Managing personality disorders: making positive connections

This article has outlined what the author believes to be the essential elements of support, guidance and training for staff working with people with personality disorders. It can be argued that programmes without these elements compromise not only the quality of care but also staff wellbeing. HMP Whitemoor, Cambridgeshire, is currently piloting a programme for the assessment and treatment of severe personality disorders. The multidisciplinary team is actively working towards the principles as defined in this paper, and is also involved in the development of skills competencies to underpin the whole process. There are several studies underway relating to the needs of the prison's staff team and these will evaluate the aforementioned principles and thereby refine the staff support, supervision and development structures. There is no apology made for the focus of this article being on staff needs. Without them being met, any service designed to care and manage people with personality disorders cannot exist, thus returning the people this programme is designed to help to a chaotic and crisis-driven existence.

[Current problems of psychiatric health care--2002]

The paper is a presentation of the most important and actual psychiatric health care problems in Poland: the financial situation of hospitals, the risks faced by the outpatient psychiatric care, maintaining the legal issues of the psychiatric patients, the situation of forensic psychiatry and legal-psychiatric expertise, post-graduate training, the level of diagnosis and therapy, availability of psychotropic drugs. Attention is paid to the importance of giving the programme of psychiatric health protection a status of evident value and that this programme should become a government (national) programme.

Forensic psychiatric nursing: a literature review and thematic analysis of role tensions

This literature review was undertaken to explore the emergent issues relating to the difficulties encountered in forensic psychiatric nursing. The rationale for the study revolved around the paucity of research undertaken to identify the constituent parts of this professional practice. The aims included both a thematic analysis of the literature and the construction of a theoretical framework to guide further research. The method was a snowballing collection of literature and a computerized database search. The results were the identification of a series of major issues, which were broadly categorized as negative and positive views, security vs. therapy, management of violence, therapeutic efficacy, training and cultural formation. From this the six binary oppositions, or domains of practice, emerged as a theoretical framework to develop further research. These were medical vs. lay knowledge, transference vs. counter-transference, win vs. lose, success vs. failure, use vs. abuse, and confidence vs. fear. Further research is currently underway.

Swedish forensic nursing care: nurses' professional contributions and educational needs

Nurses (registered nurses, RN, and licensed mental nurses, LMN) working in five Swedish forensic psychiatric units filled in a questionnaire designed for general psychiatric nursing, but modified for forensic use. In this report, data regarding how nursing care could contribute to improved care and the organizational changes needed and what knowledge the nurses need, in order to be able to meet the demands in the future, were analysed by means of content analysis. The salient findings were: (i) an interpersonal patient-nurse relationship based on trust, empathy, respect and responsibility for the patients' personal resources and knowledge seems to be the essence of nursing care and a way to improve care; and (ii) the nurses' educational needs emanate from different treatment modalities, how to perform different treatments, how to establish developing relationships and in-service training adapted to the ward-specific problems.

Towards a 'forensic lens' model of multidisciplinary training

This paper reports on research undertaken to identify if common areas of multidisciplinary training exist in the literature. The literature that specifically focused on training issues in forensic practice (mental health) was located and reviewed by coding analysis. Thirteen common areas were identified and approximately 250 content items were acknowledged. A 'forensic lens' model was established to provide a framework in which multidisciplinary training could be located. Further research is promulgated to establish the actual importance of each training area for specific forensic disciplinary groups.

Principles and strategies for teaching therapeutic responses to self-harm

This paper explains the educational principles and strategies underpinning a nursing course offered at an Australian university. The course is entitled 'Self-harm and therapeutic responses' and explores contemporary theories and practices to improve understanding and responses to people who self-harm. The course aims to shape the practices of nurses in developing healthier clinical and social environments for people who self-harm.

Countering countertransference: a forensic trainee's dilemma

Forensic psychiatry involves an adaptation to a role that is very different from the psychiatrist's previous clinical experiences. To render an unbiased forensic opinion, psychiatrists have to rise above their countertransference feelings. This takes years of practice and experience. The following is an account of a forensic trainee who faced several countertransference problems as he evaluated a patient charged with attempted murder. The case report is interspersed with a review of the relevant literature.

Undergraduate nursing students' views of mental health nursing in the forensic environment

The literature clearly demonstrates that mental health nursing tends to be viewed negatively by undergraduate nursing students. While positive clinical experiences have been found to encourage more favourable attitudes towards mental health nursing, suitable placements are becoming scarce. An evaluation of clinical placements at the Victorian Institute of Forensic Mental Health (VIFMH) was undertaken to determine whether appropriate learning opportunities were offered, and identify the impact of the placement on students' attitudes to mental health nursing. The results suggest that VIFMH provides valuable learning experiences to increase students' understanding of mental health nursing and is effective in producing more positive attitudes towards this area of practice.

Responding to people with a learning disability who offend

AIM

This article reports on a small survey conducted in one NHS trust to establish the number of people with a learning disability known by staff to have committed, or be alleged to have committed, an offence.

METHOD

A sample of 35 members of staff who were likely to be in contact with this client group were sent questionnaires. Thirty responses were received, giving a response rate of 86 per cent.

RESULTS

A total of four nurses and two clinical psychologists were in contact with 31 individuals known or alleged to have committed an offence. These offences were mainly sexual and some were violent. Several individuals had committed a number of separate offences. Respondents felt that the needs of these individuals were not adequately met by current service provision.

CONCLUSION

A planned inter-agency response is required to deal with people with learning disabilities who carry out criminal offences, rather than the current system which is vague in terms of allocating responsibility for action. The nurse's role in providing sexual health education for those with learning disabilities also needs to be considered in the light of the survey results.

