Mentally Disordered Offenders Research Articles

Investigating the criminal thinking styles of mentally disordered offenders within the UK

PurposeThis study aims to evaluate the utility and reliability of the Psychological Inventory of Criminal Thinking Styles (PICTS) to investigate the criminal cognitions of mentally disordered offenders (MDOs) from the UK.Design/methodology/approachThe reliability and validity of the PICTS scales were investigated within an MDO sample from the UK (N = 45) and compared to PICTS data from the USA and general offenders in the UK.FindingsThe findings showed that the PICTS functioned in a similar way when used in MDO and non-MDO populations, indicating that from a psychometric perspective, the PICTS scales produce consistent results across both populations. Evidence is further provided to indicate that MDOs from the UK endorse criminal cognitions at a similar level to those in the USA and at a significantly higher level than general UK offenders.Practical implicationsThe implications and insight that these findings provide into the criminal cognitions of MDOs are discussed, with specific focus on the significant difference between general offenders and offenders with serious mental illness.Originality/valueTo the best of the authors’ knowledge, this study is the first to use the PICTS with MDOs in the UK, comparing the criminal thinking styles of MDOs and non-MDOs.

“What if you listened to and involved the caregivers?” ‒ Experiences and needs amongst caregivers involved with mentally disordered offenders and mental health services

Background and objectivesOver the past 20 years, the number of mentally disordered offenders (MDOs) has increased intensively in Denmark. Consequently, the number of caregivers, families and network involved with MDOs has also increased. Despite a heightened political focus on the involvement of caregivers as an important part of the patient pathway and recovery processes, knowledge of caregivers’ experiences is very limited. The aim of this study is to illuminate experiences and needs amongst caregivers taking care of MDOs in Denmark. MethodsThe study is based on semi-structured interviews with caregivers. The content of the interviews is analysed using content and textual analysis focusing on identifying patterns and themes. ResultsCaregivers involved with MDOs perform various roles and tasks from practical support to acting as case managers. These tasks tend to put a remarkable pressure and challenges on caregivers. Furthermore, caregivers experience emotional stress such as loneliness, shame, sorrow and feelings of inadequacy. Caregivers spend a lot of time establishing sustainable narratives about mental illness and offences, in order to reduce stigma and come to terms with chaotic and extraordinary incidents, and they play an important role as carriers of hope on behalf of the patients to support processes of personal recovery. ConclusionThe majority of caregivers in this study share a fundamental experience of neither having achieved sufficient support in the trajectories leading up to the forensic debut nor being involved or receiving enough and dedicated information while the often long-term sentences to treatment or placement are ongoing.

Are Mentally Disordered Offenders Admitted to Appropriate Secure Settings according to Security Needs? A Cross Sectional Study in Belgium

Mentally Disordered Offenders (MDOs) who have been declared not criminally responsible for their offense due to their mental condition should be admitted to settings with lowest possible level of security to support their social reintegration. In the context of the reorganization of care for MDOs in Belgium, we assessed the predictors and retrospective appropriateness of 3529 MDO admissions in 2017 according to security needs. Although there was a positive association between the security needs of MDOs and the level of security of the settings to which they were admitted, there was a gap between high and lower security levels. Medium-security settings made up 46% of all admissions, covering a variety of security need profiles. Half the sample of MDOs with high security needs was found in low- and medium-security settings, while a significant proportion of MDOs with low security needs was found in medium-security settings. Clinical characteristics predicted admissions more strongly than custodial characteristics. Decision-makers should refine criteria and procedures for MDOs’ care access. Indeed, the mixed results in relation to admission appropriateness in medium-security services may result from the lack of formal guidelines.

Patterns of Lifetime Criminality in Mentally Disordered Offenders - Findings From a Nationally Representative Cohort.

