Secure Forensic Psychiatric Hospital Research Articles

Suivi longitudinal des patients psychiatriques médico-légaux : focus sur les taux de récidive et les scores de risque

Research concerning the follow-up of forensic patients after their release from a high-security facility into the community is scarce. However, results available indicate that revocation rates are rather high. Our research aimed to answer three aspects based on an analysis of court records of 168 patients discharged from a Belgian secure forensic psychiatric hospital between 2014 and 2018: (1) the revocation and recidivism rates during a 3-year follow-up period; (2) the prevalence and motives for revocations of probationary released; (3) the comparison of scores of the Violence Risk Appraisal Guide-Revised (VRAG-R) between three release measures. To our knowledge, our study is the first to compare violent recidivism risk scores between release types. The mean VRAG-R scores were higher among revoked than conditioned released patients. The latter presented higher mean score than definitively released patients. The overall results are congruent with the “good practice” of the risk principle, hence supporting the importance of basing release decisions on risk assessment principles such as the VRAG-R in a longitudinal perspective.

Adverse Childhood Experiences and Offending as a Function of Acquired Brain Injury Among Men in a High Secure Forensic Psychiatric Hospital.

Acquired brain injury (ABI) is a serious problem that disproportionately affects individuals in correctional services, but relatively little is known about ABI risks and correlates in forensic psychiatric services. We conducted a retrospective chart review of all admissions to a high secure forensic hospital in Ontario, Canada from January 2009 to December 2012 (n = 637) and collected data on ABI, psychiatric diagnoses, developmental disadvantage, criminal offending, and in-hospital aggression. A k-means cluster analysis was employed to assess risk factors by which men with ABI could be identified and multivariate general linear models were used to identify ABI-related differences in offending history and in-hospital aggression. One-fifth of the men had a documented ABI indicator. Based on our cluster analysis, ABI was more likely to be identified by greater adverse childhood experiences (ACEs), more health problems from pregnancy to childhood, and lower socioeconomic status, suggesting that ABI within the forensic context is associated with greater developmental disadvantage. Men with ABI had more serious pre-admission offences, but not more serious admission offences or in-hospital aggression. Men with ABI were more likely than those without to have higher scores on the Violence Risk Appraisal Guide or to be diagnosed with mood and personality disorders, and less likely to have a schizophrenia diagnosis, suggesting an association between ABI and general mental health pathologies but not with psychotic illness. The disadvantage of ABI among men in forensic psychiatric hospitals is most likely evinced in antisocial behaviour rather than serious mental illness. Given that ACEs are likely to precede or co-occur with ABI, strategies that mitigate ACEs hold promise for ABI prevention.

Sedentary Behaviour in the Secure Forensic Hospital Setting: A Study from Dundrum Hospital Ireland

Introduction Secure forensic mental health services offer care and treatment to mentally disordered offenders, with high rates of schizophrenia and major mental illness in these groups. Much of the excess morbidity and mortality seen among patients with schizophrenia is due to cardiovascular disease and obesity. Sedentary behaviour is associated with negative symptoms of schizophrenia and obesity.ObjectivesThe aim of this study was to ascertain the level of sedentary behaviour among inpatients in a secure forensic psychiatric hospital, Dundrum, Ireland, using a structured self-report measure of sedentary behaviours, the SIT-Q tool.MethodsA cross sectional study of self-reported sedentary behaviour was completed amongst the secure forensic inpatient population of Dundrum Hospital (N=94). Demographic details, details pertaining to diagnoses, ward level of dependency and length of stay were collated.ResultsThe majority of patients in the sample were male (89%) and the most common diagnosis was schizophrenia (71.7%). Mean age was 44.7 years (SD 11.42). 58.2% met criteria for obesity. We found high rates of self-reported sedentary behaviour across all wards of the service, with significantly high rates of sedentary behaviour being associated with screen time use in the hospital, including both personal screen time and therapeutic sessions based on screen time.Conclusions Sedentary behaviour among in-patients in secure forensic hospitals is a significant issue. Measuring sedentary behaviour in a systematic manner is possible and identifies a potentially modifiable target to reduce co-morbidity and pre-mature mortality independent of other risk factors in this vulnerable patient group.DisclosureNo significant relationships.

