High Security Settings in Flanders: An Analysis of Discharged and Long-Term Forensic Psychiatric Patients

Abstract

BackgroundTwo Forensic Psychiatric Centres (FPC) were implemented the last decade in Flanders in Ghent (2014) and Antwerp (2017). FPCs are forensic institutions for forensic psychiatric patients with a high recidivism risk and a high security need. The objective of FPCs is to create a care process with sufficient flow (from high to lower forms of security), and transitions (from specialized forensic care to regular psychiatric care).AimsTo examine the characteristics of the high security population in FPCs, treatment length, number of discharges, and discharge locations and to determine the profile of long-term patients within an FPC.MethodsA retrospective file study of an admission cohort of 654 patients admitted to FPC Ghent or FPC Antwerp was conducted. Sociodemographic, clinical, judicial and risk characteristics were analyzed. Bivariate analyses were used to test the difference between two groups: the group that was discharged to a lower security level vs. the group of long-term patients.ResultsMost patients had psychosis and personality disorders, while comorbidity was also high. Judicial histories were extensive, with many sexual index offenses. During a 6-year follow-up period, the number of referrals back to prison was low. Nearly a third of the population was discharged to a setting with a lower security level. Long-term patients typically presented with more personality disorders, higher psychopathy traits and higher risk scores and were more frequently subjected to coercive measures during treatment.ConclusionsThe Flemish FPC population is characterized by a high proportion of sex offenders as well as a high proportion of personality-disordered patients. It is this last group, and the group with elevated psychopathy traits, who remain for longer than expected and is difficult to resocialize. This study further highlights the need for clear criteria to assess the conditions of these long-term patients in Flanders.

Court-ordered inpatient psychiatric care in Switzerland: determinants of length of stay and treatment outcome

“…Consistent with a previous study ( 40 ), most of our patients have been diagnosed with co-occurring mental and SUDs, but only a low percentage met the criteria for antisocial personality disorder. MDO represent a clinically distinct group with an overrepresentation of psychotic disorders compared to regular inmates with mental disorders as already reported in several previous studies ( 4 , 9 , 18 , 41–44 ). A modest but consistent association between interpersonal violence and schizophrenia combined with comorbid SUD has been reported over the last decades ( 45 , 46 ).…”

“…In contrast, nearly 37% of the patients in forensic psychiatric hospitals in Germany have a primary diagnosis of personality disorders ( 6 ). Personality disorders were the second most prevalent diagnoses (34%) in high security patients with mandatory placement in forensic psychiatric centers in Belgium ( 18 , 51 ). Johnson and Elbogen ( 51 ) postulated that the high incidence of this pathology in criminal populations, as well as the difficulty to determine direct causality between their presence and criminal act, and define the cut-off between traits and clinically overt disorders, may explain the variability of prevalence rates for this condition among MDO.…”

“…Our results are consistent with the prevalence rates reported in Germany and Belgium, pointing to the progressive change of the clinical conception of these disorders that are no longer considered under volitional control. Importantly, Jeandarme et al ( 18 ) suggest that in countries admitting decreased or abolished responsibility, psychiatrist-judicial experts are more likely to conclude that patients with personality disorders are unable to control their behavior. Some authors have suggested that violent individuals with schizophrenia and antisocial personality disorder share common emotion processing deficits such as facial affect recognition, which might benefit from transdiagnostic treatment targets ( 52 ).…”

“…Whether or not personality disorders can be treated in secure settings remains a matter of debate. Among this group of COT inpatients, it has been suggested to distinguish those who respond to long-term therapeutic approaches within the scope of reduced risk of recidivism from those who are treatment-resistant with poor prognosis and persistent risk of reoffending ( 18 ). A dimensional model of personality, such as defined by the newly published ICD-11 manual, could provide additional cues to define the severity of the personality disorder, and its relationship to offending, rehabilitative prospects and community protection ( 59 ).…”

“…Legal frameworks governing detention vary across European countries so that the characteristics of COT are not easily comparable ( 1 , 2 , 4 ). Over the last 20 years, detailed description of inpatient COT was provided in Austria ( 17 ), Belgium ( 18 ), France ( 8 , 19 ), Germany ( 20 ), Netherlands ( 21 ), and United Kingdom ( 22 ). The Swiss Criminal Code 1 distinguishes between penalties and COT, named therapeutic measures.…”