Dutch Forensic Psychiatric Hospital Research Articles

Victimization history in female forensic psychiatric patients with intellectual disabilities: Results from a Dutch multicenter comparative study

BackgroundVictimization is highly prevalent in individuals with mild intellectual disability (MID) or borderline intellectual functioning (BIF) and is an important risk factor for mental health problems and violent behavior. Not much is known, however, about victimization history in women with MID-BIF admitted to forensic mental health care. AimsThe aim of this multicenter study is to gain insight into victimization histories and mental health problems of female forensic psychiatric patients with MID-BIF. MethodsFile data were analyzed of 126 women with MID-BIF who have been admitted to one of five Dutch forensic psychiatric hospitals between 1990 and 2014 and compared to data of 76 female patients with average or above intellectual functioning and to a matched sample of 31 male patients with MID-BIF. ResultsAll forensic patients had high rates of victimization, but women with MID-BIF showed an even higher prevalence of victimization during both childhood and adulthood and more complex psychopathology compared to female patients without MID-BIF. Compared to male forensic patients with MID-BIF, women with MID-BIF were more often victim of sexual abuse during childhood. During adulthood, the victimization rate in these women was more than three times higher than in men. ConclusionsVictimization is a salient factor in female forensic patients with MID-BIF and more gender-responsive trauma-focused treatment is needed.

Contact between victims and offenders in forensic mental health settings: An exploratory study

Victim-offender contact has been studied extensively in prisons, but research on contact between victims and mentally disordered offenders in forensic mental health settings is lacking. Therefore, an exploratory study was conducted on contact between victims and offenders in four Dutch forensic psychiatric hospitals. These offenders have committed serious (sexually) violent offenses, for which they could not be held fully responsible due to severe psychopathology. During the mandatory treatment, it is possible for offenders and their victims to engage in contact with each other if both parties agree to this. To explore the conditions under which this contact is suitable, we interviewed 35 social workers about their experiences in 57 cases from four Dutch forensic psychiatric hospitals. Findings demonstrated that, according to the social workers, no type of offense or psychopathology were obvious exclusion criteria for victim-offender contact. Social workers described offenders' problem awareness, stable psychiatric condition, and ability to keep to agreements as important factors that enable victim-offender contact. Implications and suggestions for future research are provided.

Physical Violence During Mandatory Psychiatric Treatment: Prevalence and Patient Characteristics

This study explores variables that predict physical violence in 614 (forensic) psychiatric inpatients. All violent incidents that occurred in a Dutch forensic psychiatric hospital between 2014 and 2019 ( N = 3,713) were coded with the Modified Overt Aggression Scale+ based on daily hospital reports and patients’ medical records. Binary logistic regression analyses examined which patient variables could differentiate between patients with and without physical violence during treatment and between patients with single and multiple incidents of physical violence. Variables included in the analyses were gender, legal status, borderline personality disorder, antisocial personality disorder, schizophrenia spectrum disorder, psychopathy (Psychopathy Checklist–Revised [PCL-R] score), self-harm during treatment, impulsivity, intellectual disability, and length of stay. A clear association was found between self-harm and inpatient physical violence on all outcome measures and in all analyses. Adequate monitoring of self-harm is advised as a strategy to early identify patients with a high risk to threaten ward safety.

Inpatient aggression in forensic psychiatric patients with autism spectrum disorder: the role of risk and protective factors

Purpose Patients with autism spectrum disorder (ASD) are overrepresented in forensic samples. However, research on risk assessment in forensic patients with ASD is scarce. The purpose of this paper was to examine the prevalence of short-term inpatient aggression and explore the risk and protective factors for aggression in forensic psychiatric patients with ASD (N = 32). Design/methodology/approach The association between two commonly used violence risk assessment instruments (HKT-R and SAPROF) and physical aggression during ten weeks of inpatient stay was examined in a Dutch forensic psychiatric hospital. Findings Results showed no significant association between HKT-R and SAPROF and incidents of physical aggression. This suggests that the commonly used assessment instruments may be of limited use for assessing the risk of short-term inpatient aggression in patients with ASD. Research limitations/implications Limitations to the current study include the relatively small sample size and the lack of information on index offenses. Further research with a larger, more homogeneous sample and longer follow-up is indicated to confirm the results of this study. Future research should also include the possible association between aggressive behavior of people with ASD and other factors that might be relevant, such as social cognition deficits, cognitive and sensory impairments, deficient empathy and emotion regulation problems. Originality/value To the authors’ knowledge, this is the first study to directly examine the prevalence of inpatient aggression of forensic psychiatric patients with ASD and its association with risk and protective factors.

