Toward an Integrated Sexual Policy in Forensic Psychiatry: A Mixed Method Pilot Study.

Forensic inpatients reside for long periods in restricted environments, which do not support the presence of sexual experiences or the expression of existing needs. However, sexuality and sexual health are important aspects in the overall recovery from mental illness. Given the lack of national policies, management decisions are bestowed upon individual institutions and staff members. This research aims to describe the current sexual policies in 32 forensic psychiatric wards in Flanders (the Dutch-speaking part of Belgium), varying from low to high security, and explore the perspective of forensic inpatients regarding such policies. The research questions were answered using a survey that questioned the different forensic units. Only 56% of the wards had a sexual policy at the hospital level. Results showed no significant differences in the applicable sexual policies between the security levels, but individual differences and inconsistencies exist in the rules and agreements applied among different wards. Subsequently, 15 semi-structured in-depth interviews with inpatients were conducted using a phenomenological approach. Most of the respondents were dissatisfied with their sexuality and experienced various barriers in meeting their sexual wants and needs. The results have an added value for clinical practice and lead to recommendations in the development of an integrated sexual policy.

Hospital break. An eight-year review of escapes and absconds from two high security forensic centers.

BACKGROUND: Increasing freedom of movement and community reintegration is a vital part of recovery for forensic service users. Clinical teams realize that risk of unauthorized leave exists when granting leave, tasking them with balancing the recovery-based treatment needs of the patients with the larger obligation to protect the public from undue risk of harm. While considerable literature exists on unauthorized leave from acute psychiatric units, there is still little research specific to unauthorized leave from forensic settings. AIMS: The aim of this study is twofold. First, to examine the prevalence rates and characteristics of unauthorized leaves (i.e., absconds and escapes) among 654 high security forensic patients. Second, to identify individual patient factors associated with unauthorized leaves. A broad array of risk factors is taken into account, including demographic, clinical, judicial and criminal factors. PRINCIPAL RESULTS: During the 8-year period (17th of November 2014 until 17th of November 2022), there were 59 unauthorized leaves, which represents a very low percentage (0.2%) relative to the total number of leaves. Most patients returned to the hospital or were caught within one week. The reasons that led to an unauthorized leave were in more than half of the incidents frustration and in more than a third goal-directed. Only a minority of the unauthorized leaves was associated with subsequent offending, notwithstanding substance use was more frequent. Patients that absconded or escaped more often had a personality and comorbid substance misuse disorder, but less often a paraphilic disorder. They were younger, had more convictions and higher risk scores. After logistic regression, only personality disorder, comorbid substance misuse disorder and number of convictions were independently associated with unauthorized leave. CONCLUSIONS: The results of this study indicate that ULs occurred rarely, and in most instances, patients returned within a short period without further incidents. Personality disordered patients with comorbid substance misuse and prior convictions posed the greatest risk to abscond or escape. Overall, the rate of unauthorized leaves and subsequent offending was small relative to the total number of leaves. This suggests that the risk for absconding was assessed in an adequate manner by the clinical teams. The study hopefully adds to reducing the stigma towards leaves from forensic psychiatric hospitals.

Longitudinal Change of Risk Factors During Treatment in High-Security Forensic Psychiatry in Flanders.

Empirical studies on the longitudinal change of risk factors during treatment of forensic psychiatric patients are scarce. Therefore, in the current study, changes in risk factors of 341 high-security forensic psychiatric patients in Flanders were investigated using latent growth curve analyses. Annual assessments of the Historical Clinical Future-Revised (HKT-R) at three time points were considered, starting at time of admission. A significant small improvement was found on the future scale and most future factors. However, the clinical scale did not change significantly and only one of the 14 clinical factors (i.e., problem insight) changed significantly over time. Although the forensic treatment seems to be a slow process, the sensitivity of the HKT-R to detect clinically relevant change is questioned, underscoring the importance of determining whether there are instruments capable of detecting small significant changes over time.

High Security Settings in Flanders: An Analysis of Discharged and Long-Term Forensic Psychiatric Patients.

