Just Like a Woman: Gender Role Stereotypes in Forensic Psychiatry.

The relationship between violence, gender and mental health is a complex one which is yet to be fully understood. Gender role stereotypes are social constructs that can powerfully influence and regulate human behaviour, including violence; and so it is likely that they also influence the nexus of violence management and mental health which is at the core of forensic psychiatry. In this article, we examine how gender role stereotypes might influence the practice of forensic psychiatry: specifically, in relation to women as violent offenders, as patients in secure psychiatric care and as clinicians working in forensic settings. We identify areas of development in women's forensic mental health services, and examine whether patriarchal influences and gender role stereotypes may have inadvertently impacted upon these changes. We also consider whether these changes may maintain pre-existing barriers to treatment for both men and women.

COVID-19 Vaccination in those with mental health difficulties: A guide to assist decision-making in England, Scotland, and Wales.

There is currently no specific guidance addressing vaccine hesitancy in those with mental health difficulties in the United Kingdom. This is particularly problematic when one considers that individuals with serious mental illnesses are at greater risk of infection and have poorer health outcomes for a range of reasons. There are also many individual and system level barriers to vaccination in this group. When an affected adult lacks the capacity to make a decision for themselves, it often falls to healthcare professionals to make a decision on that person's behalf and in their best interests. This article explores this matter with regard to the law in practice in the English and Welsh, and Scottish, jurisdictions and consider this with relevance to the safest approach that doctors and other healthcare professionals should take in working with patients for whom mental disorder may impact on decision-making capacity. The article focuses on psychiatric inpatients, including those who are detained involuntarily, to consider whether, and in what circumstances, COVID-19 vaccination should be given to individuals who cannot or do not consent.

Impact of homicide by a psychiatric patient on forensic psychiatrists: national survey.

AIMS AND METHOD: To explore the experiences and support needs of consultant forensic psychiatrists, whose patients had committed homicide while under their care. We circulated a survey to all forensic psychiatrists in the UK, through the Royal College of Psychiatrists, asking about their experiences of a homicide by a patient under their care. Respondents were invited to discuss their experiences further in a structured telephone interview and themes were identified from these discussions. Data were analysed quantitatively and qualitatively. RESULTS: One-third of the 86 respondents had had at least one patient who had committed a homicide while under their care. Of these, over three-quarters (78%) reported that the homicide had a significant impact on their personal life, professional life and/or mental/physical health. For some respondents, the impact was severe and long term. Respondents generally felt that they would have been helped by receiving more support in the aftermath of the homicide. CLINICAL IMPLICATIONS: Greater recognition is needed of the impact on treating psychiatrists of homicide by a patient and more support is needed for affected clinicians. Further research is necessary, including the effects of such events on colleagues in other specialties and examination of the costs versus the benefits of mandatory inquiries after homicides.

Montgomery and shared decision-making: implications for good psychiatric practice.

The 2015 Supreme Court judgment in Montgomery v Lanarkshire Health Board [2015] UKSC 11 established that consent to medical treatment requires shared decision-making based on dialogue between the clinician and patient. In this editorial, we examine what Montgomery means for standards of good psychiatric practice, and argue that it represents an opportunity for delivering best practice in psychiatric care.Declaration of interestNone.

Security of mind: 20 years of attachment theory and its relevance to psychiatry.

In this editorial, I suggest that no psychiatrist should be without a working knowledge of attachment theory, and it is a capability that all trainees should cover in the proposed new curriculum. I have focused on three domains of research to argue that attachment theory is relevant to practicing psychiatrists.Declaration of interestNone.

Motherhood and Apple Pie: A UK Perspective on Mothers Who Misuse Drugs.

In this commentary, I explore two questions raised by Angelotta and Appelbaum's study. First, I offer an English legal perspective on the protection of children from their mothers, looking at both civil (family) and criminal law. Second, I discuss the idealization of motherhood that is implied by the prosecution of pregnant women; the denigration of those who fail this ideal; and the way that idealization and denigration contribute to injustice for women. I conclude by offering comments on the implications for those assessing women accused of harming their unborn child.

Everything moves on: referral trends to a leavers' group in a high secure hospital and trial leave progress of group graduates.

