Enhancing Pre-Treatment Motivation Improves Forensic Mental Health Outcomes.

Despite evidence that psychological treatments benefit from pre-treatment intervention, there remains no published research on the value of including a pre-treatment intervention in forensic mental health settings. The present study aimed to address this gap by examining the effects of adding a brief motivational preparatory program (MPP) to standard forensic psychiatric care. The MPP was based on hope theory and motivational interviewing within a cognitive-behavioral therapy approach. MPP participants and a waitlist control group completed a battery of self-report measures of hope and motivation to change, which were compared with respect to risk, demographic, offence history, and outcome variables. There was a significant increase in client motivation for change after completing the MPP. Additionally, those who completed the MPP evidenced modest reductions in aggressive behavior, but significantly increased engagement in subsequent forensic treatment and programming.

Childhood Sexual Abuse by Women of Boys Who Go On to Sexually Offend: Review and Critical Analysis.

PURPOSE OF REVIEW: Sexual offending perpetrated by women has historically been overlooked and understudied, and the potentially unique impact of that abuse is even more so. RECENT FINDINGS: Women who have sexually offended against children typically do so against older boys, use little or no forms of force or coercion during the abuse, and are unlikely to be prosecuted or sentenced following the abuse. Boys whom women have sexually abused are unlikely to report or disclose the abuse that they have experienced, perhaps because social structures surrounding sexual abuse of boys by women are designed to minimize, excuse, or even encourage such sexual contact. The intersection of these unique features may help understand the role of childhood sexual abuse perpetrated by women in subsequent sexual offending among adult men. Men who have sexually offended experience high rates of childhood sexual abuse perpetrated by women. The relationship between experienced sexual abuse and subsequent perpetration of sexual abuse is neither linear nor causal; however, the characteristics associated with this form of abuse, such as non-disclosure and lack of sentencing, may contribute to adulthood sexual maladjustment and vulnerability to offending among men.

The Relationship Between and Correlates of Problematic Sexual Behavior and Major Mental Illness.

While research has consistently found that general distress and psychopathology are not predictive of sexual recidivism, examination of specific syndromes and their relationship to offending has revealed a potentially more complicated relationship. One proposed mechanism for the mixed findings with respect to major mental illness and sexual offending may be the confound of neurological injury. As identified in Mann et al. (2010) work on psychologically meaningful risk factors, mental illness represents an area in need of more study given the indirect influence it may exert on risk. To this end, the current paper summarizes the study of the relationship between neurological injury, psychosis and problematic sexual behavior among two Canadian samples of forensic and civil psychiatric patients. In the first study we observed higher than expected rates of sexually-themed psychotic symptoms (45%) and problematic sexual behavior (PSB; 40%) among a combined group of forensic and civil psychiatric patients (n = 109). Indeed 70 percent of those individuals who engaged in PSB endorsed sexually-themed psychotic symptoms. While comorbidity is common amongst this group, brain injury appeared to represent a specific liability. Compared to those who did not engage in PSB, those who did were almost 4x (OR = 3.83) more likely to have a documented history of brain injury (e.g., traumatic and acquired brain injury, including fetal alcohol syndrome). In the second study we sought to replicate this finding in a larger forensic sample of 1,240. However, the recorded rates of brain injury were significantly less, such that no relationship to PSB was observed. Based on the mixed findings to date, including our own data, questions remain about the nature of a potential shared vulnerability for psychosis and PSB previously postulated. Among psychiatrically complex individuals who engage in PSB, understanding etiology and links to risk are helpful, but perhaps more importantly is attention to the mechanisms through which symptoms confer risk (e.g., problem solving, sexual disinhibition, social/intimacy deficits) and how best to treat and manage them.

A preliminary evaluation of the effectiveness of dialectical behaviour therapy in a forensic psychiatric setting.

Dialectical behaviour therapy (DBT) is a therapy model incorporating elements of Eastern philosophies and cognitive behavioural principles. Originally designed for people struggling with chronic suicidality and borderline personality disorder (BPD), it has been adapted to treat complex, multi-diagnostic presentations, such as those in forensic mental health settings. To date, there has been little evaluation when the primary diagnosis is of psychosis. To explore the effectiveness of DBT, with patients, with multiple comorbidities, including psychosis, in a forensic psychiatric inpatient setting. A descriptive outcome study with a cohort of offender-patients in one specialist forensic mental health unit. Before and after treatment change scores were compared on anger, aggression, hopefulness, coping abilities, emotional intelligence, insight and subjective symptom severity scales, as well as staff-rated risk, and length of stay. Nine men and five women residents in one Canadian secure hospital completed a standard DBT programme, and self-ratings, over about 1 year. Scale scores indicated significantly increased insight and acknowledgment of problems. Apparently increased anger and vengeance scores were clinically associated. Independent staff ratings indicated reductions in risk and most patients achieved early release. This study provides support for extension of the use of DBT to offender-patients with psychosis among the complex mix in their presentation. It suggests that a randomised controlled trial with cost-benefit analysis is warranted, as well as further work, to promote understanding of mechanisms of effectiveness.

