Forensic Mental Health Patients Research Articles

Staff supported community outings among forensic mental health patients: patient characteristics, rehabilitative goals, and (the absence of) adverse outcomes.

Mental health professionals are tasked with making difficult clinical decisions in treatment settings. In the forensic system, decision making regarding staff supervised community outings (SSCOs) provides a significant challenge due to the need to balance patient liberties, mental health recovery, and public safety. This study explored the characteristics and rehabilitative nature of SSCOs, characteristics of patients attending SSCOs, and any adverse events that occurred during the outings. Employing a cross-sectional design, 110 patients who participated in SSCOs over a one-year period from a Canadian Forensic Psychiatric Hospital were included. Clinical records were reviewed to capture patient and SSCO variables. Descriptive analyses were used to calculate participant, risk, SSCO, and adverse event characteristics. Qualitative analysis was used to explore the purpose of SSCOs and rehabilitative progress that occurred during the outings. Patients attending SSCOs were comprised of long-stay patients with over half having committed a violent index offence. Almost 75% of patients had a moderate/high risk for violence and 50% of the patients had a moderate/high risk of absconding. During the study period, 463 SSCOs were completed. Most outings focused on developing skills for daily living and staff comments suggested many patients developed skills in these areas. Despite considerable risk profiles and public concern regarding forensic patients having community access, there was a single occurrence of unauthorized leave and no instances of violence or substance use. This research can disrupt stigma, demonstrating that SSCOs support a specific rehabilitative intent, promote community reintegration, and maintain public safety.

Occupational therapy with patients in forensic solitary confinement: A qualitative study.

Occupational therapists work with forensic mental health patients in solitary confinement to counter impacts of mental illness and occupational deprivation, to promote well-being and support transition to less restricted environments. There is little literature describing occupational therapy in this context. This study aimed to explore and describe the work, context and professional reasoning of occupational therapists working in solitary confinement settings within a large forensic mental health service in Victoria, Australia. A qualitative design used semi-structured interviews with 11 occupational therapists and reflexive thematic analysis. Three central organising themes, it's all about risk, the work we do and why we do what we do, provided rich description of the context and work of occupational therapists in solitary confinement settings, including approaches used to engage patients in occupation and how the Model of Human Occupation and recovery principles informed their professional reasoning. Despite the setting restrictions, participants engaged in core elements of the occupational therapy practice process and described creative work that offered patients choice and meaningful occupation. They described occupational enrichment to address occupational deprivation and create opportunities for change within the highly restrictive and risk-focussed environment of solitary confinement. Assessment was mainly unstructured, and the need for better evaluation of therapy outcomes acknowledged. Goal setting often focussed on immediate needs. Working in a risk-focussed environment influenced participants' professional reasoning and work with patients, and while they advocated for occupational opportunities for patients, frustration was experienced in response to limits to occupational therapy involvement in risk assessment. The findings address a gap in the literature about the work of occupational therapists in forensic solitary confinement. Though participants' reasoning was informed by occupational and recovery principles, and they described working in occupation-based ways, they did not always articulate explicit connections between theory and practice.

Eye movement desensitisation and reprocessing (EMDR) therapy in prison and forensic services: a qualitative study of lived experience

ABSTRACT Background: Posttraumatic stress disorder (PTSD) is common in people with serious mental illness who come into contact with the criminal justice system. Little evidence exists on EMDR treatment in forensic mental health, with no prior qualitative research exploring lived experience perspectives. Objective: This qualitative study recruited adult forensic mental health patients with PTSD and psychotic disorders, predominantly schizophrenia, who had received EMDR as part of a clinical trial, either in prison or in hospital. We sought to understand their experiences of EMDR therapy while receiving forensic care. Method: Ten in-depth, semi-structured qualitative interviews were undertaken and analysed using thematic analysis. We used an inductive, realist approach, reporting the experiences, meanings, and reality of the participants. Results: Five overarching themes were identified. First, severe trauma was ubiquitous and participants felt Seriously Messed Up by their traumatic experiences, with debilitating and enduring PTSD symptoms contributing to offending and psychosis (‘giving the voices something to feed on’). Second, EMDR was regarded with Early Scepticism. Third, the therapy itself was initially emotionally taxing and Not Easy but participants generally felt safe and persevered. Fourth, they were often surprised and delighted by results (And it Worked!), describing significant symptom reduction and personal transformation. Lastly, EMDR Fits the Forensic Setting, bringing empowerment in a place perceived as disempowering. People reported changes that increased their hope in a violence-free future. Conclusions: The limited research on EMDR in forensic mental health is unfortunate given how common PTSD is in mentally unwell offenders and its potential to impede recovery and contribute to further offending. This first qualitative study found participants experienced positive transformative change, extending beyond symptom reduction. Themes support previously published quantitative outcomes showing EMDR to be safe and effective in this cohort. EMDR was well suited to a forensic setting and was seen as an empowering therapy. Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12618000683235. Study registration: The study was registered on the Australia and New Zealand Clinical Trials Network, registration number ACTRN12618000683235 (registered prospectively, 24 April 2018), https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 374682

