Risk, resilience, and recovery in forensic mental health: An integrated conceptual model.

In this paper we describe a novel, integrated conceptual model that brings together core elements across structured tools assessing risk for future violence, protective factors, and progress in treatment and recovery in forensic mental health settings. We argue that the value of such a model lies in its ability to improve clinical efficiencies and streamline assessment protocols, facilitate meaningful participation of patients in assessment and treatment planning activities and increase the accessibility of clinical assessments to principal users of this information. The four domains appearing in the model (treatment engagement, stability of illness and behavior, insight, and professional and personal support) are described, and common clinical manifestations of each domain within a forensic context are illustrated. We conclude with a discussion of the types of research that would be needed to validate a concept model such as the one presented here as well as implications for clinical practice and implementation.

Serious Mental Illness and Sexual Offending in Forensic Psychiatric Patients.

The role of serious mental illness among those who sexually offend is not well understood. We investigated clinical and risk-related areas of difference between male forensic psychiatric patients with (n = 86) and without (n = 245) a sexual offense history, including the age at which indications of mental disorder and criminal offending first emerged, from a registry of Ontario patients adjudicated Not Criminally Responsible on account of Mental Disorder (NCRMD) from 1999-2012. We further explored motivations for offending among a subset of patients deemed NCRMD for a sexual offense specifically (n = 41). While no differences were found in the age onset of illness or offending across those with and without a sexual offending history, the former group was rated as having higher levels of historical/static risk for violence. Forensic patients with a sexual offense history were also more likely to offend against a stranger, and less likely to offend against a family member. Sexual index offenses were psychotically-motivated in the majority of cases, but with a meaningful proportion appearing to reflect criminogenic motivations, especially substance use and paraphilic interests. Results suggest greater similarity than difference among forensic patients with and without a sexual offense history, but also highlight an important divergence from the literature showing that victims of sexual offenses are frequently known to the individual committing them.

Homicide associated with psychotic illness: What global temporal trends tell us about the association between mental illness and violence.

Available evidence suggests that persons with serious forms of mental illness are 4-10 times more likely to commit homicide as compared to non-affected members of the general population. The relationship between homicide and psychotic illness has now been subject to longitudinal investigation in six different populations across eight studies covering time periods over the last six decades. With the exception of one study, these investigations demonstrate that homicide associated with psychotic illness appears relatively stable through time and, in most populations, is not related to factors that contribute to the rise and fall of total population homicide (TPH) rates. This suggests that illness and treatment factors are of most importance if we are to reduce the prevalence of this tragic illness complication.

Management of COVID-19 Response in a Secure Forensic Mental Health Setting: Réponse à la gestion de la COVID-19 dans un établissement sécurisé de santé mentale et de psychiatrie légale.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic presents major challenges to places of detention, including secure forensic hospitals. International guidance presents a range of approaches to assist in decreasing the risk of COVID-19 outbreaks as well as responses to manage outbreaks of infection should they occur. METHODS: We conducted a literature search on pandemic or outbreak management in forensic mental health settings, including gray literature sources, from 2000 to April 2020. We describe the evolution of a COVID-19 outbreak in our own facility, and the design, and staffing of a forensic isolation unit. RESULTS: We found a range of useful guidance but no published experience of implementing these approaches. We experienced outbreaks of COVID-19 on two secure forensic units with 13 patients and 10 staff becoming positive. One patient died. The outbreaks lasted for 41 days on each unit from declaration to resolution. We describe the approaches taken to reduction of infection risk, social distancing and changes to the care delivery model. CONCLUSIONS: Forensic secure settings present major challenges as some proposals for pandemic management such as decarceration or early release are not possible, and facilities may present challenges to achieve sustained social distancing. Assertive testing, cohorting, and isolation units are appropriate responses to these challenges.

Changing characteristics of forensic psychiatric patients in Ontario: a population-based study from 1987 to 2012.

PURPOSE: To quantify the demand for forensic psychiatric services in Ontario over the past 25 years and investigate whether the sociodemographic, clinical and offense-based characteristics of forensic patients have changed over time. METHODS: We investigated all forensic admissions from 1987 to 2012 resulting in a disposition of Not Criminally Responsible on account of Mental Disorder (N = 2533). We present annual proportions of patients with specified sociodemographic, clinical and offense characteristics, and investigate whether the duration of forensic system tenure varies as a function of admission year, psychiatric diagnosis, or index offense. RESULTS: There has been a steady increase in forensic admissions over this time period, particularly individuals with comorbid substance use disorders and individuals of non-Caucasian ethno-racial background. The proportion of persons committing severe violence has remained low and has decreased over time. Having a comorbid personality, neurological, or substance use disorder significantly increased forensic system tenure, as did committing a violent offense. Individuals who came into the system in earlier years had slower rates of discharge compared to more recent admissions. CONCLUSIONS: Defining the trends characterizing the growth of the forensic population has important policy implications, as forensic services are costly and involve a significant loss of liberty. The current results indicate that young, substance abusing individuals of diverse ethno-racial backgrounds and who commit relatively low-level violence comprise an increasing proportion of Ontario's forensic population, and suggest that treatment must be optimized to best serve the needs of these individuals.

