Exploring the impact of trauma-adapted yoga in forensic psychiatry.

The specialized field of forensic psychiatry deals with the care of criminal offenders who suffer from severe mental disorders. As this field is positioned at the intersection of illness, crime, and security, it poses complex challenges. While high-quality clinical studies in forensic psychiatry settings are limited, recent investigations have suggested yoga as a complementary clinical tool within correctional environments. This report of a quasi-experimental study examines the impact of a 10-week trauma-adapted yoga intervention on mental health, antisocial and aggressive behaviors, pain perception, cravings, and character maturity among 56 patients in various forensic psychiatry clinics across Sweden. In the current study, the yoga group demonstrated noteworthy reductions in negative affect states, anxiety, phobic anxiety, paranoid ideations, interpersonal sensitivity, hostility, and overall psychological distress. These reductions were not observed in the comparison group. Additionally, the yoga group exhibited a significant decrease in pain frequency and strengthened self-directedness. However, there were no significant changes in aggressive, antisocial, or self-harm behaviors or cravings in either group. The between-group analyses did not yield significant results, except for pain intensity. The trauma-adapted yoga intervention implemented within forensic psychiatry settings shows feasibility and results in multiple positive changes in patients' health.

Integrating People, Context, and Technology in the Implementation of a Web-Based Intervention in Forensic Mental Health Care: Mixed-Methods Study.

BACKGROUND: While eMental health interventions can have many potential benefits for mental health care, implementation outcomes are often disappointing. In order to improve these outcomes, there is a need for a better understanding of complex, dynamic interactions between a broad range of implementation-related factors. These interactions and processes should be studied holistically, paying attention to factors related to context, technology, and people. OBJECTIVE: The main objective of this mixed-method study was to holistically evaluate the implementation strategies and outcomes of an eMental health intervention in an organization for forensic mental health care. METHODS: First, desk research was performed on 18 documents on the implementation process. Second, the intervention's use by 721 patients and 172 therapists was analyzed via log data. Third, semistructured interviews were conducted with all 18 therapists of one outpatient clinic to identify broad factors that influence implementation outcomes. The interviews were analyzed via a combination of deductive analysis using the nonadoption, abandonment, scale-up, spread, and sustainability framework and inductive, open coding. RESULTS: The timeline generated via desk research showed that implementation strategies focused on technical skills training of therapists. Log data analyses demonstrated that 1019 modules were started, and 18.65% (721/3865) of patients of the forensic hospital started at least one module. Of these patients, 18.0% (130/721) completed at least one module. Of the therapists using the module, 54.1% (93/172 sent at least one feedback message to a patient. The median number of feedback messages sent per therapist was 1, with a minimum of 0 and a maximum of 460. Interviews showed that therapists did not always introduce the intervention to patients and using the intervention was not part of their daily routine. Also, therapists indicated patients often did not have the required conscientiousness and literacy levels. Furthermore, they had mixed opinions about the design of the intervention. Important organization-related factors were the need for more support and better integration in organizational structures. Finally, therapists stated that despite its current low use, the intervention had the potential to improve the quality of treatment. CONCLUSIONS: Synthesis of different types of data showed that implementation outcomes were mostly disappointing. Implementation strategies focused on technical training of therapists, while little attention was paid to changes in the organization, design of the technology, and patient awareness. A more holistic approach toward implementation strategies-with more attention to the organization, patients, technology, and training therapists-might have resulted in better implementation outcomes. Overall, adaptivity appears to be an important concept in eHealth implementation: a technology should be easily adaptable to an individual patient, therapists should be trained to deal flexibly with an eMental health intervention in their treatment, and organizations should adapt their implementation strategies and structures to embed a new eHealth intervention.

Coping, mental health, and subjective well-being among mental health staff working in secure forensic psychiatric settings: Results from a workplace health assessment.

