Violent Recidivism: A Long-Time Follow-Up Study of Mentally Disordered Offenders

Background: In this prospective study, mentally disordered perpetrators of severe violent and/or sexual crimes were followed through official registers for 59 (range 8 to 73) months. The relapse rate in criminality was assessed, compared between offenders sentenced to prison versus forensic psychiatric care, and the predictive ability of various risk factors (criminological, clinical, and of structured assessment instruments) was investigated. Method: One hundred perpetrators were consecutively assessed between 1998 and 2001 by a clinical battery of established instruments covering DSM-IV diagnoses, psychosocial background factors, and structured assessment instruments (HCR-20, PCL-R, and life-time aggression (LHA)). Follow-up data was collected from official registers for: (i) recidivistic crimes, (ii) crimes during ongoing sanction. Results: Twenty subjects relapsed in violent criminality during ongoing sanctions (n = 6) or after discharge/parole (n = 14). Individuals in forensic psychiatric care spent significantly more time at liberty after discharge compared to those in prison, but showed significantly fewer relapses. Criminological (age at first conviction), and clinical (conduct disorder and substance abuse/dependence) risk factors, as well as scores on structured assessment instruments, were moderately associated with violent recidivism. Logistic regression analyses showed that the predictive ability of criminological risk factors versus clinical risk factors combined with scores from assessment instruments was comparable, with each set of variables managing to correctly classify about 80% of all individuals, but the only predictors that remained significant in multiple models were criminological (age at first conviction, and a history of substance abuse among primary relatives). Conclusions: Only one in five relapsed into serious criminality, with significantly more relapses among subjects sentenced to prison as compared to forensic psychiatric care. Criminological risk factors tended to be the best predictors of violent relapses, while few synergies were seen when the risk factors were combined. Overall, the predictive validity of common risk factors for violent criminality was rather weak

A latent class analysis of mental disorders, substance use, and aggressive antisocial behavior among Swedish forensic psychiatric patients

Background: Patients in the forensic mental health services (FMHS) with a mental disorder, a co-occurring substance use disorder (SUD), and high risk of aggressive antisocial behavior (AAB) are sometimes referred to as the ‘triply troubled’. They suffer poor treatment outcomes, high rates of criminal recidivism, and increased risk of drug related mortality. To improve treatment for this heterogeneous patient group, more insight is needed concerning their co-occurring mental disorders, types of substances used, and the consequent risk of AAB. Methods: A three-step latent class analysis (LCA) was used to identify clinically relevant subgroups in a sample of patients (n = 98) from a high-security FMHS clinic in Sweden based on patterns in their history of mental disorders, SUD, types of substances used, and AAB. Results: A four-class model best fit our data: class 1 (42%) had a high probability of SUD, psychosis, and having used all substances; class 2 (26%) had a high probability of psychosis and cannabis use; class 3 (22%) had a high probability of autism and no substance use; and class 4 (10%) had a high probability of personality disorders and having used all substances. Both polysubstance classes (1 and 4) had a significantly more extensive history of AAB compared to classes 2 and 3. Class 3 and class 4 had extensive histories of self-directed aggression. Conclusions: The present study helps disentangle the heterogeneity of the ‘triply troubled’ patient group in FMHS. The results provide an illustration of a more person-oriented perspective on patient comorbidity and types of substances used which could benefit clinical assessment, treatment planning, and risk-management among patients in forensic psychiatric care

Enhanced Training by a Systemic Governance of Force Capabilities, Tasks, and Processes

The Swedish Army has transformed from 31 brigades in to two in 20 years. At the same time the Swedish area of interest has increased from 60 km from the Swedish borders to 6000 km from Brussels. The type of missions for the armed forces has changed from invasion defending operations to international interoperable operations. This overall change also has increased the necessity to become more interoperable with the partners in the Nordic, European Union, NATO and PfP countries. The NATO methods (OCC) and Core team Effectiveness (CTEF) together with the alignment of the Swedish MARTA provides the basis to assess, evaluate and accredit the Swedish forces. This paper presents a Systemic Governance of Capabilities, Tasks, and Processes applied to the requirement specification for the core battalion in Nordic Battle Group 2015. The method consists of analyzing and compiling the battalion's capabilities, tasks, activities and processes in their context and in relation to each other down to platoon level. The paper then continues to describe the development of a system providing support for assessment, evaluation and accreditation which entail that the commander and staff better can govern the education and training efforts for the force. Authors note: This work is conducted with funding and support from the Swedish Armed Forces and Swedish Strategic Foundation (grant SM12-0052). The information in this publication is the one of the authors and is not the official voice of the Swedish Armed Forces, Combitech, SAAB, Swedish National Defence College, George Mason University and University of Skövde

Implementing clinical guidelines for co-occurring substance use and major mental disorders in Swedish forensic psychiatry : An exploratory, qualitative interview study with mental health care staff

