Forensic Mental Health Services Research Articles

Gender Differences in Substance Abuse History and Offending Behavior: A Multicentre Study in Dutch Forensic Psychiatry

ABSTRACT Substance abuse is an important risk factor for offending, but is mostly studied in males. The aim of this multicentre study is to gain insight into possible gender differences in substance abuse history and offending behavior in forensic psychiatric patients. Files were analyzed of 275 women and 275 matched men who have been admitted between 1984 and 2014 to one of four Dutch gender-mixed forensic hospitals. Risk assessment ratings were related to registered violent incidents during treatment for both women and men and to official recidivism data after discharge for a subgroup of 78 women. Substance abuse history was coded as a risk factor for more than half of the women (56.7%), but significantly more often for men (68.4%). Men were more often diagnosed with substance dependence and more frequently committed the index-offense whilst intoxicated. Prediction of violent incidents during treatment was more accurate for men. A history of substance abuse was not a significant predictor for recidivism after discharge in the subgroup women. It is concluded that there are gender differences in substance abuse history and that the relationship with offending behavior seems stronger for men. These differences have implications for substance use treatment in forensic mental health services.

Tū Tahanga: A Qualitative Descriptive Study of a Culturally Adapted Violence Prevention Programme in a Forensic Mental Health Service

There is growing evidence that culturally adapted, evidence-based, violence prevention programmes can have benefits for people in correctional and forensic mental health services. Adding to this evidence is crucial, given the over-representation of Indigenous people and ethnic minorities in such services. This qualitative descriptive study describes Tū Tahanga, which combines the ManAlive violence prevention programme, with Māori (Indigenous people of Aotearoa/New Zealand) cultural concepts. This was developed for Māori service users in a forensic mental health service. Content analysis was undertaken through interviews with participants in the group (N = 11). Core aspects of ManAlive were maintained. These aspects coexist with cultural concepts of a specific healing space, a holistic Māori model of health, and the creation of family like supportive relationships reinforced by living in the same facility. This description lays a platform for future evaluative research to determine the impact of the programme on reducing violent offending.

Accessing and engaging with primary health care services following discharge from forensic secure services: the perspectives of service users and mental health practitioners

PurposePhysical health inequalities and mortality rates are higher amongst individuals with severe mental illness (SMI), including among forensic populations, than the general population. This paper aims to explore the experiences of individuals accessing primary health care following discharge from secure services, and the practitioners who support them.Design/methodology/approachFace-to-face qualitative interviews were conducted with service users (n = 4) and mental health practitioners (n = 4) within a forensic community mental health team in one NHS Trust in England in 2019. Data were analysed using the Interpretative Phenomenological Analysis.FindingsFour super-ordinate themes emerged: perceived importance of physical health, agency, responsibility and relationships. Service users mostly saw themselves as passive recipients of health care and prioritised their mental health over their physical health. Close working relationships meant that mental health practitioners were often the first contact for service users with any health issue and thus felt a sense of responsibility for their physical health care. Service users who did access primary care reported that consistency of professional, feeling understood and listened to without judgement or stigma were important.Practical implicationsInterventions for service users that include practicalities and strategies to facilitate independence in physical health care, and collaborative working between primary care and forensic mental health services, are encouraged.Originality/valueThis study highlights some of the unique challenges in forensics around improving physical health outcomes for individuals with SMI.

Genesis of change: Substance use treatment for forensic patients with mental health concerns.

Substance use disorders are highly prevalent among forensic patients. They are associated with many challenges for patients with these problems, including their ability to rehabilitate and successfully move through secure forensic mental health services, as well as increasing risk for recidivism. Traditionally, forensic services have been more adept at focusing on and treating the primary mental health diagnosis alone and have been less likely to prioritise this co-occurring patient need. Opportunities exist to foster effective treatment strategies for substance use disorders, and past research has produced positive outcomes among forensic patients in studies in both Australia and the UK to navigate a new course for patients with these problems. By providing empirically validated, co-produced and culturally competent treatment responses, forensic patients living with substance use disorders will have the opportunity to significantly improve their wellbeing and progress through the system. They will also be more prepared and equipped to face challenges upon discharge into the community, including increased availability of alcohol and other drugs, social stigma and barriers to employment. Moreover, by prioritising effective substance use treatment programs during inpatient rehabilitation, services can reduce the levels of post-discharge recidivism.

