Association Between Adverse Childhood Experiences and a Combination of Psychosis and Violence Among Adults: A Systematic Review and Meta-Analysis.

Relationships have been well established between adverse childhood experiences (ACEs) and later psychosis (29 systematic reviews) or violence (4 systematic reviews). To date, just one review has explored childhood maltreatment, specifically, and violence risk with psychosis. We conducted a systematic review and meta-analyses of a wider range of ACEs and later psychosis with actual violence compared with psychosis alone, violence alone or neither, completing searches in January 2021. In all, 15 studies met inclusion criteria, but only six included all four groups of interest. Two substantial studies recorded ACEs from sources independent of those affected and probably before emergent psychosis or violence; others relied on retrospective recall. Meta-analyses were possible only for within-psychosis-group comparisons; histories of physical abuse, sexual abuse, and having a criminal/violent parent or living with family alcohol/drug use were each associated with around twice the odds of psychosis with violence as psychosis alone. Although ACE measures in the four-way comparisons were too divergent for firm conclusions, abuse histories, and parental criminality emerged as likely antecedents, one study evidencing psychosis as mediating between ACEs and violence. Without longitudinal prospective study, pathways between ACEs and later problems remain unclear. Our findings add weight to the case for exploring ACEs in addition to abuse as possible indicators of later violence among people with psychosis and for trauma-informed interventions, which is important because some people are reluctant to disclose abuse histories.

The all-Wales forensic adolescent consultation and treatment service (FACTS): A 5-year referral cohort study.

BACKGROUND: FACTS is a Wales-wide mental health service for 10-17-year-olds with needs beyond the remit of mainstream child and adolescent mental health services (CAMHS). As a purely consultation-liaison service, it differs from other UK services in the field. AIMS: To describe a complete cohort of referrals to FACTS 2013-2017 with service exit by June 2018. METHODS: Clinical, social and offending data were extracted from FACTS records. RESULTS: 80 young people completed a FACTS episode, averaging nearly a year (309 days; range 13-859 days). Mostly boys (65, 81%) of mean age 15.4 years (range 9-18), two-thirds (n = 53) had three or more referral reasons, one invariably being threatened/actual harm to others; only half were criminal-justice involved. Half (41, 51%) were committing sexually harmful acts. Half were self-harming (41, 51%). All but seven had had at least one adverse childhood experience (ACE), nearly half (35, 44%) four or more. Nevertheless, post-traumatic stress disorder (PTSD) was rarely diagnosed (7, 9%); just over one-quarter (23, 29%) had no diagnosis at all. Correspondence analyses endorsed two distinct Attention deficit hyperactivity disorder groups, distinguished by presence/absence of evidenced brain damage or dysfunction. Suicide-related behaviours clustered with the other diagnoses, flashbacks and psychotic symptoms with no diagnosis. Change in home circumstances during a FACTS episode was slight. CONCLUSIONS: The complexity of presenting problems and service involvement evidences need for FACTS. The extent of persistently harmful sexual behaviours is a novel finding, suggesting need for more expert input for this at other service levels. Rarity of PTSD diagnoses was surprising given the extent of ACEs. This raises concerns that services focus on disorder signs rather than the child's inner life. Given the extent of problems, minimal change may be a positive outcome - especially when remaining in the community. Further development of this service should include explicit case-by-case goals and indicative outcome markers.

The Relationship Between the Big Five Personality Factors, Anger-hostility, and Alcohol and Violence in Men and Women: A Nationally Representative Cohort of 15,701 Young Adults.

Alcohol consumption is known to have a disinhibiting effect and is associated with a higher likelihood of aggressive behavior, especially among men. People with certain personality traits maybe more likely to behave aggressively when intoxicated, and there may also be variation by gender. We aimed to investigate whether the reason why men and women with certain personality traits are more likely to engage in violence may be because of their alcohol use.The Big Five personality traits and anger-hostility, alcohol consumption, and violence were measured by questionnaire in 15,701 nationally representative participants in the United States. We tested the extent to which alcohol mediates the relationship between personality factors and violence in men and women.We found that agreeableness was inversely associated with violence in both genders. Alcohol mediated approximately 11% of the effect in males, but there was no evidence of an effect in females. Anger-hostility was associated with violence in both sexes, but alcohol mediated the effect only in males. We also found that Extraversion was associated with violence and alcohol use in males and females. Alcohol accounted for 15% of the effect of extraversion on violence in males and 29% in females.The mechanism by which personality traits relate to violence may be different in men and women. Agreeableness and anger-hostility underpin the relationship between alcohol and violence in men, but not in women. Reducing alcohol consumption in men with disagreeable and angry/hostile traits would have a small but significant effect in reducing violence, whereas in women, reducing alcohol consumption among the extraverted, would have a greater effect.

Benefits and risks of conjugal visits in prison: A systematic literature review.