Exploring the lived experience of secure patients during COVID-19

PurposeIn 2019, the world was hit by a life threatening severe acute respiratory syndrome causing a global pandemic; Coronavirus disease (COVID-19). In the UK, a nationwide “lockdown” of public isolation and reduced social contact followed. The experience of COVID-19 and the lockdown for forensic secure mental health patients is yet to be understood. This study aims to explore this phenomenon from the patients’ perspective.Design/methodology/approachA qualitative approach was taken. Semi-structured interviews were carried out with six patients from a low secure unit in the UK, between November 2020 and March 2021.FindingsInterpretive phenomenological analysis generated three superordinate themes from the data, providing insight into patients’ experience: “treading water”; how they managed: “learning to swim”; and what was helpful during this time: “in the same boat”.Practical implicationsFurther consideration should be given to creating a sense of safety in wards, along with ways to continue to address the power imbalance. Interestingly, social connection may be cultivated from within the hospital setting and would benefit from further research.Originality/valueTo the best of the authors’ knowledge, this is the first study to explore secure patients’ experience of COVID-19 from the patients’ perspective, within a population often neglected within recovery research.

The Need for Practicable Normative Right-based Social Work Practice in Secure and Forensic Mental Health Services

Abstract We (both author and reader) will explore the need to develop a practicable evaluative human rights-based approach to the care, treatment and discharge of forensic mental health patients. It can be argued that patients in secure and forensic services are potentially the most marginalised and extensively stigmatised of all patient cohorts, and that the extent to which they are discriminated against should not be underestimated. We will consider the concept of right-based practice in secure and forensic mental health settings, and how the quality of practice can be strengthened. We will ground our exploration in the lived experiences of secure and forensic mental health patients and seek through the lens of lived experience to envisage what could constitute fairer and more supportive systems of care.

Quality of life, wellbeing, recovery, and progress for older forensic mental health patients: a qualitative investigation based on the perspectives of patients and staff

ABSTRACT Purpose There is a lack of research informing service requirements for older (aged≥55 years) forensic mental health patients. The aim of this research was to increase knowledge about older forensic mental health patients’ quality of life, wellbeing, recovery, and progress, in order to make recommendations of how to facilitate and enhance these factors. Methods In-depth interviews with patients (N = 37) and staff (N = 48) were undertaken; data were analysed using thematic analysis. Results Environmental (e.g., physical, structural and facilities), relational (staff, family and friends) and individual (characteristics, feelings, behaviours) factors were identified as enablers and/or obstacles to wellbeing, recovery, progress and quality of life. Conclusions The physical and psychological environment of services needs to be adapted to meet the needs of patients. Therapeutic relationships with staff should be encouraged and a person-centred and individual recovery approach adopted. Prosocial relationships with peers, friends and family need to be fostered to enable positive recovery outcomes. Older patients should be empowered to develop a sense of autonomy to enable quality of life, wellbeing, and recovery, and progress.

Sexual knowledge of Queensland forensic mental health patients: A cross-sectional quantitative study.

