Forensic Psychiatry Interdisciplinary Research Group
AIMS
The aims of the Forensic Psychiatry Interdisciplinary Research Group
(IRG) are:
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To examine the causes and treatment of destructive behaviour, including
violent and sexually offensive behaviour, in mentally disordered
people.
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To delineate relationships between psychological trauma and behaviour
disorders.
Interdisciplinary Research Group Research Report for 1996
Introduction
Forensic psychiatry continues to maintain its high political profile.
Prison populations in Britain are rising, the pressure on secure beds
in the NHS is intolerable, individual incidents (such as the Dunblane
massacre) make headline news, and all teaching centres are now trying
to develop forensic psychiatry departments. Paradoxically academic resources
in forensic psychiatry are very low. Space, funds and trained staff are
all in short supply. Nevertheless research activity in this important
area continues to grow, slowly, at the Institute of Psychiatry.
Last year we completed our epidemiological survey of English prisons,
and we produced a report on the growing suicide in prison problem, we
furnished a report on the role of the police in London in the diversion
of mentally disordered people from the criminal justice system to the
health care system, and our programme of work in the maximum security
hospital system has made a very promising start.
Prison Studies
The prison epidemiological studies have revealed a large number of important
findings. The study of sentenced prisoners identified the unmet needs
of that population and showed, for example, that well over 1000 extra
beds are needed within the NHS (mainly in maximum security) for mentally
disordered prisoners. The recent study of English prisons has indicated
that a further 100-300 beds are required for people remanded in custody,
this time mainly in medium security units and local hospitals.
Substance abuse is a particular problem among prisoners and more emphasis
needs to be given to this in the NHS. The remand survey and the Scottish
prison survey have both indicated the high suicide risk among young prisoners.
Preliminary findings suggest that patients with personality disorder
are as likely to die by suicide as psychotic prisoners and substance
abuse is of considerable importance in provoking suicidal behaviour.
An adjunct to the prison epidemiological work was a review and policy
paper identifying the national requirements for longterm medium security
units. Whilst the need is clear it is difficult to quantify exactly,
but perhaps some extra 1200 beds in England & Wales are required
to fill an important gap in the provision of services for mentally disordered
offenders.
Police and Court Studies
An elaborate observational study of the Metropolitan Police at work,
both day and night, showed that over 1% of all police detainees suffer
from serious (major) mental disorder and a further 1% probably have other
serious psychiatric disabilities. These figures are minimal and based
on observations rather than interviews. The study highlighted the urgent
need for more and better medical, especially psychiatric, involvement
with work at the police station. The "community"
embraces the local police station, the local court, and the local prison,
all centres dealing with considerably psychopathology. A special comment
has been made on the use of the "appropriate adult" in the
police station for mentally disordered people. A clear distinction should
be made between juveniles and adults.
Diverting mentally disordered offenders from the criminal justice system
to the health care system is both government policy and a central interest
of the group. Schemes and studies were proposed from the Institute long
before it became fashionable. In his time with us Philip Joseph set up
and evaluated both court schemes and care for the homeless. Tim Exworthy
has continued this work with other court schemes and a prison scheme.
Risk Assessment
"Risk assessment" has become a buzz phrase in recent years.
One or two lectures have been given by members of the research group
to indicate the importance of risk management rather than risk assessment
on its own. A major review of this field has been published. Professor
Thornicroft has received a small DOH grant to develop some instrumentation
in this field. A number of follow-up studies have been undertaken to
determine the actual outcome of patient care from those who have stayed
in maximum security and medium security hospitals.
Trauma and Antisocial Behaviour
There is a growing understanding of the centrality of the experience
of trauma in the development of repetitive antisocial behaviour. Most
of the work has focused on bad experiences in childhood or in war, but
the Joint Hospital now has extensive experience of the effects of adult
and civilian trauma. Many forensic psychiatry patients are victims, all
either create victims or have the potential to do so, the prevention
and treatment of victimisation and its consequences are therefore key
issues for forensic psychiatry. The victims' service is also planning
a series of projects concerned with the development and treatment of
traumatic psychological reactions, and Til Wykes continues to assess
the effects of assaults on nursing staff within the Joint Hospital.
Personality Disorder
There has been a strong tradition within forensic psychiatry at the Institute
for the study of patients with personality disorder. The Institute was
a pioneer in studying the effectiveness of the most important therapeutic
community for personality disordered prisoners in Britain, Grendon prison;
and treatment studies of personality disorder are continuing at Broadmoor
Hospital.
BROADMOOR HOSPITAL
The new professorial unit at Broadmoor, which was opened by Princess
Diana at the end of 1995, now forms a major part of the research group.
It is headed by Professor Pamela Taylor. There are three senior lecturer
and two lecturer posts. The unit forms a separate section within the
Department of Forensic Psychiatry and its members are full members of
the research group. At Broadmoor Hospital teaching links are being developed
with Oxford and Southampton universities, and with St Bartholomew's Hospital.
It is hoped that these links will also recruit active researchers.
