Public stigma towards mental health conditions has been subject to considerable research. Whilst there is evidence to suggest that different psychiatric diagnoses may be associated with varying levels of public stigma, research exploring the impact of such differences is limited. In the present study, we considered whether differences in diagnosis and baseline individual stigma towards mental health conditions influenced juror decision-making in a mock criminal trial. We used an online, between-groups experimental design, with N = 150 participants being manipulated between three experimental conditions ('Schizophrenia’, ‘Borderline Personality Disorder’, and ‘Complex Mental Health Condition’), and measured stigma using a validated measure. A video trial vignette depicting a case of alleged criminal damage was presented where the only manipulation was the diagnostic term. Both logistic and linear hierarchical regressions were used to consider the effect of diagnosis and stigma on guilt, which was rated both as a binary and continuous measure. The results suggest that juror stigma, but not exposure to different diagnostic terms, was a significant factor in the individual verdicts that jurors reached, associated with a medium/large standardised effect in the linear regression (β=0.54, p < .001). Heterogeneity between individual jurors in guilt ratings was high. Moreover, male jurors were also more likely to give a guilty verdict than female jurors, contrary to previous research. The study's strengths and limitations are discussed, along with implications for legal professionals and clinicians working within the criminal courts of England and Wales.
The current legislative framework for the provision of health care in the Nigerian correctional system is the Nigerian Correctional Service Act (2019). The alignment of this framework with international best practice in prison mental health care has not been examined to date. This document review critically appraises the act regarding its capacity to deliver sustainable prison mental health care by comparing its provisions and operating protocol with illustrative standards for prison mental health services. We identified important gaps in assessment during reception, treatment planning, and referral processes; medication management; 24-h healthcare provision; patient safety; environmental adequacy; workforce and collaborative arrangements; and the overall governance mechanisms for the delivery of mental healthcare in the corrections system. Despite its fledgling implementation, the current statute, with its protocol, requires relevant amendments to establish clearer provisions for mental health care delivery to those in prison.
Mental health court diversion programs are one approach aimed at reducing the rates of mental illness amongst people in jails and prisons around the world. Although meta-analytic work has examined the effects of specialized mental health courts on recidivism, less is known about non-specialty court mental health diversion programs. In the current study, we conducted a systematic review and meta-analysis to examine evidence regarding the effectiveness of non-specialty court mental health diversion programs on reducing the risk of recidivism for adults with mental illness. Following the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines, we searched PubMed, Embase, Web of Science, PSYCINFO, and Criminal Justice Abstracts. We found eight articles eligible for final inclusion, reporting 12 separate effect size estimates and including a total of 4,214 participants. We extracted relevant data and conducted a meta-analysis using a random effects model to establish a pooled odds ratio (OR) with 95% confidence interval to estimate the association between non-specialty court mental health diversion programs and recidivism. Participation in these types of court diversion programs was associated with significantly reduced odds of recidivism (OR = 0.47, 95% CI = 0.35–0.65). However, this finding should be interpreted with caution due to concerns about study quality and substantial heterogeneity, as reflected in the prediction interval (0.158–1.418). Further high-quality research is needed to confirm findings and enable a more robust and detailed understanding of the relationship across a range of contexts and subgroups. There is also a need to test service improvements aimed at increasing the rate of diversion amongst those eligible, improving the impact on recidivism and on key mental health outcomes.
Leaves are an essential part of treatment within forensic mental health services, with the goal of a gradual and safe return to society. However, such leaves may lead to public safety concerns. The present retrospective observational cross-sectional study examined patterns in evaluations of leave applications to the Dutch Advisory Board on Review of Leave and how often forensic psychiatric patients do not return from their leave (on time) and how often they commit an offence during this unauthorized absence. We also investigated whether certain patient or offence characteristics can predict unauthorized absences. We found that 375 (2.5%) of the 15,050 granted applications for leave of forensic psychiatric patients with a mandatory treatment order between 2009 and 2020 involved an unauthorized absence, and 23 (0.15%) involved an unauthorized absence with recidivism. Patients with a Cluster B personality disorder, substance use disorder, mood disorder, Psychopathy Checklist-Revised score above 26, arson or violent offence as index offence had a significantly higher chance of unauthorized absences. The standardly coded risk factors, Substance use during treatment and Breaching conditions about treatment and supervision, were also related to a higher chance of unauthorized absences. Patients with a Cluster C personality disorder, paraphilic disorder or sexual offence with a minor or homicide as index offence had a significantly lower chance of unauthorized absences. However, all these associations were very weak. Concluding, unauthorized absences are rare in the Netherlands, and although some patient and offence characteristics were associated with these absences, this relationship is weak, and predicting unauthorized absences is difficult.