Implementation of risk assessment tools in psychiatric services.

Violence remains a major risk management concern in psychiatric services with implications on the safety and well-being of patients, staff, and the public. Serious physical and psychological consequences of violence involving property damage, bodily injuries, and threat to life have been reported in mental health services. Risk assessment tools are important safeguard measures; however, research on clinical implementation is presently limited. Structured professional judgment (SPJ) risk management tools that incorporate professional discretion with analytical understanding of evidence-based risk factors are widely accepted for risk assessment. However, clinical utility is suboptimal due to several barriers, including those related to the tool, the clinical setting, and resistance from health professionals. To better understand the challenges militating against optimal implementation of risk assessment tools, we reviewed and presented some lessons from the implementation of clinical practice guidelines on a general scale and our experience implementing an SPJ tool called Hamilton Anatomy of Risk Management across a variety of psychiatric services. In summary, the clinical utility of risk assessment tools improves if the tool is psychometrically sound, concise, consensus rated, time efficient, and practical for planning risk management. User feedbacks on the tool utility are also important to sustain implementation.

Assessing Paraphilic Interests Among Women Who Sexually Offend.

PURPOSE OF REVIEW: We examine the state of scientific research on the assessment of paraphilic interests among women who have committed sexual offences. RECENT FINDINGS: Research on the assessment of sexual interests in women using genital measures shows little evidence, overall, that women's genital responses are indicative of sexual interests. Some non-genital measures of sexual interest may be a valid indicator of age interests. Very few studies have focused on women who sexually offend. At this time, there is no validated measure that can be used to assess paraphilic interests among women who sexually offend. Much research is needed to determine if some measures (other than self-report) could validly assess a variety of sexual interests in women in general, and women who sexually offend in particular (e.g. interest in children, interest in sexual violence). This research is needed to determine if paraphilic interests are involved in women's motivation for sexual offending, and to determine if such interests are predictive of sexual recidivism.

Validating the Hamilton Anatomy of Risk Management-Forensic Version and the Aggressive Incidents Scale.

The Hamilton Anatomy of Risk Management-Forensic Version (HARM-FV) is a structured professional judgement tool of violence risk developed for use in forensic inpatient psychiatric settings. The HARM-FV is used with the Aggressive Incidents Scale (AIS), which provides a standardized method of recording aggressive incidents. We report the findings of the concurrent validity of the HARM-FV and the AIS with widely used measures of violence risk and aggressive acts, the Historical, Clinical, Risk Management-20, Version 3 (HCR-20V3) and a modified version of the Overt Aggression Scale. We also present findings on the predictive validity of the HARM-FV in the short term (1-month follow-up periods) for varying severities of aggressive acts. The results indicated strong support for the concurrent validity of the HARM-FV and AIS and promising support for the predictive accuracy of the tool for inpatient aggression. This article provides support for the continued clinical use of the HARM-FV within an inpatient forensic setting and highlights areas for further research.

Major Mental Illness in Those Who Sexually Abuse.

PURPOSE OF REVIEW: There is evidence showing an increasing prevalence of mental illness in those in conflict with the law. However, there are many factors affecting the detection, treatment, and management of criminals who are mentally ill. RECENT FINDINGS: Sex offenders with major mental illness present many challenges to those providing treatment and management services. For example, it is important to consider whether sexually offensive behavior is the cause of criminal behavior or whether it is reflective of an antisocial orientation. Recent evidence suggests it may help better understand and inform risk assessment and management. This paper will review the literature on mental illness among sexual offenders, present a typology to aid in the assessment, treatment, and management of sexual offender with mental illness, and highlight important considerations when providing treatment to sexual offenders with mental illness.

Incapacity of the Mind Secondary to Medication Misuse as a Not Criminally Responsible Defense.

The manifestations of disorders of the mind may play a role in the occurrence of criminal behavior. In the majority of the cases, the presence of a psychiatric disorder is cited as the reason that an individual was not fully aware of his behavior. However, other conditions, such as seizure disorders or hypoglycemia, have also been linked to an inability to understand the nature and consequences of one's actions. On occasion, these situations can be explained by a state of automatism that may be described as insane or noninsane. In this article, we describe the case of a 77-year-old man, suffering from Parkinson's disease, where the issue of criminal responsibility associated with incapacity of the mind secondary to medication misuse was raised. We elaborate on the thinking behind this opinion and the implications according to Canadian law. Although the legal outcome of this case is specific to our jurisdiction, the clinical implication may be common to any patient suffering from a similar condition and may inform physicians, families, and lawyers.

Therapist awareness and responsibility in working with sexual offenders.