Background: Treatment of mentally disordered offenders (MDOs) is challenging as their behavior and clinical conditions can be traced to a complex constellation of major mental disorders, substance use and antisocial lifestyle. Finding subgroups of these offenders, which could guide treatment and risk assessment, is desirable. There are few long-term, prospective studies of risk factors for persistent criminal behavior among MDOs.Aims: The aims are (1) to provide a map of lifetime criminality in MDOs, (2) to identify subgroups of offenders, and (3), if such clusters exist, to test whether they differ in lifetime criminality and patterns of negative events during in-patient treatment.Methods: Background data on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment 1999–2005 (n = 125) was collected. Data on negative events during treatment (violence, threats, absconding and substance use) from date of admittance until discharge or until June 30, 2008 was gathered. Court decisions for 118 of the cohort-individuals were collected from the 1st of January 1973 until December 31, 2013. We used hierarchical cluster analysis to identify subgroups and MANOVA-analysis to examine differences between these clusters on lifetime criminality variables and negative events. A MANCOVA was used to control for time in treatment.Results: The cohort was sentenced to a total of 3,380 crimes (944 violent) during the study period. Median age at first crime was 20 years (range 15–72), and at first violent crime 27 years (range 15–72). A subgroup (n = 26) was characterized by childhood adversities, neurodevelopmental disorders and later substance use disorders and was more often associated with substance-related crimes, financial crimes and lower age at first crime. During treatment, this cluster showed higher rates of substance use and threats. When controlling for treatment time, no differences in negative events were found.Conclusions: This study replicated findings from prison populations of the existence of a more criminally persistent phenotype characterized by early-onset neurodevelopmental and behavior disorders, childhood adversities and later substance use disorders. We did not find this cluster of variables to be related to negative events during inpatient treatment when controlling for length of stay.

Offender Recovery. Forensic Patient Perspectives on Long-Term Personal Recovery Processes.

Knowledge on user experiences from mentally disordered offenders (MDOs) is still limited in a Danish context, especially regarding recovery from offences, severe mental illness, long-term admissions and often involuntarily contact with hospital psychiatry. The study is based on 34 semi-structured interviews with nine forensic patients exploring their experiences with personal recovery processes. The MDOs point out a significant number of elements and factors enhancing, supporting and limiting personal recovery processes. Long-term recovery processes for MDOs involve coming to terms with mental disorders as well as offences. Working with offender recovery implies addressing and understanding the index offence leading to psychiatric measurement as well as addressing risk and prevention of future crime. This coming to terms is an individual and deeply personal process and it often involves several and changing narratives. According to the informants, professionals play a crucial role in supporting recovery processes and maintaining hope and optimism over time. MDOs experience structural barriers limiting recovery potential, especially stigma or limited areas of participation. It is important not to focus solely on personal recovery as a one-dimensional individual process or responsibility, but as a process also marked by structural and organisational challenges.

Inpatient forensic psychiatric care: Legal provision in European countries

Abstract BodyForensic psychiatry is a specialty of psychiatry primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders(MDOs) are often cared for in secure psychiatric environments or prisons. However, the organisation of these services differs greatly between countries due to different traditions and legal frameworks. Some countries, e. g., require absent or reduced criminal responsibility (at the time of the index offence) in order to enter forensic services while others determine access on the basis of current need for treatment. Numbers detained in forensic services also vary significantly as does length of stay, raising significant economic and ethical challenges. This talk will present different legal concepts determining admission to forensic-psychiatric services, data on length of stay as well as approaches to risk assessment and treatment in Europe.DisclosureNo significant relationships.

Trait Disinhibition and NoGo Event-Related Potentials in Violent Mentally Disordered Offenders and Healthy Controls.

