Special considerations to the assessment of fitness to stand trial in Australia.

Australian criminal law presumes that defendants are fit to stand trial until proven otherwise on the balance of probabilities. Forensic mental health experts often provide opinions to the court about defendants' fitness, which requires them to understand the legal context within which the court decides the defendant's fitness status. This article outlines important case law considerations to the assessment of fitness in Australia, including the notions that fitness must be evaluated when there is a 'real and substantial question', assessments should be 'reasonable and common sense' and accommodations should be considered when impairments in capacity are evident. The essentially negligible impact of delusions, an unhelpful defence, unmanageable behaviour and poor defendant-lawyer relationship are also considered. Finally, precedent is reviewed for the use of the Presser standards in New Zealand and other pacific jurisdictions.

Sexual abuse during childhood and all-cause mortality into middle adulthood: an Australian cohort study.

OBJECTIVE: To compare mortality from all causes, internal causes (eg, cancers, circulatory and respiratory system diseases), and external causes (eg, suicide, accidents, assault) among people who were sexually abused during childhood with mortality for the general population. DESIGN: Historical cohort study. SETTING, PARTICIPANTS: 2759 people (2201 women, 79.8%) who had experienced medically assessed contact sexual abuse in Victoria while aged 16 years or younger during 1964-1995, as recorded in Victorian Institute of Forensic Medicine records. MAIN OUTCOME MEASURES: Mortality rate, based on linked National Death Index data (1980-2020), by five-year age group; sex- and age-standardised mortality ratios; comparison of rates with age- and sex-adjusted rates for the general Victorian population (incident rate ratio [IRR]). RESULTS: We included 115 deaths of people under 50 years of age in our analysis (4.2% of people sexually abused as children; 79 women, 36 men); 56 deaths were attributed to external, 56 to internal causes (cause of death information missing in three cases). In each age group from 15-19 years, the mortality rates for people sexually abused as children were higher than for the general population; age- and sex-standardised all-cause mortality ratios were highest for people aged 25-29 years (men: 16.5; 95% confidence interval [CI], 11.0-22.0; women: 19.2; 95% CI, 14.3-24.2). The age- and sex-adjusted mortality rate for people sexually abused as children was higher than in the general population for all-cause (IRR, 8.25; 95% CI, 5.92-11.5), internal cause (IRR, 5.92; 95% CI, 3.89-9.01), and external cause deaths (IRR, 12.6; 95% CI, 9.61-16.6); the differences in external cause mortality were greater for people who had experienced penetrative (IRR, 14.9; 95% CI, 10.9-20.5) than for those who had experienced non-penetrative sexual abuse as children (IRR, 8.92; 95% CI, 5.35-14.9). CONCLUSIONS: Sexual abuse during childhood is associated with higher mortality rates into mid-adulthood. Preventing child sexual abuse and intervening early to reduce the damage it inflicts is not only essential for the welfare of the child, but could also help reduce avoidable deaths later in life.

Statistical learning methods and cross-cultural fairness: Trade-offs and implications for risk assessment instruments.

The use of statistical learning methods has recently increased within the risk assessment literature. They have primarily been used to increase accuracy and the area under the curve (AUC, i.e., discrimination). Processing approaches applied to statistical learning methods have also emerged to increase cross-cultural fairness. However, these approaches are rarely trialed in the forensic psychology discipline nor have they been trialed as an approach to increase fairness in Australia. The study included 380 Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander males assessed with the Level of Service/Risk Needs Responsivity (LS/RNR). Discrimination was assessed through the AUC, and fairness was assessed through the cross area under the curve (xAUC), error rate balance, calibration, predictive parity, and statistical parity. Logistic regression, penalized logistic regression, random forest, stochastic gradient boosting, and support vector machine algorithms using the LS/RNR risk factors were used to compare performance against the LS/RNR total risk score. The algorithms were then subjected to pre- and postprocessing approaches to see if fairness could be improved. Statistical learning methods were found to produce comparable or marginally improved AUC values. Processing approaches increased several fairness definitions (namely xAUC, error rate balance, and statistical parity) between Aboriginal and Torres Strait Islanders and non-Aboriginal and Torres Strait Islanders. The findings demonstrate that statistical learning methods may be a useful approach to increasing the discrimination and cross-cultural fairness of risk assessment instruments. However, both fairness and the use of statistical learning methods encompass significant trade-offs that need to be considered. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using the Dynamic Appraisal of Situational Aggression (DASA) to assess the impact of unit atmosphere on violence risk assessment.

