There has been a lot of attention given to the use of segregation in correctional facilities, sufficient that a number of class action lawsuits have been launched, and in many cases, they have been settled. Psychiatrists and psychiatry in general have mostly watched these issues play out from the sidelines. Segregation occurs in correctional facilities and few psychiatrists work in jails and prisons. Although mental health professionals watched with interest and concern, it remained an issue in correctional settings, not in our house. In the last few decades psychiatry has done a lot of work in reducing seclusion in hospitals. The tracking of seclusion, the requirements for reassessment and seclusion justification, along with improved training of staff about the traumatic effects of seclusion have helped in reducing seclusion rates and the length of individual seclusions. Psychiatry has done well in this regard and hence it would not be surprising that many may think that the issues associated with seclusion have been dealt with. This may be an error for the following reasons.
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Battered woman syndrome: Updating the expert checklist
The aim of this article is to examine the current state of the battered woman syndrome (BWS) defence in Canada and propose an update to the list of factors considered by experts evaluating the applicability of the defence to individual cases. The history and current legal definition of the defence are presented, and theories relating to BWS are summarized. Factors required of expert testimony in BWS cases are presented; cases relevant to the development of the defence that highlights these assessment factors are discussed. In a subsequent section, limitations of the defence and the role of the expert are explored. The PTSD Checklist (used in clinician diagnosis) is summarized before an updated, BWS-specific expert checklist is proposed. The updated checklist proposes six elements to be considered by an expert assessing a BWS case: 1. environmental factors, 2. attempts to leave or alter the situation, 3. risk factors of the abuser, 4. risk factors of the victim, 5. triggers for violence, and 6. contrary evidence. It is hoped that using this checklist will help experts to cover all the essential elements they must consider in order to conclude that a woman satisfies the criteria for BWS. In particular, this updated checklist will help experts to prepare comprehensive testimony that addresses the five issues defined by Justice Wilson as the expert’s duty to assess. In addition, this checklist will help experts present a firm foundation for a defence regarding the critical question of why the night of the offence was different from all other nights.
Read moreClinicians’ Perceptions of the Implementation of the Structured Assessment of Protective Factors for Violence Risk (SAPROF) on an Inpatient Forensic Unit
The Structured Assessment of PROtective Factors for Violence Risk (SAPROF) is an assessment tool that examines protective factors when assessing violence risk. There is limited research on clinicians’ perceptions of the use and implementation of risk assessment tools, and this study aimed to examine the experiences of clinicians using the SAPROF in a low secure forensic rehabilitation inpatient unit in Canada. An exploratory research design was used, and five clinicians participated in semi-structured interviews. Data was analyzed using a thematic approach and three central themes were identified: “understanding of the patient from a strengths-based point of view, providing clinicians with a focus on how to help the patient, and bringing in opportunities to collaborate as a team”. The findings highlight the additional value of the SAPROF as a tool in helping forensic teams to adopt strengths- based approaches to risk assessment, enhancing treatment planning, and inter- professional collaboration.
Read moreComparaison franco-canadienne du développement des Cercles de soutien et de responsabilité (CSR) pour la prévention du risque de récidive des délinquants sexuels
Les Cercles de Soutien et de Responsabilité (CSR), nés il y a 24 ans à Hamilton au Canada pour répondre à l’inquiétude du public provoquée par le retour des délinquants sexuels dans la société après leur libération, se développent partout dans le monde. Ils proposent l’accompagnement de l’agresseur dans sa réinsertion sociale. Efficaces dans les pays étrangers, ces dispositifs se développent lentement en France. L’objectif de cet article est de tenter d’expliquer les freins à l’implantation des CSR en France au regard des difficultés rencontrées lors des expériences françaises passées et actuelles, mais aussi des différences interculturelles entre la France et le Canada.
Read moreAbsconsion from forensic psychiatric institutions: A review of the literature
Absconding from mental health units is referred to as a patient leaving without permission and can have significant consequences for the patient, family, community, and institution. The varying definitions of absconsion involve breaching security of an inpatient unit, accessing grounds or community without permission, gaining liberty during escorted leave or being absent for longer than permitted from authorized or trial leave. While considerable literature exists on absconsion from acute psychiatric units, there is a paucity of literature specific to forensic absconsions, despite inherent differences between patients and systems. Forensic patients are offenders who are found unfit to stand trial, or not criminally responsible on account of mental disorder. The literature indicates the absconding rate within the forensic population is expected to be low, based on the fact that the level of security in forensic units is higher than general psychiatric units. Despite the rates being considered low, the outcomes of absconding in this population can potentially be serious, thus the exploration of factors surrounding these incidents is essential. Purpose: To review the literature regarding absconsion from forensic psychiatric institutions. This review will identify potential risk factors and motivations of forensic patients that have absconded. Methods: Electronic database and hand searches were conducted to locate articles pertaining to absconding specific to forensic psychiatric institutions published from 1969-present. Search terms included “abscond”, “escape”, “AWOL”, “runaway”, “psychiatric inpatient”, “forensic institution”, & variants. All full-text articles meeting inclusion & exclusion criteria were appraised for qualitative themes, limitations, and assessed for risk of bias using appropriate CASP Checklists. The review is structured following the PRISMA checklist and framework. Results: A total of 19 articles meeting literature review criteria were identified. The majority of the articles were of retrospective case-control design (n=12). Three systematic reviews were found on absconsion that included analyses from both forensic and general psychiatric populations. Definitions for absconding were omitted or varied making comparisons between studies difficult. Much research compared demographic, static and dynamic factors. History of previous absconsion, scores on validated risk-of-violence assessment tools, substance-use disorder, acute mental state, and socio-environmental factors were consistently noted as risk-factors. Four distinct motivations for absconding emerged: goal- directed, frustration/boredom, symptomatic, and accidental. Overall, the literature suggested forensic absconsion was a rare event of short duration with low risk to the public and few re- offending incidents. Conclusions: There is a paucity of literature on forensic absconsions. A consistent definition of absconsion and use of standardized reporting protocols across forensic programs would be beneficial in order to be able to compare data on absconding events. Also, prospective studies should be undertaken to better understand the motivations and dynamic risk factors of forensic patients who have absconded and would help inform a forensic absconsion risk assessment protocol.