Changes in BMI and blood pressure after implementing a complete smoking ban in a medium secure forensic setting: A study from dundrum hospital dublin

IntroductionIn February 2020, the Central Mental Hospital Dundrum moved to a complete ban on cigarette smoking. Concerns were raised that this might represent a ‘restrictive practice’ and that patients might gain weight or see changes in their blood pressure if they were not permitted to smoke.ObjectivesThe aim of the study was to ascertain if there were changes in the blood pressure readings or body mass index of a group of patients in a secure forensic hospital after the implementation of a complete campus-wide smoking banMethodsAll patients (n=20) working with one medium cluster team were included in the study. Demographic details and data pertaining to legal status, diagnosis and length of stay in the hospital were obtained. BMI, blood pressure and medications were reviewed at the time of introduction of the smoking ban, 1st February 2020 and again 5 months later.ResultsAll those included in the study were male. The median age was 35 years, most common diagnosis was schizophrenia and mean length of stay was 4.23 years. 20% of patients were prescribed anti-hypertensives at the time of introduction of the smoking ban. All of the patients on anti-hypertensives were overweight. At follow up there was no increase in BMI noted in the patient group. Two patients had dose reductions in anti-hypertensives, three had discontinuation of bronchodilators.ConclusionsIntroducing a campus wide smoking ban in a secure forensic psychiatric hospital is both clinically positive and practically possible. There was no noted increase in incidents in the hospital during this period.

Static and Dynamic Assessment of Violence Risk Among Discharged Forensic Patients

This study evaluated the predictive validity of structured instruments for violent recidivism among a sample of 82 patients discharged from a maximum security forensic psychiatric hospital. The incremental predictive validity of dynamic pre–post change scores was also assessed. Each of the Historical-Clinical-Risk Management-20 Version 3 (HCR-20V3), Psychopathy Checklist–Revised, Short-Term Assessment of Risk and Treatability, Violence Risk Scale (VRS), and Violence Risk Appraisal Guide–Revised was rated based on institutional files. The study instruments significantly predicted community-based violent recidivism (area under the curve [AUC] = 0.68-0.85), even after controlling for time at risk using Cox regression survival analyses. Dynamic change scores computed from the HCR-20V3 Relevance ratings and from the VRS also demonstrated incremental predictive validity, controlling for baseline scores. The findings provided support for the use of the study instruments to assess violence risk and for the consideration of dynamic changes in risk—provided that valid means of assessment are employed.

The 'honeymoon effect' and 'gate fever' in a secure forensic adolescent psychiatric hospital: Do they exist?

There is limited research that comments on whether there are recurring patterns for incidents or significant events during inpatient admissions to psychiatric units. This is even more so the case for an adolescent population. This study looked at 30 consecutive female patient admissions to Bluebird House, a medium secure adolescent unit in the South of England, to identify whether both the 'honeymoon effect' (low incident rate in the first 28 days following admission) and 'gate fever' (high incident rate in the last 28 days prior to discharge) were identifiable phenomena. Analysis of the incident rate found that in our secure adolescent population, the number of incidents both in the first week and at the first 28 days was higher in comparison to the whole admission. We also did not find a consistent increase in incidents in the final 28 days of the admission.

Personality, Psychiatric, and Cognitive Predictors of Length of Time for Competency to Stand Trial Restoration

ABSTRACTCertain defendant characteristics, including psychiatric diagnosis, externalizing problems, and cognitive deficits, are associated with longer periods of restoration of competency to stand trial and general lack of treatment success. Prior research has called for a more detailed examination of symptom-level differences between defendants rapidly restored to competency and those who require lengthier treatment for competency restoration. The present study evaluated whether specific aspects of psychopathological constructs assessed by the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF), and specific cognitive abilities assessed by the Wechsler Abbreviated Scale of Intelligence (WASI/WASI-II), were associated with length of competency restoration among 344 male pretrial defendants hospitalized at a maximum security forensic psychiatric hospital. Higher Juvenile Conduct Problems (JCP) scores were associated with restoration within 90 days, and Antisocial Behavior (RC4) predicted restoration status at 90 days; no MMPI-2-RF or WASI/WASI-II scales predicted restoration status at 180 days when controlling for age. Overall, results suggested that externalizing behaviors are among factors that may play a role in predicting restoration status at select time points.

