Stigma management during reintegration of older incarcerated adults with mental health issues: A qualitative analysis.

INTRODUCTION: The number of older prisoners with mental health issues released from prisons and forensic psychiatric institutions is rising. Their successful integration is important due to its implications for the public's safety and the individual's health and well-being. However, reintegration efforts are hampered due to the double stigma attached to 'mental illness' and 'incarceration history'. To alleviate the burden of such stigma, affected persons and their social networks employ stigma management strategies. This study sought to investigate the stigma management strategies of mental health professionals supporting older incarcerated adults with mental health issues in their reintegration process. METHODS: Semi-structured interviews with 63 mental health professionals from Canada and Switzerland were carried out as part of the overall project. To address the reintegration topic, data from 18 interviews were used. Data analysis followed the thematic analysis approach. RESULTS: Mental health professionals emphasized the double stigmatization of their patients which impaired their quest for housing. Lengthy searches for placement frequently resulted in patients' unnecessary long stays in forensic programs. Nevertheless, participants outlined that they were at times successful in finding appropriate housing for their patients due to the use of certain stigma management strategies. They stated that they, first, established initial contacts with outside institutions, second, educated them about stigmatizing labels and, third, provided ongoing collaboration with public institutions. DISCUSSION: Incarcerated persons with mental health issues face double stigmatization that affects their reentry process. Our findings are interesting as they illustrate ways in which stigma can be reduced, and how the reentry process can be streamlined. Future research should include the perspectives of incarcerated adults with mental health issues to shed more light on the various options that they seek for successful reintegration after imprisonment.

Expert opinions on criminal law cases in Switzerland - an empirical pilot study.

BACKGROUND: Criminal courts of law rely on forensic psychiatric/psychological reports when clarifying legal questions of culpability, dangerousness, and the need for therapeutic measures for offenders. Incorrect decisions owing to a lack of expert report quality and comprehensibility can have serious consequences for potential victims, offenders themselves, or societal use of resources. In this pilot study, we started from the hypothesis that forensic psychiatric/psychological reports meet the minimum requirements for legally admissible expert opinions. METHODS: Within the framework of assessment by the Concordat Expert Commission of Northwestern and Central Switzerland, 58 adult criminal law reports were randomly selected. Two researchers extracted and analyzed standardized data descriptively. For quality assurance, they followed the extended codebook of the Research and Development Department of the Zürich Office of Corrections and Reintegration. RESULTS: Psychopathological findings accounted for only 1% of the reports, which seemed problematic considering that these findings reflect the personality traits of offenders. Furthermore, only 7% of offenders underwent physical examinations, and the reasons for not performing physical examinations were noted in fewer than half of these offenders. Of 26 sexual offenders, only one was physically assessed. Additional imaging or neurophysiological examinations (e.g. electroencephalogram) were conducted in only one offender. Furthermore, published baseline recidivism rates were used in only 37.9% of the reports. CONCLUSIONS: The results of this study suggest that current forensic psychiatric assessment is deficient. The infrequent use of published recidivism rates for risk communication denies prosecutors and judges solid reference values for the actual recidivism probability. Moving away from somatic medicine contradicts the federal court judgment, which disqualifies psychologists from providing a forensic report owing to their lack of expertise in physical examination. The authors recommend the multidisciplinary involvement of forensic psychiatrists and psychologists and, in certain cases, of specialists in somatic medicine to produce accurate and well-founded reports.

Encoding of everyday objects in older adults: Episodic memory assessment in virtual reality.

Introduction: Age-related decline in episodic memory performance in otherwise healthy older adults is indisputably evident. Yet, it has been shown that under certain conditions episodic memory performance in healthy older adults' barely deviates from those seen in young adults. Here we report on the quality of object encoding in an ecologically valid, virtual-reality based memory assessment in a sample of healthy older and younger adults with comparable memory performance. Methods: We analyzed encoding by establishing both a serial and semantic clustering index and an object memory association network. Results: As expected, semantic clustering was superior in older adults without need for additional allocation of executive resources whereas young adults tended more to rely on serial strategies. The association networks suggested a plethora of obvious but also less obvious memory organization principles, some of which indicated converging approaches between the groups as suggested by a subgraph analysis and some of which indicated diverging approaches as suggested by the respective network interconnectivity. A higher interconnectivity was observed in the older adults' association networks. Discussion: We interpreted this as a consequence of superior semantic memory organization (extent to which effective semantic strategies diverged within the group). In conclusion, these results might indicate a diminished need for compensatory cognitive effort in healthy older adults when encoding and recalling everyday objects under ecologically valid conditions. Due to an enhanced and multimodal encoding model, superior crystallized abilities might be sufficient to counteract an age-related decline in various other and specific cognitive domains. This approach might potentially elucidate age-related changes in memory performance in both healthy and pathological aging.

