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Challenging bias in forensic psychological assessment and testingChallenging Bias in Forensic Psychological Assessment and Testing is a groundbreaking work that addresses the biases and inequalities within the field of forensic psychology. It gives valuable insights into individual practices and wider criminal justice approaches at an international level, while providing tangible solutions to tackle the disparities. This book constructively critiques current forensic practice and psychological assessment approaches through a variety of diverse voices from pioneering researchers around the world who offer their expertise on these challenges and assist the reader to consider their potential contribution to pushing forward the frontiers of Forensic Psychology. The authors also locate the origin of these biases in order to further dismantle them, and improve the outcomes for the forensic client base – especially specific diverse populations. They emphasise the need to be creative and evolve not just in line with the real-world changes of today, but also to prevent the issues of tomorrow before they become the next news headline. This is a must read for professionals working in criminal justice, forensic psychology, legal psychology, and related fields. It is also a compelling resource for students and researchers of forensic psychology with particular interest in social diversity and inclusion.
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The validity of reconviction as a proxy measure for re-offending: Interpreting risk measures and research in the light of false convictions and detection and conviction evasion skills (DACES) and processesRisk assessment tools and intervention efficacy evaluations typically use reconviction as an outcome that is assumed to be a valid measure of the return to offending (RTO). Reconviction is however problematic as a measure of RTO because a significant amount of offending goes unreported, undetected and/or unconvicted. The consequences and implications of this measurement problem are significant for the forensic practitioner. In this chapter we outline the nature of this problem, highlighting one of the key differences between clinical formulation and actuarial assessment being that the former develops a causal model of offending behaviour whilst the latter is a largely atheoretical statistical account of factors correlating with reconviction (which is fundamentally different from RTO). We explore how clinical judgement may be predicting RTO, whereas actuarial assessment predicts reconviction (a smaller subset of those re-offending). The literature supports the idea that biases, such as racism and unequal detection and conviction rates for different groups of people, underpin convictions which are inevitably “baked in” (e.g., Mayson, 2019) to actuarial assessment; hence risk assessments are predicting outcomes that can be biased. The need to assess individual and systemic detection and conviction evasion skills and processes as part of assessment is highlighted, and a preliminary model for analysing systemic detection and conviction evasion skills and processes is presented. The importance of specifying a measurement model before interpreting reconviction as a “valid” outcome measure is highlighted
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Developing models and a framework for multi‐professional clinical supervisionThe UK government proposals for services for individuals considered to be dangerous with a severe personality disorder (DSPD) are developing. The complex task of balancing safety and therapeutic change in DSPD services will rest largely upon the skills, knowledge and practice of the staff group. As a result, one challenge for DSPD services is to provide sufficient training and support to staff, in order to ensure that adequate resources are available to assist them in processing their emotional reactions to their work. As part of this, clinical supervision systems need to be developed to offer professional support and learning, enabling individual practitioners to develop knowledge and competence and assume responsibility for their own practice (DoH, 1993). Among the service developments at Rampton Hospital an innovative multi‐professional supervision strategy has been introduced for all staff working in the unit. This paper describes the evolving supervision framework, including a new tool, the ‘Supervision Matrix’, and implementation guidelines, and describes how this supervision framework will be evaluated.
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Forensic mental health: Envisioning a more empirical future [In press]Summary Forensic mental health services provide crucial interventions for society. Such services provide care for people with mental disorders who commit violent and other serious crimes, and they have a key role in the protection of the public. To achieve these goals, these services are necessarily expensive, but they have been criticised for a high-cost, low-volume approach, for lacking consistent standards of care, and for neglecting human rights and other ethical considerations. A key concern is an insufficient evidence base to justify common practices, such as restricting leave from hospital and detaining patients for long periods. There is also insufficient quality evidence for core interventions, including psychological therapies, pharmacotherapy, and seclusion and restraint. The causes for this evidence deficit are complex but include insufficient investment in research infrastructure and fragmentation and isolationism of services, both nationally and internationally. In this Personal View, we highlight some of the major gaps in the forensic mental health evidence base and the challenges in addressing these gaps. We suggest solutions with implications at clinical, societal, and public health policy levels.
