Long-Term Forensic Psychiatric Care: Clinical, Ethical and Legal Challenges

By Peter Braun

This book provides an overview of forensic psychiatry, focusing on the provision of care in Europe as well as the legal and ethical challenges posed by long-term stays in forensic settings. Forensic psychiatric services provide care and treatment for mentally disordered offenders (MDOs) in secure in-patient facilities as well as in the community. These services are high-cost/low-volume services; they pose significant restrictions on patients and hence raise considerable ethical challenges. There is no agreed-upon standard for length of stay (LoS) in secure settings and patients’ detainment periods vary considerably across countries and even within the same jurisdiction. Thus far, little research has been conducted to identify factors associated with length of stay; consequently, it remains unclear how services should be configured to meet the needs of this patient group. This volume fills some of those gaps. Furthermore, it presents new research on factors associated with length of stay, both patient-related and organisational. Various approaches to the provision of care for long-term patients in different countries are explored, including a few best practise examples in this specific area of psychiatry. The book also addresses the perspective of those working in forensic care by reviewing quality-of-life research and interviews with patients. The authors of this volume come from a range of professional backgrounds, ensuring a certain breadth and depth in the topic discussion, and even includes patients themselves as (co-)authors.

• Language: English
• Publisher: Springer
• Release date: May 16, 2019
• ISBN: 9783030125943

Book preview

© Springer Nature Switzerland AG 2019

Birgit Völlm and Peter Braun (eds.)Long-Term Forensic Psychiatric Carehttps://doi.org/10.1007/978-3-030-12594-3_1

1. Introduction

Birgit Völlm¹  

(1)

Institute of Forensic Psychiatry, University of Rostock, Rostock, Germany

Birgit Völlm

Email: [e-mail]

Forensic psychiatry is a subspecialty of psychiatry that operates at the interface between law and psychiatry. It is concerned with patients who have committed an often serious offence and may be detained in highly restrictive secure settings. Unlike in other areas of medicine, patients with mental disorders, and even more so those who have committed serious offences, are treated not only in order to improve their own mental health and facilitate recovery but also for the protection of the public from harm from the patient. This dual role can cause tensions and dilemmas for the practitioner who has potentially incompatible duties to the patient, third parties and the wider community [1–3]. The balance between these duties may change over time and depends on the social and political context of the practitioner. Several authors have argued that currently, i.e. at the beginning of the twenty-first century, the pendulum has swung, maybe too far, to risk aversive approaches, potentially leading to restrictive practices and increasing lengths of stay (LoS) in forensic-psychiatric settings [4].

1.1 Detention of Mentally Disordered Offenders

Detention in forensic-psychiatric settings is regulated by a complex set of laws, including criminal and mental health law, which differ widely between countries. All modern legislations though recognise the concept of criminal responsibility as a prerequisite for punishment. Therefore, individuals who are found to lack responsibility for the act they have committed are treated in a different way compared to offenders with full criminal responsibility; i.e. they maybe be admitted to a psychiatric hospital rather than being punished by imprisonment. Most, but not all, countries stipulate some degree of reduced responsibility in order to be admitted to a forensic-psychiatric setting though others, e.g. the UK, only require the need for treatment in such a setting as entry criterion (thereby also allowing individuals who have not committed any offences to be admitted). Given the above, it is not surprising that rates of detention also differ widely from country to country (e.g. [5]).

While it is desirable to redirect mentally disordered offenders away from criminal justice and towards treatment settings, what is problematic about this diversion is that most countries allow detention of mentally disordered offenders (MDOs) beyond the length of the prison sentence their offence would have attracted had they been imprisoned [6]. However, some countries—Croatia, Italy, Portugal—limit the time of psychiatric detention to the time the individual would have served in prison had they been fully criminally responsible. In other countries (e.g. Germany), the proportionality of ongoing detention is taken into account, more so the longer the detention in a forensic-psychiatric facility continues, thereby balancing the patients’ right to freedom with the right of the public to be protected against the patients [7]. Detention of MDOs for lengthy periods of time, in particular longer than an equivalent prison sentence, raises important financial and ethical issues. For example, forensic-psychiatric settings are resource-intensive settings which therefore should be used only where absolutely necessary. Lengthy detention might discriminate against those with mental disorders who are subject to risk assessments before they can be released, while the same is not the case for offenders with no mental illness who are discharged at the end of their sentence regardless of any ongoing risk.

1.2 How Long Is (Too) Long?

Maybe surprisingly, there is no accepted standard for length of stay (LoS) in forensic settings. This is maybe more understandable on an international level, given the differences in legal frameworks, but guidance and clear policy are also absent within individual countries.

A recent review on long-stay in forensic settings [8] identified 69 studies on the topic of long-stay, originating from 14 different countries. The study confirmed that what constituted ‘long-stay’ was inconsistent. In addition to the differences in service provision, the situation is made more complex by the different ways in which LoS can be measured. There are principally three such ways:

1.

Admission sample: All patients admitted during a particular period are included, and their LoS calculated from admission to discharge.

2.

Cross-sectional sample: LoS is calculated from date of admission to a particular time point for all patients resident in a particular setting.

