Forensic Psychiatric Unit Research Articles

Antécédents d’adversité et types d’homicide : une étude menée en Unité pour Malades Difficiles

In this article, we explore the links between adverse childhood experiences (ACEs) and the commission of certain types of homicide(s): infanticide, filicide, uxoricide, matricide, patricide, parricide, fratricide, aviolicide, double homicide, mass killings, serial murders, and so on. The patient files of 423 male perpetrators of homicide(s) hospitalized in a French secure forensic psychiatric unit between 1963 and 2020 were examined. A thematic collection grid was specially designed to reconstruct the traumatogenic trajectories of the subjects concerned, and to thereby determine the presence or absence of different forms of ACE (physical, emotional, and sexual violence, physical and emotional neglect, exposure to domestic abuse and conjugal violence, etc.). After calculating prevalence data, multiple correspondence analyses (MCA) were performed, in order to identify patterns of association linking specific ACEs to the types of homicide investigated. Projection of the results within a multidimensional space will enable us to visualize the main associations that may be established for clinical and preventive purposes. Agglomerative hierarchical clustering (AHC) is then used to group individuals into distinct latent classes, based on the similarities and dissimilarities of the homicidal criminals studied. The profiles outlined are then discussed, as are the particularly high rates of ACEs found – especially in comparison with data obtained from other studies (carried out in general, prison or forensic populations). Finally, we suggest a few avenues for future research.

Treatment adherence in forensic patients with schizophrenia spectrum disorders discharged on long-acting injectable antipsychotics: a comparative 3-year mirror-image study.

In this retrospective 3-year mirror-image study, 81 patients with schizophrenia spectrum disorders (SSD) were categorized according to whether they were prescribed long-acting injectable antipsychotics (LAI) or not upon discharge from the inpatient forensic psychiatric unit. Antipsychotic adherence, which was staged based on the 'proportion of days covered' method, as well as other clinical outcomes was compared between pre- and post-index mirror periods. In both Oral-only (n = 46) and Oral + LAI (n = 35) groups, the number of hospitalizations, convictions and months spent in the hospital were significantly lower in the post-index period than the pre-index period. Differences in these three variables between pre- and post-index periods were NS between the two groups. A mixed effect ordinal logistic regression model with random intercept showed that the odds ratio of obtaining a higher treatment adherence score in the post-index period was more pronounced in the Oral + LAI group than in the Oral-only group, considering adherence at baseline and the length of stay during the index hospitalization as potential confounders. Discharge with LAIs in a forensic psychiatric cohort of SSD was associated with a greater mid- to long-term improvement in antipsychotic medication adherence compared to discharge with oral-only antipsychotics.

The Characteristics of Patients Admitted to a Forensic Psychiatric Intensive Care Unit in Australia

Background: Psychiatric intensive care units (PICUs) house some of the highest acuity patients within the mental health system. Little is known about patient characteristics and adverse events occurring in these settings and this study aimed to examine clinical, demographic and offending characteristics and correlates of problem behaviours for patients admitted to the first forensic PICU in Australia. Aims: To identify common characteristics held by patients admitted to one high secure forensic PICU in Australia. Method: Retrospective file review occurred for patients admitted between March 2019 and May 2020, during which 96 male patients were admitted. Results: Mean (range) age was 37.3 (21–76) years, and when admitted most patients were: single (n = 80; 83.3%), homeless (n = 52; 54.2%), had not completed high-school education (n = 60; 62.5%), had histories of trauma (n = 38; 39.6%) and antisocial behaviour (n = 40; 41.7%) in adolescence and presented with personality disorder (n = 23; 24.0%) and substance abuse (n = 93; 96.9%). Frequent problem behaviours, particularly aggression (n = 65; 67.7%), were encountered and rates of seclusion (n = 62; 64.6%) were high. Segregation in prison prior to admission and co-morbid personality disorder were associated with increased likelihood of aggression or self-harm respectively occurring. Conclusion: With high mental illness acuity and significant behavioural risk complicated by multi-vulnerability, forensic PICUs need specialist environments, models of care and high level relational and de-escalation staff expertise to maintain safety and promote recovery.

The Use of Alternative Rooms in Forensic and Regular Psychiatric Units: A Scoping Review.

