High Secure Forensic Hospital Research Articles

Closing Italian Forensic Psychiatry Hospitals in Favor of Treating Insanity Acquittees in the Community.

Originally a hedge against the death penalty, the insanity defense came to offer hospitalization as an alternative to imprisonment. In the late 19th century Italy opened inpatient services first for mentally ill prisoners and then for offenders found not guilty by reason of insanity. Within the past decade, a series of decrees has resulted in transferring the responsibility for treating NGRI acquittees and "dangerous" mentally ill prisoners from the Department of Justice to the Department of Health, and their treatment from Italy's high security forensic psychiatric hospitals (OPGs) to community regional facilities (REMSs, Residences for the Execution of Security Measures), community mental health facilities, one of which is located in each region of Italy. Today community REMSs provide the treatment and management of socially dangerous offenders. The dynamic evolution of Italy's progressive mental health system for insanity acquittees, to our knowledge the most libertarian, community oriented approach of any country, is retraced. Discussion includes cautionary concerns as well as potential opportunities for improvements in mental health services. Copyright © 2016 John Wiley & Sons, Ltd.

Psychiatric Diagnosis, Type of Crime and Victim Profile: A Study of the Population of a High-Security Forensic Hospital in the State of Sao Paulo, Brazil

Psychiatric Diagnosis, Type of Crime and Victim Profile: A Study of the Population of a High-Security Forensic Hospital in the State of Sao Paulo, Brazil

Ward Climate Within a High Secure Forensic Psychiatric Hospital: Perceptions of Patients and Nursing Staff and the Role of Patient Characteristics

Within this study the relationship between patient characteristics (age, length of stay, risk, psychopathy) and individual perceived ward climate (n=83), and differences between staff's and patient perceptions of climate (n=185) was investigated within a high secure forensic hospital. Results show that therapeutic hold was rated higher among staff compared to patients, while patients held a more favorable view on patient cohesion and experienced safety. Furthermore, patient characteristics (age, risk and psychopathy) were found to be related with individual ratings of ward climate. The findings underline the importance of assessing ward climate among both patients and staff in clinical practice.

Measuring recovery orientation in a forensic high-secure hospital

This article seeks to build on two previous articles that measured the recovery orientation of patients and staff in a high-secure forensic hospital using two subscales of the Developing Recovery Enhancing Environments Measure (DREEM). Findings indicated the Organisational Climate-Recovery scores at Time 2 suggest a more positive staff perception about the organisation. For the Recovery Markers, the patients at Time 2 appear to hold a greater personal value to the different aspects of recovery. The qualitative data for both patients and staff show a strong correlation with the values and beliefs required to support the recovery approach in a forensic high secure setting.

The predictive validity of the HCR-20 following clinical implementation: does it work in practice?

This prospective study describes the predictive validity of the Historical Clinical Risk Management-20 Scale (HCR-20) when applied to clinical practice among 109 male mentally disordered offenders in a high secure forensic hospital. Data on violent incidents including reconvictions were collected from multiple sources. The results imply that the implemented HCR-20s did not predict future violence regardless of setting (community vs inpatient) nor time (short vs long term) except for serious incidents. This may indicate that the implemented HCR-20s informed risk management through systematic tailoring of care and treatment plans. Evidence supporting this interpretation was found in a reduction in violent incidents and offending when compared to an earlier study with a similar cohort. Alternatively, the completion of a violence risk assessment by clinicians rather than researchers may have affected the quality of completed assessments. Further research is required to better understand the complex mechanisms underlying the translation of identified risk factors into risk management.

What do the experts by experience tell us about ‘what works’ in high secure forensic inpatient hospital services?

The evidence base for ‘what works’ for patients detained in high secure hospitals has predominantly been established from a clinical perspective, with the voices of those at the centre of care, the expert by experience, absent. Neglecting this voice renders an important source of information for evidence-based practice inaccessible to outcome evaluators. Twelve high secure patients considered ‘ready’ to be discharged were interviewed to explore what in their view had helped or hindered their progress to this stage. Thematic analysis steps were applied to interviews and eight themes were generated that represented valued elements of high security: temporary suspension of responsibility, collaboration in care, learning from others, supportive alliances, specific interventions (medical and psychotherapeutic), a safe environment and opportunities for work. Narratives demonstrated the complementary and unique contribution of the patient experience in informing ‘what works’, and are discussed alongside existing theories relevant to promoting clinical change and risk reduction.

