Community Forensic Mental Health Service Research Articles

Delivering remote therapy during the COVID-19 pandemic: a qualitative study with service users accessing a community personality disorder service

PurposeThe purpose of this study is to qualitatively explore the views and opinions of service users accessing remote therapy through a community forensic personality disorder service during the COVID-19 pandemic.Design/methodology/approachA qualitative exploratory approach was adopted. Nine community forensic service users accessing virtual/telephone therapy through a community forensic mental health service were interviewed using semi-structed interviews. Data was analysed using Braun and Clarke (2006) thematic analysis techniques.FindingsAnalysis resulted in three overall themes: experience of communication in the therapeutic relationship; impacts of the change to remote working and making the best of what we have. A further seven subthemes were developed. A range of advantages and disadvantages to remote therapy were highlighted.Research limitations/implicationsThis study was based on a small sample of service users accessing one community forensic service in England, and therefore caution should be taken when generalising the findings. All interviews were conducted remotely and thus may have only supported those who are able to engage in this way.Practical implicationsThis paper has the potential to inform future remote therapy guidelines. Health services should consider keeping some elements of remote working and offering this as a choice to all service users.Originality/valueThis study is, to the best of the authors’ knowledge, the first study that attempts to explore the experiences of individuals accessing remote therapy within a forensic population who have personality disorders or traits.

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in-reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial ("disability") are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.

An examination of the relationship between personality and aggression using the general aggression and five factor models

This study examined the relationships between personality and aggression using the general aggression (GAM, Anderson and Bushman [2002] Annual Review of Psychology, 53, 27-51) and five factor models (FFMs) (Costa and McCrae [1992] Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Odessa, FL: Psychological Assessment Resources). Specifically, it examined Ferguson and Dyck's (Ferguson and Dyck [2012] Aggression and Violent Behavior, 17, 220-228) criticisms that the GAM has questionable validity in clinical populations and disproportionately focuses on aggression-related knowledge structures to the detriment of other inputs, specifically personality variables. Fifty-five male offenders attending a community forensic mental health service for pre-sentence psychiatric and/or psychological evaluation were assessed for aggressive script rehearsal, aggression-supportive normative beliefs, FFM personality traits, trait anger and past aggressive behavior. With regard to relationships between five factor variables and aggression, results suggested that only agreeableness and conscientiousness were related to aggression. However, these relationships were: (1) weak in comparison with those between script rehearsal, normative beliefs and trait anger with aggression and (2) were not significant predictors in hierarchical regression analysis when all of the significant univariate predictors, including GAM-specified variables were regressed onto life history of aggression; normative beliefs supporting aggression, aggressive script rehearsal, and trait anger were significantly related to aggression in this regression analysis. These results provide further support for the application of the GAM to aggressive populations.

HCR-20 Risk Profiles of Patients Referred to Forensic Mental Health Services in New South Wales

The present study aimed to consider the HCR-20 risk profiles of forensic and civil (i.e. general psychiatric) patients referred to forensic mental health services (FMHS), in the state of New South Wales (NSW), Australia. It was hoped that by better understanding patient risk, based on HCR-20 ratings, more could be understood about the differing needs of the two patient groups. Data gathered from comprehensive assessments undertaken by trained clinicians across two service settings, a medium secure forensic facility and the NSW Community Forensic Mental Health Service (CFMHS) was utilised. Data from 129 forensic patients and 105 civil patients were included. T-tests indicated significant differences between means of civil and forensic patients on the HCR-20 and odds ratios (ORs) indicated civil patients referred to FMHS were approximately six times more likely to fall into the high-risk category on the HCR-20 (i.e. score 25 or >) than forensic patients. The nature and level of risk evident between forensic and civil patients referred to FMHS in NSW highlighted two issues: (1) The differing risk/need inherent in two patient groups accessing FMHS; and (2) The level of risk observed in civil patients referred to FMHS and therein the challenges faced by generalist mental health services in managing this patient group. The need for generalist mental health services to be better supported and the need for structured, evidence-based risk management practice to be extended to civil psychiatric patient care was indicated.

Structured Risk Assessment in Community Forensic Mental Health Practice

This paper will examine the use of the Historical Clinical Risk Management-20 (HCR-20) by Australian community forensic mental health services (CFMHS) and explore some key issues involved in the application of Structured Professional Judgment (SPJ) risk assessment tools in clinical practice. We used a survey of the use of the HCR-20 by 10 Australian CFMHSs. During the 12-month survey period, the number of assessments conducted ranged from 6 to 186 (median 55). Differences in service models impacted on who was seen, whether reassessments were undertaken, and involvement of generalist mental health staff. Most services employed quality assurance processes and accessed qualified trainers. The use of SPJ tools acknowledges the role of professional judgment while also providing a structure to ensure that relevant evidence-based factors are taken into account. The survey highlighted service model variation as well as the importance of training and quality assurance processes required to ensure that comprehensive violence risk assessments are completed in a valid and reliable fashion.