3.

Discharge sample: All patients discharged during a particular period are included with LoS calculated from their date of admission to this discharge date.

Most of the studies on LoS to date have used discharge samples; this method has the advantage that it calculates ‘true’ LoS (i.e. completed care episodes) and that there is consistency in the legal and policy context at the time of data collection. However, this approach is less suited to predict factors that affect LoS. If one is interested in the characteristics of patients who remain in the system and may have little prospect of discharge, then a cross-sectional sample is the most suitable method.

In the review by Huband et al. [8], 20 studies used a prospectively chosen LoS threshold to define a ‘long-stay’ group. The actual threshold used varied with 2 years used in Ireland and a number of UK-based studies, 5 and 8 years in medium and high secure UK settings and 10 years used in studies in Israel, Germany and Malaysia. The Netherlands, as one of the countries providing a dedicated long-stay service within forensic-psychiatric care (see Chap. 16 of this volume for more details), use a LoS of 6 years for admission to such a service.

1.3 Factors Associated with Length of Stay

Research identifying factors associated with long-stay is limited. The review by Huband et al. [8], however, identified a list of 90 potential variables explored in research as potentially associated with long-stay in forensic-psychiatric settings; 48 of these were examined in more than one study. Characteristics explored included factors around the nature of the index offence, diagnosis and symptoms and the patients’ personal, criminal, psychiatric and treatment history. For a number of characteristics, the direction of association was inconsistent, i.e. some studies found these to be associated with longer, others with shorter LoS, while some studies found no association with LoS; such characteristics included gender and a diagnosis of schizophrenia. Characteristics most commonly associated with longer LoS were an index offence of murder/homicide, overall severity of the index offence and having a violent or sexually motivated index offence. Other characteristics frequently associated with longer LoS were a history of psychiatric treatment, cognitive or organic deficit and illness/symptom severity.

1.4 This Book

Given the relative dearth of research on long-stay in forensic-psychiatric settings, it seemed timely to dedicate a whole volume to the topic. This consists of three parts. Part I addresses some of the context of long-stay in forensic-psychiatric care, e.g. the relationship between detention in criminal justice and psychiatric settings (Penrose hypothesis), comparisons between healthcare systems and ethical issues and the prevalence and characteristics of long-stay patients, the latter by example of one large, multicentre, UK-based study. Parts II deals with clinical issues such as how to measure progress in forensic care, recovery, protective factors, quality of life and occupational therapy. This part also considers particular patient groups such as sex offenders and ageing patients as well as the perspective of patients and carers themselves. Part III describes models of care for long-stay patients from a range of European countries, including those with dedicated long-stay units such as the Netherlands and those which are challenged by a lack of resources to develop high-quality care such as the Baltic states. This part also describes the newly transformed forensic service in Italy which recently abolished high secure forensic institutions in favour of a more community-based model of care. Finally, Part III concludes with a chapter considering potential barriers one might encounter transforming care by, e.g., developing care models specific to those who stay within services for a long period of time.

References

1.

Applebaum PS. The new preventative detention: psychiatry’s problematic responsibility for the control of violence. Am J Psychiatry. 1988;145(7):779–85.Crossref

2.

Boyd-Caine T. Protecting the public? Detention and release of mentally disordered offenders. Oxon: Routledge; 2012.Crossref

3.

Carroll A, Lyall M, Forrester A. Clinical hopes and public fears in forensic mental health. J Forensic Psychiatry Psychol. 2004;15(3):407–25.Crossref

4.

Petrila J, de Ruiter C. The competing faces of mental health law: recovery and access versus the expanding use of preventative confinement. Amsterdam Law Forum. 2011;3:59–68.

5.

Chow WS, Priebe S. How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990. BMJ Open. 2016;6(4):e010188.Crossref

6.

Sampson S, Edworthy R, Völlm B. Provisions for long-term forensic-psychiatric care: an international comparison of 18 European countries. Int J Forensic Ment Health. 2016;15:333–51.Crossref

7.

Edworthy R, Sampson S, Völlm B. Inpatient forensic-psychiatric care: legal frameworks and service provision in three European countries. Int J Law Psychiatry. 2016;47:18–27.Crossref

8.

Huband N, Furtado V, Schel S, Eckert M, Cheung N, Bulten E, Völlm B. Characteristics and needs of long-stay forensic psychiatric inpatients: a rapid review of the literature. Int J Forensic Ment Health. 2018;17:45–60.Crossref

Part IThe Context

© Springer Nature Switzerland AG 2019

Birgit Völlm and Peter Braun (eds.)Long-Term Forensic Psychiatric Carehttps://doi.org/10.1007/978-3-030-12594-3_2

2. Asylums and Deinstitutionalization: The Penrose Hypothesis in the Twenty-First Century

Adrian P. Mundt¹, ²  

(1)

Medical Faculty, Universidad Diego Portales, Santiago, Chile

(2)

Medical Faculty, Universidad de Chile, Santiago, Chile

Adrian P. Mundt

Email: [e-mail]

2.1 Enlightenment Split and the Rise of Lunatic Asylums in the Nineteenth Century

Prior to the French Revolution and Enlightenment, people showing deviating or disturbing behaviors were mostly confined or restrained. The Enlightenment brought changes on how societies dealt with deviant behaviors. Medical doctors started to conceptualize parts of deviant behaviors as mentally ill. Psychiatry emerged as a medical specialty to treat those illnesses. Other types of deviant behaviors were considered criminal or moral failures. This distinction has been called Enlightenment split [1] (see Fig. 2.1).

