Forensic Psychiatric Outpatients Research Articles

Staff experiences with videoconferences during the COVID-19 pandemic in forensic psychiatry outpatients

Aim To describe staff experiences with the use of videoconferences with forensic psychiatric outpatients during the COVID-19 pandemic. Method Semi-structured interviews with staff at forensic community services in the Region of Southern Denmark. Results Nine semi-structured staff interviews were conducted. Two main themes were identified through thematic analysis: Challenges due to technical uncertainty and the Use of videoconferences as support in clinical assessment and treatment. The second main theme also included a number of subthemes: Lack of opportunity for observation of a patient’s overall situation; Compromise of nurses’ professionalism; Limitation of disturbing stimuli means more focus on the conversation; Telephone contact vs. video contact—pros and cons; Expectations reflect attitudes; and Will professionalism be changed based on organizational and political perspectives? Conclusion Staff opinions on use of videoconferences in psychiatric patients differed. The nurses in particular were concerned about whether professionalism could be maintained. Others experienced patients focusing more on the conversation when it took place via video because there were fewer disturbing elements. In general, expectations seem to influence attitudes toward using videoconferences.

Are Hostility, Anger, and Aggression Involved in the Social Anxiety of Forensic Psychiatric Outpatients Convicted of a Violent Crime?

There is limited evidence in the literature that hostility, anger, and aggression are involved with social anxiety. The present study examined the relationship of personality traits and aggression with social anxiety and social skills in forensic psychiatric outpatients convicted of a violent crime. Social anxiety was mainly contributed to by neuroticism, state anger, and social skills, while neuroticism and social anxiety were the main contributors to social skills. Anger, next to neuroticism and social skills, appeared to be involved in the outpatients’ social anxiety. Neuroticism and social anxiety were found to be the main contributors to social skills.

Assessing attribution in the criminal behavior of mentally disordered offenders: Developing a Japanese version of the Gudjonsson Blame Attribution Inventory‐Revised

AbstractAimTreating individuals with a mental disorder and a history of criminal behavior (mentally disordered offenders [MDOs]) aims to enable patients to maintain their health and facilitate social rehabilitation while preventing adverse outcomes, such as violent recidivism or suicide. Understanding and responding to their own insight on their criminal behavior is crucial to achieving this goal. This article aims to develop a Japanese version of the Gudjonsson Blame Attribution Inventory‐Revised (GBAI‐R) and investigate the reliability and validity of the scale for MDOs in Japan.MethodsIn addition to developing the Japanese version of GBAI‐R (GBAI‐RJ), psychological data relevant to the Japanese study were collected and analyzed. Factor analysis was employed.ResultsSeventy‐seven Japanese native participants were recruited from forensic psychiatric inpatients, outpatients, and medical prison inmates between 2020 and 2022. The results demonstrated that the dimensions on the GBAI‐RJ had a similar factor structure to those reported in previous studies. The GBAI‐RJ has both test/retest reliability and internal consistency.ConclusionThe three dimensions Guilt Factor, External Factor, and Mental Element Factor from the original version in English are applicable to the Japanese version for assessing attribution and comparing the findings with those of the previous studies.

The effectiveness of an additive informal social network intervention for forensic psychiatric outpatients: results of a randomized controlled trial.

