Swedish Prison Research Articles

Aggressive Antisocial Behaviors Are Related to Character Maturity in Young Swedish Violent Offenders Independent of ADHD.

Antisocial personality and psychopathic traits have constantly been found to accompany criminal and aggressive behaviors, but little attention has been given to aspects of character maturity and its relation to such behaviors. The present study investigated (1) whether level of character maturity (low, medium, and high) is associated with amount of aggressive antisocial behaviors (AABs) and psychopathic traits in young men imprisoned for violent criminality, and (2) whether such an association is independent of coexisting attention-deficit hyperactivity disorder (ADHD). Swedish males (N = 270, aged 18-25) sentenced to prison for violent and/or sexual criminality in the western region of the Swedish Prison and Probation Service underwent a thorough clinical examination during their incarceration. Data on character maturity, as measured by the character dimensions Self-Directedness and Cooperativeness of the Temperament and Character Inventory, were available for n = 148 subjects and were used to divide these offenders into three groups with low, medium, and high character maturity. These groups were then compared for variables reflecting criminal history, a DSM-IV diagnosis of ADHD, conduct disorder (CD) and substance use disorders (SUD), aggressive behaviors, and psychopathic traits. Character maturity was consistently associated with less AABs and psychopathic personality traits; the group with the highest character maturity showed: (i) a later age at onset of criminality, (ii) a smaller number of prior violent criminal acts, (iii) lower prevalence of ADHD, CD, and SUD, (iv) less self-rated and expert-rated aggressive behaviors, and (v) less psychopathic traits. The association between character maturity and aggressive behaviors/psychopathic personality traits remained even when ADHD was controlled for. The only exception was sexual criminality, where the group with the highest character maturity contained the largest amount of sexual offenders. Higher character maturity appeared to be a protective factor among young male violent offenders, associated with less AABs, suggesting that character maturity is a promising target for treatment interventions for this group of individuals.

Effectiveness of the IDAP Treatment Program for Male Perpetrators of Intimate Partner Violence: A Controlled Study of Criminal Recidivism.

Despite substantial problems with intimate partner violence (IPV) worldwide, the empirical support remains weak for the effectiveness of recidivism-reducing interventions for IPV perpetrators. We conducted a controlled study of the effectiveness of the Integrated Domestic Abuse Program (IDAP), a manual-based group intervention for adult male IPV offenders. A consecutive series of 340 convicted male IPV offenders who began IDAP in the Swedish Prison and Probation Services 2004 to 2007 were compared with 452 contemporary, convicted male IPV offender controls. We obtained follow-up reconviction data from the National Crime Register and used Cox regression to model the effectiveness of IDAP versus regular treatment. Treated and control subjects were all followed until March 2, 2011, for an average time-at-risk of 4.6 years (median 4.4, SD = 1.0). Twenty-five percent ( n = 84) of IDAP participants recidivated in any violence versus 23% of controls ( n = 104); corresponding figures for IPV specifically were 19% ( n = 65) and 19% ( n = 84), respectively. Intention-to-treat analyses adjusted for individual baseline risk and follow-up time suggested marginally and non-significantly lower reconviction rates in IDAP participants versus controls (hazard ratio [HR] = 0.92, 95% confidence interval [CI] = [0.69, 1.23] for any violence and HR = 0.92, 95% CI = [0.66, 1.28] for IPV, respectively). Hence, possible recidivism-reducing effects of IDAP in this cross-cultural validation were small and impossible to secure statistically. To remedy the frustrating lack of proven effective treatments for IPV offenders, better interventions should be developed and tested. Such efforts could benefit from improved knowledge about IPV-specific, causal risk factors and more powerful treatment combinations.

