The Use of Crime Scene and Demographic Information in the Identification of Non-Serial Sexual Homicide.

As with other sexual offenders, sexual homicide perpetrators can be reluctant to talk about their criminal behavior. Therefore, in homicide cases, forensic practitioners frequently rely on crime scene information to identify any sexual behavior associated with the offense. This study aims to identify objective and readily available crime scene information, alongside information about victims and perpetrators, based on 65 cases from England and Wales in the United Kingdom of men convicted of homicide who had committed a non-serial sexual homicide and 64 cases of men convicted of homicide where the available evidence indicated that it was a non-serial non-sexual homicide. Chi-square tests and logistic regression were used to analyze the data. There were few differences in terms of demographic information and criminal histories between the two perpetrator groups. There were crime scene indicators supporting the use of Ressler et al.'s definition of sexual homicide. The victims of sexual homicide were generally found in their home with the lower half of the body exposed and with evidence of vaginal sex. Furthermore, extreme injuries and strangulation were more frequent in sexual homicides. Use of weapon was associated with a non-sexual homicide. Victims of sexual homicide were as likely to know the perpetrator as not. Potential benefits of the characteristics reported to investigators and forensic practitioners tasked with identifying sexual homicides are discussed and areas for further research suggested.

Treatment progress in medium security hospital settings for women: changes in symptoms, personality and service need from admission to discharge.

BACKGROUND: Service evaluations of medium secure hospital facilities for women are underrepresented in the extant literature. HYPOTHESIS: That positive changes in symptoms, personality traits and service need would be evident between admission and discharge among women in a medium security hospital service. METHODS: A pre-test/post-test design was used, with comparisons made between admission and pre-discharge points on a variety of measures of psychiatric symptoms and personality traits. RESULTS: There were significant improvements in mood according to Beck Depression Inventory scores, mood and other symptoms of mental disorder and distress as measured by the Brief Psychiatric Rating Scale and the Modified Post Traumatic Stress Disorder Symptom Scale, personality traits recorded using the Millon Clinical Multiaxial Inventory III and service need as measured by the Camberwell Assessment of Need, Forensic Version. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Significant positive change during treatment, in all clinical areas, is encouraging given poor outcomes for women reported in other research. Findings cannot, however, be unequivocally attributed to the treatments given. Further work is needed to improve early engagement and tailor treatment more specifically to the needs of a heterogeneous population.

Developing an assessment of fire-setting to guide treatment in secure settings: the St Andrew's Fire and Arson Risk Instrument (SAFARI).

BACKGROUND: Arson and fire-setting are highly prevalent among patients in secure psychiatric settings but there is an absence of valid and reliable assessment instruments and no evidence of a significant approach to intervention. AIMS: To develop a semi-structured interview assessment specifically for fire-setting to augment structured assessments of risk and need. METHOD: The extant literature was used to frame interview questions relating to the antecedents, behaviour and consequences necessary to formulate a functional analysis. Questions also covered readiness to change, fire-setting self-efficacy, the probability of future fire-setting, barriers to change, and understanding of fire-setting behaviour. The assessment concludes with indications for assessment and a treatment action plan. The inventory was piloted with a sample of women in secure care and was assessed for comprehensibility, reliability and validity. RESULTS: Staff rated the St Andrews Fire and Risk Instrument (SAFARI) as acceptable to patients and easy to administer. SAFARI was found to be comprehensible by over 95% of the general population, to have good acceptance, high internal reliability, substantial test-retest reliability and validity. CONCLUSIONS: SAFARI helps to provide a clear explanation of fire-setting in terms of the complex interplay of antecedents and consequences and facilitates the design of an individually tailored treatment programme in sympathy with a cognitive-behavioural approach. Further studies are needed to verify the reliability and validity of SAFARI with male populations and across settings.

The influence of admission characteristics on outcome: evidence from a medium secure forensic cohort.