Corrigendum: Impact of legal traditions on forensic mental health treatment worldwide.

[This corrects the article DOI: 10.3389/fpsyt.2022.876619.].

Exploring the mental healthcare needs of Swiss pre-trial detainees: A pilot investigation of an on-site psychiatric day clinic.

Introduction: Research has established that justice-involved individuals experience significant mental health problems. However, mental healthcare in correctional settings is often not sufficiently accessible to meet the demand. Hence, to improve the availability of mental healthcare services, especially for pre-trial detainees, the first Swiss on-site psychiatric day clinic (PDC) was established in 2019. The present cross-sectional observational study aimed to evaluate the need of psychiatric care in pre-trial detention and the PDC's potential to improve it. Methods: File record data were collected from the Office of Corrections and Rehabilitation of the Canton of Zurich. Differences in primary psychiatric care consultations and psychiatric hospital admissions between pre-trial detainees and sentenced prisoners were examined. In addition, a total cohort of pre-trial detainees of the first 18 months of PDC operations was examined to identify differences between three treatment groups: (1) pre-trial detainees exclusively treated in the PDC (n = 41), (2) pre-trial detainees exclusively treated in a psychiatric hospital (n = 58), and (3) pre-trial detainees treated in both the PDC as well as a psychiatric hospital (n = 16). Results: In the 5 years before the PDC opened, pre-trial detainees had significantly more primary psychiatric care consultations and were admitted to psychiatric hospitals on significantly more occasions than were sentenced prisoners. In the first 18 months of the PDC, psychiatric hospital admission rates for pre-trial detainees decreased by 18.5% and pretrial detainees exclusively treated in the PDC differed significantly from other treatment groups concerning mental disorder, gender, and alleged index offense. They were more likely to be diagnosed with adjustment disorders and were less likely to be diagnosed with schizophrenia spectrum disorder. Conclusion: The use of mental health care among pre-trial detainees is significantly more frequent than among sentenced prisoners concerning both primary care and inpatient treatment. Since establishment of the novel on-site PDC admissions to psychiatric hospitals were found to decrease. Data indicates that especially male pre-trial detainees with adjustment disorders benefitted from this innovative path forward in correctional healthcare. Further research is needed to improve the PDC's service for female pre-trial detainees.

Practical Issues of Medical Experts in Assessing Persons With Mental Illness Asking for Assisted Dying in Switzerland.

With about 65,000 deaths per year in Switzerland, about 1,000 assisted suicides of Swiss citizens are carried out with the help of assisted dying organizations per year. Assisted suicide, which is carried out without selfish motives on the side of the helping person, only remains unpunished if there is a free will decision by the person willing to die who has the capacity of judgement and to act independently. While this is usually accepted as an option for somatically terminally ill patients in society at large, this procedure is controversial for psychiatrically ill patients. In Switzerland the topic of assisted dying is highly debated between medical professionals. In 2018, the Swiss Academy of Medical Sciences (SAMS) put revised guidelines into force, which are in discrepancy to the current rules of the Swiss Medical Association (FMH). This article gives an overview of the past and current development of the Code of Professional Conduct and medical-ethical guidelines as well as current Swiss criminal and medical law on this topic. Practical implications for the assessment of assessing persons with mental illness in this circumstances are discussed. It is to be concluded, that persons with a mental illness seem to face extra obstacles in relation with somatically ill persons as the assessment of the prerequisites comprises additional requirements. Among other issues there is an urgent need for the elaboration of contents to be assessed and standards of procedures. The procedures and guidelines to be elaborated should be scientifically accompanied in order to gain a more reliable basis for decision-making. Multidisciplinary assessments would help to avoid biases and blind spots of a mono-disciplinary assessments. In addition, even in the case of mentally ill people, their right to self-determined suicide should not be restricted by excessive hurdles in the assessment process. Lastly, reliable funding should be secured, as it is otherwise to be expected that the complex assessment of prerequisites through multi-professional-teams or just one assessor cannot be sustained. The exercise of fundamental rights must be possible for all persons to the same extent, regardless of their financial resources.