Imprisonment and co-offending: results from a 10-year follow-up study

A recurring question in criminological research is whether prisoners meet new accomplices in prison. This article’s objective is to study co-offending among individuals who have served prison sentences. The frequency of co-offending among individuals who have been in the same prison at the same time will be examined. If gender, age, type of prison, offence type and prior experience of co-offending are significant for this type of co-offending will also be examined. The study population comprised all inmates released from a Swedish prison during a half year in 2001–2002 (n = 3.930). The follow-up period is 10 years. The results show that only 3% of those who have been in the same prison at the same time are suspected of committing offences together subsequent to release. The likelihood of being suspected of committing an offence together following the conclusion of a joint stay in the same prison is higher for those released from a closed prison who are aged 31–40, and who had committed large proportion of their offences together with others prior to the relevant prison sentence. The results suggest that the concept of criminal capital is not important for future co-offending after a joint stay in prison.

Prediction of violent reoffending on release from prison: derivation and external validation of a scalable tool

More than 30 million people are released from prison worldwide every year, who include a group at high risk of perpetrating interpersonal violence. Because there is considerable inconsistency and inefficiency in identifying those who would benefit from interventions to reduce this risk, we developed and validated a clinical prediction rule to determine the risk of violent offending in released prisoners. We did a cohort study of a population of released prisoners in Sweden. Through linkage of population-based registers, we developed predictive models for violent reoffending for the cohort. First, we developed a derivation model to determine the strength of prespecified, routinely obtained criminal history, sociodemographic, and clinical risk factors using multivariable Cox proportional hazard regression, and then tested them in an external validation. We measured discrimination and calibration for prediction of our primary outcome of violent reoffending at 1 and 2 years using cutoffs of 10% for 1-year risk and 20% for 2-year risk. We identified a cohort of 47 326 prisoners released in Sweden between 2001 and 2009, with 11 263 incidents of violent reoffending during this period. We developed a 14-item derivation model to predict violent reoffending and tested it in an external validation (assigning 37 100 individuals to the derivation sample and 10 226 to the validation sample). The model showed good measures of discrimination (Harrell's c-index 0·74) and calibration. For risk of violent reoffending at 1 year, sensitivity was 76% (95% CI 73-79) and specificity was 61% (95% CI 60-62). Positive and negative predictive values were 21% (95% CI 19-22) and 95% (95% CI 94-96), respectively. At 2 years, sensitivity was 67% (95% CI 64-69) and specificity was 70% (95% CI 69-72). Positive and negative predictive values were 37% (95% CI 35-39) and 89% (95% CI 88-90), respectively. Of individuals with a predicted risk of violent reoffending of 50% or more, 88% had drug and alcohol use disorders. We used the model to generate a simple, web-based, risk calculator (OxRec) that is free to use. We have developed a prediction model in a Swedish prison population that can assist with decision making on release by identifying those who are at low risk of future violent offending, and those at high risk of violent reoffending who might benefit from drug and alcohol treatment. Further assessments in other populations and countries are needed. Wellcome Trust, the Swedish Research Council, and the Swedish Research Council for Health, Working Life and Welfare.

Long-Term Treatment Outcome in Adult Male Prisoners With Attention-Deficit/Hyperactivity Disorder: Three-Year Naturalistic Follow-Up of a 52-Week Methylphenidate Trial.

Despite high rates of attention-deficit/hyperactivity disorder (ADHD) among adult lawbreakers, particularly the long-term effects of ADHD pharmacotherapy remain unclear, not the least because of ethical challenges with preventing control subjects in randomized controlled trials from receiving medication over prolonged time. We followed up adult male prisoners with ADHD who completed a 5-week randomized, double-blind, placebo-controlled trial followed by a 47-week open-label extension of osmotic-release oral system methylphenidate in a Swedish high-security prison from 2007 to 2010 (ClinicalTrials.gov: NCT00482313). Twenty-five trial completers were prospectively followed up clinically 1 year (24/25, 96% participated fully or in part) and 3 years (20/25, 80% participation) after trial regarding ADHD symptoms (observer and self-reports), psychosocial functioning, substance misuse, and criminal reoffending. Methylphenidate-related improvements in ADHD symptoms and psychosocial functioning obtained during the 52-week trial were maintained at 1- and 3-year follow-ups. Specifically, after 3 years, 75% (15/20) of the respondents had been released from prison, and 67% of these (10/15) had employment, usually full time. In contrast, nonmedicated respondents at the 3-year follow-up (5/20) reported more ADHD symptoms, functional impairment, and substance misuse compared with currently medicated respondents (15/20). Further, 40% of the respondents self-reported reoffending, indicating a substantially lower relapse rate than expected (70%-80%).In summary, although these observations need validation from new and larger samples, positive effects were maintained after 4 years of methylphenidate treatment. Most study completers were employed and had no relapse in substance misuse or criminality. These results suggest that motivational support and continued medication are important for improved outcome in adult criminal offenders with ADHD.