Time Trends in Homicide and Mental Illness in Ontario from 1987 to 2012: Examining the Effects of Mental Health Service Provision.

OBJECTIVE: We examine the association between rates of homicide resulting in a mental health disposition (termed mentally abnormal homicide [MAH]) and homicides without such a disposition, as well as to province-wide psychiatric hospitalisation and incarceration rates. METHOD: In this population-based study, we investigate all adult homicide perpetrators ( n = 4402) and victims ( n = 3783) in Ontario from 1987 to 2012. We present annual rates of mentally abnormal and non-mentally abnormal homicide and position them against hospitalisation and incarceration rates. RESULTS: Among the total sample of homicide accused, 3.7% were mentally abnormal. Most (82.5%) had a psychotic disorder at the time of the offense. Contrasted with declining hospitalisation, incarceration, and population homicide rates, the rate of MAH remained constant at an average of .07 perpetrators per 100,000 population. The rate of MAH was not associated with discharges from or average length of stay in psychiatric hospitals (ρ = 0.10; 0.34, P > 0.10), incarceration rates (ρ = 0.16, P = 0.42), or the total homicide rate (ρ = 0.25, P = 0.22). The proportion of MAH perpetrators with a substance use disorder increased modestly over time (ß = 0.35, R2 = 0.12, P = 0.08). CONCLUSIONS: The rate of MAH has not changed appreciably over the past 25 years. Declining psychiatric service utilisation was not associated with the rate of homicide committed by people with mental illness and, secondarily, was not linked to increases in the population homicide or incarceration rates. Substance use has become a more prevalent problem for this population.

Age onset of offending and serious mental illness among forensic psychiatric patients: A latent profile analysis.

BACKGROUND: Developmental typologies regarding age of onset of violence and offending have not routinely taken account of the role of serious mental illness (SMI), and whether age of onset of offending in relation to onset of illness impacts on the manifestation of offending over the life course. AIMS: To test whether forensic psychiatric patients can be classified according to age of onset of SMI and offending, and, if so, whether subtypes differ by sex. METHODS: Details of all 511 patients enrolled into a large forensic mental health service in Ontario, Canada, in 2011 or 2012 were collected from records. RESULTS: A latent profile analysis supported a 2-class solution in both men and women. External validation of the classes demonstrated that those with a younger age onset of serious mental illness and offending were characterised by higher levels of static risk factors and criminogenic need than those whose involvement in both mental health and criminal justice systems was delayed to later life. CONCLUSIONS: Our findings present a new perspective on life course trajectories of offenders with SMI. While analyses identified just two distinct age-of-onset groups, in both the illness preceded the offending. The fact that our sample was entirely drawn from those hospitalised may have introduced a selection bias for those whose illness precedes offending, but findings underscore the complexity and level of need among those with a younger age of onset. Copyright © 2018 John Wiley & Sons, Ltd.

The assessment of dynamic risk among forensic psychiatric patients transitioning to the community.

Individuals with serious mental illness (SMI; i.e., psychotic or major mood disorders) are vulnerable to experiencing multiple forms of adverse safety events in community settings, including violence perpetration and victimization. This study investigates the predictive validity and clinical utility of modifiable risk factors for violence in a sample of 87 forensic psychiatric patients found Not Criminally Responsible on Account of Mental Disorder (NCRMD) transitioning to the community. Using a repeated-measures prospective design, we assessed theoretically based dynamic risk factors (e.g., insight, psychiatric symptoms, negative affect, treatment compliance) before hospital discharge, and at 1 and 6 months postdischarge. Adverse outcomes relevant to this population (e.g., violence, victimization, hospital readmission) were measured at each community follow-up, and at 12 months postdischarge. The base rate of violence (23%) was similar to prior studies of discharged psychiatric patients, but results also highlighted elevated rates of victimization (29%) and hospital readmission (28%) characterizing this sample. Many of the dynamic risk indicators exhibited significant change across time and this change was related to clinically relevant outcomes. Specifically, while controlling for baseline level of risk, fluctuations in dynamic risk factors predicted the likelihood of violence and hospital readmission most consistently (hazard ratios [HR] = 1.35-1.84). Results provide direct support for the utility of dynamic factors in the assessment of violence risk and other adverse community outcomes, and emphasize the importance of incorporating time-sensitive methodologies into predictive models examining dynamic risk. (PsycINFO Database Record

Assessing illness- and non-illness-based motivations for violence in persons with major mental illness.