Impact of Legal Traditions on Forensic Mental Health Treatment Worldwide.

Background: Forensic psychiatry is a subspecialty dealing with the diagnosis and treatment of mentally ill offenders. However, forensic treatment standards vary. Differences arise among forensic treatment standards, due to variations in either the legal framework, the general psychiatric treatment standards, or the forensic training standards. Thus, to date there is no evidence-based pattern for how forensic services should be organized and provided. Aims: The aim of this article is to compare forensic services in various countries in order to contribute to the current debate on international forensic treatment standards, by informing about existing differences in available policies. Methods: This scoping review was conducted by reviewing the academic literature regarding forensic treatment around the world. Studies were identified from Pub-Med and Google-Scholar. Keywords for the search included "forensic psychiatry," "mentally ill offenders," "legal framework," "jurisdiction," and the names of geographical regions. Results: Forensic treatment admission varies significantly around the world. There are countries that do not recognize forensic psychiatry as a subspecialty, whereas other countries apply insufficient forensic training. Most countries provide inpatient treatment for mentally ill offenders. However, service organization varies, including where the services are delivered (prisons, high-security hospitals, and general psychiatric departments). Forensic services are mainly centralized, although the need for outpatient care is emerging. Discussion: Differences may originate mainly from variations in the legal tradition. These differences combined with the limited evidence on the effectiveness of the intervention imply the need for the optimization of forensic treatment standards on an international level. Therefore, further follow-up studies are needed.

What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients and mental health care professionals.

BACKGROUND: Therapist-related activities and characteristics such as empathy and genuineness are factors that significantly contribute to psychotherapy outcome. As they play a role in psychotherapy more generally, it can be expected that they are equally important in the treatment of court-mandated patients more specifically. At the same time, these treatment settings come with specific challenges-e.g. due to coercion and control-and it could thus be that some therapist-related characteristics might have a different empathy on the therapy. This interview study sought to investigate service providers' and users' perspectives on therapist-related characteristics in the context of detention. METHODS: We conducted a qualitative interview study with 41 older incarcerated persons mandated to treatment, and 63 mental health professionals (MHP). The data analysis followed thematic analysis. RESULTS: Patients and experts both emphasized the importance of treating patients with respect by taking a humanistic approach, that is, condemn the deeds but embrace the person and display genuine interest in supporting patients with any issue or concern that is of relevance to them. Furthermore, interviewees underscored that the coerciveness of the therapy context required to incorporate patients' wishes into treatment planning, recognize and respond to the patients' needs, and allow some choice within the given framework. Such inclusive attitude was deemed critical to engage and motivate patients to participate in treatment. In addition, it was emphasized that feedback and advice by the therapists need to be concrete, detailed and applied to each person's current situation. Lastly, patients questioned MHP's qualification when they did not progress in therapy. DISCUSSION: Our findings indicate that some therapist-related activities and characteristics are of particular importance in court-mandated settings. These include genuine interest in the patient, a respectful and positive attitude, as well as the capacity to target sensitive issues in a directive but non-confrontational manner. Further research needs to identify specific expressions and behaviors that are linked to the aforementioned characteristics in the forensic context. Our study therefore contributes to much-needed empirical research on clinician and patient perspectives on therapist characteristics and activities in the treatment of court-mandated patients.

Patients' Views With Regard to Personal Recovery in Forensic Psychiatry in German-Speaking Switzerland-An Explorative Study.