Forensic patients with serious mental illnesses (SMI) encounter significant challenges including active symptomatology, associated social and interpersonal impairments, psychotropic medication side effects and institutionalization, all of which negatively affect sexual functioning and possibly their acquirement of sexual knowledge. Evidence shows an increased prevalence of high-risk sexual behavior by this group however, there is an absence of literature examining the sexual knowledge of forensic patients. This quantitative cross-sectional study enrolled N = 50 patients currently under the treatment requirements of a Forensic Order and utilized the validated General Sexual Knowledge Questionnaire (GSKQ) to quantify the participants' sexual knowledge over the domains of physiology, sexual intercourse, pregnancy, contraception, sexually transmitted diseases, and sexuality. Male forensic patients scored lower than females on all domains of sexual knowledge. All participants had reasonable knowledge of physiology, sexual intercourse and sexuality; of concern were poor scores on pregnancy, contraception and sexually transmitted diseases. Thirty-five (70%) of the respondents indicated that they had some limited sex education, mostly at school. Only six (12%) received any sexual education from a health professional despite extensive contact with the forensic mental health services across many years. There is a need to assess the deficit in sexual knowledge of forensic patients in order to develop sexual health education, intervention and rehabilitative programmes that cater to the specific needs of this group to improve their sexual knowledge, encourage safe and positive sexual experiences, and enhance their quality of life.

Developing ward social climate and sense of community within a high security forensic psychiatric service: Evaluating a sense of community and social climate intervention

ABSTRACT Inpatient ward social climate and sense of community can influence the recovery and care experiences of forensic mental health patients. This research evaluated an intervention designed to improve social climate and sense of community within a high-secure psychiatric hospital in the UK. The intervention was offered across six wards: two wards received the full intervention, two received the partial intervention, and two received no intervention (control). Social climate and sense of community were measured prior to the start of the intervention 6 and 18 months into the intervention, using the Essen Climate Evaluation Schema and the Sense of Community Index-2. Changes in frequency of disruptive behaviour were also monitored across time points. Results revealed that the full and the partial intervention groups reported greater feelings of social climate than the control group. This effect was also observed across time points, with higher social climate scores in the full and partial intervention groups compared to control group at 6 and 18 months. Furthermore, social climate scorespredicted a significant reduction in frequency of incidents across time in the full intervention. These findings provide longitudinal evidence of the importance of developing ward social climate and sense of community within forensic inpatient settings.

The sexuality and sexual experiences of forensic mental health patients: An integrative review of the literature.

IntroductionSexuality is an integral aspect of the human experience that defines an individual. Robust research, substantiated by the World Health Organization, demonstrates that healthy sexuality improves mental health and quality of life. Despite this level of global advocacy and clinical evidence, sexuality and sexual health as determinants of health have been largely overlooked in the mental healthcare of patients being treated under the requirements of a forensic order (forensic patients). In this review, the authors have evaluated the literature related to the sexual development, sexual health, sexual knowledge and risks, sexual experiences, sexual behavior and sexual desires of forensic patients to inform policy and clinical practice. Furthermore, the review explored how forensic patients' sexual healthcare needs are managed within a forensic mental healthcare framework. The paper concludes with recommendations for service providers to ensure that sexual health and sexuality are components of mental health policy frameworks and clinical care.MethodsAn integrative review was utilized to summarize empirical and theoretical literature to provide a greater comprehensive understanding of the sexuality and sexual experiences of forensic patients. This included identifying original qualitative, quantitative, or mixed-method research, case reports, case series and published doctoral thesis pertaining to the research topic.ResultsTwenty-one articles were selected for review. We grouped the review findings into three main themes: 1) Forensic patient themes, 2) Forensic mental health staff themes and 3) Forensic mental health organization themes. The review demonstrated scant information on the sexual healthcare needs of forensic patients or how health services manage these needs while the patient is in a hospital or reintegrating into the community.ConclusionThere is a dearth of evidence-based, individualized or group approaches which clinicians can utilize to assist forensic patients to achieve a healthy sexual life and it is recommended that such services be developed. Before that however, it is essential to have a clear understanding of the sexual healthcare needs of forensic patients to identify areas where this vulnerable population can be supported in achieving optimal sexual health. Urgent changes to clinical assessment are required to incorporate sexual healthcare as a component of routine mental healthcare.

Hospitalization time is associated with weight gain in forensic mental health patients