(1) Background: Emotional regulation, distress and relational conflicts often occur during hospitalization and rehabilitation on psychiatric units, especially in patients suffering from severe and persistent mental disorders. While widely used in children and geriatric patients, little literature exists on the use and outcomes of alternative rooms in the context of forensic and regular psychiatric units for adult patients. Considering the scarcity of the literature on alternative use, this study is motivated by the following research question: what are the main uses and outcomes of alternative rooms in the context of forensic and regular psychiatric units? The main objective of this study is to conduct a scoping review of the use and outcomes of alternative rooms for the context of psychiatric inpatients. (2) Methods: A systematic search was performed in the electronic databases of MedLine, Web of Science, PsycNet (PsycINFO) and Google Scholar from their inception dates until 2022. (3) Results: A total of nine studies were analyzed. Sensory, multisensory rooms, Snoezelen, and comfort rooms are the types of alternative rooms discussed in these studies. Distress and anxiety reduction, increase in self-esteem, impact on seclusion rates, patient-staff communication and alliances, heart and respiration rate reduction, and improvement of alexithymia were identified among the main uses and outcomes of these rooms. (4) Conclusions: The scarcity of literature available to draw information from for this review and possible impact on improving patient outcomes and quality of treatment in psychiatric units opens the door to future studies to better understand the efficacy of such rooms. Research into the ideal implementation tactics of such rooms, long-term outcomes, and the influence on diverse patient demographics could be areas of improvement in the use of alternative rooms.

Struggling with unnecessary suffering-Registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care.

Chemical restraints are used in forensic psychiatric inpatient care, however with caution as it can feel like an assault against patients' integrity. When waiting for decisions on treatment without consent, nursing staff are expected to care for patients with severe mental ill-health without the use of medical treatment, often with a feeling of already having tried all other available means. Knowledge about how registered nurses experience such situations is sparse but could contribute to the development of both teamwork and nursing approaches that could mean reduced suffering for patients. The aim of this study was to describe registered nurses' experiences of delayed decisions on treatment without consent in forensic psychiatric inpatient care. Eleven semi-structured interviews were conducted with registered nurses working in forensic psychiatric units in Sweden. Data were analysed through qualitative content analysis. The result showed that experiences of treatment without consent were about striving to protect patients from harm, striving for collaboration during difficult circumstances and striving to do good. This was interpreted as a struggle with unnecessary suffering. For registered nurses to be able to handle such challenging situations and relieve suffering for patients, experience and master-level education in mental health nursing are highlighted. Another aspect that is highlighted is the importance of having consultants familiar with the circumstances at the unit. A method for joint reflection is suggested, to promote an open-minded work culture with a well-functioning decision-making process and ensure that both consultants and nursing staff have support.

Factors associated with COVID-19 vaccination for patients in an inpatient forensic psychiatric hospital.

The aim of this study was to assess factors associated with SARS-CoV-2 (COVID-19) vaccination in patients in 2 inpatient forensic psychiatric hospitals. This was a retrospective chart review evaluating factors associated with COVID-19 vaccination for patients residing in two inpatient forensic psychiatric hospitals between January 1, 2021 and February 28, 2022. Data was collected through electronic medical records utilizing MetaCare Enterprise™ and secure facility computer drives, individual patient paper charts, and Missouri's vaccination records database, ShowMeVax. Several variables were collected to assess factors associated with COVID-19 vaccination. Additionally, COVID-19 vaccination rates were compared to the influenza vaccination rates at these hospitals. Overall, 229 patients (84.5%) were vaccinated against COVID-19 during or before the study period and 42 (15.5%) were unvaccinated. Patients who were deemed incompetent to stand trial were less likely to receive the COVID-19 vaccine. Those that had a higher body mass index (BMI), were diagnosed with multiple comorbid conditions, not prescribed involuntary medications, were offered incentives, and received the influenza vaccine were more likely to receive the COVID-19 vaccine. Education level, race, sex, age, and being prescribed psychiatric medications did not affect vaccination status. Patient specific factors should be used when educating and offering COVID-19 vaccines to patients in an inpatient forensic psychiatric unit. Awareness of these results can facilitate targeted interventions for optimal care in a psychiatric population.