Trait disinhibition may function as a dispositional liability toward maladaptive behaviors relevant in the treatment of mentally disordered offenders (MDOs). Reduced amplitude and prolonged latency of the NoGo N2 and P3 event-related potentials have emerged as promising candidates for transdiagnostic, biobehavioral markers of trait disinhibition, yet no study has specifically investigated these two components in violent, inpatient MDOs. Here, we examined self-reported trait disinhibition, experimentally assessed response inhibition, and NoGo N2 and P3 amplitude and latency in male, violent MDOs (N = 27) and healthy controls (N = 20). MDOs had a higher degree of trait disinhibition, reduced NoGo P3 amplitude, and delayed NoGo P3 latency compared to controls. The reduced NoGo P3 amplitude and delayed NoGo P3 latency in MDOs may stem from deficits during monitoring or evaluation of behavior. NoGo P3 latency was associated with increased trait disinhibition in the whole sample, suggesting that trait disinhibition may be associated with reduced neural efficiency during later stages of outcome monitoring or evaluation. Findings for NoGo N2 amplitude and latency were small and non-robust. With several limitations in mind, this is the first study to demonstrate attenuated NoGo P3 amplitude and delayed NoGo P3 latency in violent, inpatient MDOs compared to healthy controls.

정신질환 범죄자 통원치료제도 개선방안

최근의 정신질환 범죄사건들의 경우 적절한 지원과 치료가 이뤄지지 않아 심각한 경우로 발전되는 경우를 종종 보게된다. 정신질환자 관리 사각지대, 정신질환자외래치료 방안, 정신 질환자에 대한 부정적인 편견과 차별 등이 이러한 문제를 더욱더 악화시키고 있다. 현재 정신 질환자의 치료제도는 입원치료(시설내)를 중심으로 이뤄지고 있어 이들이 퇴원시 지역사회내 에서의 통원치료(외래치료)는 매우 소홀한 편이라 하겠다. 정신질환자의 관리는 범죄이전에 는 범정부통합(보건복지부 및 지자체 주관)으로 추진되며 범죄이후는 법무부를 중심으로 중 점관리 되고 있다. 본 연구에서는 법무부의 정신질환 범죄자 치료처우와 관련하여 치료감호 후 가종료단계, 치료명령제도, 정신질환 보호관찰대상자 처우로 구분하여 현황파악과 효과적 인 정신질환 범죄자 통원(외래)치료제도 방안을 다음과 같이 제언하였다. 정신질환 범죄자의 통원치료제도의 개선을 위해서는 무엇보다 정신질환자 및 정신질환 범죄자에 대한 사회적 편 견이나 선입관을 없애야 할 것이다. 특히 언론의 자극적인 보도 등은 자제되어야 할 것이며 정신질환자들의 지역사회내에서 생활할 수 있는 생활기반이 마련되어야 할 것이다. 둘째, 가 종료자에 대한 무상치료를 확대하여 대상자의 부담을 완화시켜야 할 것이다. 이러한 비용은 국가나 지방자치단체가 지원할 수 있도록 하여야 한다. 셋째, 치료명령제의 효율화를 위해 치 료명령 담당자의 업무부담 경감화를 통한 담당 인력의 전문화, 치료의 지역사회 중심화를 위 한 외래치료명령제도의 활성화, 치료의 효율성을 제고키 위한 강제적 성격이 아닌 자발적 치 료명령제도, 즉 외래치료지원제도의 도입을 고려해 볼 수 있다. 넷째, 만기출소자의 보호관찰 기능 강화와 보호관찰소와 지역사회정신건강기관의 협업화를 통한 보호관찰 활성화를 하여야 할 것이다. 마지막으로 지역사회중심의 치료체계를 구축하여 지역 기관들간의 협력과 역할분 담, 신뢰관계형성을 이뤄야 할 것이다.

Public Attitudes Towards Offenders with Mental Illness Scale (PATOMI): Establishing a Valid Tool to Measure Public Perceptions.

This paper focuses on investigating public attitudes towards mentally disordered offenders (MDOs), by considering if the Police and Community Attitudes towards Offenders with Mental Illness (PACAMI-O; Glendinning and O'Keeffe in J Mental Health Train Educ Pract 10(2):73-84, 2015) is a valid tool. An opportunity sample of the general public (N = 504) read a fictional vignette depicting an individual with schizophrenia, then answered the PACAMI-O. An exploratory factor analysis revealed a 4 factor solution: Social distance & location of Services, Mental Health Spending, Attitudes towards Psychiatric Facilities and Community Acceptance. The results suggested that 12 items in the PACAMI-O did not contribute towards measuring public attitudes. Therefore 28 items were retained for the new, more concise, valid scale; Public Attitudes towards Offenders with Mental Illness (PATOMI). PATOMI can be used in future research to effectively assess public attitudes. Application, limitations and suggestions for future research are discussed.

