The effects of cognitive-behavioral treatment for forensic inpatients

The effects of an intramural cognitive-behavioral treatment for forensic inpatients with personality disorders in a high-security hospital were examined. Treatment was aimed at modifying maladaptive coping and social skills, at enhancing social awareness, at reducing egoistic and oppositional behaviors, and at reducing psychological complaints. The patients, who all had committed serious crimes (violence, arson, sexual offences), participated voluntarily in the study. A total of 39 patients started the study, but during the course of the study, several patients dropped out because of several reasons. Patients as a group showed significant improvements over time on psychopathological symptoms, personality traits, and coping. A significant decrease of oppositional behaviors was reported by the staff. Though the patients improved well at the group level, only a minority of patients showed reliable change over time at the individual level. The meaning of the results in relation to treatment are discussed.     

Head banging as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Introduction: ‘Head banging’ is a common form of self-harm, linked to numerous negative outcomes including significant brain damage. However, little research has investigated head banging behaviour and its correlates in clinical populations. Method: Head banging episodes were identified from the incident records (n = 5417) of two inpatient forensic services (one intellectual disability and one mental health), using relevant search terms. Rates were compared between individual patients, by gender, diagnosis and level of security. Incident accounts were analysed qualitatively using thematic analysis. Results: Head banging incidents occurred approximately every 3 days in each service, with 229 incidents recorded in 1 year. Individual patient rates varied widely, ranging from 1 to 38 incidents within 1 year. Women, and patients in higher levels of therapeutic security, were significantly more likely to engage in head banging. Qualitative incident reports indicated that head banging was associated with mental distress, anger and psychotic experiences. Discussion: Head banging occurs frequently in forensic services, and has documented associations with traumatic brain injury in affected individuals, thus negatively impacting progress through the care pathway and treatment outcomes. Further research should investigate short- and long-term management strategies and treatment approaches, in order to minimise harm.     

Assessing reliability, validity, and clinical utility of the BEST-Index in measuring living skills among forensic inpatients

The assessment of behavioral change as a result of inpatient treatment in forensic psychiatry is an important precondition for violence risk prediction in forensic psychiatry. In relation to a multitude of diagnostically based risk assessment instruments, there is a shortage of appropriate instruments with which to carry out valid and reliable therapeutic assessments that are behaviorally based and therefore appropriate for use within varied psychiatric contexts. There is also a need for instruments which will offer assessors the opportunity to examine possible relationships between criteria of social risk and criteria of more general aspects of social functioning. Tapping the issues pointed out above, the authors present an overview of a normatively based social profiling instrument (the BEST-Index), and discuss evidence for its validity, reliability, and aspects of clinical utility.     

Evaluation of a cognitive-behavioral program for chronically psychotic forensic inpatients

The present study evaluated the progress of four groups of chronically psychotic patients in treatment at De Kijvelanden Forensic Psychiatric Hospital. The psychotic patients were offered a cognitive-behavioral program, including psycho education, grief processing, stress management, functional training, coping with psychotic symptoms (Liberman module) and social skills training. Nine patients dropped out of the program. Sixteen patients who completed it scored significantly better than a control group of 16 psychotic patients, who had not yet participated in the program, on the "social skills" and "negative coping behavior" subscales of one of two observation scales used. On the other observation instrument (REHAB), however, no significant improvement in the general level of functioning was found in the group of treated patients, as compared to the control group. Apart from these two observation scales, the PANSS (structured interview for positive, negative and general psychopathological symptoms) and the SIG (self-report questionnaire for social anxiety and social responses) were used to evaluate treatment progress. Significant improvements were not found on these scales, except for a slight positive effect on the PANSS negative symptoms scale. These results illustrate the difficulties and limitations of treating chronically psychotic offenders, who often also suffer from cluster B personality disorders.     

Deliberate ingestion of foreign bodies as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Deliberate foreign body ingestion is a significant issue in prison and psychiatric settings. It is associated with serious physical complications, including bowel obstruction, perforation and haemorrhage. Episodes of deliberate foreign body ingestion were identified retrospectively from 5417 incident records from two inpatient forensic services (one mental health and one intellectual disability) over a one year timeframe, using related search terms. Rates were compared according to gender, diagnosis and level of security. Incidents of deliberate foreign body ingestion were found to occur on average every 2.7 days across the study population, with 133 incidents recorded over a one year period, accounted for by 27 patients. Women and patients in lower levels of security were significantly more likely to engage in deliberate foreign body ingestion. Staff responses to this behaviour were highly variable. Deliberate foreign body ingestion occurs frequently within inpatient forensic services, and can have significantly detrimental physical implications for affected patients. Further research should investigate the psychiatric and intellectual disability profile of such individuals in further detail, as well as exploring patient narratives; both of which will help inform development of treatment strategies.     