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Fig. 2.1

Enlightenment split, the division of abnormal behaviors in the mentally ill and criminal

Criminal behaviors were subject to emerging penal justice systems. Imprisonment became the predominating form of punishment replacing cruel, public, and violent types of punishment [2]. Mentally ill people were increasingly treated in mental asylums or psychiatric hospitals. The French medical doctor, Philippe Pinel, was one of the first proposing new recovery-oriented psychological treatments for the mentally ill, based on humanistic principals [3]. Those interventions intended to replace restraint and harsh methods of treatment. During the nineteenth century, lunatic asylums were built outside of the important cities in most European countries. In colonial times, this type of service provision was implemented worldwide [4, 5]. The lunatic asylum intended to provide therapeutic environments during retreat [6] or long-term hospitalization [4]. Similar to the prison architecture, many of these places also followed panoptical principles of architecture for surveillance [7]. The erosion of the distinction between insanity and immorality by medical scientism and the inclusion of immorality in the systems of disease were considered to be possible explanations for the increasing numbers of people in those institutions [8]. By the end of the nineteenth century, many of the institutions were housing thousands of people [9]. Increasingly custodial structures, crowding, and growing criticism gave rise to call for new approaches [10, 11].

2.2 A Century of Psychiatric Bed Removals

By the beginning of the twentieth century, important parts of the population were living in mental health institutions. The histography of psychiatry and its institutions is full of carceral narratives [12]. First ideas of psychiatric reforms came up questioning the sizes of those institutions and the numbers of people being institutionalized in mental asylums. In 1939, the British psychiatrist Lionel Sharples Penrose pointed for the first time to a possible inverse relationship between the number of people in psychiatric asylums and prisons, a notion that later was referred to as the Penrose hypothesis.

In the 1950s and 1960s, Anglo-Saxon countries systematically implemented psychiatric reforms that implied the reduction of the numbers of people living in mental asylums. Growing recognition of the detrimental effects of long-term hospitalization, the availability of new pharmacological agents in the 1950s and new models of outpatient treatments in psychiatry lead to a paradigm shift on how to best treat people with mental illness. Reforms included the creation of community housing facilities and intensified outpatient services to care for people with chronic mental illnesses. Long-term hospitalization was replaced by short-term and if necessary intermittent hospitalization. In the 1970s and 1980s, psychiatric reforms were also implemented in many other European countries. The ideas of psychiatric reforms gained political momentum in the second half of the twentieth century. Radical currents to reform psychiatry had their philosophical or ideological basis in antipsychiatric movements. The most radical implementation of psychiatric reforms took place in Italy based on the idea to reject every form of institutionalization in mental health care. The protagonist of this movement in Italy was Franco Basaglia [13] and the intention to focus on human rights of the mentally ill and dismiss all custodial structures in mental health care [14]. There were ideas to dismiss circuits of social control and give a different meaning to madness [15]. The consequences of the famous Law 180 in Italy removing nearly all psychiatric beds were critically discussed not only in Italy but across Europe starting in the 1980s [16]. There were concerns, especially about the severely chronically ill, the acutely ill, and the homeless with mental illnesses. Whereas North American countries had a more pragmatic approach to deinstitutionalization, driven by ideas of necessities, cost-savings, and efficiency [15], the South American approach was strongly influenced by Basaglia, more radical, political, and emotional [17]. In the 1990s psychiatric reforms and the corresponding service developments became the worldwide model also for low- and middle-income countries.

2.3 The Penrose Hypothesis in the Twenty-First Century

In the twenty-first century, the distinction between mentally ill and criminal behaviors continues to be a struggle. Current classifications of mental illnesses include conditions that overlap with criminal offenses such as antisocial personality disorder, pedophilia, or illicit drug use disorders. With the rise of the neurosciences, the determinism debate gained momentum again. Neuroscientists started to question current criminal justice practice based on convictions for guilt. The arguments followed a line that all thoughts and behaviors are consequences of genes, epigenetics, and experiences reflected in neuronal activities, connections, and circuits. If one had a complete understanding of all the underlying factors, one could completely predict behaviors. The possibility to make deliberate choices was considered smaller than thought before and in part illusions of the brain. Those arguments would speak in favor of medicalizing rather than criminalizing abnormal behaviors.

