Special Hospital Patients Research Articles

Book Reviews

Book reviewed in this article:Offenders, Deviants or Patients? 2nd ed. By H. Prins.The Treatment and Security Needs of Special Hospital Patients. By T. Maden, C. Curle, C. Meux, S. Burrows & J. Gunn.Psychology and Policing in a Changing World. By Peter B. Ainsworth.Why Kids Kill Parents: Child Abuse and Adolescent Homicide. By Kathleen M. Heide.Paedophiles and Sexual Offences against Children. By Dennis Howitt.Ethical Conflicts in Psychology. By Donald S. Bersoff.

Life events and psychopathy: Influence of sudden ward environmental change on psychosocial functioning in psychopathically disordered Special Hospital patients

Abstract Life events have been shown to be associated with exacerbation of mental disorders. This paper examines the effect on psychosocial functioning of a ward transposition, on patients detained in Special Hospital under the legal classification of psychopathic disorder. Following the ward's being informed of the move there was no increase in symptomatology but in the month surrounding transfer there was a statistically significant increase in the psychological, but not physical, symptomatology. This has implications for the transfer of psychopathically disordered patients from Special Hospital to medium security.

A survey of male homicide cases resident in an English special hospital.

The study examines a sample of 120 male special hospital patients whose index offence was one of homicide. Demographic, criminological and psychiatric details are described and the characteristics of those committing psychotic and non-psychotic homicides are compared. The results generally confirmed most of the findings reported in international studies of abnormal homicide. Compared with other studies on in-patient populations we found a greater than expected proportion of non-psychotic homicide offenders, the majority of whom had a clinical diagnosis of personality disorder. Key factors distinguishing psychotic from non-psychotic homicide included a pre-offence criminal history, the objective relationship between perpetrator and victim and the behaviour after the offence. Psychotic men were less likely to have a prior history of criminality and substance abuse than their non-psychotic pears but they were more likely to have had previous contact with the psychiatric services and to have known their victims. Compared with the non-psychotic group the majority of psychotic offenders remained at the crime scene or summoned help. A marked age differential between psychotic and nonpsychotic offenders was not apparent in this study.

A neurophysiological predictor of reoffending in special hospital patients

AbstractThe aim of this study was to assess a possible role for a slow brain potential measure, the Go/No Go contingent negative variation (CNV), as an indicator of subsequent reoffending by mentally disordered offenders released from a special high‐security hospital. The rationale was twofold: (1) Go/No Go CNV has been found to correlate with psychometric measures of impulsivity; (2) impulsivity has been found to predict recidivism in sexual offenders and in violent offenders generally. The subjects were 44 men compulsorily admitted to Broadmoor Hospital from 1977 to 1980 under the Mental Health Act 1959 (MHA 1959). They fell within the legal categories of psychopathic disorder (PD: n = 16) or mental illness (MI: n = 28). CNV recordings were carried out within 3 months of admission using a Go/No Go avoidance paradigm. Subjects were assigned to a ‘high risk’ (HR: n = 21) group if their Go/No Go difference fell at or beyond a standard deviation from the mean for a normal control group comprising 19 student nurses, matched for age and sex, in whom CNVs were recorded at the same time; they were otherwise classed as ‘low risk’ (LR: n = 23). Patients were followed post‐discharge for up to 15 years. Information was obtained pertaining to reconvictions, rehospitalisation and death from the special hospitals case register. Reconvictions for any offence occurred in six of 21 HR patients, compared with one of 23 LR patients, giving an overall accuracy for the predictor of 63.6%, and a relative improvement over chance of 72%. These results offer some promise that Go/No Go CNV may be a useful predictor of recidivism in mentally disordered offenders. Copyright © 1996 Whurr Publishers Ltd.