P02-79 - Community forensic mental health service, Hertfordshire- referrals and response audit

IntroductionCommunity forensic mental health teams are a new service within the widening range of specialized community services, providing an interface between Generic and Forensic Services. Few teams have been set up in the UK, and many have been developed without a pilot scheme. The service in Hertfordshire was established in 2004, with no previous audits or reports done to evaluate the working of this team.ObjectivesThis work aims to ascertain and evaluate the role of this service, comparing with standards formulated in accordance to guidelines set by Clinical Governance bodies such as NICE, DoH, FR&D, Sainsbury Centre, following principles outlined in the Reed Report. It also identifies gaps in the service and recommends implementing changes to improve clinical effectiveness.MethodsA literature review was conducted to outline the characteristics of a community forensic service. Referrals over 12 months from July 2007 until July 2008 were analysed to look into the number, source, appropriateness, acceptance, response time and response methods. Data collection involved review of notes including meeting minutes, computerised notes and patient file. Information was recorded against a question template. Analyses are represented with use of graphs.Resultsindicated the number of referrals and the quality of response from the team.ConclusionsService gaps were identified, and recommendations were made to implement proposed changes. The completion of the Audit cycle which is due in December this year will add to the evidence base which can then guide development of newer teams or improvement in functioning of existing teams.

The effects of social desirability response bias on STAXI‐2 profiles in a clinical forensic sample

This study investigated the proposition that the 'State-trait anger expression inventory' (2nd ed.; STAXI-2) is susceptible to impression management (IM) and Self-Deceptive Enhancement (SDE) in clinical forensic populations. It was hypothesized that individuals engaging in IM would report significantly lower levels of trait anger, external expression of anger, and internal expression of anger on the STAXI-2. Those reporting above average SDE were predicted to claim higher levels of anger control. A between-groups design was used, comparing STAXI-2 scores of individuals who reported high levels of IM and SDE to those who did not. One-hundred and fifty-nine male patients of a community forensic mental health service, referred for assessment of stalking behaviours, completed the STAXI-2 and Paulhus Deception Scales (PDS). Individuals engaging in high levels of IM and SDE were compared to low scorers in regard to STAXI-2 scales using Mann-Whitney U tests. Individuals engaging in IM had significantly lower levels of reported trait anger, outward expression of anger, and inward expression of anger, and higher levels of anger control. Similar results were found with the SDE scale, although the magnitude of the effect was smaller and not apparent on all subscales. The STAXI-2 was vulnerable to social desirability response bias in this sample of forensic clients. Where the STAXI-2 is used as a basis for treatment recommendations and decisions, it should be administered and interpreted in conjunction with a recognized measure of such bias to improve validity.

Stalking and harassment of mental health professionals by patients in a community forensic service

This study used a cross‐sectional survey design to investigate the incidence, experience and impact of stalking and harassment by clients on mental health professionals working in a community forensic mental health service. A response rate of 37% (N = 45) was obtained. A majority of respondents (88.9%) reported being harassed in at least one of the specified ways on at least one occasion. Of these respondents, 42.2% met the operational definition for stalking used by the study. The results support suggestions in the literature that mental health professionals may be at heightened risk of being stalked, and that it has both a personal and a professional impact. The aim of this paper is to describe the study, to highlight the implications for organisational practice, including provision of support and training, and to consider implications for future research.

Violence in stalking situations

Stalking is often viewed as a precursor to violence, but determining which stalkers might attack is a difficult task. This study overcomes shortfalls in previous investigations by adopting a pseudo-prospective design and examining potential risk factors for different types of stalker. Demographic, behavioural and diagnostic information was collected from stalkers referred to a community forensic mental health service (n=211). Potential risk factors for stalking violence were identified using odds ratios and chi2 tests, and entered into logistic regression models. Model utility was assessed using receiver operating characteristic curves. Amongst Rejected ex-intimate stalkers, violence was best predicted by previous violence, making threats and being employed (area under the curve=0.75), while for stalkers with other motives and relationships to the victim, being aged less than 30 years, substance use at the time of stalking and prior violence best predicted stalking violence (area under the curve=0.80). Stalkers at increased risk of violence can be accurately identified by examining motivational and relationship type in conjunction with specific relevant risk factors. Previous violence is a particularly important risk factor, as are threats amongst ex-intimate stalkers. Approach behaviours and psychosis were shown to be less useful in predicting violence.

The Napranum Social and Emotional Wellbeing Week

A week-long intensive outreach project to the Indigenous community of Napranum was undertaken by a Community Forensic Mental Health Service with the aim of developing the community's capacity for primary and secondary prevention of forensic mental health problems. The process of developing and implementing the project is described. The outcome is evaluated by means of qualitative feedback from community members and participants. The project was requested by the local community; planning involved extensive consultation between Queensland Health, community leaders and local service providers; and it was delivered with extensive contributions from other Queensland Health services, various non-government organizations, Indigenous opinion-leaders and public media, and an NRL football team. The outcomes are sustainable at a local level. This form of community engagement may contribute to destigmatization of mental illness in Indigenous communities, increased engagement between these communities and mental health service providers, and increased cohesiveness and morale of these communities.

