Notes Topic 9 Forensic Psych.pdf

Notes Forensic Psych Topic 9: Interventions with mentally disordered offenders Study Notes on Prisoner Mental Health and Insanity Defense Prisoner Mental Health Statistics Over 50% of prisoners have poor mental health, including conditions like depression, PTSD, and anxiety....

Notes Forensic Psych Topic 9: Interventions with mentally disordered offenders Study Notes on Prisoner Mental Health and Insanity Defense Prisoner Mental Health Statistics Over 50% of prisoners have poor mental health, including conditions like depression, PTSD, and anxiety. 15% of prisoners require specialist mental health care. 2% suffer from acute and severe mental health problems. Psychosis Symptoms: Reported by 25% of women and 15% of men in prison. Self-inflicted Deaths: 8.6 times higher in prison than in the general population. Insanity Defense If a mental health condition prevents the defendant from understanding their actions or that they were illegal, they can use the insanity defense. A successful defense may lead to a not guilty verdict. The court then decides on further action: ◦ Hospitalization or supervision orders if the offender still has mental health issues. ◦ Absolute discharge if the offender's mental health has improved. Diminished Responsibility: In murder cases, if mental illness is proven, the charge may be reduced to manslaughter, resulting in a lesser sentence. Study Notes: An International Perspective on Criminal Responsibility and Mental Illness Grossi, L. M., & Green, D. (2017). An International Perspective on Criminal Responsibility and Mental Illness. Practice Innovations, 2(1), 2-12. American Psychological Association. DOI: 10.1037/pri0000037. Legal Context of Criminal Responsibility Definition: Criminal responsibility involves assessing whether individuals should be held accountable for their actions based on mental illness, psychological functioning, and cognitive abilities. The legal understanding of criminal responsibility differs across cultures and jurisdictions. Standards: Countries like the U.S., U.K., Canada, Australia, and New Zealand typically use a dichotomous approach (sane vs. insane) grounded in the M'Naghten Rule or similar standards. Meanwhile, the Netherlands and some European nations use graded systems, assessing varying levels of responsibility, such as diminished or complete absence of responsibility. Symptoms of Mental Illness Major Mental Illnesses: Conditions like psychosis are consistently considered across jurisdictions to diminish or negate criminal responsibility. However, there are jurisdictional differences in how personality disorders (e.g., antisocial personality disorder) are treated. Some countries like the Netherlands allow for diminished responsibility in cases of personality disorders, while North America largely excludes them from insanity defenses. Cultural and Legal Variability Cross-Cultural Differences: Legal interpretations of insanity, the role of mental illness in criminal behavior, and the associated consequences vary widely between jurisdictions. For example, Sweden holds individuals accountable for their actions regardless of mental condition, while Spain and Italy offer partial criminal responsibility based on cognitive and volitional impairments. Consequences and Treatment Inpatient Treatment: In most countries, individuals found not guilty by reason of insanity (NGRI) are committed to psychiatric hospitals rather than prison. The duration and nature of the treatment may differ, with some countries emphasizing rehabilitation and public safety. Discussion Highlights Cross-Jurisdictional Evaluation Challenges: The study emphasizes the importance of understanding the cultural and legal context in which research on criminal responsibility is conducted. Differences in definitions, diagnoses, and treatment practices complicate comparisons across regions. Psychopathy and Responsibility: The study notes the complexity in evaluating psychopathic individuals. In some jurisdictions, psychopathy can diminish responsibility, while others view it as insufficient for a successful insanity defense due to the inherent difficulty in treating such individuals. Main Takeaways 1. Criminal Responsibility Varies Widely: Legal standards for determining criminal responsibility differ significantly between countries, influenced by both legal traditions and cultural norms. 2. Psychosis is Universally Recognized: Psychotic symptoms, such as hallucinations and delusions, are commonly accepted as diminishing criminal responsibility across most jurisdictions. 3. Personality Disorders are Controversial: The legal treatment of personality disorders, particularly antisocial personality disorder and psychopathy, remains a point of contention across jurisdictions. 4. Inpatient Treatment Focuses on Rehabilitation: Many jurisdictions favor rehabilitation through mandatory treatment rather than punitive measures for mentally ill offenders found NGRI. Link Between Violence and Mental Health General Overview Complex Relationship: The connection between mental illness and violence is not straightforward. Some mental disorders may be associated with an increased risk of violent behavior, but this is not true for all mentally ill individuals. Stigmatization: People with mental health issues are often misclassified or stigmatized as being more violent than they actually are. Key Points 1 Confounding Factors: ◦ Substance Abuse: Alcohol and drug abuse are often present in violent cases involving mentally ill individuals, complicating the link between mental illness and violence. ◦ Social Conditions: External factors such as poverty, unemployment, and homelessness can exacerbate both mental health issues and tendencies toward violence. 