Fixated Threat Assessment Centers: preventing harm and facilitating care in public figure threat cases and those thought to be at risk of lone-actor grievance-fueled violence.

The rediscovery of the importance of mental illness in the risk assessment and management of those who threaten, approach, and harm public figures has led to a new way of dealing with those that threaten public figures. This approach emphasises the role of "fixation" which may be defined as an intense preoccupation pursued to an abnormally intense degree. It integrates a threat assessment paradigm with the literature on stalking. The need for such an approach was highlighted in research on the prevalence of harassment of public figures. Psychiatry has a key role in this approach which sees mental health clinicians and Police work together in Fixated Threat Assessment Centres (FTACs). An FTAC functions by assessing the level of concern and sharing information to facilitate interventions that are often mental health based. The purpose is not the hopeless task of identifying those who will go on to perpetrate serious violence, rather to intervene in the group they emerge from, to prevent harm. As well as decreasing risk to the persons fixated upon, this approach improves care to the mentally disordered people who harass and threaten them and, in doing so, decreases the likelihood of their criminalization while enhancing their quality of life. As expertise in the area has grown, policing and security agencies in several countries have expanded the FTAC model to cover individuals thought at risk of lone-actor grievance-fueled violence, a term that captures both different forms of mass killing and lone actor terrorism.

Challenges to Reforming the Competence to Stand Trial and Competence Restoration System.

Many mental health and justice professionals have noted that the system that manages both competence to stand trial (CST) evaluation and competence restoration (CR) processes in criminal cases is in crisis. Public mental health services often are inundated with court referrals and are challenged to address them in a timely manner, resulting in waits for competence-related services for people in jail as well as substantial risks to criminal defendants for whom competence issues are raised. In this review, the authors describe the current CST-CR system and offer preliminary solutions to its challenges. In addition, they examine published works on the legal foundation of CST to help support the basis for this analysis. The results of this review point to the need to more effectively address the complexities of the CST-CR systems and highlight the importance of collaboration across legal and clinical systems. Guidance to states can be best facilitated by support for empirical research on the individual- and system-level factors that contribute to the waitlists and system paralysis that have a negative impact on people with serious mental illness in the criminal justice system.

Alternatives to custodial remand for women in the criminal justice system: A multi-sector approach.

Throughout the world, women involved in criminal justice systems often present with substantial needs and vulnerabilities. Diverting vulnerable people away from prison is government policy in England and Wales, but full psychiatric and social assessments are expensive and hard to access. A screening and quick response initiative - alternatives to custodial remand for women (ACRW) - was implemented across three areas of London (West, South and East) to supplement existing court liaison and diversion services, to assess the feasibility of a supplementary custodial remand service as part of a women's specialist service pathway in the criminal justice system in England. Three mental health trusts and two voluntary sector providers offered this service enhancement - a screening and service link provision in three London boroughs between 2012 and 2014. We conducted a service evaluation using routinely collected service use record data. The service made 809 contacts, of whom 104 had contact on multiple occasions. Many were identified as at risk of self-harm (46%) or had histories of hospital admission for mental disorder (36%), but few were referred either to the liaison and diversion service or specialist mental health services. The largest group of referrals was to women's community services outside the health service (e.g. counselling, domestic violence or sexual abuse services). 180 women had dependent children and 22 were pregnant, increasing the urgency to find non-custodial alternatives. As well as confirming high levels of need amongst women entering the criminal justice system, this evaluation confirms the feasibility of working across sectors in this field, providing an extra layer of service that can complement existing liaison and diversion service provision. The service was responsive and most women using it were kept out of custody. Research is now required to understand the appropriateness of the referrals, the extent to which women follow them through and the impact on their mental health and desistance from offending.

[COVID-19 and mental health services in Europe]. / COVID-19 e servizi di salute mentale in Europa.

The area of mental health is directly affected by the pandemic and its consequences, for various reasons: 1-the pandemic triggered a global lockdown, with dramatic socioeconomic and therefore psychosocial implications; 2-mental health services, which treat by definition a fragile population from the psychological, biological and social points of view, have a complex organizational frame, and it was expected that this would be affected (or overwhelmed) by the pandemic; 3-mental health services should, at least in theory, be able to help guide public health policies when these involve a significant modification of individual behaviour. It was conducted a narrative review of the publications produced by European researchers in the period February-June 2020 and indexed in PubMed. A total of 34 papers were analyzed, which document the profound clinical, organizational and procedural changes introduced in mental health services following this exceptional and largely unforeseen planetary event.Among the main innovations recorded everywhere, the strong push towards the use of telemedicine techniques should be mentioned: however, these require an adequate critical evaluation, which highlights their possibilities, limits, advantages and disadvantages instead of simple triumphalist judgments. Furthermore, should be emphasized the scarcity of quantitative studies conducted in this period and the absence of studies aimed, for example, at exploring the consequences of prolonged and forced face-to-face contact between patients and family members with a high index of "expressed emotions".