BACKGROUND: Imprisonment impacts on lives beyond the prisoner's. In particular, family and intimate relationships are affected. Only some countries permit private conjugal visits in prison between a prisoner and community living partner. AIMS: Our aim was to find evidence from published international literature on the safety, benefits or harms of such visits. METHODS: A systematic literature review was conducted using broad search terms, including words like 'private' and 'family', to maximise search sensitivity but strict criteria for inclusion - of visits unobserved by prison staff and away from other prisoners. All included papers were quality assessed. Two of us independently extracted data from included papers, according to a prepared checklist. Meta-analysis was considered. RESULTS: Seventeen papers were identified from 12 independent studies, all but three of them from North America. The only study of health benefits found a positive association with maintaining sexual relationships. The three before-and-after study of partnership qualities suggested benefit, but conjugal visiting was within a wider family-support programme. Studies with in-prison behaviour as a possible outcome suggest small, if any, association, although one US-wide study found significantly fewer in-prison sexual assaults in states allowing conjugal visiting than those not. Other studies were of prisoner, staff or partner attitudes. There is little evidence of adverse effects, although two qualitative studies raise concerns about the visiting partner's sense of institutionalisation or coercion. CONCLUSIONS: The balance of evidence about conjugal visiting is positive, but there is little of it. As stable family relationships have, elsewhere, been associated with desistance from crime, the contribution of conjugal visiting to these should be better researched.

Sentencing offenders with mental disorders, developmental disorders or neurological impairments: what does the new Sentencing Council Guideline mean for psychiatrists?

The new Sentencing Council Guideline on sentencing offenders with mental disorders, effective from 1 October 2020, is essential reading for all psychiatrists who give evidence in the criminal courts, revealing something of required judicial thinking, our common ground on public safety concerns but differences in focus on culpability and punishment.

Change in the Relationship Between Drinking Alcohol and Risk of Violence Among Adolescents and Young Adults: A Nationally Representative Longitudinal Study.

AIMS: To quantify the relationship between alcohol and violence with increasing age. METHODS: Data were from The National Longitudinal Study of Adolescent to Adult Health (ADD Health) of 20,386 people representative of the US population. Mean age at the first wave of interviews was 16.2 years, with subsequent interviews mean of 1, 6.3 and 12.9 years later. We used random-effects models and predictive marginal effects of the association between varying quantities of alcohol consumption and violence while controlling for possible confounders. RESULTS: Violence was reported by 19.1% of participants at wave I but just 2.1% at wave IV. The random-effects model showed that consuming 1-4 drinks on each occasion was associated with a modest increase in risk of violence in both males (odds ratio (OR) 1.36, 95% CI 1.13-1.63) and females (OR 1.33, 95% CI 1.03-1.72). For consumption of five or more drinks on each occasion, the risk remained similar for females (OR 1.40 (0.99-1.97)) but increased considerably for males (OR 2.41 (1.96-2.95)). Predictive marginal effects models confirmed that violence rates decreased with age. CONCLUSIONS: Alcohol is most strongly linked to violence among adolescents, so programmes for primary prevention of alcohol-related violence are best targeted towards this age group, particularly males who engage in heavy episodic drinking.

Adjustment to short-term imprisonment under low prison staffing.

AIMS AND METHOD: To understand experience of early imprisonment in one prison under low staffing levels. A researcher, independent of the prison, interviewed each prisoner soon after reception and 3-4 weeks later. The first question of the second interview was: 'I'd like to start by asking you about your experience of the last 3-4 weeks in prison'. Data are verbatim answers to this. Narratives were brief, so responses from all 130 participants were analysed, using grounded theory methods. RESULTS: The core experience was of 'routine' - characterised by repetitive acts of daily living and basic work, and little reference to life outside prison - generally resolved passively, towards boredom and 'entrapment'. CLINICAL IMPLICATIONS: This 'routine' seems akin to the 'institutionalism' described in the end days of the 1960s' mental hospitals. In an earlier study of similar men at a similar stage of imprisonment, under higher staff:prisoner ratios, experience was initially more distressing, but resolved actively and positively, suggesting that staff loss may have affected rehabilitative climate.

A randomized controlled trial of a Group psychological intervention to increase locus of control for alcohol consumption among Alcohol-Misusing Short-term (male) Prisoners (GASP).

