To Reoffend or Not to Reoffend? An Investigation of Recidivism Among Individuals With Sexual Offense Histories and Psychopathy.

Although psychopathy is a well-established risk factor for recidivism among those who have committed sexual offenses, there are nonetheless some individuals with sexual offense histories who are high in psychopathy but do not recidivate. This population-nonrecidivating psychopathic sex offenders (NRP-SOs)-was the focus of the current investigation. Data from 111 individuals with sexual offense histories who received a Hare Psychopathy Checklist-Revised (PCL-R) rating of at least 25 (suggesting the presence of psychopathy) were analyzed. With recidivism operationalized as the accrual of any new serious-that is, violent or sexual-charges, 39 recidivated (RP-SOs), whereas 72 did not (NRP-SOs). A logistic regression was conducted to assess whether NRP-SOs could be differentiated from RP-SOs. Being older at the time of release, a lesser criminal history, and being married predicted nonrecidivism. PCL-R factor scores and sexual deviance were not predictive. These findings highlight the heterogeneity that exists, even among those high in psychopathy.

Tipping the scales of justice: the role of forensic evaluations in the criminalization of mental illness.

An unprecedented number of individuals with mental illness are represented in the criminal justice system. The unending growth of mentally ill populations in the justice system has led to jails and court dockets being increasingly overwhelmed with cases involving mental illness, state hospitals devoting far more beds and resources to forensic cases, and people without a criminal commitment left waiting for mental health services as forensic cases are prioritized. Although a forensic mental health evaluation is only one component of this larger system, common problems with forensic mental health evaluations can exacerbate the criminalization of persons with mental illness in many ways. This article reviews the current literature regarding issues of quality, reliability, and validity of forensic mental health evaluations, discusses the broader impact of these issues, and offers potential solutions for the field.

Forensic psychiatry and mental health in Australia: an overview.

This article reviews the development of forensic psychiatry and mental health services in Australia for the international reader. It covers the legacy of a series of colonial systems that have contributed to a modern health service that interacts with justice systems. The development of relevant legislation, hospitals, prison services, community, and courts services is reviewed. The training and academic development of professionals is covered. Gaps in service delivery and future directions are considered.

The indistinguishables: determining appropriate environments for justice involved individuals.

Criminalizing those with mental illness is a controversial topic with a long and complex history in the United States. The problem has traditionally been dichotomized between criminals (i.e., "bad") in need of placement in jails and prisons and the mentally ill (i.e., "mad") who are need of treatment in psychiatric facilities. Recent trends demonstrate significant increases in the rates of mental illness in jails and prisons, as well as increased rates of violence within psychiatric hospitals. This would suggest that there are a group of justice involved individuals who are "indistinguishable" within the traditional dichotomous categories of dangerousness and mental illness. The authors argue for a more nuanced model that dimensionally conceptualizes dangerousness and mental illness; increased attention to situational factors that create facilities appropriate for those who are dangerous and mentally ill and more diversion programs for those inappropriate for incarceration or hospitalization.

Decriminalizing mental illness: specialized policing responses.

De-institutionalization of mental health patients has evolved, over nearly 3 generations now, to a status quo of mental health patients experiencing myriad contacts with first-responders, primarily police, in lieu of care. The current institutions in which these patients rotate through are psychiatric emergency units, emergency rooms, jails, and prisons. Although more police are now specially trained to respond to calls that involve mental health patients, the criminalization of persons with mental illness has been steadily increasing over the past several decades. There have also been deaths. The Crisis Intervention Team (CIT) model fosters mental health acumen among first responders, and facilitates collaboration among first responders, mental health professionals, and mental health patients and their families. Here, we review some modern, large city configurations of CIT, the co-responder model, the mitigating effects of critically situated community-based programs, as well as barriers to the success of joint efforts to better address this pressing problem.

The Cal-DSH diversion guidelines.

The Cal-DSH Diversion Guidelines provide 10 general guidelines that jurisdictions should consider when developing diversion programs for individuals with a serious mental illness (SMI) who become involved in the criminal justice system. Screening for SMI in a jail setting is reviewed. In addition, important treatment interventions for SMI and substance use disorders are highlighted with the need to address criminogenic risk factors highlighted.