WHAT IS KNOWN ON THE SUBJECT: Research suggests that the Dynamic Appraisal of Situational Aggression (DASA) is a useful risk assessment instrument to identify individuals who might be at risk of aggression in mental health inpatient units. Although, risk assessment research has typically focused on an individual's risk of aggression, recent research has begun exploring whether the DASA could be used to assess the likelihood that a group of patients would be aggressive. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: While the DASA was useful for assessing whether an individual was likely to be aggressive, the group average score was not a useful indicator for the likelihood of aggression once the individual DASA score was taken into consideration. Unexpectedly, patients who were assessed as high risk on the DASA were more likely to be aggressive on settled units compared to unsettled units, which included other individuals whose risk was elevated. WHAT ARE THE IMPLICATIONS FOR PRACTICE: There is not enough evidence to suggest that the group DASA average improves the identification of aggression above the individual DASA score. ABSTRACT: INTRODUCTION: The Dynamic Appraisal of Situational Aggression (DASA) is an inpatient aggression risk assessment instrument. Recently, research explored whether the unit atmosphere, as indicated by a unit's average DASA score, was related to inpatient aggression risk, but failed to control for individual risk. AIM: Investigate whether the DASA unit average score or an interaction between the unit average and an individual patient's DASA score was related to the likelihood that an individual would act aggressively. METHOD: Cox regression with repeated assessments and recurrent events was used to analyse 11,243 DASA risk assessments of 113 inpatients collected via retrospective file review. RESULTS: The unit DASA average score was not related to aggression towards staff. There was a negative interaction between the individual and the unit DASA average scores when identifying patient-to-patient aggression; high-risk patients engaged in less aggression when the unit average was heightened relative to units with lower DASA average scores. DISCUSSION: It is possible that there were more nursing interventions and/or patients engaged in greater self-regulation on unsettled units, thus reducing aggression. IMPLICATIONS FOR PRACTICE: Currently, there is insufficient evidence to suggest that the unit average score should be used to supplement individual DASA scores to identify aggression risk.

Investigating the dynamic nature of multiple risk assessment instruments in a forensic mental health hospital.

Readministration of multiple risk assessment instruments to determine the risk of aggression over the short, medium, and long term is common practice in many forensic mental health settings. Justification for the repeated administration and use of multiple instruments is based on purported differences in discriminative validity of risk factors according to whether they are characterized as static, stable, or acute, and the composition of these tools, in terms of the relative balance of different types of risk factors, which can impact the discriminative validity of these instruments over different follow-up periods. However, research has yet to determine whether the use of multiple and repeated administration of risk assessment instruments improves identification of risk, and it may be the case that the heavy burden on service providers to administer multiple instruments is unwarranted. In this study, time-dependent cox regression with repeated assessments and recurrent events was used to investigate the dynamic nature and incremental validity of the dynamic appraisal of situational aggression (DASA), short-term assessment of risk and treatability (START), and HCR-20v3, which were repeatedly rated on a sample of forensic mental health inpatients (N = 240) over a 2-year period. Results suggest that using the rolling mean or the most recent risk assessment yielded the most accurate characterization of change in aggression risk. Repeated administration of dynamic risk instrument instruments improved the identification of aggression beyond the initial risk assessment. Although static, stable, and acute factors were significantly related to aggression, the combination of data from multiple risk assessment instruments may not result in clinically meaningful improvements in risk identification. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The effects of judicial supervision on recidivism of offenders in Australia and New Zealand: a systematic review and meta-analysis.