Illuminating the gendered nature of health-promoting activities among nursing staff in forensic psychiatric care.

When people in Sweden are sentenced and handed over to forensic psychiatric care (FPC), the authorities have overall responsibility for their health recovery. How nursing staff construct gender through their relations in this context affects their understanding of health promotion activities. The aim of this study was to illuminate, using a gender perspective, the understanding of nursing staff with respect to health promotion activities for patients. Four focus group interviews were conducted with nursing staff in two FPC clinics in Sweden. The study has a qualitative inductive design with an ethnographic approach. This study sheds new light on FPC in which its dual goals of protecting society and providing care are viewed from a gender perspective. When relationships within the nursing staff group and the nurse-patient relationship are justified by the goal of protecting society, gender becomes invisible. This might cause patients' individual conditions and needs for certain types of activities to go unnoticed. One of the implications of ignoring gender relations in nursing staff health promotion activities is that it risks contributing to gender stereotypes which impact on the nurse-patient relationship and the quality of care.

A Seat at the Table.

Organized medicine and psychiatry have a long tradition of governmental advocacy and public engagement. The American Academy of Psychiatry and the Law (AAPL), since its founding 50 years ago, has made some forays into these fields. However, its involvement has been less substantial than other similarly situated professional organizations. With its increasing membership and expertise, AAPL now possesses the capacity to dedicate some of its organizational attention, energy, and resources to educating policymakers and the public on current and future topics related to forensic mental health. In addition, an increasing number and type of professional activities related to this discipline are affected by governmental regulation and public opinion. Therefore, the need to become involved in shaping policy is more urgent, particularly in light of the fact that other forensic mental health organizations have been actively involved in governmental advocacy for decades. Finally, as a field and in the near future, we likely will deal with life-changing technological innovations related to the practice of forensic psychiatry. AAPL and its members are perhaps uniquely qualified and have a responsibility to help ensure that these innovations are developed, implemented, and utilized appropriately. This can only be accomplished by having a proverbial seat at the table in the process.

[General medical care in French psychiatric units for inmates: A national survey]. / Soins médicaux généraux en unité hospitalière spécialement aménagée : une enquête nationale.

OBJECTIVES: The UHSA (UHSA) are French psychiatric units for inmates which admit detainees suffering from a psychiatric disorder requiring full-time hospital care. Non-psychiatric pathologies are overrepresented in patients with psychiatric disorders but also in detainees. As a result, patients hospitalized in UHSA are largely exposed to non-psychiatric conditions, and exploring the organization of general medical care for these patients appears very relevant. The aim of this study is to review the general medical care in all French UHSA. METHODS: A descriptive study was carried out through a survey of the nine facilities. RESULTS: All UHSA benefit from the intervention of a general practitioner. The physical clinical examination, the biological assessment and the electrocardiogram are systematically performed at the patient's admission in 7, 5 and 9 establishments, respectively. However, the offer of general medical care in UHSA seems disparate and sometimes insufficient. Specialized consultations are regularly requested during hospitalizations, but no establishment benefits from a telemedicine system or specialized consultations on site. The extraction of the patient to the general hospital is therefore systematic when such a consultation is needed. But the number of penitentiary escorts per day is limited. In 6 UHSA, medical extractions are thus regularly canceled by the penitentiary administration, sometimes without a medical opinion. Finally, the patient's regular physician is only contacted in 3 UHSA during hospitalizations. CONCLUSION: Based on these results, ways of improving the organization of general medical care in UHSA are proposed through four main axes: the structure and general organization; the general medical care; the link with the healthcare partners and the articulation with the penitentiary administration.

Profiling Mentally Ill Offenders in Hong Kong: a 5-year Retrospective Review Study.