Commentary on Lundholm et al. (2015): What came first, the steroids or the violence?

Commentary on Lundholm et al. (2015): What came first, the steroids or the violence?

Antipsychotics, mood stabilisers, and risk of violent crime

SummaryBackgroundAntipsychotics and mood stabilisers are prescribed widely to patients with psychiatric disorders worldwide. Despite clear evidence for their efficacy in relapse prevention and symptom relief, their effect on some adverse outcomes, including the perpetration of violent crime, is unclear. We aimed to establish the effect of antipsychotics and mood stabilisers on the rate of violent crime committed by patients with psychiatric disorders in Sweden.MethodsWe used linked Swedish national registers to study 82 647 patients who were prescribed antipsychotics or mood stabilisers, their psychiatric diagnoses, and subsequent criminal convictions in 2006–09. We did within-individual analyses to compare the rate of violent criminality during the time that patients were prescribed these medications versus the rate for the same patients while they were not receiving the drugs to adjust for all confounders that remained constant within each participant during follow-up. The primary outcome was the occurrence of violent crime, according to Sweden's national crime register.FindingsIn 2006–09, 40 937 men in Sweden were prescribed antipsychotics or mood stabilisers, of whom 2657 (6·5%) were convicted of a violent crime during the study period. In the same period, 41 710 women were prescribed these drugs, of whom 604 (1·4 %) had convictions for violent crime. Compared with periods when participants were not on medication, violent crime fell by 45% in patients receiving antipsychotics (hazard ratio [HR] 0·55, 95% CI 0·47–0·64) and by 24% in patients prescribed mood stabilisers (0·76, 0·62–0·93). However, we identified potentially important differences by diagnosis—mood stabilisers were associated with a reduced rate of violent crime only in patients with bipolar disorder. The rate of violence reduction for antipsychotics remained between 22% and 29% in sensitivity analyses that used different outcomes (any crime, drug-related crime, less severe crime, and violent arrest), and was stronger in patients who were prescribed higher drug doses than in those prescribed low doses. Notable reductions in violent crime were also recorded for depot medication (HR adjusted for concomitant oral medications 0·60, 95% CI 0·39–0·92).InterpretationIn addition to relapse prevention and psychiatric symptom relief, the benefits of antipsychotics and mood stabilisers might also include reductions in the rates of violent crime. The potential effects of these drugs on violence and crime should be taken into account when treatment options for patients with psychiatric disorders are being considered.FundingThe Wellcome Trust, the Swedish Prison and Probation Service, the Swedish Research Council, and the Swedish Research Council for Health, Working Life and Welfare.

Exhaled breath for drugs of abuse testing — Evaluation in criminal justice settings