Perspectives on Recruitment and Representativeness in Forensic Psychiatric Research.

Participant representativeness and statistical power are crucial elements of robust research with human participants, both of which relate to the successful recruitment of research participants. Nevertheless, such core features may often not be fully reported or duly considered in psychiatric research. Building on our experiences of collecting data in the context of forensic mental health services, we discuss issues regarding participant recruitment and representativeness in our field with its particular characteristics. A quick sampling and brief overview of the literature in four specialized forensic mental health journals is presented, demonstrating that published manuscripts rarely describe the data in sufficient detail for the reader to assess sample representativeness and statistical power. This lack of transparency leads not only to difficulties in interpreting the research; it also entails risks relating to the already meager evidence base of forensic mental health services being relevant only to a subset of patients. Accordingly, we provide suggestions for increased transparency in reporting and improved recruitment of research participants. We also discuss the balance of ethical considerations pertinent to the pursuit of increased participation rates in forensic mental health research.

The omnipresence of risk and associated harms in secure and forensic mental health services in England and Wales.

Current legislation and policy frameworks regulating the detention and treatment of mentally disordered offenders in England and Wales are predicated on the assumption that a minority of patients have enduring violent tendencies and pose a serious long-term risk to the safety of others. This paper seeks to consider the manner in which notions of risk and the imperative to contain and minimise the potential for harm, present and impact patients in secure and forensic mental health settings. Within this, we consider how mental health stigma and Beck’s concept of the Risk Society can affect the thoughts and actions of those who may be held accountable for rare but potentially serious harmful events. We consider what changes may need to be enacted within secure and forensic mental health services to reduce the incidence and severity of consequent risks of harm to patients and their mental health recovery.

Listen to hard topics with soft ears - domestic violence and family carer; a survey of referrals to a MHIDD forensic mental health service in Ireland

AimsA number of studies sought to explore and define families needs, experiences and concerns associated with being a carer for a detained person and their interaction with Forensic services (McKeown et al, 1995, MacInnes et al, 2002, Tsang et al, 2002, Absalom et al, 2012 Horberg et al, 2015).Relatives can be victims of the service user's offence (Ferriter & Huband, 2003, Tsang et al 2002), and may even blame the service user for their behaviour (Barrowclough et al., 2005). Service user becomes violent and aggressive family members are less likely to be motivated to participate, due to the service user's behaviour (MacInnes, 2000).An initial domestic violence survey of in-patient case files found that in 66%of the patients files, there were reported incidents of domestic violence in family caring relationships prior to the index offence and subsequent admission to NFMHS (Cooney, 2018).MethodA quantitative methodology was used. A domestic violence survey of referrals was conducted of 100 referrals to the National Forensic Mental Health Services – Mental Health and Intellectual & Development Disability Services between 2016-2019.Result22% of the referrals reported Domestic Violence in the family care-giving relationships.The father was recorded as the parent to be experience most Domestic Violence; 40%. Other family members who experienced domestic violence ranged from the mother 32%, brother 12% and sister 8%. Other family members were 8%.100% of the referrals did not report the domestic violence in the carer relationships, nor did referring agencies recorded safeguarding adults concerns.ConclusionThe findings from this audit raises a couple of clinical, legal and safeguarding adults work in National Forensic Mental Health Services with regards to family work. Firstly, the need to (re)conceptualising family work in the context of trauma informed care. Secondly, family work should offer some families, who are victim of crime, a restorative approach. Thirdly, safeguarding adults will need to consider complex caring relationships and acknowledged this as part of care planning and support.

Urine drug screening in women's forensic mental health services: is current practice meeting guidelines?