After decades of latency, the Penrose hypothesis came into the scientific focus again in the twenty-first century in different countries and contexts. Decades after the psychiatric reforms in Europe, concern was expressed about the increase of numbers of people in forensic psychiatric institutions and prisons co-occurring with continuous removal of beds in general psychiatry. The question arose whether an era of trans-institutionalization or reinstitutionalization had started [18]. In a recent systematic review on the Penrose hypothesis, studies were sorted according to the type of design sampling cross-sectional data, time point data, or longitudinal data [19]. Cross-sectional studies have the advantage that they can easily include large numbers of countries [20]. However, they do not acknowledge trends within countries or regions. Similar to the original study by Penrose, a study assessing different regions in Australia found that areas with more psychiatric beds had less prisoners and vice versa [21]. The largest and most systematic cross-sectional study including most countries worldwide did not detect any inverse relationship between psychiatric bed numbers and prison population rates [20]. It even found a direct positive association between psychiatric bed numbers and prison population rates in low- and middle-income countries.

A paper assessing two time points is one of the few studies from the USA addressing the Penrose hypothesis for six US states [22]. The first time point was 1968 and the second 1978. Between the two time points, there was a massive increase of the prison population and a decrease of psychiatric bed numbers. The authors concluded that there was not likely any relationship between the phenomena. However, the argument was weak and based on the history of criminal justice involvement of psychiatric inpatients and vice versa.

Longitudinal studies were first presented with data from single countries such as Hungary and Norway [23, 24]. Hartvig and Kjelsberg [23] reported a 74% decrease of psychiatric bed rates between 1960 and 2004 in Norway, whereas prison populations increased 52% and violent crime increased 900% in the same time span.

There have been more recent studies testing the Penrose hypothesis using statistical models of longitudinal data from several countries with contrasting results. The first evidence for a significant inverse relationship between the number of psychiatric hospital beds and prison population rates in a longitudinal data set is from South America [25]. In the year 1990, South American countries committed themselves to psychiatric reforms [26]. The study evaluated trends of psychiatric bed numbers and prison population rates in the two decades following this initiation of reforms. A massive increase of prison population rates was associated with the reduction of the numbers of psychiatric beds. When and where more psychiatric beds were removed, the prison population rate rose more.

A study that presented longitudinal data from Eastern and Western Europe between 1993 and 2011 did not find any significant relationship between psychiatric bed numbers and prison population rates [27]. One of the problems of this study was the great heterogeneity between the Eastern and Western European countries. A study focusing only on Western European countries found a relationship between psychiatric bed numbers and prison populations [28]. However, the relationship was less strong than the one reported for South America.

There has been further research pointing to an interdependence of the psychiatric care systems and penal justice systems: There are high rates of mental disorders in prison populations [29, 30, 31]. Severe mental illnesses frequently co-occur with substance use disorders [32] and with personality disorders [33]. Prisoners have high rates of psychiatric hospitalization prior [34, 35] and after [36] imprisonment in countries where psychiatric hospitalization is a relevant option.

In recent years, large linkage studies have pointed to a relationship between mental disorders and violent behaviors. This relationship has been understudied and has even been rejected for a long time to reduce stigma of people with mental illnesses. The risk to be convicted of violent crime is more than sixfold increased in men and more than 14-fold increased in women with schizophrenia in the 5 years following the diagnosis [37]. Linkage studies of a national crime register up to the year 2006 and a systematic whole population mental examination of late adolescents in the years 1969–1970 before obligatory military service in Swedish men showed the relationship of common mental disorders and violent crime. For the late adolescents with mental disorders, there was an increased risk to be convicted of a violent crime in the 35 years following the examination. Risks were several fold elevated for people with mental retardation, substance use disorders, and personality disorders. Even for anxiety and depression disorders, there was a modest but significant increase, whereas there was no difference for people with neurological disease [38].

The Penrose hypothesis is still unresolved, especially to what degree it is generalizable or whether it applies for specific regions and time spans. There seems to be a stronger relationship in South American low- and middle-income countries for the recent decades than in Europe. Whereas psychiatric reforms with strong reductions of psychiatric bed numbers are still ongoing in Latin America, recent decades in Europe constitute an era with post-psychiatric reforms with more modest but still overall trends for reductions of psychiatric bed numbers. Institutionalization in the twenty-first century is a dynamic process with commonly rather short but intermittent time intervals in different types of institutions and with repeated time intervals in the community. Further research is needed to trace individual pathways and how to best sustain and prolong intervals of community life. It is still open how politics, service planners, and stakeholders act upon recent findings. The fact is that most societies function with intermittent institutionalization of the mentally ill (see Fig. 2.2). Prison facilities are certainly one type of institution that has to be considered when referring to institutionalization or deinstitutionalization of mentally ill people in the future [39].

../images/416125_1_En_2_Chapter/416125_1_En_2_Fig2_HTML.png

Fig. 2.2

Institutions receiving mentally ill people and institutionalization as a dynamic process with intermittent intervals in the community

References

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Sadler JZ. Vice and mental disorders. In: The Oxford handbook of philosophy and psychiatry. Oxford: Oxford University Press; 2013. p. 451–79.

2.

Foucault M. Wahnsinn und Gesellschaft. Suhrkamp; 1973.

3.

Pelletier JF, Davidson L. At the very roots of psychiatry as a new medical specialty: the Pinel-Pussin partnership. Sante Ment Que. 2014;40(1):19–33.

4.

Piddock S. Possibilities and realities: South Australia’s asylums in the 19th century. Australas Psychiatry. 2004;12(2):172–5.