Prosecuted for Attempting Suicide: A Retrospective Study in a Malaysian Forensic Psychiatric Unit

Introduction and Study Objectives: Criminalization of suicide attempts is an archaic barrier to suicide prevention. Malaysia remains one of the few upper middle-income countries that still criminalizes suicide attempts. Globally, clinical profiles of prosecuted suicide attempters are an under-researched area. Recognizing the prosecuted would aid in understanding the survival and help in the narrative for the need for decriminalization of suicide attempts. Method and Materials: This retrospective study of clinical notes aims to describe the clinical profiles of individuals who were charged for attempted suicide and subsequently sent for criminal responsibility and fitness to plead evaluation in a forensic psychiatric unit in Malaysia from January 1, 2008, to December 31, 2019. Results: We identified 22 cases who were mostly adult males (90.9%) and half of the individuals were hospitalized post-attempt due to lethality of method. Seventy-three percent have a psychiatric disorder. Mood disorders were more prevalent (32%) followed by psychotic disorders and substance use disorders. For most of these individuals, this was the first contact with any form of mental health services and 41% defaulted their treatment before arrest. Notably, a large portion of the sample (72.7%) had no additional criminal charge. Conclusion: Criminalization of suicide attempts complicates the care pathway for individuals who attempt suicide in Malaysia. The criminal justice pathway can significantly delay treatment. Legal processes and assessments that persons prosecuted for suicide attempt have to undergo may take precedence over mental health care. The clinical outcome post-discharge is largely unknown to a group that is at increased risk of suicide. Therefore, this sample illustrates a vulnerable group who has been and will be disengaged with mental healthcare. Future research is warranted to further investigate mechanisms that are effective in addressing unmet needs of persons in suicidal crisis as opposed to utilizing the criminal justice pathway include the need for decriminalization of suicide attempts.

Psychopathy assessments in forensic psychiatry: a pilot study of Canadian practitioners’ use and perceptions

PurposeThe purpose of this study was to survey practitioners’ use and perceptions of psychopathy assessments in Canadian forensic psychiatric settings. Psychopathy assessments are widely used in forensic settings to inform decisions about sentencing, placement, rehabilitation and parole. Recent empirical evidence suggests that the utility of psychopathy assessments might be overestimated, leading to a debate about their legal and ethical justification. However, one shortcoming of these discussions is that they rely heavily on anecdotal evidence about how exactly psychopathy assessments influence forensic decisions, due to a general lack of survey data on field uses. Some data are available in European and American contexts, but little is known about Canadian clinical practice.Design/methodology/approachTo address this shortcoming in the literature, the authors conducted a pilot study of practitioners in forensic psychiatric units in Ontario (N = 18), evaluating their use of psychopathy assessments, reporting habits and their perceptions of psychopathic offenders.FindingsPractitioners reported that they primarily used the Hare Psychopathy Checklist-Revised (PCL-R) as a risk assessment tool, often in combination with other tools. Most clinicians reported using psychopathy assessments infrequently, that there was a low base rate of psychopathic offenders and their attitudes and beliefs about psychopathy were generally consistent with the empirical literature.Originality/valueThis pilot study provides novel insights into the use of psychopathy assessments in Canadian forensic psychiatry with the potential to inform current debates.

Exploring substance use as rule-violating behaviour during inpatient treatment of offender patients with schizophrenia.

BackgroundRule‐violating behaviour in the form of substance misuse has been studied primarily within the context of prison settings, but not in forensic psychiatric settings.AimsOur aim was to explore factors that are associated with substance misuse during hospitalisation in patients among those patients in a Swiss forensic psychiatric inpatient unit who were suffering from a disorder along the schizophrenia spectrum.MethodsFrom a database of demographic, clinical and offending data on all residents at any time between 1982 and 2016 in the forensic psychiatric hospital in Zurich, 364 cases fulfilled diagnostic criteria for schizophrenia or a schizophrenia‐like illness and formed our sample. Any confirmed use of alcohol or illicit substances during admission (yes/no) was the dependent variable. Its relationship to all 507 other variables was explored by machine learning. To counteract overfitting, data were divided into training and validation set. The best model from the training set was tested on the validation set.ResultsSubstance use as a secure hospital inpatient was unusual (15, 14%). Prior substance use disorder accounted for so much of the variance (AUC 0.92) that it was noted but excluded from further models. In the resulting model of best fit, variables related to rule breaking, younger age overall and at onset of schizophrenia and nature of offending behaviour, substance misuse as a minor and having records of complications in prior psychiatric treatment were associated with substance misuse during hospitalisation, as was length of inpatient treatment. In the initial model the AUC was 0.92. Even after removal of substance use disorder from the final model, performance indicators were meaningful with a balanced accuracy of 67.95, an AUC of 0.735, a sensitivity of 81.48% and a specificity of 57.58%.ConclusionsSubstance misuse in secure forensic psychiatric hospitals is unusual but worthy of clinical and research consideration because of its association with other rule violations and longer hospitalisation. More knowledge is needed about effective interventions and rehabilitation for this group.