Reviews

Abstract Abstract The Law Commission, Liability for Psychiatric Illness, Consultation Paper no. 137, London: HMSO, 1995, £13.95, 120 pp. Tony Maden, Christian Curle, Clive Meux, Stephen Burrow and John Gunn, The Treatment and Security Needs of Special Hospital Patients, London: Whurr Publishers, 1995, £75 (p/b), 134 pp. Michael Napier and Kay Wheat, Recovering Damages for Psychiatric Injwry, London: Blackstone Press, 1995, £19.95 (p/b), 191 pp. S. R. Krishnamma, The Bullad of Luzy L, Corsham, Wilts: Rani Press, 1994, £6.99 (p/b), 286 pp. Alisdaire Hickson, The Poisoned Bowl: Sex, Repression and the Public School System, London: Constable, 1995, £14.95 (h/b), 250 pp. Joel Peter Eigen, Witnessing Insanity: Madness and Mad-Doctors in the English Court, N e w Haven, CT and London: Yale University Press, 1995, £40 (h/b) 240pp. Derek Chiswick and Rosemarie Cope (eds), Seminars in Practical Forensic Psychiatry, London: Gaskell (Royal College of Psychiatrists), 1995, £17.50 (p/b), 359 pp. Bridget Dolan (ed.) Therapeutic Communities for Offenders, London: Association of Therapeutic Communities, 1994, £9.95 (p/b), 328 pp. Social Services Inspectorate, Department of Health, Not Alone: A Children's Guide to Cure Proceedings, London: HMSO, 1995, £50.00 (video, handbook, workbooks, playing cards)

Psychopathy and moral reasoning: Comparison of two classifications

Forty Special Hospital patients were assessed using two different measures of psychopathic personality—the Special Hospitals Assessment of Personality and Socialization (SHAPS) and the Psychopathy Check List-Revised (PCL-R). Subjects completed the Defining Issues Test (DIT), an assessment of moral reasoning ability. There was little agreement on classification between the two measures of psychopathy, or between either of the measures and Mental Health Act classification of psychopathic disorder. A negative correlation was found between PCL-R scores and IQ scores. Scores on the PCL-R were negatively related to moral reasoning, but the relationship did not hold when IQ was partialled out. A modest negative relationship was observed between moral reasoning and the SHAPS factor of antisocial aggression.

How many high security beds are needed? Implications from an audit of one region's Special Hospital patients

Abstract This paper describes an audit of patients from the North West Thames (NWT) region in the maximum-security Special Hospital (SH) system on 1 October 1992. The aim of the study was to identify for each patient the least restrictive setting in which their treatment might continue, thereby estimating the real demand for SH care from this region, and, by extrapolation, the future size of the SH system. The study was undertaken primarily in order to assist local service planning; preliminary results were also made available to the high security' working party set up following the completion of the joint Home Office and Department of Health review (the Reed Report) of services for mentally disordered offenders (Department of Health and the Home Office, 1991). Dr Kevin Murray, MRCPsych, consultant forensic psychiatrist, Three Bridges Unit, St Bernard's Wing, Eating Hospital, Uxbridge Road, Southall, Middlesex UB13EU DrShauna Rudge, MRCPsych, locum senior registrar, Three Bridges Unit, St Bernard's Wing, Eating Hospital, Uxbridge Road, Southall. Middlesex UB13EU Dr Sarah Lack, MRCPsych, senior registrar, Three Bridges Unit, St Bernard's Wing, Eating Hospital, Uxbridge Road, Southall, Middlesex UB13EU Dr Robert Dolan, MRCPsych, consultant forensic psychiatrist, Three Bridges Unit, St Bernard's Wing, Eating Hospital, Uxbridge Road, Southall, Middlesex UB13EU

Conjugal visits may go ahead

Possible plans to allow sexual contact between special hospital patients and their partners could relieve pressure on nursing staff, experts have said.