Given raised rates of patient suicide and violence in secure psychiatric facilities, staff in such settings are arguably at increased risk for burnout and reduced mental health. The present article responds to the recent U.K. National Institute for Health and Care Excellence (NICE) call to assess workforce well-being. This article held the following aims: (1) to quantify existing levels of mental health (i.e., depression, anxiety, distress, and posttraumatic stress) and subjective well-being (i.e., job satisfaction, life satisfaction, and four domains of burnout) and (2) to evaluate Coping Self-Efficacy (CSE) and Need for Affect (NFA) as factors associated with staff mental health and subjective well-being. We conducted a voluntary cross-sectional health needs assessment of forensic mental health staff (N = 170) between 2017 and 2018 from one National Health Service (NHS) Trust. Descriptive findings suggest staff possessed nonclinical average ranges of mental health symptoms. Subjective well-being findings showed burnout was relatively low, whereas job and life satisfaction were modest. Regression models demonstrated that (a) thought/emotion stopping beliefs were negatively associated with psychological exhaustion; (b) social support beliefs were positively associated with life satisfaction and job enthusiasm; (c) NFA Avoidance was linked with poor mental health and burnout, and; (d) NFA Approach was positively associated with two health subjective well-being indicators. Overall, assessment results suggest NHS forensic mental health staff reported relatively good health. Cognitive- and emotion-focused coping beliefs demonstrate promise as content for prevention programming. Using Emotional Labor Theory, we offer psychological services-based recommendations for future prevention programming and research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Eye movement desensitization and reprocessing (EMDR) therapy for posttraumatic stress disorder in adults with serious mental illness within forensic and rehabilitation services: a study protocol for a randomized controlled trial.

BACKGROUND: Eye movement desensitization and reprocessing (EMDR) is an evidenced-based treatment for posttraumatic stress disorder (PTSD). Forensic mental health services provide assessment and treatment of people with mental illness and a history of criminal offending, or those who are at risk of offending. Forensic mental health services include high, medium, and low-security inpatient settings as well as prison in-reach and community outpatient services. There is a high prevalence of PTSD in forensic settings and posttraumatic experiences can arise in people who violently offend in the context of serious mental illness (SMI). Successful treatment of PTSD may reduce the risk of relapse and improve clinical outcomes for this population. This study aims to assess the efficacy, risk of harm, and acceptability of EMDR within forensic and rehabilitation mental health services, as compared to treatment as usual (routine care). METHODS: This is a single-blind, randomized controlled trial comparing EMDR therapy to the waiting list (routine care). Adult forensic mental health service users (n = 46) with SMI and meeting the criteria for PTSD will be included in the study. Participants will be randomized after baseline assessment to either treatment as usual plus waiting list for EMDR or to treatment as usual plus EMDR. The EMDR condition comprises nine sessions, around 60 min in length delivered weekly, the first of which is a case conceptualization session. The primary outcomes are clinician and participant-rated symptoms of PTSD, and adverse events. Secondary outcomes include psychotic symptoms, social functioning, level of disability, self-esteem, depressive symptoms, post-trauma cognitions, and broad domains of complex posttraumatic difficulties. A trained assessor blinded to the treatment condition will assess outcomes at baseline, 10 weeks, and 6 months. Additionally, grounded theory qualitative methods will be used to explore participant experience of EMDR for a subset of participants. DISCUSSION: This study will contribute to the currently limited evidence base for EMDR for PTSD in forensic settings. It is the first randomized clinical trial to assess the efficacy, risk of harm, and acceptability of EMDR for PTSD in people with SMI in either forensic, mental health inpatient, or custodial settings. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Network, ACTRN12618000683235. Registered prospectively on 24 April 2018.

Forensic patients, treating psychiatrist and the Mental Health Review Tribunal - An ethical question?

OBJECTIVE: In inpatient forensic settings, a psychiatrist is expected to wear 'Two Hats', as a treating physician and as an expert to provide risk assessments and expert advice to the judicial authorities for leave and release decisions. Although dual roles have long been accepted as an inevitable part of independent forensic practice, there are additional ethical challenges for the treating psychiatrist to provide an expert opinion. This paper examines the specific ethical ambiguities for a treating psychiatrist at the interface of legal process related to leave and release decisions in the treatment of forensic patients. CONCLUSIONS: While respect for justice is the prevailing ethical paradigm for court-related forensic work, the medical paradigm should remain the key ethical framework for psychiatrists in treatment settings. Thus, psychiatrist should be aware of possible adverse consequences in acting as forensic experts for their patients. A conscientious adherence to clinical facts and awareness of the 'Two Hats' ethical pitfall can serve as important reference points in framing the psychiatric evidence in the decision-making process and safeguard treating psychiatrist's role.

Theta/SMR Neurofeedback Training Works Well for Some Forensic Psychiatric Patients, But Not for Others: A Sham-Controlled Clinical Case Series.