“Swimming against the tide”: conditional discharge from medium secure care

PurposeThe purpose of this paper is to explore the experiences of mentally disordered offenders (MDOs) conditionally discharged from secure hospitals on a restrictive Section of the Mental Health Act (Section 37/41).Design/methodology/approachData were derived from seven semi-structured interviews from three forensic community teams.FindingsThematic analysis identified seven predominant themes: (1) the uncertainty of the discharge timeframe; (2) fear of jeopardising discharge; (3) progress; (4) engagement with community life; (5) barriers to social engagement; (6) evolving identity and (7) someone to turn to. Findings are discussed in relation to the recovery model and the good lives model.Practical implicationsThe findings highlight the importance of fostering trust between MDOs and their care teams to encourage help-seeking. They also suggest that resources should be sequenced appropriately throughout the discharge process, to match the “window of engagement” and maximize impact and effectiveness.Originality/valueThis research gained rarely obtained first-hand perspectives from MDOs, with the findings contributing to a more effective evaluation of the discharge pathway.

Attention Problems Predict Risk of Violence and Rehabilitative Engagement in Mentally Disordered Offenders.

Mentally disordered offenders (MDOs) endorse difficulties with attention, impulsivity, and hyperactivity. Assessing these difficulties among MDOs may confer practical benefits for the management and provision of care for this population, by informing strategies to improve rehabilitative engagement and risk assessments for violence. However, there is a dearth of literature exploring these cognitive problems in MDOs in relation to outcome factors. Forty-eight MDOs from a high-security hospital completed the QbTest, which measures the domains of inattention, impulsivity, and hyperactivity. Comprehensive file review of clinical and occupational/vocational rehabilitative engagement and Historical Clinical Risk Management-20 (HCR-20) were used as outcome measures of interest. Participants displayed greater cognitive deficits in attention, impulsivity, and hyperactivity compared to the general population. The domain of inattention and omission errors was related to occupational/vocational therapy engagement as well as a higher risk of present and future violence as measured by the HCR-20. The findings suggest that QbTest is a helpful objective tool that could be incorporated into the assessment of MDOs. Specifically, inattention emerged as a strong predictor of patients’ risk of violence as well as patient’s vocational therapy engagement. Therefore, cognitive skills programs targeting attention problems should be introduced to improve outcomes for this population.

Beyond the Walls: An Evaluation of a Pre-Release Planning (PReP) Programme for Sentenced Mentally Disordered Offenders.

Background: Prison mental health services have tended to focus on improving the quality of care provided to mentally disordered offenders at the initial point of contact with the prison system and within the prison environment itself. When these individuals reach the end of their sentence and return to the community, there is an increased risk of morbidity, mortality, homelessness and re-imprisonment. New models of care have been developed to minimize these risks.Objectives: The objective of this project was to establish a Pre-Release Planning (PReP) Programme with social work expertise, to enhance interagency collaboration and improve continuity of care for mentally disordered offenders upon their release. We aimed to evaluate the first 2 years of the programme by measuring its success at improving the level of mental health support and the security and quality of accommodation achieved by participants upon release in comparison to that reported at time of imprisonment. Additionally, we aimed to explore the impact of these outcomes on rates of re-imprisonment.Methods: A process of participatory action research was used to develop and evaluate the first 2 years of the programme. This was a naturalistic prospective observational whole cohort study.Results: The PReP Programme supported 43 mentally disordered offenders, representing 13.7%, (43/313) of all new assessments by the prison's inreach mental health service during the 2 years study period. When compared with that reported at time of reception at the prison, gains were achieved in level of mental health support (FET p < 0.001) and security and quality of accommodation (FET p < 0.001) upon release. Of those participants seen by the PReP Programme, 20 (46.5%, 20/43) were returned to prison during the 2-years study period. There was no significant relationship between re-imprisonment and gains made in mental health support (FET p = 0.23) or accommodation (FET p = 0.23).Conclusions: We have shown that compared to that reported at time of reception at prison, the level of mental health support and the security of tenure and quality of accommodation both improved upon release following the intervention of the programme. Improved mental health support and accommodation were not associated with lower rates of re-imprisonment.