OBJECTIVE: Outcomes for any mental health service will vary with the characteristics of those admitted as well as with the clinical provision of the service itself. This study aims to explore, for a medium secure forensic service in England, temporal changes in (1) characteristics of those admitted and (2) outcome after discharge and (3) to examine whether such changes are related. METHOD: Baseline characteristics and reconviction outcomes were derived from multiple data sources for 550 first admissions to a medium secure forensic unit for a 20-year period. Time to reconviction was examined using Kaplan-Meier analysis and Cox regression. RESULTS: Over time, severity of admissions increased, as did discharges to prison; discharges to non-secure hospitals reduced. Risk of reconviction increased by 3.9%-4.2% for each year of admission from 1983, which was explained by the increased admission of higher-risk patients. CONCLUSION: This medium secure service admitted patients with increasing levels of risk; reoffending rates reflect admission characteristics. Service funding decisions should take account of the characteristics of those admitted. SIGNIFICANT OUTCOMES: This study indicates that the profile of patients admitted over a 20-year period increased in severity. Over time, reconviction after discharge occurred earlier after release. This increase in reconviction was explained by the type of patient admitted. LIMITATIONS: Examination of a cohort from a single medium secure unit limits the generalizability of the findings. The study focuses on a criminological outcome measure (i.e. reconviction); other domains may be equally relevant (e.g. the relief of psychological distress). Examining an entire series of admissions introduces heterogeneity by, for example, considering the outcome of men and women together.

Patients with a history of arson admitted to medium security: characteristics on admission and follow-up postdischarge.

Patients who set fires are a perennial cause of concern with psychiatric services although perhaps rather neglected in the clinical research literature. The current study considered the characteristics on admission of 129 patients, 93 men and 36 women, with a known history of arson who had been admitted to a medium secure psychiatric hospital. The distinguishing characteristics of the sample were high numbers of patients with extensive criminal histories, most probably due to high levels of prison transfer and a higher occurrence of mental illness than psychopathic disorder. Aside from return to prison, most patients were discharged either to another psychiatric hospital or directly to the community. There was a high rate of re-conviction after discharge, mainly for minor offences, with about one in 10 of discharged patients committing arson. It was established, however, that not all incidents of arson led to a prosecution. It is concluded that there are weaknesses in the areas of both risk assessment and evidence-based treatment for arsonists.

Engagement in psychosocial treatment: its relationship to outcome and care pathway progress for women in medium-secure settings.

BACKGROUND: Engaging patients in treatment in secure settings is a major challenge. Engagement is associated with a shorter length of stay, whereas treatment non-completion is associated with an increased risk of recidivism. AIMS: The aims of this study were to assess differences between high and low treatment attendees in a women's medium secure unit and to compare progress over the course of their stay. METHODS: Sixty consecutive admissions to a women's medium secure unit were classified into high and low treatment attendee groups. The two groups were compared in terms of risk behaviours and psychometric measures of symptomatology, impulsivity and personality. RESULTS: High treatment attendees had a shortened length of stay, showed less disturbed behaviour and made more progress in terms of a reduction in symptoms overall and traumatic stress symptoms specifically. Low treatment attendees were more likely to have a diagnosis of schizophrenia/schizotypal illness than personality disorder, less likely to be impulsive and more likely to have scores indicative of severe disorder on the personality subscales of the Millon Clinical Multiaxial Inventory-III. CONCLUSION: Attendance at groups in this medium security unit had clear advantages for patients and potential cost savings for services and the community, but we found a subgroup of women who found it difficult to attend. Given the small sample size, we advocate replication, but our findings suggest the following: Implications for practice development of motivational interventions to help patients make a therapeutic alliance more accurate assessment of treatment readiness, to avoid mistimed interventions that are counterproductive more effective deployment of milieu therapeutic approaches to stabilise behaviour at an early stage of hospitalisation abandonment of a 'one size fits all' approach to groups for mixed patient populations. More 'customised' approaches would allow more appropriate 'pacing' of treatment and adaptations of interventions according to need during the treatment course.

The effect on reconviction of an intervention for drink-driving offenders in the community.

This study reports an evaluation of the Drink-Impaired Drivers program in the English and Welsh probation service. Participants were adult male offenders who had been convicted of a drink-driving offence and were serving community sentences. The 1-year drink-drive reconviction rates were compared for offenders who completed the program, offenders who started but did not complete the program, and a comparison group who were not allocated to the program. At 1-year follow-up, there was no reconviction among offenders who had completed the program. Multivariate analysis showed that the noncompleters had a significantly higher rate of reconviction than the completers and comparison group.

