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.     

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.     

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.     

Predictors of length of stay in forensic psychiatry: The influence of perceived risk of violence

This study describes the prevalence of adverse events and length of stay in forensic psychiatric patients with and without a restriction order. Detailed clinical and administrative information from medical records and written court decisions was gathered retrospectively from admission until discharge for a Swedish population-based, consecutive cohort of forensic psychiatric patients (n = 125). The median length of stay for the whole cohort was 951 days, but patients with a restriction order stayed in hospital almost five times as long as patients without. Restriction orders were related to convictions for violent crime, but not for any other differences in demographic or clinical variables. The majority of the patients (60%) were involved in adverse events (violence, threats, substance abuse, or absconding) at some time during their treatment. Patients with restriction orders were overrepresented in violent and threat events. Previous contact with child and adolescence psychiatric services, current violent index crime, psychotic disorders, a history of substance, and absconding during treatment predicted longer length of stay. Being a parent, high current Global Assessment of Functioning scores, and mood disorders were all significantly related to earlier discharge. In a stepwise Cox regression analysis current violent index crime and absconding remained risk factors for a longer hospital stay, while a diagnosis of mood disorder was significantly related to a shorter length of stay.     

Contacts with public services, with special reference to mental health care, preceding a serious crime: a retrospective study of 268 subjects of forensic psychiatric investigations

Between July 1995 and June 1996, 533 subjects underwent forensic psychiatric investigation I Sweden. Odd case numbers (n = 268) were included in the study. Of these 268 people, 50% had been in contact with psychiatric services during the six-month period preceding the crime leading to forensic psychiatric assessment. Contacts with psychiatric services during the six-month period preceding the crime were significantly more common in three categories of individuals than others. These were: women, individuals who were diagnosed as having a psychotic disorder during the forensic psychiatric investigation, and individuals found to suffer from a serious mental disorder as defined in the legislation. Subjects who were found not to suffer from a serious mental disorder and were thus not eligible for special sanctions on medicolegal grounds had significantly less psychiatric contacts before the crime, as did subjects under 20 years of age. However, these two groups still had considerably more psychiatric contacts than the general population. The present results suggest that the patient category studied requires special monitoring and case management in general psychiatry in Sweden. To this end, we call for closer studies of high-risk individuals, particularly of previously violent offenders and potentially violent offenders, and closer studies of their psychiatric contacts. This will provide a basis for the development of adequate programs and guidelines for effective care and treatment within the psychiatric sector.     

Early criminal recidivism among mentally disordered offenders

Criminal recidivism was studied during 2 years in a Swedish population-based cohort (N = 318) of mentally disordered male offenders who had undergone a pretrial forensic psychiatric investigation, been convicted in subsequent trials, and been sentenced to forensic psychiatric treatment (FPT; n = 152), prison (n = 116), or noncustodial sanctions (n = 50). Recidivism was analysed in relation to index sanctions, levels of supervision, diagnoses, and criminological factors. Significantly lower recidivism in the FPT group was related to lower crime rates during periods at conditional liberty in this group alone, and recidivism was significantly more common among offenders with at least one of the two diagnoses of substance abuse disorder and personality disorder than among those with psychotic or other mental disorders alone. Age at index crime and number of previous crimes emerged as significant predictors of recidivism. The results of this study suggest that the relapse rates depend as much on level of supervision as on individual characteristics.     

Schizophrenia and violent crime: the experience of parents

Individuals with schizophrenia have an increased risk of committing a violent crime, although their contribution to the overall criminality in society is small. In this qualitative study we have interviewed parents of adult sons, diagnosed with schizophrenia and who recently had been referred to forensic psychiatric treatment due to a violent crime, with an aim to explore the parents' experiences and emotional reactions. Four events, or status passages, emerged as crucial and common for all parents. These were the onset of the mental disorder, the diagnosis of schizophrenia, the violent behaviour/criminality and the recent referral to forensic psychiatric treatment. Every passage evoked strong emotional reactions such as guilt, fear, disappointment, anger and relief, which in return led to different actions taken. Unawareness of the character and severity of their sons' mental illness and the type of violent criminality they had committed were common and complicated contacts both between the parents and their sons, and also between family members and official authorities. The findings emphasize that psychiatric health care professionals must take the initiative and responsibility for information, education and support of family members.     