A supportive social network is associated with better mental health and wellbeing, and less criminal behavior. Therefore, this study examined the effectiveness of an additive informal social network intervention to treatment as usual (TAU) among forensic psychiatric outpatients. An randomized controlled trial (RCT) was conducted in forensic psychiatric care, allocating eligible outpatients (N = 102) to TAU with an additive informal social network intervention or TAU alone. Participants receiving the additive intervention were matched to a trained community volunteer over 12 months. TAU consisted of forensic care (e.g., cognitive behavioral therapy and/or forensic flexible assertive community treatment). Follow-up assessments were conducted at 3, 6, 9, 12, and 18 months after baseline. The primary outcome was the between-group effect on mental wellbeing at 12 months. Between-group effects on secondary outcomes (e.g., general psychiatric functioning, hospitalization, criminal behavior) were explored. Intention-to-treat analyses showed non-significant between-group effects on mental wellbeing on average over time and at 12 months. However, significant between-group effects were found on hospitalization duration and criminal behavior. Specifically, TAU participants were hospitalized 2.1 times more days within 12 months and 4.1 more days within 18 months than participants in the additive intervention. Furthermore, TAU participants reported 2.9 times more criminal behaviors on average over time. There were no significant effects on other outcomes. Exploratory analyses revealed that sex, comorbidity, and substance use disorders moderated effects. This is the first RCT examining the effectiveness of an additive informal social network intervention in forensic psychiatric outpatients. Although no improvements were found on mental wellbeing, the additive intervention was effective in reducing hospitalization and criminal behavior. The findings suggest that forensic outpatient treatment can be optimized by collaborating with informal care initiatives aimed at improving social networks within the community. Future research is warranted to determine which specific patients might benefit from the intervention and if effects can be improved by extending the intervention duration and enhancing patient compliance.Clinical Trial Registration: [https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7163], identifier [NTR7163].

Patients’ and volunteer coaches’ experiences with an informal social network intervention in forensic psychiatric care: a qualitative analysis

Background:Improving supportive social networks in forensic psychiatric patients is deemed important due to the protective effects of such networks on both mental health problems and criminal recidivism. Informal interventions targeted at social network enhancement by community volunteers showed positive effects in various patient and offender populations. However, these interventions have not specifically been studied in forensic psychiatric populations. Therefore, forensic psychiatric outpatients’ and volunteer coaches’ experiences with an informal social network intervention were explored in this study.Methods:This qualitative study was based on semi-structured interviews conducted alongside an RCT. Forensic outpatients allocated to the additive informal social network intervention, and volunteer coaches, were interviewed 12 months after baseline assessment. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to identify and report patterns in the data.Results:We included 22 patients and 14 coaches in the study. The analysis of interviews revealed five main themes reflecting patients’ and coaches’ experiences: (1) dealing with patient receptivity, (2) developing social bonds, (3) receiving social support, (4) achieving meaningful change, and (5) using a personalized approach. Patient receptivity, including willingness, attitudes, and timing, was a common reported barrier affecting patients’ engagement in the intervention. Both patients’ and coaches’ experiences confirmed that the intervention can be meaningful in developing new social bonds between them, in which patients received social support. Despite, experiences of meaningful and sustainable changes in patients’ social situations were not clearly demonstrated. Coaches’ experiences revealed broadened worldviews and an enhanced sense of fulfillment and purpose. Finally, a personalized, relationship-oriented rather than goal-oriented approach was feasible and preferable.Conclusion:This qualitative study showed positive experiences of both forensic psychiatric outpatients and volunteer coaches with an informal social network intervention in addition to forensic psychiatric care. Notwithstanding the limitations, the study suggests that these additive interventions provide an opportunity for forensic outpatients to experience new positive social interactions with individuals in the community, which can initiate personal development. Barriers and facilitators to engagement are discussed to improve further development and implementation of the intervention.Trial registration:This study is registered at the Netherlands Trial Register (NTR7163, registration date: 16/04/2018).

Exploring the effects of a wearable biocueing app (Sense-IT) as an addition to aggression regulation therapy in forensic psychiatric outpatients.

