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.     

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.     

Psychopathic traits and change on indicators of dynamic risk factors during inpatient forensic psychiatric treatment

The main objective of the present study was to investigate the impact of treatment on forensic psychiatric inpatients, examining changes on 22 indicators of five dynamic risk factors for violence (i.e., egocentrism, hostility, impulsivity, lack of insight, and negative distrustful attitudes), and to relate these potential changes to level of psychopathy assessed with the Hare Psychopathy Checklist - Revised (PCL-R). Also, we studied the relationship between psychopathy and treatment compliance, as indicated by the attendance rate of therapeutic activities. Eighty-seven male patients (due to missing data on at least one measure, sample size varies from 58 to 87; 42 patients have complete datasets) were administered a standardized psychological assessment battery (self-report inventories, performance-based personality test, observer ratings) upon admission (T1) and after on average 20 months of treatment (T2). Upon admission, psychopathy (median split, PCL-R score≥22) was significantly related to a higher score on five of the 22 indicators of dynamic risk. The analyses showed no significant differences between psychopathic and non-psychopathic patients on the indicators of dynamic risk factors during 20 months of inpatient forensic psychiatric treatment. However, psychopaths showed the expected pattern of treatment noncompliance, compared to non-psychopaths. The clinical and research implications of these findings are discussed.     

Reading level and the prevalence of a dyslexic profile among patients in a forensic psychiatric clinic

This study aims to investigate Swedish language reading ability of forensic patients and the number of them that present a dyslexia profile. Another aim is to compare the reading level in different subtypes of psychiatric diagnoses. Assessments were made of 185 patients by a battery of reading tests. They were also interviewed about their schooling and their self-estimated reading and writing ability. The results show that the patients’ reading level is below average for grade six children in Swedish compulsory school, and that 16 per cent show a dyslexic profile. Male patients with an immigrant background and a diagnosis of psychosis and anxiety disorders perform the lowest when measuring literacy skills. This proportionately low reading ability can cause difficulties in understanding texts as presented in broadsheet newspapers, civic information and patient records, and might even jeopardize the understanding of adult spoken language.     

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.     

Critical incidents in a forensic psychiatric population: an exploratory study of motivational factors

This exploratory study examined the motivations for forensic clients’ engagement in critical incidents, specifically hostage-taking, barricades and roof-top protests. Using thematic analysis, a range of themes were identified. These included engaging in such incidents to seek deliberate isolation from others, gaining control, getting their needs meet, a need to communicate and being influenced by their peers. Selection of potential hostages appeared linked to feeling of grievance towards them. Yet the distress of a hostage, along with consideration as to the longer term consequences of their actions both for themselves and morally, appeared to reduce the risk of engagement in such incidents. The results are discussed in terms of Individualism, Self-Determination Theory of Motivation and Maslow’s Hierarchy of Human Needs.     

The presence of counsel at forensic psychiatric examinations

In virtually all situations involving forensic psychiatric assessments, the patient is represented by counsel. But does this fact entitle the lawyer to be present at the clinical evaluation? In a series of New York cases spanning a generation, judges have allowed presence of counsel at the psychiatric examination. The most common reason given for such a conclusion is to assure better cross-examination of the expert witness. Psychiatric evaluations mandated by law necessitate several guidelines different from those of the usual doctor/patient relationship. While we may have to accept the presence of attorneys in our consulting rooms, they should be observers only. To allow active intervention would distort the clinical process.     

HCR-20 violence risk assessments as a guide for treating and managing violence risk in a forensic psychiatric setting

Abstract

Over the past decades there has been a vast development in the research into risk factors for violence and the development of risk assessment instruments. One instrument that has been given special attention is the HCR-20 violence risk assessment scheme. However, little attention has been paid to the clinical applicability of this tool, i.e. how does this assessment scheme perform when utilized in clinical practice as a tool to guide intervention and management in order to alleviate risk of violent behaviour? The present study was a true prospective study into the utilization of the HCR-20 as a clinical routine. Data on forensic psychiatric patients (n = 81) from a forensic unit in Denmark are presented. As part of a clinical routine all patients were assessed for risk of future violence utilizing the structured professional judgement model, the HCR-20. Outcome measures were aggressive episodes during hospitalization and new convictions post discharge. The predictive validity of the HCR-20 was lower compared with previous findings. It is argued that this does not necessarily indicate poor predictive accuracy of the HCR-20. Rather, it may indicate that the HCR-20 is suitable for guiding risk management in order to prevent violent behaviour.     