Characteristics of homicide perpetrators among Italian forensic hospital inmates

OBJECTIVE: To identify distinctive clinical and social features of the psychiatric patients who committed homicide among inmates of Italian forensic hospitals. METHOD: Clinical and social characteristics of four cohorts of patients were compared: 64 inmates who committed or attempted homicide (Hs), their 64 matched controls from community services caseloads, 54 inmates who committed other crimes and their 54 matched controls from community services caseload. RESULTS: When compared with other inmates, patients who committed or attempted homicide showed less severe psychopathology (later onset of mental disorders, later contact with mental health services, lower disability scores) except for higher scores at BPRS "hostility" and "suspiciousness" factors; they also showed better premorbid adjustment (socioeconomic status, employment), and surprisingly better behavioural profile (fewer compulsory admissions, fewer previous criminal records, less substance abuse, less frequently in caseloads of community services). When compared with their matched controls, Hs had lower psychopathology, better adjustment, and a similar behavioural profile. CONCLUSIONS: Italian inmates of forensic hospitals who committed or attempted homicide have clinical features and personal histories which are far from the stereotype of the violent and dangerous psychiatric patients. The risk assessment procedures routinely performed in several countries may detect violent, but not homicidal behaviour.     

Finding a voice – the feasibility and impact of setting up a community choir in a forensic secure setting

This study reports on the feasibility and impact of running a choir for forensic psychiatric inpatients, staff and members of the local community, within the confines of a medium secure psychiatric unit. The choir ran between October and December 2013. Eight weekly workshops and a final concert performance were evaluated through participant observation and focus groups held with the participants. Between 12 and 16 male and female patients attended each workshop and the final concert. All participating patients had received a diagnosis of schizophrenia, schizo-affective disorder or personality disorder, all had committed serious violent or sexual offences and all were legally detained and receiving treatment in a forensic medium or low secure ward, under the Mental Health Act (England and Wales). Considerable benefits were reported by patients, as well as by the participating community choir members and staff. Primary benefits reported by patients included the following: improved happiness and well-being; increased confidence and self-esteem; greater emotional connectedness and reduced sense of stigma. Participating staff also reported increased feelings of well-being and happiness, greater tolerance and more positive perceptions of the functioning and capabilities of forensic psychiatric patients. The longer term benefits of music participation on the mental health and social functioning of forensic psychiatric patients require further investigation.     

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.     

Filicide, attempted filicide, and psychotic disorders

The objective of the study was to describe and discuss the cases of two women who faced criminal charges, one for attempting to murder her three children and the other for killing her 1-year-old boy. After a forensic psychiatric assessment of their level of criminal responsibility, these patients were considered not guilty by reason of insanity and were committed to forensic mental hospitals. These two patients received a diagnosis of paranoid schizophrenia, according to the DSM-IV-TR criteria. In both cases, psychotic symptoms were present before the manifestation of violent behavior, in the form of persecutory delusions, auditory hallucinations, and pathological impulsivity. The investigation into cases of filicide may contribute powerfully to expand our understanding of motivational factors underlying this phenomenon and enhance the odds for effective prevention.     

A replication study of obsessional followers and offenders with mental disorders

The purpose of this study was to compare certain demographic, clinical, and criminal variables within subgroups of obsessional followers, and compare them to a group of offenders with mental disorders to attempt to replicate earlier findings. A static group archival design utilized a non-random group of convenience and a randomly selected comparison group. Sixty-five obsessional followers and 65 offenders with mental disorders were evaluated by psychiatrists and psychologists for court ordered reasons during their criminal proceedings. Both groups were evaluated during the same period, in the same court diagnostic clinic, and generally for sentencing determinations. The obsessional followers were measured on demographic, diagnostic, pursuit, victim, threat, violence, emotional, motivational, and defense variables. Inferential comparisons that used parametric and nonparametric statistics were done within and between groups on select variables. The obsessional followers had significantly greater estimated IQ than the offenders with mental disorders, but were neither older nor better educated. There were no significant differences in the high prevalence of both DSM-IV Axis I and II diagnoses. Obsessional followers who stalked prior sexual intimates were significantly more likely to have a substance abuse or dependence diagnosis. Obsessional followers who stalked strangers or acquaintances were more likely to be delusional. The majority of the obsessional followers, primarily motivated by anger, both threatened and were violent toward person or property. The modal obsessional follower is an average or above IQ, unemployed, unmarried male in his fourth decade of life. chronically pursuing a prior sexually intimate female. He is diagnosed with substance abuse or dependence and a personality disorder NOS, and has a prior psychiatric, criminal and substance abuse history. He is angry, likely to threaten her, and assault her person or property without causing serious injury.     