OBJECTIVES: This study aimed to determine the prevalence of mental illness in offenders referred to psychiatrists from January 2011 to March 2016 and any associations between crime and mental illness in these offenders. METHODS: Case notes of offenders referred to psychiatrists at the Siu Lam Psychiatric Centre from 1 January 2011 to 31 March 2016 were reviewed. Data on sex, age on admission, educational level, principal psychiatric diagnosis, index offence, source and reason of referral, and outcome were collected. RESULTS: Case notes were reviewed for 4492 offenders (75% males) aged 14 to 93 (mean, 40.6) years. Of these, 68% were referred by the courts for psychiatric report and 32% were referred by correctional institutions for psychiatric assessment and treatment. Approximately 73% of them had a diagnosable mental disorder. The most common principal psychiatric diagnoses were schizophrenia and related disorders (25%), mental and behavioural disorders due to psychoactive substance use (20%), and mood disorders (9%). The most common index offences were theft and related offences (22%), acts intended to cause injury (20%), and illicit drug offences (11%). Offences involving violence were more prevalent in males than in females (p < 0.001). In terms of the three most common principal psychiatric diagnoses, 'acts intended to cause injury' was most prevalent in those with 'schizophrenia and other related disorders' than in those with the other two diagnoses (31% vs 19% vs 17%, p < 0.001). 'Theft and related offences' was most prevalent in those with mood disorders than in those with other two diagnoses (38% vs 20% vs 18%, p < 0.001). 'Illicit drug offences' was most prevalent in those with 'mental and behavioural disorders due to psychoactive substance' than those with other two diagnoses (22% vs 8% vs 6%, p < 0.001). CONCLUSIONS: The prevalence of mental disorders among offenders referred to psychiatrists is high. The pattern of associations between crime and mental disorders in these offenders is comparable with that reported in overseas studies. As Siu Lam Psychiatric Centre is the only facility in Hong Kong for mentally ill offenders, our sample is representative, and our results provide cross-sectional pattern of forensic psychiatric service utilisation in Hong Kong.

[Practice in forensic psychiatry: A proposed interdisciplinary model.]

Although professional practice in forensic psychiatric environments is, in our opinion, extremely complex and requires the input of different disciplines, conceptual or theoretical models guiding this practice remain rare or poorly adapted. In this article, we propose an interdisciplinary model of practice to correct this deficiency. The objectives of this article are: to report on the literature review conducted; to report, as faithfully as possible, on our general consultation process with employees practicing in a forensic psychiatric institution; and, finally, to propose an interdisciplinary practice model resulting from this general consultation within the organization.

Sequential Intercept Mapping: Developing Systems-Level Solutions for the Opioid Epidemic.

Sequential intercept mapping, a community-based application of the sequential intercept model, was recently adapted in Ohio to address the complex challenge of the opioid crisis. Sequential intercept mapping for opioids provides a framework for criminal justice, mental health and addictions treatment providers, family members and opioid-involved individuals, and other stakeholders to develop community-based responses that emphasize prevention, regulation, and treatment for opioid dependency, with a goal of reducing unintended deaths and overdoses. The authors describe a promising approach to using sequential intercept mapping to address the opioid crisis.

Forensic psychiatry in Rwanda.

Forensic psychiatry has often been neglected in nonwestern countries, including the African continent. Our aim was to assess the practices and needs for improvement in the field of forensic psychiatry in Rwanda. During a one-week visit conducted in October 2017, we interviewed key-informants working at decisional levels in the domains of health, justice and security. Two clinical workshops involving psychiatrists, psychologists and nurses were held in psychiatric facilities, including at Ndera, the main psychiatric hospital of the country. Three axes of development and improvement were identified: First there is a need for a clearer, more coherent and updated legislative framework. Second, the absence of a forensic secured unit, which compromises both quality of care for forensic patients and security of the other patients and staff, should be remediated. Third, the supervision and training in this specialized domain should be provided through international collaborations. Hopefully, Rwanda could become in the next few years a driving force for other African countries in the field of forensic psychiatry.

Evaluations of Urban Sovereign Citizens' Competency to Stand Trial.

There are few studies of sovereign citizens undergoing competency-to-stand-trial evaluations and little has been written about African-American or urban sovereign citizens. In this study, we examined competency-to-stand-trial reports of 36 New York City defendants who declared themselves to be sovereign citizens during their evaluations. All were men and 33 were African American. The majority denied recent or remote histories of psychiatric hospitalizations or substance use. Sixty-nine percent were deemed competent. Compared with those deemed competent, those deemed not competent were significantly more likely to have diagnosed psychotic disorders and to have reported histories of psychiatric hospitalizations. The 36 who declared themselves sovereign citizens were compared with 200 who did not, from a study conducted in the same forensic clinic. The sovereign citizens were significantly more likely to be male, African American, and high school graduates and were significantly less likely to report a history of psychiatric hospitalization or substance use. Compared with the nonsovereign citizens, they were less likely to receive a diagnosis of psychotic or mood disorders during the competency evaluation and were more likely to be deemed competent. Included are suggestions to assist forensic examiners conducting evaluations of these difficult cases.