Electroencephalographic (EEG) neurofeedback could be a promising treatment for forensic psychiatric patients. Increasing evidence shows some patients are unable to regulate cortical activity. Before neurofeedback can be applied successfully, research is needed to investigate the interpersonal mechanisms responsible for patients' ability to respond to neurofeedback. A single-case experimental design allows for close monitoring of individual patients, providing valuable information about patients' response to the intervention and the time frame in which changes in clinical symptoms can be observed. Four patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) substance use disorder and various comorbidities participated in a sham-controlled clinical case study. Self-report level of impulsivity and craving were assessed. Results indicate that one patient showed more improvements on behavioral measures after the neurofeedback training than did the others. This patient reported less impulsivity and reduced levels of self-reported craving. However, these findings could not be attributed to the neurofeedback intervention. The findings suggest that there is insufficient evidence for the beneficial effects of a theta/sensorimotor rhythm (SMR) neurofeedback intervention on measures of impulsivity and craving, and that there may be great interindividual differences in patients' ability to regulate cortical activity.

Either or? Reconciling Findings on Mental Health and Extremism using a Dimensional Rather than Categorical Paradigm.

The background for this paper is the debate over what role mental illness plays in radicalization to violent extremism. While one camp points to cases of abnormal functioning of perpetrators, another argues that normal psychological mechanisms are central. Through a review of these perspectives, it becomes clear that mental illness cannot be ruled out as an epi-phenomenon, but is not a necessary condition either. The paper draws on work in psychiatric nosology on dimensional and categorical conceptions of illness and argues that the perspectives in this literature reflect a categorical approach to normal and abnormal functioning. Under a dimensional perspective, findings converge. The paper concludes by showing how this new dimensional approach to the role of mental illness in radicalization has implications for the design of risk assessment tools and leads to the recommendation for stronger inter-agency cooperation between mental health professionals, social services, and police and intelligence services.

What is Truth? The Spiritual Quest of Forensic Psychiatry.

The search for truth is a foundational aim and value of forensic psychiatry. It is also a deeply spiritual exercise. It must, therefore, be possible to describe a spirituality of forensic psychiatry, which I attempt to begin in this article. This exploration opens with a discussion of spirituality and its contexts. I then examine the nature of vocation in its application to medicine, psychiatry and the law. This proceeds to a close evaluation of the attitudes and activities that I will argue occupy the groundwork of forensic practice and form pathways to truth: presence, empathy, compassion, and centering. I then examine some of the forces that harm the expression of truth in the courtroom, and the means for healing those injuries. Concern for the common good, an integral part of my own spirituality, arises repeatedly in this discussion. I conclude with thoughts on the search for truth, in our work and in ourselves, and an invitation to colleagues to imagine forensic psychiatry as a spiritual practice. My hope is that this endeavor will stimulate reflection among forensic clinicians and encourage further inquiry and explication.

Experiences of self-injury and aggression among women admitted to forensic psychiatric care.

BACKGROUND: Self-injury and institutional violence are well-known characteristics of female forensic psychiatric patients, but research on patients' experiences of these behaviours is limited. AIM: The aim of the study was to investigate how female forensic psychiatric patients describe their self-injury and aggression. METHODS: The authors performed qualitative in-depth interviews with 13 female forensic psychiatric inpatients. The interviews were analysed using thematic analysis. RESULTS: The analysis resulted in three themes describing the process of handling negative thoughts and emotions by using self-injury or aggression towards others and thereby experiencing satisfaction. Both self-injury and aggression were experienced as strategies for emotional regulation. The forensic psychiatric care was perceived as important for the women in developing less harmful strategies for coping with negative thoughts and emotions instead of injuring themselves or others. CONCLUSIONS: Self-injury and aggression are often risk-assessed separately, but results from the present study suggest that these behaviours need a more holistic approach.

The Effectiveness of the Nanta-Program on Psychiatric Symptoms, Interpersonal Relationships, and Quality of Life in Forensic Inpatients with Schizophrenia.

PURPOSE: The purpose of this study was to examine the effectiveness of the Nanta-program on psychiatric symptoms, interpersonal relationships, and quality of life (QoL) in forensic inpatients with schizophrenia (SPR). METHODS: A quasi-experimental study employing a nonequivalent control group and pre-posttest design was conducted. Participants were 38 forensic inpatients with SPR from South Korea (experimental group=18, control group=20). The intervention was conducted in 12 sessions over 12 weeks, taking 90 min per session. Data were analyzed using χ2-test and t-test with SPSS 22.0 program. RESULTS: The experimental group showed significant improvements in psychiatric symptoms (t=-2.73, p=.010) and slight improvement in interpersonal relationships (t=2.23, p=.0.34) after 12 weeks of group music therapy. There was no significant difference in QoL change between the two groups. CONCLUSION: These findings indicate that the Nanta-program is an effective intervention program for improving psychiatric symptoms and interpersonal relationships of prisoners with schizophrenia.

