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The analysis of the delinquency bringing disordered offenders into a hospital order institution reveals a lot of very conscious and well organized behavior during the criminal activity. This must be taken into account in therapy and prognosis.
In this contribution, the necessity and expediency, but also the limits of the application of psychodiagnostic methods within the scope of forensic-psychological-psychiatric expertises are discussed. A survey is given on results of statistical analysis, revision and validation gained with a personality questionnaire relevant to prison situation (PFI acc. Seitz, 1983).
ISSUE: In psychiatric and psychotherapeutic clinics that are responsible for supplying care for a region, how often are patients transferred to forensic psychiatric hospitals? Is there a tendency to "send off" aggressive or threatening patients as quickly as possible? METHOD: In the psychiatric and psychotherapeutic clinic responsible for the Berlin's Neukölln district, for one year (2000) all patients who committed a severe criminal offence immediately before or during their in-patient treatment were registered for observation in 2000. The steps of investigation and further legal consequences were recorded. RESULTS: During the period of observation, 0.1 percent of the patients were transferred from the clinic to a forensic psychiatric hospital. Weeks or months after their regular release, 0.4 percent of the patients were committed to a forensic department. The court ordered an ambulant psychiatric evaluation for 0.5 percent of the patients. CONCLUSION: Only a few patients were transferred to forensic psychiatric hospitals. A tendency to "send off" aggressive patients as soon as possible, thus abusing forensic psychiatry, was not found in this study.
This article deals with the following three problems: 1. Which aspects must be given special consideration in respect of psychological diagnosis and therapy planning in those patients who have been referred to psychiatric treatment mainly because of violence displayed by them? 2. What are the conclusions we can draw from our knowledge of the behaviour of persons whose everyday behaviour patterns seem absolutely normal or even characterized by an inhibition of their aggressive tendencies, and who suddenly and unpredictably perform acts of aggression, and what are the conclusions we can draw from our experience in respect of the therapeutic management of such patients? 3. What is our knowledge regarding the actual course of aggressions and violence between patients and therapeutic personnel in everyday psychiatric ward practice, and what are the conclusions regarding a possible improvement of such interactions by appropriate therapy?
In true medical emergencies, informed consent is presumed or implied without application of the usual standard. In the litigation over the right to refuse treatment in psychiatry, a limited right for involuntarily committed patients to refuse treatment has been upheld, absent a finding of a psychiatric emergency. Increasingly, clinicians may find that their sole extrajudicial option in instituting treatment over the patient's objection is in invoking a psychiatric emergency. The purpose of this communication is to discuss the clinical and legal issues in defining and invoking a psychiatric emergency in treatment refusal. The substantive and procedural issues in the use of the emergency exception in treatment refusal are discussed with recommendations for their use in clinical practice.
This study compares two instruments frequently used to assess risk for violence, the Violence Risk Appraisal Guide (VRAG) and the Psychopathy Checklist: Screening Version (PCL:SV), in a large sample of civil psychiatric patients. Despite a strong bivariate relationship with community violence, the VRAG could not improve on the predictive validity of the PCL:SV alone, even though the VRAG includes several ostensible violence risk factors other than psychopathy. Moreover, incremental validity analyses indicated that the remaining VRAG items accounted for little or no variance in violent outcomes once psychopathy scores were controlled. Conversely, the PCL:SV continued to account for considerable variance after controlling for the VRAG. These results reflect the limited validity of the VRAG items in civil psychiatric samples beyond the variance that is explained by the PCL:SV alone.
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BACKGROUND: Little is known about the proportion of psychiatric in-patients who lack capacity to make treatment decisions, or the associations of lack of capacity. AIMS: To determine the prevalence of psychiatric in-patients who lack capacity to make decisions about current treatment and to identify demographic and clinical associations with lack of mental capacity. METHOD: Patients (n=112) were interviewed soon after admission to hospital and a binary judgement of capacity was made, guided by the MacArthur Competence Tool for Treatment. Demographic and clinical information was collected from an interview and case notes. RESULTS: Of the 112 participants, 49 (43.8%) lacked treatment-related decisional capacity. Mania and psychosis, poor insight, delusions and Black and minority ethnic group were associated with mental incapacity. Of the 49 patients lacking capacity, 30 (61%) were detained under the Mental Health Act 1983. Of the 63 with capacity, 6 (9.5%) were detained. CONCLUSIONS: Lack of treatment-related decisional capacity is a common but by no means inevitable correlate of admission to a psychiatric in-patient unit.