[Forensic preventive assertive community treatment : Pilot project to prevent violent crimes in the context of psychiatric disorders]. / Die Forensische Präventionsambulanz : Modellprojekt zur Vermeidung von Gewalttaten im Rahmen psychischer Erkrankungen.

BACKGROUND: Since 2012, a forensic preventive outpatient clinic has been established at Ansbach District Hospital to fill a gap in general psychiatric care for patients with schizophrenia or severe personality disorders and having a high risk for violent behavior. An interdisciplinary team drawing on forensic psychiatric knowledge applies instruments for forensic risk prognosis and treatment or interventions to prevent violent crimes and to protect potential victims. Admissions depend on certain criteria, e.g., increased risk potential for violent crimes against the background of schizophrenia or severe personality disorders. OBJECTIVE: How can a forensic psychiatric preventive treatment be organized, which helps to avoid detention in a forensic commitment and is complementary to general psychiatric treatment structures? Can such a model project reach the target group? MATERIAL AND METHOD: In forensic preventive outpatient care the treatment is based on violence prevention (e.g., psychoeducation, group training, individual treatment on violence risk co-management). Data are collected using general psychiatric and forensic instruments on, e.g., risk of violence (HCR-20), global functional level (GAF), violent behavior (SDAS-9) on a regular basis. The values with respect to these instruments on admission were compared to published key factors from population samples with general and forensic psychiatric patients. RESULTS: A total of 146 patients between the ages of 18 and 79 years have so far been treated. About 4,000,000 EUR could be saved during the duration of the project because of preventing involuntary admission to a forensic hospital apart from preventing violent crimes. In contrast 3,000,000 EUR had to be spent for the new outpatient service. CONCLUSION: Indications for the efficacy of a forensic preventive care for patients with schizophrenia and severe personality disorders with a risk for violence are confirmed. Therefore, an institutionalization and a statewide implementation of forensic preventive care in terms of the forensic preventive out-patient clinic are recommended.

Sex, gender and the carceral: Female staff experiences of working in forensic care with sexual offenders.

English high-secure hospitals have contained individuals deemed mentally disordered, and dangerous, since the mid-nineteenth century. With the development of gender sensitive services female patients have been moved out of these institutions into smaller secure settings. Female staff continue to work in high secure hospitals, but are often in a minority in these services. Little is known about how female staff experience the everyday world of work. This paper is based on in-depth interviews with female nurses employed in a unit caring for detained male sexual offenders with a diagnosis of personality disorder. It forms part of a much larger discourse-analytic study of nine patients, with a history of sexual offending, and eighteen mental health nurses, which focused on talk about pornography and criminality. The findings from this project have been previously reported in Mercer and Perkins (2014). This paper demonstrates how patriarchy remains an enduring cultural characteristic of caring for men detained under the Mental Health Act (1983, 2007) because of sexually violent crimes against women and children. It textures the ward environment and the relationships between people who work within it, constructing women as 'outsiders' and producing a masculine culture which leaves female staff feeling vulnerable and at risk. The analytic focus of the paper is concerned with exploring how women experience working in the male-dominated environment of a high-security Personality Disorder Unit (PDU). Three discursive repertoires are identified: the institutional space as male, the impact of working with men detained as a result of sexual offending, and the construction of therapeutic work as a 'job for the boys'. In this world, female staff, as a product of their gender, constructed themselves both as at risk and inviting risk.

Civil Forensic Psychiatry - part 3: practical aspects of managing a medico-legal practice.

OBJECTIVES: This is the third in a series of papers on Civil Forensic Psychiatry and provides practical advice for forensic psychiatrists, general psychiatrists and trainees who are expanding or contemplating a medico-legal aspect to their practice. CONCLUSIONS: Attention to the practice setting, office layout, recording of information, management of documentation, screening of briefs and proper timetabling can improve safety, quality, reliability and workload manageability.

Risk assessment tools in criminal justice and forensic psychiatry: The need for better data.

Violence risk assessment tools are increasingly used within criminal justice and forensic psychiatry, however there is little relevant, reliable and unbiased data regarding their predictive accuracy. We argue that such data are needed to (i) prevent excessive reliance on risk assessment scores, (ii) allow matching of different risk assessment tools to different contexts of application, (iii) protect against problematic forms of discrimination and stigmatisation, and (iv) ensure that contentious demographic variables are not prematurely removed from risk assessment tools.