Mentally ill offenders in prison: the Belgian case

Systematic Aggression Registration in Forensic Psychiatric Care: A Qualitative Study on Preconditions for Successful Implementation

Available research emphasizes the importance of getting a systematic overview of inpatient aggression in forensic psychiatric care. However, the same research does not focus on how systematic aggression registration should be introduced in clinical practice. To facilitate the use of systematic aggression registration instruments, it is very relevant to gain insight into the perspective of staff members on the introduction of these instruments in daily clinical practice. Additionally, preconditions for achieving a successful implementation can be considered. Therefore, this study aims to gain insight into the perspective of the staff members on the implementation of a systematic aggression registration instrument-that is, the MOAS-in a forensic psychiatric unit. Interviews (n = 8) and a focus group with staff members were carried out. Three main themes: (1) creating the most appropriate context for introduction, (2) choice for the MOAS as relevant instrument, and (3) perpetuating the use of the MOAS in clinical practice are scrutinized. The mentioned preconditions can be used as guidelines when implementing systematic aggression registration in clinical practice. We hope that this paper can inspire other forensic psychiatric facilities to introduce systematic registration of aggressive incidents.

A qualitative inquiry on recovery needs and resources of individuals with intellectual disabilities labelled not criminally responsible

BACKGROUND

Recovery is a widely accepted paradigm in mental health care, whilst the correctional and forensic-psychiatric field is still searching for foundations for its implementation. Knowledge regarding recovery of persons with intellectual disabilities in secure contexts is limited. This study assesses recovery needs and resources among persons with intellectual disabilities labelled not criminally responsible and investigates the impact of the judicial label on recovery processes.

METHODS

A sample of 26 individuals was composed purposively, and in-depth interviews were conducted. Recurrent themes were identified using thematic analysis.

RESULTS

Traditional recovery themes emerged from the narratives, next to aspects of recovery in a forensic or correctional context. However, the operationalization and proportional impact are specific for this sample.

CONCLUSIONS

The social dimension overarches all other recovery dimensions. The integration of an explicit social rhetoric is imperative, including contextual, relational, interactional and societal dimensions. This offers pathways to reverse the traditional, paternalistic model of exclusion and classification.

The use of test instruments in forensic report writing - Explorative research in Flanders

BACKGROUND

Forensic psychiatric reports have a profound impact on the life of a defendant, on society and on the mental health system. Good-quality reports are essential but are often criticized for their lack of thorough substantiation. The use of multiple methods to obtain information, test instruments (psychological and/or risk) and third-party information are recommended.

STUDY PURPOSE

To explore the use of test instruments and third-party information, as part of a multi-method approach, in forensic psychiatric evaluations. We examined 151 court-ordered expert reports in Flanders (Belgium).

RESULTS

A psychological test instrument was used in 61% of the cases, and a risk taxation instrument in 19% of the cases. Third-party information was used in 43% of the cases.

CONCLUSIONS

A multi-method approach is not common practice in forensic psychiatric evaluations. The use of validated test instruments and third-party information can be improved. The quality of forensic reports could be improved by the establishment of a forensic observation centre and the use of a standardized approach.

Recovery of Offenders Formerly Labeled as Not Criminally Responsible: Uncovering the Ambiguity From First-Person Narratives

The recovery paradigm is a widely accepted strength-based approach in general mental health care. Particular challenges arise when applying this paradigm in a forensic context. To address these issues, the present study examined recovery based on first-person narratives of offenders formerly labeled as not criminally responsible of whom the judicial measure was abrogated. Eleven in-depth interviews were conducted to obtain information on lived experiences and recovery resources of this hard-to-reach and understudied population. The interviews focused on recovery and elements that indicated a sense of progress in life. Key themes were derived from the collected data. Descriptions of recovery resources followed recurrent themes, including clinical, functional, social, and personal resources. Participants also reported ambiguous experiences related to features of the judicial trajectory. This was defined as forensic recovery and can be seen as an additional mechanism, besides more established recovery dimensions, that is unique to mentally ill offenders.

