High Secure Unit Research Articles

The violence profile of male mentally disordered offenders in a high secure unit in Turkiye

Our knowledge of the severity and reoffending is limited for mentally disordered offenders, and studies generally evaluate without separation between different diagnostic groups. It was aimed to determine the general profile of mentally disordered offenders who are inpatients in a high secure psychiatry unit from Turkiye and to evaluate the factors associated with violence profiles among different diagnostic groups. According to the results the schizophrenia patients committed the most severe crimes, and intellectual disability patients had some different features from schizophrenia and bipolar disorder patients. History of substance misuse in the intellectual disability group (p = 0,045) and comorbid antisocial personality disorder in the bipolar disorder group (p = 0,015) were associated with increased crime severity. Substance misuse history, history of substance use during the crime, and the existence of comorbid antisocial personality disorder were associated with increased offenses in each of the three diagnosis groups. Living alone (p = 0,004) and having a suicide history (p= 0,052) were associated with the high number of offenses in the schizophrenia group. This study is the first study that compares three diagnostic groups to involve a large patient group. We believe that clinicians must evaluate these parameters for the violence risk assessment of patients.

Homicides committed by women with mental disorders: A descriptive study conducted in a French secure unit

Women remain a small minority of homicide offenders and appear to be understudied in the scientific literature. Gender-specific characteristics are however identified by existing studies. The aim of the study was to explore homicides committed by women with mental disorders, by analyzing their sociodemographic, clinical features, and criminological circumstances of the homicide. We conducted a retrospective and descriptive study among all female homicide offenders with mental disorders hospitalized in a French high-secure unit over a 20-year period (n= 30). We found that the female patients we studied were a diverse group in terms of their clinical profiles, backgrounds, and criminological characteristics. Confirming previous studies, we observed an over-representation of young women, unemployed, with a destabilized family situation and history of adverse childhood experiences. Prior self- and hetero-aggressive behavior were frequent. We found a history of suicidal behavior in 40% of cases. Their homicidal acts often occurred impulsively at home, in the evening or at night and were mainly directed toward family members (60%), especially their child(ren) (46.7%), then acquaintances (36.7%), and rarely a stranger. We found symptomatic and diagnostic heterogeneity: schizophrenia (40%), schizoaffective disorder (10%), delusional disorder (6.7%), mood disorders (26.7%), and borderline personality disorder (16.7%). Mood disorders were exclusively unipolar or bipolar depressions, often with psychotic features. The majority of patients had received psychiatric care prior to the act. We identified four subgroups, according to psychopathology and criminal motives: delusional (46.7%), melancholic (20%), homicide-suicide dynamic (16.7%), and impulsive outbursts (16.7%). We consider that further studies are necessary.

Service user involvement in a secure setting before and after the implementation of recovery-oriented practice: A quasi-experimental study.

To measure change in service user involvement in secure mental health units, before and after the implementation of recovery-oriented practice. Quasi-experimental study pretest-posttest design with non-equivalent comparison groups. Data were collected from May 2018 to December 2019 in four medium-/high-security units in Norway. Two intervention units that implemented recovery-oriented practice were compared with two comparison units that did not. Data were obtained using anonymous questionnaires at baseline and at 6-month follow-up. For intervention units, data were also obtained at a 12-month follow-up to measure sustainability of improvements over time. Twenty inpatients ('patients'; intervention group: 10, comparison group: 10) and 141 members of frontline staff ('service providers'; intervention group: 92, comparison group: 49) participated at baseline. Mann-Whitney U-tests and independent sample t-tests were applied at the group-level to analyse changes in mean scores in groups. Among patients in the intervention units, findings indicated no improvements after 6months, but significant improvements after 12months in terms of patients' opportunities to participate in formulating their individual care plans, to influence decision-making about therapy and to receive information about complaint procedures. Opportunities to participate in discussions about medication and treatment regimens did not improve. After 6months, service providers in the intervention units reported an increase in democratic patient involvement, patient collaboration and management support, but not in carer involvement and assisted patient involvement. The improvements in democratic patient involvement and management support were sustained over time. No changes were found in the comparison groups. The patients and the service providers reported a higher degree of service user involvement after implementing recovery-oriented practice. Specific work is needed to ensure patients' involvement in all domains. The findings are encouraging with respect to the potential to increase empowerment in a restricted setting through the implementation of recovery-oriented practice.