Exhaled breath is being developed as a possible specimen for drug testing based on the collection of aerosol particles originating from the lung fluid. The present study was aimed to evaluate the applicability of exhaled breath for drugs of abuse testing in criminal justice settings. Particles in exhaled breath were collected with a new device in parallel with routine urine testing in two Swedish prisons, comprising both genders. Urine screening was performed according to established routines either by dipstick or by immunochemical methods at the Forensic Chemistry Laboratory and confirmations were with mass spectrometry methods. A total of 247 parallel samples were studied. Analysis of exhaled breath samples was done with a sensitive mass spectrometric method and identifications were made according to forensic standards. In addition tested subjects and personnel were asked to fill in a questionnaire concerning their views about drug testing. In 212 cases both the urine and breath testing were negative, and in 22 cases both urine and breath were positive. Out of 6 cases where breath was negative and urine positive 4 concerned THC. Out of 7 cases where, breath was positive and urine negative 6 concerned amphetamine. Detected substances in breath comprised: amphetamine, methamphetamine, THC, methylphenidate, buprenorphine, 6-acetylmorphine, cocaine, benzoylecgonine, diazepam and tramadol. Both the prison inmates and staff members reported breath testing to be preferable due to practical considerations. The results of this study documented that drug testing using exhaled breath provided as many positives as urine testing despite an expected shorter detection window, and that the breath sampling procedure was well accepted and provided practical benefits reported both by the prison inmates and testing personnel.

Mental Illness Linked to Premature Death in Epilepsy Patients

Mental Illness Linked to Premature Death in Epilepsy Patients

Premature mortality in epilepsy and the role of psychiatric comorbidity: a total population study

SummaryBackgroundEpilepsy is associated with high rates of premature mortality, but the contribution of psychiatric comorbidity is uncertain. We assessed the prevalence and risks of premature mortality from external causes such as suicide, accidents, and assaults in people with epilepsy with and without psychiatric comorbidity.MethodsWe studied all individuals born in Sweden between 1954 and 2009 with inpatient and outpatient diagnoses of epilepsy (n=69 995) for risks and causes of premature mortality. Patients were compared with age-matched and sex-matched general population controls (n=660 869) and unaffected siblings (n=81 396). Sensitivity analyses were done to investigate whether these odds differed by sex, age, seizure types, comorbid psychiatric diagnosis, and different time periods after epilepsy diagnosis.Results6155 (8.8%) people with epilepsy died during follow-up, at a median age of 34·5 (IQR 21·0–44·0) years with substantially elevated odds of premature mortality (adjusted odds ratio [aOR] of 11·1 [95% CI 10·6–11·6] compared with general population controls, and 11·4 [10·4–12·5] compared with unaffected siblings). Of those deaths, 15·8% (n=972) were from external causes, with high odds for non-vehicle accidents (aOR 5·5, 95 % CI 4·7–6·5) and suicide (3·7, 3·3–4·2). Of those who died from external causes, 75·2% had comorbid psychiatric disorders, with strong associations in individuals with co-occurring depression (13·0, 10·3–16·6) and substance misuse (22·4, 18·3–27·3), compared with patients with no epilepsy and no psychiatric comorbidity.InterpretationReducing premature mortality from external causes of death should be a priority in epilepsy management. Psychiatric comorbidity plays an important part in the premature mortality seen in epilepsy. The ability of health services and public health measures to prevent such deaths requires review.FundingWellcome Trust, the Swedish Prison and Probation Service, and the Swedish Research Council.

The Practise of Pastoral Power : The Swedish Prison Chaplains in the 19th Century

This article analyses the images of the criminal that Swedish prison chaplains developed during the 19th century. Following Michel Foucault, such images and relations are conceptualized as pastoral power. In the 19th century prison chaplains occupied a very important position within prisons, due partly to their status as clergymen, but also to their increasing influence on debates about crime and punishment. This article argues that in many respects prison chaplains came to develop a more sophisticated understanding of the criminal and the complexities of criminality, compared to many early psychiatrists and criminal anthropologists. This understanding was primarily the result of knowledge-gathering which took place within the penitentiaries. In the mid-nineteenth century prison chaplains generally depicted crime as morally determined and as caused by the lack of knowledge and insights into the truths of Christianity. However, during the last quarter of the century, references to social and structural factors were increasingly included in broader and more heterogeneous explanations for crime. However, if non-moral factors played such a central role as the prison chaplains gradually came to assign to them, then their own authority as experts on crime as well as the status of religion within the prison system was undermined.