The experience of special hospital patients in regional secure units

Regional secure units provide one of the main routes of release for special hospital patients; a route that in many cases is unsuccessful as the patient is subsequently readmitted to the special hospital. Processes underlying this were investigated in this UK study using a grounded theory approach. The interview data obtained in 1993 from a sample of 14 readmitted special hospital patients were analysed and five explanatory categories were generated. This paper concentrates on descriptive data from two categories. One describes negative experiences of a group of patients in regional secure units; an experience often considered a 'backward step'. The second data category identifies four principal reasons for readmission; one reason, inappropriate sexual behaviour, was of particular concern due to its frequency and the possibility that it resulted from the special hospital practice of gender segregation.

Violence ratings of special hospital patients

Abstract The male population of a high security hospital is described in terms of the profile of patients' pre-admission violence (index offence and previous convictions), using a rating scale described by Robertson et al. (1987). The ratings show that Broadmoor Hospital patients exhibit a high level of violence both in terms of previous convictions and related to their index offence. Only one patient was admitted after a non-violent index offence. At Broadmoor 55 per cent of the population had previous convictions of violence before the index offence; 17 per cent had a previous history of unprosecuted violence before the present admission; 19 per cent were admitted to the hospital following a single severely violent index offence which resulted in the death or serious injury of the victim; 72 per cent of this last group have the clinical diagnosis of schizophrenia. In this study, the rating scale was noted as a useful screening instrument that can describe the violence profile of Special Hospital patients. It can help delineate different groups of violent mentally abnormal offenders for the investigation of the biological correlates of violent behaviour.

The treatment and security needs of patients in special hospitals

The treatment and security needs of a 20% cross‐section of patients in the three maximum‐security hospitals of England and Wales are described. Data were collected from case notes and interviews with each patient and with the clinical team. Patients were described in term.s of their diagnosis, source of admission and reasons for admission, past psychiatric treatment, present clinical features and estimated needs for psychiatric treatment and secure containment. The sample consisted of 296 cases. Most patients had been admitted from prison, although only 10% were serving a sentence; 21% were detained under non‐criminal treatment orders. The most common diagnosis was schizophrenia (55%) and 14% suffered from other psychoses. Most patients had long histories of psychiatric treatment and 39% were inpatients at the time of the behaviour which lead to their admission. The problem mentioned most often in admission reports was repeated assaults (56%), with the most frequent victims being other patients or hospital staff. Both the research and clinical teams rated over 80% as needing medium or higher security, with the research team identifying a need for maximum security in 37%, whilst the clinical team put this figure at 50%. A similar range of diagnoses and clinical problems was identified in patients rated as needing medium or maximum security, suggesting differences in severity only, with many patients on the borderline between these categories. The most common clinical problems were lack of insight, difficulty relating to other people and failure to respond to medication. Absconding risk was identified as an obstacle to transfer to lesser security in only 9% of patients. Only 2% of patients were expected to show any improvement in their clinical condition over the next year and only 5% were expected to improve in the next 5 years. These predictions are consistent with the long histories of hospitalisation in many patients. Between one‐ and two‐thirds of patients rated as needing medium security would require this level of security for more than 2 years, making them unsuitable for most units. Many special hospital patients’ do not require all aspects of maximum security but most have a high level of chronic psychiatric disability and extensive treatment needs. The success of any attempt to move them out of the special hospitals will depend on providing care elsewhere, particularly long‐term medium secure care, which is lacking at present. The quality of life and chances of transfer of many special hospital patients could be improved by a greater emphasis on treatment and rehabilitation within the hospitals. This has important resource implications.

The treatment and security needs of special-hospital patients: a nursing perspective.