Restraint and seclusion in psychiatric settings is associated with physical and psychological harm to patients and staff. Leveraging a dynamic aggression risk assessment instrument with targeted violence prevention can reduce aggression and restrictive practices in mental health. This study aimed to investigate the use of a predictive instrument with an aggression prevention protocol to reduce aggressive incidents. The Dynamic Appraisal of Situational Aggression (DASA) instrument assessed the risk of imminent aggression in psychiatric inpatients, and the Aggression Prevention Protocol (APP) provided staff with evidence-based interventions to reduce violence risk. DASA + APP were incorporated into standard practice within forensic and general adult inpatient units. The Modified Overt Aggression Scale (MOAS), restraint/seclusion events and pro re nata (PRN) medication were used to measure the impact of the intervention. Feedback was obtained from nursing staff to assess the feasibility and perceived utility of the intervention. There were significant reductions in average MOAS scores (pre=1.56, post=0.80, p = 0.007) and PRN medication administration (pre=4.14, post=3.63, p < 0.01). Restraint/seclusion events declined by 26% and seclusion hours by 51%. Staff perceived DASA as an objective, standardized communication tool; APP supported the least restrictive practices. This study supports the use of DASA + APP to identify the risk of aggression and guide proactive, individualized intervention. DASA + APP was effective in forensic and non-forensic units. Ongoing integration into clinical practice may enhance patient outcomes, staff satisfaction and treatment efficacy. Plain Language Summary Aggressive behaviour in psychiatric inpatient units can lead to harmful practices such as restraint, seclusion, and as-needed medication use. This study found that using a daily aggression risk assessment tool alongside a structured prevention protocol reduced aggression severity, restrictive interventions and medication use in both forensic and general psychiatric units.
Forensic mental healthcare is considered a stressful environment of professional practice. Forensic professionals encounter numerous occupational difficulties, such as dealing with violence, managing high workloads, coping with the consequences of staff shortages, and high societal pressure. To understand what is important to professionals in their work climate, this study aimed to explore the key dimensions of the work climate in forensic mental healthcare in the Netherlands, across both inpatient and outpatient settings. First, desk research was conducted. Documents were selected from the databases of the Inspection Services of Justice and Security, the Healthcare and Youth Inspectorate, and the Custodial Institutions Agency in the Netherlands. Second, eight interviews were held with forensic professionals. A thematic analysis was conducted to analyze the data. Three main dimensions were generated: (a) Fundamentals, (b) Self-Governance, and (c) Interpersonal Relationships. A main finding in this study was that meaningful formal and informal interpersonal relationships between forensic professionals seem to be of vital importance in the work climate. This study provides insights and opportunities for forensic institutions and for professionals themselves to create or maintain a supportive work climate.
Research has identified that restrictive practices, specifically the use of seclusion rooms, are traumatizing for patients and staff within forensic mental health settings. A few studies have explored the impact of seclusion practices on staff, but these have been limited to nurses' and healthcare assistants' experiences. The current qualitative study included 12 healthcare professionals from various disciplines involved in seclusion practices (healthcare assistants, mental health nurses, junior doctors, and psychiatrists). Interviews were analyzed using inductive Thematic Analysis. Four main themes emerged from the data analysis: multidisciplinary teamwork, skills required for good practice, patient-centered approach, and the impact of seclusion practices. The findings have implications for practice, including the importance of multidisciplinary team training and monthly ward-based case formulations, as well as for future research in this area.
