The impact of forced forensic psychiatric confinement on composition and structure in the personal networks of personality-disordered forensic psychiatric patients

This study explored to what extent the composition and structure of personal networks of personality-disordered forensic psychiatric patients changed before and after forced confinement in a forensic psychiatric centre. Semi-structured in-depth interviews with 36 patients and selected members of their networks were examined. During forensic psychiatric treatment, patients reported a decrease in network size, in the number of high-risk network members, and in the number of social ties between these high-risk network members. Personal relationships were of shorter duration, with lower levels of contact frequency and reciprocity. No changes were observed in the patients’ companionship, practical and emotional support networks. During forensic psychiatric treatment, patients reported some new relationships, especially with persons outside the forensic psychiatric centre. Information on compositional and structural personal network factors over time helps forensic mental health professionals to properly assess and manage the important dynamic social network conditions associated with recidivism.     

Assaultive behavior in state psychiatric hospitals: differences between forensic and nonforensic patients

Forensic patients are occupying an increasingly large number of beds in state psychiatric hospitals. The presence of these mentally ill offenders has raised concerns about the risk they present to nonforensic patients. This study compared the rate of assaults and factors associated with assaultive behavior among 308 nonforensic patients and two groups of forensic patients including 469 patients found not guilty by reason of insanity and 76 pretrial patients. Consistent with other studies, nonforensic patients had higher rates of assaults than either group of forensic patients. However, being a forensic patient did not affect the odds of assault when controlling for the effects of demographic and clinical variables in a multivariate logistic regression analysis. Factors associated with assaults in each of the three patient groups were identified using multivariate analyses. Implications are presented for treatment of assaultive behavior, mixing of forensic and nonforensic patients within state hospitals, forensic release policies, and future research.     

Incorporating index offence analysis into forensic clinical assessment

Purpose. Assessment is a core skill of clinical and forensic psychology practice and forms the basis of all ongoing engagements with offender/patients. In forensic settings, assessment involves the systematic gathering of reliable data on the characteristics of offenders and the offences which they have committed in order to develop understanding of the dynamics of offending and relevant intervention strategies. However, whilst the assessment process is aided by various protocols, no such instrument appears to exist for the assessment of an offender/patient's index offence. This paper presents a draft ‘index offence analysis guide’ designed by the present authors for this purpose and which has been piloted on prisoners and patients in secure settings. Argument. Evidence suggests that for various reasons, many clinicians do not routinely review crime scene data while working with offenders. However, this practice is arguably questionable, because how can decisions about admission, amenability to treatment, risk of reoffending, and discharge be made if there is limited awareness of what the offender/patient has done? The present authors argue that knowledge of the index offence is important to understanding the offender and suggest this can be obtained using a guide such as the one presented here. This is illustrated with an anonymous case. Conclusion. Index offence analysis should be a core task of any forensic clinician engaged in the assessment of offender/patients as it can provide a better understanding of crime scene actions and offence motivations. This can help guide treatment planning and improve risk assessments.     

Risk assessment of sexual offenders in German forensic institutions

BACKGROUND: The assessment of recidivism in sexual offenders is an urgent topic for forensic psychiatry in Germany. The call for useful predictive measures is therefore getting louder. AIMS: The present study analyses which criteria are employed by therapists in forensic hospitals to assess the dangerousness of sexual offenders. Of particular interest is whether the criteria listed in presently known prediction scores as decisive are actually used in decision-making in current forensic psychiatric practice. METHOD: Data are collected in a prospective prediction study funded by the German Research Association. RESULTS: The results reveal that therapists employ mainly clinical and less historical criteria, thus indicating substantial differences from currently known prediction scores and results of other studies. CONCLUSIONS: That therapists base their prediction of dangerousness primarily on clinical variables reveals a substantial error that has to be remedied. Further research on the extent of relevance of clinical variables is needed.     

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.     

Behind closed doors: the effect of pretrial publicity on jury deliberations

Abstract

Effective treatment of aggressive behaviour and accurate release decision making are necessary components of adequate clinical practice in forensic psychiatric units. Unfortunately, methods to identify treatment targets and ameliorate aggressive behaviour have developed at a slower pace than risk assessment technologies. Recent progress on the identification of offence paralleling or functionally equivalent behaviour offers a framework for individually tailored treatment and idiographic release decision making, although empirical scrutiny of this approach is inadequate. This paper describes an examination of the relationship between aggressive behaviour prior to admission with aggression during inpatient psychiatric treatment, and reconviction for violent offending following discharge. Results showed a relationship between pre- and post-admission aggression but no relationship between aggression during inpatient psychiatric treatment with either pre-admission aggressive behaviour or violent recidivism. These findings indicate the importance of state psychological variables, specifically those states affected by symptoms of psychiatric illness, as well as environmental activators and inhibitors of violence that operate within the hospital. These require inclusion in an adequate functional analysis of aggressive behaviour for forensic psychiatric patients.     