L’aviolicide, un parricide de substitution ? À propos d’un cas clinique

Aviolicide is a specific form of parricide, referring to the act of killing one's grandparents. It appears to be a rare event, although no precise data can be found about its occurrence, since it has not been often studied in medical literature. ObservationWe report the case of M. X, 31 years old, hospitalized in a high secure unit after killing both his paternal grandparents. This patient was born in Eastern Europe and raised by his grandparents in France. In his early twenties, he started consuming alcohol and drugs (mainly cannabis) and isolating from his relatives. He was diagnosed with paranoid schizophrenia when hospitalized at the age of 24, after a psychotic episode, with delusions of persecution towards his grandparents, aggressiveness and agitation. The delusions got more and more intense in the next years, as the patient did not take his medication. One day, after 3 days of hesitation trying to resist delusional injonctions, triggered by a minor comment from his grandmother, he violently assaulted his grandparents and killed them. He did not run away from the crime scene and went back to his everyday activities right after the assault. DiscussionWhen compared to the socio-demographic and clinical profile of the few cases of aviolicide found in literature, M. X appears to have a lot in common with them. Indeed, many of his features have been previously described: the fact that his parents suffered from alcoholism; his migration; the fact that he suffered from paranoid schizophrenia; addiction to cannabis and alcohol; a context of long lasting fight over money; the homicide happening at the victim's place; the extreme violence. Furthermore, most of the aviolicide cases happened in families where the grandparents had a parental role (after the parents died – as in M. X's case –, or the parents being symbolically absent), or were the result of the hatred towards the parents shifting to the grandparents. Based on this observation, we then compared M. X's profile and acting out to those found in the literature about parricide. We realized they were very similar, since M. X is a male in his early thirties, single, not working, diagnosed with paranoid schizophrenia several years ago and not taking his prescribed medication. As parricides often do, his acting out happened at the victims’ home, brutally triggered by a seemingly minor event, in a disorganized way, and the perpetrator does not try to run away. ConclusionThe similarities to parricide and the fact that the grandparents played a parent-like role on both a symbolical and legal level lead us to conclude that aviolicide has a similar psychopathology to parricide, and can be understood as a substitutive parricide. However, we have to underly the fact that this parricide/aviolicide profile is non specific. It is highly similar to the profile found in literature about dangerousness in schizophrenia. We end up stressing the major suicidal risk in the aftermath of such an act, as the delusion of persecution ceases after treatment and the patient starts realizing his act.

Violence risk profile of medium- and high-security NGRI offenders in Belgium

ABSTRACTUnder Belgian law, offenders not guilty by reason of insanity (NGRI) are committed by the courts to forensic mental health treatment. The use of violence risk assessment tools has become routine in these settings. However, there are no national statistics regarding violence risk assessment in the Belgian forensic population. A study was undertaken to collect risk assessment data (PCL-R, VRAG, HCR-20) on a large cohort of forensic patients committed to Medium Security units in the Flanders region and in High-Security units in the Walloon region. Flemish patients were expected to present a lower risk compared with their Walloon counterparts. Instead, data yielded by a structured risk assessment method demonstrate the opposite. Moreover, the majority of patients in Flemish facilities had committed violent offenses and were institutionalized for shorter periods whereas the majority of Walloon patients had committed sexual offenses and were institutionalized for markedly longer periods.

Punished and isolated: disabled prisoners in Norway

Serving a sentence has two purposes in Norway; it is a punishment for a crime and it is considered as an opportunity for rehabilitation to prevent repeated crime. This presupposes that all prisoners have access to activities and common rooms in the prisons. Interviews with prisoners with hearing or mobility impairments showed that accessibility is a problem in many prisons. The experiences of prisoners with hearing or mobility impairment show that lack of awareness and preparedness for their situation causes isolation as well as a decline in physical and mental health. Some prisons had cells partially adapted for prisoners with disabilities – and these were mostly located in high-security units. A majority of Norwegian prisons have some experience with disabled prisoners, but there are no systems for knowledge accumulation or sharing within the Norwegian Correctional Service. Lack of accessibility also deprived some disabled prisoners of their legal right to progression of the conditions for serving their...