The unit produces its own annual research bulletin which is distributed
internally within Broadmoor Hospital. Anyone interested in this document
can obtain a copy on application to Professor Taylor at Broadmoor Hospital.
Serious Violence and Schizophrenia
The Department of Forensic Psychiatry was demonstrating the association
between serious violence and schizophrenia at a time when this was thought
not to be an important issue. One study showed that some ten per cent
of homicides in Britain are committed by patients with schizophrenia.
Collaborative work with a multi-centre study in the USA has led to the
development of a clinical rating scale to assist with more accurate prediction
of high risk patients with schizophrenia. Other work here has shown that
such high risk patients have usually been ill for more than five years;
they have had short term psychiatric care, and have prominent delusional
beliefs which are very important to them, for which they seek evidence,
and which are often associated with an unpleasant affect. This work is
being continued at Broadmoor Hospital and a recent record survey of all
1740 patients resident in special hospital during the first six months
of 1993 yielded a subsample of 1461 people convicted of a serious offence.
Except for affective symptoms, almost no symptoms were recorded among
the non-psychotic, but delusions and affective symptoms had been common
among those with psychosis, usually schizophrenia.
Special hospital patients not uncommonly have more than one diagnosis,
so the patients were classified according to the principal disorder.
Among those with psychosis uncomplicated by any of the other principal
disorders, delusions were not only present, but driving the offence in
nearly 80% of cases. This is a higher rate of delusional drive than previously
recognised, but is compatible with this being a sample of people who
had been very seriously violent.
Hallucinations on their own were not found to have had the same sort
of impact, but they may increase risk of violence in conjunction with
delusional drive.
Case Register
The special hospitals have a case register. This was used to study the
mortality of special hospital (high security) patients resident between
1977 and 1993. This is a long stay population (average 8 years, about
two-thirds of whom have a chronic psychotic illness, usually schizophrenia,
25% a personality disorder, and the remainder mental retardation). The
sample consisted of 4704 people. The figure shows a small, more or less
constant number of unnatural deaths (mostly suicide, but including Coroners'
verdicts of accident or misadventure), more during subsequent residency
in the community or other services than while still resident in special
hospital. The number of natural deaths increased annually in the generally
older discharged groups. Both within and beyond special hospital, the
people with a chronic psychotic illness or a personality disorder show
an equivalent and important vulnerability to unnatural death which is
significantly greater than that for the people with a mental retardation.
Female Mentally Disordered Offenders
A matter of growing public concern is the management of female mentally
disordered offenders. The group will take an increasing interest in this
field. This year Tony Maden has written a book about women in prison.
Research Club
The group has a regular monthly meeting (the "119 Club") when
work in progress is presented to other members. Visitors are welcome
(secretary - Dr Tracey Heads).
Criminal Behaviour and Mental Health
Three senior member of the IRG (David Farrington, John Gunn and Pamela
Taylor) edit an international journal in forensic psychiatry and psychology
Criminal Behaviour and Mental Health.
International Work
International collaboration is difficult in a field with strong legal
and administrative aspects, but we are in regular touch with the Department
of Forensic Psychiatry in Melbourne, Australia, and with the United States
MacArthur Research Network on Mental Health and the Law. We are trying
to establish links with Japan and with Russia.
Our legal interests do not attract funds, but we continue to produce
policy and review papers on issues of topical importance.
PROJECTS IN PROGRESS
Aetiological Studies
Pamela Taylor has been awarded a small grant from the Stanley Foundation
(USA) to undertake MRI scanning of the brains of men who have a predominantly
delusional presentation of their psychosis, to determine whether they
differ from men who have a mixed presentation and men who have no psychosis.
Tonmoy Sharma has been recruited to the group as advisor, and he will
be using some newer US techniques of scanning.
Alec Buchanan has recently completed a report for the Special Hospital
Service Authority describing the circumstances in which patients from
special hospitals go on to commit serious offences after discharge.
Andrew Johns has been commissioned by the Department of Health to review
the psychological effects of cannabis misuse.
Gisli Gudjonsson is looking at the family backgrounds of people who begin
to make allegations that they were sexually abused as children, after
they have started psychotherapy. The number of such cases reported in
the UK is growing and they could become a major medico-legal problem.
Treatment Studies
Tony Maden and Sue Rutter have begun an 18 month follow-up study to describe
and evaluate the outcome of all patients who have been through our medium
security unit (the Denis Hill Unit) since it opened. An attempt will
be made to identify any relationship between ethnic origin and outcome.
Gisli Gudjonsson and Sue Rutter are analysing the clinical psychology
data which has been collected on the Unit since it began; they hope to
test associations between behaviour (eg violence, compliance) and psychological
test results. Gisli Gudjonsson is also looking in detail at all violent
incidents since the secure unit opened in 1980, to describe the nature
of change in pattern of those incidents. A trainee doctor (Chris Krasucki)
is in the process of documenting substance abuse histories in previous
inpatients; It is hoped that this will lead to the development of intervention
programmes within the inpatient services.