Characteristics and offences of women with borderline personality disorder in forensic psychiatry: a multicentre study

Although female forensic patients diagnosed with borderline personality disorder (BPD) are generally considered taxing in clinical practice, little is known about their specific characteristics or offences. In this study, 156 female forensic psychiatric patients diagnosed with BPD were compared to 113 diagnosed otherwise. Information on demographic and psychiatric characteristics, victimization, index offences, and incidents during treatment was gathered from patient files. Risk factors for recidivism were assessed using the PCL-R and historical items of the HCR-20, including items from the new Female Additional Manual (FAM). Compared to non-BPD women, BPD women were more likely to have been abused as children and to have a history of outpatient treatment. While less likely to be convicted for (attempted) homicide, a higher percentage of BPD women was convicted for arson. Comorbid substance abuse was more frequent in the BPD group and incidents towards others and themselves were more violent in nature. The PCL-R and the H-scale of the HCR-20/FAM indicated several risk factors especially important for BPD women, such as poor behavioural control, impulsivity, and irresponsibility. The results support the clinical impression that women diagnosed with BPD are a subgroup within the female forensic psychiatric population, with specific focus points for treatment and management.     

Do prior histories of violence and mental disorders impact on violent behaviour during encounters with police?

Despite sustained large-scale educational campaigns, public attitudes towards mental illness have remained persistently negative. Associated with this, recent research from Victoria, Australia, reported that police commonly associated violent behaviour with mental illness. The present study examined 4267 cases of police use of force and considered what differentiated and characterised violent from non-violent behaviours reported by police in the context of a use of force incident. The specific focus was to examine the effects that historical variables such as age, gender, prior violent offending and having a prior diagnosis of mental disorder, as well as incident specific factors such as exhibiting signs of mental disorder and substance intoxication have on violent behaviour during the use of force incident. The proximal factors of apparent mental disorder and alcohol intoxication were significantly associated with violent behaviour towards police, whilst having a history of prior violence and prior mental disorder diagnoses was not associated with violence. The results challenge traditional stereotyped views about the violence risk posed by people with prior contact with mental health services and those with prior violent offending histories. A service model that allows for psychiatric triage would be able to assist with streamlining police involvement and facilitating timely access to mental health services.     

新冠肺炎疫情下司法精神医学鉴定的应对

新冠肺炎疫情已被公认为全球性重大挑战。已经、正在,同时仍将对人类社会的诸多方面产生深远的影响。新冠肺炎疫情下司法精神医学鉴定面临诸多挑战,通过梳理疫情下已实施的有关司法鉴定方面的做法、经验,分析涉疫情主要犯罪类型,开展司法精神医学远程鉴定具有必要性和可行性。但应关注其局限性,实施之前应制定相应的操作规范。     

First report from the Swedish National Forensic Psychiatric Register (SNFPR)

To the best of our knowledge, the present register is the only nationwide forensic psychiatric patient register in the world. The aim of this article is to describe the content of the Swedish National Forensic Psychiatric Register (SNFPR) for Swedish forensic patients for the year 2010. The subjects are individuals who, in connection with prosecution due to criminal acts, have been sentenced to compulsory forensic psychiatric treatment in Sweden. The results show that in 2010, 1476 Swedish forensic patients were assessed in the SNFPR; 1251 (85%) were males and 225 (15%) were females. Almost 60% of the patients had a diagnosis of schizophrenia, with a significantly higher frequency among males than females. As many as 70% of the patients had a previous history of outpatient psychiatric treatment before becoming a forensic psychiatric patient, with a mean age at first contact with psychiatric care of about 20 years old for both sexes. More than 63% of the patients had a history of addiction, with a higher proportion of males than females. Furthermore, as many as 38% of all patients committed crimes while under the influence of alcohol and/or illicit drugs. This was more often the case for men than for women. Both male and female patients were primarily sentenced for crimes related to life and death (e.g., murder, assault). However, there were more females than males in treatment for general dangerous crimes (e.g., arson), whereas men were more often prosecuted for crimes related to sex. In 2010, as many as 70% of all forensic patients in Sweden had a prior sentence for a criminal act, and males were prosecuted significantly more often than females. The most commonly prescribed pharmaceuticals for both genders were antipsychotics, although more women than men were prescribed other pharmaceuticals, such as antidepressants, antiepileptics, and anxiolytics. The result from the present study might give clinicians an opportunity to reflect upon and challenge their traditional treatment methods.     