Association between brain structure and phenotypic characteristics in pedophilia

Studies applying structural neuroimaging to pedophiles are scarce and have shown conflicting results. Although first findings suggested reduced volume of the amygdala, pronounced gray matter decreases in frontal regions were observed in another group of pedophilic offenders. When compared to non-sexual offenders instead of community controls, pedophiles revealed deficiencies in white matter only. The present study sought to test the hypotheses of structurally compromised prefrontal and limbic networks and whether structural brain abnormalities are related to phenotypic characteristics in pedophiles. We compared gray matter volume of male pedophilic offenders and non-sexual offenders from high-security forensic hospitals using voxel-based morphometry in cross-sectional and correlational whole-brain analyses. The significance threshold was set to p < .05, corrected for multiple comparisons. Compared to controls, pedophiles exhibited a volume reduction of the right amygdala (small volume corrected). Within the pedophilic group, pedosexual interest and sexual recidivism were correlated with gray matter decrease in the left dorsolateral prefrontal cortex (r = −.64) and insular cortex (r = −.45). Lower age of victims was strongly associated with gray matter reductions in the orbitofrontal cortex (r = .98) and angular gyri bilaterally (r = .70 and r = .93). Our findings of specifically impaired neural networks being related to certain phenotypic characteristics might account for the heterogeneous results in previous neuroimaging studies of pedophilia. The neuroanatomical abnormalities in pedophilia seem to be of a dimensional rather than a categorical nature, supporting the notion of a multifaceted disorder.

Evaluation of a smoke‐free forensic hospital: Patients' perspectives on issues and benefits

In 2008, a new high secure forensic mental health inpatient hospital was opened in New South Wales as a smoke-free facility. This study describes the experience of patients and the impact of the smoke-free policy on smoking intentions and practice. The study methods included: (1) four semi-structured focus groups with 21 current patients; (2) patient surveys collected from 45 current patients; and (3) follow-up survey from 15 discharged patients. All methods included questions related to smoking history, experience of moving to and living in the smoke-free environment and smoking intentions or status post discharge. Many focus group participants indicated that they were now off cigarettes for life while some were angry about the policy. Nearly all (80%) patients surveyed smoked prior to admission. Over one-third (39%) of patients were angry at being forced to stop smoking, while 42% wanted to give up when they were admitted. Most (62%) felt they had gained weight since they stopped smoking; however, 75% indicated that living in a smoke-free environment had a positive effect on their health. Over a third (36%) of patients indicated that they intended to smoke when discharged. Post discharge, of the 12 who smoked prior to admission, seven (58%) remained non-smokers at follow up. This study describes promising findings about the experience of patients moving to a smoke-free mental health inpatient facility, including improved health and potential for sustained smoking cessation post discharge.

The Predictive Validity of the Short-Term Assessment of Risk and Treatability (START) in a Secure Forensic Hospital: Risk Factors and Strengths

There has been an increased interest among researchers and clinicians to understand the violence risk factors that are important in inpatient psychiatric settings, as well as to improve the accuracy of inpatient violence risk assessments. The Short-Term Assessment of Risk and Treatability (START) is a structured violence risk assessment instrument designed to assess multiple risk domains and protective factors that are pertinent to inpatient psychiatric care and treatment. Unlike many structured risk assessment instruments, the START is comprised solely of dynamic factors. Using a sample of 50 inpatients, the present study sought to examine the predictive validity of the START Risk and Strength scales for inpatient aggression in a high-security forensic psychiatric hospital during a 1-month follow-up period. The Risk scale predicted interpersonal violence, verbal threats, and any inpatient aggression, whereas the Strength scale predicted interpersonal violence and any inpatient aggression. The results suggest that short-term inpatient violence risk appraisals using the START are significantly predictive whether risk factors or strengths are considered.