The Psychopathy Checklist-Revised (PCL-R), low anxiety, and fearlessness: A structural equation modeling analysis.

The current study employed a large representative sample of violent male offenders within the Swedish prison system to examine the factor structure of the PCL-R and the latent variable relations between the PCL-R items and clinical ratings of low trait anxiety and trait fearlessness (LAF). Consistent with previous research, confirmatory factor analysis (CFA) revealed strong support for the four-factor model of psychopathy (Interpersonal, Affective, Lifestyle, and Antisocial). Also, a series of CFAs revealed that the LAF items could be placed on any of the PCL-R factors without any changes in model fit. Finally, structural equation modeling results indicated that a PCL-R superordinate factor was able to account for most of the variance of a separate LAF factor. Taken together, the results indicate that if low anxiety and fearlessness, as measured via clinical ratings, are part of the psychopathy construct they are comprehensively accounted for by extant PCL-R items.

From Learning to Labour to Learning to Self-Control: The Paradigmatic Change in Swedish Prison Policy

This article has been written from the position that we fail to understand the character of the changes in prison policy in the last decades if we concentrate too much on the new emphasis on control and security. By making use of Thomas Kuhn's paradigm model, the article argues that it is fertile to see the changes in Swedish prison policy during the last decades as a paradigm shift. Although the new emphasis on control and security is important, it is only one feature in a larger transformation which concerns changing perceptions of the criminal subject, new theoretical understandings, new treatment methods, as well as a new role for the prison in penal policy in general. The article conceptualizes the policy that has developed inside the Swedish Prison and Probation Service during the last decades as the developing of a new paradigm in contrast to the old prison policy paradigm of the welfare state. The article especially discusses the significance of the development of so-called evidence-based knowledge as well as the creation of a Scientific Council inside the Swedish Prison and Probation Service which have led to a re-pathologization of the criminal subject. Other features that make up the new paradigm are the numerous programmes built on cognitive therapy and the emphasis on individual risk assessments. On a general level, the new paradigm has developed during, and is congruent with, the dominance of a neo-liberal regime.

1465 – Osmotic-release oral system methylphenidate (oros-mph) treatment of adult prison inmates with adhd: a randomised controlled trial with open-label extension

Introduction ADHD is associated with pervasive cognitive, emotional and functional impairments and increased rates of coexisting disorders. Epidemiological studies indicate 25-45% of prison inmates to have ADHD. However, ADHD is often unrecognised in prison inmates and stimulant treatment was not previously evaluated in this group. Objectives Provide effective treatment for prison inmates established with ADHD. Aims Evaluate efficacy and long-term effectiveness of osmotic-release oral system methylphenidate (OROS-MPH) in adult male long-term prison inmates with ADHD. Methods A 5-week randomised, double-blind, placebo-controlled, fixed-dose (72 mg/d) trial was conducted in 30 prison inmates with ADHD and coexisting disorders. In a following 47-week open-label extension (OLE), flexible-dosing OROS-MPH was provided alongside psychosocial interventions within a high-security Swedish prison. Primary outcome was change in ADHD symptoms after 5 weeks (CAARS: O-SV). Secondary outcomes included self-reported ADHD symptoms, global severity, global functioning, cognition, motor activity, institutional behaviour and quality of life. Results OROS-MPH was highly effective and overall safe, both in the short-term relative to placebo (Cohen’s d=2.17; NNT=1.1), and in the long-term when provided alongside psychosocial interventions. Treatment continued to improve ADHD symptoms, global functioning, motor activity, cognition, quality of life, and behaviour control over the 47-week OLE. No drug misuse was reported and a majority of participants completed rehabilitation programs. Conclusions OROS-MPH effectively improved symptoms and functional impairments of ADHD in prison inmates with ADHD. We suggest that OROS-MPH provided alongside rehabilitation programs could be a feasible and effective multimodal intervention for adults with ADHD and coexisting disorders within a prison setting

Effects of Drug Treatment Units in Swedish Prisons

This article presents the findings from an evaluation of the care provided at treatment units for drug abusers in Swedish prisons. A total of 741 inmates who were placed in prison treatment units in 2006 are compared with individuals with whom they were matched on the basis of their statistical risk for reoffending, and who served prison terms during the years 2001–2002. Half of the inmates in the treatment group were placed in units working with a 12-step programme, while the remainder were placed in treatment units employing cognitive programmes. The study shows positive results with respect to reoffending. The greatest differences were found in the following subgroups: males, inmates who were at least 30 years of age, those who completed their stay in a treatment unit, and those who had spent at least 4.5 months in a treatment unit.

