This paper focuses on the occupational experiences of five men living within a forensic mental health unit over a year. This study used a descriptive qualitative case study methodology to explore the meaning and value placed on daily life (activities, occupations and routines), and how this changed over time. The men's stories showed a complex picture of their experiences of daily life. This study demonstrated the impact of the environment on the men and the ongoing challenge of the need to balance treatment/therapy with security demands and opportunities. Three interrelated themes were identified: (1) Power and Occupation; (2) Therapy or Punishment; (3) Occupational Opportunities within Restrictions. These findings serve as a reminder to clinical teams to reassess the value of occupations attributed by their patients and the impact of the secure environment, whilst also acknowledging the potential for occupations to have a negative impact on well-being.

Empirical research has demonstrated a link between legal coercion and treatment engagement following conviction among those with severe personality disorder. Legal coercive pressures were often applied by the Indeterminate Sentence for Public Protection (IPP), until it was replaced by the Extended Determinate Sentence by the Legal Aid, Sentencing and Punishment of Offenders Act 2012. In this paper, it is proposed that use of the new determinate sentence will lessen motivation for treatment engagement. One effect of treatment refusal may be greater reliance by the Secretary of State for Justice on his jurisdiction to transfer prisoners due for release to secure hospital transfers under the Mental Health Act 1983. Not only will this risk posturing undermine the principal aim of the Offender Personality Disorder Implementation Pathway to improve treatment engagement among the target group, it will also have negative implications for medical practitioners working in secure forensic hospitals. To demonstrate what is at stake, the paper briefly recapitulates empirical findings familiar to readers of the journal, before drawing on original unpublished data.

Psychopathy is a personality syndrome comprised of interpersonal, affective, and behavioral features that has emerged as a correlate of intimate partner violence perpetration. One commonly used self-report measure of psychopathy is the Psychopathic Personality Inventory-Short Form. The current study employed a multi-trait, multi-method approach to test convergent and discriminant validity of the measure in partner-violent couples by comparing males' self-report of psychopathy to the informant report of their female partner (N = 114). It was hypothesized that the female partner-report of the male's psychopathy would be highly correlated with the male report of his own psychopathy, thus providing evidence for the construct validity and interrater reliability of the PPI-SF. Analyses found that male and female reports were correlated significantly on the two major factors of the PPI-SF. Furthermore, the female-report explained a significant amount of variance over and above men's self-report on PAI scales designed to indicate antisocial personality traits.

This study examined the relationships between psychopathy (primary and secondary), intelligence and emotional responding in a sample of 50 university students, using a task measuring autonomic responses to 40 pictorial stimuli (20 neutral and 20 emotionally provoking). Results indicated no significant direct relationship between primary or secondary psychopathy and emotional response, or primary or secondary psychopathy and intelligence. However, a significant moderating effect of intelligence on the association between both psychopathy factors and emotional response was observed, indicating those scoring higher on psychopathy but with lower intelligence portray the expected emotional responses to the affective stimuli (primary: = -.56, < .05; secondary: = .80, <.001). These findings indicate abnormal reactivity to emotional stimuli in lower intelligence, higher psychopathic individuals, and suggest differing roles for the two facets of psychopathy in affective responsiveness deviations.

Non-completion is a significant problem in treatments for personality disorder (PD), and is associated with poorer outcomes. Clinicians routinely attend to engagement issues with people diagnosed with PD and so we accessed their views about the techniques they used to facilitate treatment engagement with service users with PD. Twenty-three clinicians from a range of disciplines were asked how they defined treatment engagement, what they thought were the causes of treatment engagement problems in people with PD, and what techniques or strategies they used to enhance engagement of people with PD. Data were analysed using inductive thematic analysis. Staff working with people with PD have broad views on the factors that are implicated in treatment engagement for their client group. Consequently, the techniques they use to engage service users are wide-ranging, addressing issues to do with services, individuals, therapies and therapists. Given the limited published data thus far, the suggestions generated may be of value to other practitioners in improving service user engagement.