Research on violence perpetrated by individuals with major mental illness (MMI) typically focuses on the presence of specific psychotic symptoms near the time of the violent act. This approach does not distinguish whether symptoms actually motivate the violence or were merely present at the material time. It also does not consider the possibility that non-illness-related factors (e.g., anger, substance use), or multiple motivations, may have been operative in driving violence. The failure to make these distinctions clouds our ability to understand the origins of violence in people with MMI, to accurately assess risk and criminal responsibility, and to appropriately target interventions to reduce and manage risk. This study describes the development of a new coding instrument designed to assess motivations for violence and offending among individuals with MMI, and reports on the scheme's interrater reliability. Using 72 psychiatric reports which had been submitted to the court to assist in determining criminal responsibility, we found that independent raters were able to assess different motivational influences for violence with a satisfactory degree of consistency. More than three-quarters (79.2%) of the sample were judged to have committed an act of violence as a primary result of illness, whereas 20.8% were deemed to have offended as a result of illness in conjunction with other non-illness-based motivating influences. Current findings have relevance for clarifying the rate of illness-driven violence among psychiatric patients, as well as legal and clinical issues related to violence risk and criminal responsibility more broadly.

The impact of structured decision making on absconding by forensic psychiatric patients: results from an A-B design study.

BACKGROUND: Few studies have investigated absconding from forensic hospitals and there are no published studies of interventions aimed at reducing these incidents in forensic settings. We present a study of the impact of a new policy using structured professional judgment and an interdisciplinary team-based approach to granting privileges to forensic patients. We assess the impact of this policy on the rate and type of absconding from a metropolitan forensic facility. METHODS: Following concern about the rate of absconding at our hospital, a new policy was implemented to guide the process of granting hospital grounds and community access privileges. Employing an A-B design, we investigated the rate, characteristics, and motivations of absconding events in the 18 months prior to, and 18 months following, implementation of this policy to assess its effectiveness. RESULTS: Eighty-six patients were responsible for 188 incidents of absconding during the 42-month study window. The rate of absconding decreased progressively from 17.8% of all patients at risk prior to implementation of the new policy, to 13.8% during implementation, and further to 12.0% following implementation. There was a differential impact of the policy on absconding events, in that the greatest reduction was witnessed in absconsions occurring from unaccompanied passes; this was offset, to some extent, by an increase in absconding occurring from within hospital units or from staff accompanied outings. Seven of the absconding events included incidents of minor violence, and two included the commission of other illegal behaviors. The most common reported motive for absconding across the time periods studied was a sense of boredom or frustration. Discharge rate from hospital was 22.9% prior to the implementation of the policy to 22.7% after its introduction, indicating no change in the rate of patients' eventual community reintegration. CONCLUSIONS: A structured and team-based approach to decision making regarding hospital grounds and community access privileges appeared to reduce the overall rate of absconding without slowing community reintegration of forensic patients.

Developmental typologies of serious mental illness and violence: Evidence from a forensic psychiatric setting.

OBJECTIVE: To identify subgroups of forensic psychiatric patients based on the age onset of serious mental illness and offending and assess the external validity of the subgroups with theoretically based sociodemographic, clinical, legal and risk-related variables. METHOD: The age onset of serious mental illness and criminal contact was ascertained for a sample of 232 patients. A range of sociodemographic, clinical, legal and risk-related variables were coded to assess whether age onset subgroups differed in a manner consistent with the literature on typologies of mentally ill offenders. RESULTS: One-quarter of the sample was classified as early starters (patients whose first offense occurred before becoming mentally ill), while two-thirds were late starters (where first offense occurred following illness onset). A small percentage (8%) of patients were deemed late late starters, defined as late starters who had experienced 10+ years of illness and were >37 years upon first arrest. A larger proportion of early starters had a substance use disorder, antisocial personality disorder and a greater number of static/historical risk factors for violence. Early starters were younger upon first arrest and had more previous criminal contacts compared to late starters and late late starters. Mental illness was found to start later in life for late late starters; this group was also more likely to have been married and to have a spouse as victim in the index offense. CONCLUSION: We found support for distinct subgroups of mentally ill offenders based on the age onset of illness and criminal contact. Compared to late starters, offenses committed by early starters may be motivated more frequently by antisocial lifestyle and attitudes, as well as more instrumental behaviors related to substance abuse. In addition, late late starters may represent a distinct third subgroup within late starters, characterized by relatively higher levels of functioning and social stability; future work should replicate. Findings suggest different rehabilitation needs of the subgroups.