2 Clinical Aspects of Violence: ◦ Psychotic Disorders: Some evidence suggests that individuals with psychotic disorders, such as schizophrenia, may have a higher risk of violence, but this is not universal. ◦ Personality Disorders: People with personality disorders (e.g., antisocial personality disorder) or substance use disorders tend to have higher rates of violent behavior. 3 Victimization of Mentally Ill Individuals: ◦ Higher Risk of Being Victims: Mentally ill individuals are more likely to be victims of violence than perpetrators. This often leads to misunderstanding and bias against them. 4 National Trends: ◦ Increase in Violence Among Mentally Ill: Some national data shows a rise in violence among mentally ill populations, but this is often influenced by overlapping factors like substance abuse and societal trends. Important Considerations Misclassification Issues: The relationship between mental illness and violence can be misinterpreted due to inadequate definitions or confounding variables. Public Perception: There is a tendency to overestimate the role of mental illness in violent crime, leading to potential policy biases that negatively impact mentally ill individuals. Conclusion Multifaceted Issue: The link between mental illness and violence is influenced by a range of clinical, social, and environmental factors. The majority of mentally ill individuals are not violent, and those with violent tendencies often have additional factors (e.g., substance abuse) that contribute to their behavior. Study Notes: The Restricted Patient System (from "Mentally Disordered Offenders - The Restricted Patient System," Dec 2017) 1. Purpose Overview of the restricted patient system for mentally disordered offenders in England and Wales. 2. Legal Framework Governed by statutes like Mental Health Act 1983, Criminal Procedure (Insanity) Act 1964, and others. 3. Key Definitions Restricted Patients: Offenders requiring special controls. 4. Routes to Restriction 1 Hospital Orders (ss37/41) 2 Hospital and Limitation Directions (s45A) 3 Transferred Prisoners (ss47/49, 48/49) 5. Types of Orders Covers hospital orders, directions, and management. 6. Secretary of State’s Powers Admission, detention, discharge, and community leave approvals. 7. Discharge Process Involves absolute or conditional discharge. 8. Hospital Transfers Consent required for restricted patients. 9. Community Leave Granted under Section 17 for rehabilitation. 10. Tribunal Reviews Patients’ right to apply for discharge review. 11. Victim Rights Statutory protections under the Domestic Violence Crime and Victims Act 2004. 12. Repatriation Handling transfers within the UK or abroad. Key Takeaways Restricted patients are mentally disordered offenders managed under strict controls prioritizing public safety. The Secretary of State plays a critical role in patient management, ensuring rehabilitation while maintaining public protection. Discharge processes include robust monitoring and recall mechanisms to prevent harm. Victims’ rights are integrated into decisions about discharge and community leave.  Quiz Notes 9.7 Types of section A Second Opinion Appointed Doctor (SOAD) provides independent oversight and review of compulsory treatment plans for patients detained under the Mental Health Act, ensuring their rights and best interests are protected. Section 136 allows a police constable to move a person to a place of safety. Section 136 of the Mental Health Act allows a police constable to detain and remove a person from a public place to a place of safety if they believe that the person is suffering from a mental health disorder and is in immediate need of care or control to protect them or others. The place of safety can be a hospital, police station, or another suitable location where the person can be assessed by mental health professionals. This provision is intended to ensure that individuals in mental health crises are given appropriate care in a secure environment. A person detained under Section 37(41) of the Mental Health Act (which often applies to individuals involved in criminal cases who are detained for treatment instead of imprisonment) may be granted leave by the Secretary of State for the Home Office. This means that the individual can be allowed to leave the hospital temporarily, under certain conditions, while still under detention, if it is considered appropriate and safe for them and the public. This decision is typically based on medical recommendations and risk assessments. The 3 Statutory criteria that must be satisfied if a patient is to continue to be detained in a hospital under the Mental Health Act: 1. Appropriate medical treatment available 2. necessary for the health and safety of patient or protection of others 3. patient has a mental disorder which makes it appropriate they be detained in hospital for medical treatment. Mental health Act: under this act a person can be sectioned (involuntarily committed to a psychiatric hospital). A Notional Section 37 of the Mental Health Act begins when an individual's prison