Methodological considerations in the evaluation of offender interventions: the problem of attrition.

Attrition from offender interventions presents methodological problems when the effectiveness of the intervention is under evaluation. This article proposes a treatment-received (TR) design, which incorporates one-to-one matching on criminogenic variables. This design permits the comparison of completer, noncompleter, and nonstarter groups with their paired comparisons and, hence, allows a more accurate evaluation of program completion and noncompletion effects. A sample of 173 offenders, referred to one of two general offending behavior cognitive skills programs within community settings, was matched one-to-one by criminogenic variables to offenders from an appropriate comparison group. Reconviction analyses were undertaken using intention to treat (ITT) analysis, TR analysis using the full comparison group, and TR analysis using matched comparison groups. The ITT design found no impact of group membership on reconviction. The TR designs, however, provided evidence of moderate effects of completion: For every three completers, five of the matched comparison group members were reconvicted. The analysis also suggested a noncompletion effect: Noncompleters were twice as likely as their matched comparison group to be reconvicted.

Treatment of chronic anorexia nervosa: a 4-year follow-up of adult patients treated in an acute inpatient setting.

Despite evidence from a number of long-term follow-up studies of anorexia nervosa that nearly 50% of patients eventually make a full recovery, controlled trials of psychotherapy for anorexia nervosa are lacking. Those with severe and enduring problems represent a considerable therapeutic challenge. Thirty-four consecutive adult referrals to the inpatient treatment unit who fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for anorexia nervosa were examined pre-admission, post-discharge and 4 years after admission. Characteristics of remitted and non-remitted patients were examined. Secondary analyses considered the differences between patients with anorexia nervosa, restricting type and anorexia nervosa binging/purging type. The findings highlight a number of differences between patients with anorexia nervosa (restricting type) versus anorexia nervosa (binging/purging type) as well as remitted versus non-remitted patients. The use of a comprehensive battery of assessments found that resolution of eating disorder symptomatology was paralleled by improvements in emotional and psychological distress and improvement in body image perception and coping skills. Better results were obtained for those who had continuity of care on an outpatient basis. This pattern is particularly significant given the more 'chronic' nature of the sample that were older, with a higher incidence of binge-eating and purging than previous samples. Results provide some encouragement for the treatment of those adults with anorexia nervosa who typically have less favourable outcomes.

Evaluation of the addressing substance-related offending (ASRO) program for substance-using offenders in the community: a reconviction analysis.

This article reports an evaluation of the Addressing Substance-Related Offending program in the English and Welsh Probation Service. Participants were 319 adult male offenders who had a history of substance use and were serving community sentences. A quasi-experimental design was used to compare the reconviction rates of offenders who completed the program, offenders who started but did not complete the program, and a comparison group of offenders who were not allocated to the program. Multivariate analysis showed that at one-year follow-up the completers had a significantly lower rate of reconviction and longer time to reconviction than the non-completers, and the non-completers had a significantly higher rate of reconviction and shorter time to reconviction than the comparison group. No differences were found in reconviction between the completers and comparison group.

Long-term suicide risk in forensic psychiatric patients.

The objectives of this study was to describe the rate of suicide and other causes of death in first admissions to a (medium) secure forensic psychiatric facility. All 595 patients were followed up for a maximum of 20 years. Death certificates were obtained and Standardized Mortality Ratios (SMRs) were calculated. At the June 2003 census, 57 patients (9.6%) had died of whom 18 (3.0%) had committed suicide; if deaths categorized as open verdicts are included the number rises to 26 (4.4%). The SMR for death by suicide was higher for a Mental Health Act classification of Mental Illness (SMR = 3,553) compared to Psychopathic Disorder (SMR = 1,892). The risks of mortality in this population are high from any cause, particularly from suicide.

Dealing with Feelings: the effectiveness of cognitive behavioural group treatment for women in secure settings.