Characteristics and motivations of absconders from forensic mental health services: a case-control study.

BACKGROUND: Absconding from hospital is a significant health and security issue within psychiatric facilities that can have considerable adverse effects on patients, their family members and care providers, as well as the wider community. Several studies have documented correlates associated with absconding events among general psychiatric samples; however, few studies have examined this phenomenon within samples of forensic patients where the perception of threat to public safety in the event of an unauthorized absence from hospital is often higher. METHODS: We investigate the frequency, timing, and determinants of absconding events among a sample of forensic psychiatric patients over a 24-month period, and compare patients who abscond to a control group matched along several sociodemographic and clinical dimensions. We explore, in a qualitative manner, patients' motives for absconding. RESULTS: Fifty-seven patients were responsible for 102 incidents of absconding during the two year study window. Forensic patients who absconded from hospital were more likely to have a history of absconding attempts, a diagnosed substance use disorder, as well as score higher on a structured professional violence risk assessment measure. Only one of the absconding events identified included an incident of minor violence, and very few included the commission of other illegal behaviors (with the exception of substance use). The most common reported motive for absconding was a sense of boredom or frustration. CONCLUSIONS: Using an inclusive definition of absconding, we found that absconding events were generally of brief duration, and that no member of the public was harmed by patients who absconded. Findings surrounding the motivations of absconders suggest that improvements in therapeutic communication between patients and clinical teams could help to reduce the occurrence of absconding events.

Motivational influences in persons found not criminally responsible on account of mental disorder: a review of legislation and research.

This paper provides a review of the legislative reforms and case law that have impacted the defense of Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canada over the past three decades. As in other jurisdictions internationally, we observe that legislative reforms of procedural, as opposed to substantive, aspects of the NCRMD defense have impacted the manner in which NCRMD criteria are applied in common practice. More people are being declared NCRMD in recent years, and there is greater heterogeneity in the offending and psychiatric profiles of these individuals, suggesting that NCRMD criteria are being applied more liberally over time. In light of the substantial growth of the forensic mental health system over the past two decades, witnessed both in Canada and abroad, we propose that the study of motivational influences underlying the offending behaviors of persons with serious mental illness (SMI) is necessary to begin disentangling symptom-based offending from violent and antisocial behaviors that may have other motives. This, in turn, can help to determine legal issues, better define the nature of each person's offending and treatment needs, and provide a more fine-grained analysis of the drivers behind the growth experienced by the forensic system.

An Examination of Predictive Validity and Change in Risk Factors for Stalking over Time.

This study investigates the predictive validity of two risk instruments for stalking, the Guidelines for Stalking Assessment and Management (SAM) and the Stalking Risk Profile (SRP), in a sample of 86 forensic psychiatric patients. We compare these tools against a well-validated violence risk assessment measure (Historical, Clinical, Risk Management-20, Version 3 (HCR-20V3)) for violent and stalking-related outcomes. Dynamic (mutable) components of each tool were rated at three annual intervals and revealed significant change across time. The HCR-20V3, SAM, and SRP measures showed comparable ability to classify those who recidivated with further stalking from those who did not (area under the curves = .72-.73, P < 001). Time-varying scores from the dynamic subscales of the HCR-20V3 and SAM contributed significantly to the prediction of stalking, whereas nonstalking violence was primarily forecast by the static (Historical) scale of the HCR-20V3. This suggests comparable validity of general violence and stalking risk tools for assessing the risk of stalking in forensic patients. Stalking-specific risk factors on the SAM and SRP will likely be of added clinical value in terms of tailoring risk management and treatment plans. Findings also emphasize the importance of attending to changes in risk status over time and incorporating time-sensitive methodologies into predictive models.

Homicide in the context of psychosis: analysis of prior service utilisation and age at onset of illness and violence.