AimsTo investigate adherence to Trust guidelines for urine drug screening amongst female forensic psychiatric inpatients.BackgroundThe use of illicit substances is an important risk factor which needs to be considered in the management and treatment of forensic psychiatric patients. Research has demonstrated that a high proportion of women admitted within secure services in the UK have a history of substance use. Substance misuse amongst this population can lead to an increased risk of violence, re-offending and mental health relapse; which can pose a significant threat to the safety of other patients, staff and the public. It is therefore important that regular drug screening is carried out to minimise such risks. Ardenleigh is a blended female secure unit in Birmingham. The service has established specific substance use guidelines, outlining the need for each patient to have a personalised drug screen care plan in place. Here we present the findings of an audit completed in 2019.MethodA six month retrospective electronic case note audit for female inpatients admitted to Ardenleigh as of 1st September 2019 (n = 27). We compared drug screen care plans and frequency of urine drug screens over 6 months with the recommendations of the current service-specific Trust guidelines. Care plans should include: information regarding random drug screening; frequency of random drug screening; triggers for increased risk of substance misuse; and consequences for a positive test result to be contained within inpatient care plans.ResultPatient aged between 20 and 56 years old (median age 31). Fewer than half of inpatients (41%) had a documented random drug screen completed within the review period. In terms of care-planning, only 52% of patients had random drug screening mentioned in their care plan. 22% of patient care plans reported the actions/consequences for a positive test result. Not a single care plan mentioned how frequently patients should be being tested or potential triggers for increased risk of drug misuse amongst inpatients.ConclusionCurrent practice and recording of drug screening amongst female forensic psychiatric patients is poor compared to expected standards. The lack of consistency in drug screening raises concerns regarding whether potential substance misuse amongst inpatients may be going undetected, and therefore impacting the recovery of patients. Improvements to drug screening practice should be considered in order to ensure optimal recovery and safety to patients and others.

A Clinical Decision Support System to Prevent Aggression and Reduce Restrictive Practices in a Forensic Mental Health Service.

Preventing aggression and reducing restrictive practices in mental health units rely on routine, accurate risk assessment accompanied by appropriate and timely intervention. The authors studied the use of an electronic clinical decision support system that combines two elements, the Dynamic Appraisal of Situational Aggression instrument and an aggression prevention protocol (eDASA+APP), in acute forensic mental health units for men. The authors conducted a cluster-randomized controlled trial incorporating a crossover design with baseline, intervention, and washout periods in a statewide, secure forensic mental health service. The study included 36 mental health nurses (13 men and 23 women, ages 20-65 years) with direct patient care responsibility and 77 male patients (ages 21-77 years) admitted to one of two acute mental health units during the baseline and intervention periods. eDASA+APP implementation was associated with a significant reduction in the odds of an aggressive incident (OR=0.56, 95% confidence interval [95% CI]=0.45-0.70, p<0.001) and a significant decrease in the odds of administration of as-needed medication (OR=0.64, 95% CI=0.50-0.83, p<0.001). Physical aggression was too infrequent for statistical significance of any effects of eDASA+APP to be determined; however, incidents of physical aggression tended to be fewer during the eDASA+APP phase. These results support the use of the eDASA+APP to help reduce incidents of aggression and restrictive practices in mental health units.

COVID-19 in forensic psychiatry settings: The unique vulnerability of patients in secure services

IntroductionSecure forensic mental health services treat patient with high rates of treatment resistant psychoses, typically schizophrenia. These groups have high rates of obesity and medical co-morbidities. Population based studies have identified high risk groups in the event of SARS-CoV-2 infection, including those with long term medical conditions.ObjectivesThe aim of this study was to compare the vulnerability to serious adverse outcome in the event of COVID-19 infection in a forensic psychiatric patient population.MethodsAll patients of a complete National Forensic Mental Health Service (n=141) were rated for risk of adverse outcome in the event of SARS-CoV-2 infection, using two structured tools, the COVID-AGE tool and the COVID-Risk tool.ResultsEighty-two patients (58.2%) met criteria for obesity, 32 had type II diabetes and 28 were hypertensive. Mean chronological age was 45.5 years (SD 11.4, median 44.1), while mean COVID-AGE was 59.1 years (SD 19.4, median 58.0), mean difference 13.6 years (SD 15.6) paired t=10.9, df=140, p=0.000. Three patients (2.1%) were chronologically over 70 years compared to 40 (28.4%) with a COVID-AGE over 70 (X2=6.99, df=1, p=0.008, Fishers exact test p=0.027).ConclusionsThese risk assessments may identify the extent of increased risk among a uniquely medically vulnerable patient group. Patients in secure forensic psychiatric services represent a high-risk group for adverse outcomes in the event of SARS-COV-2 infection. Population based cocooning and self-isolating guidance based on chronological age may not be sufficient. There is an urgent need for better physical health research and treatment in this group.

