Bad cases research and reviews the perilous progress of forensic psychiatry
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Bad cases, research and reviews The perilous progress of forensic psychiatry. Pamela J Taylor. Bad case? when one person with a mental disorder seriously harms others when such a case stigmatises others with mental disorder when psychiatrists/mh workers are defined by a single case

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Bad cases research and reviews the perilous progress of forensic psychiatry l.jpg

Bad cases, research and reviewsThe perilous progress of forensic psychiatry

Pamela J Taylor

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  • Bad case?

  • when one person with a mental disorder seriously harms others

  • when such a case stigmatises others with mental disorder

  • when psychiatrists/mh workers are defined by a single case

  • when one case alone drives law and policy

  • Research:

  • Are you serious?

  • But there is some –

  • ** Epidemiology

  • ** Growth in understanding of mechanisms

  • ** Outcome studies

  • ** International perspectives

  • Reviews:

  • Clear terms of reference

  • Take account of accumulated individual cases

  • Draw on wider evidence, including research

  • from a multiagency and multidisciplinary perspective

  • Inform policy, law and practice

Bad cases neither new nor local l.jpg
‘Bad cases’ neither new nor local

  • In UK

    1st January 1843 Daniel McNaughton mortally wounded Edward Drummond

    19th June 1843 House of Lords: The McNaughton Rules

  • Occur worldwide

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b. 23.11 1963

Dropped out of school; disowned by father

Co-workers descn :quiet & unremarkable, but a bit of a loner

1999: schizophrenia

After one month in treatment judged "capable of taking care of himself"

and released.

in and out of hospital 1999.

kicked out of several apartments e.g. for throwing his garbage from the balcony 2000

On May 23 2001, again committed to mental hospital, but left after one day; did not return.

‘institutionalized even more often than he had been arrested’

On June 8th 2001, court case pending, took OD, ran amok in

a school

Wrestled down by staff within minutes; described as being in an extremely confused state when arrested

Later, on interrogation he stated:

Anything and everything has become unbearable. Time and time again I tried kill myself but I could not do it. I wanted to be arrested and get the death sentence

Takuma was hanged barely three years after the attacks

Mamoru Takuma

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System changes

  • June 9th 2001 Prime Minister Jun-ichiro Koizuni:

    The imperfection of the law has become clear and certain changes to Japan’s psychiatric system should be considered for mentally ill offenders

  • 18th March 2002 ruling Lib-Dems proposed new policy which included establishment of special forensic psychiatry wards in general mental hospitals

  • July 2003, Diet enacted:

    Law Concerning Medical Treatment and Observation for People Who Commit Serious Harm to Others Under the Condition of Lost Mind and the Like 2003

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Kazuo Yoshikawa

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Aged 29

High achiever

Several years of m. illness

13 voluntary hospitalisations in 2+ years

3,500 pps of casenotes

Hospitalised 24.11.1998

Medically discharged

15th December 1998

‘ought to have an intensive case manager’

disorganised, unable to manage his money, care for himself and becomes non-compliant with meds

thought disordered

talking to himself

very delusional

Had attacked at least 13 people including health care staff in the period

Bedlam on the Streets

Maybe they should have just stenciled it in large letters on AG’s forehead:

Ticking time bomb, suffers schizophrenia, if off medication, run for cover!

Winerip, 1999

December 26th 1998

had missed 2 OP dates

Clinic worker wrote to him that if he hadn’t called by January 6th 1999 his case would be closed

January 3rd 1999 pushed Kendra Webdale to her death under a subway train

Trial no.1 hung jury

Trial no 2. convicted of second degree murder and sentenced to 25years-life

Trial no 3. pending, plea bargain guilty as before, 23 years + five years supervision and psychiatric supervision.

Andrew Goldstein



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System changes: Kendra’s Law

  • November 1999, New York State Assembly and Senate passed The New York Mental Hygiene Law 1999 (MH Law 9.60)

    The Assisted Outpatient Treatment Program

  • Mandate for medication, & maybe ‘periodic blood tests/urinalysis, individual or group therapy, day treatment, ed/vocational training, supervision of living arrangements, and any other service’

  • No criminal penalty; patient may be removed from community for 72 hours obs if 1. a physician determines; 2. clinical decompensation; compliance not attained

  • Intended population:

    mentally ill people who are capable of living in the community with the help of family, friends and mental health professionals, but who, without routine care and treatment, may

    relapse and become violent or suicidal, or require hospitalization.

