The national trajectory project of individuals found not criminally responsible on account of mental disorder. Part 5: how essential are gender-specific forensic psychiatric services?

Characteristics associated with criminal responsibility assessment outcomes among women in Central Canada

The number of women involved with forensic mental health systems internationally is rising, however, limited research has explored the characteristics of those assessed for criminal responsibility. We investigated the demographic, psychiatric, and criminological characteristics of women recommended as eligible or ineligible for the defence of Not Criminally Responsible (NCR) on account of mental disorder following a criminal responsibility assessment in Central Canada. Data were collected through retrospective chart reviews of court-ordered criminal responsibility assessments for 109 women referred for evaluations between 2003 and 2019. Accused were an average age of 34.55 years, predominately identified as Indigenous (37.7%) or Caucasian (20.8%), and had often been charged with assault (47.7%). Women identified in the reports as NCR-eligible were significantly more likely to be employed, experience delusions during the index offence, and have expert reports linking their mental health symptoms to NCR legal criteria. They were also significantly less likely to have a personality disorder, substance-related diagnosis, or have used substances during the index offence. Delusions during the index offence significantly predicted assessment recommendations when controlling for age at assessment order, current substance-related diagnosis, and whether the expert report linked mental health symptoms to NCR legal criteria. Findings indicate the key factors considered by forensic mental health professionals when conducting criminal responsibility assessments with women. Meaningful differences exist between women identified as NCR-eligible and ineligible, with findings illustrating who may be more likely to receive services within the Canadian forensic mental health system.

A systematic review of gender-responsive and integrated substance use disorder treatment programs for women with co-occurring disorders

Background: Integrated and gender-responsive interventions, designed to target co-occurring substance use and psychiatric disorders in women, may be effective in addressing gender-specific challenges.Objectives: This systematic review aims to identify integrated gender-responsive substance use disorder treatments for women, summarize evaluations of these treatments, and address gaps in the literature.Methods: We searched PsycINFO, PubMed, and MEDLINE on September 24, 2021, and March 10, 2022. Included articles were randomized-controlled trials, secondary analyses of naturalistic studies, or open-label studies of integrated and gender-responsive treatments from any year that assessed both substance use and mental health/trauma outcomes.Results: We identified N = 24 studies (participants = 3,396; 100% women) examining Seeking Safety, Helping Women Recover and Beyond Trauma, A Woman's Path to Recovery, Modified Trauma Recovery and Empowerment Model (TREM), Breaking the Cycle, VOICES, Understanding and Overcoming Substance Misuse, Women's Recovery Group, Female Specific Cognitive Behavioral Therapy, and Moment by Moment in Women's Recovery. Across treatments there were significant improvements over time; Seeking Safety, Helping Women Recover, and TREM were associated with significantly better substance use and mental health outcomes relative to the comparison groups.Conclusions: Integrated gender-responsive treatments are a promising approach to treating women with co-occurring substance use and mental health concerns, and broad clinical implementation stands to benefit women. However, there remains a lack of studies evaluating substance use treatments in women with severe mental illness (e.g., psychotic-spectrum disorders) who differ in their needs and capacity.

What do we know about the experience of seclusion in a forensic setting? An integrative literature review

Seclusion is used in forensic and general mental health settings to protect a person or others from harm. However, seclusion can result in trauma-related harm and re-traumatization with little known about the experience of seclusion for consumers in forensic mental health settings from their perspectives. This article explores consumer experiences of seclusion in forensic mental health settings and explores the differences between female and male experiences of seclusion. Five electronic databases were systematically searched using keywords and variations of experience, attitude, seclusion, coercion, forensic mental health, and forensic psychiatry. Inclusion criteria were original peer-reviewed studies conducted in adult forensic mental health settings reporting data on the experiences of or attitudes towards seclusion. Seven studies met the criteria for inclusion and a quality assessment was undertaken. Results found consumers in forensic mental health settings perceive seclusion to be harmful, a punishment for their behaviour, and largely a negative experience that impacts their emotional health. Some consumers report positive experiences of seclusion. Differences in the experience of seclusion for females and males are unclear. Further research is required to understand the experience of seclusion for women in forensic mental health settings. Identification and consideration of differences in the experience of seclusion for males and females may assist in identifying sex-specific interventions and may inform policy and practices to eliminate or reduce the trauma associated with seclusion use.