P02-168 - Lipid monitoring of patients taking clozapine in a high secure forensic hospital

AimsTo review current practice of lipid monitoring for patients prescribed colzapine and to improve the health of patients taking clozapine.MethodologyThis was a retrospective audit targeting all patients who were taking Clozapine from May 2008 to April 2009 inclusive. Data was collected from pharmacy records, the heath centre records and patients’ personal care records. Current practice within the hospital was then compared with the standards proposed by the Maudsley Guidelines.ResultsThe total number of patients who were prescribed clozapine between May 2008 to April 2009 was 65. Of these patients 54 met the identified standards. We identified two patient groups; 56 patients were taking clozpaine for more than one year and nine patients were taking clozapine for less than one year. Out of those patients who were taking clozapine for more than one year, standards were met for 89% of patient (n = 50) compared to only 44% (n = 9) of those patients who were taking it for less than 1 year. Also, of those patients who had been taking clozapine for less than one year and do not meet the standard, none of them had lipid monitoring at three monthly intervals.ConclusionAlthough the vast majority of patients in the hospital who were prescribed Clozapine had their lipids monitored appropriately, a small percentage did not. Monitoring of lipid levels was particularly lacking in the first year of treatment.

Outcomes of a drug and alcohol relapse prevention programme in a population of mentally disordered offenders

Substance misuse that is co‐morbid with mental disorder may increase the risk of crime, particularly of a violent nature. It is therefore essential that dual‐diagnosis patients in forensic services receive adequate intervention and treatment to minimise future substance use and potential for criminal behaviour. One such intervention is the Relapse Prevention Programme (Saying No; Coping and Social Skills Programme) developed in a high secure forensic hospital. An evaluation of the programme was conducted, with pre‐ and post‐ intervention using four measures, the Drug Taking Confidence Questionnaire (DTCQ), the Multidimensional Locus of Control Questionnaire, the Stages of Change Questionnaire and the Rosenberg Self‐Esteem Scale, with 83 male participants who had completed the programme. Results indicate that there was significant change in the DTCQ post‐treatment while no other measures yielded a statistically significant result. Possible reasons, implication for practice and limitations of the current study are discussed.

Personality Traits as Predictors of Inpatient Aggression in a High-Security Forensic Psychiatric Setting: Prospective Evaluation of the PCL-R and IPDE Dimension Ratings

The Dangerous and Severe Personality Disorder (DSPD) initiative in England and Wales provides specialized care to high-risk offenders with mental disorders. This study investigated the predictive utility of personality traits, assessed using the Psychopathy Checklist-Revised (PCL-R) and the International Personality Disorder Examination, with 44 consecutive admissions to the DSPD unit at a high-security forensic psychiatric hospital. Incidents of interpersonal physical aggression (IPA) were observed for 39% of the sample over an average 1.5-year period following admission. Histrionic personality disorder (PD) predicted IPA, and Histrionic, Borderline, and Antisocial PDs all predicted repetitive (2+ incidents of) IPA. PCL-R Factor 1 and Facets 1 and 2 were also significant predictors of IPA. PCL-R Factor 1 and Histrionic PD scores were significantly associated with imminence of IPA. Results were discussed in terms of the utility of personality traits in risk assessment and treatment of specially selected high-risk forensic psychiatric patients in secure settings.

PW01-118 - Personality traits and response inhibition in pedophile sexual abusers, pedophile internet abusers and controls - preliminary results