European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders

Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.

Psychometric Examination of Treatment Change Among Mentally Disordered Offenders: A Risk–Needs Analysis

The present study examined the association of psychiatric symptomatology, criminal attitudes, and treatment changes within these domains to violent and general recidivism in a sample of 614 mentally disordered offenders. Significant pre–post changes were found on multiple measures of criminal attitudes, symptomatology, and readiness for change. Antisocial Intentions and Attitudes Toward Associates (from the Measure of Criminal Attitudes and Associates [MCAA]) predicted general recidivism and covaried with the Big Four criminogenic need domains on the Level of Service Inventory–Ontario Revision; none of the remaining psychometric measures significantly predicted violent or general recidivism. Although pre–post changes were seldom linked to changes in recidivism, positive changes in Antisocial Intentions (MCAA) significantly predicted reductions in general recidivism via Cox regression survival analysis, controlling for baseline risk and pretreatment attitudes score. Risk and need implications of psychometric assessments of treatment change in mentally disordered offender populations are discussed.

»Hun plejer da at kunne tåle, at jeg truer med at hente en motorsav ...« – Vold og trusler mod offentligt ansatte undersøgt i en dansk retspsykiatrisk population

English title: “But she usually tolerates when I threaten to get a chainsaw ...” A study of assaults against public servants among a population of Danish mentally disordered offendersThe issue of violence and threats against public servants has attracted significant public attention in recent years and plays an important role in the ongoing discussion of possible explanations for the recent significant growth in the number of sentences to psychiatric treatment in Denmark. The proportion of sentences given for violence and threats against public servants (Danish Penal Code § 119) has increased dramatically, from 5 % in 1980 to approximately 25 % of the total annual number of new sentences to some kind of psychiatric measure in 2014. Studies show that victims are most frequently social and health care assistants, nurses and physicians. This study is part of a larger mixed method study comprising all patients treated in a specialized forensic outreach team (ForACT) in the Mental Health Services in the Capital Region of Denmark over a period of 7½ years (20062014) (n=181). The types of assault against public servants examined in this sample are diverse, varying from mockery and verbal threats to physical attacks with severe injuries. Displaying complexity and diversity, the mentally disordered offenders (MDOs) in this study are generally characterised as having significant social problems, severe mental illness, substance use issues, and extensive criminal records. MDOs in the sample who have been convicted under § 119 seem to score higher than MDOs never convicted of assaults against public servants on a range of parameters, e.g., criminal onset, type of crime(s) committed, and frequency of psychiatric hospitalisation.

The Emotional Experience of Mentally Disordered Offenders (MDO): An Exploratory Study Using Smallest Space Analysis (SSA)

ABSTRACTThe study explored the emotions felt during a criminal offense within a Mentally Disordered Offender (MDO) population and the impact that specific mental disorders have on an offender’s emotional experience. Fifty-six MDOs were asked to complete a questionnaire that explored the emotions they felt during a specified offense. Using Smallest Space Analysis (SSA), results found two emotional regions within the population: Pleasure and Displeasure. Further analysis found that specific mental disorders have an impact on the emotional experience of offenders. Overall, the results highlighted that MDOs show differences in emotional functioning compared to offenders without mental disorders.