Introduction: Patients with substance use disorders (SUD) and co-occurring mental disorders (COD) within forensic psychiatric care often suffer poor treatment outcomes and high rates of criminal recidivism, substance use, and psychiatric problems. This study aimed to describe the conditions for, and mental health care staff's experiences with, implementing integrated SUD-focused clinical guidelines, including assessment and treatment for patients with COD at a high-security forensic mental health services (FMHS) facility in Sweden. Methods: Study staff conducted nineteen semi-structured interviews with health care staff experienced in administering the new SUD assessment and treatment. The study conducted a thematic analysis to describe the health care staff's experiences with these guidelines and suggestions for improvement. Results: Most participants reported appreciation for the implementation of clinical guidelines with an SUD focus, an area they considered to have previously been neglected, but also noted the need for more practical guidance in the administration of the assessments. Participants reported the dual roles of caregiver and warden as difficult to reconcile and a similar, hindering division was also present in the health care staff's attitudes toward SUD. Participants' reports also described an imbalance prior to the implementation, whereby SUD was rarely assessed but treatment was still initiated. One year after the implementation, an imbalance still existed, but in reverse: SUD was more frequently assessed, but treatment was difficult to initiate. Conclusions: Despite indications of some ambivalence among staff regarding the necessity of the assessment and treatment guidelines, many participants considered it helpful to have a structured way to assess and treat SUD in this patient group. The imbalance between frequent assessment and infrequent treatment may have been due to difficulties transitioning patients across the “gap” between assessment and treatment. To bridge this gap, mental health services should make efforts to increase patients' insight concerning their SUD, flexibility in the administration of treatment, and the motivational skills of the health care staff working with this patient group. Participants considered important for enhancing treatment quality a shared knowledge base regarding SUD, and increased collaboration between different professions and between in- and outpatient services

Enhanced Training through Interactive Visualization of Training Objectives and Models

Military forces operate in complex and dynamic environments [1] where bad decisions might have fatal consequences. A key ability of the commander, team and individual warfighter is to quickly adapt to novel situations. Live, Virtual and Constructive training environments all provide elements of best practices for this type of training. However, many of the virtual training are designed without thorough consideration of the effectiveness and efficiency of embedded instructional strategies [2], and without considering the cognitive capabilities and limitations of trainees. As highlighted recently by Stacy and Freeman [3], large military training exercises require a significant commitment of resources, and to net a return on that investment, training scenarios for these events should systematically address well-specified training objectives, even if they often, do not. In order to overcome these shortcomings with both Live and Virtual training systems and following our previous work [4,5,6], this paper presents a design solution for a proof-of-concept prototype that visualizes and manages training objectives and performance measures, at individual and collective levels. To illustrate its functionality we use real-world data from Live training exercises. Finally, this paper discusses how to learn from previous training experiences using data mining methods in order to build training models to provide instructional personalized feedback to trainees.NOVA 20140294 (Knowledge Foundation

Enhanced Training through Interactive Visualization of Training Objectives and Models

Military forces operate in complex and dynamic environments [1] where bad decisions might have fatal consequences. A key ability of the commander, team and individual warfighter is to quickly adapt to novel situations. Live, Virtual and Constructive training environments all provide elements of best practices for this type of training. However, many of the virtual training are designed without thorough consideration of the effectiveness and efficiency of embedded instructional strategies [2], and without considering the cognitive capabilities and limitations of trainees. As highlighted recently by Stacy and Freeman [3], large military training exercises require a significant commitment of resources, and to net a return on that investment, training scenarios for these events should systematically address well-specified training objectives, even if they often, do not. In order to overcome these shortcomings with both Live and Virtual training systems and following our previous work [4,5,6], this paper presents a design solution for a proof-of-concept prototype that visualizes and manages training objectives and performance measures, at individual and collective levels. To illustrate its functionality we use real-world data from Live training exercises. Finally, this paper discusses how to learn from previous training experiences using data mining methods in order to build training models to provide instructional personalized feedback to trainees.NOVA 20140294 (Knowledge Foundation

Forensic Psychotherapy in Forensic Mental Health

Forensic psychotherapy is a talking cure that aims to work with meaning making processes and defensive manoeuvres in offenders, in order to make them progress in their search for the meaning of the offence. An offence can be understood and contextualized once it is considered from the perspective of the life history of the offender. At the same time, the question of where the violent or sexual motives come from, are much more difficult to grasp. This paradox is problematic to society, that wants an answer from the criminal, but it is also problematic to the criminal him- or herself. The development of the embeddedness of forensic psychotherapy in English and Dutch forensic mental health institutions and the relevance of training are described and explained. For Belgium, two small scale projects are discussed that cater for mentally ill offenders who have difficulties to cope with more intensive psychiatric care. Within these projects, patients are offered the possibility to take part in therapeutic activities on a voluntary basis. The aim is to motivate people, who have difficulties to socialize, participate in group and reconnect with other