Preventing and reducing violence is of high importance for both individuals and society. However, the overall efficacy of current treatment interventions aimed at reducing aggressive behavior is limited. New technological-based interventions may enhance treatment outcomes, for instance by facilitating out-of-session practice and providing just-in-time support. Therefore, the aim of this study was to assess the effects of the Sense-IT biocueing app as an addition to aggression regulation therapy (ART) on interoceptive awareness, emotion regulation, and aggressive behavior among forensic outpatients. A combination of methods was used. Quantitatively, a pretest-posttest design was applied to explore group changes in aggression, emotion regulation, and anger bodily sensations associated with the combination of biocueing intervention and ART. Measures were assessed at pretest, after 4 weeks posttest, and after one-month follow-up. During the 4 weeks, a single-case experimental ABA design was applied for each participant. Biocueing was added in the intervention phase. During all phases anger, aggressive thoughts, aggressive behavior, behavioral control, and physical tension were assessed twice a day, and heart rate was measured continuously. Qualitative information regarding interoceptive awareness, coping, and aggression was collected at posttest. 25 forensic outpatients participated. A significant decrease in self-reported aggression was found between pre- and posttest. Furthermore, three-quarters of participants reported increased interoceptive awareness associated with the biocueing intervention. However, the repeated ambulatory measurements of the single-case experimental designs (SCEDs) did not indicate a clear effect favoring the addition of biocueing. On group level, no significant effects were found. On the individual level, effects favoring the intervention were only found for two participants. Overall, effect sizes were small. Biocueing seems a helpful addition to increase interoceptive awareness among forensic outpatients. However, not all patients benefit from the current intervention and, more specifically, from its behavioral support component aimed at enhancing emotion regulation. Future studies should therefore focus on increasing usability, tailoring the intervention to individual needs, and on integration into therapy. Individual characteristics associated with effective support by a biocueing intervention should be further investigated, as the use of personalized and technological-based treatment interventions is expected to increase in the coming years.

Forensic Psychiatric Outpatients' and Therapists' Perspectives on a Wearable Biocueing App (Sense-IT) as an Addition to Aggression Regulation Therapy: Qualitative Focus Group and Interview Study.

Given the increased use of smart devices and the advantages of individual behavioral monitoring and assessment over time, wearable sensor-based mobile health apps are expected to become an important part of future (forensic) mental health care. For successful implementation in clinical practice, consideration of barriers and facilitators is of utmost importance. The aim of this study was to provide insight into the perspectives of both psychiatric outpatients and therapists in a forensic setting on the use and implementation of the Sense-IT biocueing app in aggression regulation therapy. A combination of qualitative methods was used. First, we assessed the perspectives of forensic outpatients on the use of the Sense-IT biocueing app using semistructured interviews. Next, 2 focus groups with forensic therapists were conducted to gain a more in-depth understanding of their perspectives on facilitators of and barriers to implementation. Forensic outpatients (n=21) and therapists (n=15) showed a primarily positive attitude toward the addition of the biocueing intervention to therapy, with increased interoceptive and emotional awareness as the most frequently mentioned advantage in both groups. In the semistructured interviews, patients mainly reported barriers related to technical or innovation problems (ie, connection and notification issues, perceived inaccuracy of the feedback, and limitations in the ability to personalize settings). In the focus groups with therapists, 92 facilitator and barrier codes were identified and categorized into technical or innovation level (n=13, 14%), individual therapist level (n=28, 30%), individual patient level (n=33, 36%), and environmental and organizational level (n=18, 20%). The predominant barriers were limitations in usability of the app, patients' motivation, and both therapists' and patients' knowledge and skills. Integration into treatment, expertise within the therapists' team, and provision of time and materials were identified as facilitators. The chances of successful implementation and continued use of sensor-based mobile health interventions such as the Sense-IT biocueing app can be increased by considering the barriers and facilitators from patients' and therapists' perspectives. Technical or innovation-related barriers such as usability issues should be addressed first. At the therapist level, increasing integration into daily routines and enhancing affinity with the intervention are highly recommended for successful implementation. Future research is expected to be focused on further development and personalization of biocueing interventions considering what works for whom at what time in line with the trend toward personalizing treatment interventions in mental health care.