Validation of the full and brief Externalizing Spectrum Inventory in Dutch forensic inpatients

The Externalizing Spectrum Inventory (ESI) was designed for assessing a broad spectrum of externalizing problems, including impulsive-aggressive behavior and substance abuse. After translation of the ESI into Dutch, a computerized version of the full Dutch ESI (ESI-NL) was administered to a mixed sample consisting of inpatients in forensic and addiction care (n = 99) and non-psychiatric community participants (n = 104). Internal consistencies, test–retest reliabilities, ‘predictive’ validity of the full and 160-item ESI-NL total scores and subscales were examined, along with the correlations between these two versions. The results indicated high reliability and predictive validity for both versions and a strong similarity between the two in direct comparisons. The 160-item Dutch ESI is recommended for clinical studies on violence proneness and externalizing problem behavior.     

Mindful yoga as an adjunct treatment for forensic inpatients: a preliminary evaluation

Although emerging evidence of yoga interventions shows benefits for people with schizophrenia, research is lacking regarding yoga interventions among forensic inpatients. This pilot study investigated the acceptability and effectiveness of an eight-week mindful yoga programme in improving psychological outcomes in 26 forensic inpatients. Outcome measures included the Five Facet Mindfulness Questionnaire, the Perceived Stress Scale, the Hospital Anxiety and Depression Scale and the Clinical Outcomes in Routine Evaluation – Outcome Measure as well as a qualitative component post-intervention and at two-month follow-up. Trends in the predicted direction suggested reductions in clinical symptoms over time, specifically anxiety. Key themes revealed increased body awareness, relaxation and self-directed yoga practices and breathing techniques for anxiety management. Ninety-two percent reported acceptance of the programme. Preliminary findings are encouraging and warrant further research into the application of mindful yoga in the management of distress and risk with forensic inpatients.     

Behavior on the ward of personality-disordered inpatients and chronically psychotic inpatients during a three-year stay in a Dutch forensic psychiatric hospital

To gain insight into the behavior of a group of personality-disordered patients and a group of chronically psychotic patients during their stay in a Dutch forensic psychiatric hospital, data on these patients were collected biannually for seven years. Three aspects of the patients’ behavior were examined: the prediction of institutional behavior shortly after admission, changes in the patients’ behavior on the ward during their stay in hospital, and the prediction of these changes. In the personality-disordered patients, observed irritation/anger and aggressive behavior on the ward turned out to be positively related to psychopathy, the PCL-R lifestyle and antisocial facets, and the neuroticism domain. A positive relationship was also found between aggressive behavior on the ward and trait anger. In the chronically psychotic patients, a positive relationship was found between irritation/anger and the PCL-R interpersonal and lifestyle facet. During a stay of three years, the aggressive behavior of both patient subgroups, which was already low at the start, did not decrease further, but their prosocial behavior increased. In the personality-disordered patients, relatively high scores on the antisocial facet of the PCL-R indicated an increase in prosocial behavior, whereas in the chronically psychotic patients no relationship was found between any PCL-R facet and behavior change. Effect studies on treatment programs for forensic psychiatric inpatients have to contend with the problem of a low base rate of institutional aggression. Therefore, we advise that such studies focus not only on a decrease in negative behaviors but also on an increase in positive behaviors.     

Antemortem records of forensic significance among edentulous individuals

The identification of edentulous individuals is problematic due to poor provision of labelled dental prostheses. Dental records may still provide useful information for odontologists in the comparative identification process. The purpose of this study was to determine the level of forensically significant information contained within the dental records of a population of denture wearers attending the University of Manchester School of Dentistry. Two hundred and two dental records were examined and a proforma completed. The mean age of the patients was 72 years. Medical history were absent in 4% of all records and only 67.8% of the written records were rated as good. Thirty-two percent of the records contained one or more panoramic radiographs but 30% of these were over 3 years old rendering their usefulness in identification procedures questionable. In total only 18% of the examined records contained antemortem information that would enable identification. These data suggest that the process of denture marking is an essential in order to ensure that the identification of this population can be undertaken expediently by dental means.     