This meta-analysis compares recidivism reduction in problem-solving courts employing judicial supervision in Australia and New Zealand to traditional processes. Using a four-phased search strategy, 16 studies totalling a treatment sample of 6588 individuals and 32,147 comparison participants were identified from 7161 unique records. Meta-analyses indicate that the problem-solving courts significantly reduced both the odds and incidences of recidivism compared with standard justice processes but that the heterogeneity observed within the latter analysis plus reliance on weak methodologies limits the strength of these conclusions. Studies at risk of bias may have had an undue influence on the odds of recidivism analysis. Additionally, the benefits of treatment on the incidence of recidivism are closely linked to the overlap of measurement and treatment periods. The findings suggest a positive impact from judicial supervision but further rigorous research is needed that closely matches experimental samples, strictly measures participants post-intervention and meticulously reports pertinent information.

Determinants and Outcomes of the Therapeutic Alliance in Treating Justice-Involved Youth: A Systematic Review of Quantitative and Qualitative Research.

A large body of research supports the role of the therapeutic alliance in predicting positive change in psychotherapy. This systematic review examined determinants of alliance quality and its association with treatment outcomes in an under-served and under-researched population-justice-involved youth-with whom several challenges and contextual considerations arise that bear relevance to the alliance. The search strategy yielded 23 independent studies meeting eligibility criteria and describing diverse treatments: 14 quantitative records synthesized narratively and nine qualitative studies that underwent thematic analysis. A complex picture emerged, precluding firm conclusions about factors linked to enhanced alliances and the alliance-outcome relationship with justice-involved youth. Nevertheless, some promising findings were noted across quantitative studies, including potential treatment benefits related to alliance growth and creating positive alliances with caregivers. The review also highlighted the potential relevance of the young person's relationships with peers and parents and their treatment readiness and expectations to alliance quality. Drawing on adolescent, caregiver, and therapist perspectives, the thematic synthesis of qualitative studies generated themes related to key elements of constructive alliances and their role in creating a foundation for initiating change. An integrated discussion is provided, highlighting practical implications and suggestions for addressing methodological limitations and substantive knowledge gaps.

The cross-cultural fairness of the LS/RNR: An Australian analysis.

OBJECTIVE: Cross-cultural research into risk assessment instruments has often identified comparable levels of discrimination. However, cross-cultural fairness is rarely addressed. Therefore, this study explored the discrimination and fairness of the Level of Service/Risk, Need, Responsivity (LS/RNR) within a sample of Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander males. HYPOTHESES: We hypothesized that discrimination would not be significantly different for Aboriginal and Torres Strait Islander individuals and non-Aboriginal and Torres Strait Islander individuals. We further hypothesized that some fairness definitions would be unsatisfied. METHOD: The study included 380 males (Aboriginal and Torres Strait Islander, n = 180) from Australia. Discrimination was assessed with the area under the curve (AUC) and cross AUC (xAUC). To determine fairness, error rate balance, calibration, predictive parity, and statistical parity were used. RESULTS: The discrimination of the LS/RNR was not statistically different (p = .61) between groups. The xAUC identified disparities (p < .001), with the LS/RNR being unable to discriminate between Aboriginal and Torres Strait Islander nonreoffenders and non-Aboriginal and Torres Strait Islander reoffenders (xAUC = .46, 95% CI [.35, .57]). Disparities among certain fairness definitions were identified, with Aboriginal and Torres Strait Islander individuals scoring higher on the LS/RNR (d = 0.52) and nonreoffenders being classified as high risk more often. CONCLUSIONS: The findings suggest that the LS/RNR may not be a cross-culturally fair risk assessment instrument for Australian individuals, and standard discrimination indices with comparable levels do not imply that a risk assessment instrument is cross-culturally fair. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Emergency department presentations in the first weeks following release from prison among men with a history of injecting drug use in Victoria, Australia: A prospective cohort study.

OBJECTIVE: Rates of emergency department (ED) use are higher among people released from prison than in the general population. However, little is known about ED presentations specifically among people with a history of injecting drug use (IDU) leaving prison. We measured the incidence of ED presentation in the three months following release from prison, among a cohort of men with histories of IDU, and determined pre-release characteristics associated with presenting to an ED during this period. METHODS: We analysed linked survey and administrative data from the Prison and Transition Health (PATH) study (N = 400) using multiple-failure survival analysis. RESULTS: Twenty-one percent (n = 81/393) of the cohort presented to an ED at least once within the three months after release from prison. The incidence of ED presentation was highest in the first six days after release. Cox proportional hazards modelling showed that a history of in-patient psychiatric admission and housing instability were associated with increased hazard of an ED presentation, and identifying as Aboriginal and Torres Strait Islander was associated with decreased hazard. CONCLUSIONS: In our study, ED presentations following release from prison among people with a history of IDU was linked to acute health risks related to known mental health and social vulnerabilities in this population. Greater collaboration and systems integration between prison and community health and support services is needed to reduce presentations to ED and associated morbidities among people with a history of IDU after release from prison.