Deinstitutionalization and other factors in the criminalization of persons with serious mental illness and how it is being addressed.

One of the major concerns in present-day psychiatry is the criminalization of persons with serious mental illness (SMI). This trend began in the late 1960s when deinstitutionalization was implemented throughout the United States. The intent was to release patients in state hospitals and place them into the community where they and other persons with SMI would be treated. Although community treatment was effective for many, there was a large minority who did not adapt successfully and who presented challenges in treatment. Consequently, some of these individuals' mental condition and behavior brought them to the attention of law enforcement personnel, whereupon they would be subsequently arrested and incarcerated. The failure of the mental health system to provide a sufficient range of treatment interventions, including an adequate number of psychiatric inpatient beds, has contributed greatly to persons with SMI entering the criminal justice system. A discussion of the many issues and factors related to the criminalization of persons with SMI as well as how the mental health and criminal justice systems are developing strategies and programs to address them is presented.

Covariates of the Severity of Aggression in Sexual Crimes: Psychopathy and Borderline Characteristics.

Whereas risk assessment literature on sexual offending has primarily focused on prediction of subsequent sexual crimes, and not the severity of those crimes, the first aim of the present study was to identify variables that predict the amount of damage to victims in sexual crimes compared with those that predict general aggressiveness. The second aim was to ascertain whether adding emotional instability measurements, as in borderline personality disorder (BPD), would add incremental variance to that captured by the facets of the Psychopathy Checklist-Revised (PCL-R). Trained raters assessed on the PCL-R, BPD, and measures of severity of sexual and nonsexual violence 302 adults who had sexually offended. PCL-R's Antisociality and two externalizing BPD factors (one from the standard and one from the alternative criteria) were significant predictors of violence both in sexual and nonsexual crimes. In contrast, deficits in the PCL-R's Affective facet (2) predicted victim damage in sexual contexts only, whereas the Lifestyle Impulsivity facet (3) of the PCL-R predicted violence in nonsexual contexts only. These findings suggest that adding measures of emotional dysregulation to commonly used instruments like the PCL-R, which assesses callousness and antisociality, may be beneficial for predicting violence.

Long-Term Predictive Validity of the Juvenile Sex Offender Assessment Protocol-II: Research and Practice Implications.

The current study evaluated the predictive validity of the Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) scores in a sample of juveniles who recidivated sexually or nonsexually as adults. Participants included 166 juveniles who had previously sexually offended and were followed into adulthood for an average of 10.75 years. Results of area under the receiver operating characteristic curve (AUC) analyses supported the predictive validity of the J-SOAP-II Total Score, Scale 1, and Static Score in regard to adult sexual recidivism, and predictive validity was found for all J-SOAP-II scores (except Scale 1) in regard to adult nonsexual recidivism. Implications for future research on the assessment of risk factors and treatment needs for adolescents who commit sexual offenses are discussed.

[The forensic preventive outpatient clinic in Ansbach : Evaluation of the model project for treatment of psychiatric risk patients]. / Die forensische Präventionsambulanz Ansbach : Evaluation des Modellprojekts zur Behandlung psychiatrischer Risikopatienten.

BACKGROUND: Patients suffering from severe mental disorders and who have an increased risk of violent behavior, tend to be insufficiently cared for until committing a violent offense leads to compulsory placement in a forensic psychiatric clinic. OBJECTIVE: The concept of the preventive outpatient clinic has been recently published in this journal. The aim of the study was to evaluate whether treatment in the outpatient clinic is preventive with respect to violence and whether there is a positive therapeutic outcome. METHOD: The study design was quasi-experimental and longitudinal. The control group consisted of comparable patients from an adjacent healthcare catchment area. Measurements were taken on admission (t0) and after 6 and 12 months of treatment (t1 and t2, respectively). Dynamic risk factors, i.e. subscales C and R of the history clinical risk-20 version 2 (HCR-20 V2) scale and global assessment of functioning (GAF) scale were used as indicators of treatment success, involving both clinician ratings and self-reports. Multiple imputed data for 70 subjects in the experimental group and 51 in the control group were analyzed by mixed effects models with group as a fixed effect. RESULTS: The interaction effect between time and group was statistically significant for the R (risk management) subscale and the GFA values but not for the C (clinical risk) value (after Bonferroni correction), whereby controls were made for multiple testing. CONCLUSION: The hypothesis with respect to the efficacy of the treatment could be maintained regarding risk markers and global assessment of functioning. With respect to clinical parameters there was a positive tendency in the expected direction. The data therefore indicate a positive effect of the preventive outpatient clinic for the patients treated.