Just Like a Woman: Gender Role Stereotypes in Forensic Psychiatry

The relationship between violence, gender and mental health is a complex one which is yet to be fully understood. Gender role stereotypes are social constructs that can powerfully influence and regulate human behaviour, including violence; and so it is likely that they also influence the nexus of violence management and mental health which is at the core of forensic psychiatry. In this article, we examine how gender role stereotypes might influence the practice of forensic psychiatry: specifically, in relation to women as violent offenders, as patients in secure psychiatric care and as clinicians working in forensic settings. We identify areas of development in women's forensic mental health services, and examine whether patriarchal influences and gender role stereotypes may have inadvertently impacted upon these changes. We also consider whether these changes may maintain pre-existing barriers to treatment for both men and women.

[COVID-19: Professional practices in closed institutional settings]

INTRODUCTION

While governments have focused efforts on implementing health measures such as physical distancing and confinement to protect communities from the spread of COVID-19, some researchers focused on the significant impact of these measures on mental health and well-being. Persons with mental disorders who are both institutionalized and justice-involved in psychiatric and forensic hospitals find themselves more vulnerable to these measures and more limited in their movements and activities.

AIMS

The purpose of this paper is to examine the changes in practice in response to the pandemic and their potential impact on individuals in institutional settings.

RESULTS

A rapid review including 69 publications identified nine major themes in the literature, which will serve as a framework to analyze the experience of one forensic psychiatry institution in Canada. These themes are: 1) population-specific vulnerability factors; 2) staff management and training; 3) early discharge, parole, and community integration; 4) management of contagion in closed spaces; 5) sanitary measures and personal protective equipment; 6) care and service continuity; 7) use of technology to maintain social ties and services; 8) legal mechanisms and individual rights; and 9) post-pandemic realities.

CONCLUSION

Although this is the first pandemic of such international magnitude, experts point to an increase in epidemics over the past decade and continued growth in the coming decades. It is thus essential to learn from this health crisis in order to be prepared and minimize their potential impact on vulnerable populations in the future. The reflections presented here could be contrasted with the lived-experiences of people in institutions in order to nuance the data and propose new strategies.

Female Forensic Patients May Be an Atypical Sub-type of Females Presenting Aggressive and Antisocial Behavior

The percentage of forensic psychiatric patients who are female varies from 5 to 13% in Europe, rises to 18% in England and Wales, and sits at 15% in Canada. Similarly, many fewer women than men are incarcerated in correctional facilities. While these statistics supposedly reflect less antisocial and aggressive behavior (AAB) among females than males, not all findings support this supposition. Data from prospective longitudinal studies show that aggressive and antisocial behavior onsets in childhood, and in a small group of females it remains stable across the life-span. Unlike similar males, few of these females are convicted of crimes. This article begins with a review of descriptive studies of females sentenced by criminal courts to treatment in forensic psychiatric hospitals and moves on to present evidence showing that most female AAB does not lead to criminal prosecution. Next, studies of female AAB are reviewed, noting that it onsets in early childhood and, that in a small group remains stable across the life-span. Subsequent sections of the article focus on the two most common mental disorders presented by female forensic patients, schizophrenia and borderline personality disorder, highlighting what is known about the sub-groups of women with these disorders who present AAB. The article concludes with recommendations for earlier identification by psychiatric services of women presenting mental disorders and AAB, treatments to reduce both the symptoms of their mental disorders and their life-long AAB, and the research that is needed in order to improve the effectiveness of these treatments. The real possibilities of prevention of the development of AAB, and even perhaps aspects of the mental disorders that plague female forensic patients, are described.

Balancing security and care: Gender relations of nursing staff in forensic psychiatric care

This study departs from the built-in tension of the dual goals of forensic psychiatric care in Sweden, which are to protect society as well as to care for patients. The majority of violence that takes place is perpetrated by men. Therefore, the views of nursing staff on violence as a gendered phenomenon have an impact on the care provision. There is a need for further knowledge of how norms of violence are intertwined with the construction of gender. The aim of this study was to use a gender perspective to demonstrate the views of nursing staff on security and care and the consequences for their relationships with patients. The study adopts an ethnographic approach, with data consisting of field notes from participatory observations and interviews with nursing staff at two maximum-security clinics. We show how the perceptions of nursing staff about gender relations are based on heteronormative thinking, which affects their practice. This implies that if gender is ignored in relation to the dual goals, there is a risk of perpetrating patterns of unequal conditions. Therefore, it is vital to make gender visible to counteract unequal conditions for nursing staff and address patients' individual care needs.