BACKGROUND AND AIM: Reducing alcohol misuse by male prisoners is an important global issue. Control of drinking behaviour could be a useful target for intervention in this population, and locus of control could be a causal factor in this. We aimed to assess the effect of a clinical psychologist-facilitated group intervention on male prisoners' locus of control of drinking behaviour. DESIGN: A two-arm, single-site, open, randomized controlled trial. SETTING: A category B local training prison in South Wales, housing about 770 mainly sentenced men. PARTICIPANTS: Prisoners serving less than 2 years who met inclusion criteria for pre-imprisonment alcohol misuse, alone or with drug misuse. A total of 119 were allocated to the intervention arm and 119 to the control arm; 104 and 87, respectively, completed the post-randomization baseline interview and 68 and 60 completed a second interview approximately 4 weeks later, respectively, after intervention or treatment as usual (TAU) alone. INTERVENTION: Nine clinical psychologist-facilitated groups in the prison over 3 weeks. Range of participants per session was one to seven, with three to five most usual. MEASURES: The primary outcome was locus of control of behaviour (LCB); secondary outcomes included mental state generally (comprehensive psychiatric rating scale/CPRS) and specifically (Beck Depression Inventory/BDI). An integral process evaluation was conducted. FINDINGS: LCB scores decreased during the study, but without significant intervention effect [-1.7, 95% confidence interval (CI) = -5.1 to 1.6, P = 0.329]. Change among completers in the control group was from a mean score of 37.4 [standard deviation (SD) = 10.0] to 33.7[SD = 11.7] and in the intervention group from 37.4 (SD = 11.6) to 31.9 (SD = 11.8). Secondary outcomes, including change in mental state, did not differ between arms, but 686 (64%) sessions were lost, most because of 'prison issues'. CONCLUSIONS: A clinical psychologist-facilitated group intervention did not have a statistically significant effect on sense of control of drinking behaviour among men with pre-imprisonment alcohol misuse serving less than 2 years in a South Wales prison. The study proved coterminous, however, with 40% prison staff cuts which seem likely to have contributed to the high loss of group sessions and possibly overwhelmed any treatment effect. Intervention completion failures, previously cited as harmful, had no effect here, so the trial should be repeated when the prison climate improves.

Remorse in psychotic violent offenders: An overvalued idea?

Expressing remorse - or not - appears to influence criminal justice outcomes, but preliminary exploration of both judicial and psychological concepts suggests they lack clarity. We asked the following questions: does psychosis impair capacity for, or expression of, remorse for a homicide or other serious harm to others? Is failure to express remorse for an offence associated with recidivism? We conducted systematic reviews of empirical literature on remorse for serious violence while psychotic, and on relationships between remorse and reoffending regardless of mental state. No articles on remorse for homicide or other serious violence while psychotic were identified. There is weak evidence that lack of remorse is associated with reoffending generally, but nothing specific to psychosis. The literature is strong enough to support a case for research into valid measurement of remorse for offending, associations of such measures with recidivism, and whether a change in remorse can be effected - or matters. It is not strong enough to support reliance on perceptions of the presence or absence of remorse as a basis for judicial decisions.

Advancing community safety through forensic mental health research / Mejorando la seguridad comunitaria mediante la investigación en salud mental forense

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Serving a community sentence with a mental health treatment requirement: Offenders' perspectives.

BACKGROUND: Safe alternatives to custody for offenders with mental disorder are vital, not least as self-harm, and violence rates are rising among them in prisons. In England and Wales, the Criminal Justice Act 2003 allows a mental health treatment requirement (MHTR) to supplement a community or suspended prison sentence, but this combination is poorly understood and rarely sought. AIM: To explore offenders' perspectives on the MHTR. METHODS: We interviewed all 25 consenting offenders under an MHTR in two probation areas. Verbatim transcripts of their audio-taped narratives were analysed using grounded theory methods. RESULTS: Their core concern was "instability," characterised by many health and social difficulties and resolved by achieving stability, which included not reoffending as well as becoming healthy, substance free, and "having a life." Most considered that the MHTR helped their motivation and service provision, but some cited poor supervisor accessibility, supervisor role confusion, and sense of stigma under the order as stressful and threatening good outcomes. CONCLUSIONS: This first account of offenders' perspectives on the MHTR suggests a model in which, under it, offenders see themselves making progress as courts require. They understand the risk of return to court and imprisonment if in breach. This model of understanding how MHTRs work could provide for professional guidance and evaluation of their effectiveness.

Psychosis and homicide.

PURPOSE OF REVIEW: The contribution of people with psychosis to homicide statistics is small, but there is a statistically significantly higher rate of homicide among them than in the general population. Legal authorities and the wider public call for more information. Our aim was a narrative synthesis of empirical literature generated by systematic searches for the five complete years 2013-2017. RECENT FINDINGS: One article showed that people with psychosis are five times more likely to be homicide victims than those without, but focus remains on perpetrators. Consensus is that although psychotic symptoms contribute to homicidal acts, so do many of the variables that increase homicide risk more generally - including substance use, trauma histories and access to weapons; thus, both the epidemiology of homicide and some details, like method, may be country specific. In 2013-2017, variation in service provision as a risk factor for homicide has emerged more clearly but, overall, research made few homicide-specific advances. SUMMARY: Criminal homicide is, fortunately, uncommon in most countries. Homicides by people with psychosis are so rare that they do not rate mention in the 2013 United Nations Global Survey of Homicide. This may account for the limitations to much research for this group. Despite some homicide-specific evidence of advantage for early intervention for psychosis, impact of improving treatment - the most promising way forward - will generally have to be inferred from the not entirely satisfactory surrogate of effects of treatment on violent offending more generally.