This paper reports on the results of a qualitative study funded by the Economic and Social Research Council (ESRC) looking at multidisciplinary team decisions to admit sentenced offenders with antisocial personality disorder to a medium secure unit. The aim of the study was to examine admission decision-making from a multidisciplinary perspective, and to explore the interprofessional dynamics and contextual pressures informing those decisions. The primary method of data collection was 12 semi-structured interviews with a convenience sample of various multidisciplinary staff involved in pre-admission assessment and post-assessment decision-making. Data was then coded according to the dialectic of competitive and cooperative goal seeking within groups. The findings suggest that, whilst both forms of goal seeking inform admission decisions, the presence of significant resource pressures will lead to decisional solidarity among the multidisciplinary team. When minor professional disagreements arise, they are resolved by the group leader, the Responsible Clinician, in order to maximise group productivity. It is argued that the discursive-limiting effect of resource pressures on group decision-making may weaken the morale of certain front line staff, if not undermine institutional purpose.

Offenders with antisocial personality disorder (ASPD) are widely assumed to reject psychotherapeutic intervention. Some commentators, therefore, argue that those with the disorder are better managed in the criminal justice system, where, following the introduction of indeterminate sentences, engagement with psychological treatment is coercively linked to the achievement of parole. By comparison, National Institute of Clinical Excellence guidelines on the management and treatment of ASPD recommend that those who are treatment should be considered for admission to specialist psychiatric hospitals. The rationale is that prison-based interventions are underresourced, and the treatment of ASPD is underprioritised. The justification is that offenders with ASPD can be rehabilitated, they are motivated. One problem, however, is that little is known about why offenders with ASPD seek treatment or what effect subsequent treatment has on their self-understanding. The aim of this paper is to address these unresolved issues. It draws on the findings of Economic and Social Research Council (ESRC) funded qualitative study examining the experiences of sentenced male offenders admitted to a specialist personality disorder ward within the medium secure estate and the medical practitioners who treat them. The data are analysed with reference to Michel Foucault's work on and in power relations. Two arguments are advanced: first, offenders with ASPD are motivated by legal coercive pressures to implement a variety of Foucauldian-type strategies to give the false impression of treatment progress. Second, and related, treatment does not result in changes in self-understanding in the resistive client with ASPD. This presupposes that, in respect of this group at least, Foucault was mistaken in his claim that resistive behaviours merely mask the effectiveness of treatment norms over time. Nevertheless, the paper concludes that specialist treatment in the hospital setting effect changes in the resistive offender's self-understanding, but not if the completion of treatment results, as is commonplace, in his prison readmission.

A mapping exercise as part of a pathway study of women in secure psychiatric services in the England and Wales was conducted. It aimed to (i) establish the extent and range of secure service provision for women nationally and (ii) establish the present and future care needs and pathways of care of women mentally disordered offenders (MDO) currently in low, medium and enhanced medium secure care. The study identified 589 medium secure beds, 46 enhanced medium secure beds (WEMSS) and 990 low secure beds for women nationally. Of the 589 medium secure beds, the majority (309, 52%) are in the NHS and under half (280, 48%) are in the independent sector (IS). The distribution of low secure beds is in the opposite direction, the majority (745, 75%) being in the IS and 254 (25%) in the NHS. Medium secure provision for women has grown over the past decade, but comparative data for low secure provision are not available. Most women are now in single sex facilities although a small number of mixed sex units remain. The findings have implications for the future commissioning of secure services for women.

Several questions remain unanswered regarding the extent to which the principles and practices of patient-centered care are achievable in the context of a forensic mental health hospital. This study examined patient-centered care from the perspectives of patients and providers in a forensic mental health hospital. Patient-centered care was assessed using several measures of complementary constructs. Interviews were conducted with 30 patients and surveys were completed by 28 service providers in a forensic mental health hospital. Patients and providers shared similar views of the therapeutic milieu and recovery orientation of services; however, providers were more likely to perceive the hospital as being potentially unsafe. Overall, the findings indicated that characteristics of patient-centered care may be found within a forensic mental health hospital. The principles of patient-centered care can be integrated into service delivery in forensic mental health hospitals, though special attention to providers' perceptions of safety is needed.

