Excellence in forensic psychiatry services: international survey of qualities and correlates.

BACKGROUND: Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development. AIMS: To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security. METHOD: A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire. RESULTS: Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score. CONCLUSIONS: Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

Between psychopathy and deviant socialization: A close look at the mafia men.

The Italian mafia organizations represent a subculture with values, beliefs and goals that are antithetical to and undermining of the predominant society. The conduct of individual members includes such extreme violence for material gain, it may at least superficially suggest a severe personality disorder. Since the first edition of the DSM and into the 21st century, various terms have been used, sometimes interchangeably, but over time inconsistently, to designate the mentality and practices of mafia members. Only recently has the psychology of mafia members become a focus of serious scientific study. Following broader national multicenter research, the present study aimed at investigating the possible differences in psychopathy between those mafia associates who had been convicted only of mafia association (Group A, bosses), and those who were also convicted of violent crimes (Group B, soldiers). The Psychopathy Checklist-Revised (PCL-R) was administered to n = 48 male inmates convicted of mafia association (Mage 45.0 years, SD 10.9, range 20-80 years); Group A consisted of n = 26 (54%) subjects, Group B n = 22 (46%). Most of the sample (73%) did not manifest psychopathy (PCL-R ≥ 25) nor Mann-Whitney U test disclosed significant differences in the total PCL-R scores between the study groups. We found significantly higher scores of PCR-R factor 1 (interpersonal / affective) in the members of the mafia association also convicted of violent crimes (PCL-R F1, group A: 5.8 ± 3.7; group B: 7.9 ± 3.5; p < 0.05), this difference appeared explainable on the basis of a higher component of affective psychopathy. These initial results add to the limited literature on mafia and psychopathy and seem to suggest the existence of a specific component of psychopathy in the subgroup of mafiosi with overtly violent conduct.

Reform of Forensic Mental Health Services in Italy: Stigma and Blaming the Messenger: Hermenoia.

About 40 years after the reforms leading to the closure of psychiatric hospitals (Ospedale Psichiatrico [OP]) in Italy in favor of a widespread model with a strong rehabilitation emphasis, Italy has chosen to close High Security Hospitals as well (Ospedale Psichiatrico Giudiziario [OPG]). The new forensic treatment model is expected to be more respectful of the person, including the perpetrators of violent crimes, and aims to be less stigmatizing and more rehabilitative. Despite the favorable premises of the reform (Law n. 81/2014), Italian psychiatrists are now obliged to answer calls to give evidence on strictly legal issues such as the social dangerousness of the mentally ill offender drawing on evidence or paradigms that many believe do not belong to medical knowledge. Psychiatrists must now learn to communicate about the relationship between psychiatry and society as required by law. This public expression engages with the cultural climate of society. Otherwise, the risk is of increasing the level of complexity leading to real misunderstandings that paradoxically may feed the stigma. The Italian reform provides an opportunity for reflection on some issues concerning psychiatric action, on how the public perceives the mentally ill and their psychiatrists, on the relationship between psychiatry and the world of law, on clinical methodologies for structured professional judgment, on public communication regarding severe mental illness, and the risk that psychiatrists may inadvertently be blamed for conveying an unwelcome message about mental illness and social dangerousness-we have called this social sensitivity against psychiatrists "hermanoia," blaming the messenger. The authors do not provide certain solutions but propose good practices.

Differences Between Readmitted and Non-readmitted Women in an Italian Forensic Unit: A Retrospective Study.

The main objective of this study was to compare readmitted (RW) and non-readmitted (NRW) female psychiatric patients after being conditionally or unconditionally released from Italian inpatient forensic psychiatry services, in order to identify variables that were significantly linked with readmission. This study included all patients who were discharged from the female Residences for the Execution of the Security Measure (REMS) of Castiglione delle Stiviere from January 2008 to June 2015 who were not readmitted until December 31, 2018 (48). In addition, data were collected on female patients who were discharged from the same REMS before 2008 and readmitted from January 2008 to December 2018 (42). A key finding of our study was that the readmission into a female REMS was positively associated with the presence of substance use disorders (SUD) and a primary diagnosis on Axis II. To a lesser extent, younger age, being unconditionally discharged when first released, having had a shorter length of inpatient stay and having committed a crime against property for the first REMS admission was also variables that were apparently linked with readmission. The present research continues the previous research on gender-specific mentally ill offenders. Hence, the decision to proceed separately with a sample of men only and one of women only. For all these reasons, young female patients with personality disorder and SUD perhaps should remain longer in REMS and be released with conditions. In most European countries, the length of stay depends on the clinical condition and risk assessment, with some exceptions where the courts set a maximum length of stay at the outset, as in Italy. All the factors listed above influence the risk assessment. Finally, from integrating these findings into the increasing international literature on conditional release and considering the recent changes in the Italian forensic treatment model, we recommend continuing research on individual risk and protective factors as well as risk assessment instruments on conditionally and unconditionally released inpatients with genders studied separately.