Systematic Aggression Registration in Forensic Psychiatric Care: A Qualitative Study on Preconditions for Successful Implementation.

Available research emphasizes the importance of getting a systematic overview of inpatient aggression in forensic psychiatric care. However, the same research does not focus on how systematic aggression registration should be introduced in clinical practice. To facilitate the use of systematic aggression registration instruments, it is very relevant to gain insight into the perspective of staff members on the introduction of these instruments in daily clinical practice. Additionally, preconditions for achieving a successful implementation can be considered. Therefore, this study aims to gain insight into the perspective of the staff members on the implementation of a systematic aggression registration instrument-that is, the MOAS-in a forensic psychiatric unit. Interviews (n = 8) and a focus group with staff members were carried out. Three main themes: (1) creating the most appropriate context for introduction, (2) choice for the MOAS as relevant instrument, and (3) perpetuating the use of the MOAS in clinical practice are scrutinized. The mentioned preconditions can be used as guidelines when implementing systematic aggression registration in clinical practice. We hope that this paper can inspire other forensic psychiatric facilities to introduce systematic registration of aggressive incidents.

Patient outcomes in an Australian low secure forensic psychiatric rehabilitation inpatient unit: a 10-year retrospective study

The aim of this study is to investigate the background and discharge outcomes of the forensic patient population rehabilitated through a low secure forensic psychiatric rehabilitation inpatient unit. Currently within Australia and internationally there is a scarcity of research completed within this setting. A quantitative methodology was selected coupled with descriptive statistics to investigate a total of 23 patients and analyse their demographics, historical information, length of stay and post-discharge outcomes including readmission and breach of forensic orders. This study provides insights into this unique patient group and further clarifies their psychiatric treatment and biopsychosocial needs. A significant variance was found within patient length of stay throughout each stage of the forensic system. Low rates of readmissions and breaches of forensic orders were found. Additional research is needed in this low secure psychiatric rehabilitation setting to clarify the forensic pathways of care and needs amongst this cohort.

Zero violence or zero seclusion. Which is more acceptable in our hospitals?

IntroductionThere is an established association between serious mental illness and violence. Secure forensic psychiatric services provide care and treatment to mentally disordered offenders. The majority of patients in forensic services suffer from severe mental illnesses such as schizophrenia, with co-morbid polysubstance abuse and maladaptive personality traits. Psychiatric services are under significant pressure to reduce the use of seclusion and restrictive practices, whilst mandated to provide safe environments for patients and staff.ObjectivesTo determine the number and characteristics of violent incidents in a secure forensic hospital in Ireland.MethodsA retrospective review of all incidents in Central Mental Hospital, Ireland between 1st March 2019 and 31st August 2021 was completed. Incidents were categorised into physical assaults and other violent incidents. Demographic measures and measures of violence risk (HCR-20), functioning (GAF), programme completion and recovery (DUNDRUM tool) were collated.ResultsA total of 321 incidents took place during the period examined, of which 47 (14.6%) involved physical assaults perpetrated by patients. Between March 2020 and August 2021, numbers of assaults increased by 50% and 78% compared to the preceding six-month period respectively. The majority of assaults were committed by a relatively small group of patients. Victims of assaults were more likely to be patients (n=27, 57.4%) and more likely to be males (n=43, 91.9%).ConclusionsPhysical assaults and other violent incidents happen in forensic and general psychiatric units. Restrictive practices, used in accordance with the law, are necessary at times to prevent serious harm to patients and staff in psychiatric hospitals.DisclosureNo significant relationships.

Predictive Utility of the Imminent Risk Rating Scale: Evidence From a Clinical Pilot Study.