Psychiatric nurses who are key workers or primary nurses within special hospitals are well placed to comment on their patients' needs and the benefits, and shortfalls, of trying to meet these within a maximum-security environment. In this survey, nurse respondents gave information on two groups of special-hospital clients, though they themselves were unaware of any group differentiation. Those who were not seen as requiring continued care within maximum security, as judged by other team investigators, were conceptualized by the researcher as 'leavers'. The survey revealed that in relation to those continuing to require maximum security--the 'stayers'--'leavers' retained exceptionally high levels of deficits related to their potential for community reintegration. Deficits in cognitive, social and life skills were as prevalent among those considered to need lower levels of security, and closer contact with the community, as those remaining within the special-hospital service. It also became clear that the effective management of special-hospital residents demanded a necessary conflict of interests: client-centred flexibility within the constraints of secure custody. There were also inconsistent features between the hospitals, as was shown in the differential provision of parole for patients. Only the survey sample from Broadmoor had access to this important resource. The conclusion is that, with the special hospitals' unequivocal commitment to maintain security, not all treatment and security needs of patients are appropriately met. Certain opportunities should, perhaps, be provided within new, alternative facilities.

What happens to Special Hospital patients admitted to medium security?

Abstract Most studies of discharged Special Hospital patients have examined the outcome of patients discharged directly into the community. Some have included patients transferred to NHS hospitals, but there have been no reports of the progress of Special Hospital patients transferred to regional secure units (RSUs). This article describes the outcome of all the Special Hospital patients who were admitted to and discharged from medium secure units in the West Midlands region over 10 years. There were 51 patients included in the study and the follow-up ranged from 10 years to 6 months with a mean of 5.3 years The main findings were similar to other Special Hospital studies, in that patients with a legal classification of psychopathic disorder had a poorer prognosis dian mentally ill patients. No other factors could predict success or failure, such as sociodemographic variables, nature of offence, previous criminal and psychiatric histories, or past history of substance abuse. In the study failure was defin...

A study of absconding by special hospital patients: 1976 to 1988

Abstract Absconding by Special Hospital patients is taken seriously and attracts considerable attention; however, there has been no published research on the topic. The present study looks at the demographic details of Special Hospital absconders over a 13-year period and at characteristics of the absconding events. The absconding group was compared with a control group admitted during the same period. Absconding was rare. In most cases the duration was short, with all absconders being eventually found, 33 per cent returning of their own accord. There was an excess of patients with a classification of psychopathic disorder in the absconding group and fewer with a classification of mental illness. Absconders rarely offended whilst at liberty and with two exceptions such offences were trivial in nature. There was a preponderance of patients with psychopathic disorder in the group that offended whilst at liberty. Apart from the group who offended when at large the absconsion did not seem to hinder subsequent...

Alcohol-related offending in male special hospital patients.

In a sample of 61 male Special Hospital patients, 11 (18%) were identified as having alcohol-related problems prior to admission. Ten of these alcohol-abusers were interviewed to gather further information about their drinking, offending, and the relationship between the two. Alcohol abusers showed more serious criminality than non-abusers, having significantly more previous convictions and being responsible for a disproportionately high number of offences of murder and manslaughter. Alcohol-related problems appear to have developed quickly in adolescence culminating in the index offence at around 30 years of age. At this time, the mean self-reported weekly alcohol consumption was 240 units (one unit = 8.5gm alcohol). All but one man admitted to a relationship between alcohol and crime, and most showed motivation to change their future drinking behaviour.

Lithium carbonate in chronic schizophrenia — a brief trial of lithium carbonate added to neuroleptics for treatment of resistant schizophrenic patients

The value of lithium carbonate as an adjunctive treatment of resistant schizophrenia was tested in a 4-week clinical trial using a single-blind, randomized, consent design. Treatment and control groups were drawn from a population of detained patients in an English special (maximum security) hospital. The 2 groups were comparable in terms of age, sex, severity of symptoms, length of hospitalization and concurrent neuroleptic dosage. The addition of lithium carbonate to the treatment regimen did not result in symptomatic improvement in patients completing the treatment protocol. The ethical and practical difficulties raised by the trial are discussed.