Family Support Groups for Family Members of Mentally Ill Offenders: Family Expectations and Experiences

Family Support Groups (FSGs) are developed for family members of mentally ill offenders. This study investigates family treatment expectations and experiences of an FSG. Family members were interviewed before ( n = 20) and after ( n = 17) attending an FSG. Results show that family members hesitated or were curious about the FSG, expected to receive peer support and universality of problems, to receive information and advice and thought about the safety and respect of the group. Family members experienced the treatment as helpful because it was supportive, they gained new insights and they felt relieved and satisfied. Many family members see the guidance of the therapists and the differences in family and gender roles as an added value of attending an FSG. However, considering the limitations of the study, future studies should gain insight in and stress the importance of the meaning of therapeutic processes for family members confronted with different psychiatric disorders and/or situations.

A 17-Year National Study of Prison Suicides in Belgium

BACKGROUND

Suicide is a leading cause of mortality in prisoners worldwide, yet empirical data on this matter are lacking in Belgium.

AIMS

This study sought to describe characteristics associated with a consecutive series of suicides in Belgian prisons from 2000 to 2016 inclusive, in order to inform suicide prevention strategies.

METHOD

All documented cases of suicide ( N = 262) were reviewed using a standardized assessment checklist. Official records were abstracted for prisoners' sociodemographic, criminological, and clinical information, as well as for suicide-related characteristics.

RESULTS

Over the 17-year study period, suicides accounted for one third of all deaths in Belgian prisons. The average annual suicide rate in Belgium from 2000 to 2016 was 156.2 per 100,000 prisoners. Examination of all cases highlights both individual (psychiatric disorders and a history of suicide attempt) and situational (the early period of incarceration, interfacility transfers, and placement in solitary confinement) factors common in many prison suicides; some of them amenable to (clinical) management, which presents several potential avenues for suicide prevention.

LIMITATIONS

Given the absence of a matched control group, no conclusions could be ascertained regarding risk factors.

CONCLUSION

Suicide is a common, preventable cause of death among prisoners in Belgium. The results underscore the timely need for national standards and guidelines for suicide prevention in Belgian prisons.

Are the benefits of autonomy satisfaction and the costs of autonomy frustration dependent on individuals' autonomy strength?

OBJECTIVE

From a self-determination theory perspective, individuals are assumed to benefit and suffer from, respectively, the satisfaction and frustration of the psychological need for autonomy, even if they score low on autonomy strength. Yet, previous studies on need strength are scarce, operationalized need strength differently, and produced inconsistent findings.

METHOD

In two studies among 224 South African adults (M_age  = 24.13, SD = 4.25; 54.0% male) and 156 Belgian prisoners (M_age  = 38.60, SD = 11.68; 88.5% male), we investigated the moderating role of autonomy valuation and desire in the relations of autonomy satisfaction and frustration with a variety of well-being and ill-being indicators.

RESULTS

Study 1 provided some evidence for the moderating role of mostly explicit autonomy desire (rather than explicit autonomy valuation). In Study 2, neither explicit nor implicit autonomy desire played a consistent moderating role.

CONCLUSIONS

Overall, these findings are congruent with a moderate (albeit not with a strong) interpretation of the universality claim made within self-determination theory, provide initial evidence for a differentiation between deficit-based and growth-oriented interpersonal differences in need strength, and indicate that the potential moderating role of need strength deserves continued attention before any firm conclusions can be drawn.