IntroductionPrevious studies have found substantial weight gains in forensic mental health patients (FMHP) during hospitalisation. However, previous studies have not compared in- and outpatients, thus the weight change could be a general change over time. Research on the association between proportional hospitalization time (PHT) and weight change is lacking.ObjectivesTo investigate the association between time hospitalized and weight change among FMHP.MethodsRetrospective cohort study including FMHP with schizophrenia or bipolar disorder treated in the Region of Southern Denmark between 01jan2016 and 06apr2020. Patient characteristics and data on body weight was extracted from electronic medical records. The association between PHT and weight change per year was analyzed using linear regression. PHT was determined between each measurement as the total number of days hospitalized divided by the total number of days. Analyses were adjusted for gender, age, smoking, and antipsychotic medication.ResultsThe cohort included 328 FMHP, of which 91% were diagnosed with schizophrenia. PHT had a significant positive dose-response association with weight change, with an estimated difference of +4.0 kg/year for FMHP who were hospitalized 100% of the time, compared to FMHP who were exclusively treated as outpatients. The associations were different for FMHP belonging to different categories of BMI at baseline (test for interaction; p=0.006). Underweight hospitalized FMHP had the largest difference in weight gain compared to FMHP treated outside hospitals (+18.0 kg/year, p=0.006), and the difference was smallest in obese FMHP (+2.3 kg/year, p=0.21).ConclusionsPHT was positively associated with weight change among FMHP.DisclosureNo significant relationships.

Systems and Processes that Enable Progress for Older Forensic Mental Health Patients

Older forensic mental health patients have complex needs and requirements; service provision is required to address mental health, offending risk and issues associated with aging (geriatric care). This study aimed to identify the systems and processes that enable valued progress (in terms of quality of life, health, wellbeing, recovery and reduced risk) for older forensic mental health patients. Interviews were conducted with 48 members of staff working with these patients in secure hospitals or the community. Thematic analysis was used to analyze the data. Four overarching themes were identified regarding what facilitated or acted as a barrier in relation to quality of life, health, wellbeing and recovery. Multidisciplinary input, an individualized approach and implementing holistic and needs-led care was found to facilitate progress. However, lack of resources, excluding the patients in care planning, gaps in expertise and knowledge, and a lack of specialized units that could address mental health, forensic and elderly needs were found to be barriers. Extensive, multilevel and wide-ranging support is required specifically for older forensic mental health patients. Joint working is required between older adult and forensic mental health services incorporating geriatric medicine expertise in order to implement co-produced care and treatment plans.

Staff perspectives on barriers to and facilitators of quality of life, health, wellbeing, recovery and reduced risk for older forensic mental-health patients: A qualitative interview study.

There is a lack of research informing service delivery for older forensic mental health patients. This study explored service provision in forensic mental health inpatient and community services in England, investigating what is required for progress in terms of quality of life, health, wellbeing, recovery and reduced risk, and the barriers and facilitators associated with this. Semi-structured interviews were undertaken with 48 members of staff working with older forensic mental health patients in secure inpatient units or the community in England. Data were analysed using thematic analysis. Two global themes 'What works' and 'What doesn't work' were identified comprising themes representing environmental, interpersonal and individual factors. 'What works' included: positive social support and relationships; individualised holistic patient-centred care; hub and spoke approach to patient care; and suitable environments. 'What doesn't work' included: absence of/or maladaptive relationships with family and friends; gaps in service provision; and unsuitable environments. For older patients to progress to improved quality of life, health, wellbeing and reduced risk, multilevel and comprehensive support is required, comprising a range of services, interventions, and multidisciplinary input, and individualised to each patient's needs. The physical environment needs to be adapted for older patients and provide a social environment that seeks to include supportive families, friends and expert professional input. A clear patient progression pathway is required; this must be reflected in policy and provision.

Transparency and accountability are needed to clarify large differences in the use of forensic orders across Australia

ObjectiveAlthough wide variation in the use of community treatment orders mandating treatment for patients with mental illness is well known, there is much less information on the use of forensic orders mandating treatment for patients diverted from justice systems. We therefore examined the use of forensic mental health orders in Australia using routinely available data. MethodWe completed a retrospective review of publicly reported data about forensic orders and health or criminal justice outcomes across Australia's jurisdictions. Data on the initiation and prevalence of forensic orders were extracted from annual reports by health and justice system entities with governance of forensic mental health patients. Linear mixed models were used to test for differences between jurisdictions in the number and rate of increase of forensic orders per capita open at the end of each calendar year, and the patterns of forensic order use and reporting were analysed for lessons regarding a minimum data set about the number of forensic orders, rates of re-offending, and vulnerable cohorts including Indigenous and female patients. ResultsWhile larger states generally provided useful information about the health engagement of people on forensic orders, no states routinely reported recidivism data or fully addressed vulnerable cohorts, although Victoria provided some information about Indigenous patients and Victoria and Tasmania about female patients. There were significant differences between jurisdictions on both the number of forensic orders in place in 2003, and in the rate of increase in forensic orders between 2003 and 2020. Consistent with the relative number of forensic orders extant in 2003, Queensland showed a large and NSW a moderate rate of increase in the number of people on forensic orders per capita compared with Victoria and WA. ConclusionsA standard set of minimum reported data is needed to monitor and interpret the causes and consequences of large variations in forensic systems across jurisdictions, with the greatest potential benefits for Indigenous and female patients.