Involuntary placement of a mentally ill person in a psychiatric hospital and care institution

IntroductionIn the mental health area, the most problematic issues are the involuntary placement of the mentally ill in closed institutions, both under civil and criminal proceedings, and their involuntary treatment. Despite the international efforts of harmonizing measures, the nature and practice of the services still vary from country to country.ObjectivesTo analyse involuntary placement of persons with mental disorders in closed institutions under civil and criminal proceedings, which include both psychiatric hospitals and care institutions.MethodsReview and analysis of regulations and practice of involuntary placement of a person with a mental disorder in a closed institution in the context of Estonian, Finnish, Russian, and English law, health care and social system.ResultsEstonian, Finnish, Russian, and English law distinguish between criminal and civil proceedings regarding involuntary placement of a mentally ill person in a closed institution. However, specifics of the proceedings are different among the countries, e.g. judicial involvement, and deadlines. Also, the provision of forensic mental health services differ among these countries, e.g. in Estonia offenders and non-offenders are kept separately, whilst in England and Russia patients are not distinguished so strictly.ConclusionsThe distinction between involuntary placement of the mentally ill in criminal and civil proceedings is distinguished primarily for the reason that in one case the risk arising from the person is directly realized by committing an unlawful act and in the other case the risk arising from the person is directed at themselves or is not qualified as an unlawful act.

Stratification of a medium secure forensic care pathway according to risk and need: A study from dundrum hospital

IntroductionSecure forensic mental health services have a dual role, to treat mental illness and reduce violent recidivism. Those admitted to secure forensic services have a significant history of violence and treatment needs in multiple domains including psychiatric illness, violence and other areas such as substance misuse and physical health.ObjectivesThe aim of this study was to ascertain if the units in a medium secure forensic hospital are stratified according to individual risks and needs. We also aimed to clarify if there were differences in the symptom level, risks and needs of those with and without community leave and to clarify the risks and needs of the female patients and ID patients.MethodsThis is a cross sectional study a cohort of patients (n=138) in a secure forensic hospital.ResultsThere was a total of 138 patients, the majority of whom were male (n=123, 89.1%). The most common diagnosis was schizophrenia (n=99, 71.7%). Placements in the care pathway of the medium secure forensic hospital were associated with level of symptomatology (PANSS positive), dynamic violence risk (F=26.880,P&lt;0.001), DUNDRUM-3 therapeutic programme completion (F=44.067,P&lt;0.001), and DUNDRUM 4 recovery (F=59.629,P&lt;0.001). Patients with community leave had better scores than those without leave on violence risk (F=77.099, P&lt;0.001), therapeutic programme completion (F=116.072, P&lt;0.001) and recovery (F=172.211, P&lt;0.001).ConclusionsStratifying secure forensic psychiatric hospitals according to individual risks and needs provides in-patient care in the least restrictive setting appropriate for individuals, however niche groups such as female forensic patients and ID patients may need special consideration.