This qualitative study explores practitioners' perceptions and experiences of a brief joint working intervention within the Offender Personality Disorder community pathway. Ten practitioners were recruited through purposive sampling and took part in online semi-structured interviews, which were analyzed using thematic analysis. Themes suggested that joint working helped probation practitioners to better understand the people they supervised and to develop new ways of working. Collaboration, responsive working, established relationships, and active engagement were highlighted as good practices. Challenges included power dynamics, probation practitioners' fear and cynicism, limited timeframes, and external pressures. The study highlights the benefits of a relational approach to joint working and makes practice recommendations. This study was conducted by the Research Involving Service Users Excels (RISE) team. RISE was made up of people with lived experience of prison, probation, and forensic mental health systems, alongside National Health Service and probation employees.
Forensic mental health treatment represents a specialized form of care aimed at stabilizing psychiatric illness, reducing hospital readmission risk, and supporting reintegration into the community. Various factors are consistently associated with forensic mental health and treatment planning. One relevant factor is exposure to an interpersonal potentially traumatic event (PTE), which is common among forensic inpatients. We analyzed data from 5,105 forensic hospital admissions in Ontario, Canada, between 2013 and 2023, examining whether exposure to sexual, physical, and/or emotional abuse relates to psychiatric symptom severity (i.e., aggression, positive symptoms, depressed mood, and manic symptoms). After accounting for confounding factors (age, gender, education), any exposure to PTE was associated with increased severity of positive symptoms, depressed mood, and manic symptoms, but not aggressive behavior. Timing of PTE exposure (within 1 year versus more than 1 year ago) did not relate to outcomes. Effects were more pronounced among sufferers of polytrauma, highlighting the cumulative burden of PTE exposure. PTE exposure was related to greater symptom severity in men and women, but it was associated with aggression and higher symptom severity in cases of polytrauma among women only. These findings underscore the importance of trauma-informed care and gender-responsive approaches in forensic mental health services.
Public involvement in research is advocated by research authorities and funding bodies worldwide. In the United Kingdom (UK), it is considered achievable and expected in all types of health and social care research. However, lived-experience involvement in prison and forensic mental health research remains rare. This qualitative study reports the experiences of National Health Service (NHS) staff, probation staff, and people with lived experience collaborating in a unique research group within a secure mental health setting in England. Qualitative interviews were undertaken with six staff and four lived-experience researchers. Reflexive thematic analysis was applied, supported by NVivo software. Two themes were identified: Relationship Matters and This Feels Valuable, each with two subthemes: Balancing the Scales and Safe and Secure; and Collaboration Improves Our Research, but It's Challenging and Personal and Professional Growth. This study provides evidence that collaborative research can benefit forensic mental health settings and outlines factors that contributed to positive experiences for the researchers. There was lived-experience involvement throughout this study.
The Dynamic Appraisal of Situational Aggression (DASA) is a tool designed to assess the risk of violence in inpatient adult mental healthcare. Despite its empirical support, there is limited understanding of how the DASA is used to guide risk management. We interviewed twelve nursing staff across two forensic hospitals, exploring how the tool is operationalised and how nursing staff use the DASA score to guide their risk management. In the services studied, the DASA was being used as intended to assess violence risk. A key theme was the use of the DASA to share risk information, the initial step of the pathway from assessment to risk management. When integrating the DASA output with risk management, the DASA prompted nurses to undertake further assessment and/or put patient care plans into action, rather than choose an intervention stratified from the DASA score. The findings identify an important consideration of whether an assessment tool is designed to structure one's judgement (whilst not entirely displacing the user's experience and knowledge), or whether the tool needs to prescriptively guide clinical decision-making. This study builds an understanding of how risk assessment tools are implemented in real-world practice and the pathway from risk assessment to management outcomes.
