present evidence of being a risk of harm to others. This article describes the clinical characteristics of 30 consecutive female patients admitted to a highly specialised adolescent forensic inpatient service. Key results include a very high rate of incidents of risk behaviours exhibited by female patients within the unit but good clinical outcomes. The majority of patients had severe symptoms of mental disorder, especially emotional instability, self-harm behaviours and aggressive behaviours. Few had diagnoses of mental illness. Assessment findings from the Millon Adolescent Clinical Inventory and the Structured Assessment of Violence Risk are discussed, as are parallel with studies from other female secure services.     

Variations in mental health problems, substance use, and delinquency between African American and Caucasian juvenile offenders: implications for reentry services

The incarceration of young people is a growing national problem. Key correlates of incarceration among American youth include mental health problems, substance use, and delinquency. The present study uses a statewide sample of incarcerated youth to examine racial differences in African American and Caucasian juvenile offenders' outcomes related to mental health, substance use, and delinquency. The data indicate that relative to Caucasian offenders, African American offenders report lower levels of mental health problems and substance use but higher levels of delinquent behavior such as violence, weapon carrying, and gang fighting. The data further reveal that African American offenders are more likely than Caucasian offenders to be victims of violence and to experience traumatic events such as witnessing injury and death. Recognition of these patterns may help to improve postrelease services by tailoring or adapting preexisting programs to patterns of risk factors and their relative magnitudes of effect.     

Violent girls in adolescent forensic care are more often psychotic and traumatized than boys in the same level of care

Background: Most research on violent perpetrators is based on male samples. Aims: To compare girls and boys admitted to an adolescent forensic unit due to physically violent and/or sexually coercive behavior. Methods: On an adolescent forensic ward, demographics, family, treatment, crime and victimization histories, diagnose, psychiatric symptoms and violent behaviors during care of all adolescents are collected in a cumulative database. These were compared between girls and boys admitted due to violent behaviors. Results: Girls were more often diagnosed with schizophrenia group psychoses. The symptom profiles and violence risk ratings did not differ by sex. The girls were less antisocial in general. They were more suicidal and displayed more promiscuous behaviors, and they had more commonly been victims of sexual abuse. During inpatient care they displayed much more often violent and uncontrollable behaviors than the boys. Conclusion: Treatment approaches that respond to the special needs of aggressive girls are required.     

Violent women: a multicentre study into gender differences in forensic psychiatric patients

To gain insight into the relatively small, but increasing group of women in forensic psychiatry, a retrospective multicentre study was started gathering information from the files of 275 female patients of four Dutch forensic psychiatric hospitals on characteristics and violence risk factors. Overall, a picture emerged of severely traumatized women with complex psychopathology with multiple previous treatment failures and many incidents during treatment. The present study investigates specific psychiatric and criminal characteristics of female patients by comparing their data to those of 275 male forensic psychiatric patients. Various prominent differences were found, for example, women had more complex histories of victimization, were more often diagnosed with borderline personality disorder, were more likely to commit homicide and arson and less likely to commit sexual offenses, and were more often involved in inpatient aggression than their male counterparts. Several recommendations for gender-responsive treatment and directions for future research are provided.     

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.     

Deceptive behaviour and instrumental violence among psychopathic and non-psychopathic violent forensic psychiatric patients

Deceptive behaviour and instrumental violence are well-known psychopathic features and as such play important roles in the assessment of psychopathy. This study examined first, the nature of the violence committed by offenders that have been admitted to forensic psychiatric care and whether scores on the Psychopathy Checklist: Screening Version (PCL:SV), Part 1, were associated with the instrumentality of violence. Second, we examined the proneness of offenders to re-frame the instrumentality in their past violent crimes, and whether this was associated with scores on the PCL:SV. The results show that the PCL:SV, Part 1 (interpersonal/affective features), was positively related to the officially coded instrumentality of the violent crimes. As expected, this association disappeared when the instrumentality was self-reported. However, the majority of the patients tended to exaggerate the reactivity of their violent crimes when it was self-reported, indicating that most offenders, independently of level of psychopathy, used deception when questioned about the characteristics of their past violent crimes. The reasons for, and implications of, the use of deception are discussed.     

Mental Disorder, Violence, and Gender

Recent studies have reported comparable rates of violence among men and women with mental disorder, raising important issues for clinical risk assessment. This study examines the relationship between gender and violence using data from the MacArthur Violence Risk Assessment Study. Patients in acute psychiatric wards were interviewed 5 times over the year following their discharge to the community. Results showed some differences between men and women in the violence committed immediately following discharge, with rates for men being higher. But the prevalence of violence over the 1 year was similar for female and male discharged patients. However, there were substantial gender differences in the situational context of the violence committed. Men were more likely to have been drinking or using street drugs, and less likely to have been adhering to prescribed psychotropic medication, prior to committing violence. The violence committed by men was more likely to result in serious injury than the violence committed by women, and men were more likely than women to be arrested after committing a violent act. Women were more likely to target family members and to be violent in the home.     