A large clinical research programme being undertaken by Pamela Taylor
in three special hospitals (Broadmoor, Rampton & Ashworth) is a study
of patients in maximum security with schizophrenia who are resistant
to treatment or resisting it. The project will include a diagnostic and
symptomatic survey from case records, a detailed descriptive account
of a sample of special hospital patients with treatment resistant schizophrenia,
and a randomised trial and follow up of patients started on clozapine
or risperidone. Tracey Heads has included an assessment of early childhood
experiences as possible factors to distinguish between the violent and
the less violent. Martin Butwell is also undertaking a descriptive account
of the trends in referrals, admissions and bed occupancy over the eight
years 1985-92. Preliminary analysis of the diagnostic and symptom survey
of special hospital patients confirms the importance of delusions as
risk factors.
Interface Between Law and Behavioural Sciences
Gisli Gudjonsson and his colleagues continue with their series of studies
of remanded and convicted individuals who assert that during police questioning
they made false confessions. It has already been shown that some psychiatric
patients are particularly likely to make false confessions and this work
is of considerable pioneering interest.
Pamela Taylor, in conjunction with Angus Cameron and Michael Kennedy,
is studying the impact of legal changes on care provision. A paper on
the impact of judicial review is ready for publication. Models of throughcare
and the care planning approach are to be tested in a special hospital
sample.
A study of changes in anger in special hospital patients brought about
by a therapeutic theatre project has been conducted by Clive Meux and
David Reiss.
Organisation of Services
Following earlier psychiatric needs assessments of the prison population
of England and Wales, and of the English special hospitals, Tony Maden
and his colleagues (Celia Taylor and Deborah Brooke) are currently conducting
a national epidemiological survey of untried prisoners to determine their
mental health and psychiatric needs. In this way a total picture of the
psychiatric needs of the offender population in this country is gradually
being put together. Earlier papers have already influenced Department
of Health and Home Office policies. The clinical services here have pioneered
the development of care in the community for mentally disordered offenders.
FUTURE PLANS
John Gunn, and David Farrington are seeking funds to re-examine 400 males
born in Camberwell in 1951-4. These men form the Cambridge Delinquent
Development cohort which has been so productive in determining important
correlates of criminal behaviour. This time it is hoped to interview
them to determine their psychiatric histories and pathology with a view
to relating contemporaneously collected data with this new psychiatric
outcome data.
The studies of brain structure and function being carried out by Pamela
Taylor will, it is hoped, be amplified by a new series of studies. The
availability of an improved portable MRI scanner has made volumetric
analysis feasible in Broadmoor patients.
David Forshaw has established a specialised inpatient service for addictive
behaviours at Broadmoor Hospital. He hopes to describe and evaluate this
new service.
Pamela Taylor proposes a follow-up study of the prisoners she studied
12-15 years ago. This was the pioneer study mentioned above, which showed
a relationship between psychosis and violence. It is hoped to determine
whether the subjects have had further criminal careers, and whether they
still survive.
It is proposed that a monograph will be written putting together the
various studies which have been undertaken on the epidemiology of abnormal
offenders with the view of drawing up a needs assessment of mentally
disordered offenders in institutions. The group is also hoping to extend
its work into risk assessment by designing user friendly instruments
for general psychiatrists and paramedics, as well as conducting intensive
follow-up studies of "dangerous patients."
Tim Exworthy is seeking funds for a follow up study of mentally disordered
offenders diverted from custody. Sophie Davison, an SHSA research fellow
who has just completed her criminology degree, will be working with Pamela
Taylor on a comparative study on men with personality disorder referred
for a special hospital bed, between those accepted, those rejected, and
those in prison never referred. It is hoped to extend this work to include
women with personality disorder. Andrew Johns and Pamela Taylor are planning
a study of factors influencing the disposal of life sentenced prisoners
who are cared for in special hospitals.
David Reiss is proposing to collaborate with Professor Checkley in studying
cortisol levels in patients with post-traumatic stress disorder (PTSD).
David Reiss and Tonmoy Sharma are also writing a protocol to examine
brain function in traumatised patients, using the functional MRI scanner.
Ronan McIvor is examining the growth hormone response to apomorphine
in patients with PTSD. John Gunn and David Reiss have been negotiating
a source of newly traumatised patients who can be studied as they recover
and treated in experimental ways. The burns unit at Queen Victoria Hospital,
East Grinstead, is interested in this work and a joint proposal for funding
is being rafted. Pamela Taylor and Mark Turner are examining a large
set of reports from one defence expert in the psychological trauma field,
to understand better the areas of conflict in legal cases. Celia Taylor
is trawling Broadmoor Hospital for pedigrees of patients who are both
violent and suffer from schizophrenia, with a view to conducting molecular
genetic studies on any identified. This work will be done in collaboration
with Professor Mullan of the University of South Florida. A new development
for 1996 has been closer collaboration with Professor Jeremy Coid of
St Bartholomew's Hospital. Professor Coid holds six grants valued at
more than half a million pounds, studying such matters as personality
disorder in opiate users, needs assessments of mentally disordered offenders,
and severe mental disorder in Afro-Caribbean people. Professor Coid is
now a full member of the IRG and we hope to welcome other members of
his team later and perhaps undertake collaborative work.