The subjects of this study are prisoners who were hospitalized from custody in a psychiatric clinic. All of such patients of one psychiatric clinic during the period from 1976 till 1978 were compared with a random sample of other psychiatric patients using case reports and other data. Differences were found concerning social, personal, psychiatric, and criminal history as well as psychopathological state and diagnosis. Compared to the complete population of prisoners of the area, prisoners from solitary confinement (mostly remanding custody) were overrepresented. Other risk factors for psychiatric hospitalization of prisoners are described. The results are discussed from prophylactic, therapeutic, and humanitarian points of view.
Pseudopsychopathic schizophrenia (PPS) forms a diagnostic unity, comprising aspects of schizophrenic process and antisocial personality disorder. Perusal of the psychiatric literature reveals that this diagnostic entity has fallen into oblivion. Recognition of this neglected category is important from therapeutic, academic and medico-legal points of view.
Is arrest and prosecution an acceptable response to assault committed by a psychiatric inpatient? The first reported case of such a response was in 1978, and the second not until seven years later. Soon after, an inconclusive debate over the propriety of prosecuting patients, with additional illustrative examples, took place in the psychiatric literature. The present author adds three more case reports in this communication, as well as outlines what actually occurs in his state. Three very recent publications have clarified the conflicts and ethical issues in this still-delicate discussion. It is concluded that predatory patient behavior should, in selected circumstances, correctly lead to the imposition of criminal sanctions, whether initiated by victims or clinicians.
The author outlines the general trends of crime and the treatment of criminals in Japan, and trends of mentally disordered offenders in Japanese penal institutions. Further, he explains the treatment of the mentally disordered offenders in Japanese medical prisons. The author analyzes the Hachioji Medical Prison's treatment record, particularly in regards to the reincarceration rate, which markedly decreases when family support and psychiatric treatment are properly present after release. Finally, the author stresses the value of correctional psychiatric treatment in the medical prison; it is expected to play an important role in contributing to the rehabilitation of mentally disordered offenders and "patients difficult to treat," and bringing about more open and innovative community-centered mental health services.
BACKGROUND: The attribution of blame for criminal act has an impact, both on the way the offender must come to terms with the offence and on the risk of recidivism. Blame attribution has been found to be related to the type of crime and personality. AIMS: This study examined the relationship of blame attribution and feelings of guilt in violent female offenders, according to factors related to crime, background and personality. METHODS: The Gudjonsson Blame Attribution Inventory (BAI) and the Defense Style Questionnaire (DSQ) were administered to 58 violent female offenders. The Hare Psychopathy Checklist-Revised (PCL-R), Structured Clinical Interview II for DSM-IV (SCID II) and clinical interviews were used for assessment. RESULTS: Lower scores of guilt feelings were found in women than has been reported for men. The feelings of guilt were higher in homicide than in other violent crimes, but lower in the cases where women had committed prior violent crimes. No differences were found between psychiatric patients and prisoners. The duration of hospitalisation and incarceration did not result in differences in blame attribution and guilt, but when the victims survived, guilt feelings seemed to increase with the passing of the time. External attribution was related to motives of crime, but traumatic experiences did not have a crucial impact upon blame attribution. The attribution of blame and the amount of guilt feelings were found to be related to personality. Women scoring high on psychopathy reported less guilt than women with low scores. The corresponding result was not obtained in the group of women with antisocial personality disorder, who, however, showed an unexpectedly low use of external attribution. CONCLUSION: The results suggest that it might be difficult for women to cope with the violent offence and that the characteristics of psychopathy seems to have a crucial impact on the guilt feelings and consequently on coping with the crime in female offenders.