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Elderly offenders at Wathwood Hospital: perspectives and practicalitiesAims. The following project explores where Wathwood Hospital stands in provision of services to its elderly patients. Background. The only dedicated forensic medium secure unit for elderly offenders in England is the St. Andrews medium secure unit in Northampton with only 17 beds. Due to the limited beds, other units must accommodate elderly patients, which raises the question whether these units can provide the appropriate services for this very vulnerable population. Method. Inclusion Criteria: Male >55 years of age Admitted from 2012 onwards (from when database was maintained) Data were gathered using patient electronic records including index offence, mental disorder, physical health comorbidities and discharge destinations. Patient identifiable data were anonymized to protect their identities. A staff survey was also conducted to find their perspective on managing elderly patients and whether Wathwood Hospital had the appropriate resources for elderly offenders in their area of work. Result. A total of 220 referrals were searched with only 9 patients >55 years. Index offenses, mental disorder diagnoses, physical comorbidities including cognitive assessments in the form of memory tests and brain imaging were also collated for identified patients from electronic patient records. Index offences included violence against person, arson, homicide, robbery, threatening behaviour and dangerous driving and affray. Diagnoses included learning disability, delusional disorder, paranoid schizophrenia, bipolar affective disorder, alcohol dependence, personality disorder and depressive disorder. Patients had multiple comorbidities such as diabetes, COPD, hypertension, coronary artery disease and musculoskeletal problems. Out of the nine admitted patients, only six had an ACE with an average score of 70.83. Five patients had brain imaging, with two normal results and the others showing some degree of atrophy and ischemic changes. Discharge destinations included medium secure units, low secure unit and prison. One patient unfortunately died during admission and four are still inpatients. A staff survey conducted showed their perspective on the challenges in managing elderly patients and whether Wathwood Hospital had the appropriate resources for them to work with elderly offenders in their area of work. All results will be explained through tables and graphs. Conclusion. It's evident that there are challenges in managing elderly patients in units not specifically designed to manage them. This is also due to the lack of geriatric training and resources available to allied health care professionals to carry out their respective work. It's therefore crucial we formulate more inclusive strategies to address these challenges.
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The improvement of the quality of medical reviews of patients in seclusion in Rampton HospitalAims. Improve and standardise the quality of medical seclusion reviews (MSRs). Acknowledge existing good practise. Highlight areas for improvement. Improve the awareness of doctors performing MSRs of the requirements in the Mental Health Act Code of Practice (MHA CoP) Background. MSRs are an essential clinical tool to ensure safe and consistent patient care. Patients detained in seclusion can be at heightened risk of poor mental and physical health, in addition to being a risk to themselves and others. There is clear guidance in the MHA CoP regarding what areas require to be covered in a MSR. Method. A retrospective audit of all MSRs in September 2019 across all patients within all directorates within Rampton Hospital was undertaken. 281 inpatients were identified within Rampton Hospital, and 61 of these patients were found to have had seclusion in September 2019. A total of 439 MSRs were identified for these patients. The standard applied was the MHA CoP guidance for MSRs: 1) MSRs should be conducted in person, and should include: 2) Review of physical health 3) Review of psychiatric health 4) Assessment of the adverse effects of medication 5) Review of observations required 6) Reassessment of medication prescribed 7) Assessment of the patient's risk to others 8) Assessment of the patient's risk of self-harm 9) Assessment of the need for continuing seclusion 100% compliance with targets or a reason why it was not possible was expected to be documented. Result. The results show there is a large variation in compliance with the MHA CoP. The area with the highest compliance was the completion of reviews in person-(99.3%). The criterion with the average worst compliance was whether the need for physical observations was reviewed-(4.3%). Physical health was reviewed in 86.1% of cases, in contrast to psychiatric health at 38.3%. The adverse effects of medication and reassessment of medication prescribed were recorded in only 8.9%. The risk from the patient to others was recorded in 25.3%, whereas risk to self was recorded in 10.7%. The need for continuing seclusion was recorded in 72.7%. Conclusion. The quality of MSRs at Rampton Hospital is currently inadequate. Improvement in practice is required to meet accepted standards and ensure safe, consistent patient care. Ways to improve this are being considered, including improving the knowledge of the MHA CoP and providing a MSR template.