Risk Assessment and Management in Practice: TheForensicareRisk Assessment and Management Exercise

There is an emerging consensus that the assessment and management of adverse outcomes in mental health, such as violence and self harm, is best achieved by approaches which incorporate validated tools using "structured professional judgement". Although several useful tools have emerged from the literature, there is no clear consensus on the best way to integrate these with clinical practice. This paper describes a framework, the Forensicare Risk Assessment and Management Exercise (F.R.A.M.E.), employed by a statewide community forensic mental health service, which incorporates two structured professional judgement tools, and explicitly integrates these into case management and psychiatric treatment. The potential benefits of the framework are discussed in the context of contemporary trends in risk assessment and management. The F.R.A.M.E. appears to assist with the task of integrating risk assessment with clinical management. Formal evaluative research is indicated before it can be recommended for use by other services.

Treatment and Security Outside the Wall: Diverse Approaches to Common Challenges in Community Forensic Mental Health

This article describes the Community Forensic Mental Health Services in Australia and their different service models. It discusses the service models used and why they have developed this way. The interface between CFMHS, mainstream mental health and secure inpatient forensic mental health services needs to be clear and common issues are outlined. The future directions for CFMHS are suggested, which include demonstrating that CFMHS are effective in delivering what they profess to do.

Clinical Characteristics of Community Forensic Mental Health Services

Community forensic mental health teams are a new service within the widening range of specialized community mental health services. The characteristics of these novel services are poorly defined. Two commonly described service models in the United Kingdom are the integrated model (forensic specialists working within community mental health teams) and the parallel model (forensic specialists working on a separate specialist team). The study reported here aimed to establish clear definitions of these service models. A literature review and a focus group of ten service professionals were conducted to identify candidate characteristics of services in community forensic mental health teams. A total of 31 characteristics were identified and used to prepare the first-round questionnaire for the two rounds of a modified Delphi consultation, which is an expert opinion and consensus method, with a multidisciplinary panel of 32 mental health professionals experienced in community forensic work. Twenty-nine staff (91 percent) completed the two rounds of consultation. Thirteen service characteristics differentiated the integrated and parallel models. Key characteristics of parallel teams included having their own team base, separate referral meetings, a specialist management line, specialist supervision, protected funding, forensic psychology, good links with criminal justice systems, and capped caseloads. Integrated teams were distinguished by their close links with community mental health services and acceptance of more referrals from primary care. Integrated and parallel models of community forensic mental health teams differ on many service characteristics. Defining these characteristics will help in researching the pros and cons of each model in the treatment and risk management of mentally ill offenders in the community.

Survey of community forensic psychiatry services in England and Wales

Background: Forensic psychiatry is one of the last specialist mental health services to develop a community orientation. In the UK community forensic mental health services have begun to develop, but little is known about how widespread these services are and which therapeutic models and organisational structures are used. Aims: To establish the number of community forensic teams in England and Wales and to describe their composition, workload and service model. Method: We identified all community forensic services in England and Wales. A postal questionnaire was sent to each team leader to obtain details of service provision. Information was requested on catchment area, location, staffing, caseload and referrals. Information was obtained on therapies offered (e.g. anger management) and on links with other agencies (e.g. bail hostels). We also gathered information on risk assessment tools, referral procedures and access criteria for the services. Results: Thirty seven services were identified; 26 (70%) responded to the survey. The majority of services covered a mixed urban/rural area and were based in regional secure units. Most (80%) services operated parallel to generic community mental health teams. Caseloads varied from 50 to 150 patients; individual caseloads from 6 to 24. All services offered risk assessment and case management, half offered anger management and cognitive behaviour therapy. Few services offered treatment for personality disorder, sex offenders or substance misuse. Conclusions: The survey demonstrates the variability in community forensic services across England and Wales. Most services provide comprehensive risk assessment but not specialized therapies to reduce offending behaviour. The survey highlights the need for service models to be evaluated in order to inform future service development.

A psychoanalytic view of two forensic mental health services.

The work of forensic mental health practitioners is particularly challenging because of the pervasive and long-term difficulties of mentally disordered offenders and the combined therapeutic and custodial duties of forensic services. Despite this, little has been written about the psychological impact of this type of work on staff and the organization of forensic services. The focus in this article is on two services where the author worked: a regional secure unit (RSU) and community forensic mental health service. The complexity of the task in both services is discussed. Suggestions are made about the feelings, conscious and unconscious, which the task and working environment arouse in practitioners. Observations relating to the working culture of the two services are offered, broadly understood as organizational defences against anxiety in the staff groups. Concepts from the psychoanalytic study of organizations are used to analyse these observations. There is a discussion as to how to limit the need for the development of organizational defences in forensic mental health.