The relationship between attachment styles and Cluster B personality disorders in prisoners and forensic inpatients

The relationship between attachment styles and Cluster B personality disorders were examined among prisoners, forensic inpatients and controls from the general population. Forensic inpatients and prisoners reported significantly less frequently the secure attachment style (Relationship Questionnaire) and significantly more the fearful attachment style compared to the normal controls. Both forensic groups could not be distinguished from each other. Further, prisoners, forensic inpatients and controls could not be differentiated on the basis of the dismissing nor the preoccupied attachment style. With respect to personality pathology, almost all relationships between Cluster C pathology, on the one hand, and attachment styles, on the other, were significant. Cluster A pathology was clearly related to the secure and fearful attachment style. With respect to cluster B pathology, the results were more specific but also less clear. The results were strongly dependent on the way the personality pathology variables were treated, as either categorical or dimensional. None of the cluster B personality pathology variables were associated with the fearful attachment style and histrionic personality pathology was negatively associated with the dismissing attachment style. Antisocial personality features were associated with a dismissing attachment style. Borderline personality pathology, when treated as a categorical variable, was significantly related to the preoccupied attachment style. These results show that (1) cluster A and cluster C pathology are more strongly associated with attachment than cluster B, (2) treating personality data as either dimensional or categorical is of major importance to the conclusions that can be drawn, (3) it is important to control for the influence of co-morbid personality pathology when examining the relationship between (Cluster B) personality pathology and attachment.     

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.     

Risk of homicidal behavior among discharged forensic psychiatric patients

We studied the risk of homicidal behavior among 281 released male forensic psychiatric patients during the 14-year period 1978–1991. Released patients were about 300 times more likely to commit a homicide than the general male population during the first year outside hospital, and the corresponding risk was 53-fold during a mean follow-up period of 7.8 years. The odds ratio for committing a homicide among all Finnish schizophrenics during the 12-year period 1980–1991 was 9.7, which indicates that previous criminality associated with schizophrenia also increases the risk of homicidal behavior remarkably when compared with schizophrenia per se. We believe that this kind of epidemiological approach is a useful method of identifying and classifying factors associated with very high risk of homicidal behavior and preventing homicidal behavior among high-risk populations.     

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.     

Clinical forensic examination findings in assault cases among adolescents

Child and youth criminality has risen markedly over the past 25 years and causes increasing concern to the general public. The clinical forensic examination cases of youth violence victims examined at the Institute of Legal Medicine of the Hanover Medical School and its Oldenburg Branch between 1999 and 2008 were retrospectively analyzed. In all, 55 adolescents (37 females, 18 males; median age 15.5 years) were examined. In most cases the suspect was a close (40.0%) or passing (23.6%) acquaintance. 16 assaults were committed by two or more adolescents jointly. Most of the juveniles were victims of sexual assaults (56.4%). In 15 victims of sexual offences (51.7%) diagnostic findings were obtained on the basis of anogenital injuries and/or the presence of sperm. In summary, the analysis shows that adolescents frequently become victims of sexual assault. In addition, youth violence is often committed in a group.     

Relationships between legal and clinical factors among forensic hospital patients

Recognizing that established relationships enhance understanding and therefore improve clinical intuition and inference, the authors examined clinical and legal characteristics of a legally and clinically heterogeneous population of maximum security forensic hospital patients (n = 380). Several findings serve to substantiate outcomes of previous studies of subgroups of offenders. Some new relationships among legal and clinical variables are established. The relationship between admission legal status and Axis I diagnosis is dependent upon the Axis II diagnosis. Those admitted for competency evaluations have the lowest percentage of psychotic diagnoses and the highest IQ. Kidnapers have the highest percentage of psychotic diagnoses and there is a relationship between previous incarceration and drug treatment refusal. The authors discuss clinical implications, generalizability, and the needs for further investigation.     

Explanations for violent behaviour—An interview study among forensic in-patients

The alleged relation between mental disorder and violent criminal behaviour has been investigated mainly from an epidemiological perspective. Population-based registry studies have shown that violence occurs more frequently among people with mental disorders, like schizophrenia and bipolar disorder, compared with control subjects, but that the increased risk is largely mediated by drug abuse and socio-economic deprivation. The aim of this study was to explore how patients who have committed violent or sexual crimes and have been sentenced to forensic psychiatric care by a Swedish court of law construed their criminal actions in terms of causes. Forty-six participants from six different Swedish forensic psychiatric clinics were included in the study. A semi-structured interview study was conducted and the data was analysed using a thematic analysis. A large group of the participants did not believe that the mental disorder played any role in the criminal events. Contributing causes that were mentioned were drug abuse and social factors.