The impact of COVID-19 restrictions on social relationships of forensic psychiatric outpatients with preexisting social network-related problems: A mixed methods study

ABSTRACT This study aimed to explore the impact of the COVID-19 restrictions on social relationships of forensic psychiatric outpatients with preexisting social network-related problems. Data from 70 participants of an ongoing randomized controlled trial, investigating the effectiveness of a social network intervention among forensic psychiatric outpatients, were examined. Demographic characteristics, quality of social relationships, loneliness, and social support were assessed at baseline. During the COVID-19 pandemic, an additional questionnaire that contained quantitative and qualitative questions regarding the impact of COVID-19 restrictions on social relationships was administered. Participants showed high levels of loneliness and dissatisfaction with social relationships before COVID-19. The majority of forensic outpatients perceived no changes on social relationships due to the COVID-19 restrictions. Qualitative results revealed some participants already lived socially isolated. Negative changes on social relationships were related to deterioration of social contacts, interruption of daytime activities, changed mental health care, and well-being. Emotional loneliness predicted deteriorated general and romantic relationships. These findings suggest that social relationships of forensic patients with preexisting social network-related problems remain of concern throughout the COVID-19 pandemic.

Development of a Wearable Biocueing App (Sense-IT) Among Forensic Psychiatric Outpatients With Aggressive Behavior: Design and Evaluation Study.

BackgroundThe ability to regulate anger is often impaired in forensic psychiatric patients, frequently resulting in aggressive behavior. Although some treatment programs are partially successful in enhancing aggression regulation and reducing recidivism among specific subgroups, generalizable conclusions on the effectiveness of these interventions cannot be drawn to date. In forensic outpatient care, low treatment adherence and a predominant focus on cognitive control in most treatment programs may entail some of the factors impeding treatment. Technology-based interventions may address some of these treatment challenges.ObjectiveThe aim of this study is to explore whether a new technology-based biocueing intervention, the Sense-IT app, can be a valuable addition to aggression regulation treatment programs in forensic outpatient care. The Sense-IT app, which provides the user with real-time physiological feedback and behavioral support, is developed to strengthen emotional awareness and facilitate real-life practice. In this study, we aim to develop and evaluate an updated version of the Sense-IT app that is suitable for forensic outpatients with aggressive behavior.MethodsFirst, we conducted a design study to assess the attitudes of forensic professionals and patients toward biocueing and to collect requirements for a biocueing app for this specific population. On the basis of this information, we developed an updated version of the Sense-IT app. In an evaluation study, 10 forensic outpatients used the app for 2 weeks. The app’s acceptability, usability, and clinical outcomes (aggression, anger, and recognition of bodily signals related to anger) were measured before and after the intervention using both quantitative and qualitative measures.ResultsThe design study revealed a cautiously positive attitude toward the use of biocueing as an addition to aggression regulation therapy. The evaluation study among forensic outpatients demonstrated moderate acceptability and adequate usability for the new version of the Sense-IT app. Exploratory analysis revealed a significant decrease in trait aggression postintervention; no significant changes were found in other anger-related clinical outcomes. To further increase acceptability and usability, a stable functioning app with self-adjustable settings, the use of smartwatches with a longer battery life, and the use of the patient’s own smartphone devices were recommended.ConclusionsThis study, which is one of the first attempts to enroll and evaluate the real-life use of a biocueing intervention among forensic outpatients, emphasized the importance of involving both patients and therapists throughout the development and implementation process. In the future, experimental studies, including single-case experimental designs using ecological momentary assessment, should be performed to evaluate the effectiveness of the Sense-IT intervention on clinical outcomes. An open attitude toward new technology, allowing exploration of the potential benefits of the Sense-IT app case-by-case, and training of therapists in using the app are expected to facilitate its integration in therapy.

Testing the Effects of a Virtual Reality Game for Aggressive Impulse Management: A Preliminary Randomized Controlled Trial among Forensic Psychiatric Outpatients.

