Mentally disordered offenders. Flashcards
High security special hospitals in the UK:
House and provide treatment for the most serious mentally disordered offenders assessed as needing a high lvl of security (sec).
Problems:
Patients typical far away from home
Huge diff between high sec and returning to community.
Glancy Report (Department of health and social security, 1974). Butler Report Department of health and social security, 1975).
Advocated the need for more regionally based medium secure units, which would both enable patients to be nearer to home, and also to be treated in conditions of lesser security than special hosps.
These units come to be known as Medium Secure Units (MSUs).
Following similar reasoning, the opening of Low Secure Units (LSUs).
HSU’s, MSU’s, and LSU’s:
High sec units (e.g. Broadmoor Hosp): - To cater for patients who present in an acute stage of their mental illness.
MSUs and LSU: - To cater to patients with more long standing illnesses who response poorly to treatment.
Mentally disordered offenders (MDO’s) - clinical presentations:
High rates of comorbidity - patients who fulfil diagnostic criteria for more than one disorder - dual diagnosis.
- Schizophrenia
- Paranoid Schiz
- major affective disorders
- Persoanlity Disorder
- Psychopathy and Offending
- Intellectual disability and developmental disorders
- Substance misuse
Schizophrenia
Most common diagnosis within forensic mental health settings.
Significant perceptual disturbance - the positive symptoms of hallucinations, delusions and thought disorder.
May or may not be accompanied by the negative symptoms - flattened affect, avolition, anhedonia.
paranoid schizophrenia
Most common form of schiz found in forensic health settings.
Persecutory and sometimes grandiose delusions
In some cases indivs’ offending beh can be directly linked to psychotic experience.
major affective disorder:
Bipolar disorder - dramatic fluctuations in mood states.
Depression - persistent and extreme low mood states, that interfere with an indivs functioning.
Mood congruent psychotic symptoms can be present during episodes of illness, such as auditory and visual hallucinations and delusions. - e.g. an indiv may believe that they own a property empire or that they are a music celebrity, in association with a manic ep.
Personality disorder
Generally less common than shiz.
Antisocial, borderline, paranoid and narcissistic personality disorders are arguably the most common in secure forensic psychiatry services.
Found elevated base rate for violence among subjects with a DSM-5 PD diagnosis..
90% of sexual offenders suggested to have at least one PD.
Psychopathy and ASPD are not separate diagnostic entities, but psychopathic ASPD is a more severe form than ASPD alone, with greater risk of violence
Intellectual disability and dev disorders
Typically mild intellectual disability (ID).
Exhibit relatively minor offending that if not controlled could become more frequent, or serious.
Indivs w IDs have been shown to be more susceptible to mental illness.
Increase in referrals of indivs with ASDs within forensic mental health services. - poor impulse control and have deficits with regards to interpersonal skills that undermine their ability to interpret social situations and to empathise with others.
Substance misuse disorders:
Highly prevalent in this pop for a number of reasons.
Typically comorbid with another MH condition and has enormous impact upon prognosis.
Department of health, 2000: between ⅓ and ½ of all ppl with severe mh probs have comorbid problematic substance misuse.
There is a wealth of ev that among psychiatric pops, substance misuse is the most sig risk factor for relapse and associated violence.
Biopsychological risk factors:
Hopelessness Impulsive and aggressive tendencies History of abuse Major physical illness Prev suicide attempt and fam history of suicide.
Methods of risk assessment in secure settings:
Unstructured clinical judgement - flexible, little inter-rater reliability, hard to get predictive validity.
Actuarial RA tools - static rf predictors, etc, more empirically based, disadv - leaves aside clinical judgements, leaves out indiv aspects.
Structured professional judgement - combination of good features of both.
Structured professional judgement instruments follow a core six step methodological process:
Gather info Identify risk factors Dev risk formulation Consider risk scenarios Dev risk management strategies Summary judgement of risk
Historical Clinical Risk-20 (HCR-20):
A framework to support decision making about an indivs risk of violence.
Conceptual framework that:
Prompts understanding of any past vio
Helps describe the future risk of vio that an indiv potentially poses to others.
Attempts to describe what that violence might look like
Aims to facilitate strategies for reducing that risk.
Based on empirically and clinically supported risk factors - a shift towards integrating research and clinical practice.
Profesh guidelines, an aide memoire. - structure that supports, rather than replaces clinical judgement.
Conceptual basis of the HCR-20 v3 Structure:
Historical items - violence, antisoc beh, relationships, employment, SM, major mental disorder, PD, traumatic exp’s, violent attitudes, treatment or supervision response, etc.
Clinical items - Insight, MI, Instability, need for treatment, violent ideation or attempt, risk, symptoms of major mental disorder, treatment or supervision response, etc.
Risk management - Living sitch, plans, profesh services, personal supports, treatment responsiveness, compliance, coping, stress, etc.
HCR-20 v3 Administration Step 1:
Info about past violent beh and ideation.
Identifying the social, interpersonal, affective and cog precipitants of patients violence is critical in terms of understanding and formulating a person’s risk.
HCR-20 v3 Administration Step2:
Presence of risk factors.
Rating process for rf’s
Document ev.
Historical factors refer to areas of past functioning, behaviours and exp’s.
Coding time frame for these rf’s is lifetime.
Evaluators should rate these as present, even if no longer active.
Clinical factors focus on recent or current psychosocial, mh, and beh functioning.
Coding timeframe:
Select important milestone and make ratings since that point.
Choose past 6 months if evaling someone for first time.
Extend rating period longer only if indiv has been under obvs, treatment or supervision for that time period and has been relatively stable during that.
Clinical factors should periodically be re-evaluated.
HCR-20 v3 Administration Step3:
Relevance of rf’s:
Determine which of rf’s rated as present or partially present may play a causal role on violence, at the indiv lvl.
HCR-20 v3 Administration Step4:
Risk formulation:
Must provide solid understanding of why a person has acted vio in the past, and why they might again in the future.
Such as understanding is necessary to manage future vio, and hence how best to reduce risk.
5Ps model - Weerasekera, 1996.
Problem - risk of what?
Predisposing - or vulnerability, factors.
Precipitating factors - or triggers to harm.
Perpetuating - or maintenance factors.
Protective factors.
HCR-20 v3 Administration Step5:
Risk scenarios
Dev informed, reasoned projections - i.e linked to and derived from case facts about future behs amd the contexts that may lead to certain vio outcome.
Recommended types of scenarios:
Repeat - engages in the same type of vio, for similar reasons as past vio.
Twist - change in nature of vio - victim selection or use of weapons.
Escalation - (worst case scenario), is one in which the severity of vio worsens over time.
Optimistic (best case scenario), severity of vio decreases.
HCR-20 v3 Administration Step6:
Management planning.
Address rf’s taking into account formulation and scenarios. - follows the Risk-Need-Responsivity (RNR) model.
Management includes range of risk reduction strategies at the disposal of agencies or persons responsible for the supervision of an indiv:
Monitoring
Supervision
Treatment
Victim safety planning
HCR-20 v3 Administration Step7:
Conclusory Opinions:
Summarise concerns about risk lvl and prioritization of services.
Summary risk ratings made for:
Risk of future vio generally, or case prioritisation.
Risk for serious physical vio
Risk for imminent vio
Case review - the higher the risk posed by a person, the sooner the case should be reviewed.
