Improving forensic tribunal decisions: the role of the clinician

The influence of changes in clinical factors on high-security forensic custody dispositions

The demand for forensic psychiatric beds is increasing, while many individuals are "stuck" in the system. Index offense severity and other legal considerations are associated with longer forensic stays but factors amenable to change such as symptoms of mental illness and aggression may also influence forensic decisions. We examined forensic review board decisions over time among 89 men admitted to a high-security forensic hospital. Almost half received a disposition to remain at their first hearing. Overall, dispositions were not associated with violence risk. The odds of a disposition to remain were higher for men with more in-hospital assaults and higher scores on a measure of clinical factors. Dispositions changed over time and this change was sensitive to clinical factors. We conclude that decisions were consistent with a cascading system of loosening security over time. Further longitudinal research following large samples through the forensic system is recommended.

Structured versus unstructured judgment: DUNDRUM-1 compared to court decisions

BACKGROUND

Criteria to determine in which level of security forensic patients should receive treatment are currently non-existent in Belgium. Courts largely rely on the evaluations of the prison psychiatrists and psychologists to form their decision. None of the few available instruments - e.g., the DUNDRUM-1 - is currently used to provide structured clinical judgment when determining security level.

METHOD

DUNDRUM-1 scores were collected for 150 forensic patients. Security levels according to DUNDRUM-1 assessment were compared to security levels as decided by the court.

RESULTS

There was little agreement between DUNDRUM-1 scores and proposals for secure care made by the court. The DUNDRUM-1 predicted eventual admission to a high security setting, but not a medium security setting.

CONCLUSION

The DUNDRUM-1 is an instrument that can help clinicians and judges to make more reliable and transparent decisions regarding secure care. However, further research with regard to practical applicability is needed.

Predictors of Mental Health Review Tribunal (MHRT) outcome in a forensic inpatient population: a prospective cohort study

BACKGROUND

Previous studies have investigated factors associated with outcome at Mental Health Review Tribunals (MHRTs) in forensic psychiatric patients; however, dynamic variables such as treatment compliance and substance misuse have scarcely been examined, particularly in UK samples. We aimed to determine whether dynamic factors related to behaviour, cooperation with treatment, and activities on the ward were prospectively associated with outcome at MHRT.

METHODS

At baseline, demographic, clinical, behavioural, and treatment-related factors were ascertained via electronic medical records and census forms completed by the patient's clinical team. Data on MHRTs (i.e., number attended, responsible clinician's recommendation, and outcome) were collected at a 2-year follow-up. Logistic regression analyses were performed to determine factors associated with outcome among those who attended a MHRT within the follow-up period. Of the 135 forensic inpatients examined at baseline, 79 patients (59%) attended a MHRT during the 2-year follow-up period and therefore comprised the study sample. Of these 79 patients included in the current study, 28 (35%) were subsequently discharged.

RESULTS

In univariable analyses, unescorted community leave, responsible clinician's recommendation of discharge, and restricted Mental Health Act section were associated with a greater likelihood of discharge at MHRT; whilst inpatient aggression, a recent episode of acute illness, higher total score on the Historical Clinical Risk - 20 (HCR-20), higher HCR-20 clinical and risk scores, and agitated behaviour were negatively associated with discharge (p < 0.05). In multivariable analyses, HCR-20 clinical scale scores and physical violence independently predicted outcome at tribunal after controlling for other dynamic variables.

CONCLUSION

By identifying dynamic factors associated with discharge at tribunal, the results have important implications for forensic psychiatric patients and their clinical teams. Our findings suggest that by reducing levels of agitated behaviour, verbal aggression, and physical violence on the ward, achieving unescorted community leave, and targeting specific items on the HCR-20 risk assessment tool, patients may be able to improve their changes of discharge at a MHRT.

Preventative detention decisions: reliance on expert assessments and evidence of partisan allegiance within the Canadian context

The purpose of this study was to examine judges' written reasons for sentencing in preventative detention hearings and the expert risk assessment reports presented, to determine the level of reliance placed on expert risk assessment reports and to examine the presence of partisan allegiance within the Canadian context. Results demonstrated that judges' decisions were consistent with expert assessments in terms of risk, treatment amenability, and risk management. Experts' ratings of treatment amenability and risk management were also significant predictors of the designation outcome, indicating that judges rely on this information in making their final decision. Finally, there was evidence of partisan allegiance, with prosecution-retained Psychopathy Checklist-Revised scores being significantly higher than defense-retained experts' scores. The results have implications for the development of consistent guidelines for the communication of risk, treatment amenability, and management information.

