Module 3: Neurodevelopment, Mental Health and Mental Illness Flashcards
Lecture 1 - Introduction to forensic mental health
Where do forensic health care professionals work?
maximum security hospitals (Broadmoor, Rampton, Ashworth)
• medium secure units
• low security units
• outpatient services
• prison services (including YOIs)
- the NHS is now responsible for providing this, rather than the ministry of justice and this has caused difficulties,
e.g. many people in prison are undiagnosed with ADHD
• police, military, security services
- military forensics can also have problems in terms of how the patients are viewed and how investigations are
carried out
- note that these services span both children and adults – the age of criminal responsibility is 10 and sometimes they have
to give evidence at court as well
Lecture 1 - Introduction to forensic mental health
What are typical patients presenting problems?
offenders with forensic health problems may have more than one of these, so it’s very hard to treat. Have to figure out what mental health problems may have contributed to crimes:
• severe mental illness
- schizophrenia, bipolar disorder, major depression
• personality disorder
- antisocial, borderline, paranoid variants
• other mental health problems
- anxiety, depression, OCD
• substance misuse
- alcohol, prescribed/illicit drugs
• organic problems
- traumatic brain injury, Korsakoff’s syndrome
• developmental disorders -intellectual disabilities, ADHD, autistic spectrum
• trauma
- PTSD, history of physical and sexual abuse (i.e. sometimes they may be acting out their reactions to past trauma)
• pschological problems
- anger, violent atttiudes, self-esteem, lack of empathy, interpersonal problems
Lecture 1 - Introduction to forensic mental health
What are the mental health sections?
- Section 3 (Civil Section)
- Section 35 (Remand to Hospital for Report)
- Section 36 (Remand to Hospital for Treatment – 28 days)
- Section 37 (Hospital Order – 6 months)
- Section 38 (Interim Hospital Order – 12 weeks max – convicted but waiting to be sentenced)
- Section 48/49 (Home Office Warrant – Transfer of a civil prisoner in urgent need of treatment)
- Section 37/41 (Hospital Restriction Order – unlimited) most severe
- Section 47/49 (Home Office Warrant – for transfer of a prisoner to hospital)
Lecture 1 - Introduction to forensic mental health
what are assessment focuses in forensics?
people without a mental health problem may only have the 2nd and 3rd points:
- clinical issues
- criminogenic factors
- risk of harm to self and others
Lecture 1 - Introduction to forensic mental health
What are the types of assessments?
medical and nursing assessment
- psychiatric and physical health care needs (this is important since institutionalisation can result in the person
acquiring many condi#ons such as diabetes)
- previous psychiatric and developmental history
- diagnosis (clinical syndromes and personality)
- comorbidity
- substance dependence
• psychological assessment
- problems, deficits, needs, strengths
- cognitive, neuropsychological (people may have cognitive distortions, e.g. they think that sex with a 7 year old is
bad but sex with a 15 year old is okay
- psychosexual
- insight, denial processes, malingering
- treatment and rehabilita#on needs
- motivation to engage in assessment/treatment
• criminogenic assessment
- problem-solving skills
- violent aNtudes and anger
- attitude towards offences
- blame attribution – who do they blame? the victim / their mental illness / past experiences, etc.
- remember that it’s possible that their mental illness has nothing to do with their offence
- victim empathy
- one of the ways to assess is to see how much they can empathise with other victims, but this can be very
low for psychopaths who have little empathy
- belief systems
- relationship between offending and illness
- relationship between offending and substance misuse
• occupatitinal therapy assessment
- functional living skills
- some people moving out of institutions may be very scared because they could find it very difficult to get a job
and reintegrate into society
- *• social work assessment**
- housing, family, money
- *• risk assessment (**note that this involves consideration of past, present and future circumstances)
- offending
- violence towards others
- deliberate self harm
- substance misuse
- noncompliance with treatment
- absconding from institution
- poor engagement with services and ability to cope in the community
Lecture 1 - Introduction to forensic mental health
What are the three methods of risk assessment?