In an effort to prevent inpatient violence on forensic psychiatric units, it is necessary to have a feasible and effective measure for nursing to screen for risk of short-term verbal and physical aggression. The Imminent Risk Rating Scale (IRRS; Starzomski & Wilson, 2015) showed promise in an initial validation study. This study aimed to further examine the predictive validity of the IRRS by utilizing clinical pilot data collected from a forensic inpatient unit. Nursing staff scored the IRRS for adults who were hospitalized for at least 1 week ( n = 109), as well as outcomes related to verbal and physical aggression as measured by the Modified Overt Aggression Scale. The results from the clinical pilot data provided additional support for the potential use of the IRRS for predicting physical and verbal aggression in a forensic inpatient setting, although further rigorous empirical research is needed. The findings are important for nursing staff in the prediction and prevention of inpatient violence.

Choreographies of sexual safety and liminality: Forensic mental health and the limits of recovery

Medium secure forensic psychiatric units are unique environments within the broader “post asylum” landscape of mental health services. Length of stay is much greater and restrictions on behavior, including sexual behavior, are legally and institutionally legitimated, due to concerns regarding risk. As a result, sexuality is rarely explored experientially with service users and no official policies on sexual conduct and sexual safety have yet been developed.

Effects of Implementing the Short-Term Assessment of Risk and Treatability for Mechanical Restraint in a Forensic Male Population: A Stepped-Wedge, Cluster-Randomized Design.

The assessment and formulation of the risk of violence and other unwanted behaviors at forensic psychiatric facilities have been attempted for decades. Structured professional judgment tools, such as the Short-Term Assessment of Risk and Treatability (START), are among the recent attempts to overcome the challenge of accomplishing these goals. This study examined the effect of implementing START in clinical practice for the most serious adverse events among the target group of severely mentally ill forensic psychiatric inpatients. Results were based on the use of mechanical restraints as an outcome. This study is a pragmatic, stepped-wedge, cluster-randomized controlled trial and was conducted over 5 years. It included eight forensic psychiatric units. Fifty out of 156 patients who had a basic aggression score of more than 0 were included in the study. We found that the rate of mechanical restraint use within the START period were 82% [relative risk (RR) = 0.18], lower than those outside of the START period. Patients evaluated within the START period were also found to have a 36% (RR = 0.64) lower risk of having higher Brøset Violence Checklist scores than patients evaluated outside the START period. Previous studies on START have primarily focused on validation, the predictive capability of the assessment, and implementation. We were only able to identify one study that aimed to identify the benefits and outcomes of START in a forensic setting. This study showed a significant reduction in the chance for inpatients in a forensic psychiatric facility to become mechanically restrained during periods where the START was used as risk assessment.

Factors Influencing the Length of Hospital Stay in a Safety Measures Psychiatric Hospital in Romania.

A growth in the number of patients admitted to forensic psychiatric services has been reported worldwide. At the same time, an increase in the length of hospital stay of these patients was observed. To identify the factors that influence the length of hospital stay in a Romanian forensic psychiatric sample, as well as to compare the socio-demographic, clinical and criminological features of the "long stay" and "shorter stay" patients. This was a retrospective, cross-sectional study that included all patients admitted to Săpoca Psychiatry and Safety Measures Hospital according to article 110 of the Penal code (n=650) over a period of 11 years (2008-2018). Long stay was considered as a period of hospitalization greater than 5 years. The average length of hospital stay in the sample was 3.20 years. Approximately one quarter (n=154) of the patients were classified as "long stay". The variables that were significantly associated with length of stay included the main psychiatric diagnosis, social support, the severity of the offence and the perpetration of violence. Overall, our findings are in line with observations made by researchers from other countries. Our study highlights the need for further, more detailed research on the patients admitted to forensic psychiatric units in Romania.