  • Reductions in all three attained, law renewed 20th June 2005 for further five years

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A UK Departure

  • b. 7th June 1960

  • In care, temp 1967, perm.1972

  • 1st Offence 1972

  • All adolescence in care or custody

  • 1st psychiatric admission 1980

  • Mostly in prison 18-32

  • 1992 CMHT paranoid personality


  • 1994 personality disorder

  • Substance misuse disorders

  • April 1996 probation order ended

  • 4th July 1996 CPN concerned

  • 9th July 1996 Russell attacks

  • 23rd July admitted to MSU for detox

  • 12th November 1996 discharged

  • 23rd January 1997 brief readmission

  • July 1997 Arrest

  • 23rd October 1998 first convicted

Michael Stone

Lin & Megan


& Josie Russell

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Official responses

  • Does the Home Secretary believe that further measures will be needed to deal with offenders who are deemed to be extremely violent because of mental illness or personality disorder, but whom psychiatrists diagnose as not likely to respond to treatment?

    Alan Beith, MP

  • Yes, I entirely agree with the Right Hon. Gentleman that there must be changes in law and practice in that area. We are urgently considering the matter with my Right hon . Friends in the Department of Health … the psychiatric profession … 20 years ago adopted what I would call a common sense approach … but these days go for a much narrower interpretation of the law.

    Jack Straw, MP. Hansard 26th October 2000

  • The Panel is of the firm view that the policy debate concerning the adequacy of the law, policy and guidance should take place in the context of the actual facts of the case of Michael Stone, as opposed to the incomplete and in some cases inaccurate acounts that have appeared to date.

    South East Coast Strategic HA, Kent County Council, Kent Probation Area commissioned independent report, 30th November 2000, published October 2006

New laws l.jpg

Criminal Justice Act 2003

Imprisonment for public protection

Indefinite sentences for a convicted person considered to be dangerous to the public

Usually given a tariff, but must complete courses and show change

Government prediction of need: 900 places

The reality: 4,800 in July 2008

(33 released)

New projection 12,000 by 2014

Higher rates of mental disorder than other prisoners:

1/5 in previous treatment

1/5 on medications

The Mental Health Act 2007

Mental disorder means any disorder or disability of mind

Promiscuity or other immoral conduct, and sexual deviance no longer excluded

Detention if:

Suffering from a mental disorder of a nature or degree …

Appropriate medical treatment (AMT) is available

AMT is that medical treatment which is appropriate the case, taking into account the nature and degree of the mental disorder and all other circumstances of the case

New Laws

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  • What is it?

  • A severe disorder of personality

  • a ‘more likely than not’ risk of offending

  • a link between the two

  • Building new services

  • four high security units 302 places

  • some medium secure capacity <100 places

  • Costs

  • capital cost c.# 330,000 per places

  • revenue cost c. #250,000 per place per year

  • Treatment programmes

  • Research evaluation

But as elsewhere most of our single driving cases are of schizophrenia too l.jpg

b. 18th May 1963

Good school record

Mother ill 1980, left UK; d.1985

1986 ‘rambling’; ‘odd behaviour’; first violence; left UK; 1st mh admission

1987 returned to UK; June:schizophrenia

July: depression

January 1988: ‘drug induced psychosis’ or ‘manipulation for a bed’

1988-92 many assessments/admissions for schizophrenia and threatening behaviour/violence

Saw 43 different psychiatrists in this period


14th August paranoid schizophrenia

10th September: normal mental state, abnormal personality

1st December: SW - ‘nothing untoward in attitude or behaviour’

10th December: failed outpatient appointment

17th December: killed Jonathan Zito

17th December: FME diagnosed ‘psychotic personality disorder’

18th December: psychiatrist - ’psychotic unfit for interview’

22nd December: fp - psychotic needs urgent transfer to hospital

But, as elsewhere, most of our single, driving cases are of schizophrenia too

Christopher Clunis

Jonathan Zito

Constructive outcomes the zito trust some knowledge generation l.jpg

1994: Guidance issued by the Department of Health HSG(94)27

Requiring full independent inquiry into a homicide committed by someone previously in contact with mental health services.