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Violence risk assessment instruments in forensic psychiatric populations: A systematic review and meta-analysisBACKGROUND: Although structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered. METHODS: In our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716. FINDINGS: We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I(2)=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I(2)=0%) and Violence Risk Appraisal Guide (0·63-0·75; I(2)=0%), to 0·64 for the Static-99 (0·53-0·73; I(2)=45%). INTERPRETATION: Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support. FUNDING: Wellcome Trust.
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Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic reviewBACKGROUND: Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world. AIM: To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009. METHOD(S): Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing. RESULT(S): In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14 days (range, 14 days to >9 months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data. CONCLUSION(S): Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes. Copyright © 2023 John Wiley & Sons Ltd.
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A community of women in prison: More than a voice – therapeutic use of visual and psychodramatic artsThis chapter explains the context of the only women's democratic therapeutic community (DTC) in the English prison estate, at Her Majesty's Prison (HMP) Send. Following a brief history, it highlights the importance of recognising distinctive contextual factors reflected in the experience of women–as residents, visitors and staff–by contributions in their own words. Based on staff reports and self-reporting by women like Amaal, the introduction of psychodrama as a core creative therapy (CCT) and its short-term use to support the art therapy frame opened up new therapeutic possibilities for women who feel drawn to drama and embodied ways of working, and also for those to whom this implies a step out of the comfort zone. Psychodrama and art therapy enabled past maladaptive life experiences to be adaptively revisited, through creative experiences with a positive impact on the present and future of DTC residents. Creative warm-up for therapy was deemed important: contained spontaneity was enhanced by these, and potential protagonists were encouraged to take back to their small talking groups the themes they named in the initial part of the psychodrama sessions, or depicted in their art work. Whether these themes were worked through in action or not, art and psychodramatic warm-up exercises, as well as both protagonist and auxiliary role-taking seemed to warm up the women for further therapeutic work in talking groups, enhancing their self-confidence, self-reflection and prosocial relating. CCTs seemed to allow for affirmative adaptive experiences, which reinforced new adaptive ways of thinking, managing emotions and behaving. Adequate support and supervision of the psychodramatist and her participation in staff meetings was deemed crucial for creative group work to flourish in a safe, contained, sustained way, built on and built by the DCT living-learning experience as a whole. The CCT model presented in this chapter is neither static nor prescriptive. The combination and format of the CCTs offered to women in prison have been evolving. The approach adopted, incorporating practice-based evidence and residents’ experiences and reflections, adds to the existing work from male DTCs demonstrating the role of CCTs in enhancing practice and improving outcomes. (PsycInfo Database Record (c) 2023 APA, all rights reserved) (Source: create)
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The characteristics, convictions, and incidents of risk of women in the national high secure healthcare service for womenPurpose: A service evaluation was conducted to characterise all admissions to the National High Secure Healthcare Service for Women (NHSHSW).Design/methodology/approachData were obtained from computerised records, case notes, and the hospital’s Risk Department. Data collected included the date of incident, incident type, location of incident and name of aggressor. The severity of incidents were reported from 2010 onwards. Some data are presented in three time bands: 2007, 2008–2011, and 2013–2015 in order to illustrate changes. Some data is presented in three age bands based on age at admission: under 30 years old, 30–39 years old and 40 years and over.Findings105 women were admitted into the service between January 2007 and 30 June 2015. The majority of women had a diagnosis of personality disorder (81.0 per cent), a history of trauma (e.g. it was documented that 71.4 per cent had experienced sexual abuse) and had received a criminal conviction (90.5 per cent). A total of 8934 risk incidents were reported and the majority of women (N = 101, 96.2 per cent) were involved in at least one incident during their admission. The majority of recorded incidents involved self-harm (70.9 per cent).Originality/ValueLittle has been published about the NHSHSW population. This article outlines the characteristic profiles of women detained in high secure care.Practical implicationsThe complex background and clinical characteristics highlight the need for trauma-informed practice. Continuous monitoring is required to ensure effective practices.