Self-injurious behavior in forensic mental health care populations happens frequently and affects not only the individuals involved but also other patients and treatment staff. Moreover, it is linked to violent behavior toward others and is a predictor of suicide. There is still a limited understanding of the underlying functions of self-injurious behavior in forensic patients. This study aimed to enhance this understanding by analyzing 299 incidents of self-injurious behavior recorded between 2008 and 2019 within a gender-mixed Dutch forensic population. The functions of these incidents were categorized by three researchers using the proposed functions of self-injurious behavior identified by Gallagher and Sheldon. Multilevel analyses were conducted to account for repeated incidents per patient and to examine gender and diagnostic differences in functions and severity of self-injurious behavior. The most common function of self-injurious behavior was affect regulation, which was more common among women than among men. Among men, the expression of aggression and control was more common than in women. We recommend that the functions of self-injurious behavior be questioned more directly and specifically to gain a better understanding and to help provide adequate intervention. Further research, particularly qualitative studies, is needed to explore the functions and treatment of self-injurious behavior within forensic populations more deeply.
Involuntary treatment orders can be used to compel individuals deemed incompetent to receive care that is considered necessary for their health condition. This article describes the varying perceptions of the legal procedures associated with involuntary treatment orders. Semi-structured interviews were conducted with 40 participants (service users, family members, healthcare professionals, and lawyers). The overarching theme "at the intersection of legal and clinical issues" captures the ways in which involuntary treatment orders are experienced and used at the crossroads of two distinct systems. Three interrelated themes were identified. The first theme, The Construction and Negotiation of Involuntary Treatment Orders, examines how involuntary treatment orders are shaped through formal legal criteria, informal clinical reasoning, institutional norms, and strategic negotiation, often revealing tensions and overlaps between legal and clinical logics. The second theme, Relational Dynamics in the Initiation of Involuntary Treatment Orders, focuses on how interpersonal interactions among different key actors influence perceptions of fairness, legitimacy, and coercion in the process surrounding involuntary treatment orders. The third theme, Barriers and Inequities in Access to Justice, highlights how structural, procedural, and psychosocial factors constrain service users' ability to exercise their rights and shape unequal experiences within the legal process.
Inpatient forensic psychiatric rehabilitation is based on patient symptoms, life activities performance and perceived risks to self and others. Self-ratings provide insights into patients' perspectives. We have found differences between self-ratings and staff-ratings using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). To understand rating differences, we performed a qualitative study exploring patients' reasoning when self-rating WHODAS. Eighteen participants with a psychotic disorder and a history of aggression, cared for at a low to medium secure forensic psychiatric inpatient clinic in Sweden, were interviewed using verbal concurrent probing when self-rating the WHODAS. Participants' responses during the concurrent probing interview were summarised under three central themes: difficulties understanding and expressing language associated with the questionnaire; cognitive difficulties; and contextual rating difficulties. The analysis of two additional questions, about meaningfulness and validity, resulted in one further theme: Value of doing the rating. The usability of the questionnaire and of the self-rating process was not uniform, given differences in participants' language-related and cognitive abilities, as well as some questions not being readily applicable to an inpatient setting. Overall, the questions may prompt self-reflection, which could increase patient participation and self-awareness.
This study examined whether education, indirect contact, and a combination of education and indirect contact was associated with lower scores of forensic stigma. Undergraduate students (N = 698) were randomly assigned into one of four conditions: An education video that provides empirical evidence challenging the myths about forensic patients, a contact video using clips from a documentary about a real forensic patient, a combination of both education and contact videos, and a control video providing general psychology facts. Participants completed questions about demographic characteristics, previous education in forensic psychology, and contact with forensic patients, as well as completing the Forensic Stigma Scale-Revised which measures the key stereotypes driving forensic stigma (i.e. dangerousness/unpredictability and responsibility/blame). Overall, participants in the education and combined condition had the lowest scores of forensic stigma. Participants in the contact condition scored similar to the control group. There were significant effects for gender (men and women) within conditions. The findings support the use of education interventions as an effective means of addressing stigma towards forensic patients.
In New Zealand, service users who are M & amacr;ori (Indigenous people of New Zealand) comprise roughly half of the population in forensic mental health services (FMHS). An actuarial risk assessment instrument, the Dynamic Appraisal of Situational Aggression (DASA) has been introduced to reduce the risk of imminent inpatient aggression, which is prevalent in such services. The current study is a qualitative descriptive design, enhanced by aspects of participatory action research, to evaluate the suitability of the DASA for M & amacr;ori from a M & amacr;ori perspective. Two hui (a M & amacr;ori gathering) were held with seven M & amacr;ori nurses and a M & amacr;ori cultural advisor from a FMHS. The first hui (n = 7) explored M & amacr;ori perspectives on the strengths, limitations and suitability of the DASA for M & amacr;ori, and the second hui (n = 6) reflected on appropriate adaptations to the measure. The findings of this study confirmed support for using the DASA with M & amacr;ori. However, five recommendations were made for adaptations for cultural enhancement. Such cultural enhancement would require further refining with M & amacr;ori cultural advisors and psychometric testing to ensure the validity and reliability of the DASA for M & amacr;ori.