Communicating the risk of violent and offending behavior: review and introduction to this special issue

How to communicate risk of recidivism in correctional and forensic contexts has been a subject of scholarly discussion for two decades. This emerging literature, however, is sparse compared with studies on the assessment of risk for violent and offending behavior. In this special issue of Behavioral Sciences and the Law, we have gathered together empirical and review papers exemplifying promising directions and methodologies. We begin with a review of the state of the field, and lessons that can be drawn from research into medical risk assessment and risk communication, finding that many of the same principles apply to the forensic context. How risks are framed, and how numerate assessors are, affects how risk information is understood and applied. We discuss the existing research bearing on these issues, as well as the conceptual, practical, empirical, and legal implications of communicating risk using numerical or categorical risk terms. Along with the seven articles in this volume, we suggest directions for future research on measuring and communicating change, understanding and managing the statistical literacy of those who use and communicate risk assessments, and developing a theoretical framework for forensic risk communication research. We hope this volume will help integrate and invigorate research into forensic risk communication.

Factors associated with recommitment of NGRI acquittees to a forensic hospital

The current archival study assesses risk factors associated with recommitment of 142 individuals adjudicated Not Guilty by Reason of Insanity (NGRI) from civil settings to a forensic hospital in New York State. Within 10 years of transfer from a forensic hospital, 40 (28.2%) were recommitted. Using survival analyses to account for the wide range in opportunity for recommitment, period of transfer (i.e., pre versus post the 1995 case of George L, which clarified factors related to assessments of dangerousness) and the Historical scale and specific items of the HCR-20 emerged as important risk factors for recommitment. Specifically, hazard of recommitment was 2.9 times higher for those with high Historical scores as compared to those with low scores. However, few individual risk factors were associated with recommitment. Prior supervision failure, negative attitude, problems with substance use, and absent or less serious major mental illness and relationship problems were informative in predicting recommitment over 10 and 3 year follow-up periods.

Dynamic and static factors associated with discharge dispositions: the national trajectory project of individuals found not criminally responsible on account of mental disorder (NCRMD) in Canada

The majority of individuals found not criminally responsible on account of mental disorder (NCRMD) in Canada spend some time in hospital before they are conditionally or absolutely (no conditions) discharged to the community by a legally mandated review board. By law, the decision to conditionally discharge an individual found NCRMD should be guided by the need to protect the public, the mental condition of the accused, and the other needs of the accused, especially regarding his/her community reintegration. At the time of this study, Canadian legislation and case law required that the review board disposition should be the "least onerous and least restrictive" possible for the accused. This means that, if there is no evidence that the person poses a significant risk to public safety, he/she must be released. However, the Canadian Criminal Code does not specify the criteria that must be considered when making this risk assessment. This leads to two questions. (1) What predicts review board dispositions? (2) To what extent do disposition determinations reflect evidence-based practices? The present study examined dynamic and static predictors of detention in custody, conditional discharge (CD), and absolute discharge (AD) dispositions among persons found NCRMD across the three largest provinces in Canada. The National Trajectory Project (NTP) examined men and women found NCRMD in British Columbia (BC), Québec (QC), and Ontario (ON) between May 2000 and April 2005, followed until December 2008. For the purposes of this study, individuals who had at least one hearing with a review board were extracted from the NTP dataset (N = 1794: QC = 1089, ON = 483, BC = 222). Over the course of the study, 6743 review board hearings were examined (QC = 3505, ON = 2185, BC = 1053). Despite advances in the risk assessment field, presentation of a comprehensive structured risk assessment to the review board was not the norm. Yet our findings suggest that review boards were taking into account a combination of empirically validated static and dynamic risk factors, as represented by the items of the HCR-20 risk assessment scheme. Particular attention was being paid to the behavior of the patient between hearings (e.g., violent acts, compliance with conditions). Severity of index offense was associated with review board decisions; though index severity is not related to recidivism, it is an important consideration in terms of public perceptions of the justice system and can be related to better established risk factors (i.e., criminal history and prior violence). Historical factors had more influence on the decision to detain someone, while clinical factors were more influential on an AD decision. Disposition stability was the most common trajectory, meaning that a patient with a prior CD disposition was most likely to receive another CD disposition at the next hearing. Static and dynamic risk factors found in the HCR-20 influenced review board determinations, although presentation of a complete structured risk assessment is the exception, not the norm. Results suggest that clinicians recommending less restrictive dispositions are more likely to include a comprehensive risk assessment with their recommendation. An alternative explanation is that, when there is no comprehensive assessment of risk, the review board tends to be more cautious and apply more restrictive dispositions. The practice seems to be contrary to the legislation at the time of the study, given that there should be a presumption that the patient is not a significant threat.