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Long-term outcomes after discharge from medium secure care: still a cause for concern?People admitted to medium secure psychiatric care are recognised to still be at risk of experiencing adverse outcomes upon discharge. However, little is known about the outcomes of patients admitted more recently to medium secure care or the long-term outcomes of people many years after discharge. The aim of this study was to assess the mortality, conviction and readmission outcomes of a cohort of first admissions discharged from an English medium secure psychiatric unit between July 1983 and June 2013. Data on background characteristics were obtained from medical records. Outcome data were obtained from multiple sources for 843 patients discharged prior to the census date of 30 June 2013. The risk of death from both natural and unnatural causes was much higher than that of the general population. Of those patients that were discharged, 369 patients (43.8%) were convicted of an offence during the follow-up period, two-thirds of which were convicted within the first 5?years following discharge. Five hundred and ten patients (61.6%) were readmitted to psychiatric care. Patients discharged from medium secure care are at long-term risk of experiencing premature death, conviction and readmission to secure and non-secure psychiatric care.
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Staff perspectives on barriers to and facilitators of quality of life, health, wellbeing, recovery and reduced risk for older forensic mental-health patients: A qualitative interview studyObjectivesThere is a lack of research informing service delivery for older forensic mental health patients. This study explored service provision in forensic mental health inpatient and community services in England, investigating what is required for progress in terms of quality of life, health, wellbeing, recovery and reduced risk, and the barriers and facilitators associated with this.MethodsSemi-structured interviews were undertaken with 48 members of staff working with older forensic mental health patients in secure inpatient units or the community in England. Data were analysed using thematic analysis.ResultsTwo global themes ?What works? and ?What doesn?t work? were identified comprising themes representing environmental, interpersonal and individual factors. ?What works? included: positive social support and relationships; individualised holistic patient-centred care; hub and spoke approach to patient care; and suitable environments. ?What doesn?t work? included: absence of/or maladaptive relationships with family and friends; gaps in service provision; and unsuitable environments.ConclusionsFor older patients to progress to improved quality of life, health, wellbeing and reduced risk, multilevel and comprehensive support is required, comprising a range of services, interventions, and multidisciplinary input, and individualised to each patient?s needs. The physical environment needs to be adapted for older patients and provide a social environment that seeks to include supportive families, friends and expert professional input. A clear patient progression pathway is required; this must be reflected in policy and provision.
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“Some body else”: Harlequin’s journey in forensic sandplay and gender dysphoriaForensic Sandplay tells tragically ambivalent tales from deep within the unconscious, and body and mind, of devastating physiological and psychological impact of a parental split, abandonment-trauma, loss, and bereavement, from the masculine (and death of the father), and emotional and physical abuse from the feminine (mother). Using both sand trays at a time, Alex’s identity formation existed in the periphery between male and female, and masculine (conscious) and feminine (unconscious) energies in emotional detachment, de-personalisation and over-separation. Sacrificial archetypes, such as Harlequin, surrender the ego to the Self in order for previously masked emotional states, and aspects of Self, to become known, in a process of initiation; containing, liberating, and uniting internal opposing forces, and achieving balance (Jung et al., 1964). As a pretending Fool, yet paradoxically, intelligent Trickster, Harlequin transcends resistance and emancipates suppressed anxieties and threat sensitivity. Through uncovering buried, past resentment, and safely exploring the risk of gender violence, control and rigidity are abandoned in a dual representation of both masculine and feminine forces, in order for self-preservation, adaptation, authenticity, acceptance, and self-realisation. Alex’s separation of body and mind took authority, and desperately sought a sense of agency. Alex’s prohibited sexual and emotional life (perhaps witnessed in hand-printing in the sand) required bodily acknowledgement, and in being seen. (PsycInfo Database Record (c) 2022 APA, all rights reserved) (Source: chapter)
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"When you have got like twenty thousand thoughts in your head, that one little thing can just make it all go away": Trauma and non-suicidal self-injury in forensic settingsThis chapter explores the relationship between trauma and non-suicidal self-injury (NSSI) within forensic settings. In particular, it considers prevalence rates, pathways to NSSI, and the dual risk presented by those who engage in both NSSI and violence. The primary reference group for this chapter is those in the National High Secure Healthcare Service for Women (NHSHSW) and it considers responses within this setting to understand, manage, and reduce the occurrence of NSSI, considering the impact of these on both staff and patients. The chapter advocates Trauma-Informed treatment responses for this population, drawing on the Trauma and Self-Injury (TASI) service. Interwoven throughout the chapter are the lived experiences of patients, using the patients voice as part of the narrative.