Considerations for Pursuing Multiple Session Forensic Interviews in Child Sexual Abuse Investigations.

Multiple session forensic interviews (MSFI) are a useful tool in the field of child sexual abuse forensic interviewing given the complexity of disclosures and the variety of child-centered needs observed in practice. This paper focuses on the Children's Advocacy Centers of Texas (CACTX) model for conducting MSFIs, illustrated by a description of the statewide training models offered to member centers and enumeration of the MSFI protocol guidelines implemented by one center. A brief history and review of the single session forensic interview (SSFI) is provided followed by considerations for MSFIs in order to establish the development of current and new practices. Clarification of terms are outlined with examples of cases to distinguish between multiple sessions and subsequent sessions. The MSFI guidelines presented demonstrate how an MSFI can fit with the SSFI model.

The Cutting Edge of Forensic Interviewing.

This article contextualizes new knowledge about forensically interviewing and assessing children when there are concerns about child abuse. The article references the impact of the Child Abuse Prevention and Treatment Act and the circumstance in the 1980s where investigators and clinicians had little guidance about how to interview children about alleged sexual abuse. It further speaks to the consequences of lack of interview guidelines and how videotaped interviews in the McMartin Pre-school cases served as the catalyst for the backlash against child interviewers and their interview techniques. Painful as the backlash was, it led to research and evidence-based practice in interviewing children about child sexual and other abuse. Principal among the practice innovations were forensic interview structures to be used when there is alleged child sexual and other abuse and the strong preference for one interview by a skilled interviewer, who is nevertheless a stranger to the child. Although these innovations satisfied many professionals in the child maltreatment field and critics of child interviewers, the new practices did not address a number of abiding issues: 1) how to meet the needs of children who are unable to disclose maltreatment in a single interview, 2) how to determine which children are suggestible in a forensic interview, and 3) how decisions are made about the likelihood of abuse, based upon the child's information during the interview. The articles in this special section address these cutting-edge issues.

Searching for Truth: The Forensic Interviewer's Use of an Assessment Approach While Conducting Child Sexual Abuse Interviews.

This study examined the assessment approach interviewers use while conducting interviews to assess truth as narratives are gathered in children's disclosure statements by examining 100 forensic interviews completed at a Children's Advocacy Center. A descriptive review was used to examine the steps engaged by interviewers as they followed a protocol and content analysis was used to identify interviewers' questioning strategies as they assessed children's disclosure narratives during interviews. Findings indicate that interviewers apply a protocol in order to support advancing to a phase of eliciting details in children's narratives. Questioning strategies included using a variety of question types to progress from general to specific, incorporating interview aids sparingly as necessary, and integrating multidisciplinary team feedback. Findings suggest that an assessment approach is inherent to the process of actively conducting a forensic interview. Rather than assessment beginning strictly upon completion of children's narratives, this paper describes how interviewers incorporate an assessment framework throughout interviewing.

Evaluation of official procedures for suicide prevention in hospital from a forensic psychiatric and a risk management perspective.