1834 – The need for specialist service for offenders with autistic spectrum disorder within high secure psychiatric care

Introduction There are 3 High Secure Psychiatric Hospitals in United Kingdom. The Autism Act passed in 2009 introduced the Adult Autism Strategy, which sets out how local services should be improved to meet the needs of adults with Autism. There are specialist services available to care for offenders with Autism in low and medium secure forensic settings but there is a lack of dedicated support in high secure settings. Objective The objective was to identify whether current care provided for such patients is appropriate. Aim The aim of the audit was to evaluate the need for specialist service for offenders with Autistic Spectrum Disorder within High Secure Psychiatric Care. Method The hospital wide secure email system was used to identify wards which had patients with ASD. A questionnaire was developed which explored the clinical practice, willingness and knowledge of the Gold standards of care. It was circulated on the 9 identified wards to the staff on 3 different shifts. 100 completed forms were received which were stored in a secure area. Results The results revealed that most of the staff was aware about ASD but majority had not heard about standard approach of care. Majority of the staff were willing to train and work in a dedicated ASD team. Conclusions Effort should be made to increase awareness and train the staff to care for offenders with ASD. Work should be done towards accreditation with the National Autistic Society to set up specialist care for ASD patients in High Secure Unit.

582 – Study of correlation between terrorisim and mental disorders at ibin-alhaithim high secure unit

Background It is generally thought that schizophrenia does not predispose subjects to homicidal behavior However; many previous studies have suffered from notable methodological weaknesses. In particular, obtaining comprehensive study groups of violent offenders has been difficult. Iraqi police have been able to solve increasingly percentage of homicides during the last few years with gradual rebuilding of infrastructure of police and judicial system; these bodies are totally collapsed after fall down of previous regime. Objectives To study the sociodemographic characteristics of schizophrenic charge patients with homicidal accusation, and to find out the characteristic of victims of patients admitted in the secure unit. Methods file system In Ibin-AL-Hiatham Secure unit where examined for various socio demographic data, the 118homicidal admitted consequently in the secure unit were examined between July 2003, and July 2008. The files were systematically checked for DSM-IV schizophrenia criteria. Conclusion The study revealed that the number of males dominant females, simply because males more liable to break the law than females, higher number of urban living offenders is over represented mainly because psychiatric services are more accessible to them than rural residents. Victims are mostly of first degree relatives of the offenders. In an Arab culture however as Iraq is one of them, issues related to honor killing and male jealousy which are assumed to be of delusional nature in this study, are relatively frequent.

‘Everybody Knows that the Prisoner is Going Nowhere’: Parole Board Members’ Views about Dangerous and Severe Personality Disorder in England and Wales

The Dangerous Severe Personality Disorder (DSPD) Programme has been a controversial initiative in England and Wales. First introduced in 1999, DSPD became a highly contested operational as opposed to diagnostic term, used to define a population convicted of violent offences who were admitted for treatment within one of four high security units established for men. The aim of this paper is to explore the outcomes of Parole Board (PB) reviews with DSPD prisoners and investigate PB members’ views about DSPD. Nearly all PB members observed that the high security location of the DSPD units was more influential to their decision-making than the label of DSPD. PB members highlighted their expectation that DSPD prisoners make a journey through different levels of security before release is an appropriate consideration. A key finding was that admission to DSPD services could be seen to have disrupted a prisoner’s progression and challenged PB members’ conceptions of the appropriate (and likely) future progression pathways available to prisoners. These findings have implications not only for the development of the new offender personality disorder pathway in England and Wales but also for other jurisdictions seeking to respond to the long-standing question of how to respond to high risk offenders with personality disorder.

P-671 - Homicidal behavior in schizophrenics in ibin-AL-Haitham High Secure Unit, in AL-Rashad Teaching Mental Hospital, Baghdad

Few papers reported that schizophrenia predisposes to homicidal behavior. The aim of this paper is to report our experience with homicidal behavior in Schizophrenic patients admitted at Ibin-AL-Haitham a high secure unit, in AL-Rashad Teaching Mental Hospital, Baghdad. Homicide offenders are subjected to intensive forensic psychiatric investigations in Iraq. Therefore, it was possible to obtain and review data of 118 homicide offenders admitted in Ibin Al-Hiathim Secure Unit in AL-Rashad Teaching Hospital of Baghdad during period from July 2003 to July 2008. The percentage of schizophrenia in this sample was 44% and 57% of schizophrenic offenders were in the age group (20–40years). There were more males; simply because males are more liable to break the law than females. Higher number of urban living offenders is probably attributed to the fact that psychiatric institutions and services are more accessible, and accurate recording in urban areas than in rural areas. Victims are mostly of first degree relatives of the offenders. According to our experience there is a strong relationship between schizophrenia and homicidal behavior.