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Wilbraham L. Reconstructing Harry: a genealogical study of a colonial family ‘Inside’and ‘outside’the Grahamstown Asylum, 1888–1918. Med Hist. 2014;58(02):166–87.

6.

Edginton B. Moral architecture: the influence of the York Retreat on asylum design. Health Place. 1997;3(2):91–9.

7.

Braun B, Kornhuber J. Germany’s unique panoptical asylum--an appreciation of the first Bavarian mental home in Erlangen. Fortschr Neurol Psychiatr. 2013;81(3):162–8.

8.

Kosky R. From morality to madness: a reappraisal of the asylum movement in psychiatry 1800–1940. Aust N Z J Psychiatry. 1986;20(2):180–7.

9.

Hunter JM, Shannon GW, Sambrook SL. Rings of madness: service areas of 19th century asylums in North America. Soc Sci Med. 1986;23(10):1033–50.

10.

Luchins AS. The rise and decline of the American asylum movement in the 19th century. J Psychol. 1988;122(5):471–86.

11.

Weiss KJ. Asylum reform and the great comeuppance of 1894-or was it? J Nerv Ment Dis. 2011;199(9):631–8.

12.

Engstrom EJ. History of psychiatry and its institutions. Curr Opin Psychiatry. 2012;25(6):486–91.

13.

Giovanni de Girolamo MD, Barale F, Politi P, Paolo Fusar-Poli MD. Franco Basaglia, 1924–1980. Am J Psychiatr. 2008;165(8):968.

14.

Foot J. Franco Basaglia and the radical psychiatry movement in Italy, 1961–78. Crit Radic Soc Work. 2014;2(2):235–49.

15.

Scheper-Hughes N, Lovell AM. Breaking the circuit of social control: lessons in public psychiatry from Italy and Franco Basaglia. Soc Sci Med. 1986;23(2):159–78.

16.

Papeschi R. The denial of the institution. A critical review of Franco Basaglia’s writings. Br J Psychiatry. 1985;146(3):247–54.

17.

Fusar-Poli P, Bruno D, Machado-De-Sousa JP, Crippa J. Franco Basaglia (1924—1980): Three decades (1979—2009) as a bridge between the Italian and Brazilian mental health reform. Int J Soc Psychiatry. 2011;57(1):100.

18.

Fakhoury W, Priebe S. Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare. Psychiatry. 2007;6(8):313–6.

19.

Kalapos MP. Penrose’s law: Methodological challenges and call for data. Int J Law Psychiatry. 2016;49(part A):1–9.

20.

Large MM, Nielssen O. The Penrose hypothesis in 2004: patient and prisoner numbers are positively correlated in low-and-middle income countries but are unrelated in high-income countries. Psychol Psychother. 2009;82(1):113–9.

21.

Biles D, Mulligan G. Mad or bad?—The enduring dilemma. Br J Criminol. 1973;13(3):275–9.

22.

Steadman HJ, Monahan J, Duffee B, Hartstone E. Impact of state mental hospital deinstitutionalization on United States prison populations, 1968-1978. J Crim Law Criminol. 1984;75:474.

23.

Hartvig P, Kjelsberg E. Penroses law revisited: the relationship between mental institution beds, prison population and crime rate. Nord J Psychiatry. 2009;63(1):51–6.

24.

Kalapos MP. Penrose’s law: reality or fiction? Mental health system and the size of prison population–international overview. Orv Hetil. 2009;150(28):1321–30.

25.

Mundt AP, Chow WS, Arduino M, Barrionuevo H, Fritsch R, Girala N, Priebe S. Psychiatric hospital beds and prison populations in South America since 1990: does the Penrose hypothesis apply? JAMA Psychiat. 2015;72(2):112–8.

26.

Larrobla C, Botega NJ. Psychiatric care policies and deinstitutionalisation in South America. Actas Esp Psiquiatr. 1999;28(1):22–30.

27.

Blüml V, Waldhör T, Kapusta ND, Vyssoki B. Psychiatric hospital bed numbers and prison population sizes in 26 European countries: a critical reconsideration of the penrose hypothesis. PLoS One. 2015;10(11):e0142163.

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Chow WS, Priebe S. How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990. BMJ Open. 2016;6(4):e010188.

29.

Fazel S, Seewald K. Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry. 2012;200(5):364–73.

30.

Mundt AP, Baranyi G, Gabrysch C, Priebe S, Fazel S. Substance use during imprisonment in low and middle-income countries. Epidemiol Rev. 2018;40(1):70–81. https://​doi.​org/​10.​1093/​epirev/​mxx016.

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Baranyi G, Cassidy M, Priebe S, Fazel S, Mundt AP. Prevalence rates of posttraumatic stress disorder in prisoners. Epidemiol Rev. 2018;40(1):134–45. https://​doi.​org/​10.​1093/​epirev/​mxx015.

32.

Mir J, Kastner S, Priebe S, Konrad N, Ströhle A, Mundt AP. Treating substance abuse is not enough: comorbidities in consecutively admitted female prisoners. Addict Behav. 2015;46:25–30.

33.