Aggressive behavior in incarcerated youth presents a significant problem for staff, co-residents and the functioning of the institution. This study aimed to examine the predictive validity of an empirically validated measure, designed to appraise the risk of imminent aggression within institutionalized adult psychiatric patients (Dynamic Appraisal of Situational Aggression; DASA), in adolescent male and female offenders. The supervising staff members on the residential units rated the DASA daily for 49 youth (29 males and 20 females) over two months. The results showed that DASA total scores significantly predicted institutional aggression in the following 24 and 48 hrs; however, the predictive validity of the DASA for institutional aggression was, at best, modest. Further analyses on male and female subsamples revealed that the DASA total scores only predicted imminent institutional aggression in the male subsample. Item analyses showed that , and predicted institutional aggression more strongly as compared with other behavioral manifestations of an irritable and unstable mental state as assessed by the DASA.

This study tested the hypothesis that adolescent-onset alcohol abuse (AOAA) would both mediate and moderate the effect of childhood conduct disorder on antisocial behaviour in late adolescence and early adulthood. A sample comprising 504 young men and women strategically recruited from the community were grouped using the criteria of the Diagnostic and Statistical Manual (DSM-IV, American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: APA), as follows: neither childhood conduct disorder (CCD) nor alcohol abuse/dependence; CCD but no alcohol abuse or dependence; alcohol abuse/dependence but no CCD; both CCD and alcohol abuse/dependence. The outcome measure was the sum of positive responses to 55 interview items capturing a variety of antisocial behaviours engaged in since age 15. Severity of lifetime alcohol-related and CCD problems served as predictor variables in regression analysis. Antisocial behaviour problems were greatest in individuals with a history of co-occurring conduct disorder (CD) and alcohol abuse/dependence. While CCD was strongly predictive of adult antisocial behaviour, this effect was both mediated and moderated (exacerbated) by AOAA.

The emotions shame and guilt may represent a critical stepping stone in the rehabilitation process. Often referred to as "moral" emotions owing to their presumed role in promoting altruistic behavior and inhibiting antisocial behaviors, shame and guilt provide potentially exciting points of intervention with offenders. In this article, we describe current psychological theory and research that underscores important differences between shame and guilt. We note parallels between psychologists' conceptions of guilt and shame, and criminologists' conceptions of reintegrative and disintegrative shaming. We summarize recent research investigating the implications of these moral emotions for criminal and risky behavior, with special emphasis on the handful of studies conducted with actual offenders. We conclude with a discussion of implications for treatment in criminal justice settings.

Previous research investigating the relationship between Borderline Personality Disorder (BPD) and sleep problems, independent of depression, has been conducted on small atypical samples with mixed results. This study extends the literature by utilizing a much larger sample and by statistically controlling for depression and substance dependence. Subjective reports of sleep problems were obtained from 513 jail inmates (70% male) incarcerated on felony charges. Symptoms of BPD were significantly associated with sleep problems even when controlling for depression. Thus, sleep problems associated with BPD cannot be attributed simply to co-morbid symptoms of depression and substance dependence was ruled out as proximal causes for this relationship. Symptoms of depression, but not Antisocial Personality features, were related to sleep problems independent of substance dependence. Treatment of individuals with BPD may be more effective if sleep problems are explicitly addressed in the treatment plan.

Amnesia for the perpetration of violent offences is an important issue in medico-legal proceedings. Previous studies of amnesia have mainly relied on selected groups of unconvicted offenders, which raises the question of how reliable the findings are. The purpose of this study was to examine the prevalence and phenomenological qualities of amnesia in violent offenders. In semi-structured interviews with 105 young offenders convicted of serious violence, 20 (19%) reported partial amnesia for their offence and only one (1%) reported complete amnesia. Amnesia was associated with high alcohol intake, emotional ties to the victim, and cognitive processing during the assault. Complete amnesia for violent crime appears to be less frequent than suggested by previous reports using unconvicted samples. The findings have implications for the clinical assessment of claimed amnesia for violent crime and are potentially of medico-legal significance.