The Guidance led to nearly 300 independent inquiries up to June 2005

Limitations of the system and challenges to it

Munro & Rumgay 2000, BJPsy

40 reports 1988-1997

11 (27.5%) predictable

26 (65%) preventable

Constructive outcomes?The Zito Trust & Some knowledge generation

The national confidential inquiry into suicide and homicide by people with mental illness l.jpg

Consecutive series of cases since April 1996 drawn from the [Home Office] Homicide Index

Psychiatric reports for court when available (49%) [R v Reid]

Previous offending data from the National Crime Operations Faculty

Cases submitted to mh services in area of last residence for each case

Where service contact identified, questionnaire sent to consultant psychiatrist

April 1999-Dec 2003

Total n 2684

Life time history of any mental disorder

806 30%

Life time schizophrenia

141 5%

Life time contact with mh services

486 18%

Contact with services in the last 12 months

249 9%


41 21% any diagnosis

23 56% with schizophrenia

7 per year

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

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How bad is the single case effect? [Home Office] Homicide Index

  • They do tend to be what the wider public knows about our field

  • Forensic and other psychiatrists can be seduced by the single notorious case, but

  • a handful of cases have certainly been the catalyst for substantial change in law and sometimes service provision

  • What is the evidence for effectiveness of the changes?

  • What impact have such cases had on knowledge generation in the field?

Research in forensic psychiatry mental health are you serious l.jpg
Research in forensic psychiatry/mental health: are you serious?

  • Recent emergence as a recognised specialty

  • High growth rate, competing demands and financial disincentives

  • Small size of the specialty

  • Effective use of range and differences between relevant disciplines

  • Special ethical issues

  • Funding and political factors

  • Complexity of research models required

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Special ethical issues: first steps towards research with prisoners

  • Application to designated ethics committee:

    a multi-centre ethics committee (MREC) under the

    National Health Service (NHS) Central Office for

    Research Ethics Committees (COREC), which -

  • requires prior written approval from prison governors

  • therefore pre-application liaison with prison staff

  • and ‘sponsorship’ - approval in principle by the university or trust

  • In practice MREC committee members are unfamiliar with prison research or prisoners

  • Committee works to time ‘targets’ rather than a process of facilitating ethical research

But success here is only the beginning of the ethics approval process l.jpg
But success here is only the beginning of the ethics approval process -

  • Once NHS MREC approval obtained:

  • Research submission to the Prison Service Planning Group (PSPG) if more than one prison to be involved

  • NHS research governance permission through the Primary Care Trust (PCT) covering each prison

  • for fmh: NHS research governance permission from each Mental Health Service Provider Trust (MHT)

e.g. for one five site project 11 separate applications:


And what about money and politics l.jpg

And what about money? approval process -and politics?

Research expenditure per year of potential life lost for selected causes of death reiss roth 1993 l.jpg
Research expenditure per year of potential life lost for selected causes of death Reiss & Roth 1993


A uk funding crisis for forensic mental health research l.jpg

40% of all clinical academics NHS funded selected causes of death

Annual Department of Health spend on NHS research £680m

Other government department annual spend on NHS research £180m

Research Councils £440m

HE funding Councils paid directly to medical schools £400m

100% forensic mental health clinical academics NHS funded

Annual Department of Health spend on fmh research £1.3m

Other government department spend on fmh research c. £2m

Research Councils negligible

No medical School funding for fmh research

No dedicated charity

A UK funding crisis for forensic mental health research

Best Research for Best Health (consultation) Analysis of UK

Mental Health Research Funding

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An indication of the challenge in setting up good enough research modelsexamples from psychosis and violence

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Associations between psychosis and violence are complex and multi-directional

  • Increased vulnerability to becoming victims of violence

    * directly: Lehman & Linn ’84, Mueser et al ’98, Walsh et al 2003

    * indirectly: 1. neighbourhood of residence Silver 2000, Logdberg, 2004

    2. press/public fear/hostility Ward 1997

  • Violent victimisation may predispose to psychosis Spauwen et al, 2006; Bebbington et al 2004

  • Violent victimisation may predispose to violence e.g. Widom, 1997; Caspi et al, 2002

  • Both? Heads et al, 1997

  • Increased vulnerabilities once in the criminal justice system, e.g. elevated suicide rate Shaw et al 2003

  • More likely to perpetrate violence? - but

  • More vulnerable to arrest Robertson 1988

  • More vulnerable to miscarriage of justice Hilgendorf 1980, Gudjonsson et al 1993, Pearse et al, 1998

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Accumulating knowledge multi-directional