Gender-Sensitive Violence Risk Assessment: Predictive Validity of Six Tools in Female Forensic Psychiatric Patients

Most violence risk assessment tools have been validated predominantly in males. In this multicenter study, the Historical, Clinical, Risk Management–20 (HCR-20), Historical, Clinical, Risk Management–20 Version 3 (HCR-20V3), Female Additional Manual (FAM), Short-Term Assessment of Risk and Treatability (START), Structured Assessment of Protective Factors for violence risk (SAPROF), and Psychopathy Checklist–Revised (PCL-R) were coded on file information of 78 female forensic psychiatric patients discharged between 1993 and 2012 with a mean follow-up period of 11.8 years from one of four Dutch forensic psychiatric hospitals. Notable was the high rate of mortality (17.9%) and readmission to psychiatric settings (11.5%) after discharge. Official reconviction data could be retrieved from the Ministry of Justice and Security for 71 women. Twenty-four women (33.8%) were reconvicted after discharge, including 13 for violent offenses (18.3%). Overall, predictive validity was moderate for all types of recidivism, but low for violence. The START Vulnerability scores, HCR-20V3, and FAM showed the highest predictive accuracy for all recidivism. With respect to violent recidivism, only the START Vulnerability scores and the Clinical scale of the HCR-20V3demonstrated significant predictive accuracy.

A Study Into the Severity of Forensic and Civil Inpatient Aggression.

Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment.

Inpatient violence in a Dutch forensic psychiatric hospital

PurposeInpatient violence can have a major impact in terms of traumatic experiences for victims and witnesses, an unsafe treatment climate, and high-financial costs. Therefore, the purpose of this paper is to gain more insight into patterns of violent behavior, so that adequate preventive measures can be taken.Design/methodology/approachData on inpatient violence in a Dutch forensic psychiatric hospital between 2008 and 2014 were extracted from hospital files on 503 patients.FindingsMore than half of all the patients (n=276, 54.9 percent) displayed verbal aggression on at least one occasion, whereas 27.2 percent of all patients (n=137) exhibited one or more incidents of physical violence. Female patients were responsible for more physically violent episodes than male patients. Patients admitted with a civil court order exhibited more violent behavior than patients with a criminal court order. Violent patients with a civil commitment had a significantly longer length of stay than non-violent patients with a civil commitment. More violence was found to take place on the earlier days of the week.Originality/valueThis study points at important differences between groups of forensic inpatients in frequency and type of inpatient violent behavior and in temporal factors. Interventions aimed at reducing the number of violent incidents should take these differences into account. Further research is necessary to gain more insight into the background of inpatient violence.

Gender Differences in Victimization and the Relation to Personality Disorders in Forensic Psychiatry

ABSTRACTGender differences in victimization were retrospectively examined in 218 male and 218 female patients who have been admitted to one of four Dutch forensic psychiatric hospitals between 1984 and 2014. Case files were studied and variables relating to victimization and psychopathology were coded. It was found that the prevalence rates of victimization were higher among female patients than among male patients, both during childhood and adulthood. Childhood sexual abuse was found to be more prevalent among women than men, however, no differences were found for emotional and physical abuse or neglect during childhood. Women with a history of emotional or sexual abuse were significantly more often diagnosed with borderline personality disorder than women without childhood victimization. Men with a history of physical abuse were significantly more often diagnosed with antisocial personality disorder than men without childhood victimization. Clinical and policy implications of this study for forensic practice are discussed.

Using MMPI–2–RF Correlates to Elucidate the PCL–R and Its Four Facets in a Sample of Male Forensic Psychiatric Patients

ABSTRACTThis study documents the associations between the MMPI–2–RF (Ben-Porath & Tellegen, 2008) scale scores and the Psychopathy Checklist Revised (PCL–R; Hare, 2003) facet scores in a forensic psychiatric sample. Objectives were to determine how the MMPI–2–RF scales might enhance substantive understanding of the nature of the 4 PCL–R facets and to discern possible implications for the treatment of psychopathic patients. A sample of 127 male forensic psychiatric offenders admitted to a Dutch forensic psychiatric hospital completed the PCL–R and the MMPI–2. Exploratory stepwise regression analyses assessed the prediction of the PCL–R total and its facet scores from MMPI–2–RF scales at its 3 hierarchical levels. Conceptually meaningful results emerged at each level of the MMPI–2–RF hierarchy, including several consistent differences between predictor sets across the facets. Interestingly, ideas of persecution (RC6) was a specific predictor of PCL–R Facet 2, a facet noted for its association with treatment failure. Results are compared and contrasted to the extant body of empirical work to date, and some tentative clinical implications are offered.