Is a Forensic Cohabitation Program Recovery-Oriented? A Logic Model Analysis

Background. Recovery orientation is a movement in mental health practice. Although general mental health services have taken the lead in promoting recovery, forensic psychiatric systems have lagged behind because of the need to reconcile recovery principles with the complexities of legal mandates. Advocating recovery and making systemic changes can be challenging because they require seeking a balance between the competing duties to the patient and the public. This paper used a logic model framework to demonstrate a cohabitation program that placed a woman and her newborn infant in a secure forensic rehabilitation unit, and analyzed the key assumptions of recovery upon which it was based. Methods. This was a qualitative program evaluation. Data collection involved individual interviews with the woman, the infant’s father, five primary healthcare providers, and five system administrators, and 11 focus groups with unit staff and other patients. Content analysis was used to guide the data analysis and develop the critical components of the program logic model. Results. A logic model that consists of input (team building, program planning, staff and patient preparation, resource management), output (logistic activities, risk management, mental healthcare, staff/other patient support, discharge preparation), and outcome (individual, provider, system, and society) components was developed. Conclusions. This study demonstrates a recovery-oriented program for a woman cohabitating with her baby in a secure forensic psychiatric rehabilitation unit. The logic model provided a comprehensive understanding of the way the recovery principles, such as shared decision-making, positive risk-taking, informed choices, and relational security, were implemented.

Workplace characteristics of forensic and nonforensic psychiatric units associated with posttraumatic stress disorder (PTSD) symptoms.

Workplace factors associated with the development of posttraumatic stress disorder (PTSD) in inpatient psychiatric settings have received limited attention. In this study, we examined critical exposures, patient care stressors, and aspects of workplace environment that are potentially associated with PTSD symptoms in a sample of 633 clinical staff (68% nursing staff, 70% female) who provided direct day-to-day care for patients, and indicated they worked in either forensic (57%) or nonforensic units (43%). Forensic staff reported more direct exposure (74%) to a wider variety of potentially traumatic events and chronic stressors than nonforensic staff (66%). Forensic staff also endorsed more PTSD symptoms. Using the PTSD Checklist for DSM-5 (PCL-5; Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition, DSM-5), 22% of forensic staff and 11% of nonforensic staff met the screening cut-off for possible PTSD; PTSD symptom scores were predicted both by direct exposure and unit type. Additionally, workplace environment and organizational trust were negatively correlated with PTSD symptom scores, where forensic staff reported a greater degree of incongruence with their workplace and lower levels of trust in management, compared with nonforensic staff. These results offer a snapshot of the more adverse work environment and associated risks faced by clinical staff on forensic units compared with nonforensic settings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Cross-Sectional Survey of Patients and Staff on Inpatient Forensic Psychiatric Units During COVID-19 Outbreak.

Outbreaks of COVID-19 on inpatient forensic units present a unique challenge as early release is not possible and some facilities were not designed to achieve sustained social distancing [1]. The enforcement of droplet and contact (D&C) precautions required during an outbreak creates further confines and restrictions for patients that are typically subject to considerable constraint during their care. From December 2020 to January 2021 43 clinicians and 12 patients on inpatient forensic units under unit-wide D&C precautions during COVID-19 outbreaks completed a cross-sectional survey regarding their experience. Virtual focus groups were also conducted to triangulate the qualitative feedback from clinicians. The survey and focus groups found the themes of enablers, barriers, and desired changes to care provision during an outbreak. Findings are discussed within the broader context of outbreak interventions and the provision of services to those living and working on forensic inpatient units experiencing outbreaks requiring the unit-wide implementation of D&C precautions.

Assessing protective factors to prevent post-discharge violent behaviour: Towards an assets-based approach for clinical risk management

Medium secure forensic psychiatric units (MSUs) in the UK aim to be recovery-oriented to enable discharge to community-based services. Risk assessments are key to discharge planning, but clinical practice tends to focus on risk factors for violence rather than protective factors associated with a decrease in risk. The aims of this study were to investigate the reliability and validity of the Structured Assessment of Protective Factors (SAPROF) as a useful measure to support an assets-based approach when planning discharge from MSUs. A prospective cohort follow-up design was chosen for this study using a confidential inquiry design to ensure a total sample of all discharges. All forensic patients discharged from 32 NHS MSUs over a 12-month period were assessed at discharge and followed-up at six and 12 months post discharge. The occurrence and frequency of post-discharge violence were compared with discharge SAPROF scores. The inter-rater reliability between SAPROF raters was very high and the SAPROF significantly predicted community violence and scores were strongly correlated with violence frequency. The higher the SAPROF score the higher the protection against violence and the risk significantly diminished. Assessing protective factors is essential to identify assets and prevent violence with a focus on what makes somebody safe. This study supports the use of the SAPROF to inform discharge planning. Cultivating protective factors is likely to be motivating for patients and the SAPROF can provide an objective, reliable measure of internal, motivational and external assets that reduce risk and support defensible decision making at discharge.