Since 1990, sound c.s. epidemiological studies on frequency of violence-mental illness association

Some longitudinal data; growing attention to pathway studies

Basic understanding of illness mechanisms

‘black box’ outcome studies

Management framework studies


Interpersonal studies

Subgroup specific studies:

* women

* specified ethnic

minority groups

Complex treatment studies

Allowance for regional and international differences

But, in spite of the difficulties, facts are accumulating and there is greater awareness of real gaps in knowledge

Testing for frequency of association between violence psychosis a variety of methods l.jpg
Testing for frequency of association between violence & psychosis: a variety of methods

  • Psychosis among perpetrators of crime with high clear up rate: homicide

  • Incidence/prevalence psychosis among criminals

  • Incidence/prev. crime among those with psychosis

  • Records linkage by birth cohort

    4 European studies; violence 4-7 X general population

  • Restricted community survey: ECA, USA 4 X

  • Modified community survey: New York 3X

  • True community survey: New Zealand: 10X

  • Trends: Australia records linkage 1975-95 – slight equivalent increase in violence over time patients & public

  • Population attributable risk 5.2% - health and criminal records linkage - 98,000 patients, 21,119 violent crimes Sweden

Links between alcohol other drug use and violence with and without mental disorder l.jpg
Links between alcohol, other drug use and violence with and without mental disorder

A cross-sectional US based

household surveySwanson et al, 1990

  • An Australian records linkage study

    Wallace et al, 1998

  • Schizophrenia and violence:

  • 7x homicide rate and 2.4x non-fatal violence rate of general population

  • schizophrenia + substance use:

  • 29x homicide rate and 19x non-fatal violence rate of general population

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Bringing longitudinal data to bear on explanations of associationsArseneault, Caspi, Moffitt, Taylor, Silva, 2000

The cohort:

  • 93% of all births in Dunedin 01.04.1972-31.03.1973

  • 1037 children, 51.6% male

  • Assessed 3,5,7,9,11,13,15,18,21*.

  • At 21, 94% survivors recruited – 961

  • DIS based diagnoses

  • Court convictions and self-reported violence

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The Dunedin birth cohort: mental disorder and violence at 21 associations












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Proportion of disorder & violence association independently accounted for by selected explanatory variablesArseneault, Moffitt, Caspi, Taylor, Silva, 2000

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Research questions for a high security hospital cohort in England

  • What diagnoses are associated with comorbid substance use diagnosis?

  • What are the patterns of substance use in the month prior to a serious index offence?

  • Case record study of all people resident 1993 with psychosis and/or personality disorder n=1330

Comorbid substance use groups l.jpg
Comorbid substance use groups England

Categorised such that groups are mutually exclusive

Cannabis group: 30/36 used cannabis only; 6 also had alcohol use diagnosis

Other/mixed drug group: 32/53 diagnosed with multiple drug use disorder; 2 used multiple drugs and alcohol, others single illicit drug use disorders

Pd only vs pd psychosis l.jpg
PD only vs PD + psychosis England

Alcohol use disorder Χ2=6.47, p <.05

Cannabis use disorder Χ2=44.2, p <.001

Other / mixed drug use disorder Χ2=13.1, p <.001

PD only

PD + psychosis

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Patterns of substance use in the pathway to the index offence

  • 77% with alcohol use disorder were using alcohol in the month before the offence

  • 63% were drinking in the 24 hours before the index offence

  • In the cannabis group, 64% used drugs in the pre-offence month

  • 22% were using in the 24 hours before the index offence

  • Of those with other/mixed drug use disorders, 57% were using drugs in the month prior to the index offence

  • 34% were using in the 24 hours before the index offence.

  • Few people without a prior substance use diagnosis misused alcohol or drugs in the period before the index offence:

    15% in the month prior, most choosing alcohol

    9% in the final 24 hours, again most misusing alcohol

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Psychosis and substance use offence

Substance use is significantly less prevalent in those driven to the IO by psychotic symptoms …

… perhaps psychosis and substance use provide separate explanations for dangerousness?