sentence ends. This section allows for their continued detention in a hospital for psychiatric treatment if they are still considered to require care and pose a risk. It ensures that individuals transitioning from prison can receive the necessary mental health support even after their sentence has been completed. Study Notes on Secure Hospital Care for Carers, Institute of Mental Health. (2018). Secure hospital care: Information for carers. University of Nottingham. Introduction Purpose of the Guide: To help carers understand secure hospital care, providing them with information to support their relatives or friends. Emotional Impact on Carers: Carers may experience a range of emotions, including fear, helplessness, and confusion when a loved one is admitted to a secure hospital. Definition of a Carer: A carer provides unpaid support to someone unable to cope on their own due to illness or disability. This includes mental health issues, with carers playing a crucial role in providing practical and emotional support. Types of Secure Services 1 High Secure Services: For individuals presenting a grave danger; includes facilities like Broadmoor, Rampton, and Ashworth hospitals. These services cost approximately £275,000 per patient per year, with lengthy stays averaging eight years. 2 Medium Secure Units: These regional secure units are for patients posing a serious public danger and cost around £175,000 per year. The average length of stay is 18-24 months, though some may stay longer. 3 Low Secure Services: For individuals posing a significant danger, often those transitioning from higher security levels or coming from general psychiatric care. Legal Matters Mental Health Act (MHA) 1983: Governs involuntary admission to secure services, categorizing individuals under "civil" or "criminal" sections. The MHA also includes provisions for those with mental disorders, excluding substance abuse alone. Important Sections: ◦ Section 3: Civil section for non-offenders, requiring detention for treatment. ◦ Section 37: Criminal section, allowing court-ordered hospital admission instead of imprisonment. ◦ Sections 41, 47, and 49: Concern restrictions and transfers from prison to hospitals, requiring Ministry of Justice approval. Admission and Discharge Admission Process: Involves assessments by various professionals. Patients start on admission wards for further evaluations and development of a care plan. CPA Meetings: Regular review meetings (Care Programme Approach) involve all professionals involved in a patient's care and include input from carers. These meetings help track progress and plan further interventions. Discharge: Discharge is planned and discussed between the patient and clinical team, with opportunities for the patient to challenge their detention through Mental Health Review Tribunals (MHRTs) and Managers’ Hearings. Hospital Environment Security Levels: Includes physical (fences, locked doors), procedural (restrictions on items, observations), and relational security (staff-patient relationships). Restrictions: Visitors and patients face various restrictions, such as searches, limitations on personal items, and monitored communication in high secure settings. Leave from the hospital is heavily controlled and requires approval. Visiting Rules: Visitors must follow strict hospital procedures, such as advanced booking and adhering to what can and cannot be brought into the hospital. Treatment in Secure Hospitals Types of Treatment: Includes medication, psychological therapies, and nursing care. Psychological interventions often follow a stepped approach, beginning with short-term therapy and progressing to more complex treatments like Dialectical Behavioural Therapy (DBT) and offence-related work. Offence-Related Work: Targets specific types of offending behavior (e.g., violence, sexual offences), often delivered in both individual and group settings, including relapse prevention strategies. Roles of Key Personnel Multi-Disciplinary Team (MDT): Comprises various professionals involved in the patient's care, including: ◦ Care Coordinator: Oversees the patient's care and ensures coordination across services. ◦ Responsible Clinician (RC): Usually a psychiatrist with overall responsibility for the patient under the MHA. ◦ Named Nurse and Associate Nurse: Responsible for day-to-day nursing care and regular sessions with the patient. ◦ Psychologist, Social Worker, and Occupational Therapist (OT): Provide specialized interventions and support for improving the patient's mental health and skills. Carers' Rights and Involvement Confidentiality: Carers may receive information about their relative's care, but this depends on the patient's consent. However, carers' concerns are listened to, and information can still be shared generically. Attending Meetings: Carers can attend CPA meetings and participate in discharge planning with the patient's consent. Making Complaints: Carers should contact the care coordinator, PALS (Patient Advice and Liaison Service), or the service commissioner if they have concerns about the care provided. What Are Secure Hospitals in the UK? Secure hospitals in the UK are specialized mental health facilities designed to treat individuals who have been diagnosed with a severe mental illness and pose a danger to themselves or others. These hospitals operate at different levels of security, including high, medium, and low-secure