Child and adolescent forensic psychiatry survey--in Scotland

OBJECTIVES

To review the provision of Adolescent Forensic Services, and assess the need for the development of a separate service as exists for adult mentally disordered offenders.

DESIGN AND SUBJECTS

To investigate by postal survey to all child and adolescent psychiatrists in Scotland.

RESULTS

There is a lack of forensic adolescent expertise in Scotland and a perceived need for it. Child and adolescent psychiatrists are required to deal with difficult forensic cases, without appropriate training.

CONCLUSION

A child and adolescent forensic service for Scotland needs to be developed.

The Canadian Criminal Code provisions for mentally disordered offenders: a survey of experiences, attitudes, and knowledge

OBJECTIVE

To systematically survey Alberta psychiatrists and lawyers regarding their knowledge of, attitudes toward, and experiences with the Criminal Code provisions regarding mentally disordered offenders to better understand the lack of impact in practice patterns.

METHOD

A survey design was used, and 2 questionnaires, 1 for lawyers and 1 for psychiatrists, were developed and mailed out.

RESULTS

Out of 245 surveys sent to psychiatrists, 141 were returned, giving a response rate of 57%. The number of lawyers practising criminal law could not be determined, and 5273 surveys were sent to all lawyers on the Law Society of Alberta mailing list. Of these, 564 were returned, giving an overall response rate of 11%. The response rate for lawyers practising criminal law is unknown. Overall, lawyers were younger than psychiatrists. Most of the respondents in both groups were men. Overall, attitudes toward offenders with mental illness were very similar among lawyers and psychiatrists. Compared with lawyers, psychiatrists had significantly more correct responses to the items assessing knowledge. With a highest possible knowledge score of 27, the average score was 16 (SD 5.7) for psychiatrists and 13 (SD 7.23) for lawyers.

CONCLUSIONS

The lack of familiarity with many of the key provisions among psychiatrists and lawyers is worrisome and suggests the need for educational materials to improve knowledge of the Criminal Code provisions governing mentally disordered offenders.

Violence risk assessment and risk communication: the effects of using actual cases, providing instruction, and employing probability versus frequency formats

This article describes studies designed to inform policy makers and practitioners about factors influencing the validity of violence risk assessment and risk communication. Forensic psychologists and psychiatrists were shown case summaries of patients hospitalized with mental disorder and were asked to judge the likelihood that the patient would harm someone within six months after discharge from the hospital. They also judged whether the patient posed a high risk, medium risk, or low risk of harming someone after discharge. Studies 1 and 2 replicated, with real case summaries as stimuli, the response-scale effects found by Slovic and Monahan (1995). Providing clinicians with response scales allowing more discriminability among smaller probabilities led patients to be judged as posing lower probabilities of committing harmful acts. This format effect was not eliminated by having clinicians judge relative frequencies rather than probabilities or by providing them with instruction in how to make these types of judgments. In addition, frequency scales led to lower mean likelihood judgments than did probability scales, but, at any given level of likelihood, a patient was judged as posing higher risk if that likelihood was derived from a frequency scale (e.g., 10 out of 100) than if it was derived from a probability scale (e.g., 10%). Similarly, communicating a patient's dangerousness as a relative frequency (e.g., 2 out of 10) led to much higher perceived risk than did communicating a comparable probability (e.g., 20%). The different reactions to probability and frequency formats appear to be attributable to the more frightening images evoked by frequencies. Implications for risk assessment and risk communication are discussed.

Decisional capacity for informed consent in schizophrenia research

BACKGROUND

The adequacy of subjects' informed consent to research is the focus of an important public and professional debate. The potential impairment of decisional capacity in persons with schizophrenia is central to the discussions. This study ascertains the decisional capacity for informed consent in schizophrenic research subjects, to determine if reduced capacity relates to specific aspects of psychopathologic features and to test the hypothesis that reduced capacity can be remediated with an educational informed consent process.

METHODS

Decisional capacity was assessed for 30 research subjects with schizophrenia and 24 nonill (normal) comparison subjects. Measures of psychopathologic features and cognition were obtained for the subjects with schizophrenia. Subjects who performed poorly on the decisional capacity measure received an educational intervention designed to improve their ability to provide informed consent and were then retested.

RESULTS

The patient group did not perform as well as the controls on initial decisional capacity assessment. Poor performance was modestly related to the extent of symptoms but robustly related to cognitive impairments. Following the educational intervention, the performance of subjects with schizophrenia was equal to that of the nonill comparison group.

CONCLUSIONS

Many persons with schizophrenia may be challenged by the cognitive demands of an informed consent process for research participation. In many cases, their reduced capacity can be compensated by a more intensive educational intervention as part of the informed consent process.

Ensuring that forensic psychiatry thrives as a medical specialty in the 21st century

The author contends that forensic psychiatry will thrive as a legitimate medical specialty in the 21st century only if it helps to fulfill the crucial requirement of medical systems in the new health care era. The article presents six basic requirements of future medical systems: effective, efficient, and responsible organizations; quality educational programs of the appropriate type and size; linkage to health care networks; primary care capacity and services; restructured systems for research; and effective leadership. Specific opportunities for forensic psychiatry to help meet these requirements are outlined. The author presents major implications of these opportunities for forensic academicians and practitioners as well as for the American Academy of Psychiatry and the Law.

Russian forensic psychiatry

Two forensic psychiatric clinics visited on an exchange trip to Russia are described. The legal system for mentally disordered offenders in these institutions is also summarized, as is the training of psychiatrists in Russia.