Recovery orientation (RO) is a modality of supporting patients to improve self-determination, leading a meaningful life and well-being in general. This approach is widely studied in general psychiatry, but evidence is lacking for forensic inpatient settings in Switzerland. While secure forensic clinics tend to be regarded as total institutions, which are an anathema to RO, a project to implement RO interventions in this setting was financed by the Swiss Federal Office of Justice. This explorative study investigates baseline expectations and views of patients in forensic wards in German-speaking Switzerland in the context of a recovery-oriented intervention. As such wards are non-existent in Latin-speaking Switzerland, the investigation could only be carried out in this language region. Six focus groups with 37 forensic inpatients were conducted. Thematic analysis revealed two major and several subthemes. The major theme "heteronomy" includes the subthemes "stigmatization and shame," "coercion," "lack of support," "mistrust," "waiting," and "structural impediments." The subthemes "learning to live with the disorder and working on oneself," "participation," "connectedness," "confidence," and "joie de vivre" belong to the major theme "regaining self-determination." In this way, results of prior research are extended to forensic peculiarities. Furthermore, the personal views of patients are discussed in detail regarding their possible influence on therapeutic outcomes and personal recovery. These findings should be of help to therapeutic staff in the respective setting to be better informed about, and to counter the effects of, heteronomy and long-term hospitalization. Important in this regard is the concept of procedural justice and the subjective client's perception thereof.

Long-Term Recidivism of Mentally Disordered Offenders Considered "Dangerous to the Public" in Switzerland.

Objectives: The commissions for risk assessment of offenders dangerous to the public were established in 1995 in Switzerland. The main goal was to reduce recidivism of offenders released into the community by means of identifying high-risk offenders and recommending measures for offender management. This study investigates long-term recidivism data of this high-risk cohort of offenders. Methods: Baseline data included risk assessment of one of the commissions, the type of index offense, and psychiatric disorders according to ICD-10 for the total cohort of offenders examined by the commissions between 1995 and 2009. Criminal records were drawn in 2019 for all offenders from the Swiss Federal Office of Justice. Results: From a total of 147 offenders 35 recidivated within a median time at risk of 9.1 years (31.8%), of which 10 (9.1%) recommitted a severe offense. Within the treatment status, sentences (imprisonment and preventive detention) were compared to court-ordered measures (in- or outpatient court ordered treatment, civil court mandated treatment, vocational training facility). There were no significant differences comparing treatment status, different diagnostic groups, type of index offense and other risk factors. Except of age at release (or relapse), which predicted recidivism with younger subjects showing higher recidivism rates (p = 0.014). Conclusion: Our study showed that over a long-term time at risk this high-risk cohort showed a similar recidivism rate as many other studies with different cohorts. With appropriate management recidivism rates in high-risk offenders can be lowered allowing them being consecutively reintegrated into society. The finding that younger subjects have higher recidivism rate was reproduced in this population.

Indirect and Neuropsychological Indicators of Pedophilia.

The present study aimed to differentiate pedophilic child sex offenders (CSOs) from nonoffending controls (CTLs), as well as contact from noncontact CSOs. For this purpose, we investigated 21 contact CSOs, 20 noncontact CSOs (child pornography offenders), as well as 21 CTLs on neuropsychological test measures and indirect test measures of sexual interest. Multiple logistic regression models showed that three parameters of indirect tests and two neuropsychological test parameters allowed the differentiation of CSOs from CTLs with a maximum accuracy of 87%. The profile of contact and noncontact CSOs was remarkably similar and the optimal model for this group differentiation had a maximum accuracy of 66%, with slightly increased levels of risk-taking behavior and greater susceptibility for perceptual interference in contact CSOs than in noncontact CSOs. The findings suggest that standardized, objective methods can support the assessment of sexual offenders against children in forensic psychiatry and legal psychology.

Reducing recidivism using the Reasoning and Rehabilitation program: a pilot multi-site-controlled trial among prisoners in Switzerland.