Patterns of Maltreatment Co-Occurrence in Incarcerated Youth in Australia.

Child maltreatment research is increasingly recognizing the need to capture patterns of co-occurrence between different types of abuse/neglect and to consider their associations with psychosocial functioning. Few studies have examined these issues in justice-involved youth despite the fact that rates of maltreatment and trauma-related psychopathology are disproportionately high among this population. This study examined profiles of self-reported child physical abuse, sexual abuse, emotional abuse, and neglect among incarcerated juveniles in Victoria, Australia, using latent class analysis. We also investigated associations between maltreatment profiles and mental health and behavioral problems. Data pertaining to juveniles' experiences of maltreatment and mental health and behavioral functioning were collected from interviews, questionnaires, files, and administrative datasets. A three-class solution provided the best fit for the data and was conceptually meaningful: a "low/rare maltreatment" class (41%); "high physical and emotional abuse" class (23%); and a "poly-victimization" class (36%). Youth in the "poly-victimization" class experienced especially serious mental health and behavioral disturbances, including higher rates of mental illness, greater severity of internalizing and externalizing symptoms, impulsivity, substance abuse, self-harm and suicidal behavior, irritability, and early-onset violence. Results suggest there may be benefit in considering screening and assessment procedures in youth justice settings to identify poly-victimized youth in need of more intensive monitoring and treatment to address their complex clinical and behavioral profiles.

Psychiatric well-being among men leaving prison reporting a history of injecting drug use: A longitudinal analysis.

BACKGROUND: Community reintegration from prison is typically stressful, with several health and social outcomes impacting psychiatric well-being during this time, often exacerbated among individuals with histories of drug use. Longitudinal data was used to assess change in psychiatric well-being over 2 years following release from prison among men who reported a recent history of injecting drug use. METHODS: Data for this study come from the Prison and Transition Health cohort study of 400 men recruited in prison prior to release and followed up over three time points. Psychiatric well-being was assessed using the 12-item General Health Questionnaire. We calculated change in individual General Health Questionnaire scores between interviews and identified covariates associated with General Health Questionnaire score using linear mixed-effects regression. RESULTS: Data from 690 follow-up interviews among 326 participants were included in analyses. There was considerable variation in individuals' General Health Questionnaire scores. Moving accommodation frequently and frequent illicit drug injections were associated with an increase in General Health Questionnaire score (i.e. decline in psychiatric well-being). Two or more prior adult imprisonment episodes, social supports and past month primary healthcare attendance were associated with a decrease in General Health Questionnaire score. CONCLUSION: Our findings identify health, social and structural influences on psychiatric well-being after release from prison that can inform re-entry programmes to support community reintegration.

Strategies to maximise study retention and limit attrition bias in a prospective cohort study of men reporting a history of injecting drug use released from prison: the prison and transition health study.

BACKGROUND: There are significant challenges associated with studies of people released from custodial settings, including loss to follow-up in the community. Interpretation of findings with consideration of differences between those followed up and those not followed up is critical in the development of evidence-informed policies and practices. We describe attrition bias in the Prison and Transition Health (PATH) prospective cohort study, and strategies employed to minimise attrition. METHODS: PATH involves 400 men with a history of injecting drug use recruited from three prisons in Victoria, Australia. Four interviews were conducted: one pre-release ('baseline') and three interviews at approximately 3, 12, and 24 months post-release ('follow-up'). We assessed differences in baseline characteristics between those retained and not retained in the study, reporting mean differences and 95% confidence intervals (95% CIs).  RESULTS: Most participants (85%) completed at least one follow-up interview and 162 (42%) completed all three follow-up interviews. Retained participants were younger than those lost to follow-up (mean diff - 3.1 years, 95% CI -5.3, - 0.9). There were no other statistically significant differences observed in baseline characteristics. CONCLUSION: The high proportion of participants retained in the PATH cohort study via comprehensive follow-up procedures, coupled with extensive record linkage to a range of administrative datasets, is a considerable strength of the study. Our findings highlight how strategic and comprehensive follow-up procedures, frequent contact with participants and secondary contacts, and established working relationships with the relevant government departments can improve study retention and potentially minimise attrition bias.