Gender Differences in the Assessment and Manifestation of Psychopathy: Results From a Multicenter Study in Forensic Psychiatric Patients

abstractGender differences were explored in PCL-R codings and the manifestation of psychopathy in 197 female and 197 male patients admitted between 1984 and 2013 to one of four Dutch forensic psychiatric hospitals. Four groups were compared with respect to criminological characteristics, historical violence risk factors and psychiatric characteristics including incidents during treatment. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual (FAM; de Vogel, de Vries Robbé, van Kalmthout, & Place, 2012) was used to define women with psychopathy. The four groups were: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R ≥ 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R ≥ 30). Overall, it was found that women and men with psychopathy show multiple similarities in their personal and criminal histories, but there were also several gender differences. Women with psychopathy compared to men with psychopathy committed more fraud, offended more often out of relational frustration, were more often diagnosed with the Borderline Personality Disorder, and showed less physical violence, but more manipulative and self-destructive behavior during treatment. Overall, women obtained lower scores on the PCL-R than men. Predictive validity of the PCL-R for physical violence during treatment was good for men and moderate for women. When verbal violence was included in the definition of violence, the predictive validity of the PCL-R was good for both the female and male sample. Implications of this study for forensic practice are discussed and several directions for future research are provided.

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.

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.

Substance use disorders in forensic psychiatric patients

There is a lack of detailed information on the role of substance use disorders (SUD) as a substantial factor in offences and treatment in forensic psychiatric patients. The aim of this study was to get a better understanding of these specifics. Clinical records of 193 male patients admitted to a Dutch forensic psychiatric hospital were scrutinized on anamnestic, diagnostic and risk assessment data. One of the central findings was that the prevalence of SUDs was high. Patients with an SUD had a more extensive criminal history, unstable and deviant lifestyle and higher risk of violent behavior than patients without a substance use disorder. No differences were found in duration of treatment, aggressive incidents and leave. Another important finding was that a distinction could be made between patients with substance use as a primary criminogenic risk factor and patients with substance use as a secondary risk factor. Although substance use is identified as a general risk factor, this study supports the idea of sub categorization of patients with an SUD and emphasizes the need for a different treatment approach. Further study is needed to identify specific treatment approaches, based on more differentiated profiles of these patients.

The Role of Personal Social Networks in Risk Assessment and Management of Forensic Psychiatric Patients

Social network factors are usually not accounted for in the clinical practice of risk assessment/management.This article introduces a social network analysis as an instrument to systematically chart the relationships and personal networks of forensic psychiatric patients. During the period 2005 to 2007, the so-called Forensic Social Network Analysis (FSNA) was developed in a Dutch forensic psychiatric hospital. A case study describes the FSNA concepts and shows the benefits of using FSNA as a practical tool for assessment and management of individual risk behavior.

Risk assessment in female forensic psychiatric patients: a quasi-prospective study into the validity of the HCR-20 and PCL-R

This study examined the postdictive validity of the HCR-20 and the PCL-R in a sample of 45 female ex-patients of Dutch forensic psychiatric hospitals. For this purpose the HCR-20 and PCL-R were coded using documented information. Recidivism data were collected from the Dutch Ministry of Justice. Interrater reliabilities for the HCR-20 and PCL-R were excellent. Recidivists and non-recidivists differed significantly in terms of their mean scores on the H (historical) scale of the HCR-20. Their mean scores on the other subscales and their total scores on the HCR-20 and the PCL-R showed no significant differences. The base rate for violent recidivism was 16%. Subscale scores and total scores on the HCR-20 and the PCL-R did not postdict violent recidivism. Risk judgments based on these instruments demonstrated the same poor predictive validity. There are indications that historical items, notably substance abuse and a history of violence, have some predictive value for violent outcome in female forensic psychiatric patients.

Static and Dynamic Patient Characteristics as Predictors of Criminal Recidivism: A Prospective Study in a Dutch Forensic Psychiatric Sample.

If clinicians in forensic psychiatry want to reduce risk of reoffending in their patients, they require insight into dynamic risk factors, and evidence that these add predictive power to static risk indicators. Predictors need to be evaluated under clinically realistic circumstances. This study aimed to validate dynamic and static variables as predictors of reconviction in a naturalistic outcome study. Data on static and dynamic risk factors were collected for 151 patients discharged from Dutch forensic psychiatric hospitals. Community follow-up was prospective, with a 5.5 year minimum. A prediction model was developed using Cox regression analysis. The magnitude of the predictive power of this model was estimated using receiver operating characteristic (ROC) analysis. The final prediction model contained four static and no dynamic predictors. The model's ROC area under the curve was .79 (95% CI .69-.89). Clinical risk ratings were non-predictive. Post hoc analyses exploring the influence of subgroups of patients did not yield better models. It is concluded that a small set of static predictors yielded a good estimate of future reconvictions; inclusion of dynamic predictors did not add predictive power.