OBJECTIVES: This study evaluated whether the Reasoning and Rehabilitation (R&R2) program was effective in reducing recidivism, minimizing dropout rates, and improving outcomes related to attitudes, behaviors, and personality among people living in detention. METHODS: Data were collected in eight Swiss German-speaking prisons among males detained for violent offenses using a quasi-experimental controlled design (R&R2: n = 129, treatment as usual [TAU]: n = 84). Measures included recidivism, dropout rate, and self-report questionnaires (hostile attribution bias, aggressiveness, interpersonal problems, and willingness to accept responsibility). Data were analyzed using mixed-effect models. RESULTS: Participants in the R&R2 group were less likely to reoffend in comparison with the TAU group in the intention-to-treat (n = 51, odds ratio = 0.75, p = .060) and the per-protocol (excluding dropouts; n = 38, odds ratio = 0.65, p = .068) analyses. They also had lower self-reported scores of spontaneous and reactive aggressiveness (p = .047 and p = .070) and excitability (p = .086). CONCLUSIONS: The findings of this pilot project were promising, with the R&R2 program leading to reduced recidivism and dropout rate. Even though these results should be considered preliminary, the R&R2 program appeared to be a relevant approach in reducing recidivism after prison.

Psychopathy, Neuroticism, and Abusive Behavior in Low Risk Child Sex Offenders.

Personality traits are considered as an important aspect in the assessment of child sex offenders (CSOs). The current study sought to elucidate the association between neuroticism, psychopathy, and abusive behavior in low risk CSOs. 43 pedophilic CSOs and 21 controls (CTLs) completed the NEO-Personality Inventory-Revised (NEO-PI-R), Psychopathy Checklist: Screening Version (PCL:SV), and Multiphasic Sex Inventory (MSI). Our results revealed small differences in PCL scores between CSOs and CTLs, with comparatively low levels of psychopathy in both groups. Higher levels of neuroticism were associated with higher PCL scores, in both CSOs and CTLs. However, higher PCL scores in CSOs did not correlate with higher MSI total scores on the subscale child molest. These findings suggest an ambiguous role of psychopathy in CSOs: higher levels of psychopathy co-occur with higher levels of neuroticism, but psychopathy does apparently not modulate abusive behavior, at least not in low risk offenders, as currently investigated.

Plasma and serum brain-derived neurotrophic factor (BDNF) levels and their association with neurocognition in at-risk mental state, first episode psychosis and chronic schizophrenia patients.

Objectives: Brain-derived neurotrophic factor (BDNF) is involved in numerous cognitive processes. Since cognitive deficits are a core feature of psychotic disorders, the investigation of BDNF levels in psychosis and their correlation with cognition has received increased attention. However, there are no studies investigating BDNF levels in individuals with an at-risk mental state (ARMS) for psychosis. Hence, the aims of the present study were: (1) assessing peripheral BDNF levels across different (potential) stages of psychosis; (2) investigating their association with cognition.Methods: Plasma and serum BDNF levels and neuropsychological performance were assessed in 16 ARMS, six first-episode psychosis (FEP), and 11 chronic schizophrenia (CS) patients. Neuropsychological assessment covered intelligence, verbal memory, working memory, attention and executive functioning.Results: Both plasma and serum BDNF levels were highest in CS, intermediate in FEP and lowest in ARMS. Multiple regression analysis revealed a significant positive association of plasma BDNF levels with planning ability across all groups.Conclusions: The lower peripheral BDNF levels in ARMS compared to FEP and CS might point towards an important drop of this neurotrophin prior to the onset of frank psychosis. The associations of peripheral BDNF with planning-abilities match previous findings.

Inhibition and attentional control in pedophilic child sexual offenders - An event-related potential study.

OBJECTIVE: Impaired response inhibition might play a role in child sexual offences. Recording of event-related potentials (ERPs) can help to clarify whether child sexual offenders (CSOs) show an altered processing of stop signals and commission errors. METHODS: In the current ERP study, we investigated these processes in a Go/Nogo task on two groups of CSOs, pedophilic contact CSOs and non-contact CSOs (child pornography offenders), as well as on non-offenders as controls. RESULTS: Behaviorally, CSOs showed a slight, but non-significant increase of the false alarm rate to Nogo cues, as compared to controls. The amplitudes of the ERP components N2 and P3 to Nogo cues followed by correctly withhold responses did not vary between CSOs and controls. The analysis of the ERPs to committed errors showed that the Ne amplitudes (reflecting error detection) did not differ between the groups either, whereas the Pe amplitudes (reflecting error evaluation and error awareness) were strongly diminished in CSOs. This diminishment was primarily found in contact CSOs. CONCLUSIONS: The findings suggest that response inhibition, processing of stop signals, and error detection are not necessarily impaired in CSOs. However, CSOs appear to dedicate less cognitive resources to the evaluation of committed errors. SIGNIFICANCE: This selective alteration could reflect a reduced sense of responsibility for misconduct in this offender group, which might contribute to their delinquent behavior.