BACKGROUND: Women in secure psychiatric settings have gender specific treatment needs. The current study examined the feasibility of a Dealing with Feelings Skills Group training for dual diagnosis women admitted to a medium secure setting. METHOD: A pre-test--post-test design was used to evaluate a group programme adapted from dialectical behaviour therapy skills training. RESULTS: Most patients had a primary diagnosis of personality disorder. Treatment completers (n = 29) were compared with non-completers (n = 15). Clinically significant changes in treatment completers were apparent on coping response measures of positive reappraisal, problem solving and alternative rewards; on measures of anxiety and suicidality; on self-reported ability to engage in activities to reduce negative mood and to recognize mood changes. Self-harming and aggressive behaviours also reduced in the 3 months following group treatment. CONCLUSION: An adapted coping skills component of DBT benefit many dual diagnosis patients: issues related to treatment drop-out and failure to benefit are discussed.

Structural, item, and test generalizability of the psychopathy checklist--revised to offenders with intellectual disabilities.

The Psychopathy Checklist-Revised (PCL-R) is the most widely used measure of psychopathy in forensic clinical practice, but the generalizability of the measure to offenders with intellectual disabilities (ID) has not been clearly established. This study examined the structural equivalence and scalar equivalence of the PCL-R in a sample of 185 male offenders with ID in forensic mental health settings, as compared with a sample of 1,212 male prisoners without ID. Three models of the PCL-R's factor structure were evaluated with confirmatory factor analysis. The 3-factor hierarchical model of psychopathy was found to be a good fit to the ID PCL-R data, whereas neither the 4-factor model nor the traditional 2-factor model fitted. There were no cross-group differences in the factor structure, providing evidence of structural equivalence. However, item response theory analyses indicated metric differences in the ratings of psychopathy symptoms between the ID group and the comparison prisoner group. This finding has potential implications for the interpretation of PCL-R scores obtained with people with ID in forensic psychiatric settings.

Assessing comorbid substance use in detained psychiatric patients: issues and instruments for evaluating treatment outcome.

This review assesses the issues involved in the selection and treatment of patients comorbid for mental illness and substance misuse being treated in secure psychiatric facilities. It includes those individuals who have a history of offending and whose placement is the result of severe behavioral disturbance. The relevant issues in the assessment and treatment of these patients are reviewed and a battery of tests is suggested on the basis of their usefulness with this population in terms of their brevity, ease of administration, and for their value in planning treatment, providing motivational feedback, and monitoring change. The paucity of assessment tools developed specifically for this patient population is highlighted.

The development of a 'best practice' service for women in a medium-secure psychiatric setting: treatment components and evaluation.

The inadequacy of inpatient facilities for women with severe psychiatric and co-morbid difficulties has been repeatedly documented. The establishment of effective therapeutic programmes for women in medium psychiatric facilities is also in their infancy, and little research has been undertaken. This article describes the development of a 'best practice' psychological treatment programme for women with a dual diagnosis. Emphasis is placed on the need to develop further intensive gender-specific services using an established model for effective therapeutic service development. In addition to a detailed description of the group therapy programme, staff training initiatives, methods for ensuring treatment integrity and a methodology for service evaluation is given.

Usefulness of the CANFOR-S for measuring needs among mentally disordered offenders resident in medium or low secure hospital services in the UK: a pilot evaluation.

BACKGROUND: The short form of the forensic version of the Camberwell Assessment of Needs (CANFOR-S) (Thomas et al., 2003) is of potential value in all clinical forensic settings, but so far reported mainly with high security hospital patients. AIMS: To conduct a pilot study of the feasibility of using the CANFOR-S in medium and low security hospital units and to report preliminary findings there. METHODS: Thirty-six of 38 patients on one medium secure ward for women, one low secure ward for women and one low secure ward for men, all in the same hospital, agreed to participate in the study. Staff and patients completed the CANFOR-S as part of a larger formal assessment package. RESULTS: All the women and 18 of the 20 men completed the CANFOR-S. It was found to be easy and quick (25 minutes) to use, and acceptable. Staff and patient ratings were similar on all but one item: needs with regard to safety to others, with staff consistently rating more. Men and women were similar in number of needs, but had different needs profiles. Those in medium security were generally more needy than those in low security. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The CANFOR-S is feasible for clinical practice, with results perceived as useful in treatment planning by patients and staff. More widespread use could improve service planning.

