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PubMed2006

Cues they use: clinicians' endorsement of risk cues in predictions of dangerousness.

Clinical predictions of violence are a necessary part of clinical practice despite extensive literature validating the use of actuarial rather than clinical prediction. The current study examined clinicians' use of risk cues in predictions of violence. Clinicians identified several risk cues as significant in clinical assessments of risk, including a history of assaults, hostility, medication noncompliance, paranoid delusions, presence of psychosis, and family problems. However, further results indicated that clinician-endorsed risk cues lack predictive power in the present sample.

Criminal Psychology↗

PubMed2006

The application of civil commitment law and practices to a case of delusional disorder: a cross-national comparison of legal approaches in the United States and the United Kingdom.

Legal approaches to civil commitment in the United States and the United Kingdom are compared. A concise overview of the historical evolution of civil commitment in both countries precedes a discussion of the present scheme of commitment standards in each system. These current standards in U.S. and U.K. jurisdictions are then applied to a hypothetical case of delusional disorder. A discussion of the constructive use of civil commitment in patients with delusional disorder who may be dangerous focuses on its value as a preventive measure against potential harm to self or others, as well as the pros and cons of coercive assessment and treatment. Despite the many differences in approach to commitment, the authors concur that in both countries the patient with delusional disorder was committable before the commission of a serious criminal offense.

Commitment of Persons with Psychiatric Disorders↗

PubMed2006

Short-Term Assessment of Risk and Treatability (START): The case for a new structured professional judgment scheme.

The Short-Term Assessment of Risk and Treatability (START) is a new structured professional judgment scheme intended to inform multiple risk domains relevant to everyday psychiatric clinical practice (e.g. risk to others, suicide, self-harm, self-neglect, substance abuse, unauthorized leave, and victimization). The article describes the processes involved in establishing an interdisciplinary approach to risk assessment and management. The authors present a review of the rationale for START, including the value of dynamic variables, the importance of strengths, and the extent to which clinicians must be attentive to multiple risk domains, reflecting theoretical and scientific evidence of the overlap among risks. Using the development, validation, and implementation of START as an example, the authors describe the processes by which other researchers, clinicians, and administrators could adapt existing assessment schemes or create new ones to bridge some remaining gaps in the risk assessment and management continuum.

Antisocial Personality Disorder↗

PubMed2002

Proposals for managing dangerous people with severe personality disorder: new legislation and new follies in a historical context.

Current proposals in England and Wales to ' capture' an ill-defined group of anti-social and violent people within the widest possible definition of mental disorder, and thereby to detain them under proposed new mental health legislation, is criticized and critiqued on intellectual, ethical and pragmatic grounds. The view is taken that psychiatrists must utterly reject these proposals which, if adopted, would make them primarily agents of social control. Psychiatrists and other mental health professionals must fight to retain the essentials of ethical and effective treatment earned trust and primary responsibility to the individual patient which these proposals seek to undermine and pervert.

Dangerous Behavior↗

PubMed2002

Developing services for people with dangerous and severe personality disorders.

This paper describes the conflicting attitudes that exist within wider society and the people who deliver services for people with dangerous and severe personality disorder. The importance of recognizing the nature of these conflicting attitudes that are based on the desire for ' punishment', ' keeping society safe' and ' treatment and care' is discussed. Potential ways of resolving these conflicts at an organizational and practice level are explored. The resolution might involve replacing the notions and associated practices of ' punishment' and ' safety' with ' containment', and ' treatment and care' with psychosocial therapy and rehabilitation.

Dangerous Behavior↗

PubMed2002

Managing the unmanageable: psychotherapy in Grendon Prison.

This paper provides an account of some of the organizational and dynamics issues that emerge in a setting that contains and provides psychotherapy to 230 severely personality-disordered and dangerous men. It proposes that in addition to their strategic managerial role, the senior team have an additional task to provide psychodynamic containment for the clinical work of the organization by tracing the journey of dynamics on the clinical factory floor up the organizational structure to the senior team. A conceptualization of this work is proposed, and some implications discussed.

Dangerous Behavior↗

PubMed2005

Temporal reliability of psychological assessments for patients in a special hospital with severe personality disorder: a preliminary note.

BACKGROUND: The new programme for assessing those with dangerous and severe personality disorder relies heavily on psychological assessments of personality disorder and risk. METHODS: The temporal reliability of assessments of psychopathy (PCL-R), risk (HCR-20) and personality was assessed using the International Personality Disorder Examination (IPDE) in 15 randomly selected male prisoners in a high secure hospital carried out at intervals varying between a mean of nine and 19 months after initial assessments by a variety of assessors. RESULTS: Using the intra-class correlation coefficient the agreement varied between 0.57 (HCR-20), 0.58 (PCL-R) and 0.38-0.70 for IPDE personality disorders, with the best agreement for antisocial personality disorder (0.70). COMMENT: These levels of agreement are consistent with other recent work on temporal reliability of personality instruments but are a little too low for confidence in these measures alone in the assessment process.

Adult↗

PubMed2002

Risk assessment as collective clinical judgement.