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.     

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.     

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.     

Mentally challenged patients in a forensic hospital: a feasibility study concerning the executive functions of forensic patients with organic brain disorder, learning disability, or mental retardation

The past years have seen an increasing number of patients of lower intelligence or with organic brain disorder being committed into our forensic psychiatry. Our clinic has an ongoing scientific project to investigate the possibilities of reducing costs while at the same time guaranteeing adequate treatment and enforcement practice in forensic hospitals. This current project did not take these kinds of patients into consideration initially. This feasibility study is intended to examine if and to what extent these patients can be part of the scientific project. All patients of forensic psychiatry in Rostock (Mecklenburg-Western-Pomerania) with an IQ<80 (learning disorder) or a primary or secondary organic brain dysfunction that have been committed to the clinic since 2009 are included. These patients went through an extensive battery of neuropsychological tests. Furthermore, the treating psychotherapists had to rate the prognoses for criminal re-offending at discharge. Patients affected by lower intelligence or an organic brain dysfunction achieve lower results in neuropsychological testing than other patients participating in the main project. Nevertheless, participation in neuropsychological testing does not appear to overtax them. Future examination of the patients will be conducted to investigate to what extent certain therapeutic methods have been of noticeable benefit to this problematic group.     

Traumatic brain injury in a forensic intellectual disability population

Traumatic brain injury (TBI) screening in forensic populations has been recommended, due to a high prevalence, links to specific offence profiles and poorer outcomes, such as higher rates of psychiatric disturbance, longer stays in prison, and reoffending. Research focusing on TBI among offenders with intellectual disability (ID) is lacking. This study therefore describes the implementation of TBI screening using the Brain Injury Screening Index (BISI©), TBI prevalence and correlates in a forensic ID service. TBI appeared under recorded in case notes, with considerably more patients self-reporting TBI. Reported causes of TBI differed somewhat to the general population, including childhood physical abuse, self-harming behaviour, and assault. Approximately one-third of injuries did not receive any treatment. Though further adaptations may be required on current screening measures for TBI in offenders with ID, screening can provide valuable information, contributing positively to individual patient therapeutic and risk formulations.     

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.     

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)     

Inpatient aggression by mentally ill offenders: a retrospective case-control study

A retrospective case-control study was conducted examining relationships between patients’ socio-demographic, clinical and admission characteristics and inpatient aggression. Patients aged 18–64?years with a recent offence episode, who were admitted to a regional acute mental health unit, were included as cases (N?=?82), while controls comprised the next available admission, matched for age and gender (N?=?82). The prototypical patient was a young, single male, with a diagnosis of schizophrenia, a history of substance use and previous psychiatric admissions. The majority of cases had a history of aggression and recent offences against public order. They also revealed a higher likelihood of involvement in ‘less serious’ aggressive incidents (e.g. verbal threats or demands) during the index admission. Clinically, knowledge of each patient’s recent offence history, arrival mode and observed characteristics on admission (including any verbal aggression) may be important in the management of subsequent inpatient aggression.     

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.     

Narratives of criminal action and forensic psychology

Purpose. In commenting on Youngs and Canter's (2011) study, Ward (2011) raises concerns about offenders’ personal narratives and their link to self‐concepts and identity. His comments relate to explorations of personal life stories rather than the narratives of actual crimes that are the focus of Youngs and Canter's (2011) study. The elaboration of this different focus helps to allay many of Ward's (2011) concerns and reveals further possibilities for developing the narrative approach within forensic psychology. Methods. The focus on offenders’ accounts of a particular crime allows the development of a standard pro forma, the Narrative Role Questionnaire (NRQ), which deals with the roles a person thinks they played when committing a crime. These roles act as a summary of the criminal's offence narrative. Multivariate analysis of the NRQ clarifies the specific narrative themes explored by Youngs and Canter (2011) . Results. The examination of the components of the NRQ indicates that offence narratives encapsulate many psychological processes including thinking styles, self‐concepts, and affective components. This allows the four narrative themes identified by Youngs and Canter to provide the basis for rich hypotheses about the interaction between the dynamics of personal stories and identity. The four narratives of criminal action also offer a foundation for understanding the particular, detailed styles of offending action and the immediate, direct processes that act to instigate and shape these. Conclusion. These developments in our understanding of offence narratives generate fruitful research questions that bridge the concerns of investigative and correctional applications of narrative theory.     