Suicidal ideation while incarcerated: Prevalence and correlates in a large sample of male prisoners in Flanders, Belgium

Prisoners constitute a high-risk group for suicide. As an early stage in the pathway leading to suicide, suicidal ideation represents an important target for prevention, yet research on this topic is scarce in general prison populations. Using a cross-sectional survey design, correlates of suicidal ideation while incarcerated were examined in a sample of 1203 male prisoners, randomly selected from 15 Flemish prisons. Overall, a lifetime history of suicidal ideation and attempts was endorsed by 43.1% and 20.3% of respondents, respectively. Approximately a quarter of all prisoners (23.7%) reported past-year suicidal ideation during their current incarceration, which was significantly associated with both imported vulnerabilities (psychiatric diagnoses and a history of attempted suicide) and variables unique to the prison experience (lack of working activity, exposure to suicidal behaviour by peers, and low levels of perceived autonomy, safety and social support) in the multivariate regression analysis. A first-ever period of imprisonment and a shorter length of incarceration (≤12months) were also associated with increased odds of recent suicidal ideation. Collectively, the current findings underscore the importance of both vulnerability factors and prison-specific stressors for suicidal ideation in prisoners, and hence the need for a multi-faceted approach to suicide prevention in custodial settings. In addition to the provision of appropriate mental health care, environmental interventions that target modifiable aspects of the prison regime could provide a substantial buffer for the onset and persistence of suicidal ideation in this at-risk population.

How family members of mentally ill offenders experience the internment measure and (forensic) psychiatric treatment in Belgium: A qualitative study

Mentally ill offenders in Belgium can be subjected to mandated care under an "internment measure" if they are viewed as a danger to society. This study investigated how family members of mentally ill offenders experience this internment measure and view the (forensic) psychiatric treatment of their relative. Semi-structured interviews were conducted with 24 relatives and analysed using Nvivo 11. Six different themes emerged: (1) the criminal offence and the internment measure as an additional stigma, (2) ambivalent feelings towards the judicial system, (3) prison is not the right place to be, (4) mental health support as an answer to problems, (5) fight a losing battle, and (6) while there is life there is hope. The experiences of family members indicate the need for improved treatment guidelines that allow earlier compulsory interventions to prevent crime and preferential admission to (forensic) psychiatric facilities rather than prisons. In addition, family members expressed the need for better communication from mental health professionals and the judicial system during the process and greater availability of peer support.

Critical incidents and judicial response during medium security treatment

This study examined inpatient incidents in three Flemish forensic medium security units and analyzed the subsequent judicial reactions to these incidents. During medium security treatment, incidents were reported for more than half of the participants. The most frequently registered incidents were non-violent in nature, such as absconding and treatment non-compliance. The base rate for physically violent incidents was low. Although crime-related incidents during medium security treatment were rarely prosecuted and adjudicated, the base rate of revocation - and hence drop-out from treatment - as a result of these incidents was high.

Reconviction and revocation rates in Flanders after medium security treatment

AIM

To examine the criminal outcome of Flemish forensic psychiatric patients ('internees') after medium security treatment. Also, the effect of conditional release on recidivism of two subgroups (internees under conditional release and internees who received unconditional release) was examined.

METHOD

Reconviction rates and revocation rates were collected for all participants. Kaplan-Meier survival analyses were used to investigate recidivism rates while controlling for time at risk.

RESULTS

During the 10-year period, 502 offenders were discharged from medium security treatment. Over a follow-up period averaging 3.6years, 7.4% of discharged patients were reconvicted or received a new 'not guilty by reason of insanity' (NGRI) verdict for a violent offence. One-quarter of the population had their conditional release revoked. Part of the study population was granted unconditional release. Reconviction rates were higher after unconditional release in comparison to conditional release.

CONCLUSIONS

The results of this study suggest that the court supervision of NGRI patients in Flanders is effective in protecting the community from further offending.