Background: Suicide is a severe public health problem, in 2008 the Italian ministerial recommendation n° 4 on the management of suicide defined key areas for the identification of suicidal risk in hospital wards. The guidelines are important in defining professional liability issues, in line with Law 24 of 8/3/2017 'Gelli-Bianco'. Our study aimed to investigate the appropriateness of the official documents on suicide prevention delivered by Italian hospitals and their compliance with the ministerial recommendation.Methods: The Italian hospitals' public procedures on suicide prevention issued between 2008 and 2019 (n = 33) were retrieved thorough web search and further evaluated according to their compliance with the 2008 Italian ministerial recommendations.Results: The guidelines documents were generally in line with the ministerial recommendation. However, we found a lack of implementation in the specific training of health professionals. Most guidelines provided no risk stratification, nor specific procedures for different risk degrees or diagnoses. More than half of the documents did not report standardised tools for the assessment of suicidal risk.Conclusions: The public procedures on suicide prevention in Italian hospitals present general indications, leaving room for interpretation. Public procedures should be implemented with greater attention to the elements of judgement in the assessment of suicidal risk.KEY POINTSProcedures for suicide prevention are of uttermost importance for psychiatrist working in hospital.Standards in suicide risk evaluations are needed.Comparison between procedures can improve risk assessment and evaluation.

Validation of the Change or Stop Testosterone-Lowering Medication (COSTLow) Scale Using the Delphi Method Among Clinical Experts.

Guidelines for pharmacological treatment of patients with paraphilic disorders have been developed by a working group of the World Federation of Societies of Biological Psychiatry (Thibaut et al., 2010 ). With an increasing duration of experience and number of treated patients as well as aging patients, change of or withdrawal from testosterone-lowering medications (TLM) has become an important issue. The current study aimed to assess the quality of a structured professional judgment procedure that helps switching or discontinuing TLM in patients with paraphilic disorders. We used the Delphi method to estimate the quality of 10 factors originally proposed by the authors. A total of 30 experts participated in the first stage; 18 experts participated in the second stage. The experts' assessment resulted in an instrument of 15 factors that can be used to structure the process of changing or discontinuing TLM. These factors can be grouped into five broader categories: age and duration of treatment; therapeutic alliance; psychopathology and risk factors; motivation; and compliance and level of control. The developed COSTLow-R Scale provides an instrument that can be used to structure the process of changing or discontinuing TLM in patients with severe paraphilic disorders.

Post-conviction polygraph testing of sex offenders.

Post-conviction polygraph testing of sex offenders (typically referred to as PCSOT) is common in the US, increasingly applied in England and Wales, but hardly if ever used elsewhere in the world. This article provides an account of the nature and aims of PCSOT, research into its efficacy, and controversies associated with it.

Assessing risk for inpatient physical violence in a female forensic psychiatric sample - comparing HCR-20v2 with the female additional manual to the HCR-20v2.

Purpose and aim: Out from the sparse literature on risk assessment for violence committed by women the Female Additional Manual (FAM) was developed to be a complement to the HCR-20v2. The aim of this study was to investigate and compare the psychometrics of the HCR-20v2 with and without the FAM on risk for inpatient physical violence for female forensic psychiatric patients. Methods: The participants were 100 female patients admitted to forensic psychiatric care in a high-security clinic, assessed by clinicians with the HCR-20v2 during their admission. Researchers performed the FAM, both retrospectively and prospectively. The follow-up period was 12 months before being discharged. Results: Four main results were found; first, many risk factors were present although the summary risk ratings were mainly low to moderate. Secondly, the reliability was in general good, where the HCR-20v2 mainly showed higher reliability without than with the FAM, indicating that FAM risk factors did equal or did not contribute to a higher reliability. Third, the internal validity was higher for the HCR-20v2 than for the FAM. Risk factors correlated stronger with the summary risk ratings for the HCR-20v2 than for the FAM. Fourth, the validity for inpatient physical violence was high for the total score of both the HCR-20v2 and the FAM, but contradictory to previous finding the validity for summary risk ratings was not significant. Conclusions: The results support the use of HCR-20v2 when assessing risk for inpatient violence for female forensic psychiatric patients, but with only some support for adding or changing risk factors according to the FAM.

Hermeneutic caring conversations in forensic psychiatric caring.