Vitamin D deficiency in an inpatient forensic intellectual disability service.

No research has examined vitamin D deficiency among inpatients within forensic intellectual disability services, despite their potentially increased risk. Tests of serum 25(OHD) concentration in blood are routinely offered to patients within the service as part of the admission and annual physical health check. Results were classified as deficient <25, insufficient <50, sufficient 50-75 or optimal >75. Deficient or insufficient patients were offered supplement treatment and retested within 6 months. Levels were compared between groups: level of security and gender. At baseline, 87% of patients were deficient or insufficient, whilst 13% were sufficient or optimal. At follow-up, 53% had sufficient or optimal levels. However, some patients remained deficient (13%) or insufficient (34%) due to non-compliance with treatment. Women appeared more likely to be deficient. High levels of vitamin D deficiency were found among this population. Vitamin D screening and treatment is a simple and effective way of improving the physical health of this population.

Evidence for Greater Forensic Education of all Psychiatry Residents.

Booth and his colleagues have made an important contribution to the emerging evidence base that shows education in forensic psychiatry topics can improve attitudes toward the field. Given the desinstitutionalization of those with severe mental illness from state psychiatric facilities and the incarceration of many individuals with severe mental illness in correctional facilities, the need to train many more psychiatrists with competence in correctional settings is clear. Simply training more forensic psychiatrists will not both meet the psychiatric needs of incarcerated patients and fulfill the essential roles forensic psychiatrists play in the justice system. Therefore, it is essential that all psychiatry residency programs include time allotted to forensic psychiatry just as time is allotted to the other major subspecialties, including child and adolescent psychiatry, addiction psychiatry, geriatric psychiatry, and psychosomatic medicine. It is likely that the only way to achieve this necessary outcome is through advocacy for the Accreditation Council for Graduate Medical Education (ACGME) to mandate a rotation in forensic psychiatry, for psychiatry residency programs to be accredited.

Measuring Children's Suggestibility in Forensic Interviews.

According to the scientific literature, childrens' cognitive development is not complete until adolescence. Therefore, the problems inherent in children serving as witnesses are crucial. In preschool-aged children, false memories may be identified because of misinformation and insight bias. Additionally, they are susceptible of suggestions. The aim of this study was to verify the levels of suggestibility in children between three and 5 years of age. Ninety-two children were examined (44 male, 48 female; M = 4.5 years, SD = 9.62). We used the correlation coefficient (Pearson's r) and the averages variance by SPSS statistical program. The results concluded that: younger children are almost always more susceptible to suggestibility. The dimension of immediate recall was negatively correlates with that of total suggestibility (r = -0.357 p < 0.001). Social compliance and source monitoring errors contribute to patterns of suggestibility, because older children shift their answers more often (r = 0.394 p < 0.001). Younger children change their answers more times (r = -0.395 p < 0.001).

The Rey Auditory Verbal Learning Test forced-choice recognition task: Base-rate data and norms.

The present study describes a novel Forced-Choice Response (FCR) index for detecting poor effort on the Rey Auditory Verbal Learning Test (RAVLT). This retrospective study analyzes the performance of 4 groups on the new index: clinically referred patients with suspected dementia, forensic patients identified as not exhibiting adequate effort on other measures of response bias, students who simulated poor effort, and a large normative sample collected in the Gulf State of Oman. Using sensitivity and specificity analyses, the study shows that much like the California Verbal Learning Test-Second Edition FCR index, the RAVLT FCR index misses a proportion of individuals with inadequate effort (low sensitivity), but those who fail this measure are highly likely to be exhibiting poor effort (high specificity). The limitations and benefits of utilizing the RAVLT FCR index in clinical practice are discussed.

Forensic Interviews for Child Sexual Abuse Allegations: An Investigation into the Effects of Animal-Assisted Intervention on Stress Biomarkers.

The use of therapy animals during forensic interviews for child sexual abuse allegations is a recommendation by the Therapy Animals Supporting Kids Program to help ease children's discomfort during the forensic interview process. Based on this recommendation, this study incorporated a certified therapy canine into the forensic interview process for child sexual abuse allegations. This study investigated changes in salivary cortisol, immunoglobulin A, blood pressure, and heart rate as a result of forensic interview phenomenon (e.g., outcry) incorporating animal-assisted intervention versus a control condition in children (N = 42) interviewed for alleged child sexual abuse. The results supported significantly greater heart rate values for the control group (n = 23) who experienced sexual contact and/or indecency than the experience of aggravated sexual assault compared to no difference in HR for the intervention group (n = 19). The results suggest that the presence of the canine in the forensic interview may have acted as a buffer or safeguard for the children when disclosing details of sexual abuse. In the intervention group, children's HR was lower at the start of the forensic interview compared to the control group. Finding an effect of having a certified handler-canine team available during the forensic interview on physiological measures of stress has real-world value for children, child welfare personnel, and clinical therapists. It is suggested that animal-assisted intervention be expanded to children facing other types of trauma and to treatment programs for child survivors of sexual abuse.