Euthanasia for Detainees in Belgium

In 2011, Frank Van Den Bleeken became the first detainee to request euthanasia under Belgium's Euthanasia Act of 2002. This article investigates whether it would be lawful and morally permissible for a doctor to accede to this request. Though Van Den Bleeken has not been held accountable for the crimes he committed, he has been detained in an ordinary prison, without appropriate psychiatric care, for more than 30 years. It is first established that Van Den Bleeken's euthanasia request plausibly meets the relevant conditions of the Euthanasia Act and that, consequently, a doctor could lawfully fulfill it. Next, it is argued that autonomy-based reasons for euthanizing him outweigh complicity-based reasons against doing so, and that, therefore, it is also morally permissible for a doctor to carry out the euthanasia request.

Older offenders deemed criminally irresponsible in Flanders (Belgium): Descriptive results from a retrospective case note study

INTRODUCTION

In Belgium, offenders who are deemed criminally irresponsible for their criminal actions because of mental illness or intellectual disability are subject to a specific safety measure with the dual objective of protecting society and providing mandated care to the offender. While Belgian law requires that offenders who are deemed criminally irresponsible should be in a hospital, clinic or other appropriate institution outside of prison, in practice, about one-third of all such offenders still reside in prison. Whether imprisoned or living in settings outside prison, there is a dearth of knowledge on the characteristics of the aging population among the criminally irresponsible offenders.

OBJECTIVE

This paper aimed to explore the characteristics of older offenders categorized as criminally irresponsible in Flanders (northern Belgium) with a focus on the differences between imprisoned older offenders deemed criminally irresponsible and their peers who are residing outside prison.

METHOD

A retrospective case note study of all offenders deemed criminally irresponsible, >60years of age (n=174), was conducted in the four Commissions of Social Defense, which implement the procedure in the case of those deemed criminally irresponsible in Flanders. The files were screened for (1) demographic characteristics, (2) criminal history as well as (3) mental and physical health issues.

RESULTS

One-fourth of the population were >70years of age. A total of 30.5% were in prison. Compared to their non-imprisoned peers, the imprisoned offenders had a history of having committed more serious violent crimes towards persons, such as homicides and sexual crimes. In addition, imprisoned older offenders categorized as criminally irresponsible are characterized more explicitly by personality traits that are likely to reduce their chances of being transferred to more appropriate settings in the community.

IMPLICATIONS

A comprehensive and systematic screening of all older offenders deemed criminally irresponsible with regard to health needs and social functioning, including age-related deterioration, alcoholism, and other causes of social disadvantages, is warranted to detect potentially hidden problems.

Treatment and Control: A Qualitative Study of Older Mentally Ill Offenders' Perceptions on Their Detention and Care Trajectory

The life of older mentally ill offenders (OMIOs) is often characterized by successive periods of detention in correctional facilities, admissions to psychiatric services, and unsuccessful attempts to live independently. Through in-depth interviews, eight personal stories from OMIOs under supervision of the commission of social defence in Ghent (Belgium) were analyzed in the phenomenological research tradition. The results of the study reveal that OMIOs had more positive and less negative experiences in prison settings when compared with other institutional care settings. Independent living, unsurprisingly, is favored the most. This may be due to the fact that the latter option fosters personal competence, feelings of being useful, personal choices, and contact with the "outside" world. Even in later lifetime, a combined approach of risk assessment with improvement of well-being remains valuable to stimulate offender rehabilitation. Therefore, more research into concepts that could be used to support OMIOs needs further consideration.

The blurred vision of Lady Justice for minors with mental disorders: records of the juvenile court in Belgium

PURPOSE

This study examined (1) the information present in juvenile court records in Belgium (Flanders) and (2) whether there are differences in information between records that mention a mental disorder and those that do not.

METHOD

The file study sample included 107 court records, and we used a Pearson's chi-square test and a t-test to analyze the information within those records.

RESULTS

Information in juvenile court records varied considerably. This variability was evident when we compared juvenile court records with and without mention of a mental disorder. Significantly more information about school-related problems, the functioning of the minor, and the occurrence of domestic violence was included in records that mentioned a mental disorder compared with records that did not.