Neuroticism in child sex offenders and its association with sexual dysfunctions, cognitive distortions, and psychological complaints.

Studies in child sex offenders (CSO) often report deviant personality characteristics. In our study, we investigated neuroticism in CSO and tested the hypothesis that CSO with high neuroticism show more serious abuse behavior and are more likely to exhibit sexual dysfunction and cognitive distortions, as compared to CSO with low neuroticism. A sample of 40 CSO (both child sexual abusers and child sexual material users) was split into two subsamples based on their neuroticism scores, obtained by the NEO-Personality Inventory-Revised (NEO-PI-R) questionnaire. Subsequently, we compared their scores in the Multiphasic Sex Inventory (MSI) questionnaire and Symptom Checklist-90-Revised (SCL-90-R). Our results show that CSO exhibited higher levels of neuroticism than controls, but were still in the normal range. In CSO, neuroticism was associated with sexual dysfunction and cognitive distortions, rather than with more severe abuse behavior. Moreover, neuroticism in this group was linked to a broad range of psychological problems and psychopathological symptoms, such as somatization or anxiety. Our findings suggest that neuroticism even below the level of personality disorder is associated with a broader range of psychological problems in CSO, which should be addressed in therapy.

Neuroticism as a risk factor for child abuse in victims of childhood sexual abuse.

Findings on the relationship of experienced sexual abuse and abuse behavior in adulthood are ambiguous. However, associations between experienced abuse and neuroticism as well as between neuroticism and active child abuse have been reported repeatedly. In our study, we compared pedosexual child abusers with consumers of internet child pornography and control subjects with adult-sexual preference with regard to traumatic childhood experience (Childhood Trauma Questionnaire, CTQ), personality traits (NEO - Personality Inventory - Revised, NEO-PI-R), and sexual abnormalities (Multiphasic Sex Inventory, MSI). In an initial analysis, sexual abuse experienced in childhood was not directly linked to sexual abuse behavior in adulthood. However, this relationship was mediated by neuroticism. In a second step, the CTQ scales were conflated and, using a structural equation model, direct links between the overall level of abuse experienced in childhood (generally high CTQ levels) and sexual abuse behavior in adulthood revealed again the mediation by neurotic personality. We conclude that the overall level of abuse experienced in childhood in general, and less sexual abuse experience in particular, modulates the tendency for child sexual abuse behavior in adulthood. Data suggest that, depending on the resilience of an individual, abuse experience during childhood increases the likelihood of developing neurotic personality traits in later life, which are in turn considered to increase the risk of child sexual abuse in child sex offenders.

Increased superior frontal gyrus activation during working memory processing in psychosis: Significant relation to cumulative antipsychotic medication and to negative symptoms.

OBJECTIVES: Impairment in working memory (WM) is a core symptom in schizophrenia. However, little is known about how clinical features influence functional brain activity specific to WM processing during the development of first-episode psychosis (FEP) to schizophrenia (SZ). We compared functional WM-specific brain activity in FEP and SZ patients, including the effects of the duration of illness, psychopathological factors and antipsychotic medication. METHODS: Cross-sectional study of male FEP (n=22) and SZ (n=20) patients performing an n-back task when undergoing functional magnetic resonance imaging (fMRI). Clinical features were collected by semi-structured interviews and medical records. RESULTS: The SZ group performed significantly worse than the FEP group in the 2-back condition. The SZ group also showed significantly higher activation in the left superior frontal gyrus in the 2-back versus 0-back condition (2-back>0-back). This frontal activation correlated positively with negative symptoms and with cumulative antipsychotic medication during the year before the fMRI examination. There were no significant correlations between activation and duration of illness. CONCLUSION: There was greater frontal neural activation in SZ than in FEP. This indicated differences in WM processing, and was significantly related to cumulative antipsychotic exposure and negative symptoms, but not to the duration of illness.