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Early trauma, psychosis, and violent offendingPsychosis tends to be an experience that socially isolates the sufferer and generates fear and distance in others. This is likely intensified when this presentation is combined with offending. In this chapter, using case examples we describe the possible pathway to psychosis through trauma and the links to violence. We illustrate the function and method in “madness”, clear evidence for the need to understand, and make sense of, what is being communicated through delusional and/or psychotic experience, and the importance of looking beyond diagnostic frameworks. In doing so, we can explore the function of hypervigilance, the parallels with childhood experience, and the efforts to avoid further victimisation.
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Trauma, personality disorder, and offendingThis chapter provides an overview of the presence and relevance of childhood traumas in the histories of individuals who have been given a diagnosis of personality and offended. A summary of the impact of childhood traumas, adverse attachments, and adversity and the lack of relational security on individuals’ personality development is described in relation to the diagnostic traits for personality disorders and dynamic risk factors. A service user provides his narrative of the impact of childhood attachment adversity and traumas on his development, mental health, and offending and describes what has been significant in supporting his recovery journey so far. The significant overlap across these areas and the increasing recognition of the need to understand developmental antecedents of individuals’ mental health difficulties and offending are highlighted. Current psychological treatment approaches across forensic services, including those based on a developmental model, are briefly described and the application of Schema Therapy for individuals who have been given a diagnosis of personality disorder and offending is discussed. Overall, the importance of asking individuals what has happened to them and developing a shared understanding of the impact of what happened to them is considered fundamental to supporting development and risk reduction.
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Trauma and intellectual disabilityIndividuals with Intellectual Disabilities (ID) are exposed to higher rates of adverse experiences in childhood than those without ID. However, there is also an under-reporting of trauma-related disorders in this population, possibly attributed to communication deficits in those who experience it and diagnostic overshadowing. These issues are further compounded when exploring the role of trauma and offending in this population due to legal and social variations in what constitutes challenging versus criminal behaviour. This chapter looks to draw together our current understanding in this area, its implications for clinical practice, and provides a case example.
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Deafness and trauma: A journey to equitable trauma-informed careThis chapter explores the unique relationship between Deafness and trauma and emphasises the fundamental need for an equitable and inclusive trauma-informed care for Deaf people in forensic services. It describes the prevalence of trauma in the Deaf population, the trauma experience of many Deaf children and the unique characteristics of trauma experienced in the Deaf population. The chapter also offers key insights into the experience of being Deaf in the Criminal Justice System, highlighting that Deaf individuals are often vastly overrepresented (and often stuck) within it. The chapter explores in detail what is needed to achieve equity in trauma care for Deaf people in forensic services. The chapter aims to promote the importance of a resilience – and a strength – orientated approach to care that produces balance between retribution and rehabilitation, resilience and empowerment in a system that has re-traumatised Deaf people for too long. This chapter emphasises need for equality in research, strategy, delivery, and evaluation.
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From care to custody?This chapter explores the social care system’s role in trauma and adversity experienced by young people in care and the potential impact on the trajectory from care to custody. We include the unique perspectives of care-experienced individuals and highlight a need for more research that captures the voices of a marginalised population. Finally, we provide recommendations for practitioners and policy makers to embed trauma-informed care and identify bottom-up and top-down processes to ensure a more integrated, proactive, and compassionate system.