ObjectivesRecent research about pedophilia suggested an association between pedophilia, neurocognitive disturbance and specific personality profiles. Especially neuropsychological functions associated with the prefrontal and motor processing loops showed to be impaired in pedophilia. But in most studies about pedophilia subjects were recruited from high security forensic hospitals. The results might therefore be influenced by selection bias. To overcome this bias we conducted a study that aimed to compare neurocognitive disturbance and specific personality profiles of pedophile sexual abusers, pedophile internet abusers and controls.MethodsWe included until now 5 male pedophile sexual abusers, 4 male pedophile internet abusers and 6 male control subjects. Subjects were matched for age and IQ. Personality profiles were assessed by SKID and MMPI. Response inhibition was tested in a classical Go/NoGo task.ResultsAssessments of personality profiles showed similar sub threshold profiles for the controls and the group of internet abusers while subjects from security forensic hospital setting fulfilled criteria of personality disorders. Accordingly showed the Go/NoGo task higher rates of failed response inhibition in the group of paedophilic subjects from high security forensic hospital setting and lower rates for pedophile internet abusers and/or controls.ConclusionsOur preliminary data suggests that results of recent studies about neurocognitive disturbance and neuroimaging correlates of paedophilia might be influenced by selection bias and might rather reflect impairment of personality and social interaction in a broader sense. Future research about paedophilia should consequently aim to disentangle personality impairment from sexual orientation.

Prediction of institutional aggression among personality disordered forensic patients using actuarial and structured clinical risk assessment tools: prospective evaluation of the HCR-20, VRS, Static-99, and Risk Matrix 2000

Entry to the Dangerous and Severe Personality Disorder (DSPD) service in England and Wales is heavily determined by risk status, and therefore requires valid procedures for monitoring changes in risk over time in order to make risk management decisions and determine patients’ suitability for transfer to lower security settings. Yet little is known about the validity of current risk assessment tools with the new DSPD population. This study reports a prospective evaluation of the predictive accuracy of the HCR-20, VRS, Static-99, and Risk Matrix 2000 with 44 consecutive admissions to the DSPD unit at a high secure forensic psychiatric hospital. Thirty eight per cent of the sample exhibited interpersonal physical aggression (IPA) on one or more instances over an average 1.5 year period following admission, and a similar percentage caused damage to property (DTP) on one or more occasions over the same period. All tools predicted DTP. HCR-20 Total and scale scores predicted IPA with structured final risk judgements also predicting repetitive (2 + incidents of) IPA. HCR-20 Risk Management scores were significantly associated with imminence of IPA. Results were discussed in terms of the practical utility of these tools with high risk forensic psychiatric inpatients.

S18-04 Schema focused therapy for forensic patients with personality disorders: New research findings

Rationale:Schema Focused Therapy (SFT) has proven effective in outpatients with Borderline Personality Disorder (PD)(Giesen-Bloo et al., 2006). To test the effectiveness of SFT with forensic patients, we have begun a multi-center randomized clinical trial of SFT for male forensic patients with Antisocial, Borderline, Narcissistic, or Paranoid PDs.Methods:One hundred twenty patients will be enrolled from 7 high security forensic hospitals (“TBS clinics”) in The Netherlands. Patients are randomly assigned to receive either SFT or usual forensic treatment. Patients receive 3 years of therapy, and are assessed every 6 months for changes in PD symptoms, recidivism risk, and other outcomes. Following treatment completion, patients will be followed an additional 3 years to assess actual recidivism.Results:Since 2007, 39 patients (mean PCL-R score = 25.0, SD = 6.6) have been enrolled in the study, 22 have completed their 12-month assessments, and 11 their 18-month assessments. Only 3 have dropped out. Recruitment is ongoing, with expected completion of the project in 2012. Pilot data on a different sample of N = 18 forensic PD inpatients treated in SFT for a mean of 1.9 years (SD = 0.8) is encouraging. Nine of the 18 patients showed reliable improvement, and only one showed reliable deterioration (mean d-score = 0.84, SD = 0.95, p &lt; .01).Conclusions:SFT appears to be a promising treatment for forensic patients with Antisocial and other Cluster B PDs.

Being ordinary in extraordinary places: Reflective practice of the total situation in a total institution

This paper examines a ‘Foulkesian type’ Balint group for psychiatry trainees set in a high secure forensic hospital. Within a Balint group, group processes and dynamics are not examined. Deviation from this format is construed as resistance, and destructively getting in the way of the primary task. This paper reports on a case‐based reflective practice group operating on a more Foulkesian group analytic model and argues that the revised principles of method proposed here – paying attention to context; group processes; and creating an atmosphere where group curative factors are in play – can help trainees to sustain an emotional reservoir for their patients. Further, these principles do not get in the way of the primary task but can add to an understanding of the individual transference and counter‐transference issues, and can place these in context within the organization and society. This is particularly important in total institutions such as forensic units. Clinical material from this group is used to support this claim.