Evaluator agreement in placement recommendations for insanity acquittees

Research has examined differences between psychologists and psychiatrists in opinions on trial competency and criminal responsibility, but there is little research on such differences in risk assessment. This study examined the impact of disciplinary affiliation on opinions regarding whether new insanity acquittees should be hospitalized or released, and the risk factors given the most weight by each discipline. There was no significant difference between disciplines in the frequency of recommendations for hospitalization versus release. However, the concordance rate at the individual case level was only moderate when controlling for chance, which raises questions about the reliability and validity of forensic risk assessments in real-world settings. A number of variables emerged as significant in the decision-making of each discipline, with some differences noted.

Risk assessment instruments in clinical practice

OBJECTIVE

To determine whether the items in one of the most widely validated instruments of violence risk assessment, the Historical-Clinical-Risk Management-20 (HCR-20), are used in review board hearings to assess the risk of violence by people found Not Criminally Responsible on account of Mental Disorder (NCRMD).

METHOD

This study was conducted from October 2004 to August 2006 in Quebec's sole forensic psychiatric hospital and 2 large civil psychiatric hospitals designated for the care of people declared NCRMD in the Montreal metropolitan area. The risk assessments presented by clinicians at annual review board hearings and the boards' rationale for the release or detention of people found NCRMD were contrasted with the risk assessments conducted by the research team using the HCR-20. The final sample was comprised of 96 men.

RESULTS

Very few of the risk factors identified by prior research (HCR-20 items) were mentioned in the hearing process, whether in clinical reports, discussions during the hearing, or in the disposition justification.

CONCLUSIONS

The findings confirm that there remains a significant gap between research evidence and risk assessment practice.

To detain or to release? Correlates of dispositions for individuals declared not criminally responsible on account of mental disorder

OBJECTIVE

The extent to which risk assessment advances have influenced release decision-making by review boards (RBs) of individuals found not criminally responsible on account of mental disorder (NCRMD) remains unclear. Our objective is to identify the psychosocial, criminological, and risk measure correlates of RB decision-making.

METHOD

Data were collected through structured interviews and file reviews conducted between October 2004 and August 2006 in the sole forensic psychiatric hospital in Quebec and in 2 civil psychiatric hospitals in a large metropolitan area designated to care for people found NCRMD. The final sample consisted of 96 men.

RESULTS

Dynamic, clinical risk factors are associated with decisions to detain or release people found NCRMD, rather than traditional historical risk factors such as criminal history.

CONCLUSION

Dynamic variables seem appropriate for the RBs to consider given the intention of the NCRMD legislation. Further, dynamic variables provide direction for titration of treatment and supervision. Results are discussed regarding enhancing evidence-informed RB dispositions.

Education in forensic psychiatry

PURPOSE OF REVIEW

The present review focuses on the education needs and related pedagogical aspects of education in forensic psychiatry.

RECENT FINDINGS

Physicians specializing in other fields generally deal with concepts that are thoroughly addressed in forensic psychiatry, such as the ability of patients to consent to treatment, confidentiality, victimization, and risk factors for auto and hetero-lesive behaviour. Present practices like the advance of e-health and patients' rights call for ethical and responsible attitudes. There are a variety of programs providing specific training for psychiatrists willing to work in the forensic area and renewed pedagogical trends are gradually being incorporated. Many articles point out the need to enforce the teaching of expert communication abilities while others warn of the poor economic incentive of forensic psychiatry as a career.

SUMMARY

Forensic psychiatry teaching is undergoing a period of significant evolution and expansion. New didactic trends, specific pedagogical research and an increase in training needs in other fields of medicine are promising. It is important to ensure that the formal training provided in every country is comparable and that those who teach and learn this complex field are acknowledged.