Forty-five revolutions per minute: a qualitative study of Hybrid Order use in forensic psychiatric practice

Psychiatrists who recommend a Hybrid Order (Section 45A) as a disposal option at the point of sentencing accept that the convicted individual, as well as being mentally disordered and in need of treatment, is also culpable and deserving of criminal punishment. Ethical and clinical concerns have typically limited its clinical use. However, in 2015 the Court of Appeal specified in R v Vowles and others that the Hybrid Order disposal should be considered first in terms of potential mental health disposals. This judgement sets a high threshold for the use of the hospital order which has been the bedrock of inpatient forensic psychiatric practice since 1983. This study sought to explore the attitudes of consultant forensic psychiatrists towards the use of the Hybrid Order in the wake of the Vowles judgement. We interviewed 12 consultant forensic psychiatrists with longstanding experience of psychiatric sentencing recommendations. We found that the majority of consultants considered the Hybrid Order to be a valuable disposal option when used under specific circumstances. However, significant concerns were raised about its use in those with an enduring psychotic illness. Community aftercare arrangements for Hybrid Order disposals were viewed as inferior to community aftercare arrangements for Section 37/41 patients.     

The character of danger in psychiatric practice: are the mentally ill dangerous?

This paper explores the question of dangerousness and the mentally ill. Research for this paper was stimulated by the death by homicide of two psychiatrists in Oregon in 1985. The paper reviews three distinct areas in the psychiatric literature: the arrests of mental patients, assaults against psychiatrists and other mental health professionals, and assaultive behaviors exhibited by patients in hospitals and other psychiatric settings. The author concludes that the risks are real but are dependent, for the most part, on setting and the acuteness of illness. Realism in regard to risk is critical for the mentally ill, their families, professional caregivers, and society in general.     

After Oregon's insanity defense: : A comparison of conditional release and hospitalization

This paper is one in a series of reports on the characteristics of persons committed to the Oregon Psychiatric Security Review Board (PSRB) and their treatment and disposition while subject to its jurisdiction. For the purpose of this discussion, we have focused on conditional release and attempt to answer a number of questions. How do the individuals who are placed in the community differ from those who remain hospitalized? Do the two mechanisms of conditional release in this system, by judges or the PSRB, differ in terms of the kinds of people that they are likely to release? Lastly, what features distinguish those individuals who manage to succeed in their release plans from those who do not?