Background: Two Forensic Psychiatric Centres (FPC) were implemented the last decade in Flanders in Ghent (2014) and Antwerp (2017). FPCs are forensic institutions for forensic psychiatric patients with a high recidivism risk and a high security need. The objective of FPCs is to create a care process with sufficient flow (from high to lower forms of security), and transitions (from specialized forensic care to regular psychiatric care). Aims: To examine the characteristics of the high security population in FPCs, treatment length, number of discharges, and discharge locations and to determine the profile of long-term patients within an FPC. Methods: A retrospective file study of an admission cohort of 654 patients admitted to FPC Ghent or FPC Antwerp was conducted. Sociodemographic, clinical, judicial and risk characteristics were analyzed. Bivariate analyses were used to test the difference between two groups: the group that was discharged to a lower security level vs. the group of long-term patients. Results: Most patients had psychosis and personality disorders, while comorbidity was also high. Judicial histories were extensive, with many sexual index offenses. During a 6-year follow-up period, the number of referrals back to prison was low. Nearly a third of the population was discharged to a setting with a lower security level. Long-term patients typically presented with more personality disorders, higher psychopathy traits and higher risk scores and were more frequently subjected to coercive measures during treatment. Conclusions: The Flemish FPC population is characterized by a high proportion of sex offenders as well as a high proportion of personality-disordered patients. It is this last group, and the group with elevated psychopathy traits, who remain for longer than expected and is difficult to resocialize. This study further highlights the need for clear criteria to assess the conditions of these long-term patients in Flanders.

The use of coercive measures in a high security setting in Belgium: Prevalence and risk factors.

Coercive measures are often used in forensic psychiatric settings as a strategy to manage violent and other problematic behavior. Few studies have been published regarding the use of coercive measures in high security populations. This is the first empirical study on this subject in Belgium. The aim of the present study was to examine the prevalence rates of coercive measures in Flanders' two high security settings and to identify individual patient risk factors for being subjected to a coercive measure. The study included all patients (N = 654) who were admitted in the Forensic Psychiatric Centres of Antwerp or Ghent over a six-year period. Data on the use of coercive measures (seclusion, mechanical restraint, and chemical restraint) were registered prospectively. Several regression analyses were conducted with multiple independent variables. The results show that half of the population (50.3%) was subjected to at least one coercive measure during admission in one of the high security settings. A small subgroup of patients (6.4%) was the subject of half of all coercive measures (50,4%). Seclusion was the most frequently used coercive measure (48.3%), followed by chemical restraint (20.2%). The prevalence rate of mechanical restraint was very low (0.8%) compared to previous research in similar populations. Various individual risk factors were significantly associated with a higher use of coercive measures. Clinical implications are discussed and the importance of developing international standards on recording and reporting on coercive measures is highlighted.

Criminal responsibility evaluations: Benchmarking in different countries.

Forensic mental health experts play a crucial role in criminal responsibility evaluations. However, the quality of these assessments has at time come under scrutiny and has been heavily criticized. A literature review revealed significant differences between countries concerning legal frameworks and procedures for conducting these assessments. The findings suggest that although some countries can be seen as a "role model", there still is room for improvement.

The impact of androgen deprivation therapy on bone mineral density in men treated for paraphilic disorder: A retrospective cohort study.