This ethnographic study explores how a research team navigated power dynamics while developing patient-oriented research practices in a high-secure forensic mental health care setting. Data were collected through team meetings, interviews, and field notes. The study explored how power was understood and addressed at individual, interpersonal, and structural levels. The three themes and six subthemes focused on the importance of acknowledging power within the system, power given to the project through community support, and power held by researchers. Researchers learned to navigate strict policies, procedures, and practices within the forensic environment, focusing on building trust with staff while ensuring patient autonomy and engagement. Equitable communication, particularly with patients, was critical in garnering support for patient-oriented research, often requiring the use of accessible language. Lastly, reflexivity allowed the research team to critically reflect on their biases and positionalities, fostering power-balanced relationships essential for authentic engagement. Findings suggest that addressing power imbalances early and often, and building on the support of staff champions, are key considerations for conducting patient-oriented research in forensic mental health settings.
Individuals with mental health needs, including those with dual diagnosis of substance use disorders, who encounter the criminal justice system often face multiple layers of stigma tied to their identities as 'offenders', people with mental illness, and substance 'users'. Additional stigmas may stem from factors such as homelessness or belonging to marginalized ethnic or cultural groups. These labels can severely impact mental health, increase the likelihood of further involvement with the criminal justice system, impact on self-identity, and limit access to opportunities in education, housing, and employment. More broadly, these negative assumptions undermine a person's social citizenship and their capacity to lead a meaningful, prosocial life. As a result, reducing the stigma experienced by individuals with these intersecting identities is crucial. This special issue sought to collate contemporary research from around the world on the topic of forensic mental health stigma and make suggestions for moving the field forward.
Rates of reoffending among forensic patients discharged from secure hospital care are known to be low, but comparatively little is known about contact with health services after discharge. This study describes the patterns and correlates of health service contact among discharged Forensic Patients in New South Wales (NSW), Australia. Records of Emergency Department (ED) presentations, hospital admissions, and ambulatory mental health care were linked to the records of the 227 Forensic Patients. Two thirds of the sample had contact with ambulatory mental health services within a month of discharge, and most (81.5%) presented to an ED or were admitted to a hospital during the study period. Factors associated with earlier hospital contact included being of English-speaking background, anti-social personality traits, and having a non-homicide related index offence. Predictors of ambulatory mental health contact within one month included prior contact with mental health services, non-homicide related index offence, prior criminal charges, and co-morbid substance use disorder. Early and continued engagement with community mental health services is an important component of community forensic mental health care. The high rate of hospital admission in the sample may reflect the assertive follow-up received by most Forensic Patients through proactive engagement with mental health services and the low tolerance for signs of relapse.
Many people hold the misconception that people with mental illness are dangerous and, consequently, should be feared. This stigma is reinforced by the overrepresentation of people with mental illness in the U.S. criminal legal system. This overrepresentation is due to ineffective policies making it difficult to adequately identify and treat this population within the legal system. To address this, two studies were conducted on CloudResearch. The first study examined public attitudes towards correctional policies and explored associated attitudinal factors. The second study built on these findings by testing interventions to decrease stigma and increase support for rehabilitation. Findings show that participants were more supportive of rehabilitative policies compared to punitive policies aimed at justice-involved people with mental illness. Participants' fear of people with mental illness, fear of criminal behavior, perceived mutability of mental illness, and perceived mutability of criminal behavior were examined in relation to support for both punitive and rehabilitative policy. Imagined contact did not effectively increase support for rehabilitative policy, but education did. Future research can build on these findings by improving the interventions and identifying other attitudinal factors that could be paths for intervention.