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.

Characteristics of male patients admitted to an adolescent secure forensic psychiatric hospital

This paper examines the characteristics of a group of 64 young men, who were consecutively admitted to Bluebird House, an NHS mixed gender, adolescent forensic, medium secure hospital. The characteristics examined focus on the young men’s clinical presentations, as informed by the Millon Adolescent Clinical Inventory, and their ICD10 (WHO 1992) diagnoses. The paper also examines the males’ route into, and out of, Bluebird House, as well as their risk profiles, especially with regards to others, as informed by Structured Assessment of Violence Risk in Youth findings and staff recorded incidents. Correlational analysis is performed to try and understand this population, with statistically significant findings highlighted. The discussion considers the trajectory for some of these young men into adult personality disorders, their presentation and prognosis compared to their female counterparts, and how their presentation contrasts with adult male forensic populations.

Recovery and concordance in a secure forensic psychiatry hospital - the self rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales.

BackgroundDetention in a secure forensic psychiatric hospital may inhibit engagement and recovery. Having validated the clinician rated DUNDRUM-3 (programme completion) and DUNDRUM-4 (recovery) in a forensic hospital, we set out to draft and validate scales measuring the same programme completion and recovery items that patients could use to self-rate. Based on previous work, we hypothesised that self-rating scores might be predictors of objective progress including conditional discharge. We hypothesised also that the difference between patients’ and clinicians’ ratings of progress in treatment and other factors relevant to readiness for discharge (concordance) would diminish as patients neared discharge. We hypothesised also that this difference in matched scores would predict objective progress including conditional discharge.MethodIn a prospective naturalistic observational cohort study in a forensic hospital, we examined whether scores on the self-rated DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales or differences between clinician and patient ratings on the same scales (concordance) would predict moves between levels of therapeutic security and conditional discharge over the next twelve months.ResultsBoth scales stratified along the recovery pathway of the hospital, but clinician ratings matched the level of therapeutic security more accurately than self ratings. The clinician rated scales predicted moves to less secure units and to more secure units and predicted conditional discharge but the self-rated scores did not. The difference between clinician and self-rated scores (concordance) predicted positive and negative moves and conditional discharge, but this was not always an independent predictor as shown by regression analysis. In regression analysis the DUNDRUM-3 predicted moves to less secure places though the HCR-20 C & R score dominated the model. Moves back to more secure places were predicted by lack of concordance on the DUNDRUM-4. Conditional discharge was predicted predominantly by the DUNDRUM-3.ConclusionsPatients accurately self-rate relative to other patients however their absolute ratings were consistently lower (better) than clinicians’ ratings and were less accurate predictors of outcomes including conditional discharge. Quantifying concordance is a useful part of the recovery process and predicts outcomes but self-ratings are not accurate predictors.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-015-0433-x) contains supplementary material, which is available to authorized users.

Mural art therapy for young offenders hospitalised with a mental illness

To describe a mural art therapy project completed within an adolescent unit of a secure forensic psychiatric hospital. The planning, implementation and consecutive stages of the mural art therapy project are described. Pertinent themes are identified. A cohort of adolescent forensic inpatients was engaged in a group therapeutic process involving collaboration, design and the completion of an art mural. The participants generally approved of the project and identified themes of gaining a sense of achievement, empowerment, teamwork, involvement and ownership. The art mural transformed and improved the visual and spatial environment of the Adolescent unit courtyard. Mural art therapy was acceptable to young offenders hospitalised with mental illness, which has relevance for adolescent psychiatric units and youth detention centres.