Poor parenting and antisocial behavior among homeless young adults: links to dating violence perpetration and victimization

Though research has examined risk factors associated with street victimization among homeless young people, little is known about dating violence experiences among this group. Given homeless youths' elevated rates of child maltreatment, it is likely that they are at high risk for dating violence. As such, the current study examined the association between child maltreatment and parental warmth with dating violence perpetration and victimization through substance use and delinquency among a sample of 172 homeless males and females. Results from path analysis revealed that physical abuse, sexual abuse, and neglect were all significant correlates of both substance use and delinquency, whereas lack of parental warmth was only associated with substance use. Neglect and substance use had direct effects on dating violence and substance use and was found to mediate the relationship between physical abuse and dating violence. Finally, females, older youth, and non-Whites had significantly higher levels of dating violence compared with their counterparts.     

Mentalisation-based therapy (MBT) in a high-secure hospital setting: expert by experience feedback on participation

Evidence for mentalisation-based therapy (MBT) is increasing in relation to the treatment of personality disorder. Individuals with personality disorder are over-represented in inpatient, forensic and forensic inpatient mental health services. This study explores MBT within a forensic setting as an intervention designed to moderate deficits linked to violence and to improve adaptive coping. Interpretative phenomenological analysis was conducted on interviews with four patients who completed MBT at a high-secure hospital. Findings suggest that MBT-enhanced participants’ mentalising which had a positive impact upon their capacity to manage their behaviour and emotions. MBT further enabled participants to process past experiences of violence and develop some degree of empathy for others, which led to a trend in abstinence from risk behaviours. Findings contribute a secure inpatient perspective on the experience of MBT and to MBT clinical outcomes.     

Violence risk profile of medium- and high-security NGRI offenders in Belgium

Under Belgian law, offenders not guilty by reason of insanity (NGRI) are committed by the courts to forensic mental health treatment. The use of violence risk assessment tools has become routine in these settings. However, there are no national statistics regarding violence risk assessment in the Belgian forensic population. A study was undertaken to collect risk assessment data (PCL-R, VRAG, HCR-20) on a large cohort of forensic patients committed to Medium Security units in the Flanders region and in High-Security units in the Walloon region. Flemish patients were expected to present a lower risk compared with their Walloon counterparts. Instead, data yielded by a structured risk assessment method demonstrate the opposite. Moreover, the majority of patients in Flemish facilities had committed violent offenses and were institutionalized for shorter periods whereas the majority of Walloon patients had committed sexual offenses and were institutionalized for markedly longer periods.     

12-Month Prevalence,Trends, Gender Differences,and the Impact of Mental Health Services on Intimate Partner Violence Perpetration Among Discharged Psychiatric Inpatients

Minimal research has examined partner violence committed by individuals with severe mental illness. This study examined rates of IPV in the first year post-discharge from psychiatric hospitalization, trends over time, gender differences, and the impact of follow-up mental health services. One in five (20.3 %) patients committed at least one act of IPV in the first year. Whereas women were more than twice as likely to perpetrate IPV, men were nearly twice as likely to be violent toward non-family members. Risk of IPV was highest immediately post-discharge and decreased over time, with the sharpest decline after 20 weeks in the community. Mental health treatment was associated with a 40 % decrease and medication non-adherence a 50 % increase in risk for IPV. Partner violence is a prevalent concern among discharged psychiatric patients, and these findings suggest that coordinated risk management efforts should focus on the time immediately following hospital discharge.     

Patient characteristics related to length of stay in Dutch forensic psychiatric care

Create an overview of characteristics of patients in long-term forensic psychiatric care (LFPC) with a higher length of stay (LOS) care compared to patients in regular forensic psychiatric care (RFPC) with a shorter LOS. Data were collected from 139 patient records. This study examined whether patients in LFPC differ from patients in RFPC on sociodemographic data, legal data and clinical data and whether those characteristics are able to predict LOS. Patients in LFPC were more often born in a Dutch Caribbean country, less often had a substance abuse disorder, were more often emotionally neglected during childhood, had a higher HCR-20 risk item score, a higher security needs score, a higher (less successful) recovery score, were more often recidivist and had absconded more often than RFPC patients. Certain characteristics were able to distinguish the longer LOS group which might be useful to establish sequel services and enhance treatment efficiency.     

Extent and characteristics of woman batterers among federal inmates

Efforts to identify men who batter women in clinical settings have increased in recent years, but batterer research in United States federal prisons is lacking; low security federal prisons are logical places to consider batterer screening and treatment given the number of men, the domestic violence "risk markers" associated with these men and the likelihood they will be released and return to female partners. This study examined intake assessment data for 115 low security federal inmates. The inmates evidenced high levels of risk markers for woman battering, one in three (33%) acknowledged recent physical violence against women partners, 1 in 10 (13%) admitted severe violence, and the self-identified batterers showed more substance use and personality problems than other inmates. The findings suggest that batterer screening and treatment may be needed in federal prisons and that more research is warranted with a burgeoning male population that ultimately returns to society.