Violent Behavior in Forensic Residential Facilities: The Italian Experience After the Closure of Forensic Psychiatric Hospitals

Zanalda, Enrico; Cori, David De; Ala, Grazia; Sodano, A Jaretti; Zuffranieri, Marco

doi:10.1007/978-3-030-33188-7_12

Cited by 3 publications

(4 citation statements)

References 25 publications

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“…This could be explained by the fact that, although at low risk of reporting professional liability involvement, psychiatrists are burdened by strong stress linked to other factors [15], such as dealing with suicidal patients [24], those who are violent [25], or those exhibiting abnormal behaviors due to substance intoxication [26]. Furthermore, they often have a duty of care for people with personality disorders (including antisocial) [9], for which there are few therapeutic means at their disposal.…”

Section: Discussionmentioning

confidence: 99%

“…Italian psychiatrists constitute a critical group for study due to their unique legal context. In the 1970s, Italy underwent mental health reforms, leading to a shift towards primarily outpatient, community-based care [9]. This resulted in the establishment of territorial facilities where psychiatrists care for patients, even those with serious disorders and complex rehabilitative needs.…”

Section: Introductionmentioning

confidence: 99%

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Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Morena,

Di Fazio,

Scognamiglio

et al. 2023

Medicina

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Background: Defensive medicine is characterized by medical decisions made primarily as a precaution against potential malpractice claims. For psychiatrists, professional responsibility encompasses not only the appropriateness of diagnosis and treatment but also the effects of their interventions on patients and their behaviors. Objective: To investigate the socio-demographic, educational, and occupational characteristics and work-related attitudes that may serve as predictors of defensive medicine among Italian psychiatrists. This research extends the results of a previous analysis based on a national survey. Methods: A secondary analysis of the database of a national survey on attitudes and behaviors of Italian psychiatrists regarding defensive medicine and professional liability was performed for this study. Results: Among 254 surveyed psychiatrists, 153 admitted to practicing defensive medicine, while 101 had this attitude with less than half of their patients. The first group was predominantly comprised of women (p = 0.014), who were younger in age (43.34 y 9.89 vs. 48.81 y 11.66, p < 0.001) and had fewer years of professional experience (12.09 y ± 9.8 vs. 17.46 y ± 11.2, p < 0.001). There were no significant differences in prior involvement in complaints (p = 0.876) or the usual place of work (p = 0.818). The most prominent predictors for practicing defensive medicine were (1) considering guidelines and good clinical practices not only for their clinical efficacy but also or exclusively for reducing the risk of legal complaints for professional liability (OR = 3.62; 95%CI, 1.75–7.49), and (2) hospitalizing patients with violent intentions even if not warranted according to their mental state (OR = 2.28; 95%CI, 1.50–3.46, p < 0.001). Prioritizing protection from professional liability over patients’ actual needs in prescribing or adjusting drug dosages and in involuntary hospitalization, as well as prescribing lower dosages than recommended for pregnant patients, were identified as additional predictors. Finally, years of professional experience exhibited a protective function against defensive practices. Conclusions: Psychiatrists advocate the need to implement a ‘risk management culture’ and the provision of more balanced duties in order to ensure ethical and evidence-based care to their patients. A particular source of concern stems from their professional responsibility towards not only the health of patients but also their behavior. However, these aspects conflict with a limited potential for assessment and intervention based on effective clinical tools. A reform of professional liability that considers the specificities of patients cared for by mental health services could contribute to reducing the risk of defensive medicine.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Morena,

Di Fazio,

Scognamiglio

et al. 2023

Medicina

View full text Add to dashboard Cite

show abstract

“…Within these settings inpatients with psychiatric disorders who committed a criminal offense, without criminal responsibility but still considered socially dangerous, are held and treated. The healthcare professionals encourage inpatients to participate in a recoveryoriented rehabilitation project, in order to return them to community services as soon as possible (Catanesi et al 2019;Zanalda et al 2020).…”

Section: Introductionmentioning

confidence: 99%

Vulnerabilities of High-Security Forensic Psychiatry Residences in Italy during the COVID-19 pandemic: a qualitative survey and a proposal for recovery and prevention