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So what about psychotic symptoms l.jpg

So, what about psychotic symptoms? VIOLENT OFFENCE - HIGH SECURITY HOSP. ‘PURE’ PSYCHOSIS PATIENTS (N=593)

Delusions and threat control override symptoms l.jpg


A belief - acceptance of proposition without evidence

A ‘normal delusion’: belief held to be false because held by a political, cultural or religious opponent

A ‘psychotic delusion’: Absolute conviction of the truth of a proposition which is idiosyncratic, incorrigible, ego-involved and often preoccupying’

Kraupl Taylor, 1979

Standardised schedules

Bell et al, 2006

Threat/control-override symptoms

Feeling that one’s mind is dominated by forces beyond one’s control

Feeling that thoughts are being put into one’s mind that are not one’s own

Feeling that there are people who wish to do one harm

From Psychiatric Epidemiologic Research Interview Dohrenwend et el, 1980

Delusions and threat/control-override symptoms

Studies associating delusions with violence l.jpg
Studies associating delusions with violence VIOLENT OFFENCE - HIGH SECURITY HOSP. ‘PURE’ PSYCHOSIS PATIENTS (N=593)

  • Taylor, 1985, especially serious violence; pre-trial prisoners, UK

  • Robertson and Taylor, 1993, pre-trial prisoners, UK

  • Taylor et al, 1998, almost all serous violence, high security hospital patients, UK

  • Appelbaum et al, 2000, mostly minor/moderate violence, general psychiatric patients, USA

  • Teasdale et al, 2006, as Appelbaum sample, confirmed association with threat delusions for men, not women

  • Swanson et al, 2006, USA-wide sample general psychiatric patients, association with more serious violence

Studies associating tco symptoms with violence l.jpg
Studies associating TCO symptoms with violence VIOLENT OFFENCE - HIGH SECURITY HOSP. ‘PURE’ PSYCHOSIS PATIENTS (N=593)

  • Link and Steuve, 1994, USA general psychiatric patients and community controls in New York

  • Swanson et al, 1996, 3-centre USA study general psychiatric patients

  • Link et al, 1998 Israeli population based sample

  • Bjørkly & Havik, 2003, small Norwegian sample seriously mentally ill and violent patients

  • Stompe et al, 2004, Austrian NGRI men – more serious violence

  • Hodgins et al, 2003, forensic and general psychiatry discharged men, Canada, Germany, Finland & Sweden; longitudinal study; at least one TCO

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Does social context make a difference? VIOLENT OFFENCE - HIGH SECURITY HOSP. ‘PURE’ PSYCHOSIS PATIENTS (N=593)

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Why be concerned about social context? VIOLENT OFFENCE - HIGH SECURITY HOSP. ‘PURE’ PSYCHOSIS PATIENTS (N=593)relationship of perpetrator to victim & seriousness of index offence (n=975) Johnston & Taylor, 2003

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  • Among UK psychotic male offenders those driven to offend by their delusions, more serious violence and social networks more intact than those not delusionally driven Taylor, 1993

  • Among all first forensic evaluation violent offenders with schizophrenia in Sweden 1992-2000, injuries to family members more serious than injuries to others

    Nordström & Kullgren, 2003

  • Among all Swedish schizophrenic homicides 1992-2000, those killing family members more likely to have been delusionally driven Nordström et al, 2006

Whoever they talk to about their delusions probably not the psychiatrists mccabe et al 2002 l.jpg
Whoever they talk to about their delusions – probably not the psychiatristsMcCabe et al, 2002

  • Qualitative study of 32 patients and 7 psychiatrists

  • Patients actively tried to talk about the content of their delusions and other psychotic symptoms

  • The psychiatrists responded with hesitation, a question, a smile or a laugh; if relatives/lay carers present, the psychiatrists then asked the carer a question

  • Mean length per interview of specific talk about psychotic symptoms: 67 seconds

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Problem: any concern that delusions change in relation to talking about them depends on giving up a belief about these beliefs

  • A delusion: any false judgement held with 1.’extraordinary conviction’

    2. ‘imperviousness to other experiences and to compelling counter-argument’

    3. ‘their content is impossible’. Jaspers, 1913

  • A delusion has 7 defining characteristics, including

    ‘… unresponsive to the presentation of evidence contrary to the belief’ Oltmanns, 1988

  • A delusion is a fixed, false belief, held with absolute conviction and not amenable to reason (DSM-IV)

    APA, 1997

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Beliefs and delusions: steps towards a dimensional view talking about them depends on giving up a belief about these beliefs

  • Successful out-patient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt Beck, 1952

  • Hallucinations and delusions as points on continua Rating scale evidence. Strauss, 1969

  • A multi-dimensional view of delusions. Kendler et al, 1983

  • Techniques for measuring psychological change. Shapiro, 1961

  • A longitudinal perspective. Hole et al,1979; Brett-Jones et al, 1987.