Protocol for the CONNECT Study: A National Database and Prospective Follow-Up Study of Forensic Mental Health Patients in Germany.

In Germany, the most frequently used legal section to order forensic mental health treatment is § 63 of the Penal Code (Strafgesetzbuch; StGB). This disposition is primarily aimed at individuals with major mental illnesses who are not fully responsible for a criminal act they committed. Despite evaluation and follow-up studies being conducted within individual hospitals or federal states we lack key epidemiological data on this patient group across the whole country. The present study aims to fill this gap by conducting an annual survey of all eligible forensic mental health hospitals to develop a database of basic clinical, legal and demographic data. Staff at participating hospitals will complete an online survey answering questions about individual patients using routinely collected hospital records. Over the duration of the study, eight-and-a-half years, we aim to collect data on approximately N = 6,450 patients. Alongside important clinical data, we will use official reconviction data at 3- and 6-year follow-ups to investigate the number and types of crimes committed by discharged patients. We aim to extend the scientific literature on factors associated with reconviction in the Risk-Needs-Responsivity model by also measuring the extent to which treatment engagement and programme completion during care predicts reconviction. This study protocol describes the background and theoretical framework for this study, its methods of data collection and analysis, and steps taken to ensure compliance with ethical and data protection principles.

Hospitalisation time is associated with weight gain in forensic mental health patients with schizophrenia or bipolar disorder

Introduction People with mental disorders have higher mortality from lifestyle diseases than the general population. Forensic mental health patients (FMHPs) are often hospitalised for longer periods of time than non-FMHPs. Thus, hospitalisation may have a greater effect on the risk of lifestyle diseases in FMHPs. Objective Investigate associations between proportional hospitalisation time (PHT) and change in body weight or other cardiometabolic risk factors among FMHPs. Methods Retrospective cohort study including all FMHPs with schizophrenia or bipolar disorder, prescribed antipsychotics, and treated between 01 January 2016 and 06 April 2020 in the Region of Southern Denmark either in forensic units or as outpatients. Associations between PHT and, respectively, primary and secondary outcomes were analysed using linear regression. PHT was determined between each measurement of the outcomes as the number of days hospitalised divided by the total number of days within the time-period. The primary outcome was weight change and secondary outcomes were change in waist circumference (WC), blood pressure, estimated average glucose (eAG), HDL, LDL, total cholesterol, and triglycerides. Analyses were adjusted for gender, age, smoking, and antipsychotics. Results The cohort included 490 FMHPs, of which 440 were diagnosed with schizophrenia. PHT had a significant positive dose-response association with weight change, with an estimated difference of +4.0 kg/year for FMHPs who were hospitalised 100% of the time, compared to FMHPs who were exclusively treated as outpatients. The association interacted with baseline BMI. From the secondary outcomes, the association with PHT was only statistically significant for WC. Conclusions PHT was positively associated with weight gain.

A Qualitative Study on Sexuality and Sexual Experiences in Community Forensic Mental Health Patients in Queensland, Australia.

This qualitative study reports on the sexuality and sexual experiences of community-based forensic mental health participants. The findings indicate that these participants feel the need for intimacy and want to engage in sexual activity more often than their neurotypical Australian peers. Participants identified their mental health and the side effects of compliance with prescribed psychotropic medications were barriers to achieving their desired level of sexual activity. Participants supported the notion that mental health teams were positioned to assist patients navigate the psychological, cultural, education and physical barriers to achieving sexual health and wellbeing. We propose several interventions to support these participants and other community forensic mental health patients in attaining healthy relationships, understanding their sexual health, and gaining more fulfilling sexual experiences. These interventions, which include sex education, upskilling in socialization and communication, and regular medication reviews, could be delivered as part of the holistic care provided by mental health teams. Mental health clinicians should be offered appropriate training to assess patients and have discussions related to sexuality, sexual experiences and sexual health needs.

The Sexual Development, Sexual Health, Sexual Experiences, and Sexual Knowledge of Forensic Mental Health Patients: A Research Design and Methodology Protocol.