Drug treatment in Swedish prisons – moving towards evidence-based interventions?

Aim This article reviews the development in Sweden of prison-based drug treatment (PBDT) from the 1970s to the present situation. Data The data consists of committee reports, white papers, research reports and interviews with two senior managers from the Swedish Prison and Probation Services (SPPS). Results The 1970s and 1980s trials with milieu therapy in prisons were followed by the introduction of cognitive programmes in the 1990s. Due to the growing number of prisoners with drug problems, the Prison Anti-Drug Effort increased the number of places and programmes for drug treatment in prisons. As of 2000, the scientific evaluation of all prison-based drug treatment has been strongly emphasised. Drug control has increased since 2004, and the very concept of PBDT is now approached rather more rigorously and scientifically. Conclusion The SPPS programme evaluations are scientifically formed, but changes in practice are slow to emerge. The SPPS runs a more restricted policy compared to treatment outside, which leads to some evidence-based treatment methods being rejected. Also, PBDT is somewhat under threat by changes in the prisons’ internal organisation with growing specialisation in different wings, as well as by the poor financial situation of the SPPS.

Signs of Resistance? Swedish Probation Officers' Attitudes towards Risk Assessments

The Swedish Prison and Probation Service has been influenced by the ‘What Works’ agenda since the late 1990's and an orientation towards risk and risk management has gradually become visible in the organization. But there is, within the probation service, a discrepancy between two types of logics — an organizational logic and a professional logic. Although guidelines prescribe the use of risk-assessment tools, they are in reality seldom used by practitioners. Through an examination of the reasons given by the probation officers who expressed doubts or concerns about the risk-concept, we question whether this could be seen as signs of resistance based on professional logic.

Emotional labour and emotional strain among Swedish prison officers

This article explores emotional labour strategies among Swedish prison officers, and shows how these affect their well-being. Case studies of five Swedish prisons and a national survey of prison officers are used. Analysis indicates that prison officers perform complex forms of emotional labour. Owing to differences in subcultures and informal norms, the strategies officers use in managing their displays of emotion vary between wings and roles. Different strategies may cause different kinds of emotional strain. So-called ‘surface acting’ may lead to cynicism and alienation, whereas ‘deep acting’ may lead to stress and exhaustion. Finally, the lack of opportunities for recovery is discussed.

Co-Offending Among Prison Inmates

The objective is to study the nature of co-offending among individuals who have previously spent time together in prison. Are new contacts established during a prison term that then result in co-offending subsequent to release? This question is examined on the basis of register data relating to all individuals released from Swedish prisons during a 6-month period ( n = 3,930). The data show that 2% of the group were suspected of co-offending subsequent to having spent time together in prison. The findings are discussed on the basis of theoretical perspectives focusing on trust, contacts with other offenders, the size of the criminal networks involved, and criminal capital.

Educational services in Swedish prisons: successful programs of academic and vocational teaching

This article examines Swedish prison academic and vocational programs. The article synthesizes various case studies reported concerning Sweden’s prisons and describes the use of successful practices. Data from a previous study conducted in Swedish prisons are presented to show the need for education for offenders and its benefits. A key concept of successful prison management, the Normalization Principle is discussed. In addition, the Prison Treatment Act, established by Sweden in 1994, shows the need for prisoners to be provided with suitable work. This information aids in establishing positive foundations for offender’s lives leading to successful re-integration back into society.