units. They are often referred to as forensic services, as many of the individuals in these hospitals have either committed offences while mentally ill or have been found to be suffering from mental illness during legal proceedings. Secure hospitals provide a structured environment with a strong focus on recovery-oriented treatment rather than punishment, aiming to stabilize the patients' mental health and reduce their risk to the public (7778_Secure_Hospital_Ca…). Why Are People Treated in Secure Hospitals? People are treated in secure hospitals because they have a mental health disorder that makes them a danger to themselves or others. Most patients in these hospitals are detained under the Mental Health Act after being assessed as needing treatment in a secure environment. Often, these patients have committed crimes due to their mental illness, or their mental illness was discovered while they were in the prison system. Secure hospitals are meant to provide these individuals with the care and treatment they need to manage their condition and, ultimately, reintegrate into the community (7778_Secure_Hospital_Ca…). What Makes Secure Hospitals Different from Other Psychiatric Hospitals in the UK? Secure hospitals differ from other psychiatric hospitals in the UK primarily due to their security measures and focus on public protection. These hospitals have different levels of security, ranging from high- security facilities, such as Broadmoor and Ashworth, to medium and low-security units. Each level of security has specific restrictions and protocols to manage the risks associated with the patients being treated. For instance, high-secure hospitals typically house patients who present a grave and immediate danger and have robust physical and procedural security, such as multiple perimeter fences and stringent access controls. Medium-secure hospitals offer care for individuals who pose a serious danger but require less restrictive security measures than high-secure hospitals. Low-secure hospitals focus on individuals who pose a significant risk to themselves or others but are often in the process of being rehabilitated back into the community (7778_Secure_Hospital_Ca…). In comparison to general psychiatric hospitals, secure hospitals also offer specialized forensic mental health care, with an emphasis on managing criminal behavior related to mental illness and addressing the unique challenges of patients transitioning between the justice and healthcare systems (7778_Secure_Hospital_Ca…). Study Notes on Key Features of Secure Recovery in Forensic , Drennan, G., & Wooldridge, J. (2014). Secure recovery: Approaches to recovery in forensic mental health settings. Routledge. Introduction to Recovery in Forensic Settings Context: Forensic settings, which often include individuals with repeated contact with both the criminal justice and mental health systems, are uniquely challenging environments for recovery. Individuals in these settings face double stigma due to their offenses and mental health conditions. Importance of Recovery: Recovery is critical despite the complexity of these individuals' circumstances, emphasizing the need for individuals to regain hope, control, and the ability to build a life beyond illness. Core Principles of Recovery 1. Hope: Key Element: Maintaining belief in the possibility of a fulfilling life is crucial for individuals in forensic settings. Personal Meaning: Recovery must include personal meaning and understanding. Relationships are central in fostering hope. 2. Control: Regaining Control: Individuals must regain control over their lives and symptoms, which is particularly challenging in restrictive environments like forensic services. Shared Decision-Making: This involves balancing evidence-based practice with personal preferences, ensuring that patients have choices regarding their care. 3. Opportunity: Life Beyond Illness: Recovery requires individuals to be part of the community, not just within a facility. Access to employment, housing, and social inclusion is vital. Pro-Social Activities: Meaningful occupation helps individuals redefine their purpose beyond criminal behavior, fostering positive social roles. Challenges to Recovery in Forensic Settings Stigma and Low Expectations: Individuals in forensic settings often face low expectations from staff, family, and society, which can hinder their recovery. Dual Responsibility: Recovery must address both mental health recovery and offender recovery, which includes dealing with guilt, shame, and taking responsibility for offenses. Applying Recovery Principles Jason's Story: A fictional case used to demonstrate the application of recovery principles. Jason, diagnosed with schizoaffective disorder, exemplifies the need for recovery approaches that address both mental health issues and criminal behavior. ◦ Key Elements: Understanding Jason's life story, including his trauma and offending behavior, is critical in shaping his recovery. Staff and Service Users' Role: ◦ Building Trust: Developing relationships where service users feel understood is critical. Staff must engage in meaningful conversations and avoid simply focusing on risk management. ◦ Encouraging Choice: Despite the restrictions in forensic settings, patients should still have some control over their treatment and recovery plans. Key Features of Secure Recovery 1. Supporting Recovery along the Care