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.     

A prospective study of pathways to hospital readmission in Canadian forensic psychiatric patients

Individuals admitted to secure care often experience lengthy hospitalizations and are likely to be admitted on more than one occasion. In the context of growing demand and costs associated with secure care, the current study investigates the frequency and reasons for readmission among 87 forensic patients recently discharged into the community. We identify risk factors that are associated with the likelihood of readmission and describe areas of overlap and discordance with the existing literature in civil and forensic samples. Using a prospective design that included patient follow-up interviews and records review, we found that 28% of patients were readmitted on one or more occasions over a 12-month period. Psychiatric decompensation, substance use, and treatment non-adherence were the central reasons prompting readmission. Patients with one or more readmissions were found to have spent significantly more time in the forensic mental health system as compared to patients not readmitted. They were more likely to have a substance use disorder and were estimated to be at higher risk for violence. Results replicate the finding of low rates of serious violence and reoffending among discharged forensic patients, and substantiate the centrality of substance use as a growing and clinically important treatment issue.     

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.     

PCL-R psychopathy predicts disruptive behavior among male offenders in a Dutch forensic psychiatric hospital

In this study, the relationship between psychopathy, according to the Dutch language version of Hare's Psychopathy Checklist-Revised (PCL-R), and various types of disruptive behavior during inpatient forensic psychiatric treatment is investigated. Ninety-two male participants were administered the PCL-R following admission to an inpatient forensic hospital. From daily hospital information bulletins, incidents of verbal abuse, verbal threat, physical violence, and violation of hospital rules were derived. Also, the number of seclusion episodes was recorded. As expected, significant correlations were found between PCL-R scores and verbal abuse, verbal threat, violation of rules, total number of incidents, and frequency of seclusion. Psychopaths (PCL-R > or = 30) were significantly more often involved in incidents than nonpsychopaths. Multiple regression analyses revealed that the PCL-R Factor 2 score in particular contributed uniquely to the prediction of the total number of incidents. The findings are discussed in terms of their clinical implications.     

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.     

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.     

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 forensic psychiatric evaluation of mental disorders in diabetic patients

The article deals with the results of investigation of psychic disturbances in 7 patients with diabetes mellitus. Psychic dysfunctions which are important for forensic psychiatric practice (depressions, transitory psychotic episodes at the background of hyperglycemia and pathologic states with consciousness disturbance, psychomotor excitement and incorrect behaviour in hypoglycemic states) were analysed. Characteristics were noted which contributed to diagnosing in patients with diabetes mellitus, the states of temporary morbid mental disorder and choosing correct expert conclusion in relation to persons who committed indictable actions.     

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

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

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.     

Domestically and generally violent forensic psychiatric outpatients: personality traits and behavior

A group of 63 domestically violent patients and a group of 103 generally violent patients at a Dutch forensic psychiatric outpatient clinic are examined with regard to personality traits and problem behaviors to develop treatment programs for domestically violent patients. The domestically violent patients are more unstable from a psychological viewpoint but not more inclined to anger than the average Dutch male. They report less anxiety in situations in which criticism can be given but more anxiety in situations in which someone can be given a compliment. When comparing domestically violent patients with generally violent patients, domestically violent patients score lower on anger as disposition and on aggressive behavior than the generally violent patients do. However, both groups do not differ from each other in their score on the dimension of psychopathy.     

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.     

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.     

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.     

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.