Characteristics of People With Intellectual Disabilities in a Secure U.S. Forensic Hospital

Prior research examining persons with intellectual disabilities who have committed criminal offenses has focused primarily on correctional populations, or those who reside in secure forensic settings in the United Kingdom and Australia. This study describes 235 persons with intellectual, developmental, and cognitive disabilities who reside in a secure forensic psychiatric hospital in the Midwestern United States. Participants were further divided into groups of persons with pervasive developmental disorders (n = 35), fetal alcohol syndrome (n = 18), traumatic brain injuries (n = 52), or IQ scores falling within the range of moderate (n = 20) or mild (n = 55) mental retardation or borderline intellectual functioning (n = 55). These participants presented with significant histories of childhood maltreatment and adversity, serious psychiatric impairment, criminal histories marked by multiple arrests and serious violent behavior, and frequent histories of institutionalization and out-of-home placement. Their adaptive functioning within the community was characterized by limited histories of normative intimate relationships; sporadic, unskilled employment; and difficulties with maintaining residential and psychiatric stability. Important commonalities and future research needs are discussed. Important differences and similarities between groups are discussed and compared with other available literature.

Characteristics of female patients admitted to an adolescent secure forensic psychiatric hospital

Bluebird House is the only mixed gender NHS secure forensic psychiatric hospital for adolescents in the South of England. It has admitted more than 30 female patients since the service opened in 2008. The admission criteria are that patients must be detained under the Mental Health Act and present evidence of being a risk of harm to others. This article describes the clinical characteristics of 30 consecutive female patients admitted to a highly specialised adolescent forensic inpatient service. Key results include a very high rate of incidents of risk behaviours exhibited by female patients within the unit but good clinical outcomes. The majority of patients had severe symptoms of mental disorder, especially emotional instability, self-harm behaviours and aggressive behaviours. Few had diagnoses of mental illness. Assessment findings from the Millon Adolescent Clinical Inventory and the Structured Assessment of Violence Risk are discussed, as are parallel with studies from other female secure services.

A review of violent incidents in a multilevel secure forensic psychiatric hospital: is there a seasonal variation?

There have been several attempts made to reduce the occurrence of violence in hospital settings, with most professional organizations taking a stance. The impact of violent incidence on the therapeutic environment and the cost in human terms led to the declaration by the World Health Organization that violence is a public health problem. There are strategies for reducing violence that flow out of known trends. We sought to examine the trends in institutional violence in a contextual sense. We reviewed the records of all incidents of violence, categorized by severity, victims and trends over five years in a multilevel secure forensic hospital in Canada. The rate of violence perpetrated by female patients was significantly higher than for male patients. Higher occurrence of violence was recorded in the winter months compared with any other season and was related to unstructured activities. There is a window of opportunity to develop some engaging programmes during the long winter months and improve supervision at all times of unstructured activity. The reasons for increased women perpetration and the winter peak of violence require further investigation.

Effects of group metacognitive training (MCT) on mental capacity and functioning in patients with psychosis in a secure forensic psychiatric hospital: a prospective-cohort waiting list controlled study

BackgroundMetacognitive Training (MCT) is a manualised cognitive intervention for psychosis aimed at transferring knowledge of cognitive biases and providing corrective experiences. The aim of MCT is to facilitate symptom reduction and protect against relapse. In a naturalistic audit of clinical effectiveness we examined what effect group MCT has on mental capacity, symptoms of psychosis and global function in patients with a psychotic illness, when compared with a waiting list comparison group.MethodsOf 93 patients detained in a forensic mental health hospital under both forensic and civil mental health legislation, 19 were assessed as suitable for MCT and 11 commenced. These were compared with 8 waiting list patients also deemed suitable for group MCT who did not receive it in the study timeframe. The PANSS, GAF, MacArthur Competence Assessment Tool- Treatment (MacCAT-T) and MacArthur Competence Assessment Tool-Fitness to Plead (MacCAT-FP) were recorded at baseline and repeated after group MCT or following treatment as usual in the waiting list group.ResultsWhen baseline functioning was accounted for, patients that attended MCT improved in capacity to consent to treatment as assessed by the MacCAT-T (p = 0.019). The more sessions attended, the greater the improvements in capacity to consent to treatment, mainly due to improvement in MacCAT-T understanding (p = 0.014) and reasoning . The GAF score improved in patients who attended the MCT group when compared to the waiting list group (p = 0.038) but there were no changes in PANSS scores.ConclusionMeasures of functional mental capacity and global function can be used as outcome measures for MCT. MCT can be used successfully even in psychotic patients detained in a forensic setting. The restoration of elements of decision making capacity such as understanding and reasoning may be a hither-to unrecognised advantage of such treatment. Because pharmacotherapy can be optimised and there is likely to be enough time to complete the course, there are clear opportunities to benefit from such treatment programmes in forensic settings.

