Sexual offending by young people causes significant harm to victims, families and communities. Treatment engagement and completion are therefore important for reducing future harm; however, young people who drop out of, or refuse to engage in, treatment present a unique challenge for clinicians and justice systems. Drawing on Bronfenbrenner's (1979) ecological systems theory, this study explored clinicians' perspectives on the barriers to treatment engagement and completion for young people who have sexually offended in the Australian context. Semi-structured interviews were conducted with clinicians who provided or facilitated treatment for young people who had sexually offended (N = 22). Two major themes were identified: family factors and program factors. Family factors included caregiver shame, minimisation, stigma, competing household demands, limited family support and instability in out-of-home care. Program factors included barriers to accessing treatment, the limitations of office-based service delivery, regional and remote access issues and the need for programs to continue working through the young person's broader ecology when direct engagement is limited. The findings suggest that attrition should not be understood solely as individual non-compliance, but as a product of the interaction between the young person and their family and their interaction with community services and policy systems. The paper provides practice and policy recommendations for strengthening ecological approaches to treatment engagement and reducing attrition.
This study examined the relationship between dimensions of impulsivity, as conceptualized in the UPPS model, and cognitive distortions. Cognitive distortions were conceptualized according to Franceschi's framework (2007) and examined among adult males serving short prison sentences in France, in comparison to individuals from the general population. The sample comprised 83 participants: 41 incarcerated men serving short prison sentences (aged 19-48 years) and 42 men from the general population with no criminal history (aged 22-49 years). Participants completed the UPPS Impulsive Behavior Scale and the Cognitive Distortions Scale for Adults (EDC-A). Compared with the inmate group, the comparison group showed lower perseverance. In contrast, the inmate group reported significantly more cognitive distortions overall, particularly negative ones. In the inmate group, urgency, lack of premeditation, and lack of perseverance were positively associated with both positive and negative cognitive distortions. Beyond the comparison, we also explored whether these patterns varied within the inmate group according to reason for incarceration, recidivism status, and detention duration. Some differences were found according to recidivism status and reason for incarceration, and detention duration moderated several associations between impulsivity and cognitive distortions. These findings suggest that impulsivity-related self-regulation difficulties may be broadly linked to distorted reasoning in incarcerated men, supporting the clinical relevance of early assessment and targeted cognitive-behavioral interventions in correctional settings.
Australian forensic inpatient populations experience high rates of severe mental illness, trauma exposure, substance misuse, and psychosocial disadvantage, factors that may act as responsivity barriers within rehabilitation frameworks. Creative arts and music-based interventions have an emerging evidence base for improving engagement, emotional processing, and recovery-oriented outcomes within mental health and forensic settings. Hip-hop therapy (HHT) has been described as a culturally responsive intervention for individuals less likely to engage in conventional talk-based therapies. The present study evaluated the Rhythm & Rhymes Adolescent/Adult Program (RRAP), an Australian HHT-informed 12-week group intervention implemented within a high-secure forensic hospital in NSW, Australia. Sixty-two participants aged 14 to 65 years participated across 12 groups. Participants completed validated pre- and post-intervention psychometric measures assessing psychiatric symptoms, depression, anxiety, hopelessness, trauma symptoms, and coping responses. Participation in RRAP was associated with reductions in psychiatric symptoms, depression, and anxiety, alongside improvements in adolescent coping responses. Attrition was low and observed engagement was high. Findings suggest RRAP/HHT may represent a feasible and acceptable adjunct to treatment-as-usual within forensic inpatient settings. RRAP may also support therapeutic engagement, emotional expression, and responsivity among individuals experiencing severe mental illness within restrictive environments during inpatient rehabilitation.
Relational security is an increasingly used concept in forensic mental health practice, where an equal working relationship for de-escalation and prevention of aggression and violence is emphasized. However, there is no uniform definition of relational security. The aim of this paper is to gain more insight into the existing definitions of relational security. In this scoping review, 34 definitions of relational security were found. After thematic analysis, the following themes emerged, representing different elements within these themes: a. what relational security is on a conceptual level and the context it relates to, b. the core components of relational security and to whom it applies, c. bringing relational security into practice, and d. objectives of relational security. The content analysis shows many variations between existing definitions, which makes it impossible to provide a common definition based on this study. However, certain elements such as the relationship between staff and patients, knowledge about the patients, and risk assessment were reasonably consistent throughout the definitions. This study highlights the necessity to further explore the distinctive components of relational security and reach consensus on an overall definition that is useful for (training in) the psychiatric forensic and prison-like settings.