Prior laboratory experiments among healthy samples found that training avoidance movements to angry faces may lower anger and aggression, especially people high in trait anger. To enrich this training and make it more suitable for clinical applications, the present researchers developed it into a Virtual Reality Game for Aggressive Impulse Management (VR-GAIME). The current study examined the effects of this training in a randomized controlled trial among forensic psychiatric outpatients with aggression regulation problems (N = 30). In addition to the aggression replacement training, patients played either the VR-GAIME or a control game. Aggressive behavior was measured pre-, half-way, and post-treatment via self-report and clinicians ratings. No difference was found between the VR-GAIME and the control game. However, the participants reported gaining more insight into their own behavior and that of others. Future VR intervention tools in clinical settings may capitalize more on their benefits for self-reflection within interpersonal settings.

Shaping Blended Care: Adapting an Instrument to Support Therapists in Using eMental Health.

BackgroundAlthough eMental health interventions, especially when delivered in a blended way, have great potential to improve the quality and efficiency of mental health care, their use in practice lags behind expectations. The Fit for Blended Care (FfBC) instrument was developed to support therapists and clients in shaping blended care in a way that optimally fits their needs. However, this existing version cannot be directly applied to specific branches of mental health care as it is too broad and generic.ObjectiveThe goal of this study is to adapt the existing FfBC instrument to fit a specific, complex setting—forensic mental health care—by means of participatory development with therapists.MethodsThe participatory process was divided into 4 phases and was executed by a project team consisting of 1 manager, 3-5 therapists, and 1 researcher. In phase 1, general requirements for the adaptation of the existing instrument were discussed in 2 focus groups with the project team. In phase 2, patient-related factors that influence the use of an existing web-based intervention were elicited through semistructured interviews with all 18 therapists working at an outpatient clinic. In phase 3, multiple focus groups with the project teams were held to create the first version of the adapted FfBC instrument. In phase 4, a digital prototype of the instrument was used with 8 patients, and the experiences of the 4 therapists were discussed in a focus group.ResultsIn phase 1, it became clear that the therapists’ main requirement was to develop a much shorter instrument with a few items, in which the content was specifically tailored to the characteristics of forensic psychiatric outpatients. The interviews showed a broad range of patient-related factors, of which 5 were used in the instrument: motivation for blended treatment; writing about thoughts, feelings, and behavior; conscientiousness; psychosocial problems; and social support. In addition, a part of the instrument was focused on the practical necessary preconditions that patients should fill by themselves before the treatment was developed. The use of the web-based prototype of the instrument in treatment resulted in overall positive experiences with the content; however, therapists indicated that the items should be formulated in a more patient-centered way to encourage their involvement in discussing the factors.ConclusionsThe participatory, iterative process of this study resulted in an adapted version of the FfBC instrument that fits the specific forensic context and supports shared decision making. In general, the adaptiveness of the instrument is important: its content and implementation should fit the type of care, the organization, and eHealth intervention. To adapt the instrument to other contexts, the guidelines described in this paper can be followed.

Improving mental wellbeing of forensic psychiatric outpatients through the addition of an informal social network intervention to treatment as usual: a randomized controlled trial

BackgroundForensic psychiatric patients often suffer from a multitude of severe psychiatric and social problems. Meanwhile multimodal evidence-based interventions are scarce and treatment effectiveness is in need of improvement. The main goal of forensic psychiatric treatment is to address psychiatric and social factors and thereby mitigate criminal behaviour. Notably, a supportive social network is an important protective factor for criminal behaviour. As such, improving a poor social network may decrease the risk of criminal recidivism. This study aims to examine the effectiveness of the addition of an informal social network intervention (FNC) to treatment as usual (TAU) among forensic psychiatric outpatients.MethodsIn a mono-center randomized controlled clinical trial with two parallel groups, forensic psychiatric outpatients with social network-related problems (N = 105) will be allocated to either TAU + FNC or TAU alone. The informal social network intervention consists of a 12-month coaching intervention, performed by the forensic network coach (a volunteer trained by an informal care institute). Assessments will be conducted at baseline and 3 months, 6 months, 9 months, 12 months, and 18 months after baseline. The primary outcome variable is mental wellbeing. Psychiatric functioning, criminal recidivism, substance abuse, quality of life, social network, social support, loneliness and self-sufficiency are included as secondary outcomes. A variety of potential mediators and moderators of effectiveness will be explored. Additionally, a qualitative evaluation of effectiveness will be performed.DiscussionThis study will contribute to the existing literature of forensic treatment effectiveness as it is the first RCT examining the effectiveness of adding a social network intervention in a forensic outpatient population. If effectiveness is shown, forensic mental health care could be optimized by collaborating with informal care or community initiatives aimed at improving a positive social network. In addition, results will provide insight regarding mediators and moderators of treatment effectiveness.Trial registrationThis study is registered at the Netherlands Trial Register (NTR7163). Date of registration: 16 april 2018.