Pathway Collaborative Care: Recovery requires active collaboration between service users and staff. Care must be structured around principles like relational security and shared decision-making. Care Programmes: Structured programs like the Care Programme Approach (CPA) help organize recovery-oriented care by involving large multi-professional teams that regularly assess and plan patient care. 2. Quality of Relationships Relational Security: Relationships between staff and patients are crucial for recovery. Strong, trusting relationships foster hope and collaboration. Consistency: High staff turnover and inconsistency can disrupt recovery. Service users benefit from stable care teams and clear communication. Do's and Don'ts: Effective relationships are built on open communication, respect, and appropriate boundaries. Staff must avoid creating barriers that could hinder recovery. 3. Risk and Safety Managing Risk: While ensuring safety is a priority, the recovery process requires balancing safety with opportunities for personal growth and pro-social risk-taking. Safety Planning: A collaborative approach to managing risks helps individuals pursue their goals safely, reducing restrictive practices and fostering independence. Positive Risk-Taking: Service users are encouraged to gradually take more responsibility for their actions within a supportive framework that reduces risk while promoting growth. 4. Opportunities for Meaningful Occupation Life Beyond Illness: For individuals in forensic settings, recovery involves discovering what makes life worth living. Engaging in meaningful, structured activities provides a sense of purpose and agency. Occupational Opportunities: Activities should be pro-social and health-affirming. Service users are encouraged to participate in community-based activities, employment, and education. Success Stories: Examples like the development of "Recovery Colleges" provide service users with opportunities to co-produce and co-deliver educational content, further supporting their recovery. 5. Peer Support Peer Roles in Recovery: Peer support workers, who have lived experience in forensic services, can offer unique and valuable insights, providing support and hope to others in similar situations. Buddy Systems: These systems, where experienced patients help newer patients adjust, have been successfully implemented in some secure units, fostering a supportive community environment. Challenges: Despite the benefits, establishing formal peer support roles in forensic settings can be challenging due to concerns about safety and the emotional toll on peer workers. Conclusion Balancing Offender and Mental Health Recovery: Recovery in forensic settings is multifaceted, requiring individuals to address both their mental health challenges and the consequences of their offenses. Collaboration and Hope: Successful recovery relies on the collaboration between staff and service users, fostering hope, and providing opportunities for individuals to regain control of their lives. Commitment to Change: Recovery-oriented care in forensic settings requires a commitment to organizational change, prioritizing relationships, safety, and personal growth for both staff and patients. Fred's Case - Key Points Summary Age: 21-year-old male with schizophrenia. Incident: Arrested for the murder of his mother, whom he believed to be a witch. Mental Health: Known to mental health services since age 16; stopped taking medication before the offense. Psychosis: Experiencing auditory hallucinations, delusions, and religious preoccupations; believed he was "cleansing" his mother of the devil. Substance Use: Heavy cannabis use exacerbated his psychosis. History: Past suicide attempts, family tensions, poor medication adherence, and religious obsessions. Legal Outcome: Potentially not guilty by reason of insanity. Clinical Needs: Requires treatment in a secure hospital; recommendations include medication optimization, CBT, and substance misuse intervention. 1. Fred may be found not guilty by reason of insanity as he evidently has a ‘disease of the mind’ and there is evidence to suggest this led to a ‘defect of reason’ to the extent that he did not know that what he was doing was wrong. A psychiatrist would need to assess whether Fred knew the action of killing his mother was wrong at the time of the offence. This third criteria would need to be present for an insanity defence to be successful. 2. Fred’s presentation warrants treatment in a secure hospital. He has a mental health condition to a degree that requires treatment in hospital, he presents an ongoing risk to himself and others, and his condition is treatable. If he is transferred prior to sentencing it is likely that this will be on a section 48/49. At trial, Fred is likely to be recommended a section 37/41 given the seriousness of his offence. 3. The clinical team needs to consider: medication side effects, meeting religious needs, meaningful occupation (i.e. education and employment), weight gain and healthy lifestyle changes, substance misuse, victim’s family (father and sister). 4. Treatment recommendations: medication optimisation, substance misuse intervention, CBT (cognitive behavioural therapy) for psychosis, restorative justice intervention, victim support, occupational therapy (including support to find a meaningful job), psychoeducation around diagnosis, substance use and medication.