Psychopathy, malignant narcissism (MN), and sadism (SD) are normally viewed as separate constructs in both clinical and academic settings, though there is substantial overlap in their defining features. Psychopathy is not a formal diagnostic category in contemporary classification systems but is widely treated as a dimensional forensic and personality domain used to describe severe antagonistic personality configurations. This article argues that maintaining strict boundaries among these concepts is unnecessary and obscures their shared motivational core. We propose that psychopathy should be understood as the primary explanatory framework, with MN and SD representing characteristic expressions rather than independent entities. Examination of dominant clinical and theoretical formulations indicates that MN largely reiterates core psychopathic features, with SD serving as its most distinctive element. When SD is ego-syntonic and experienced as rewarding, it can be coherently situated within psychopathy, at which point MN contributes little unique nosological or explanatory value. Drawing on psychometric, clinical, and forensic research, we argue that sadistic motivation is central to the most dangerous forms of psychopathy, while narcissistic traits reflect a specific affective and interpersonal presentation. From this perspective, the Dark Triad and Dark Tetrad become redundant. Clarifying psychopathy in motivational and affective terms may improve diagnostic precision, inform treatment planning, and strengthen forensic risk assessment.
To date, research investigating the role of socially supportive relationships on service users' recovery in the context of forensic inpatient admissions is scarce. This study aimed to explore the protective effects of socially supportive relationships on objective measures of recovery in the context of admissions to secure hospital. Family, peer and intimate partner support variables were constructed based on Historical Clinical Risk Management (HCR-20v3) risk assessments of 330 service users. Secondary data analyses of National Health Service care records using generalised linear models and proportional hazards modelling were conducted to measure the impact of social support on service users' length of stay in hospital, risk incidents during inpatient admissions and total number of admissions to hospital. Results demonstrated protective effects of family and intimate partner support on objective measures of recovery, particularly regarding incidences of violence and the overall number of inpatient admissions. Findings are discussed in relation to existing theory and research, and implications for practice and future research are suggested, with a focus on the unmet need for family intervention and outreach in forensic mental health services.
Rapid tranquillisation (RT) is a commonly used restrictive practice in mental health; however, reducing its use has been a longstanding international priority. In this context, addressing potential unlawful RT use may be a crucial starting point for improving mental health care practices. We aimed to explore changes over time in RT use in adult mental health inpatient settings from the perspective of the Danish Psychiatric Patient Complaints Board and Appeals Board. We included all published board reports from 2018 to 2023, reviewed available material and extracted information related to RT complaints. Descriptive statistics and content analysis were applied. RT use was involved in 20.2% of all decisions on average. While the number of decisions increased modestly, the proportion of overturned RT-related decisions decreased substantially. Across 56 identified cases involving 74 episodes, RT was frequently deemed unlawful due to factors such as insufficient documentation of de-escalation attempts or inconsistencies in medication. Over the period, approvals were more likely if the clinical situation was well described in the medical record. Although legal criteria remained unchanged, the interpretation and application appear to have evolved, reflecting greater sensitivity to complex situations. Further research is needed to deepen understanding of how RT and related complaint outcomes change over time.
This article describes how one community healthcare trust in England introduced a referral procedure to support risk management for patients detained under Mental Health Act Hospital Orders, with and without restriction, who had been assessed as requiring management under MAPPA Level 1. In the Trust, it was routine for MAPPA referrals to be made for individuals who were assessed as falling under Level 2 or Level 3, but not Level 1, there being no requirement to do so. This article sets out the background to, and justifications for, the introduction of the process and gives information about the number of referrals and patient characteristics since the procedure was introduced in 2021. The referral process is illustrated with two case studies. The article includes reflections on the information gathered and makes recommendations for future research including the need for an empirical assessment of the impact, if any, of the process on offending and re-offending. It makes recommendations for future policy, practice, and research so as to support detained patients at Level 1 and enhance victim safety planning and public protection.
The unmet mental health needs within Immigration Removal Centres in the United Kingdom present critical challenges. This study examines barriers to safeguarding and accessing mental health care through content analysis of nine His Majesty's Inspectorate of Prisons inspection reports. Key challenges were identified in two categories: institutional impacts and service provision. Institutional barriers include inadequate reception screening, inconsistent use of interpreting services, staff shortages, and limited awareness of vulnerability safeguards such as Rule 35 and ACDT processes. Service provision issues encompass significant staff vacancies, uneven access to psychological therapies, and unsuitable facilities. Although some centres exhibit promising practices, most struggle to meet detainees' needs effectively. Detention practices, including indefinite durations and prison-like regimes, exacerbate mental health deterioration among detainees, many of whom have pre-existing trauma. Findings call for improved staff training, better interagency communication, and increased investment in mental health services. This study highlights the need for systemic reform to address mental health disparities and promote humane, effective immigration management. Further research should explore scalable, rights-based approaches to care and detention alternatives.