CONCLUSION

The content of the juvenile court records varied, particularly with regard to the mental health status of the minor in question. We suggest guidelines to standardize the information contained in juvenile court records.

Mandatory neurotechnological treatment: ethical issues

What if neurofeedback or other types of neurotechnological treatment, by itself or in combination with behavioral treatment, could achieve a successful "rewiring" of the psychopath's brain? Imagine that such treatments exist and that they provide a better long-term risk-minimizing strategy compared to imprisonment. Would it be ethical to offer such treatments as a condition of probation, parole, or (early) prison release? In this paper, I argue that it can be ethical to offer effective, non-invasive neurotechnological treatments to offenders as a condition of probation, parole, or (early) prison release provided that: (1) the status quo is in no way cruel, inhuman, degrading, or in some other way wrong, (2) the treatment option is in no way cruel, inhuman, degrading, or in some other way wrong, (3) the treatment is in the best interests of the offender, and (4) the offender gives his/her informed consent.

Prison psychiatry

PURPOSE OF REVIEW

Prison psychiatry is a secluded area of the psychiatric care system, which in fact often provides treatment for those who do not have access to community-based healthcare systems. The aim of this review is to give an impression of the special challenges of psychiatric work behind bars and to emphasize current trends in prison psychiatry.

RECENT FINDINGS

In prisoners, mental disorders are more common than in the general population. There is evidence that prison suicide rates do not reflect general population suicide rates, suggesting that variation in prison suicide rates possibly also reflects differences in the provision of psychiatric care. Good transitional preparation preceding release seems to be necessary to reduce the risk of poor health outcome, but is hard to achieve. Up to now, there is no clear decision on whether it is useful or possible to treat adult prisoners with attention-deficit/hyperactivity disorder with stimulants.

SUMMARY

Prison psychiatry has to deal with a disproportionate burden of psychiatric disease in prisoners. Adequate psychiatric treatment options may reduce suicide behind bars. Further research should focus on the special needs of individuals who are out of reach of the conventional community-based health system.

An assessment of personality disorders with the Five-Factor Model among Belgian inmates

Many international studies report a high prevalence of personality disorders among inmates on the basis of (semi)-structured diagnostic interviews. The present study proposes a self-reported evaluation of personality disorders using the NEO PI-R. The sample consists of 244 male and 18 female inmates (N=262) who were psychologically assessed. The analysis of the five psychological domains shows that the French-speaking Belgian inmates are as stable, as extroverted, more closed, more agreeable and more conscientious than the normative sample. The NEO PI-R facets are also analyzed. The mean Cohen's d (.26) is small. Two personality disorders have medium effect sizes: obsessive compulsive personality disorder (high) and histrionic personality (low). Small effect sizes exist for antisocial personality (low), psychopathy (low), narcissistic personality (low), schizoid personality (high) and borderline personality (low). In our view, the context of the assessment can partially explain these results but not entirely. The results do not confirm previous studies and question the high rates of psychiatric prevalence in prison.

Intelligent diagnosing of intellectual disabilities in offenders: food for thought

Research on offenders with intellectual disabilities (IDs) in the criminal justice arena is on the rise, reflected by a growing number of relevant publications each year. However, there is a long recognized methodological problem that hampers the comparability of empirical studies and that raises doubts about the accuracy of prevalence rates, comorbidities, and various correlates and characteristics. In this paper we will argue that the crux of the problem can, on the one hand, be found in the plurality of assessment methods for intelligence and adaptive functioning, which are not all sufficiently reliable and valid. On the other hand, assessment of IQ in criminal justice and mental health-related areas appears to be informed more by practical aspects and needs rather than grounded in a solid theoretical model. Hence, we suggest that the Cattell-Horn-Carroll (CHC) model of intelligence has potential value in this regard, and deserves a closer look. Finally, we will discuss its incorporation into, and possible implications for, criminal justice practice and future study designs.