Substance use disorders in forensic psychiatric patients

There is a lack of detailed information on the role of substance use disorders (SUD) as a substantial factor in offences and treatment in forensic psychiatric patients. The aim of this study was to get a better understanding of these specifics. Clinical records of 193 male patients admitted to a Dutch forensic psychiatric hospital were scrutinized on anamnestic, diagnostic and risk assessment data. One of the central findings was that the prevalence of SUDs was high. Patients with an SUD had a more extensive criminal history, unstable and deviant lifestyle and higher risk of violent behavior than patients without a substance use disorder. No differences were found in duration of treatment, aggressive incidents and leave. Another important finding was that a distinction could be made between patients with substance use as a primary criminogenic risk factor and patients with substance use as a secondary risk factor. Although substance use is identified as a general risk factor, this study supports the idea of sub categorization of patients with an SUD and emphasizes the need for a different treatment approach. Further study is needed to identify specific treatment approaches, based on more differentiated profiles of these patients.

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.

Social support, attachment and externalizing behavior in forensic patients with attention-deficit hyperactivity disorder

This study was designed to provide more insight into the relationship between social support and externalizing behavior in forensic patients with ADHD. Because ADHD is highly associated with psychosocial impairment, we expected poor social support and attachment insecurity (i.e., preoccupied, fearful, and dismissive attachment) to be associated with higher levels of externalizing behaviors in forensic patients with ADHD. Self-reports of 32 forensic male outpatients with ADHD (M age = 35.34) were compared with self-reports of healthy (n = 32; M age = 33.84), and 'at risk' control males with (a history of) psychological problems (n = 30; M age = 36.47) from the general population. In addition, associations between social support, attachment and externalizing behaviors (i.e., aggression, antisociality, anger and hostility) were examined within the sample as a whole. Analyses of variance showed that forensic patients with ADHD had higher levels of externalizing behaviors and insecure attachment, and lower levels of secure attachment compared to both healthy and at risk controls. Multivariate regression analyses showed that social support was not associated with any of the externalizing behaviors, after accounting for attachment. In contrast, insecure attachment was associated with higher levels of all externalizing behaviors examined. Finally, insecure attachment best explained antisociality and hostility, suggesting that attachment is more important than other psychopathological risk factors that distinguish the different groups.

Cognitive predictors of reactive and proactive aggression in a forensic sample: A comparison with a non-clinical sample

This study aimed at examining cognitive predictors of reactive and proactive aggression in a forensic-psychiatric (n = 80) and a non-clinical sample (n = 98; Brugman et al., 2015). Three different cognitive predictors were incorporated: (1) attentional bias towards aggressive stimuli (measured with Emotional Stroop task) and towards angry faces (measured with a visual search task); (2) interpretation biases (measured with Aggressive Interpretative Bias Task (AIBT) and a vignette task), and (3) implicit self-aggression association (measured with a Single-Target Implicit Association Task). To measure aggression, the Reactive-Proactive Aggression Questionnaire (RPQ) and the Taylor Aggression Paradigm (TAP) were used. An automatic self-aggression association positively predicted proactive aggressive behavior on the TAP in both samples. Furthermore, this self-aggression association predicted, increased self-reported proactive aggression (RPQ) in the forensic sample only. Pain, injury, and danger interpretations reported on the vignettes, negatively predicted self-reported proactive aggression in both samples. A stronger aggressive interpretation bias on the AIBT predicted more reactive aggressive behavior (TAP) in the non-clinical sample only. Taken together, findings show both common and distinct mechanisms in reactively vs. proactively driven aggressive behavior.

Staff's perception of Patients' affiliation and control in a Highly Secure Psychiatric Setting

Effective interactions between patients and staff have been associated with positive ward climate and therapeutic effects, but also pose a challenge in high secure forensic psychiatric settings. The goal of this study was to gain more insight into i) the characteristics that play a role in how staff members perceive the interpersonal style of patients, and ii) whether these perceptions are related to patients' evaluation of ward climate and satisfaction with daily staff. Staff members (n = 69), rated the interpersonal style of 102 male patients. Satisfaction with daily staff and ward climate were rated by 45 patients. Results show that patient characteristics (primary diagnosis, patient age, disruptive behavior, recent problems with symptoms of major mental disorder and recent problems with treatment or supervision response) were related to how staff perceived the interpersonal style (i.e., affiliation and control) of patients. Furthermore, the level of affiliation was positively related to patients' satisfaction with daily staff. Patients that were seen as more controlling by staff were less satisfied with the safety on their ward (as a factor of ward climate). The results indicate that perception of patients' interpersonal style entails patient related information and can be relevant for staff to use in their work.

Patients' and volunteer coaches' experiences with an informal social network intervention in forensic psychiatric care: a qualitative analysis

BACKGROUND

Improving supportive social networks in forensic psychiatric patients is deemed important due to the protective effects of such networks on both mental health problems and criminal recidivism. Informal interventions targeted at social network enhancement by community volunteers showed positive effects in various patient and offender populations. However, these interventions have not specifically been studied in forensic psychiatric populations. Therefore, forensic psychiatric outpatients' and volunteer coaches' experiences with an informal social network intervention were explored in this study.

METHODS

This qualitative study was based on semi-structured interviews conducted alongside an RCT. Forensic outpatients allocated to the additive informal social network intervention, and volunteer coaches, were interviewed 12 months after baseline assessment. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis was used to identify and report patterns in the data.

RESULTS

We included 22 patients and 14 coaches in the study. The analysis of interviews revealed five main themes reflecting patients' and coaches' experiences: (1) dealing with patient receptivity, (2) developing social bonds, (3) receiving social support, (4) achieving meaningful change, and (5) using a personalized approach. Patient receptivity, including willingness, attitudes, and timing, was a common reported barrier affecting patients' engagement in the intervention. Both patients' and coaches' experiences confirmed that the intervention can be meaningful in developing new social bonds between them, in which patients received social support. Despite, experiences of meaningful and sustainable changes in patients' social situations were not clearly demonstrated. Coaches' experiences revealed broadened worldviews and an enhanced sense of fulfillment and purpose. Finally, a personalized, relationship-oriented rather than goal-oriented approach was feasible and preferable.

CONCLUSION

This qualitative study showed positive experiences of both forensic psychiatric outpatients and volunteer coaches with an informal social network intervention in addition to forensic psychiatric care. Notwithstanding the limitations, the study suggests that these additive interventions provide an opportunity for forensic outpatients to experience new positive social interactions with individuals in the community, which can initiate personal development. Barriers and facilitators to engagement are discussed to improve further development and implementation of the intervention.

TRIAL REGISTRATION

This study is registered at the Netherlands Trial Register (NTR7163, registration date: 16/04/2018).