Brink J. Epidemiology of mental illness in a correctional system. Curr Opin Psychiatry. 2005;18(5):536–41.

34.

Mundt AP, Kastner S, Mir J, Priebe S. Did female prisoners with mental disorders receive psychiatric treatment before imprisonment? BMCPsychiatry. 2015;15(1):1

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Sodhi-Berry N, Knuiman M, Preen DB, Alan J, Morgan VA. Predictors of post-sentence mental health service use in a population cohort of first-time adult offenders in Western Australia. Crim Behav Ment Health. 2014;25(5):355–74.

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Alan J, Burmas M, Preen D, Pfaff J. Inpatient hospital use in the first year after release from prison: a Western Australian population-based record linkage study. Aust N Z J Public Health. 2011;35(3):264–9.

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Fazel S, Wolf A, Palm C, Lichtenstein P. Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden. Lancet Psychiatry. 2014;1(1):44–54.

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Moberg T, Stenbacka M, Tengström A, Jönsson EG, Nordström P, Jokinen J. Psychiatric and neurological disorders in late adolescence and risk of convictions for violent crime in men. BMC Psychiatry. 2015;15(1):299.

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Lamb HR, Weinberger LE. Persons with severe mental illness in jails and prisons: a review. Psychiatr Serv. 1998;49(4):483–92.

© Springer Nature Switzerland AG 2019

Birgit Völlm and Peter Braun (eds.)Long-Term Forensic Psychiatric Carehttps://doi.org/10.1007/978-3-030-12594-3_3

3. Challenges in Comparing Health-Care Systems Across Different Countries

Hans Joachim Salize¹   and Harald Dreßing¹

(1)

Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany

Hans Joachim Salize

Email: [e-mail]

3.1 The Inter-sectoral Perspective

The variety of approaches worldwide for placing and treating mentally ill offenders pose huge methodological challenges for any evaluation. In many countries, general psychiatry and the prison sector are involved to varying degrees in the placement and treatment of mentally ill offenders in addition to forensic psychiatry. This requires a comprehensive perspective that is able to capture the specific contribution of each of these sectors and to understand the interdependencies between them.

These sectors and their interaction are regulated by rules, laws or legal traditions that are deeply rooted in the history and identity of a country. To make it even more complex, in many countries the legal frameworks for the placement and treatment of mentally ill offenders are under permanent review or change. From an international perspective, the issues are complex and the judicial and medical approaches are highly diverse.

Indicators or statistical measures taken from only one sector would most certainly lack explanatory power for describing a forensic care system in its totality. For example, the number of forensic beds provided in a country is rather meaningless when a substantial proportion of mentally ill offenders is routinely placed in prison or in general psychiatric wards. Moreover, there is no agreed international definition of the characteristics that qualify a bed in any institution as a forensic psychiatric bed.

From an inter-sectoral perspective, forensic psychiatry may be seen as a comparatively new sector. It may refine the Penrose hypothesis from the 1930s that stated an inverse relationship between the number of prison inmates and the number of psychiatric hospital beds in a society. As forensic psychiatric hospitals were rarely available or completely unknown at the time, they are likely to moderate this simple equation.

While Penrose’s association between psychiatric hospital beds and prison occupancy was confirmed by a number of past studies, more recent ones have shown the influence of factors such as judicial concepts or the economic strength of countries. An analysis of secondary data from 158 countries found that prison and psychiatric populations were positively correlated in low- and middle-income countries, but no such relationship was found in high-income countries [1]. More detailed analyses showed a common trend of decreasing numbers of psychiatric beds in European countries such as England, Germany, Italy, the Netherlands, Spain or Sweden during the last decades, while forensic psychiatric beds, supported housing and the prison population increased during the same period [2]. However, the association between the two systems disappeared when adjusting for the gross national product [3].

The contribution to or role of forensic psychiatry in an overall trend of re-institutionalization in mental health care, as it has been labelled recently [4], must be analysed further. It is still not clear how the expansion of forensic psychiatry affects the traditional pathways of care of persons at risk. One hypothesis discusses an undercurrent tendency in general psychiatry to shifting difficult to treat, violent or aggressive patients into the area of responsibility of forensic psychiatry, although these patients may still belong to the original clientele of general psychiatry and should be treated there.

Indeed, in some countries non-compliant and violent severely mentally ill patients are referred to forensic psychiatric hospitals more often and faster, while the number of their voluntary and involuntary episodes in general psychiatric hospitals prior to the referral to forensic psychiatry tends to decrease. This might be a paradox effect of stricter civil detention laws in order to reduce involuntary admissions of mentally ill patients into psychiatric hospitals [5]. As another reason, insufficient risk assessment procedures in general psychiatry have been discussed [6].

These examples show that it is essential to collect and provide information from neighbouring sectors such as general psychiatry and the prison system when describing a forensic psychiatric system. The interdependency of these sectors must be described.