2 Terrorism Charge Offenders Admitted at Ibin-Al-Haithim High Secure unit Rashad Mental Teaching Hospital in Baghdad; a Socio-demographic Study

Research on belief perseverance often suggests that people maintain or even strengthen their beliefs in response to disconfirming evidence. However, many studies demonstrating belief perseverance have presented participants with mixed evidence. The present research investigated whether people maintain their beliefs in response to a single pattern of findings. Across four studies, participants consistently shifted their beliefs in response to the evidence, even when it challenged their views on religion (Studies 1–3), politics (Study 3), gun control (Study 3), and capital punishment (Studies 3–4). Participants were also receptive to mixed evidence, shifting their beliefs in response to the first study presented and shifting back in response to the second (and overall, depolarizing in response to the evidence). Participants not only updated their beliefs about the research question but also sometimes their position on the issue. In some cases, bias emerged in participants' evaluations of evidence, but not in others. Evaluations of evidence quality generally predicted belief change in response to the evidence and did not largely explain the degree of belief maintenance participants exhibited. These findings suggest that people may be receptive to counter-attitudinal evidence when the findings are clear, and highlight the importance of further examining the conditions under which biased assimilation and belief perseverance (vs. change) occur.

Implementation of the Short Term Assessment of Risk and Treatability (START) in a Forensic High Secure Unit

Our objective was to describe and analyze the implementation process of the Short Term Assessment of Risk and Treatability in a forensic high secure unit in Norway. A stepwise implementation procedure was used and an educational package on practical use of the START in the clinic was developed. A questionnaire about START was given to the staff at the end of the first implementation phase and semi-structured qualitative interviews with staff on the content of security decision processes were carried out. Also, a log of the actual number of completed START scorings was made, including the number of ratings and the regularity of these ratings finished within this time frame. After six months’ implementation the questionnaire showed that 74% of the staff agreed that the evaluations made on the basis of START were interdisciplinary. Seventy-three percent also agreed that START contributed significantly to a more systematic risk assessment and management, and 79% said the START was useful as a tool in risk assessments and treatment planning. Informants from the interview study described how the START structured their clinical judgement. At the same time, the START fulfilled their wish to address both the patients’ strengths and risks. The START continued to be in regular use after the more intensive implementation process.Our results indicate that the implementation of START had led to interdisciplinary security decisions with a broader perspective of the patients’ situation.

76. Homicidal behavior and patients with epilepsy admitted at Ibin-Al-Haitham High Secure Unit, Al-Rashad Teaching Mental Hospital, Baghdad

76. Homicidal behavior and patients with epilepsy admitted at Ibin-Al-Haitham High Secure Unit, Al-Rashad Teaching Mental Hospital, Baghdad

S27-02 Results from a validation study comparing ideographic and nomothetic risk assessment instruments

During the judicial process there are several decision points which require an assessment of recidivism risk: e.g. decisions regarding sentence severity or the form of detention (i.e. low or high security unit), level of treatment, or decisions regarding transfers to open correctional facilities or release. Psychiatric experts called on by the court are required to not only assess recidivism risk, but also state if risk may be lowered by forensic psychotherapy. In the case of treated sex and violent offenders treatment progress has to be evaluated by the therapist and by external experts, before an offender will be released from a correctional institution. When considering the variety of available risk assessment instruments the question arises, which instrument is most suited for decision making. For instance, the “value” of an instrument can be determined by its validity for a specific target population, and by its validity for a specific outcome: Is the instrument valid for a specific offender population or judicial or correctional setting? For what kind of outcome criterion has the instrument been developed and validated?

Risk stratification and the care pathway.