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.     

Exploring gender issues in the development from conduct disorder in adolescence to criminal behaviour in adulthood

Using results from a large Norwegian follow-up study of former adolescent psychiatric in-patients we have traced the progression from mental disorders requiring hospitalisation in adolescence to registered criminal behaviour in adulthood, particularly highlighting gender differences. A nationwide representative sample of 1095 adolescent psychiatric inpatients (46% females) was followed up 15–33 years after admission to the National Centre for Child and Adolescent Psychiatry in Oslo, Norway. In adolescence 45% fulfilled the DSM-IV criteria for a disruptive behaviour disorder. At follow-up, 63% of the males and 39% of the females had a criminal record. Among females, psychoactive substance use disorder in adolescence seemed to be a sine qua non for later registered criminality, with intravenous drug use a potent risk factor for life-course-persistent criminality. The same strong association between drug use and criminality was not found in males. Factor analysis demonstrated that while the DSM-IV Conduct Disorder criteria structure was similar across genders, the prevalence of the various forms of expression was different in males and females. The differences between individuals with violent and non-violent crimes were more substantial in males than in females. There were marked gender differences in the criminal profiles observed, with the females' criminal career developing in a less serious manner than in males: females had later criminal debut, a lower number of acts on record, less diverse criminal behaviour, and an escalation in the severity of offences over time was less frequently encountered. However, secular trend analyses indicated that gender differences had diminished over the last several decades, with females “catching up” with their male counterparts. Overall, the results demonstrated important qualitative and quantitative gender differences in the criminal behaviour of former adolescent psychiatric in-patients. The results may be of use in prevention.     

Forensic psychiatric inpatients and aggression: An exploration of incidence,prevalence, severity,and interventions by gender

BackgroundPrevious investigations suggest that women judged to be not criminally responsible on account of mental disorder (NCR-MD) differ markedly from their male counterparts in important ways, underscoring the necessity of subsequent study.ObjectiveThe goal of the present study was to inform our understanding of the presenting profile of female forensic psychiatric patients and contrast their risk of inpatient aggression with their male counterparts.MethodThe population of patients assessed and/or treated at a secure Canadian forensic psychiatric hospital were available for study. In total, 527 patients had complete data and were part of intensive retrospective file reviews; inpatient aggression was evaluated using the Overt Aggression Scale.ResultsWomen were no less likely than men to have a violent index offence and to perpetrate inpatient aggression. Examining the range of aggressive behaviours and severity levels did little to increase the relevance of gender to inpatient risk.DiscussionFemale forensic patients represent a highly selected subgroup of women with exceptional clinical and behavioural challenges and associated treatment needs.     

An exploration of childhood victimization and family-of-origin characteristics of sexual offenders against children

A comparison of the childhood victimization experiences and family-of-origin characteristics of 33 sexual offenders against children, 66 violent offenders, and 25 nonviolent offenders participating in assessment or treatment at a forensic division of a Canadian psychiatric hospital was undertaken using a semistructured interview designed specifically for this study. Overall, 31.5% of the sample reported contact sexual abuse (i.e., oral, vaginal, or anal) by age 14. Sexual offenders against children reported significantly more sexual abuse than both violent and nonviolent offenders and were more likely to have been sexually propositioned and exposed to. Sexual offenders against children were also more likely to report physical discipline as the primary type of discipline in the home. Analyses of the variables concerning characteristics of parents, siblings, and significant others also indicated significant differences between groups. Implications of these findings on the intergenerational hypothesis are discussed as well as their relevance for treatment.