Changing characteristics of forensic psychiatric patients in Ontario: a population-based study from 1987 to 2012

PURPOSE

To quantify the demand for forensic psychiatric services in Ontario over the past 25 years and investigate whether the sociodemographic, clinical and offense-based characteristics of forensic patients have changed over time.

METHODS

We investigated all forensic admissions from 1987 to 2012 resulting in a disposition of Not Criminally Responsible on account of Mental Disorder (N = 2533). We present annual proportions of patients with specified sociodemographic, clinical and offense characteristics, and investigate whether the duration of forensic system tenure varies as a function of admission year, psychiatric diagnosis, or index offense.

RESULTS

There has been a steady increase in forensic admissions over this time period, particularly individuals with comorbid substance use disorders and individuals of non-Caucasian ethno-racial background. The proportion of persons committing severe violence has remained low and has decreased over time. Having a comorbid personality, neurological, or substance use disorder significantly increased forensic system tenure, as did committing a violent offense. Individuals who came into the system in earlier years had slower rates of discharge compared to more recent admissions.

CONCLUSIONS

Defining the trends characterizing the growth of the forensic population has important policy implications, as forensic services are costly and involve a significant loss of liberty. The current results indicate that young, substance abusing individuals of diverse ethno-racial backgrounds and who commit relatively low-level violence comprise an increasing proportion of Ontario's forensic population, and suggest that treatment must be optimized to best serve the needs of these individuals.

Factors Associated with Review Board Dispositions following Re-hospitalization among Discharged Persons found Not Criminally Responsible

In the Canadian forensic mental health system, a person found Not Criminally Responsible on account of Mental Disorder (NCRMD) and given a conditional discharge returns to the community while remaining under the jurisdiction of a provincial/territorial Review Board. However, the individual can be re-hospitalized while on conditional discharge, for reasons such as substance use, violation of conditions, or violence. We investigated whether being re-hospitalized has an impact on the factors associated with the subsequent Review Board disposition. Persons found NCRMD from the three largest Canadian provinces who were conditionally discharged at least once during the observation period were included in the sample (N = 1,367). These individuals were involved in 2,920 disposition hearings; nearly one-third of patients (30%) were re-hospitalized after having been conditionally discharged by the Review Board. The factors examined included the scales of the Historical Clinical Risk Management-20 and salient behavior that occurred since the previous hearing, such as substance use or violence. The greater presence of clinical items resulted in a greater likelihood of a hospital detention decision at the next hearing. The effect was larger for the re-hospitalized group than for the group who successfully remained in the community since the last hearing. The results suggest that dynamic factors, specifically indicators of mental health, are heavily weighted by the Review Boards, consistent with the literature on imminent risk and in line with the NCRMD legislation. Copyright © 2016 John Wiley & Sons, Ltd.

Research Priorities in Mental Health, Justice, and Safety: A Multidisciplinary Stakeholder Report

This paper is based on the report following the National Research Agenda Meeting on Mental Health, Justice, and Safety held in Montreal on November 19, 2014, which convened academics; health, social, and legal professionals; and people with lived experience of mental illness from across Canada. The goal was to identify research priorities addressing relevant knowledge gaps and research strategies that can translate into public policy action and improvements in evidence-based services. Participants identified key challenges: (1) inadequate identification and response to needs by civil mental health services and frontline law enforcement, (2) limited specialized resources in forensic and correctional settings, (3) fragmented care and gaps between systems, (4) limited resources for adequate community reintegration, and (5) poor knowledge transfer strategies as obstacles to evidence-based policies. Knowledge gaps were identified in epidemiology and risk reduction, frontline training and programs, forensic and correctional practices, organizations and institutions, knowledge transfer, and rehabilitation. Finally, participants identified potential sources of support to conduct real time research with regard to data collection and sharing. The findings represent a roadmap for how forensic mental health systems can best proceed to address current challenges through research and practice initiatives, drawing from lived, clinical and research experiences of a multidisciplinary group of experts.

The national trajectory project of individuals found not criminally responsible on account of mental disorder in Canada. Part 1: context and methods

The National Trajectory Project examined longitudinal data from a large sample of people found not criminally responsible on account of mental disorder (NCRMD) to assess the presence of provincial differences in the application of the law, to examine the characteristics of people with serious mental illness who come into conflict with the law and receive this verdict, and to investigate the trajectories of NCRMD-accused people as they traverse the mental health and criminal justice systems. Our paper describes the rationale for the National Trajectory Project and the methods used to collect data in Quebec, Ontario, and British Columbia, the 3 most populous provinces in Canada and the 3 provinces with the most people found NCRMD.