Investigating the predictive validity of Static-99/99R scores in a sample of older sexual offenders.

There is limited information regarding the use of risk assessment tools with aging offender populations. It is known that the likelihood of offending behaviour decreases with age, a small group of men either continue or begin to offend sexually in the later decades of life. The current study investigated the predictive validity of the Static-99 and the Static-99R, in a sample of convicted Australian sex offenders aged 50 and older. A sample of 118 participants was identified, of which 17 (14.4%) re-offended within a follow-up period ranging from four months to 20 years (M = 9.07 years). There were seven recidivists (13.46%) above the age of 60 years (n = 52) and 10 aged 40 to 59.9 years (n = 66). Both the Static-99 and Static-99R demonstrated moderate predictive validity with both age groups. The limitations of this study are discussed as well as recommendations for future research.

The Prison and Transition Health (PATH) cohort study: Prevalence of health, social, and crime characteristics after release from prison for men reporting a history of injecting drug use in Victoria, Australia.

BACKGROUND: People who inject drugs are overrepresented in prison and have diverse and complex health needs. However, outcomes after release from prison are poorly understood, limiting effective interventions supporting community reintegration. We describe the prevalence of socio-demographics, physical and mental health, alcohol and other drug use, and crime characteristics of men with histories of injecting drug use after their release from prison in Victoria, Australia. METHODS: Data come from the Prison and Transition Health (PATH) prospective cohort study. Interviews were undertaken approximately three, 12, and 24 months after release from their index prison episode and were completed in the community, or in prison for those reimprisoned during the study. We present cross-sectional descriptive statistics for each follow-up wave of the PATH study. RESULTS: Among 400 men recruited into PATH, 85 % (n = 336) completed at least one follow-up interview; 162 (42 %) completed all three interviews. Participants reported social disadvantage and health inequity, including high rates of unemployment, homelessness, and physical and mental health morbidities at each follow-up time point. Rapid return to illicit substance use was common, as was overdose (ranging 9 %-13 %), receptive syringe sharing (ranging 20 %-29 %), involvement in crime-related activities (ranging 49 %-58 %), and reimprisonment (ranging 22 %-50 %) over the duration of follow-up. CONCLUSION: Men in this study experienced substantial health and social challenges across a 24-month prospective follow-up period. Improved understanding of characteristics and experiences of this group after release from prison can inform more coordinated and continued care between prison and the community.

A Clinical Decision Support System to Prevent Aggression and Reduce Restrictive Practices in a Forensic Mental Health Service.

OBJECTIVE: Preventing aggression and reducing restrictive practices in mental health units rely on routine, accurate risk assessment accompanied by appropriate and timely intervention. The authors studied the use of an electronic clinical decision support system that combines two elements, the Dynamic Appraisal of Situational Aggression instrument and an aggression prevention protocol (eDASA+APP), in acute forensic mental health units for men. METHODS: The authors conducted a cluster-randomized controlled trial incorporating a crossover design with baseline, intervention, and washout periods in a statewide, secure forensic mental health service. The study included 36 mental health nurses (13 men and 23 women, ages 20-65 years) with direct patient care responsibility and 77 male patients (ages 21-77 years) admitted to one of two acute mental health units during the baseline and intervention periods. RESULTS: eDASA+APP implementation was associated with a significant reduction in the odds of an aggressive incident (OR=0.56, 95% confidence interval [95% CI]=0.45-0.70, p<0.001) and a significant decrease in the odds of administration of as-needed medication (OR=0.64, 95% CI=0.50-0.83, p<0.001). Physical aggression was too infrequent for statistical significance of any effects of eDASA+APP to be determined; however, incidents of physical aggression tended to be fewer during the eDASA+APP phase. CONCLUSIONS: These results support the use of the eDASA+APP to help reduce incidents of aggression and restrictive practices in mental health units.