BACKGROUND: Guidelines suggest treating men with paraphilic disorder with androgen-deprivation therapy (ADT). However, little evidence is available about the long-term impact on bone loss and how to manage this adverse event. OBJECTIVES: The aim of this study is to assess the impact of ADT on bone mineral density (BMD) in men treated for paraphilic disorder with the androgen receptor blocker cyproterone acetate (CPA) and/or GnRH agonist triptoreline (GnRHa) and to evaluate the effect of treatment with bisphosphonates. METHODS: Baseline and follow-up dual-energy X-ray absorptiometry scan (DXA-scan) data (lumbar and femoral T-scores) were retrospectively extracted from electronic medical files of paraphilic men who received CPA and/or GnRHa. RESULTS: A total of 53 patients with a mean age of 39.1 years (range 17.5-74.6) were included. Lumbar (-0.39 ± 0.17, Mean ± SEM, p = 0.046), femoral neck (-0.34 ± 0.09, p = 0.002) and total femur (-0.33 ± 0.12, p = 0.014) T-scores decreased significantly in the CPA-only group (n = 13) during a mean follow-up of 6.0 ± 5.3 years. In the GnRHa group (n = 29), T-scores at all sites decreased significantly over 6.6 ± 4.4 years (lumbar: -0.55 ± 0.12, p < 0.001, femoral neck: -0.53 ± 0.09, total femur: -0.44 ± 0.09, p < 0.001). In the group, who received bisphosphonates (n = 11), no significant T-score change was observed (lumbar: -0.25 ± 0.14, p = 0.106, femoral neck -0.15 ± 0.17, p = 0.402, total femur -0.25 ± 0.14, p = 0.106) during 5.0 ± 2.8 years of follow-up. DISCUSSION AND CONCLUSION: Following a mean duration of 6 years of ADT, we observed a significant decline in BMD of approximately half a standard deviation in T-score at lumbar and femoral site. Although the number of patients who received bisphosphonates was limited, this treatment seems to have a positive stabilizing effect on bone density.

Is non-completion of treatment related to security need?

BACKGROUND: Treatment completion difficulties are common in forensic mental health settings and may have a profound impact on recidivism rates. AIMS: To test for associations between measures of risk and of security needs on the one hand and treatment non-completion on the other among male offender-patients in one medium security hospital. METHODS: We conducted a retrospective file study in a Flemish medium security hospital. A random sample of 25 treatment non-completers was compared to a random same-size sample of completers, each rated, blind to outcome, on the DUNDRUM-1 security needs scale from data recorded at the time of admission to the unit. 'Non-completion' was defined as any failure to complete treatment, whether staff-terminated or self-terminated; in Flanders, failure to comply with the judicial conditions of placement can result in re-imprisonment. We used binary logistic regression to test relationships between treatment completion/non-completion and security need, measured with the DUNDRUM-1, together with a range of possible confounding variables. RESULTS: Most patients had psychosis and/or personality disorder and often substance use disorders also. Treatment non-completion was invariably staff ordered because of security breaches. DUNDRUM-1 and PCL-R Facet 4 scores at the time of admission and HCR-20 scores during admission were significantly higher among non-completers than completers, but after binary logistic regression, only the DUNDRUM-1 rating was independently associated with non-completion. CONCLUSIONS: Our study showed that an admission DUNDRUM-1 rating, indicating levels of security need, co-varies only to a small extent with the historical items of the HCR-20, so may be regarded as measuring complementary domains. While conditions in Flanders at the time of the study complicated it in that medium security hospital units offered the highest level of hospital security available, the finding that non-completion of treatment was particularly likely when the DUNDRUM-1 indicated a higher security need than facilities could provide may have implications for all secure hospital services.

Androgen Deprivation Therapy in Pedophilic Disorder: Exploring the Physical, Psychological, and Sexual Effects From a Patient's Perspective.

BACKGROUND: The use of androgen deprivation therapy (ADT) shows promising results in the treatment of paraphilic disorders. Although the side effects of ADT can be intrusive, there is no research into the experiences of patients with pedophilic disorder themselves. AIM: This research aims to explore the psychological, physical, and sexual experiences of ADT from the perspective of sex offenders diagnosed with pedophilic disorder. METHODS: Twelve semistructured in-depth interviews with male adults diagnosed with pedophilic disorder were conducted using a phenomenological approach. Six of the 12 respondents were on luteinizing hormone-releasing hormone agonists and the remaining on anti-androgens. Half of each group were inpatients, and the other half outpatients. The respondents were recruited in collaboration with one psychiatric hospital. The data were analyzed with help of a qualitative software application NVivo. OUTCOMES: The respondents described experiences on the use of ADT on a physical, psychological, and sexual level. RESULTS: The most prominent physical side effects mentioned were bone loss, weight gain, and breast formation. The respondents generally described a positive influence of the medication on their well-being. They felt more relaxed and experienced a reduction in frequency and intensity of sexual fantasies, anger, and aggressive feelings in general. In addition, all the respondents noticed a lower frequency of sexual contact and masturbation. Most of the participants experienced the use of ADT as a mandatory decision made by the treating psychiatrist. CLINICAL IMPLICATIONS: This study recommends informing patients and their loved ones on the potential side effects of ADT. Furthermore, training forensic counselors on potential side effects of ADT and methods to alleviate them can promote the dissemination of information and will encourage the informed consent procedure. STRENGTHS & LIMITATIONS: This is the first qualitative study about the experiences of ADT in men diagnosed with pedophilic disorder in Belgium. Future studies should include more than one treatment center. CONCLUSION: The majority of the participants had a positive attitude towards ADT in general. Boons L, Jeandarme I, Vervaeke G. Androgen Deprivation Therapy in Pedophilic Disorder: Exploring the Physical, Psychological, and Sexual Effects From a Patient's Perspective. J Sex Med 2021;18:353-362.