BACKGROUND: Public stigma and fear are heightened in cases of extreme violence perpetrated by persons with serious mental illness (SMI). Prevention efforts require understanding of illness patterns and treatment needs prior to these events unfolding. AIMS: To examine mental health service utilisation by persons who committed homicide and entered into forensic care, to investigate the adequacy of mental healthcare preceding these offences. METHOD: Forensic patients across two mental health hospitals in Ontario with an admitting offence of homicide between 2011 and 2021 were identified (n = 112). Sociodemographic, clinical and offence-related variables were coded from the health record and reports prepared for the forensic tribunal. RESULTS: Most patients (75.7%) had mental health contacts preceding the homicide, with 28.4% having a psychiatric in-patient admission in the year prior. For those with service contacts in the year preceding, 50.9% had had only sporadic contact and 70.7% were non-adherent with prescribed medications. Victims were commonly known to the individual (35.7%) and were often family members in care-providing roles (55.4%). Examination of age at onset of illness and offending patterns suggested that most persons admitted to forensic care for homicide act in the context of illness and exhibit a low frequency of pre-homicide offending. CONCLUSIONS: Many individuals admitted to forensic care for homicide have had inadequate mental healthcare leading up to this point. Effective responses to reduce and manage risk should encompass services that proactively address illness-related (e.g. earlier access and better maintenance in care) and criminogenic (e.g. substance use treatment, employment and psychosocial supports) domains.

Innovations in violence risk assessment: What aviation can teach us about assessing and managing risk for rare and serious outcomes.

This paper describes several ongoing challenges in the field of violence risk assessment (VRA), particularly with respect to establishing acceptable levels of measurement reliability and validity of commonly used risk assessment instruments, and demonstrating their ability to reduce risk and avert harmful outcomes. Drawing on analogous concepts from the risk assessment and management process in the aviation industry, several key lessons and aspirational principles for research and practice in the field of VRA are described. It is argued that significantly more attention is required to evaluate the ability of VRA tools to generate effective risk management plans that measurably lower risk and rates of violent outcomes. Three propositions for advancing common VRA research designs are discussed: (1) improved operationalization of risk management plans and their ability to reduce violence; (2) improved measurement of change in risk status over prospective follow-up periods, and (3) a stronger emphasis on short-term assessments with closer temporal proximity between risk factors and outcomes. Collectively, these advancements may enhance the validity and utility of VRA instruments by permitting better specification of the conditions under which risk factors exert effects, and the development of effective risk management plans that join together explanatory frameworks for the causes of violence with strategies to avoid their recurrence.

Motivational Influences and Trajectories to Violence in the Context of Major Mental Illness.

Developmental trajectories regarding the age onset of violence and offending have not routinely considered the role of major mental illness (MMI). In parallel, despite several studies investigating the relationship between MMI, violence and offending, fewer have identified motivational processes that may link illness to these outcomes in a more direct and proximal manner. This study investigates whether subtypes of forensic psychiatric patients deemed Not Criminally Responsible on account of Mental Disorder (N = 91) can be identified based on the age onset of mental illness and offending behavior, and whether information on motivational influences for offending-elicited both from the patient directly and detailed collateral information-contributes to the clinical utility of this typology. Results indicated that most patients reported engaging in violence (51%) or antisocial behaviors (72%) prior to the onset of MMI, but that the index offense(s) resulting in forensic admission were predominantly psychotically motivated. In contrast to patients for whom the onset of MMI occurred prior to offending, patients exhibiting premorbid violence had higher levels of risk and criminogenic need; they were more likely to be diagnosed with personality and substance use disorders, and to have conventional (i.e., non-illness-related) motivations ascribed to their index offense. Findings are consistent with the existing literature regarding subgroups of mentally disordered offenders, but provide new information regarding proximal risk factors for violence through better identification of motivational processes.

Gender differences in risk factors for violence: an examination of the predictive validity of the Structured Assessment of Violence Risk in Youth.

The research literature on predicting violence is particularly lacking in specifying risk factors for violence in adolescent girls. The recently developed Structured Assessment of Violence Risk in Youth [SAVRY; Borum et al., 2006] shows promise as it is empirically derived and incorporates dynamic factors in its assessment of risk. To date, there exists little information attesting to the reliability and validity of the SAVRY, and few investigations of the SAVRY's utility across gender. This study investigated the SAVRY in a sample of 144 high-risk adolescents (80 males and 64 females), focusing on gender discrepancies in the predictive utility of the measure. Results indicate that the SAVRY moderately predicts violent and non-violent reoffending in the entire sample, and also suggest that the SAVRY operates comparably across gender. Although not precluding the existence of gender-specific domains of risk, current results suggest that validated risk factors in boys hold relevance for the prediction of violence and delinquency in girls.