Rates of suicide and violence are higher amongst male prisoners than the general population. This study aimed to explore the emotional experiences of male prisoners in the distal and immediate lead-up to acts of suicide and violence. Nine male prisoners created drawings of their emotions in the lead-up to an act of suicide and/or violence. Accompanying verbal interview data was collected to explore the narrative of these drawings. Polytextual thematic analysis was conducted on both the visual and audio data. Three themes were found. 'The outside picture' depicted the emotions that male prisoners exhibited externally. 'The inside picture' illustrated the internal emotions felt by male prisoners which were often complex and abstract. 'The complexity of the picture' denotes the complicated relationship between emotions and suicide/violence. Male prisoners experience a range of emotions in the lead up to acts of suicide and violence, with a similar set of emotions being experienced immediately prior to both suicide and violence. This study has illustrated the benefits of using a novel and creative methodology, and has demonstrated that future research with male prisoners could benefit from adopting a participatory visual methodology.

The link between imprisonment and adverse mental health is well established and linked to both recidivism and prison misconduct, with negative consequences for prisoners, the prison system and society. To help minimise these impacts, appropriate mental health interventions are required. However, owing to finite resources to deliver healthcare in prisons, interventions must be both clinically and cost-effective. A systematic literature search was conducted using various medical and economic databases. The search aimed to identify full economic evaluations (comparing costs and consequences of two or more interventions) of mental health interventions for adult prisoners during incarceration. Results were intended to identify evidence gaps and highlight areas for future research. Only one publication met all eligibility requirements, with several limitations identified. This finding highlighted a clear lack of cost-effectiveness evidence for use by decision makers within the prison setting. This emphasises the need for future research to incorporate economic evaluation during the early stages of research design. Research should aim to incorporate both intervention costs and wider healthcare resource use, which may be affected, and generic outcomes, such as quality-adjusted life years (QALYs), which enable comparison across various disease areas and against pre-determined thresholds.

Persistent psychiatric symptoms can serve as a major barrier to the successful reintegration of parolees with mental illness. Thus, it is important to identify factors that might impact their mental health recovery, such as low adherence to their treatment regimen. Although many studies have examined the issue of psychiatric medication nonadherence, very few studies have focused specifically on justice-involved individuals. The strength of the clinician/patient working alliance has been found to be significantly associated with psychiatric medication adherence in prior research, but this relationship has not been assessed in a parolee population. Logistic regression analysis was used to determine if patient-rated working alliance was a significant predictor of low psychiatric medication adherence while taking into account alcohol/illegal drug use, age, and ethnicity in a sample of recently released parolees with mental illness (N=49). Patient-rated working alliance, age, and ethnicity were not significant predictors of low adherence. Alcohol/illegal drug use during the follow-up period was associated with a significantly increased likelihood of meeting the criteria for low medication adherence (OR=8.36; 95% CI=1.60, 43.66). The findings from this study highlight the importance of addressing alcohol and illegal drug use issues as part of the psychiatric treatment plan for returning prisoners with mental illness.

Previous studies with men suggest that certain psychopathic traits vary with age. Specifically, younger men score higher on psychopathic traits measuring impulsive-antisocial behavior, including impulsivity, irresponsibility, and criminal versatility, compared to older men. On the other hand, younger and older men score comparably on psychopathic traits reflecting core personality traits of interpersonal and affective dysfunction, including conning and manipulative behavior and a lack of empathy, guilt, and remorse. However, it is currently not known whether psychopathic traits similarly vary with age among women. This study examined whether psychopathy scores (assessed via the Hare Psychopathy Checklist - Revised [PCL-R]) varied with age among a sample of 501 incarcerated women ranging from 19 to 57 years of age. Consistent with previous studies performed with men, younger women scored higher on psychopathic traits measuring impulsive-antisocial behavior (i.e., PCL-R Factor 2, Facet 3, and Facet 4 scores) compared to older women. However, scores on PCL-R Factor 1, Facet 1, and Facet 2, assessing core personality traits, including interpersonal and affective dysfunction, were comparable across women in different age categories investigated. Results obtained in this preliminary study suggest the variation of PCL-R Factor 2 traits and the stability of PCL-R Factor 1 traits across the lifespan is invariant across gender.