  • US McArthur study group: up to 1/3 people had changes in delusions over each 10 week interval Appelbaum et al, 2004

Maudsley assessment of delusions schedule mads taylor et al 1994 l.jpg

BELIEF ***** MAINTENANCE talking about them depends on giving up a belief about these beliefs

seeking support for belief

‘finding’ it

adjusting belief on contradiction


being frightened by it


Action (+ve act)

Withdrawal (-ve)





Maudsley Assessment of Delusions Schedule (MADS) Taylor et al. 1994

Belief maintenance factors l.jpg
Belief maintenance factors talking about them depends on giving up a belief about these beliefs

  • Has anything happened to support your belief that ..

  • Asking you to think about it now, can you think of anything at all that has happened that goes against your belief that ….

  • Let me suggest something to you, something that would not fit with your belief …… if that were to be so, tell me how you think you would react, how that would affect your belief.

Let me suggest something to you that would not fit with your belief how you think you would react l.jpg
Let me suggest something to you that would not fit with your belief ……how you think you would react?

  • Suggestion ignored; persistently denied as possible

  • Situation accommodated into belief system, so belief and situation are consistent

  • Belief changes in conviction but not content

  • Belief dropped in the face of contradictory evidence

Hypothetical challenge and action on delusions l.jpg

ACTORS belief ……

Ignores 9 (39)

Accommodates 1 ( 4)

Changes convic’n 12 (52)

Dismisses delusion 1 ( 4)


45 (80)


8 (14)

3 ( 5)

X23=15.77 P<0.002

Hypothetical challenge and action on delusions

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Cognitive behaviour therapy for schizophrenia Jones et al, 2005

CBT* involves:

recipient establishing links between thoughts, feelings and actions wrt target symptoms

correction of misperceptions, irrational beliefs & reasoning biases

recipient monitoring behaviours and/or promotion of alternative ways of coping

RCTs for schizophrenia/schiz. like illnesses: 30 papers, 19 trials

2154 subjects, of whom 925 had CBT according to the definition*

Compared to standard care -reduced risk of staying in hospital (1x62); improved medium term mental state (2RCTs, n=123), but no consistent effect; no effect on relapse/ readmission (4RCTs, n=357)

Compared to supportive psychotherapy or psycho-educational approaches, no effect.

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Limited by the measures 2005

No study measured adverse effects, whether on the study participants or on those giving the treatment (or on anyone else outside the treatment circle)

Why should this matter in studying psychosis and violence?

  • Any interactions powerful enough to modify behaviour may do so in unwanted as well as wanted directions

  • Trained, neutral therapists are not the only people who will interact with psychosis sufferers

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So, where next? 2005

  • Observing/recording dialogue about delusions?

  • Being more inclusive of those in the natural social network

  • Towards a typology of challenge? – what forms does it take? Establishing pathways to belief formation?

  • Testing different forms of challenge?

  • Establishing samples for evaluation according to type of belief formation?

  • Being more explicit about & intrusive into characteristics of those refused research and research refusers?

  • Not neglecting to measure side effects/adverse outcomes as well as target features

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Communicating about delusions: hypothetical routes to violence


Cog. origins

Serious violence

Delusion change



Mild/mod violence

Affective change


Hallucinatory origins



Everyday stressors



Personal style

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Effect of atypical antipsychotic medication on violence outcome research

  • Six naturalistic studies clozapine: 63-100% reduction in violenceOverview Taylor & Buckley, 2000

  • Broadmoor mirror study: 52 pts, reduction on all violence measures 3-12 mths post-clozapine

    Duffet et al, 1998

  • Rampton outcome study, 50 pts, 12 discontinued, most of the rest reduction in symptoms & violence

    Delal et al, 1999

  • Ashworth 106 patients consistently on clozapine, 98 not; matched for sex, disorder & length of stay; 6.5 years later 20% clozapine cases and 75% non-clozapine cases still resident

    Swinton et al, 2000

  • No RCTs

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Factors tested for effect on length of stay l.jpg

Sex: 224 men 54 women n.s.

Ethnic group: 93 A/C 185 W/I n.s.

Admission age (med.) 32 m (24-79) 26 w (23-55) n.s.

Pure psychosis/+pd 224 54 n.s.