3.1.1 Issues to Address

Following the methods and findings from the few international studies available in the field, a framework for describing and evaluating the placement and treatment for mentally ill offenders should address at least the following issues and aspects:

Legal frameworks and judicial traditions

Basic philosophies and key concepts

Diagnostic, assessment and review processes

Court trial procedures

Routine practices in placing and treating mentally ill offenders

Forensic service provision (capacities, inpatient and outpatient services)

Discharge procedures and forensic psychiatric aftercare

Interaction with other sectors (general psychiatry, prison system)

Coordination of care across sectors

Outcomes and effectiveness of forensic psychiatric care

Forensic care budgets

Availibility and quality of health and juridical reporting systems

Each issue depends on or interacts with some or all of the others and impedes the implementation of research frameworks. It also limits the information provided by health or judicial reporting systems in a country that usually do not encompass neighbouring sectors. To standardize such indicators across countries and harmonize their application is a methodological challenge. Without this information, however, any description of a nation’s forensic psychiatric care system is neither full nor comprehensive.

3.1.2 Assessment Methods

Internationally, most health and judicial reporting systems provide only rudimentary data on forensic psychiatry. Usually estimates on the number of court trials of mentally ill offenders per year or the number of beds in forensic psychiatric services are available and not much more. Definitions or data collection methods differ from country to country. When forensic psychiatry is organized on a federal state or province level, standards may differ even within countries. Instead of relying on administrative data, research studies in the field must define indicators and develop adequate and feasible data collection procedures on their own. This requires assessments on a service or patient level. This may balance the inaccuracies of administrative data, but it often has to deal with the disadvantages of small sample sizes. The collaboration with national or regional experts in the field may support the supply with relevant information. However, the high research cost of such bottom-up studies is another reason for the lack of international studies or standardized comparisons in the field.

The following paragraphs are detailing some of the most essential methodological and practical problems to be solved when trying to collect data on forensic psychiatric systems across countries.

3.2 Legal Frameworks, Basic Philosophies and Key Concepts

Every country provides specific laws, codes or other legal instruments for regulating judicial procedures concerning mentally ill offenders and their subsequent placement and treatment.

Due to the multifaceted problems, the rules and regulations are subject to permanent change in many countries. A constant change might allow for adapting the regulations to take into account the scientific progress or newly developed treatments. However, this means adapting routine practices continuously.

The constitutional and administrative structure of countries moderates the process. In some countries rules and regulations apply nationwide. In others forensic legislation may be federal or regional. In Germany, e.g. there are 16 federal states providing forensic psychiatric institutions on a federal state level. In the UK, England and Wales share a common legal body that differs from that in Scotland or Northern Ireland. In these cases, laws regulating the placement and treatment of mentally ill offenders may be spread over several different code books, particularly in the case of procedural regulations.

More generally, international legal frameworks may differ considerably with regard to key concepts or procedures. In German-speaking and Scandinavian countries, e.g. trial procedures as well as the resulting placement order or treatment regimes are perceived as a strictly formal process based on a detailed legal framework. The whole process is under close supervision of the responsible judicial authority. In other countries, e.g. in the UK or in France, health-care professionals may be given more discretionary powers.

A basic concept relevant in all jurisdictions to some degree is the criminal responsibility of an accused person. As a key concept, criminal responsibility is decisive for the trial procedure and the decision of the court in the case an offender suspected to be mentally ill. Depending on the assessment, it significantly influences the court decision. Countries that take the concept of criminal responsibility as central for the whole process of conviction are usually those whose juridical system is based on the Roman law tradition. It may be handled in a dichotomous (either given or absent) or in a graded manner (diminished responsibility). Countries whose legal tradition is based on the Common or Anglo-Saxon law instead may tend to ignore the concept of responsibility in favour of a more flexible way of managing justice in the best interest of the individual and the society [7].

To demonstrate and understand the role of such key concepts, the semi-standardized instrument of flow charts has been established in recent studies. These flow charts depict the juridical systems of a country in total [8, 9]. Figure 3.1 gives an example.

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Fig. 3.1

Flow chart of trial procedures and pathways to detention and/or care of mentally ill offenders in Germany [8]. Salize HJ, Dressing H, editors. Placement and treatment of mentally disordered offenders – legislation and practice in the European Union. Lengerich: Pabst Science Publishers; 2005

These flow charts have proved to be helpful for a short but sufficient enough overview of the key features of a system in question, including the decisive steps of court trial procedures and pathways to care. They are recommended for any cross boundary comparison of forensic psychiatry systems.

On a conceptual level, there is a considerable international variation regarding the range of disorders that are covered by the legal frameworks for mentally disordered offenders. In particular, paraphilia, substance abuse or personality disorders are inconsistently considered as related to a status of non-responsibility in case of an offence. This affects epidemiological or administrative data. Depending on the in- or exclusion of these disorders, the clientele eligible for being placed in a forensic psychiatric service may differ considerably between countries.

3.2.1 Forensic-Psychiatric Assessment

The assessment of the mental state of an accused person is crucial for the subsequent placement and/or treatment. The expertise of professionals responsible for delivering a forensic psychiatric assessment is of utmost significance for all further proceedings, in particular for the court decision. As a consequence, the background of experts, their qualification and professional training require special attention, as does the legally defined role and potential impact of an assessment during, before and after the trial.