Neurocognitive Function and Fetal Alcohol Spectrum Disorder in Offenders with Mental Disorders.

Individuals with a history of offending behavior show high rates of mental disorder as well as fetal alcohol spectrum disorder (FASD). Neurocognitive impairments are common in both mental disorders and FASD and may interface with offending behavior. Understanding these impairments could effectively inform clinical considerations among this population. The purpose of this study was to characterize the life experiences and examine the neurocognitive profile of a group of adult forensic psychiatric outpatients. We also investigated potential differences between offenders with FASD and the rest of the sample. Data were collected on 45 subjects on numerous variables, including demographics, background information, offending histories, and comorbidities. Subjects also completed extensive neurocognitive testing. The sample was primarily male (82.2%) with a mean age of 42 years. There was a high prevalence of lifetime adversity and varied offense histories. Subjects showed the most significant neurocognitive impairment in executive function, visual memory (immediate and delayed recall), and full-scale IQ. The FASD group (n = 12) did not differ significantly from the No-FASD group (n = 33) on any background variables. The FASD group showed significantly lower neurocognitive scores in the areas of verbal IQ, full-scale IQ, working memory, processing speed, and expressive vocabulary.

Employment-Related Factors of Forensic Psychiatric Outpatients with Psychotic Disorders.

PurposeEmployment is important for forensic psychiatric patients with psychotic disorders, in terms of reduction in symptoms, improving the quality of life, and preventing re-offenses. However, few detailed studies on employment status in such patients exist. We aimed to determine the employment rate among forensic psychiatric outpatients with psychotic disorders and identify the factors associated with employment.Patients and methodsThe study population comprised 406 patients with psychotic disorders who completed a forensic outpatient treatment order, were aged <65 years at discharge from a forensic psychiatric ward and provided written informed consent. Psychotic disorders were defined as psychiatric disorders classified into F2 in the International Statistical Classification of Diseases and Related Health Problems, 10th edition. Demographic data were collected from the medical records of the inpatient treatment period. Prognostic data during the outpatient treatment order period was provided by the reintegration coordinators responsible for coordinating the patients’ social environment during this period. Exploratory univariate and multivariable logistic regression analyses identified the factors associated with employment.ResultsThe mean age at discharge was 44.4±10.8 years. The mean follow-up period was 2.69±1.01 years. There were 4.6 times more men (n=334) than women (n=72). During the outpatient treatment order period, 56 of 406 participants achieved employment (13.8%). Participants who committed serious crime, including homicide, arson, robbery, and sexual assault, had a lower employment rate compared to participants who committed bodily injury crimes (multivariable odds ratio, 0.421; 95% confidence interval, 0.220–0.807). History of substance use and living with family after discharge from a forensic psychiatric ward positively contributed to employment.ConclusionThe employment rate among forensic psychiatric outpatients with psychotic disorders was low and was similar to that reported in previous studies on general psychiatric patients with schizophrenia. Furthermore, serious criminal behavior negatively impacted employment.