Patients in Broadmoor Hospital from the South Western region: an audit of transfer procedures

Broadmoor Hospital is one of the three special hospitals covering England and Wales. It provides approximately 500 beds for mentally disordered patients who on account of their dangerous, violent or criminal propensities constitute a grave and immediate danger to the public, requiring treatment in conditions of special security (Section 4, National Health Service Act, 1977). It is generally recognised, however, that there are patients in special hospitals no longer requiring treatment in conditions of maximum security. These patients could probably be more appropriately cared for elsewhere if the facilities existed in general psychiatric hospitals or the community. However, special hospital consultants frequently encounter significant obstacles when attempting to transfer patients to local hospitals. Dell (1980) highlighted this problem, suggesting that 16% of special hospital patients were waiting to leave, following the agreement of the DHSS and the Home Office to their transfer. This delay appeared to be due to hospitals not wanting to accept patients who might prove to be difficult or dangerous. At the time of this current study (March 1990) these difficulties in transferring patients were particularly relevant as two of the special hospitals, Broadmoor and Ashworth (Park Lane and Moss Side) were full for male patients and therefore closed to male admissions, despite a continuing demand for beds.

Fitness to plead and psychiatric reports.

The role of the psychiatrist in the determination of fitness to plead is reviewed by reference to 77 pre-trial psychiatric reports prepared on 31 Special Hospital patients detained under the provision of Section 5(1)(c) (Unfit to Plead) of the Criminal Procedure (Insanity) Act 1964. Each psychiatric report was analysed using a standardized checklist which addressed the legal criteria used to determine fitness to plead, the nature of the alleged offence and the clinical diagnosis. The results showed that almost 40% of the reports made no mention of fitness to plead at all and that only one-third of the reports made a statement about fitness to plead which was supported by reference to standard legal criteria. The results of this study support earlier work which has suggested that psychiatrists have a poor understanding of the issues surrounding fitness to plead and criminal responsibility. These findings are discussed in relation to recommendations made by the Report of the Committee on Mentally Abnormal Offenders, 1975 (Butler Report) and legislative changes introduced by the Mental Health Act 1983.

A computerized form of the Eysenck Personality Questionnaire: A clinical study

Initially, 275 patients at five clinical sites were assessed with either the standard version or a computerized version of the Eysenck Personality Questionnaire as part of the Leicester/DHSS project on microcomputer-aided assessment. Of this group, 170 were retested with the alternative form of the test. High correlations were found between the standard and computerized versions for all scales, except for the P scale which was unduly distorted by a subsample of Special Hospital patients. For other groups of subjects, P scale reliability was high. No differences were found between the standard and computerized versions of the tests on any scale when the first administration data were analyzed separately. These results are interpreted as indicating that the computerized version of the test may be used, where appropriate, in place of the standard version.

Frontal lobe functions and personality in mentally abnormal offenders

This study addresses the recent controversy regarding frontal lobe deficits in psychopaths (Gorenstein, 1982; Hare, 1984) and more generally the question of a relationship between psychopathy as variously attributed (by legal criteria, by clinical-behavioural criteria, and by psychometric criteria) and performance on a task used in the assessment of frontal lobe function, Nelson's Modified Wisconsin Card Sorting Test (MWCST). Two samples of Special Hospital patients were tested as well as a small group of normal healthy volunteers. Patients classified legally as suffering from a ‘Psychopathic Disorder’ did not differ on MWCST measures from patients classified legally as ‘Mentally Ill’. There were no differences on performance measures comparing patients assessed as ‘high’ or ‘low’ on Hare's Psychopathy Checklist. Comparison between psychometrically derived patient groups corresponding to Blackburn's (1974) ‘primary’ and ‘secondary’ psychopathic types yielded statistically significant results: ‘secondary’ psychopaths showed significantly more total errors and achieved significantly fewer categories than did ‘primary’ psychopaths and controls. This suggests that the discrepancy between Gorenstein's (1982) and Hare's (1984) results can parsimoniously be explained by their use of different selection criteria to select their ‘psychopaths’. However, it is suggested that performance deficits on the MWCST such as were obtained in ‘secondary’ psychopaths are not a correlate of ‘psychopathy’ (however defined), but rather reflect an inability to maintain set resulting from an over-appraisal of threat on the part of the anxious, socially withdrawn individual.