Pozza

Ferretti

Carabellese

et al. 2020

Preprint

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Italy is the first European country severely hit by the COVID-19 pandemic after the outbreak in Wuhan. In our healthcare context, the closing of forensic psychiatric hospitals in 2014 completed the long transition from a containment approach for offenders with severe mental disorders to a model oriented to recovery and community reintegration. High-Security Forensic Psychiatry Residences (REMS) were implemented by regional health authorities. Within these settings, inpatients with severe psychiatric disorders who committed a criminal offense, without criminal responsibility but still considered socially dangerous, are held, and treated. The current COVID-19 emergency represents a severe stressful event which has a potentially negative impact on the recovery process of the inpatients and on the work-related health of the psychiatric professionals. The present paper consists of two sections. In the first one, we discuss the organizational and clinical issues emerged in the forensic psychiatry system in Italy. We identify vulnerable groups and processes and suggest long-term prevention strategies at both clinical and organizational levels. Within the second section, we present the findings of a qualitative exploratory survey conducted in four different REMS immediately after the stop of the lockdown. Based on a qualitative approach, this survey explored the COVID-19 effects on mental health of REMS inpatients and healthcare workers. Thematic analysis showed five key themes: “Intervention and prevention strategies during the lockdown decision making”; “Inpatients’ reactions to the pandemic”; “Psychological reactions of the healthcare staff”; “Recovery process and relations with community mental health services”; “Lessons for the future learned from the COVID-19”.

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“…An adequate time perspective will allow more reliable evaluations in the coming months, but the COVID emergency is already allowing us to confirm that it is appropriate to limit the number of beds in structures of last resort such as the REMS 9 (in Piedmont 40 beds for 4.356 million inhabitants 10 ). The reason for this is that it becomes extremely complicated, should the need arise again, to transfer these patients to their homes or to a halfway house by revoking detention security measures 7 .…”

mentioning

confidence: 99%

Forensic psychiatry in the time of coronavirus: The Italian security residences put to the test in a public health emergency

Zuffranieri

Zanalda

2020

Psychiatry Clin Neurosci

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The COVID-19 emergency significantly affected the functioning of almost all activities in Italy 1 . Healthcare services were heavily involved. Even those not on the frontline dealing with the outbreak, had to immediately change their operational procedures 2,3 . Hospitals were largely adapted to the reception of COVID-positive patients and local residential facilities set up barriers both to the entry of new patients and to outside visitors. Many patients returned home where isolation could be guaranteed. Even in prisons, visits by external staff were suspended and procedures for inmates' release, when legally possible, were accelerated. In Italy, with the definitive closure of forensic psychiatric hospitals, security residences (REMS) have been established in all regions 4 . REMS are territorial psychiatric rehabilitative health facilities for offenders who are mentally incapacitated and considered to be highly dangerous to society; each REMS can accommodate 20 patients. Most of the offenders are treated in the ordinary psychiatric residential facilities, which in our region treat 2500 patients, about 10% of them offenders 5 .With the start of the COVID-19 Phase 1, characterized by the total lockdown of the population, an operational procedure adapted from the guidelines laid down at the national level by the National Health Authority 6 , was prepared in Piedmont specifically for the two local REMS. The application of these regulations has led to various modifications, some of which are particularly significant. First of all, the inclusion in REMS was limited to people already in prison or people who were difficult to control in the community during lockdown. The waiting list 7 to enter REMS was, therefore, blocked and court orders were temporarily put on hold, particularly where clinical and safety monitoring was guaranteed in the patients' current placement. Swab-positive COVID patients have been managed in isolation within REMS if they were asymptomatic or paucisymptomatic and directed to hospitals if they presented more severe symptoms. The REMS that had positive cases among their patients had to be divided into two zones, respectively COVID and COVID-free zones, with separate routes of entry. Comprehensive use of appropriate PPE was also instated.

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Violent Behavior in Forensic Residential Facilities: The Italian Experience After the Closure of Forensic Psychiatric Hospitals

Cited by 3 publications

References 25 publications

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Vulnerabilities of High-Security Forensic Psychiatry Residences in Italy during the COVID-19 pandemic: a qualitative survey and a proposal for recovery and prevention

Forensic psychiatry in the time of coronavirus: The Italian security residences put to the test in a public health emergency

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