Introduction: There is substantial evidence that severe mental illness (SMI) can have significant impacts on general development, knowledge acquisition, and quality of life including sexual function. However, whilst the sexual development, sexual health, sexual experiences and sexual knowledge of the broader Australian community and the Australian prisoner population have been well-described, these concepts have been less explored in people with a SMI. In particular, there is an absence of research around these topics involving people who are subject to a treatment order (aka a Forensic Order) under the relevant jurisdictional Mental Health Act.Methods and Analysis: People currently under the treatment requirements of a Queensland Forensic Order will be invited to participate in this descriptive, mixed-method study. The study will be conducted in three phases. The first two phases will involve 50 participants (100 face-to-face quantitative interviews) with the aim of mapping sexual development, sexual health, sexual experiences, and sexual knowledge. The third phase will involve qualitative semi-structured interviews with a purposely enrolled, informant-rich cohort identified through the quantitative surveys until saturation is reached. Quantitative data will be analyzed using descriptive and comparative statistics. Qualitative data will be analyzed by content analysis of the major themes.Ethics and dissemination: The project has ethics approval from a Queensland Health Human Research Ethics Committee. Results will be reported to participants and other stakeholders at seminars and conferences and through peer-reviewed publications.Strengths and Limitations of this Study: This is a mixed-method study which engages with participants by using face-to-face interviews. The study is conducted in three phases which sub-divide the research into the following areas: (1) demographics, general health, and sexual health, (2) sexual knowledge and experiences, and (3) sexual knowledge gaps. This study uses electronic data capture to efficiently record and analyse participant responses. This study captures self-reported data and uses non-probability sampling from a population who have been pre-selected through an arms-length approach—both these processes elevate the risk of bias.

A strengths model and violence risk assessment with individuals not criminally responsible on account of mental disorder (NCRMD) in Canada

ABSTRACT A Strengths Model of violence risk assessment, integrating a strengths-based psychosocial history in mental health recovery and protective factors of violent risk reduction, is proposed to address the concern about overprediction of violence in assessment with forensic mental health patients based on risk factors of violence. A case illustration is presented to demonstrate the Model’s capability to promote a more balanced violence risk assessment and formulate individualized risk management and recovery plan predicated on the person’s strengths and resources. Implications for clinical practice and the potential in research to enhance predictive validity and accuracy in violence risk assessment are discussed.

Exploring High Secure Forensic Patients’ Experiences of Familial Support: An Interpretative Phenomenological Analysis

Research has identified positive relationships between familial support and outcomes for forensic mental health patients. Such support has been linked to reduced recidivism, improved mental health and increased prosocial behavior. Whilst some studies have explored families’ experiences of providing such support, there is a paucity of research exploring patients’ narratives. Using Interpretative Phenomenological Analysis, the current study interviewed patients at a high secure forensic hospital and asked questions about their experiences of familial support. Results indicated four superordinate themes; Connection, Growth, Power, and Ambivalence. These results are discussed in relation to existing findings and clinical implications. Areas for future research are suggested.

Strong Associations Between Childhood Victimization and Community Violence in Male Forensic Mental Health Patients.

Background: Childhood abuse and neglect increase the risk of both mental disorders and violent behavior. Associations between child relational adversities and violent behavior have not been extensively investigated in forensic mental health settings. We asked whether the extent of child adversities predicts the extent of violence in the community in forensic mental health patients.Methods: We included 52 male patients at a medium security forensic mental health ward, with diagnoses of predominantly paranoid schizophrenia and other schizophrenia and psychotic disorders. Seventy-five percent had comorbid substance abuse. We extracted information on six types of child adversities based on clinicians' administrations of the Historical Clinical Risk Management 20 version 3 (HCR 20) scale and summary notes in electronic patient journals. These same sources were used to extract information on war trauma and interpersonal violence in the community. We established cumulative scales for exposure to number of types of child adversities and number of incidents of community violence.Results: Physical and emotional abuse, emotional and physical neglect, and bullying were associated with higher levels of community violence. We observed a linear, significant increase in the frequency of community violence with cumulative numbers of child adversity types.Conclusions: Cumulative exposure to child adversities may be associated with higher degrees of violence in forensic mental health patients, with the most violent patients having the most extensive exposures to adversities. An enhanced focus on child adversities in risk assessment and management of violence may be considered in forensic inpatient settings.