The prevalence and manifestation of substance use paralleling behaviours in a secure forensic psychiatric hospital

Co-morbid substance dependence is common in patients of secure psychiatric services. Identifying opportunities for intervention, monitoring progress in treatment and assessing risk of relapse are compromised by this group's limited access to illicit substances. This research investigated the validity of the substance use paralleling behaviour (SUPB) framework, which was developed to assist staff in identifying behaviours indicative of substance dependence in controlled environments. Thirty-one patients admitted to the acute units of a secure forensic psychiatric hospital were interviewed and assessed with the Brief Psychiatric Rating Scales, the structured clinical interview for DSM disorders substance use disorders module, and an original questionnaire measuring motivations for drug use and behaviours indicative of substance dependence in a controlled setting (SUPBs). Results showed that patients with a history of substance dependence preceding admission engaged in more SUPBs during hospitalisation than ...

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.

What's the point? Towards a methodology for assessing the function of psychiatric inpatient aggression

There are few examples in the literature of the application of functional analysis to psychiatric inpatient aggression. Structural assessment approaches have dominated. This paper introduces a system for classifying the functions of aggression in psychiatric inpatients that was applied to 502 aggressive behaviours exhibited by patients in a secure forensic psychiatric hospital. At least one function was identified for the majority of aggressive incidents; the most common functions pertaining to patients’ responses to the restrictions and demands of the inpatient setting, to express anger or to punish others perceived as provocative, and to maintain status. There was little evidence suggesting that aggression was used to obtain tangible rewards, to reduce social isolation, or to simply observe the suffering of others. Differences in the function of aggressive behaviour were found across victim types. Results of this study have implications for the prediction and prevention of inpatient aggression and for the treatment of aggressive inpatients.

Individual characteristics predisposing patients to aggression in a forensic psychiatric hospital

The assessment and management of aggression have become crucial components of psychiatric inpatient care and the focus of considerable research attention. This study examined the relationships between characteristics of psychiatric inpatients with aggressive behaviour in a forensic psychiatric hospital. Demographic and clinical characteristics, patients' social behaviour, and histories of aggression and substance use were obtained for every patient admitted to the Thomas Embling Hospital, a secure forensic psychiatric hospital, during 2002. Of these patients, 110 completed an additional assessment of psychotic symptoms and a battery of psychological tests measuring anger expression and control, assertiveness, and impulsivity. Results indicated that a recent history of substance use, an entrenched history of aggression, recent antisocial behaviour, and symptoms of psychosis including thought disturbance, auditory hallucinations, and conceptual disorganisation contributed to aggression.

The Relationship Among Malingering, Psychopathy, and the MMPI-2 Validity Scales in Maximum Security Forensic Psychiatric Inpatients

ABSTRACT The records of 392 men hospitalized in a maximum security forensic psychiatric hospital were reviewed. Demographic information was collected as well as data from the men's performance on the Psychopathy Checklist-Revised (PCL-R) and Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Prevalence rates for malingering were low across the sample. However, results of chi-square analysis revealed that those who scored high on the PCL-R received a diagnosis of malingering significantly more frequently than those who scored low on the PCL-R. Clinical applications and theoretical implications of the results are discussed.