Index offence: homicide 71 n.s.

non-fatal violence 153 n.s.

sexual 18 n.s.

CD/fire 21 n.s.

Seriousness of phys.harm n.s.

Restricted cases 184 n.s.

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International perspectives DISCHARGED HIGH SEC. PD PATIENTS

  • Sweden – Per Lindqvist

  • Wales – Pamela Taylor

  • Australia – Paul Mullen

  • New Zealand – Jeremy Skipworth

  • Denmark – Peter Kramp

  • South Africa – Sean Kaliski

  • Japan – Kazuo Yoshikawa

  • Canada – Pierre Gagne

  • Scotland – Lindsay Thompson

  • Advisors: Phil Fennell, Nicola Gray, John Gunn, Mary McMurran, John Monahan, Paul Rogers


Swanzdsajcs we are spread around the world so what do we have in common l.jpg
SWANZDSAJCS: we are spread around the world, so what do we have in common?

  • A philosophy of treatment – and not just containment - for the mentally disordered offender

  • Core members of the clinical teams have had specialist clinical training in the treatment of such people and work in –

  • purpose designed specialist services designated for a defined geographical region, so are

  • familiar with the application of laws and service delivery in those jurisdictions

The questions behind our research l.jpg
The questions behind our research: have in common?

  • To what extent can we rely on literature from research in one country to inform work in another?

  • To what extent can we rely on literature from research in one time period to inform work in another?

  • To what extent is our core clientele and work sufficiently similar that -

  • We can enhance outcome studies by pooling data for certain outcome measures, even internationally, and/or

  • Capitalize on our differences to test the results of the natural experiment of discharging our patients within different legislative and social frameworks

The nature of public review under consideration l.jpg
The nature of public review under consideration group

  • Conducted by a group of individuals, usually from different professional and practice groups and agencies, who

  • advertise the intent to review

  • consult widely in doing so

  • publish the result of their deliberations in the public domain

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Is public inquiry and review inherent in the culture of England and Wales?

There is a long history of such reviews

e.g. Reports from Select Committees on Criminal and Pauper Lunatics & on the Better Regulation of Madhouses in England 1807-16

There are often several pertinent reviews happening simultaneously

e.g. general service reviews, specific service reviews, an individual homicide inquiry

Response to notification of a review is extensive

e.g. The Corston Report on ‘women with particular vulnerabilities in the criminal justice system’ received c. 250 individual submissions: 11 from families, c. 60 from individuals & the rest from organisations.

Major reviews, particularly government sponsored reviews, do have some impact

e.g. 1992 Dept Health & Home Office review for England recommended decrease in high security beds and increase in medium security beds - done

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Impact of reviews? England and Wales?YES


High security

Hospitals shrinking


Medium & low security

hospitals expanding

..even in New Zealand

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Research evidence of impact of such Inquiries/Reviews? England and Wales?

Effect on service users?

What before and after change studies? ………NONE

What outcome studies?

Re-offending; re-admission; mortality

but, rarely take account of confounding variables –

even time at risk

What studies measuring change over time? …..ONE?

in admission/discharge cohorts?

in re-offending?

in other outcomes? e.g. better service user experiences/health?

Effect for wider public? ……………NONE?

Why so little?

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Questions posed within the review England and Wales?

How can forensic services integrate more effectively within a mental health whole system?

How can inter/intra agency collaboration be improved?

How can treatment options, patient safety and proximity to family and home services be improved ?

How can patient flow be improved within the whole system retaining safe and effective service provision and public confidence?

How can more efficient and controlled use be made of secure service expenditure?

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Key features of the review model England and Wales?

Full engagement of all interested parties across the professional, service user and carer and wider community constituencies

gain support for the review process

fully inform maintenance and change

build ownership for emerging improvements

Methods used included

workshops, seminars and conferences

literature review, acknowledging the evidence base

regular briefings for frontline staff, their leaders and other opinion formers

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Conclusions England and Wales?

  • Cautious optimism about the impact of at least some ‘bad cases’, but -

  • Essential to build on the issues they raise in research

  • Research in the field is challenged from every angle

    ** New resources for research are essential

    ** Better understanding of the special ethical & practical

    issues raised by the field also important

  • Knowledge base growing, and we can more clearly identify major gaps, especially at the clinical interface

  • Major public service reviews can be a useful method of ensuring the ‘d’ of R&D is pursued, as well as signposting strategic development of academic, service and clinical development alike