Modelo Holístico de Evaluación de la Prueba Testifical (HELPT) / A holistic model for the evalutation of the testimony (Helpt)

En este trabajo se presenta una propuesta de protocolo de evaluación de las declaraciones e identificaciones realizadas por posibles víctimas de delitos. El protocolo, denominado HELPT, se enmarca en un enfoque holístico de evaluación de la prueba testifical que considera todos los posibles factores de influencia: de codificación, de retención y de recuperación. Entre estos factores resultarán relevantes a) la capacidad para testificar de las víctimas, donde se tienen en cuenta los procesos cognitivos de atención, percepción, memoria y lenguaje; b) las características específicas del delito; c) los antecedentes del hecho evaluado y sus consecuencias; d) otros factores que pudieran afectar a la calidad y exactitud de las declaraciones e identificaciones, como el número de veces que la víctima tuvo que contar lo ocurrido, los métodos empleados para obtener el relato y posibilidades de sugestión. El método contempla procedimientos específicos de análisis exhaustivo de los expedientes y de formulación y contrastación de hipótesis (Scott y Manzanero, 2015), de evaluación de la competencia para testificar (Contreras, Silva y Manzanero, 2015) y de obtención de las declaraciones (González, Muñoz, Sotoca y Manzanero, 2013)

A proposed protocol for evaluating the statements and identifications made by the potential victims of crimes is presented in this paper. The protocol, called HELPT, is part of a holistic approach to evaluating the testimony that takes into account all possible factors of influence: encoding, retention and recovery. Among these factors, the following will be relevant: a) the ability of victims to testify, as well as cognitive processes of attention, perception, memory and language; b) the specific characteristics of the offence; c) the history of the event and its consequences; d) other factors that might affect the quality and accuracy of the statements and identifications, such as the number of times the victim had to tell what happened, the methods used to obtain the story and possibilities of suggestion. The method includes specific procedures for exhaustive analysis of the testimonies and for the formulation and testing of hypotheses (Scott & Manzanero, 2015), the evaluation of the competence to testify (Contreras, Silva, & Manzanero, 2015) and the obtaining of statements (González, Muñoz, Sotoca, & Manzanero, 2013)

Assessment of problematic sexual interests with the penile plethysmograph: an overview of assessment laboratories.

Phallometric testing, or penile plethysmography (PPG), is an objective measure of sexual arousal for males. While extensive research on the reliability and validity of PPG has promoted its reputation as the "gold standard" of objective measurement of sexual arousal, there is a lack of standardization of stimulus sets and interpretation of results between sites. This article describes the laboratory protocol employed for PPG at the Royal Ottawa Mental Health Centre's Sexual Behaviours Clinic (SBC) in Ottawa, Ontario, as well as those used by the Sexual Behaviors Clinic and Lab (SBCL) in the Community and Public Safety Psychiatry Division (CPSPD) of the Department of Psychiatry and Behavioral Sciences at Medical University of South Carolina (MUSC) in Charleston, South Carolina. The need for standardization in both testing protocol and stimuli use across sites are highlighted.

The clinical, forensic and treatment outcome factors of patients with autism spectrum disorder treated in a forensic intellectual disability service.

BACKGROUND: To describe the characteristics of those with autism spectrum disorder (ASD) treated within a forensic intellectual disability hospital and to compare them with those without ASD. METHOD: Service evaluation of a cohort of 138 patients treated over a 6-year period. RESULTS: Of the 138, 42 had an ASD. Personality disorders and harmful use or dependence on drugs were significantly lower in the ASD group. The ASD group was less likely to be subject to criminal sections or restriction orders. Self-harm was significantly higher in the ASD group. There were no differences in the length of stay and direction of care pathway. CONCLUSIONS: Although the ASD and non-ASD groups differ on clinical and forensic characteristics, their treatment outcomes appear similar. This suggests that the diagnostic category of ASD alone may be inadequate in predicting the treatment outcome. There is a case to identify distinct typologies within the ASD group.