Lived experience roles in forensic in-patient treatment

wThe development of recovery-oriented practice in mental health has brought about a much greater prominence to the place of lived experience workers. Many aspects of indvidualised recovery-oriented care have been taken up in forensic mental health settings. However, the introduction of lived experience workers is arguably significantly more difficult when the dual vulnerabilities of forensic mental health services users are considered (Drennan &amp; Alred, 2012). This paper will describe a multi-layered approach to the introduction of lived experience roles in a forensic in-patient unit. Roles have developed from being solely ward-based, to service-wide roles that include participation in management and service development, the creation of a Recovery College Forensic Campus, and to co-production and co-delivery of the psychological therapies programme. In addition to ‘mapping’ these developments in co-production, this paper will also describe the development of the governance structures that have been necessary to support this infrastructure. Lived experience workers require recruitment, vetting, placement, and aftercare, when they engage in the activities available. On-going mental health and risk stability cannot be assumed, and so regular formal and informal psychosocial support is required to ensure that workload pressures do not negatively impact on other service users and staff. The paper will suggest that much more attention needs to be paid to the development of organisational infrastructure to sustain and manage the growth of lived experience roles in forensic mental health settings than is currently in place.DisclosureNo significant relationships.

At Risk of What? Understanding Forensic Psychiatric Inpatient Aggression through a Violence Risk Scenario Planning Lens

Violence risk assessment is an essential component of forensic mental health services designed to help mitigate and manage the re-occurrence of violence. Although there is large body of evidence supporting structured risk assessments, there is no empirical evidence regarding scenario planning—a specific component of the structured professional judgment approach to violence risk assessment. The purpose of this study was to investigate the base rates and concurrent validity of inpatient aggression scenarios to provide information about risk scenarios. Among a large representative sample of forensic psychiatric patients (N = 1240), the prevalence of risk scenarios (Repeat, Escalation, Twist, and Improvement scenarios) was investigated by retrospectively coding changes in inpatient aggression. The results suggested that Improvement scenarios, including a continued desistance of aggression, were common. Aggression scenarios shared significant pattern of associations with the Historical-Clinical-Risk Management-20 and the Psychopathy Checklist—Revised. Overall, this study presents initial empirical evidence related to violence risk scenario planning. Implications from these findings include how scenario planning may intersect with evaluator bias in forensic mental health assessments.

Is there adequate evidence to support the use of compassion focused therapy group interventions with forensic mental health service users? A rapid evidence assessment

Compassion focused therapy (CFT) is a model of psychotherapy based on cultivating the capacity for compassion to others and self. The evidence base has grown considerably in the last decade regarding CFT’s effectiveness for a range of mental health problems. However, the literature supporting CFT as a treatment provision for forensic service users with mental health needs is lacking despite the observed overlap in needs between this population and their non-offending clinical counterparts. This rapid evidence assessment (REA) sought to evaluate the current evidence of CFT’s effectiveness as a group therapeutic intervention with clinical populations to allow consideration of the use of CFT with individuals with both mental health and criminogenic needs. A search of electronic databases was undertaken and after a process of review and extraction 10 papers were included. These studies showed promising effects of group-level CFT for those with complex mental health needs. Some evidence emerged of CFT generating significant improvements compared to no treatment and treatment as usual (TAU), but insufficient evidence has been produced in respect of whether CFT can supersede traditional ‘gold-standard’ approaches such as Cognitive Behavioural Therapy (CBT). Tentative conclusions are made regarding the applicability of CFT interventions but the observed reductions in shame and self-criticism and a move towards more guilt-based motivational drives suggest that this approach shows some promise in being able to assist forensic service users in taking more responsibility for their harmful actions and foster social and affiliative processes with others. Further high quality RCTs are needed in order to make firm conclusions about the clinical utility of this therapy for forensic populations with mental health needs.

Establishing comprehensive forensic mental health services in Qatar.

Qatar has experienced exponential economic and healthcare infrastructural development recently. Mental health has been prioritized for development by the state with the launching of the ambitious National Mental Health Strategy in 2013 which incorporates the development of specialist Forensic psychiatry services. Traditionally, some aspects of forensic psychiatry care were provided under general psychiatry, being largely reactive. The new strategy supported the development of specialist Forensic service with a focus on developing safer communities, preventing victimization and supporting the criminal justice system. We provide an overview of the development of this service in Qatar, one of the first of its kind in the region.

Forensic e-mental health: Review, research priorities, and policy directions.