Mortality and suicide rates in patients discharged from forensic psychiatric wards in Japan

BackgroundJapanese forensic mental health services for patients with psychiatric disorders under the Medical Treatment and Supervision Act was initiated in 2005; however, the prognosis of those patients is not well-known, particularly regarding mortality and suicide. This study aimed to evaluate the all-cause mortality and suicide rate in forensic psychiatric outpatients who had been discharged from forensic psychiatric wards in Japan. MethodsParticipants included 966 patients who had been discharged from forensic psychiatric wards. Data were collected from July 15, 2005 to July 15, 2018 at 29 of the 33 forensic psychiatric wards in Japan. Only the patients who provided written informed consent were included. We and collaborators at each forensic psychiatric ward identified demographic data of participants from the medical records for the inpatient treatment period. The reintegration coordinators, who belonged to the Ministry of Justice, investigated the prognosis of the participants during the outpatient treatment order period. We then connected demographic data and participants’ prognosis for analysis. The crude rates (CRs) and standardized mortality ratios (SMRs) were calculated to analyze all-cause mortality and suicide rates. Univariate analysis was performed to examine the factors associated with all-cause mortality and suicide rates using the Cox proportional hazards ratio model. ResultsThe participants included 3.3 times as many men (n=739) compared to women (n=227), and their combined mean age was 47.3 (SD=12.9). The most common primary psychiatric diagnosis was psychotic disorders (81.3%). The mean follow-up period was 790.2 days (SD=369.6). The total observation period was 2091.2 person-years. The CR for all-cause death was 812.9 per 100,000 person-years (95% CI [426.5, 1199.4]), while the SMR for all-cause death was 2.2 (95% CI [1.3, 3.5]). The CR for completed suicide was 478.2 per 100,000 person-years (95% CI [181.8, 774.6]). The suicide SMR was 17.9 (95% CI [8.6, 32.9]) overall, 7.7 (95% CI [2.5, 18.0]) for men, and 79.4 (95% CI [25.8, 185.2]) for women. Univariate analysis showed that women had higher completed suicide risk than men (hazard ratio=3.599, 95% CI [1.041, 12.445]). ConclusionThe all-cause mortality and completed suicide rates were higher in participants than observed in the general population consistent with the results of previous international studies.

Single-item predictive validity of the Short-Term Assessment of Risk and Treatability (START) for violent behaviour in outpatient forensic psychiatry

ABSTRACTThe single-item predictive validity of the Short-Term Assessment of Risk and Treatability (START) has not been thoroughly investigated, although this has great clinical relevance for the selection of treatment targets. Furthermore, it remains unclear whether the characteristic START additions of scoring strengths next to vulnerabilities and selecting key items, add incremental predictive validity. Finally, predictive validity has primarily been studied in inpatient settings and included mainly patients with a psychotic disorder. We analysed data from a mixed diagnostic sample of 195 forensic psychiatric outpatients with a 3-month and 170 patients with a 6-month follow-up period, using logistic regression analysis. The occurrence of violent or criminal behaviour was established based on the case manager’s recordings in the patient’s file. Only 5 of the 20 START items were found to have predictive validity: Impulse Control, Attitudes, Material Resources, Rule Adherence and Conduct. The last three were the only items for which incremental predictive validity was found with respect to scoring it as a strength and a vulnerability. Selection of key items did not add to the predictive validity. While possibly having therapeutic significance, the scoring of strength next to vulnerability and the selection of key items, may not be beneficial for risk assessment.

Retrospective parental rejection is associated with aggressive behavior as well as cognitive distortions in forensic psychiatric outpatients.

Objective: Parental rejection in childhood is associated with the increased risk of aggression in adulthood and is thought to contribute to the development of inaccurate beliefs regarding own or others' behavior (i.e., cognitive distortion) as well. Different forms of aggression are thought to be linked to different types of cognitive distortions. This, however, is unclear in adults. Additionally, it is unknown if parental rejection predicts the presence of aggression and cognitive distortions in adults displaying severe aggression. Method: One hundred twenty-three adult forensic psychiatric outpatients with aggression regulation problems were recruited. Least absolute shrinkage and selection operator (Lasso) regression analysis and path analyses were conducted to investigate distinct patterns of cognitive distortions, as measured by use of the How I Think Questionnaire, and the role of perceived parental rejection, as measured by use of the Parental Rejection and Acceptance Questionnaire. Results: Cognitive distortions related to opposition-defiance (e.g. disrespecting rules) and to physical aggression were most strongly associated with the disposition to act aggressively. Furthermore, a direct association was found between parental rejection and this current disposition. This association was partially mediated by cognitive distortions related to opposition-defiance. Conclusion: The current study supports the notion that parental rejection has profound consequences on adult behavior. Acknowledgement of the impact of cognitive distortions on current aggression might be of importance for treatment. A stronger focus on altering distinct cognitive distortions may be more successful in reducing aggression.