Testing the Factor Structure of the Psychopathy Checklist: Screening Version (PCL:SV) in an Australian Violent Offender Population.

Although psychopathy is a correlate of recidivism, including violent offending, the inclusion of antisocial behavior items in the Psychopathy Checklist (PCL) assessment instruments has been debated. Further, the latent factor structure underpinning the PCL measures has not been comprehensively validated in Australia. This study examined the construct validity of the PCL:SV in a sample of 192 Australian male violent offenders using structural equation modeling. The incremental validity of including the antisocial behavior items for predicting recidivism was also assessed. Approximately one-third of the sample had high scores on the PCL:SV. Construct analyses indicated strongest support for two distinct three-factor models of PCL psychopathy, with the established two- and four-factor models demonstrating poorer fit. The Antisocial factor improved predictive accuracy incrementally relative to the other three factors (Interpersonal, Affective, and Lifestyle). Area under the curve analyses revealed predictive accuracy for recidivism only for factors containing the antisocial behavior items. Findings contribute to the construct and predictive validity of the PCL measures and are discussed relative to contemporary forensic risk assessment practice.

The Personality Inventory for DSM-5-Brief Form: An Examination of Internal Consistency, Factor Structure, and Relationship to Aggression in an Incarcerated Offender Sample.

This study evaluated the internal consistency and factor structure of the Personality Inventory for DSM-5-Brief Form (PID-5-BF), and its relationship to aggression in 438 incarcerated Australian male offenders. Results provide support for the internal consistency and five-factor and bifactor structure of the PID-5-BF. The PID-5-BF total score, as well as the domains of Antagonism, Disinhibition, and Negative Affect (low), demonstrated significant relationships with aggression. These results provide preliminary support for the psychometric properties of the PID-5-BF within prison settings, and suggest that a PID-5-BF assessment may be useful within forensic settings to screen for broad maladaptive personality characteristics that are indicative of a greater propensity for aggressive behavior.

Predictive validity of the HCR-20V3 in a sample of Australian forensic psychiatric patients.

The Historical Clinical Risk Management-20 Version 3 is the latest iteration in the HCR-20 series, adopting novel changes such as the addition of Relevance ratings and non-requirement to include the Psychopathy Checklist-Revised. This study aimed to examine these changes and compare the predictive validity of the HCR-20V3 to the HCR-20V2. The sample comprised of 100 forensic psychiatric patients, retrospectively followed up for a maximum period of approximately 13 years post-discharge from the Thomas Embling Hospital. Recidivism data were sourced from official police records. Results indicated good to excellent inter-rater reliability. The HCR-20V3 significantly predicted violent recidivism (area under the curve = .70 to .77), levels of accuracy that were not significantly different from the HCR-20V2. HCR-20V3 Relevance ratings failed to add incremental validity above Presence ratings; however, the PCL-R improved upon the HCR-20V3's validity. The study represented one of the first evaluations of the HCR-20V3 in Australia.

Assessing the Link Between Intimate Partner Violence and Postrelationship Stalking: A Gender-Inclusive Study.

The link between intimate partner violence (IPV) during a relationship and postrelationship stalking (PRS) is poorly understood. The vast majority of relevant studies focus either on male perpetration or female victimization and use highly selective samples. The current study aimed to illuminate the link between IPV and PRS perpetration and victimization, respectively. To this end, heterosexual male and female university students (n = 422) retrospectively self-reported on IPV during their most conflicted relationship and a wide range of pursuit behavior after the dissolution of this romantic relationship. Using empirical criteria, participants were classified as stalkers or nonstalkers based on their responses. A relationship between male-perpetrated IPV and PRS perpetration was detected. There was no systematic relationship between IPV and PRS perpetration in women. In contrast, there was a link between IPV and stalking victimization that followed a similar, linear trend in both male and female victims. A larger proportion of participants were classified as stalking victims as IPV severity increased. Implications for research (e.g., the importance of gender-inclusive studies), clinical practice (e.g., how to prevent stalking after an abusive relationship), and future directions (e.g., the need for prospective studies using more diverse samples) are discussed.