Long-Term Forensic Mental Health Services: An Exploratory Comparison of 18 European Countries

ABSTRACTThe objective of this study was to explore current provisions within forensic mental health inpatient services for people who require longer-term care within Europe. We used a structured questionnaire and follow-up semi-structured interviews with experts in forensic psychiatry in 18 European countries. All experts interviewed acknowledged the issue of ‘long-stay’ in forensic psychiatry with patient characteristics including chronic mental disorder, treatment-resistance and violent behavior. Formal and informal definitions of ‘long-stay’ varied widely between countries. Eight experts stated that long-stay services are currently available in their country. Of the countries without long-stay services, five experts expressed a need develop them. Improved quality of life and promotion of wellbeing were emphasized as the fundamental treatment philosophy. Even without an agreed definition of ‘long-stay’, it is clear that a proportion of mentally disordered offenders (MDOs) are ‘stuck’ in ‘the system’. Experts shared common concerns in terms of political pressures to contain dangerous MDOs for ensuring public safety as well as ethical debates regarding long-term forensic mental health care. Further research is required to promote dialogue between and within countries to address the balance of patient' rights and public safety, and to produce longitudinal and economic analyses of existing long-stay forensic service provisions.

It feels like Armageddon: identification with a female personality-disordered offender at a time of cultural, political and personal attack

ABSTRACTThis paper describes work undertaken at a secure unit for female mentally-disordered offenders in the United Kingdom. It addresses the use of psychoanalytic music therapy within the institution, in particular using material pertaining to an individual diagnosed with a psychotic illness and personality disorder, detained long term in an acute ward of the hospital. The work took place at a time when huge cuts to the UK’s National Health Service (NHS) were being implemented, and arts therapies were one of the resources that had been downscaled. A theme running throughout the paper examines the author’s personal challenges as a newly qualified therapist and the way in which the institutional dynamics impacted upon the work. Also explored are some of the challenges the therapist faced that arose as a result of shared experiences that resonated strongly between client and therapist. The main body of the paper addresses key psychoanalytic concepts that underpinned the work. In music therapy, a growing body of clinical work focusing upon attachment and mentalisation is emerging, and in also considering the complex needs and ways of relating of the client from these perspectives, the author hopes to contribute towards this.

Inpatient forensic-psychiatric care: Legal frameworks and service provision in three European countries

Laws governing the detention and treatment of mentally disordered offenders (MDOs) vary widely across Europe, yet little information is available about the features of these laws and their comparative advantages and disadvantages. The purpose of this article is to compare the legal framework governing detention in forensic psychiatric care in three European countries with long-established services for MDOs, England, Germany and the Netherlands. A literature review was conducted alongside consultation with experts from each country. We found that the three countries differ in several areas, including criteria for admission, review of detention, discharge process, the concept of criminal responsibility, service provision and treatment philosophy. Our findings suggest a profound difference in how each country relates to MDOs, with each approach contributing to different pathways and potentially different outcomes for the individual. Hopefully making these comparisons will stimulate debate and knowledge exchange on an international level to aid future research and the development of best practice in managing this population.

Adjudicating mentally disordered offenders in Ghana: The criminal and mental health legislations

The involvement of mentally disordered offenders (MDOs) in the criminal justice system (CJS) is currently a major public health concern. This has culminated in several empirical researches over the years, with a particular focus on addressing the problem. The present study examines the criminal and the mental health legislations available to offenders raising fitness to stand trial issues, as well as those pleading insanity at the time of the offense (insanity defense) in Ghana. The legislations are examined within a framework of reducing the overrepresentation of MDOs in the CJS. In doing so, comparisons are made to similar legislations in other commonwealth jurisdictions, when necessary. Regarding fitness to stand trial, it is evident that the Ghanaian legislation does not contain discrete fitness indicators, relative to, for instance, Canada. Yet, it is interesting that the terminologies ‘unsound mind’ and ‘incapable of making a defence’ used in the proviso convey similar meaning and requirements to those used in other jurisdictions. The insanity defense standard, on the other hand, is also heavily influenced by the M'Naughton Rules in England. The defense consists of two separate cognitive tests, each of which can result in an acquittal. One of the tests strictly emphasizes knowledge of the nature and consequences of the act while knowledge of the wrongness of the criminal act is implied in the other. However, none of the tests takes into consideration uncontrollable impulse arising from mental disorder. The study proposes some revisions and amendments to the insanity legislation in its current formulation. Recommendations are also offered for critical areas that warrant research attention in relation to MDOs in Ghana, and in Africa as a whole.