It was hypothesised that patients admitted to forensic mental health facilities are stratified along the pathway through care according to levels of need. Level of risk and psychopathology should vary with different levels of security. Seventy-five men in a forensic hospital were interviewed by three trained clinicians using the HCR-20 (Historical Clinical Risk Assessment) - clinical and risk items, The Health of the Nation Scales - Secure (HoNOS-SECURE), PANSS (Positive and Negative Syndrome Scale), GAF (Global Assessment of Functioning) and the CANFOR (Camberwell Assessment of need Forensic Version). The mean scores on a variety of clinical measures were higher in admission/high security areas and progressively lower in rehabilitation and pre-discharge areas. As patients moved through the pathways of care, they improved in a number of areas including psychiatric morbidity, risk, function, unmet needs. The following results stratified significantly; the HCR-20 summated clinical and risk (F = 9.2, df = 5, p < 0.001), the HoNOS secure (F = 18.2, df = 5, p < 0.001), PANSS (positive, general and total), GAF, staff and user unmet needs on the CANFOR. The data indicate that the theoretical organisation of the units of the hospital into high, medium and low security units to form a coherent pathway through care is reflected in practice. This is a transparent route out of secure care in which restrictions are proportionate to risk and supports proportionate to need. It is unclear whether alternative models, consisting of a series of generic unstratified units for admission and discharge, all at the same level of therapeutic security, allow for the provision of treatment programmes and relational interventions appropriate to the patient's stage of recovery and rehabilitation.

Prescribing Patterns and the Use of Therapeutic Drug Monitoring of Psychotropic Medication in a Psychiatric High-Security Unit

The aim of this study was to investigate the use of psychotropic medication and therapeutic drug monitoring in a high-security psychiatric unit and to compare the doses and serum concentrations both with the recommended intervals and with the doses and serum concentrations in a control group. One hundred thirty-two patients were admitted in the period from January 2000 to December 2005. All available samples were used when comparing serum concentrations and doses with the recommended ranges. For the comparison of doses and serum concentration-to-dose (C:D) ratios with the control group only 1 sample from each patient was used. A total of 459 analyses of 27 different drugs in samples from 8 women and 73 men were included. The median number of therapeutic drug monitoring analyses per patient was 4 (range 1-29). Thirty-seven of the 81 patients (46%) used 2 or more antipsychotics at the same time. Clozapine, lamotrigine, olanzapine, quetiapine, ziprasidone, and zuclopenthixol were often given in doses above the recommended. The serum levels were frequently above those recommended for clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and zuclopenthixol. The serum levels were significantly higher in the study group than in the control group for clozapine, lamotrigine, quetiapine, and zuclopenthixol. The given dose was significantly higher in the study group than in the control group for clozapine, lamotrigine and zuclopenthixol. The C:D ratio was significantly lower in the study group than in the control group for olanzapine but higher for quetiapine. The non-evidence based practice of high-dose polypharmacy with several antipsychotics is widely used in this unit. The use of higher doses in the study group than in the control group was not due to differences in metabolism or adherence to treatment between the 2 groups. The frequent use of therapeutic drug monitoring did not seem to have a great impact on the prescribed doses.

Imprisoning Resistance: Life and Death in an Australian Supermax. By B. Carlton (Sydney: Institute of Criminology Press, 2007, 292pp. $45.00)

In Imprisoning Resistance: Life and Death in an Australian Supemax, Bree Carlton chronicles the official and unofficial stories behind events which occurred in Jika Jika High Security Unit located in Pentridge Prison in Victoria, Australia, between 1980 and 1987. Both Jika Jika and H-Division (its predecessor) were the sites of violence, resistance, prisoner assaults and prisoner deaths, which, according to Carlton, resulted in inadequate official responses throughout the institutional lives of both these units. Part of Carlton's rationale for this work is to provide a critical examination of the internal disciplinary regime of Jika Jika. In addition, this book questions the adequacy of the discourses that emerged from official inquiries into various critical events that took place both in Jika Jika and in H-Block. Carlton suggests that official accounts were concerned with salvaging the legitimacy of the Victorian Office of Corrections and did not include the level of scrutiny required for public accountability.

Nurse preceptorship in a high secure unit

Nurse preceptorship in a high secure unit

Les « pousseurs de métro » : à propos de huit cas de patients hospitalisés en unité pour malades difficiles

“Subway pushers” have been newspapers' highlights but also a forensic subject. Through eight case reports of offenders sent to high secure unit (unité pour malades difficiles Henri Colin), a profile of homeless psychotic man without any outpatient treatment has been found. Crimes seem unmotivated, where as delusions or hallucinations exist. Meta-analysis confirms this profile, though some alcoholic pushers have been described. Prevention of these tragic accidents rests on psychiatrists' awareness of homeless mentally ill people risk and safety subway programs.

Le suicide en milieu pénitentiaire

The prevalence of suicide in prison remains high despite a number of measures recently taken. There are multiple reasons for this and the risk is highest when the individual is first admitted to prison or placed in a high security unit. This has to be taken into account by staff and to this end their training should be improved.