Critical incidents and judicial response during medium security treatment

Longitudinal Change of Risk Factors During Treatment in High-Security Forensic Psychiatry in Flanders

Empirical studies on the longitudinal change of risk factors during treatment of forensic psychiatric patients are scarce. Therefore, in the current study, changes in risk factors of 341 high-security forensic psychiatric patients in Flanders were investigated using latent growth curve analyses. Annual assessments of the Historical Clinical Future-Revised (HKT-R) at three time points were considered, starting at time of admission. A significant small improvement was found on the future scale and most future factors. However, the clinical scale did not change significantly and only one of the 14 clinical factors (i.e., problem insight) changed significantly over time. Although the forensic treatment seems to be a slow process, the sensitivity of the HKT-R to detect clinically relevant change is questioned, underscoring the importance of determining whether there are instruments capable of detecting small significant changes over time.

Hospital break. An eight-year review of escapes and absconds from two high security forensic centers

BACKGROUND

Increasing freedom of movement and community reintegration is a vital part of recovery for forensic service users. Clinical teams realize that risk of unauthorized leave exists when granting leave, tasking them with balancing the recovery-based treatment needs of the patients with the larger obligation to protect the public from undue risk of harm. While considerable literature exists on unauthorized leave from acute psychiatric units, there is still little research specific to unauthorized leave from forensic settings.

AIMS

The aim of this study is twofold. First, to examine the prevalence rates and characteristics of unauthorized leaves (i.e., absconds and escapes) among 654 high security forensic patients. Second, to identify individual patient factors associated with unauthorized leaves. A broad array of risk factors is taken into account, including demographic, clinical, judicial and criminal factors.

PRINCIPAL RESULTS

During the 8-year period (17th of November 2014 until 17th of November 2022), there were 59 unauthorized leaves, which represents a very low percentage (0.2%) relative to the total number of leaves. Most patients returned to the hospital or were caught within one week. The reasons that led to an unauthorized leave were in more than half of the incidents frustration and in more than a third goal-directed. Only a minority of the unauthorized leaves was associated with subsequent offending, notwithstanding substance use was more frequent. Patients that absconded or escaped more often had a personality and comorbid substance misuse disorder, but less often a paraphilic disorder. They were younger, had more convictions and higher risk scores. After logistic regression, only personality disorder, comorbid substance misuse disorder and number of convictions were independently associated with unauthorized leave.

CONCLUSIONS

The results of this study indicate that ULs occurred rarely, and in most instances, patients returned within a short period without further incidents. Personality disordered patients with comorbid substance misuse and prior convictions posed the greatest risk to abscond or escape. Overall, the rate of unauthorized leaves and subsequent offending was small relative to the total number of leaves. This suggests that the risk for absconding was assessed in an adequate manner by the clinical teams. The study hopefully adds to reducing the stigma towards leaves from forensic psychiatric hospitals.

Exploring substance use as rule-violating behaviour during inpatient treatment of offender patients with schizophrenia

BACKGROUND

Rule-violating behaviour in the form of substance misuse has been studied primarily within the context of prison settings, but not in forensic psychiatric settings.

AIMS

Our aim was to explore factors that are associated with substance misuse during hospitalisation in patients among those patients in a Swiss forensic psychiatric inpatient unit who were suffering from a disorder along the schizophrenia spectrum.

METHODS

From a database of demographic, clinical and offending data on all residents at any time between 1982 and 2016 in the forensic psychiatric hospital in Zurich, 364 cases fulfilled diagnostic criteria for schizophrenia or a schizophrenia-like illness and formed our sample. Any confirmed use of alcohol or illicit substances during admission (yes/no) was the dependent variable. Its relationship to all 507 other variables was explored by machine learning. To counteract overfitting, data were divided into training and validation set. The best model from the training set was tested on the validation set.

RESULTS

Substance use as a secure hospital inpatient was unusual (15, 14%). Prior substance use disorder accounted for so much of the variance (AUC 0.92) that it was noted but excluded from further models. In the resulting model of best fit, variables related to rule breaking, younger age overall and at onset of schizophrenia and nature of offending behaviour, substance misuse as a minor and having records of complications in prior psychiatric treatment were associated with substance misuse during hospitalisation, as was length of inpatient treatment. In the initial model the AUC was 0.92. Even after removal of substance use disorder from the final model, performance indicators were meaningful with a balanced accuracy of 67.95, an AUC of 0.735, a sensitivity of 81.48% and a specificity of 57.58%.

CONCLUSIONS

Substance misuse in secure forensic psychiatric hospitals is unusual but worthy of clinical and research consideration because of its association with other rule violations and longer hospitalisation. More knowledge is needed about effective interventions and rehabilitation for this group.

Patients are changing - The ripple effects of changing the law and creating new forensic beds in Belgium

Clinical impressions suggest that forensic patients in Belgium have more complex needs regarding care and risk in recent years than before. In this article, we analyzed psychometric data regarding patients' symptoms, risk estimates, antisocial personality traits, and functional capabilities over a 10-year span in a medium-security unit for rehabilitation of forensic patients. Data from a total of 129 patients with a main diagnosis of psychosis were analyzed. Results confirmed that patients had higher risk assessment estimates, more psychopathic/antisocial personality traits, and lower cognitive and functional capabilities. The average psychotic symptom levels and protective factors did not statistically change over the ten-year period. The changes are thought to be due to a new forensic law and the creation of new high- and medium-risk beds.

Who Are the Victims of NGRI Acquittees? A Study of Belgian Internees

BACKGROUND

The limited literature on victim characteristics of offenders found not guilty by reason of insanity (NGRI) shows that most victims are adults who are known to the offender. It is currently unclear whether victims are mainly male or female or whether there are differences in the type of victims according to the offenders' psychiatric disorder.

METHOD

Victim characteristics were retrospectively collected from 362 NGRI acquittees, and the influence of psychiatric diagnoses on victim profiles was examined.

RESULTS

Victims were mainly adult acquaintances and were equally likely to be male or female. Family members and caregivers were the most frequent type of acquaintance victims. Further analyses suggest that these victim characteristics are similar for perpetrators with different psychiatric diagnoses.

CONCLUSION

Victimization of strangers and minors was unlikely in NGRI offenders.