On patients who explode: surviving petrifying psychotherapeutic experiences

Although most of our patients will enter the consulting room quite quietly, often in a depressive state, having contained their sadistic impulses, a tiny fraction of those with whom we work will attack us in a variety of chilling ways. In this article, the author describes in detail two particularly terrifying clinical experiences in which a patient either threatened to kill him or actually sullied his consulting room with bodily fluids. Drawing upon his psychotherapeutic encounters not only with intellectually disabled patients and forensic patients but, also, with those who presented as ordinary “normal-neurotics”, the author considers the phenomenology of these “bomb”-like explosions and explains how he attempted to maintain a classical psychoanalytical focus of understanding, which consisted of a careful scrutiny of the countertransference and a firm commitment to the interpretation of unconscious material, whilst under attack. Furthermore, he examines the essential role of speaking with experienced colleagues who will provide essential supervision or assistance during these challenging chapters of clinical practice. The author also considers the many ways in which “bombs” can be hurled not only by the more obviously dangerous or disturbed individuals but, also, with surprising frequency, by those with no criminal history whatsoever, who, upon first encounter, often present as reasonably healthy.

Deprivation and delinquency in the adolescent forensic patient

Drawing upon Donald Winnicott’s classic paper, “Delinquency as a Sign of Hope”, the author has underscored the importance of recognising the role of emotional loss in the aetiology and treatment of adolescent forensic patients, and she has elucidated how this particular psychoanalytical lens can assist psychotherapists to work more effectively with deprivational trauma. The author has also described her experience as both a field social worker and as a forensic psychotherapist, and has shared moving clinical material with great clarity and generosity, demonstrating the value of incorporating Winnicott’s insights into the forensic consulting room. In particular, the author has examined how the patient can use the psychotherapist as an understanding object who can help to counteract earlier deprivations.

Social determinants of health in male forensic patients admitted at a tertiary psychiatric hospital in South Africa

Introduction: Social factors are increasingly being used to determine health outcomes. The concept of social determinants of health has been used to shape policies that address disparities. There is a paucity of such studies in the forensic setting. This study aimed to use social determinants of health to identify social factors that are associated with being a male forensic patient. Methods: The study was a retrospective two-group (forensic and non-forensic) comparison clinical record review. Association was identified through independent and multivariate statistical analysis. Results: The study sample comprised of 296 patients, 56.4% ( n = 167) of which were non-forensic. The majority of the sample was black African, 50 years and older, single, unemployed and had attended main-stream schooling. Race ( p < .01), employment status ( p < .02), not completing high school ( p < .01), previous imprisonment ( p < .01), drug use ( p < .01) and not being on medication prior to admission ( p < .01) were significantly associated with being a forensic patient. Multivariate logistic regression analyses also confirmed these associations. Conclusion: Social determinants of health ought to be targeted to improve health outcomes of psychiatric patients. Collaborations between mental health, public health, law and policy makers as well as non-/governmental agencies may lead to change. Human rights of individuals with mental illness may thus be enhanced in the long run.

FORENSIC MENTAL HEALTH IN EUROPE: SHARED LEGAL HERITAGE AND CONTEMPORARY LANDSCAPE

This paper provides an overview of some of the key features of forensic mental health systems around Europe. Forensic mental health systems share in common the aim to assist in the rehabilitation of people diagnosed with a mental disorder and reduce reoffending or risk of harm. How these aims are pursued varies across the continent. We suggest that best practices can be learnt from observing different countries’ approaches. This paper has six foci: legal traditions in Europe, the concept of criminal responsibility, patient pathways through forensic systems, epidemiological studies of forensic patients, training programmes in forensic mental health, and recent developments in the field across Europe. Readers should reflect on these topics in the context of their own country and how these diverge/converge from the countries described in this paper.

Self-Harm Among Forensic Psychiatric Inpatients With Schizophrenia Spectrum Disorders: An Explorative Analysis

The burden of self-injury among offenders undergoing inpatient treatment in forensic psychiatry is substantial. This exploratory study aims to add to the previously sparse literature on the correlates of self-injury in inpatient forensic patients with schizophrenia spectrum disorders (SSD). Employing a sample of 356 inpatients with SSD treated in a Swiss forensic psychiatry hospital, patient data on 512 potential predictor variables were retrospectively collected via file analysis. The dataset was examined using supervised machine learning to distinguish between patients who had engaged in self-injurious behavior during forensic hospitalization and those who had not. Based on a combination of ten variables, including psychiatric history, criminal history, psychopathology, and pharmacotherapy, the final machine learning model was able to discriminate between self-injury and no self-injury with a balanced accuracy of 68% and a predictive power of AUC = 71%. Results suggest that forensic psychiatric patients with SSD who self-injured were younger both at the time of onset and at the time of first entry into the federal criminal record. They exhibited more severe psychopathological symptoms at the time of admission, including higher levels of depression and anxiety and greater difficulty with abstract reasoning. Of all the predictors identified, symptoms of depression and anxiety may be the most promising treatment targets for the prevention of self-injury in inpatient forensic patients with SSD due to their modifiability and should be further substantiated in future studies.

Neurocognition and social cognition in patients with schizophrenia spectrum disorders with and without a history of violence: results of a multinational European study

Objective Neurocognitive impairment has been extensively studied in people with schizophrenia spectrum disorders and seems to be one of the major determinants of functional outcome in this clinical population. Data exploring the link between neuropsychological deficits and the risk of violence in schizophrenia has been more inconsistent. In this study, we analyse the differential predictive potential of neurocognition and social cognition to discriminate patients with schizophrenia spectrum disorders with and without a history of severe violence. Methods Overall, 398 (221 cases and 177 controls) patients were recruited in forensic and general psychiatric settings across five European countries and assessed using a standardized battery. Results Education and processing speed were the strongest discriminators between forensic and non-forensic patients, followed by emotion recognition. In particular, increased accuracy for anger recognition was the most distinctive feature of the forensic group. Conclusions These results may have important clinical implications, suggesting potential enhancements of the assessment and treatment of patients with schizophrenia spectrum disorders with a history of violence, who may benefit from consideration of socio-cognitive skills commonly neglected in ordinary clinical practice.

A multinational case−control study comparing forensic and non-forensic patients with schizophrenia spectrum disorders: the EU-VIORMED project

Background The relationship between schizophrenia and violence is complex. The aim of this multicentre case–control study was to examine and compare the characteristics of a group of forensic psychiatric patients with a schizophrenia spectrum disorders and a history of significant interpersonal violence to a group of patients with the same diagnosis but no lifetime history of interpersonal violence. Method Overall, 398 patients (221 forensic and 177 non-forensic patients) were recruited across five European Countries (Italy, Germany, Poland, Austria and the United Kingdom) and assessed using a multidimensional standardised process. Results The most common primary diagnosis in both groups was schizophrenia (76.4%), but forensic patients more often met criteria for a comorbid personality disorder, almost always antisocial personality disorder (49.1 v. 0%). The forensic patients reported lower levels of disability and better social functioning. Forensic patients were more likely to have been exposed to severe violence in childhood. Education was a protective factor against future violence as well as higher levels of disability, lower social functioning and poorer performances in cognitive processing speed tasks, perhaps as proxy markers of the negative syndrome of schizophrenia. Forensic patients were typically already known to services and in treatment at the time of their index offence, but often poorly compliant. Conclusions This study highlights the need for general services to stratify patients under their care for established violence risk factors, to monitor patients for poor compliance and to intervene promptly in order to prevent severe violent incidents in the most clinically vulnerable.