INTRODUCTION: Risk assessment occupies an increasingly important position in psychiatry. This paper contends that collective judgement is the optimal method of assessing risk. THE MEANING OF RISK: Risk has a dual meaning: emotional and judgemental. RISKS FACED BY STAFF: Assaults, threats and survival anxiety. THE EFFECTS OF DANGER ON THE GROUP: Staff wariness and resistance, attribution of blame. THE AMBIGUOUS TASK: For a group to function well it must have a clear task. Custodial roles can lead to ambiguity. THE EMOTIONS OF LARGER GROUPS: Externally directed hostility, internal homogenization of views. SOCIAL DEFENCES: Rituals can develop in forensic institutions, as well as militarism. ANTI-THERAPEUTIC CULTURE: Sadism may develop where a marked power differential develops. THE ROLE OF THE LEADER: Danger intensifies the feelings about leaders, perhaps idealization, perhaps disaffection. Leaders and others need to agree on risk assessment or fragmentation will occur. THE MODIFICATION OF RISK: The assessment of risk may modify it. Mutual hostility must be reduced. Dialogue and understanding are needed. A CLIMATE FOR RISK ASSESSMENT: The environment should be less authoritarian and more democratic, so that patients can join a group and internalize its values. Reflective space is also required. CONCLUSIONS: Risk assessment is best described in terms of human endeavour, not in the language of scientific measurement.

Adult↗

PubMed2006

A comparison of offenders with intellectual disability across three levels of security.

BACKGROUND: A number of authors have described, with disparate results, the prevalence of people with intellectual disability and their characteristics, in a range of offender cohorts defined by service use. These have included high security, a range of criminal justice services and community services. There is a need for research comparing cohorts of offenders with intellectual disabilities across different settings. AIM AND HYPOTHESIS: To conduct such a comparison and test the hypothesis that severity of characteristics measured will be highest in highest levels of residential security. METHOD: A clinical-record-based comparison a offenders with intellectual disability in high security (n = 73), medium/low security (n = 70), and a community service (n = 69). RESULTS: Groups were similar in age and tested IQ levels. Early psychiatric service contact had been more likely in the lower security groups. In line with the hypothesis, more complex presentations, in particular comorbid personality disorder, was more likely in the highest security group. Both fatal and non-fatal interpersonal violence convictions were significantly related to group, with more in the high security group sustaining a conviction both at the index offence and prior to that. Over 50% of all groups had at least one conviction for a sexual offence. A regression model accounting for 78% of the variance was made up largely of disposal variables (Mental Health Act status and probation) and indications of antisocial traits (criminal damage, lifetime conviction for murder and ICD-10 personality disorder classification). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The authors show that context of sampling affects most relationships between intellectual disability (ID) and offending when the methods for measuring ID are held constant. The results also present several questions on the relationship between risk, services available in an area and referral to higher security.

Adult↗

PubMed2003

Changes in patterns of excessive alcohol consumption in 25 years of high security hospital admissions from England and Wales.

BACKGROUND: It is now generally acknowledged that alcohol abuse increases the risk of violence among people with major mental disorder. Studies in the 1980s and earlier, however, tended to report an inverse relationship between their alcohol use and violence. AIMS: A study was undertaken to test a hypothesis that among people with major mental disorder considered to pose a serious risk to others the likelihood of excessive alcohol consumption in a period leading up to a violent or dangerous act has increased over time. METHODS: Analysis was made of annual high security hospital admission cohort case register data of 1 January 1975 to 31 December 1999; alcohol use data were taken from interview and records, and problem drinking defined as consumption of alcohol in excess of 21 units per week during the 12 months prior to the index offence or act. RESULTS: There was a linear increase in the proportion of patients in five-year admission cohorts who had engaged in excessive alcohol consumption during the year prior to their index offence or act. The increase was steeper among women than men, but cut across all diagnosis and offending groups. It was strongly associated with increasing tendency to abuse illicit drugs. CONCLUSIONS: The greater proportion of patients affected by excessive alcohol consumption occurred in spite of a reduction over the same period in admission of people in the diagnostic groups most likely to be implicated in substance misuse (personality disorder). This increased trend may simply reflect similar trends in the general population, but may also be associated with a lack of services or current consensus on appropriate treatment for patients whose mental illness is complicated by excessive alcohol use. Regardless, the trend suggests a growing need for 'dual diagnosis' services within and outside high security hospital.

Adolescent↗

PubMed2004

Getting to grips with severe personality disorder.

Explore the source record for details and available documents.

Adult↗

PubMed2004

Motivating factors for male forensic patients with personality disorder.

INTRODUCTION: Treatability is currently a crucial component for detention under the Mental Health Act (England and Wales) for the Psychopathic Disorder (personality disorder) classification and there is continuing debate about the nature and assessment of treatability of individuals with personality disorder. Previous research has identified motivation to engage in treatment as a significant factor in the assessment of treatability; however, motivation is not a static predictor but a state of readiness or eagerness to change, which may fluctuate from one time or situation to another. While previous studies have explored factors within the individual that are used to assess treatability, this study aims to explore what, if any, aspects of an inpatient forensic setting influence patients' motivation to engage in treatment. METHOD: The study examines patients' experiences of engaging in treatment in an inpatient forensic Personality Disorder Directorate using a qualitative approach to identify possible service-, ward- and therapist-level influences on patients' motivation to engage. RESULTS: Preliminary categories were identified across the data, including: support, treatment, safety, external belief, belonging, internal motivation and therapeutic relationship. CONCLUSIONS: Implications for the service are identified and areas for further qualitative exploration are highlighted.

Adult↗

PubMed2006