As past overviews have shown, the professional background, experience or qualification of the experts, appointment or certification procedures or the formats in which the results have to be reported to the court do differ remarkably, at least across Europe [8] (Table 3.1). To mandatorily appoint more than one expert for a mental state assessment may increase its quality. Sweden has a very flexible approach in this regard, when providing a so-called minor forensic assessment for less severe cases and a major forensic assessment to which a team of psychiatrists, psychologists, social workers and nurses is contributing.

Table 3.1

Legal regulations for the psychiatric assessment of mentally ill offenders across Europe [8]. Salize HJ, Dressing H, editors. Placement and treatment of mentally disordered offenders – legislation and practice in the European Union. Lengerich: Pabst Science Publishers; 2005

The Netherlands: The participation of at least two experts with different professional background is mandatory

Sweden: Four experts contribute to a major forensic assessment: psychiatrist, psychologist, and social worker nurse

aEngland and Wales: Two physicians contribute to the assessment, one has to be a psychiatrist

bSweden: one expert in case of minor forensic assessment, more than two in case of major forensic assessment

It is the basic task of any expert or team conducting a forensic assessment to examine and describe the overall medical condition and the mental state of a suspect or defendant. Often this is extended to additional medico-legal aspects, e.g. the ability to control one’s actions, the issue of insight, potential dangers to the public or the likelihood of recidivism. Although the examination of these aspects goes beyond the basic medical tasks of reaching a diagnosis and recommending appropriate treatment, there are several countries where—at least according to the legal regulations—being trained as a psychiatrist is not mandatory for conducting such an assessment and reporting to the court. Instead, physicians from any medical subdiscipline might be sufficient. In these countries, most often experienced forensic psychiatrists are usually allocated in routine practice, too. However, it is not unlikely that such in-demand experts may not be available when needed. This may pose risks for those being assessed by persons with minor experience in the mental health-care field. Training programmes for forensic psychiatrists differ in intensity and standards internationally—if they are available at all. It is therefore an international challenge to develop standardized curricula for forensic psychiatry training and to harmonize the forensic psychiatric assessments internationally. The implementation of quality assurance or certification procedures may be useful.

3.2.2 Service Provision

The organizational structure of services eligible to treat mentally ill offenders tends to reflect how national laws balance the interests of public safety on the one hand and individual rights and treatment needs of persons concerned on the other. Whether a service is configured primarily for detention purposes or for treatment purposes may significantly affect the daily life and care of patients. Therefore it plays a role to which degree prison or general psychiatric services are officially or informally involved in the placement or treatment of mentally ill offenders.

Some countries, like Germany, have integrated their forensic services tightly into the mental health-care system, whereas other countries have developed separate systems or services for mentally ill offenders that are set apart from general psychiatry. In emphasizing security aspects, some countries may favour centralized high security facilities for detaining and treating forensic patients at selected places in the country, as it is the case, e.g. in Greece or Ireland. Depending on the interaction with other sectors and the legal prerequisites that may open up such opportunities, these models may tend to overlap with high security units of the penal system or be open for difficult to treat or violent patients from general psychiatry, too. Additionally, there are countries with a completely different strategy. Italy has recently closed down the nation’s six traditional forensic hospitals (on average 200 beds each) and replaced them with small-scale community-based residential facilities with 20 beds maximum [10].

As a consequence, before describing the forensic psychiatric capacities for placing and treating mentally ill offenders and calculating indicators such as a nation’s forensic bed rate (number of forensic beds per population), a standardized definition of what qualifies a forensic bed and in which sector (general psychiatry, specialized forensic psychiatry, penal system) these beds may be provided is necessary. As departments of health or justice do not tend to rely on standardized definitions, routine health or juridical reporting data have to be checked in terms of what exactly they are actually counting.

With the growing development of outpatient forensic psychiatric services, it also has to be differentiated between inpatient and outpatient capacities. During a 5-year period from 2005 to 2010, Germany, e.g. has increased its forensic outpatient services from 19 to 77. Every forensic hospital or ward is now equipped with an outpatient treatment unit. This has multiplied the number of mentally ill offenders treated as outpatients from 662 in 2005 to 3.628 in 2010 [11].

3.2.3 Outpatient and Forensic-Psychiatric Aftercare

The availability of forensic psychiatric aftercare could be essential for preventing relapses and for decreasing re-offending. The emphasis on forensic outpatient treatment is rather new compared to the shift towards community-based care in general psychiatry that started decades ago. For a long time, forensic psychiatry has widely been perceived as inpatient care. The continuity of care after discharge and the prevention of re-offending and relapsing was not a main concern. Thus, indicators of forensic psychiatric outpatient or aftercare facilities are essential for assessing the quality of a forensic-psychiatric system and should be included in any study in this field. Research studies on long-term outcomes of forensic psychiatric care are needed in particular.

3.3 Overlap with Prison Sector

An inter-sectoral perspective should not be restricted to psychiatry settings or services alone but include the overlap of the forensic-psychiatric sector with the penal system. As pointed out, the estimation of placement and treatment capacities for mentally ill offenders in the penal system should be mandatory for any data collection that is supposed to describe a forensic psychiatric system.

However, estimating the size of informal prison capacities for forensic-psychiatric cases