Clinical risk management in High-Security Forensic Psychiatry Residences. Protecting patients and health professionals: perspectives and critical issues of the Law 81/2014

Protection of Prisoners with Mental Health Disorders in Italy: Lights and Shadows after the Abolition of Judicial Psychiatric Hospitals

In Italy, a person suffering from a mental disorder who commits a crime will be given a custodial security order and serve the period of admission at a Residenza per la esecuzione delle misure di sicurezza (REMS) (Residence for the Execution of Security Measures, hereinafter "REMS"). These institutions have been established recently and though equipped with the necessary safety measures, the focus is on psychiatric therapy. Despite being present on a national scale, access is very limited in terms of capacity. Immediate remedial measures are needed, so much so that the European Court of Human Rights recently condemned Italy for this very reason. This article, through a review of the constitutive principles of these institutions, shows how they have very positive aspects such as the attention to necessary psychotherapy in order to protect the right to health and the real taking charge of the fragility of the subjects; however, it is seen how there are many negative aspects linked above all to the scarce availability of places in these structures. The article provides suggestions on a more comprehensive strategy for facilities for detainees with mental disorders.

Impact of Legal Traditions on Forensic Mental Health Treatment Worldwide

Background

Forensic psychiatry is a subspecialty dealing with the diagnosis and treatment of mentally ill offenders. However, forensic treatment standards vary. Differences arise among forensic treatment standards, due to variations in either the legal framework, the general psychiatric treatment standards, or the forensic training standards. Thus, to date there is no evidence-based pattern for how forensic services should be organized and provided.

Aims

The aim of this article is to compare forensic services in various countries in order to contribute to the current debate on international forensic treatment standards, by informing about existing differences in available policies.

Methods

This scoping review was conducted by reviewing the academic literature regarding forensic treatment around the world. Studies were identified from Pub-Med and Google-Scholar. Keywords for the search included "forensic psychiatry," "mentally ill offenders," "legal framework," "jurisdiction," and the names of geographical regions.

Results

Forensic treatment admission varies significantly around the world. There are countries that do not recognize forensic psychiatry as a subspecialty, whereas other countries apply insufficient forensic training. Most countries provide inpatient treatment for mentally ill offenders. However, service organization varies, including where the services are delivered (prisons, high-security hospitals, and general psychiatric departments). Forensic services are mainly centralized, although the need for outpatient care is emerging.

Discussion

Differences may originate mainly from variations in the legal tradition. These differences combined with the limited evidence on the effectiveness of the intervention imply the need for the optimization of forensic treatment standards on an international level. Therefore, further follow-up studies are needed.

Non-intimate Relationships and Psychopathic Interpersonal and Affective Deficits as Risk Factors for Criminal Career: A Comparison Between Sex Offenders and Other Offenders

Sex-offenders are at risk of criminal recidivism. For the treatment to be truly effective, it must be individualized. For this purpose, an accurate assessment should focus on criminological, psychological, and psychopathological features. The present study compared sex offenders with other offenders on historical experiences (i.e., problems with violence, anti-social behaviors, problems with personal relationships, problems with substance use, traumatic experiences, and parenting style). In addition, given the association between life events and psychopathy, we explored whether the relation between life events and crime type (sexual crime vs. other types of crime) might be moderated by psychopathy traits (interpersonal and affective deficits and antisocial behavior). Eighty-eight sex offenders (76% of whom child molesters) and 102 other offenders were included. The Historical, Clinical and Risk Management - 20 item Version 3 (HCR-20V3) and Psychopathy Checklist-Revised (PCL-R) were administered. The scores of the HCR-20V3 Historical scale items were computed to assess life events. The scores of the PCL-R factors, F1 Interpersonal affective deficits and F2 Antisocial behavior, were recorded. The presence of a history of problems with non-intimate relationships was the only significant risk factor for sexual crime compared with other crimes. Interpersonal and affective deficits provided an increased likelihood of being sex offenders as compared with other offenders when problems with non-intimate relationships were possibly/partially or certainly present.

DSM-5 personality trait facets amongst child molesters: an exploratory comparison with other types of offenders

Background

DSM-5 provided a dimensional model of personality disorders which may be more clinically informative for the assessment and management of prisoners than a categorical one, as diagnoses of personality disorders alone cannot explain the type of violence. The role of DSM-5 personality facets is however understudied in child molesters, and no study compared these clinical features between individuals who have committed sex crime against children and those who have committed other types of crime. The present study compared DSM-5 personality trait facets between prisoners who had committed sex crime against children, prisoners who had committed property crime (i.e., robbery, fraud) and those who had committed crime against the person (i.e., homicide, assault or violence not implying a sexual element). A further aim was to explore which facets were associated with sex crime against children as compared with the other types of crime, controlling for socio-demographics (age, gender), psychiatric comorbidity (presence of any psychiatric diagnoses) and general psychopathy traits.

Methods

One hundred sixty-seven prisoners participated (91 had committed sex crime against children, 25 property crime, and 51 committed a crime against the person) and completed the Personality Inventory for the DSM-5 and the Psychopathy Checklist-Revised.

Results

Prisoners who had committed sex crime against children reported higher Restricted Affectivity traits than those who had committed property crime and crime against the person and higher Irresponsibility traits than those who had committed property crime. The results of a multinomial logistic regression analysis showed that on the one hand being a man, having a higher age, and the presence of a psychiatric comorbidity were more likely to be related to sex crime than property crime, on the other hand higher Irresponsibility personality traits, being a man, and the presence of a psychiatric comorbidity were more likely to be related to sex crime against children than crime against the person.

Conclusions

The Irresponsibility facet might be specific to child molesters and can differentiate this group from offenders who have committed other crime types. This facet might be considered a key target of a tailored assessment and treatment planning during clinical practice with child molesters.