Pharmacological treatment of sexually aggressive forensic psychiatric patients

This paper deals with pharmacotherapy for sexual offenders. Findings published in the international literature on the effectiveness of libido-suppressing medication and some of our first (limited) experiences with pharmacological treatment of sexual offenders in a Dutch forensic psychiatric hospital are described. In line with the literature, our preliminary clinical experiences with anti-androgen medication suggest that it brought about a reduction in the number of sexual incidents in the hospital as well as a decline in other types of disruptive inpatient behaviour (e.g. aggression), but the number of patients treated (n=4) was too few to allow adequate statistical testing. On the basis of the literature, however, it seems fair to conclude that in cases posing a high risk of re-offending into hands-on sexual crimes, anti-androgen medication can be effective in combination with regular cognitive-behavioural treatment.

The HCR‐20 in personality disordered female offenders: a comparison with a matched sample of males

AbstractThis study examines the predictive validity of the HCR‐20 in a sample of 42 female patients admitted to a Dutch forensic psychiatric hospital. The findings are compared with those for a matched sample of 42 male forensic psychiatric patients. The inter‐rater reliability of the HCR‐20 was good for both female and male patients. There were significant differences between female and male patients in mean HCR‐20 item scores, but the mean H, C and R‐subscale scores and total score were comparable. The base rate for inpatient violence was similar for female (30%) and male patients (29%), but the base rate for violent recidivism after discharge was significantly higher for the male sample (43%) compared with the female sample (13%). For male patients, the HCR‐20 demonstrated good to excellent predictive validity for violent outcome (violent recidivism and inpatient violence); however, predictive accuracy for female patients was much lower. In females, only the HCR‐20 final risk judgment, and not the HCR‐20 total score, demonstrated significant predictive validity for violent outcome. Copyright © 2005 John Wiley &amp; Sons, Ltd.

Type of Discharge and Risk of Recidivism Measured by the HCR-20: A Retrospective Study in a Dutch Sample of Treated Forensic Psychiatric Patients

This retrospective study examined the predictive validity of the HCR-20, a violence risk assessment instrument. The HCR-20 as well as the Psychopathy Checklist-Revised (PCL-R) were coded on the basis of file information of 120 patients discharged from a Dutch forensic psychiatric hospital between 1993 and 1999 (average follow-up period 72.5 months). The patients were divided into four groups according to type of discharge: 1) discharge by the court in line with the hospital staff's advice and after a transmural phase; 2) discharge by the court in line with the hospital staff 's advice, but without a preceding transmural phase; 3) discharge by the court against the hospital staff's advice; and 4) readmission to another institution. Recidivism data (reconvictions) from the Ministry of Justice were related to the risk assessments. The base rate for violent recidivism was 36%, and 52% for general recidivism. The HCR-20 and PCL-R total scores demonstrated good predictive validity for violent recidivism (AUC = .82 and .75, respectively). The HCR-20 was a significantly better predictor of violent recidivism than unstructured clinical judgment stated in hospital staff 's advice to the court. In addition, the HCR-20 total score predicted significantly better than the PCL-R total score, although the difference in AUC values was no longer significant when the item ‘Psychopathy’ was removed from the HCR-20 total score.

Predictive validity of the SVR-20 and Static-99 in a Dutch sample of treated sex offenders.

In this retrospective study, the interrater reliability and predictive validity of 2 risk assessment instruments for sexual violence are presented. The SVR-20, an instrument for structured professional judgment, and the Static-99, an actuarial risk assessment instrument, were coded from file information of 122 sex offenders who were admitted to a Dutch forensic psychiatric hospital between 1974 and 1996 (average follow-up period 140 months). Recidivism data (reconvictions) from the Ministry of Justice were related to the risk assessments. The base rate for sexual recidivism was 39%, for nonsexual violent offenses 46%, and for general offenses 74%. Predictive validity of the SVR-20 was good (total score: r = .50, AUC = .80; final risk judgment: r = .60, AUC = .83), of the Static-99 moderate (total score: r = .38, AUC =.71; risk category: r = .30, AUC = .66). The SVR-20 final risk judgment was a significantly better predictor of sexual recidivism than the Static-99 risk category.