BACKGROUND:: In forensic psychiatric care, a hermeneutic caring conversation between caregivers and patients can improve health outcomes. The hermeneutic approach entails starting from the whole and involves openness for what is shown as well as paying attention to the different parts. One way to deepen these conversations is to take advantage of both the caregivers' and the patients' life experiences. RESEARCH QUESTIONS:: The purpose of the study is to discuss and reflect on what hermeneutic caring conversations can mean for a deepened understanding of the movement in the health processes of patients in forensic care, patients who are in deep suffering. RESEARCH DESIGN:: This study uses a hermeneutic methodology. Conversations with patients receiving care in forensic psychiatry are deepened using texts from philosophy, caring science, and poetry. The outcome emerges through a phase of creating patterns. PARTICIPANTS:: Three patients in forensic care. ETHICAL CONSIDERATIONS:: This study builds on a doctoral thesis approved by The Ethical Review Board at the Faculty of Medical and Health Sciences, Linköping, Sweden. FINDINGS:: Hermeneutic caring conversations provide a possibility for rich caring conversations with patients who are often not given a voice. These conversations are seen as ethical expressions of hermeneutic caring communion that affect patients' health processes in a positive way. DISCUSSION:: It takes courage and responsibility to initiate and conduct these conversations as the patients volunteer to share their suffering. In hermeneutic caring conversations, the caregiver's attitude is crucial for the transference of knowledge. CONCLUSION:: This study provides a preliminary outline for hermeneutic caring conversations. A caring culture that provides time and space to prepare hermeneutic caring conversations is a prerequisite for the implementation of hermeneutic caring conversations.

Changes in patient safety culture: A patient safety intervention for Finnish forensic psychiatric hospital staff.

AIM: To evaluate how a 3-year patient safety intervention, more specifically, the implementation of a patient safety incident reporting system, influences patient safety culture. BACKGROUND: Positive patient safety culture improves both the quality of health care and patient safety. Nevertheless, nursing managers need tools that can help them develop and evaluate patient safety culture. METHODS: The Hospital Survey on Patient Safety Culture was used to evaluate patient safety culture at two Finnish forensic psychiatric hospitals (study and control) over two periods, baseline and follow-up. Data were analysed using Z-score and T test statistics. RESULTS: The follow-up results from the study hospital showed that five patient safety culture dimensions exhibited a significantly (p < 0.05) positive change in positive response rates over the 3-year period. Furthermore, nine out of twelve patient safety culture dimensions at the study hospital showed a significant improvement in mean score. At the control hospital, only the dimension of frequency of reporting events showed a significantly positive change (p < 0.05) in mean score. CONCLUSION: This research shows that the studied patient safety intervention (implementation of the patient safety incident reporting system) significantly influences patient safety culture. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers should utilize a variety of patient safety interventions to improve patient safety and focus on leveraging information from patient safety incidents to advance patient safety culture.

The Therapeutic Relationship in Forensic and General Psychiatric Settings.

INTRODUCTION: Therapeutic relationship in forensic psychiatry is believed to be affected by the coercive setting and the role conflict of the therapists as both treaters and court-appointed experts. The aim of the study was to examine and compare the therapeutic relationship in forensic and general psychiatric settings. MATERIAL AND METHODS: 52 forensic patients and 66 general psychiatric patients filled in the Psychopathy Personality Inventory - Revised (PPI-R), the Inventory of Interpersonal Problems - German Version (IIP-D), the Questionnaire on Motivation for Psychotherapy (Fragebogen zur Erfassung der Psychotherapiemotivation (FPTM)) as well as the Working Alliance Inventory - Short Revised (WAI-SR). We applied descriptive analyses, calculated univariate t-tests as well as multivariate T-tests and performed general linear models. RESULTS: The quality of the therapeutic alliance does not differ significantly between forensic and general psychiatric patients. Moreover, patients of forensic psychiatry consider therapeutic techniques applied by their therapists as more valuable for achieving their therapeutic aims than patients of the general psychiatry. DISCUSSION: The therapeutic relationship in forensic psychiatry is as viable as in general psychiatry. This can be regarded as a result of the long-term therapy in the context of forensic psychiatry which allows more time to be spent on relationship building than in a general psychiatry setting where therapy is limited to a few weeks.