Who Are the Victims of NGRI Acquittees? A Study of Belgian Internees.

BACKGROUND: The limited literature on victim characteristics of offenders found not guilty by reason of insanity (NGRI) shows that most victims are adults who are known to the offender. It is currently unclear whether victims are mainly male or female or whether there are differences in the type of victims according to the offenders' psychiatric disorder. METHOD: Victim characteristics were retrospectively collected from 362 NGRI acquittees, and the influence of psychiatric diagnoses on victim profiles was examined. RESULTS: Victims were mainly adult acquaintances and were equally likely to be male or female. Family members and caregivers were the most frequent type of acquaintance victims. Further analyses suggest that these victim characteristics are similar for perpetrators with different psychiatric diagnoses. CONCLUSION: Victimization of strangers and minors was unlikely in NGRI offenders.

Structured versus unstructured judgment: DUNDRUM-1 compared to court decisions.

BACKGROUND: Criteria to determine in which level of security forensic patients should receive treatment are currently non-existent in Belgium. Courts largely rely on the evaluations of the prison psychiatrists and psychologists to form their decision. None of the few available instruments - e.g., the DUNDRUM-1 - is currently used to provide structured clinical judgment when determining security level. METHOD: DUNDRUM-1 scores were collected for 150 forensic patients. Security levels according to DUNDRUM-1 assessment were compared to security levels as decided by the court. RESULTS: There was little agreement between DUNDRUM-1 scores and proposals for secure care made by the court. The DUNDRUM-1 predicted eventual admission to a high security setting, but not a medium security setting. CONCLUSION: The DUNDRUM-1 is an instrument that can help clinicians and judges to make more reliable and transparent decisions regarding secure care. However, further research with regard to practical applicability is needed.

Risk Factors Associated With Inpatient Violence During Medium Security Treatment.

Violence is a common phenomenon both in regular and forensic psychiatric settings, and has a profound impact on staff and other patients. Insight into the individual risk factors associated with violence in forensic psychiatric settings is rare and is therefore the subject of this research. A retrospective file study in three medium security units in Flanders was conducted to compare non-violent inpatients with inpatients who engaged in (verbal and physical) violent behavior. Binary logistic regression analyses were used to examine which variables contributed independently to the risk of violence. The results showed that absconding during treatment was independently associated with physical violence. A personality disorder diagnosis and general non-compliance with treatment were associated with verbal violence. Both types of violence predicted early termination of treatment. Contrary to previous research, the results from the risk assessment tools were not associated with inpatient violence. Clinical implications are discussed and include, among others, that clinicians should remain vigilant for early warning signs of non-compliance during treatment.

Predicting Institutional Aggression in Offenders with Intellectual Disabilities Using the Violence Risk Appraisal Guide.

BACKGROUND: One of the most extensively tested risk assessment instruments in offenders with an intellectual disability (OIDs) is the Violence Risk Appraisal Guide (VRAG). The purpose of this prospective study was to test the ability of this instrument to predict institutional aggression in OIDs. METHOD: VRAG scores were collected for 52 OIDs, and staff registered aggressive incidents during a period of 6 months. Predictive accuracy was analysed using several performance indicators. RESULTS: The VRAG was not able to significantly predict aggressive behaviour, although a trend towards significance was found for interpersonal physical aggression. Furthermore, the VRAG was only accurate in prospectively identifying low-risk individuals. CONCLUSION: Compared to other studies, demonstrating good predictive validity for institutional aggression in OIDs, the VRAG performed poorly in this study. The usefulness of this instrument in identifying high-risk offenders is questioned. Until further evidence is available from studies using multiple performance indicators, clinicians have to be very careful in relying on the results of a risk assessment tool.