Forensic e-mental health is an area of psychology that is relatively underdeveloped considering technological advancements and the many mental health needs of justice-involved individuals It includes the procurement, storage, sharing, and provision of forensic mental health information and services via electronic means and is associated with improved accessibility, efficiency, cost-savings, and safety During the COVID-19 pandemic, clinics, hospitals, jails, prisons, and the courts rapidly adopted these modalities for service continuity out of necessity, rather than choice In the absence of formal guidelines, practitioners, researchers, and policymakers were left searching for answers: what forensic e-mental health technologies are available, what was their research evidence, and what could the future hold? A primer covering the many aspects of technology-assisted forensic practice and research was overdue To address this knowledge gap, we reviewed the e-mental health research base encompassing forensic evaluations and interventions Considering stakeholders' needs, cost, and feasibility, we prioritized key topics that should rise to the top of the forensic e-mental health research agenda: the psychometric properties of forensic e-mental health assessments, impact of video recording evaluations, how to assess and treat diverse populations, restoration of competence to proceed, continuum of care, minimizing treatment attrition, and decreasing substance use We report how to plan for and overcome logistical hurdles when implementing forensic e-mental health policy, utilize technology for training and education, and harness digitized data across the forensic realm In conclusion, we find that there is ample opportunity for leveraging technology to improve forensic mental health practice, research, and policy (PsycInfo Database Record (c) 2020 APA, all rights reserved)

Adolescent Threats and Violence: An Intriguing Difference

Relatively little is known about young people who engage in targeted acts of violence. In this study, we explored a sample of young people referred to a youth forensic mental health service for a risk assessment of general violence risk, targeted violence risk, or both general and targeted violence risk. Exploratory comparisons were made across mental health issues and criminogenic risk factors, and results indicated that young people referred for a threat-only assessment were around 20 times more likely to have a depressive mood disorder than young people referred for a violence-only assessment. Furthermore, young people referred for a threat assessment had lower rates of physical abuse, family mental health issues, and prior offending. These results indicate that young people referred for an assessment of targeted violence risk may be distinguished from young people referred for general violence risk, which has important implications for their assessment and treatment.

What does effective allyship between social work and lived experience workers look like in the Australian forensic mental health context?

ABSTRACT While forensic social work has a long history, it continues to struggle with its identity within a multidisciplinary team environment. Some jurisdictions have witnessed the development of informal partnerships between social work teams and lived experience workers, but little is known about their operation. Against this background, the aim of this project was to explore the presence, nature and operation of these partnerships in forensic mental health services. Social workers and lived experience workers from Australia and New Zealand attended a two-day summit to share practice-based experiences and engage in small group discussions. The Summit identified both a range of service models across forensic mental health services, and a keen interest in amassing practice-based wisdom to enable more formalised partnerships between social work and lived experience workers. Recommendations arising can be used as a platform to shape the future development and directions of allyship in forensic mental health practice.

Outcome Measures in Forensic Mental Health Services: A Systematic Review of Instruments and Qualitative Evidence Synthesis.

Abstract Background Outcome measurement in forensic mental health services can support service improvement, research, and patient progress evaluation. This systematic review aims to identify instruments available for use as outcome measures in this field and assess the evidence for the most common instruments, specific to the forensic context, which cover multiple outcome domains. Methods Studies were identified by searching seven online databases. Additional searches were then performed for 10 selected instruments to identify additional information on their psychometric properties. Instrument manuals and gray literature was reviewed for information about instrument development and content validity. The quality of evidence for psychometric properties was summarized for each instrument based on the COnsensus-based Standards for health Measurement INstruments (COSMIN) approach. Results A total of 435 different instruments or variants were identified. Psychometric information on the 10 selected instruments was extracted from 103 studies. All 10 instruments had a clinician reported component with only two having patient reported scales. Half of the instruments were primarily focused on risk. No instrument demonstrated adequate psychometric properties in all eight COSMIN categories assessed. Only one instrument, the Camberwell Assessment of Need: Forensic Version, had adequate evidence for its development and content validity. The most evidence was for construct validity, while none was identified for construct stability between groups. Conclusions Despite the large number of instruments potentially available, evidence for their use as outcome measures in forensic mental health services is limited. Future research and instrument development should involve patients and carers to ensure adequate content validity.