OBJECTIVE: To examine the rate and characteristics of seclusion among a group of patients admitted to an adult acute psychiatric unit as a precursor to planning an audit cycle and quality improvement project. METHODS: A retrospective chart review of all inpatient admissions to an adult acute unit over a 12 month period was undertaken with the use of a specially developed proforma. A comparison of secluded and non-secluded patients was described, and, where possible, statistically analysed. RESULTS: Four hundred and fifty admissions occurred during the study period, resulting in 140 episodes of seclusion. This represented a seclusion rate of 31% per admission. In contrast to patients who were not secluded, those secluded were more likely to be young, admitted involuntarily and with a diagnosis of schizophrenia. The most common indicator of seclusion was risk to others (74%) followed by risk to self (61%) and risk of absconding (55%). Length of time in seclusion ranged from 1 to 49 h with a mean of 9 h. Thirty-nine per cent of secluded patients were secluded on two or more occasions. Interventions including counselling, time out and medication were used in 71% prior to seclusion; however, in 29% no intervention was documented. Seclusion was more likely to occur in the evenings, when staff/patient ratios were lower. CONCLUSION: Seclusion remains an important part of psychiatric practice. As expected, the use of seclusion in an adult acute unit reflected indirect measures of illness severity. Its use needs to be carefully reviewed and monitored, representing as it does the greatest restriction on a person's freedom.
OBJECTIVE: Due to the passing of new laws and pressure caused by rising costs in public financing, forensic psychiatry and prisons must develop alternatives to conventional treatment in a closed setting. This paper gives an overview of the relevant research results on the therapy of offenders or mentally ill lawbreakers, elucidates the effects of community-based approaches and takes these as a basis for practical recommendations. METHODS: Survey of the relevant literature. RESULTS: Following a time of therapeutic pessimism, the last decades have demonstrated the general effectiveness of treating offenders and lawbreakers. Adequate therapy has resulted in an up to 30% reduction of relevant re-offences. The positive effect in treating offenders was confirmed especially for community-related approaches. Additional research is necessary to further improve effectiveness. The requirements for a successful community-based therapy for offenders derived from the literature are summarised. CONCLUSIONS: There is still limited information on the differential effects of successful ambulant measures after serving one's sentence in a prison or forensic psychiatric security facility. The current legal situation in the Federal Republic of Germany is conductive to gain the knowledge required for achieving more effective therapy of offenders after discharge, which would contribute to better protection of the public.
The analysis of 11 cases of violent offenses committed during hospital order treatment in the Haina Forensic Psychiatric Hospital between 1985 and 1991 showed that biographical and forensic variables are more powerful predictors of dangerousness than treatment and psychopathological data. In more than half of these cases it was at least questionable whether the individuals had been placed correctly inside the hospital order system. In comparison to data found in inmate populations and a new study from North America the question arises as to whether the treatment might not have contributed to increase dangerousness in at least some of our cases.
This study examined the clinical correlates of lack of insight in bipolar disorder. In 28 acutely manic patients interviewed upon hospitalization and/or discharge, mean scores on the Insight and Treatment Attitudes Questionnaire (ITAQ) improved only slightly, from 12.0 on admission to 15.5 on discharge (p = .08), despite marked improvement in other psychiatric symptoms. A reciprocal relationship was found between higher ITAQ scores and involuntary hospitalization (r = -.38). Like schizophrenia, bipolar disorder appears to be a condition in which poor insight is a prominent characteristic.
In recent years, the use of group therapy approaches with Aboriginal or Native Canadians/American Indians has become widely accepted. However, many advocates of this approach rarely consider the implications of group therapy for culturally heterogeneous groups, such as when non-Aboriginal peoples are involved or when there are Aboriginal peoples from different cultures and/or with different degrees of orientation to Euro-Canadian culture. This article documents the use of one form of group therapy for Aboriginal offenders in a forensic psychiatric facility, where this degree of cultural heterogeneity exists. The article concludes that, at least within a forensic psychiatric setting, group therapies that mirror the social, cultural, racial, and class structures of Euro-Canadian society are problematic in the treatment of traditional Aboriginal offenders but much less so for acculturated Aboriginal offenders.