- Unstructured professional judgment
- Actuarial e.g. VRAG, SORAG
- Structured professional judgement, e.g. HCR-20V3, RSVP, PCL-R
Lecture 1 - Introduction to forensic mental health
Outline the HCR-20V3
HCR-20V3
- assesses risk for violence in those with mental or personality disorder
- evaluates 10 Historical, 5 Clinical and 5 Risk management factors (HCR)
- goal is to provide a risk management plan
- the historical (H) scale:
- 10 items that are rela#vely fixed (sta#c) risk markers for violence
- items have strong empirical support as violence risk factors:
• previous violence (ased on frequency and severity)
• young age at first violence (under 20 is considered young)
• rela#onship instability (unstable/conflictual in#mate rela#onoships)
• employment problems (unstable employment or unemployment, not employability)
• substance use problems (serious impairment of func#oning)
• major mental illness (disturbances of thought, affect or intellect)
• life#me diagnoses according to ICD, DSM)
• psychopathy (severe traits of psychopathic personality according to PCL-R or PCL-SV
• early maladjustment (serious conduct problems or vic#misa#on)
• personality disorder (any non-psychopathic personality disorder, life#me diagnoses from ICD, DSM)
• prior supervision failure (failure during ins#tu#onal or community placement – escape, breach,
misconduct)
- the clinical (C) scale:
- 5 dynamic (changeable) risk factors related to clinical/mental status
- based on recent/current func#oning
- may be par#cularly relevant for imminent risk for violence
- important for planning treatment and management
- includes:
• lack of insight (into mental disorder, treatment needs, anger, triggers, etc.)
• nega#ve aNtudes (pro-criminal, an#social, pessimis#c, or an#-authority aNtudes)
• ac#ve symptoms of MMI (disturbances of thought, affect, percep#on)
• impulsivity (behavioural, cogni#ve, or affec#ve instability and overreac#vity
• unresponsiveness to treatment (resistant or refractory to treatment designed to ameliorate
criminal, psychiatric, psychological, social or voca#onal problems)
- the risk management (R) scale:
- based on projec#ons about future circumstances, whether in the ins#tu#on or in the community
- relevant for devising management and treatment plans
- has implica#ons for monitoring risk-relevant factors
- risk management is difficult for pedophiles, because they some#mes create groups/rings, so externally
everything seems fine but there are actually things going on behind the scenes :S
- includes:
• plans lack feasibility (no plans, plans unsuited to the individual’s needs, or unavailable resources)
• exposure to destabilisers (hazardous condi#ons e.g. weapons, substances, vic#ms)
• lack of personal support (focus is on personal/emo#onal support)
• noncompliance with remedia#on aXempts (won’t aXend or comply with treatment,
rehabilita#on, or supervision programs)
• stress (exposed to serious psychosocial stressors / unable to cope with stress
Lecture 1 - Introduction to forensic mental health
Outline the treatment
Treatment and management goals
• safety of pa#ent and others within the ins#tu#on or in the community
• improving and maintaining the physical and mental health of the pa#ent
• violence and offence reduc#on
• improve daily living skills !★ Medical interven#ons
• medica#on for major mental illness and comorbid condi#ons, physical health needs, side effects
• PRN “when required” medica#on, e.g. for acute disturbance in mental state
• nursing care and medical checks !★ Occupa#onal therapy interven#ons
• independent living skills
• educa#on and literacy
• occupa#onal
• cooking and self-care
• financial management
• computer skills !★ Social work interven#ons
• housing arrangements (home, hostel, etc.)
• community support liaison
• family contact
• job centre
• financial arrangements
• local support agencies !★ Psychological interven#ons
• CBT for psychosis, anxiety, depression, OCD, insight into illness (individual or group)
• cogni#ve schema therapy for personality disorders (individual)
• substance misuse (individual or group)
• anger management (individual or group)
• criminal thinking styles
• social skills training (individual or group)
• psychoeduca#on and mo#va#onal interviewing (individual)
• trauma therapy (individual)
• violence reduc#on / psychosexual offence related work (individual or group)
• empathy and vic#m empathy
• social perspec#ve taking
• moral reasoning skills
• offending behaviour programmes, e.g. Reasoning and Rehabilita#on (R&R), R&R2, SOTP (group)
- however, the comple#on rates for offender behaviour programmes (OBPs), is only around 80%
- drop-outs have higher rates of recidivism than completers and non-starters
- due to ins#tu#onal reasons and characteris#cs associated with dropout:
• ASPD, recent violence, psychopathy
• impulsivity
• IQ
• self-esteem
Lecture 7 - Contingency Management
What are some of the moral and ethical issues surrounding contingency management?
- bribery: paying people to act against their wishes
- however, they are being offered rewards to achieve
outcomes that are most desirable, not forced into
acting against wishes - coercion: compels people to behave using pressure/duress
- but it is voluntary, with a prospect of gain, not loss
- paternalistic: undermines individual autonomy
- but it could be said to facilitate autonomy when it
makes it more likely that people act in line with their
originally considered preferences (people who
actually wanted to quit smoking) - unfair: people should not be paid to do what they should do
- but it is potentially a more effec#ve way of changing behaviour and improving health
- waste of money: poor use of the public purse, where there are many competing demands
- but there are potentially large health benefits from a modest increase in health expenditure
- may be more effective than current strategies, plus saves a lot of money in the longterm