Read moreInternational Journal of Risk and Recovery, Beginning of an Exciting Journey
A few years ago, members of the forensic psychiatry research team at St. Joseph’s Healthcare Hamilton started an exciting journey with the decision to create a new forensic mental health journal.
Read moreIs the Anticipated Consent to Treatment in Advance Directives a Solution to Compulsory Treatment in Forensic Psychiatry?
As a result of a German Federal Constitutional Court decision on compulsory treatment, in its state Law the federal state of Hesse has newly regulated the possibility of compulsory treatment (Section 7 Paragraph 2 of the Hesse Law on the Enforcement of Court-ordered Hospital Treatment) and expressly incorporated the observance of a patient’s advance directive as defined by Sections 1901a and 1901b of the German Civil Code (Bürgerliches Gesetzbuch [BGB]). Having been sentenced to a hospital treatment order under section 63 of the Ger- man Criminal Code (Strafgesetzbuch [StGB]) in the Vitos Haina Forensic Psychiatric Hospital, thirteen patients with schizophrenia stated in a patient’s advance directive that they wished to be treated with certain antipsychotic medication in case of a recurring psychotic episode. In particular, the patient’s advance directive stated that this treatment should be compulsory if necessary. Based on a case vignette this article delineates both the motivation of the patients for such a patient’s advance directive, as well as the legal limitations and the enforceability of such a patient’s advance directive. There is no prevailing view in the jurisdiction or literature on the utilization of a patient’s advance directive to guarantee an explicitly desired treatment in case of incapacity for consent. This article wishes to highlight the perspectives of those directly affected and to encourage discussion. While of special interest for forensic psychiatry, these considerations may also be of importance for treatment considerations in general psychiatry.
Read moreForensic Psychiatry in the Largest Secure Ward in Portugal: Characteristics of the Population and Psychopharmacological Intervention
Forensic psychiatry is defined as a specialty of psychiatry in which clinical and scientific knowledge is applied to the legal system, both with regard to civil and criminal law. Nowadays, the largest security ward is in Coimbra, at the University Hospital. It comprises 111 patients: 91 males and 20 females. The aim of the security measures, according to the penal code, is the protection of legal assets and psychosocial rehabilitation. In our sample, the most frequent diagnosis was Schizophrenia (37.8%); Moderate Intellectual Disability (23.4%) and Mild Intellectual Disability (14.4%) were the second and third most frequent diagnoses. The criminal acts accounting for the most prevalent security measures fell under domestic violence (19.8%) first, followed by attempted murder (16.2%), and theft (14.5%). The elaboration of a therapeutic and rehabilitation plan is essential, and its aim is to diminish the person’s dangerousness. It is fundamental to think of the safety ward as a health production space and not as a place of mere disease management or “dangerous states”, thus trying to solve the patient’s problems.
Read moreThe Implementation of Cognitive Behavioural Therapy for Psychosis (CBTp) in a Forensic Setting: Lessons Learned and Future Directions
Schizophrenia is a debilitating psychotic illness that affects approximately 1% of the population. Within the Canadian forensic psychiatric system, patients are detained under a provincial Review Board after being found not criminally responsible (NCR) on account of a mental disorder. Here, the prevalence rate of schizophrenia is 53% [1]. Even with the use of psychotropic medication, it is estimated that approximately only 25% of patients fully recover from the illness [2]. The presence of active psychotic symptoms increases the risk of violent behaviour [3]. Thus, psychological interventions have been developed to be employed in conjunction with medication to assist in managing or even reducing symptomatology.
Read moreScales for Evaluating the Acceptance of the Rape Myth: Benefits and Limitations
Society’s views regarding rape and sexual aggression have significantly evolved in recent years. Rape is now a felony, and the context of marital rape is an aggravating circumstance. Nonetheless, common representations could tend to minimize the perpetrator’s responsibility and to excuse their actions. This shows acceptance of a set of attitudes, beliefs and stereotypes that we call the Rape Myth. Acceptance of these representations or of the Rape Myth is widespread, including among those who work in the legal and healthcare fields and among jurors, and may lead to a reduced penal response [1,2]. It also exists among rape victims and may prevent them from reporting the events or being able to reconstruct them precisely [3]. The existence of strong correlations between acceptance of the Myth and a propensity for rape and other coercive sexual behaviour [4-7] underscores the importance of this factor. In this way, the acceptance of the Rape Myth could lead to cognitive distortions that rationalize, minimize or justify the behaviours of sexual offenders [8,9]. Cognitive distortions also serve to protect sexual abusers’ image so that they do not feel guilty, blame themselves or consider themselves to be monsters.
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