BACKGROUND: Moving on from high secure psychiatric care can be a complex and potentially stressful experience, which may hinder progression. A leavers' group in a UK high secure hospital is offered to support patients with this transition. AIMS: The aims of this study are to investigate characteristics of patients referred for the leavers' group and compare outcomes for leavers' group graduates with those for patients who never attended a leavers' group for any reason. METHODS: A retrospective quasi-experimental design was applied to data extracted from various records sources - within and outside the high security hospital. RESULTS: About one-fifth of patients who left the hospital on trial leave during the study were referred to the leavers' group (N = 109). Referred patients were significantly more likely to have either been admitted from another high-security hospital or transferred from prison for treatment and have a diagnosis of paranoid schizophrenia. Patients not referred had a significantly higher rate of previously refusing to participate in groups. There was a tendency for rate of return from trial leave for group graduates to be lower than that of patients who did not attend the leavers' group, but this just failed to reach statistical significance (rate ratio [RR] = 1.04; CI 0.97-1.11). CONCLUSIONS: A leavers' group appeared to be a valued therapy option for people who had spent a long time in high secure psychiatric care, or those who continued to require hospital treatment beyond prison tariffs. There was a low return rate from trial leave, which made the evaluation of this outcome difficult. A detailed study into both the reasons for return from trial leave and successes would provide further information on ideal preparation for moving on. Copyright © 2016 John Wiley & Sons, Ltd.

Commentary: Stories and histories in forensic psychiatry.

In this commentary, I reflect on the narratives of offending that are generated in the courtroom and those that are generated in the therapeutic space between an offender patient and his or her therapist. I discuss the similarities and differences between these different stories and explore the role of the psychiatrist in both cases.

Violence risk assessment as a medical intervention: ethical tensions.

Risk assessment differs from other medical interventions in that the welfare of the patient is not the immediate object of the intervention. However, improving the risk assessment process may reduce the chance of risk assessment itself being unjust. We explore the ethical arguments in relation to risk assessment as a medical intervention, drawing analogies, where applicable, with ethical arguments raised by general medical investigations. The article concludes by supporting the structured professional judgement approach as a method of risk assessment that is most consistent with the respect for principles of medical ethics. Recommendations are made for the future direction of risk assessment indicated by ethical theory.

Locks, keys, and security of mind: psychodynamic approaches to forensic psychiatry.

In this article, we discuss psychological approaches to the understanding of acts of violence and, specifically, psychodynamic approaches to both formulation and treatment. We suggest that the key theoretical paradigm of a psychodynamic approach involves the exploration and elaboration of the meaning of a violent act for the offender and describe the relevance of this approach for both legal assessments and clinical services in secure residential care. We argue that a psychodynamic approach can improve the quality of assessments of both psychopathology and risk and inform effective therapeutic interventions in hard-to-treat patients.

Commentary: Thereby hangs a tale--the creation of tragic narratives in forensic psychiatry.

In my commentary, I suggest that the criminal court is a place where justice examines tragedy, as described by Aristotle in his Poetics. I suggest that there are strong parallels with Aristotle's account of tragic narratives and the concepts of representation and performance of forensic expert testimony, as described by Griffith and Baranoski-especially in relation to the creation of voice. On this account, the forensic expert's psychiatric court report acts as a tragic narrative that makes defendants come alive as people. Such performance is crucial for the criminal justice process, where there are competing accounts of the truth, and the expert narrative can articulate the voice of different parties. However, there are other legal fora where the role of the forensic psychiatric voice may be less clear. I close by suggesting that we continue to need rich and subtle exploration of these topics, as exemplified by the work of Griffith and Baranoski.

Becoming a caregiver: attachment theory and poorly performing doctors.

CONTEXT: In this paper, I review a theoretical paradigm (attachment theory) which facilitates an understanding of how human care-giving and care-eliciting behaviours develop and are maintained over the lifespan. I argue that this paradigm has particular utility in: (i) the training of doctors; (ii) understanding why some doctors and medical students experience high levels of stress, and (iii) developing interventions to help those who struggle to manage high levels of work-related stress. METHODS: I carried out a review of key texts and previously published studies of attachment styles in caregivers. RESULTS: Large-scale epidemiological studies, using valid and reliable measures, show that insecure attachment styles are found in a proportion of normal populations of both males and females. Insecure attachment is associated with impaired stress management and subtle deficits in care-giving sensitivity. It is reasonable to assume that a proportion of students entering medical training and doctors with performance problems may have insecure attachment styles which influence how they approach their training experience and how they manage occupational stress. CONCLUSIONS: Attachment theory is a useful paradigm for thinking about training as a professional caregiver. Insecure early attachment experiences may be a risk factor for poor stress management in some medical students and doctors who are exposed to increasing demands as carers. These findings lead to suggestions for possible research and support interventions.