Patients’ views of the quality of Danish forensic psychiatric inpatient care

The present study describes the quality of psychiatric care among forensic inpatients in Denmark who answered the Danish version of the Quality in Psychiatric Care–Forensic In-Patient (QPC–FIP) instrument. A sample of 143 patients (response rate 53%) from 25 of the 27 specialized forensic units in Denmark participated in the study. The patients’ ratings of the quality of care were generally high. The highest rating was found for the quality of the secluded environment and the lowest for patient participation in the care. The results showed that several factors influenced the patients’ ratings. Women rated the quality of care lower in comparison to men. Patients living together with someone before admission, patients with a lower level of education, and patients who were better informed regarding their diagnosis, who was the responsible physician, and where to complain rated the quality of care higher. We can recommend the use of the Danish version of the QPC–FIP instrument for measuring and improving the quality of care in forensic inpatient care.     

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.     

Seasonal variation of seclusion incidents from violent and suicidal acts in forensic psychiatric patients

BackgroundA seasonal variation in violence and suicidal behaviour has been reported in several studies with partially congruent results. Most of forensic psychiatric patients have a history of severe violent behaviour that often continues in spite of regular treatment. In the forensic psychiatric hospital environment aggressive and suicidal acts are often sudden and unpredictable. For reasons of safety, rapid and intensive coercive measures, such as seclusion and restraint, are necessary in the treatment of such patients.ObjectiveTo examine whether these involuntary seclusions have a seasonal pattern, possibly similar than the reported seasonal variation in violence and suicidal behaviour. By investigating the possibility of a seasonal variation of seclusion incidents from violent and suicidal acts, it may become possible to improve the management of forensic psychiatric patients.MethodsThe hospital files of all secluded patients at Niuvanniemi Hospital from 1 January 1996 to 31 December 2002 were examined. In total, 385 patients (324 male and 61 female) were identified as being secluded at least once in 1930 different incidents (1476 from male and 454 from female patients). Seasonal decomposition and linear regression with dummy month variables were used to examine the possibility of annual variations for seclusions.ResultsThe seasonal variation of involuntary seclusion incidents was statistically significant. According to the linear regression model, most of the seclusion incidents, affecting many different patients, began in July and August, and were concentrated throughout the fall until November. The sum of all seclusion days was lowest in January and highest between July and November (difference + 31% to + 37%).ConclusionsThese findings are mainly in agreement with results from other studies on seasonal variation and violent behaviour. The allocation of staff for late summer and fall might enhance the management of forensic psychiatric patients, thus leading to possible decreases in seclusion incidents. The factors affecting violent, aggressive and suicidal behaviours are complex and more investigation is needed to understand, identify, intervene and effectively reduce such behaviours.     

Posttraumatic stress disorder in tort actions: forensic minefield

The authors discuss posttraumatic stress disorder (PTSD) as a basis for personal injury litigation. Three case examples raise issues related to: (1) the controversy surrounding expansion of tort liability, (2) the courtroom use of psychiatric nomenclature as represented in the DSM (e.g., PTSD), and (3) ethical concerns regarding psychiatric expert witnesses. Psychiatrists became easy targets when problems related to personal injury "stress" cases developed. A careful analysis, however, demonstrates that the issues are complex and multifaceted. For example, tort liability expansion was primarily instituted to compel a greater provision of liability insurance, not to reward stress claims. The increasing use of psychiatry's DSM in the courtroom has occurred despite explicit precautions against forensic application. Finally, the need for psychiatric expert witnesses has increased because courts have gradually usurped some psychiatric clinical prerogatives and because there has been a trend toward greater consideration of emotional pain and suffering. Although psychiatric expert witnesses have not been beyond reproach, critics have attempted to impeach the entire psychiatric profession for the questionable actions of the minority. The authors provide a detailed analysis of current problems, offer suggestions for improvement, and provide an educational counterpoint to the "hysterical invective" that often greets psychiatric testimony.