Predicting discharge in forensic psychiatry: the legal and psychosocial factors associated with long and short stays in forensic psychiatric hospitals

In Germany, both the number of patients treated in forensic psychiatric hospitals and the average inpatient treatment period have been increasing for over thirty years. Biographical and clinical factors, e.g., the number of prior offences, type of offence, and psychiatric diagnosis, count among the factors that influence the treatment duration and the likelihood of discharge. The aims of the current study were threefold: (1) to provide an estimate of the German forensic psychiatric patient population with a low likelihood of discharge, (2) to replicate a set of personal variables that predict a relatively high, as opposed to a low, likelihood of discharge from forensic psychiatric hospitals, and (3) to describe a group of other factors that are likely to add to the existing body of knowledge. Based on a sample of 899 patients, we applied a battery of primarily biographical and other personal variables to two subgroups of patients. The first subgroup of patients had been treated in a forensic psychiatric hospital according to section 63 of the German legal code for at least ten years (long-stay patients, n=137), whereas the second subgroup had been released after a maximum treatment period of four years (short-stay patients, n=67). The resulting logistic regression model had a high goodness of fit, with more than 85% of the patients correctly classified into the groups. In accordance with earlier studies, we found a series of personal variables, including age at first admission and type of offence, to be predictive of a short or long-stay. Other findings, such as the high number of immigrants among the short-stay patients and the significance of a patient's work time before admission to a forensic psychiatric hospital, are more clearly represented than has been observed in previous research.     

An empirical investigation of written risk communication in forensic psychiatric evaluations

Abstract

There has been an increased interest in approaches for improving violence risk assessment, but less so how to communicate risk assessment results. We studied the written risk communication of 142 cases of forensic psychiatric evaluations in Sweden. The results suggested that risk for criminal recidivism was communicated in the vast majority of the cases (122 out of 142), but that risk was primarily communicated when the risk was perceived to be high. A six-item protocol to assess the content of the risk communication suggested that the communication was well elaborated in 21/122 of the cases, moderately elaborated in 53/122, poorly or very poorly elaborated in 43/122, and non-elaborated in 5/122 of the cases. Level of elaboration was only vaguely related to sociodemographic characteristics pertaining to the assessed (sex, age, citizenship) and the type of crime committed, but highly correlated to clinical diagnoses (DSM-IV) as well as contextual factors of the evaluation (which professional group and which clinic the assessment was performed).     

Intimacy training in a forensic psychiatric setting: an experiment

This article is about intimacy training in two forensic psychiatric hospitals. This training is an experiment in which patients are trained in skills relating to intimacy and sexuality through real physical contact with a therapist. It is a way of treatment in those cases in which other, usually verbal methods, have failed to accomplish (sexual) behaviour change, and it can feed or revitalise verbal therapy. The purpose of the training is (a) to make the patient aware of the feelings intimate contact with a woman provokes and (b) to increase the patient's social and sociosexual skills so that he learns how to handle his intimate and sexual wishes, needs, and limits, and those of his partner. The training aims at diminishing the risk of new offences. The experiment is intended to provide answers to questions about the effectiveness of this kind of training in relationship to this aim.     

HELP: an educational forensic psychiatric assessment program

This paper describes the establishment of an educational group, Health through Education in Law and Psychiatry (HELP), within an inpatient forensic psychiatric assessment service. Until recently HELP sessions have been provided twice weekly to suitable patients during their stay of some 30 days at the Metropolitan Toronto Forensic Service (METFORS). We first outline very briefly the function of METFORS, then describe the HELP project broadly, and finally discuss the rationale of the program in greater detail. Our point is that programs of this type form an added resource in assessment and in the early stages of treatment. We also argue that, along with the accepted clinical role in assessment, forensic psychiatrists and colleagues in related disciplines can serve a valuable role as teacher and therapist.     

Understanding motives for aggression in forensic psychiatric patients: a preliminary study

The primary aim of this study was to explore motivations underpinning aggression among men detained within conditions of high security. Thirty men residing at a high secure psychiatric hospital completed self-report measures, including the Aggression Motivation Questionnaire, Revised EXPAGG and Barratt Impulsiveness Scale-IIr. The Historical items of the Historical, Clinical and Risk-Management (HCR-20) and the Psychopathy Checklist-Screening Version were rated. A subsample of participants agreed to complete a functional assessment on an aggressive incident that had occurred during their placement (n = 9). Increased psychopathy and impulsivity, and the presence of historical risk items were predicted to associate with higher levels of both aggression motivation and beliefs supportive of aggression. Young age at first violent incident and personality disorder related positively to aggression motivation. Thematic analysis conducted on the functional assessments identified social recognition, emotion regulation, communication and protection as functions underpinning aggression. Results are discussed with regards to their implication for violence treatment and assessment, with a focus on motivation recommended.     

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.