Bases psicopatológicas do crime violento: estudo caso-controle retrospectivo de pacientes delirantes criminosos e não-criminosos

OBJETIVO: Estudar os aspectos do delírio que podem estar relacionados à ocorrência de crime violento por pacientes delirantes. MÉTODOS: Estudo caso-controle retrospectivo comparando dois grupos de 30 pacientes psicóticos delirantes. O grupo estudado consiste de pacientes delirantes internados em uma Casa de Custódia do estado de São Paulo, Brasil, e o grupo comparado consiste de pacientes de enfermarias psiquiátricas comuns. Foram utilizadas as escalas PANSS, MINI e MMDAS. RESULTADOS: Em relação às dimensões do delírio, o grupo-caso teve menor pontuação em "inibição de ação por causa do delírio" e "afeto negativo". CONCLUSÃO: Delírios que induzem a inibição de ações aparentemente também reduzem o potencial de ações violentas e, ao contrário do que se afirma correntemente, pacientes delirantes assustados ou com outros afetos negativos associados ao delírio parecem cometer menos atos violentos. Portanto, fatores intrínsecos inerentes a algumas dimensões do delírio podem ser relevantes na ocorrência de crimes violentos cometidos por pacientes psicóticos.

Moving On: A Group for Patients Leaving a High Security Hospital

In this paper, the authors describe the work of a group set up for those patients who are leaving a high security forensic psychiatric hospital, all having been detained under the 1983 Mental Health Act for England and Wales. Background information on the hospital is presented, as well as an overall view of the patients and their problems. The origins of the group are documented, followed with examples of group dynamics peculiar to the practice of forensic psychotherapy and conscious and unconscious anxieties on the part of the therapists as well as the patients.

Assessment of the side effects of antipsychotic medication

Antipsychotic medication is the first-line treatment for people with psychosis in the State Hospital, Carstairs: Scotland's only high-security forensic hospital. The Clinical Standards for Schizophrenia (Clinical Standards Board for Scotland 2001) require clinicians to use standardised rating scales to monitor the side effects associated with medication. Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) (Day et al 1995) was implemented in the hospital in December 2003. A baseline audit was carried out following its implementation to establish the incidence of side effects. Of those patients audited (n=152), 87 (57 per cent) reported either low or medium (n=51, 34 per cent) LUNSERS scores, indicating an acceptable level of medication tolerance. It is expected that clinicians will continue to use LUNSERS as part of their routine clinical practice to help inform patients and meet national standards.

Evaluation of the HCR-20 Violence Risk Assessment Scheme in a Belgian forensic population

Violence risk assessment constitutes a major concern in forensic psychiatry, psychology and related fields. Numerous instruments like the Hare Psychopathy Checklist (PCL-R, Hare, 1991) and the Violence Risk Appraisal Guide (VRAG) have been developed in the aim of improving precision in the prediction of violence. This study assesses the reliability index of the HCR-20 Violence Risk Assessment Scheme and evaluates its relationship with the PCL-R the Buss and Perry's self-report Aggression Questionnaire (AQ) and the type of offenses officially registered. All participants (n=86) are male adult offenders detained in a Belgian high-security forensic hospital. The mean IQ and age were respectively, 81,03 and 36,71. Items common to these instruments were omitted in order to avoid a circular effect. Results showed that the HCR-20 was significantly related to the PCL-R: the historical factor was strongly correlated to the PCL-R factor 2 while the clinical factor was strongly correlated to the PCL-R factor 1. The HCR-20 was significantly related to the AQ: the historical factor was strongly correlated to the AQ Physical Aggression factor and to the Anger factor. As regards to the HCR-20 relations with offenses, its Historical factor was related to both violent (assault and battery, robbery) and non-violent offenses (drug offenses, theft). Finally, the HCR-20 was also positively related to "instrumental" and rather premeditated homicide but negatively related to psychotic homicide. The overall findings are congruent with -published data on the convergent validity of the HCR-20.