Critical incidents and judicial response during medium security treatment.

This study examined inpatient incidents in three Flemish forensic medium security units and analyzed the subsequent judicial reactions to these incidents. During medium security treatment, incidents were reported for more than half of the participants. The most frequently registered incidents were non-violent in nature, such as absconding and treatment non-compliance. The base rate for physically violent incidents was low. Although crime-related incidents during medium security treatment were rarely prosecuted and adjudicated, the base rate of revocation - and hence drop-out from treatment - as a result of these incidents was high.

PCL-R field validity in prison and hospital settings.

Recent field studies have questioned the interrater reliability (IRR) and predictive validity regarding (violent) recidivism of the Psychopathy Checklist-Revised (PCL-R). Using a forensic psychiatric sample, the current study investigated discrepancies in scoring between hospital and prison settings, as well as differences in predictive validity across these two settings. PCL-R information was collected from prison and hospital files, resulting in 224 PCL-R total scores and 74 double scores. When examining repeated measurements, large individual differences were found together with an intraclass correlation coefficient (ICCA,1) of .42 for the total score. Discrepant results were found for Factor 2, with repeated scores within the same setting having an ICCA,1 of .28 versus an ICCA,1 of .57 for repeated scores between settings. However, areas under the curve (AUCs) from receiver operating characteristic (ROC) analyses for total, factor and facet scores did not differ between settings. For the whole sample, Factor 2 scores marginally predicted violent and general recidivism after 2 years (AUC = .62 and .63), whereas Factor 1 did not predict (violent) recidivism. Consistent with recent studies from other countries, these results suggest inadequate field reliability and validity in prison and hospital settings in Flanders (Belgium). (PsycINFO Database Record

Reconviction and revocation rates in Flanders after medium security treatment.

AIM: To examine the criminal outcome of Flemish forensic psychiatric patients ('internees') after medium security treatment. Also, the effect of conditional release on recidivism of two subgroups (internees under conditional release and internees who received unconditional release) was examined. METHOD: Reconviction rates and revocation rates were collected for all participants. Kaplan-Meier survival analyses were used to investigate recidivism rates while controlling for time at risk. RESULTS: During the 10-year period, 502 offenders were discharged from medium security treatment. Over a follow-up period averaging 3.6years, 7.4% of discharged patients were reconvicted or received a new 'not guilty by reason of insanity' (NGRI) verdict for a violent offence. One-quarter of the population had their conditional release revoked. Part of the study population was granted unconditional release. Reconviction rates were higher after unconditional release in comparison to conditional release. CONCLUSIONS: The results of this study suggest that the court supervision of NGRI patients in Flanders is effective in protecting the community from further offending.

Intelligence is in the eye of the beholder: investigating repeated IQ measurements in forensic psychiatry.

BACKGROUND: A stable assessment of cognition is of paramount importance for forensic psychiatric patients (FPP). The purpose of this study was to compare repeated measures of IQ scores in FPPs with and without intellectual disability. METHODS: Repeated measurements of IQ scores in FPPs (n = 176) were collected. Differences between tests were computed, and each IQ score was categorized. Additionally, t-tests and regression analyses were performed. RESULTS: Differences of 10 points or more were found in 66% of the cases comparing WAIS-III with RAVEN scores. Fisher's exact test revealed differences between two WAIS-III scores and the WAIS categories. The WAIS-III did not predict other IQs (WAIS or RAVEN) in participants with intellectual disability. DISCUSSION: This study showed that stability or interchangeability of scores is lacking, especially in individuals with intellectual disability. Caution in interpreting IQ scores is therefore recommended, and the use of the unitary concept of IQ should be discouraged.