Aggression control therapy for violent forensic psychiatric patients: method and clinical practice.

Aggression control therapy is based on Goldstein, Gibbs, and Glick's aggression replacement training and was developed for violent forensic psychiatric in- and outpatients (adolescents and adults) with a (oppositional-defiant) conduct disorder or an antisocial personality disorder. First, the conditions for promoting "treatment integrity" are examined. Then, target groups, framework, and procedure are described in detail, followed by the most important clinical findings during the period 2002 to 2006. Finally, new programme developments are mentioned, with aggression control therapy as a starting point.

The importance of appropriate allocation to offending behavior programs.

This study examined the impact on reconviction of appropriate allocation to three general offending behavior programs involving adult male offenders in the English and Welsh Probation Service. Appropriate allocation was defined by level of risk for reconviction. There were three allocation groups: too low, appropriate, and too high. Using a quasi-experimental design, the reconviction rates of offenders who were allocated to and completed a program, offenders allocated to a program who failed to start, and a comparison group were compared. It was found that the appropriateness of allocation affected reconviction independently of treatment group. Furthermore, in line with the risk principle, there was an interaction between treatment group and the appropriateness of allocation.

Development of the Observation Scale for Aggressive Behavior (OSAB) for Dutch forensic psychiatric inpatients with an antisocial personality disorder.

The Observation Scale for Aggressive Behavior (OSAB) has been developed to evaluate inpatient treatment programs designed to reduce aggressive behavior in Dutch forensic psychiatric patients with an antisocial personality disorder, who are "placed at the disposal of the government". The scale should have the sensitivity to measure changes in the possible determinants of aggressive behavior, such as limited control of displayed negative emotions (irritation, anger or rage) and a general deficiency of social skills. In developing the OSAB 40 items were selected from a pool of 82 and distributed among the following a priori scales: Irritation/anger, Anxiety/gloominess, Aggressive behavior, Antecedent (to aggressive behavior), Sanction (for aggressive behavior) and Social behavior. The internal consistency of these subscales was good, the inter-rater reliability was moderate to good, and the test-retest reliability over a two to three week period was moderate to good. The correlation between the subscales Irritation/anger, Anxiety/gloominess, Aggressive behavior, Antecedent, Sanction was substantial and significant, but the anticipated negative correlation between these subscales and the Social behavior subscale could not be shown. Relationships between the corresponding subscales of the OSAB and the FIOS, used to calculate concurrent validity, yielded relatively high correlations. The validity of the various OSAB subscales could be further supported by significant correlations with the PCL-R and by significant but weak correlations with corresponding subscales of the self-report questionnaires. The Observation Scale for Aggressive Behavior (OSAB) seems to measure aggressive behavior in Dutch forensic psychiatric inpatients with an antisocial personality disorder reliably and validly. Contrary to expectations, a negative relationship was not found between aggressive and social behavior in either the OSAB or FIOS, which were used for calculating concurrent validity.

Long-term outcomes after discharge from medium secure care: a cause for concern.

BACKGROUND: There are few long-term follow-up studies of patients discharged from medium secure units in the UK, even though these units were introduced over 20 years ago. AIMS: To describe mortality, rates of reconviction at different time periods; violent behaviour (not leading to conviction), readmission and employment, after discharge from a medium secure unit. METHOD: Of 595 first admissions over a 20-year period, 550 discharged cases were followed-up. Multiple data sources were used. RESULTS: Fifty-seven (10%) patients had died, of whom 18 (32%) died by suicide, and the risk of death was six times greater than in the general population. Almost half (49%) of those discharged were reconvicted and almost two-fifths (38%) of patients were readmitted to secure care. CONCLUSIONS: Community psychiatric services need to be aware that those discharged from medium secure care are a highly vulnerable group requiring careful follow-up if excess mortality, high levels of psychiatric morbidity and further offending are to be prevented.