Lack of correspondence between the reactive proactive questionnaire and the impulsive premeditated aggression scale among forensic psychiatric outpatients.

The most studied bimodal classifications of aggressive behavior are the impulsive/premeditated distinction measured with the Impulsive Premeditated Aggression Scale and the reactive/proactive distinction measured with the Reactive Proactive Questionnaire. The terms of these classifications are often used interchangeably, assuming that reactive aggression is equivalent to impulsive aggression and that proactive aggressive behavior is the same as premeditated aggression. The correspondence or discrepancy between both aggression classifications/questionnaires, however, is understudied. Therefore, the current study investigated the correspondence between the RPQ and IPAS in a sample of 161 forensic psychiatric outpatients (FPOs) with severe aggressive behavior. Correlation analysis revealed a limited correspondence between the RPQ and IPAS. Cluster analyses derived three clusters from the RPQ as well as the IPAS: these clusters did not match in 60.3% of the cases. Furthermore, the notion that the RPQ measures trait aggression whereas the IPAS assesses state aggression could not be verified. The present study indicates that aggression subtypes as measured by use of the RPQ and IPAS correspond only partially and should not be used interchangeably. Furthermore, it was suggested that RPQ focuses more on actual aggressive behavior and the IPAS more on emotions and their regulation. Future research is needed to elucidate the applicability of both questionnaires in further detail.

Alexithymia as a potential source of symptom over-reporting: An exploratory study in forensic patients and non-forensic participants.

The traditional interpretation of symptom over-reporting is that it indicates malingering. We explored a different perspective, namely that over-reporting of eccentric symptoms is related to deficits in articulating internal experiences (i.e., alexithymia). Given that alexithymia has been linked to sleep problems and that fatigue may fuel inattentive responding to symptom lists, we administered measures of alexithymia (TAS-20) and symptom over-reporting (SIMS), but also sleep quality (SLEEP-50) to forensic psychiatric outpatients (n = 40) and non-forensic participants (n = 40). Forensic patients scored significantly higher on all three indices than non-forensic participants. In the total sample as well as in subsamples, over-reporting correlated positively and significantly with alexithymia, with rs being in the 0.50-0.65 range. Sleep problems were also related to over-reporting, but in the full sample and in the forensic subsample, alexithymia predicted variance in over-reporting over and above sleep problems. Although our study is cross-sectional in nature, its results indicate that alexithymia as a potential source of over-reporting merits systematic research.

Associations Between Neurocognitive Characteristics, Treatment Outcome, and Dropout Among Aggressive Forensic Psychiatric Outpatients.

Aggression Replacement Training (ART) is widely used to reduce aggression and is considered to be effective although there are also inconsistent results. Studies investigating the effectiveness of ART do not focus on neurocognitive characteristics. Focusing on these aspects would result in enhanced understanding of underlying mechanisms of ART. The current open uncontrolled treatment study assessed whether neurocognitive characteristics were associated with change in aggression during the social skills and anger control modules of ART among forensic psychiatric outpatients. Furthermore, differences between treatment dropouts and completers and change in these characteristics during ART were examined. A reduction of trait aggression, cognitive distortions, and social anxiety was observed. Neurocognitive characteristics were not associated with change in aggression, could not distinguish treatment completers from dropouts, and did not change after ART. It is suggested that new paradigms should be developed which take into account the social context in which these impairments appear.