Most forensic psychiatric patients are diagnosed with schizophrenia or schizoaffective disorder. Psychotherapy is recognized as an important part of treatment for this patient population, yet no clinical guidelines exist. This mixed-method systematic review aimed to evaluate the scope, quality, and findings of psychotherapy research involving this population. Following the Joanna Briggs Institute methodology, thirteen studies were included after critical appraisal. A convergent-segregated synthesis approach was used due to heterogeneity in study designs and outcomes. Only two studies provided sufficient qualitative data for formal synthesis, while the remaining studies were narratively summarized. Meta-analysis was not feasible due to methodological heterogeneity and small sample sizes. Most studies examined cognitive-behavioral or skills-based interventions, suggesting potential improvements in social functioning, psychiatric symptoms, and reductions in violence. However, these findings were largely derived from small, non-controlled studies. A smaller number of studies have explored music and art therapies, suggesting potential benefits for negative symptoms and self-narrative, though the evidence remains limited. High-quality research, including patient perspectives, women, and the phenomena of the working alliance, is critical to develop the evidence base for forensic psychiatric patients who are diagnosed with schizophrenia or schizoaffective disorder.
This review presents a meta-aggregation of qualitative studies exploring the needs of caregivers for individuals with mental illness who have offended and are in secure forensic services. While much research has examined carers' experiences and burdens, few studies focus specifically on their needs. To address this gap, this review systematically synthesised qualitative evidence to develop a comprehensive understanding of forensic carers' perspectives. A systematic search was conducted across five databases (Web of Science, PsycINFO, ProQuest, CINAHL Plus, and Scopus), supplemented by grey literature and manual reference screening. Following quality appraisal, five studies met inclusion criteria, with quality scores ranging from 65% to 81%. Data extraction and synthesis were undertaken using a structured meta-aggregation approach. Six interrelated themes emerged: (1) Emotional responses, (2) Coping strategies, (3) Carers' need for guidance: Navigating the mental health system and accessing information, (4) The need for support in managing family dynamics and the practical burden of caregiving, (5) Collaborative partnerships: Moving from exclusion to transparent inclusion, and (6) Relational stability as a buffer against isolation. Findings indicate that carers face significant emotional distress and require reassurance, guidance, and inclusion to sustain resilience, reflecting challenges that extend beyond those identified in general mental health caregiving.
Older adults represent one of the fastest-growing populations in secure mental health settings, yet their specific needs remain under-researched. This pilot study provides an international comparison of older forensic psychiatric inpatients across Switzerland, Canada, and the Netherlands. Using cross-sectional data from medical records, we examined demographic characteristics, psychiatric diagnoses, substance use, suicide attempts, psychotropic and psychosocial treatments, and risk assessment practices among male inpatients aged 50 and older. Despite high comparability in demographic and criminological profiles, notable differences emerged in clinical presentations, treatment modalities, and risk assessment tools used. The findings underscore the urgent need for age-sensitive forensic mental health services and standardized international approaches to care. Given the broadly similar demographic and sentencing profiles, comparability across countries appears plausible. Future prospective studies should examine clinical and criminal characteristics to determine whether observed differences reflect sample heterogeneity or system-level influences on diagnosis and risk assessment. This study contributes to the growing body of evidence necessary for developing tailored interventions and enhancing international collaboration in forensic psychiatry.
Gypsy, Roma and Traveller communities experience the poorest outcomes across multiple domains, including over-representation in the Criminal Justice System. Despite several government publications, limited research explores their specific experiences within criminal justice services. This scoping review aimed to synthesise existing literature on the prison experiences of Gypsy, Roma and Traveller individuals, particularly regarding the extent to which their cultural needs are met. The review included qualitative studies published in English from 1994 onward, focusing on Gypsy, Roma and Traveller individuals' prison experiences. A search of three academic databases and grey literature was conducted, and screening followed PRISMA-ScR guidelines. Variables were extracted to assess inclusion criteria, summarise findings, and chart demographic data such as gender and country of origin. Twelve studies met the inclusion criteria. Core themes identified included discrimination, limited understanding of Gypsy, Roma and Traveller culture and relationships, and inadequate opportunities to meet cultural needs in custody. Although the small number of studies limits generalisability, the recurrence of these themes across different contexts indicates systemic issues. Overall, the findings suggest that Gypsy, Roma and Traveller prisoners have predominantly negative experiences, with key cultural needs unmet and poorly understood. The findings suggest more focused research and policy development are needed to address these systemic shortcomings within custodial environments.
