Methodological development: structured outcome assessment and community risk monitoring (SORM)

This paper describes an effort to develop a clinical tool for the continuous monitoring of risk for violence in forensic mental health clients who have left their institutions and who are dwelling in the community on a conditional release basis. The model is called Structured Outcome Assessment and Community Risk Monitoring (SORM). The SORM consists of 30 dynamic factors and each factor in SORM is assessed in two ways: The current absence, presence or partial och intermittent presence of the factors, which is an actuarial (systematized and 'objective') assessment. Secondly, the risk effect, i.e. whether the presence/absence of factors currently increases, decreases or is perceived as unrelated to violence risk, is a clinical (or impressionistic) assessment. Thus, the factors considered via the SORM can be coded as risk factors or protective factors (or as factors unimportant to risk of violence) depending on circumstances that apply in the individual case. Further, the SORM has a built-in module for gathering idiographical information about risk-affecting contextual factors. The use of the SORM and its potential as a risk monitoring instrument is illustrated via preliminary data and case vignettes from an ongoing multicenter project. In this research project, patients leaving any of the 9 participating forensic hospitals in Sweden is assessed at release on a variety of static background factors, and the SORM is then administered every 30 days for 2 years.     

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.     

Psychopathy (PCL-R) as a Predictor of Violent Recidivism Among Criminal Offenders with Schizophrenia

Hare's Psychopathy Checklist-Revised (PCL-R) was used to test the hypothesis that psychopathy predicts violent recidivism in a cohort subjected to forensic psychiatric investigation and consisting of male violent offenders with schizophrenia (N = 202). Psychopathy was assessed with retrospective file-based ratings. Mean follow-up time after detainment was 51 months. Twenty-two percent of the offenders had a PCL-R score 26 (cutoff), and the base rate for violent recidivism (reconvictions) during follow-up was 21%. Survival analysis revealed that psychopathy was strongly associated to violent recidivism (log-rank = 17.71, df = 1, p < 0.0001). The area under the curve (AUC) of the receiver operating characteristics (ROC) of PCL-R total score to predict violent recidivism varied between different time frames from .64 to .75. Cox regression analyses revealed that other potential risk factors could not equally well or better explain violent recidivism in the cohort than psychopathy as measured by PCL-R.     

Psychopathy (PCL-R) Predicts Violent Recidivism Among Criminal Offenders with Personality Disorders in Sweden

Psychopathy as conceptualized with Hare's Psychopathy Checklist Revised, PCL-R, has attracted much research during the 1990s. In the Scandinavian countries, few studies that empirically support the validity of North American risk assessment techniques in our regional context have been published. The purpose of this paper is to explore the predictive power of the PCL-R in a population of personality-disordered violent offenders subjected to forensic psychiatric evaluation in Sweden. Following release from prison (n = 172), discharge from forensic psychiatric treatment (n = 129), or probation (n = 51), a total of 352 individuals were followed for up to 8 years (mean = 3.7 years) with reconviction for violent crime as endpoint variable (base rate 34%). As the estimate of predictive power, the area under the curve of a receiver operating characteristic (AUC of ROC) analysis was calculated. For PCL-R scores to predict 2-year violent recidivism, AUC of ROC was .72 (95% CI: .66–.78). In addition, the personality dimension of psychopathy (Factor 1) and the behavioral component (Factor 2) both predicted 2-year recidivism significantly better than random: AUC of ROC .64 (95% CI: .57–.70) and .71 (95% CI: .65–.77), respectively. We conclude that psychopathy is probably as valid a predictor of violent recidivism in Swedish forensic settings as seen in previous North American studies.