Ex-armed forces personnel constitute the largest known occupational group in prison but there is little evidence regarding their mental health, or substance misuse, needs. A total of 105 participants were interviewed and measures assessing symptoms of common mental health (CMH) problems and substance misuse were completed along with a review of their health care records. Forty (38%) participants screened for current CMH problems (CCMH) and high levels of dual symptomology and alcohol misuse were assessed. Thirty-nine (37%) had a mental health diagnosis recorded, most commonly for post-traumatic stress disorder (PTSD), depression and personality disorder. Those who screened for a CCMH problem were more likely to have pre-service vulnerability to negative health outcomes and those with dual symptomology were more likely to have experienced deployment during their service. Findings suggest the mental health needs of this group are similar to the general prison population. Potentially higher prevalences of PTSD and alcohol misuse may direct service provision.

Relative risks of violence in psychiatric patients are high compared to the general population and existing evidence in non-psychiatric populations may not translate to reductions in violence in psychiatric populations. We searched 10 databases including Medline, EMBASE, CINAHL and Scopus, from inception until August 2015 for systematic reviews and meta-analyses of violence prevention interventions in psychiatry. Reviews were included if they used a hard outcome measure (i.e. police or hospital recorded violence, or reincarceration) and contained randomized or non-randomized controlled studies. Five reviews met our inclusion criteria ( = 8876 patients in total), of which four received a GRADE rating of 'low' or 'very low'. Three randomized studies ( = 636) reported that therapeutic community interventions may reduce reincarceration in drug-using offenders with co-occurring mental illness ('moderate' GRADE rating). The lack of intervention research in violence prevention in general and forensic psychiatry suggests that interventions from non-psychiatric populations may need to be relied upon.

Suicidal behavior is a significant problem in United States jails. Suicidal ideation (SI) is an established precursor to suicidal behavior in incarcerated populations. No studies to date have examined the prevalence of SI or its correlates in a mixed gender U.S. jail sample. The purpose of the present study was to document rates of SI in a mixed gender jail sample and examine socio-demographic and psychiatric correlates. This study of 511 jail inmates found that approximately 16% of participants reported clinically significant SI upon incarceration. White participants, suicide attempters, and those with a psychiatric diagnosis history endorsed greater SI. Reported SI did not differ by sex and was not correlated with age. Clinically, results indicate that screening for SI in jail samples is necessary to identify high-risk individuals for intervention to prevent suicidal behavior.

This preliminary analysis assesses how judges view the use of behavioral genetics evidence on genetic influences to mental disorders in court. Twenty-one semi-structured interviews, analyzed using constant comparative analysis, were conducted with California trial court judges. Most judges reported the beneficial effects of this evidence being presented in court, particularly as a mitigating factor for sentencing. Yet some judges viewed it as an aggravating factor and expressed concerns about genetic privacy. Judges described initial reactions to being potentially presented with evidence on genetic influences to mental disorders as apprehension, curiosity, and sympathy. Judges also reported putting significant trust in experts on these issues. Findings suggest some judges are skeptical of this evidence, but largely open to its presentation. Sympathetic reactions may result in mitigating attitudes of some judges. As judges significantly trust experts, some judges could also be overly trusting of genetic evidence and expert opinion on these issues.

Mass murder, particularly mass shootings, constitutes a major, growing public health concern. Specific motivations for these acts are not well understood, often overattributed to severe mental illness. Identifying diverse factors motivating mass murders may facilitate prevention. We examined 1,725 global mass murders from 1900-2019, publicly described in English in print or online. We empirically categorized each into one of ten categories reflecting reported primary motivating factors, which were analyzed across mass murderers generally, as well as between U.S- and non-U.S.-based mass-shooters. Psychosis or disorganization related to mental illness were infrequently motivational factors (166; 9.6%), and were significantly more associated with mass murder committed using methods other than firearms. The vast majority (998, 57.86%) of incidents were impulsive and emotionally-driven, following adverse life circumstances. Most mass murderers prompted by emotional upset were found to be driven by despair or extreme sadness over life events (161, 16.13% within the category); romantic rejection or loss, or severe jealousy (204, 20.44% within the category); some specific non-romantic grudge (212, 21.24% within the category); or explosive, overwhelming rage following a dispute (266, 26.65% within the category). Results suggest that policies seeking to prevent mass murder should focus on criminal history, as well as subacute emotional disturbances not associated with severe mental illness in individuals with poor coping skills who have recently experienced negative life events.