The article aims to address the ethical implications of therapist reactions to sexual offender treatment and, in doing so, increase awareness and understanding of the interaction between the clinician and the challenges of working with sexual offenders. The effects of providing psychological services in general, and to sexual offenders specifically, are reviewed, including the impact on services provided. Practice implications are also discussed as the authors consider the negative effects (e.g., burnout) that therapists experience due to treatment quality and the ethical issues and responsibilities surrounding clinical reactions. Finally, the authors summarize research on self-care and practice recommendations for effectively and ethically working with sexual offenders.

A description of sexual offending committed by Canadian teachers.

The aim of this investigation was to describe teachers who sexually offend against youth and the circumstances related to these offenses. Archival Violent Crime Linkage Analysis System reports were obtained from the Royal Canadian Mounted Police, and demographic and criminal characteristics for the offender, as well as information about the victim and offense, were selected for analyses. A descriptive approach was used to analyze the qualitative reports for a group of 113 Canadian sexual offenders between 1995 and 2002. The results provide a description of adult male teachers who offended within their position of trust as well as offense and victim characteristics.

Clerics who commit sexual offenses: offender, offense, and victim characteristics.

The aim of this investigation was to undertake an exploratory analysis of clerics who sexually offend and the circumstances related to these offenses. Thirty-three adult male religious leaders who had been charged with a sexual offense against a child or adolescent were included in the study. This study examined descriptive information about offenders, their victims, as well as characteristics of the crimes. Notable trends included the following: religious leaders tended to offend against boys living with both parents, the offense often took place at the clergy's residence, and the offense involved fondling the victim. The study also compared offenders with single versus multiple victims on crime variables and differences were noted with respect to victim access.

Child care providers who commit sexual offences: a description of offender, offence, and victim characteristics.

The aim of this investigation was to undertake an exploratory analysis of child care providers who sexually offend against children and adolescents and the circumstances related to these offences. Archival Violent Crime Linkage Analysis System (ViCLAS) reports were obtained from the Royal Canadian Mounted Police (RCMP), and demographic and criminal characteristics for the offender, as well as information about the victim and offence, were selected for analyses. A descriptive approach was used to analyze the qualitative reports for a group of 305 Canadian sexual offenders between 1995 and 2002. Adult male (N = 163) and female ( N = 14), along with juvenile male (N = 100) and female (N = 28) child care providers who were involved in a sexual offence against a child or adolescent are described. This article provides unique information about the crimes committed by child care providers in that it is focused on crime characteristics, rather than on personality or treatment variables. Furthermore, it represents a comprehensive examination of this type of offender by including understudied groups, namely juvenile and female offenders.

Denial predicts recidivism for some sexual offenders.

This study examined whether there were variables that moderated the relationship between denial and recidivism among adult male sexual offenders. The first study (N = 489) found that the relationship with sexual recidivism was moderated by risk (as measured by the Rapid Risk Assessment for Sexual Offense Recidivism) but not by psychopathy (as measured by the Psychopathy Checklist-Revised). Contrary to expectations, denial was associated with increased sexual recidivism among the low-risk offenders and with decreased recidivism among the high-risk offenders. Post hoc analyses suggested that the risk item most responsible for the interaction was "relationship to victims". For incest offenders, denial was associated with increased sexual recidivism, but denial was not associated with increased recidivism for offenders with unrelated victims. These interactions were substantially replicated in two independent samples (N = 490 and N = 73). The results suggest that denial merits further consideration for researchers as well as those involved in applied risk assessment of sexual offenders.

Vicarious traumatization: the impact on therapists who work with sexual offenders.

This article reviews the descriptive and empirical literature examining vicarious traumatization in therapists treating sexual offenders. Vicarious traumatization in sexual offender therapists is described, including an examination of the relationships between vicarious traumatization and client, therapist, and setting and therapy characteristics. Special attention is given to those unique factors that contribute to the development of vicarious traumatization in this group, as well as consideration of why therapists treating offenders or victims may differ in their experience and development of vicarious traumatization. Evidence from the research reviewed suggests that sexual offender therapists do experience symptoms of vicarious traumatization. Factors most strongly associated with the development of vicarious traumatization in sexual offender therapists include professional experience, treatment setting, and coping strategies employed by the therapists. Implications and recommendations for professionals and policymakers are discussed.

The utility of the diagnosis of pedophilia: a comparison of various classification procedures.

This study examined the utility of the diagnosis of pedophilia in a sample of extra-familial child molesters assessed at a university teaching hospital between 1982 and 1992. Pedophilia was defined in one of four ways: (1) DSM diagnosis made by a psychiatrist; (2) deviant phallometric profile; (3) DSM diagnosis and a deviant phallometric profile; and, (4) high scores based on the Screening Scale for Pedophilic Interest (Seto & Lalumière, 2001). Demographic data, psychological tests, and offence history were obtained and group differences were analyzed along with the ability of certain variables to contribute uniquely to the classification of pedophilia. Results indicated that few significant differences existed on psychological measures between pedophilic and nonpedophilic extra-familial child molesters regardless of the classification system employed. Finally, results indicated that the procedures used to define pedophilia were not significantly related to one another. Results are discussed in terms of the utility of the diagnosis of pedophilia.