is usually perpetrated by fathers or step- abuse is less common. Adolescent offending is associated Rates of sexual offenses Rates of recorded sexual offenses are shown on b p. 685. Many sexu al offenses are not reported. Rates of sexual reoffending Extra-familial child offenders > offenders against adults > incest offenders. Internet offenses A growing concern over the l ast two decades has been the role of the Internet in providing a method of distribution of obscene and/or unlawful sexual material (particularly images of children). The fast rate of technological developments and the global reach of the Internet, crossing legal jurisdicti ons, has left the police and legal authori- ties in many countries struggling to keep pace and the law in this area is still developing. The recently adopted Section 63 of the Crimin al Justice and Immigration Act 2008 (in England and Wales) and Section 42 of the Criminal J ustice and Licensing (Scotland) Act 2010 (in Scotland) criminalize possession of what it re fers to as \200\230extreme pornographic images \200\231. 17_Semple_Chap17.indd 683 12/7/2012 3:49:46 PM CHAPTER 17 Forensic psychiatry 684 Sexual offenses 2 Characteristics of sex offenders A heterogeneous group \200\224possible r elevant factors: deviant sexual fantasy, sexual dysfunction, abnormal per- sonality (impuls ivity, lack of empathy, inhibition, social anxiety), relation- ship dif \201 culties (poor social skills, social isolation), alcohol or drug misuse, denial and minimization of offen ding, cognitive distortions (regarding sex, women, or children), problems with assertivenes s and control of anger, previous histories of victimization. Mental disorder and sex offend ing The most common mental dis- orders found in sex offenders: personality disorder, paraph ilias, alcohol and substance misuse; severe mental illness is rare. Sex offenders with psyc hosis share many of the features of other sex offenders and offending is rarely due to spec i \201 c psychotic symptoms. Disinhibition due to mania or organic disorders may lead to, usually minor, sexual offenses. Most sex offenses committed by people with LD are associate d with lack of sexual knowledge, poor social skills, and inability to express a normal sex drive appropriately. A few more serious and persistent LD offenders may share characteristi cs of other sex offenders. Assessment of sex offenders Full psychiatric history and MSE \200\224 emphasis on the nature of the incident(s), psychosexual history, and previ- ous of fenses, utilizing sources of information other than the accused. It may be dif \201 cult t o build up a full picture of a person \200\231s sexual fantasies and activi- ties. Some cen ters (mainly in North America) use penile plethysmography (measuring the extent of penile e rection in response to various stimuli). Risk assessment (b p. 692) Consider the following factors: sexual devi- ation; personality disorder; mental illness; substance misuse; relati onship problems; employment problems; previous offenses (sexual and non-sex- ual); previous supervision failure; frequency, types, and escalation in sexual offending; physical harm t o victims and use of weapons; denial/minimization and cognitive distortions; future plans a nd attitudes towards intervention. Management of sex offenders Some mentally disordered off enders require treatment in hospital (esp. those with mental illness or marked LD). In psyc hotic sex offenders it is usually important to address fac- tors common to other sex offend ers. Those with personality disorders, paraphilias, and substance misuse are normally deale d with by the crimi- nal justice system. Within the criminal justice system, both in prison and the community, group CBT programs have been developed. A small number of sex offenders receive psychodynamic treatment at specialist clinics. Medications such as anti-androgens, anti-gonadotrophins, and SSRIs may be used in a few offenders. Speci \201 c legal provisi ons The Sex Offenders Act 1997 requires sex offenders to register their address with the po lice. The Crime and Disorder Act 1998 enables courts to impose Sex Offender Orders on convi cted sex offenders who are not registered under the Sex Offender Act and whose behavior giv es cause for concern. The order requires the offender to register with the police and to de sist from behavior that has been identi \201 ed as indicative of future risk. The same Act allows courts to impose extended sentences on sex offenders. The extended sentence compris es a custodial element with an \200\230extended \200\231 period of supervision 17_Semple_Chap17.indd 684 12/7/2012 3:49:46 PM SEXUAL offenses 2 685 post-release for up to 10yrs. Amendments to the Sexual Offenses Act 2003 allow courts to ap ply a \200\230Sexual Offenses Prevention Order \200\231 (SOPO) even for offenses not prima rily sexual in nature. Offenders issued with a SOPO are added to the sex offenders \200\231 register and are barred from speci- \201 ed behaviors. The \200\230Protection of Childr en and Prevention of Sexual Offenses (Scotland) Act 2005 allows for the application of the similar \200\230Risk of Sexual Harm Order \200\231 (ROSHO) to offenders in Scotland. Box 17.3 Recorded sexual offenses Sexual offenses recorded by the police in each of the jurisdictions in the British Isles in 2001 or 2001 \200\2232. Note that different jurisdictions have different ways of de \201 ning and classifying sexual offenses. England and Wales (2001 \200\2232) Buggery Indecent assault on a male Gross indecency betwe en males Rape of a female Rape of a male Indecent assault of a female Unlawful sexual inter course with a girl Unlawful sexual intercourse with a girl <16 Incest Procuration Abduction Bigamy Soliciting or importuning by a man Abuse of position of trust Gross indecency with a child Total offenses Indecent exposure (recorded with other offenses Scotland (2001) Rape Assault with intent to rape Indecent assault Lewd and libidinous practices Indecent exposu re Incest Homosexual acts Sexual intercourse with a girl <16 Prostitution offenses Other cr imes of indecency Total crimes NI (2001 \200\2232) Rape Attempted rape Buggery Indecent assault of female Indecent assault of female child Indecent assault of male Indecent assault of male child Homosexual acts In decent exposure Indecent conduct towards a child Other sexual offenses Total offenses 354 3613 163 252 40 27 286 308 9008 735 21765 170 34 55 1336 5 333 23 93 130 263 74 1648 32 1431 RoI (2001) Sexual assault Sexual offense involving mentally impaired person Gross indecency Buggery Unlawful carnal knowledge Rape (section 4) Bestiality Aggravated sexual assault In decency Rape of a female Incest Brothel keeping Prostitution Total offenses 408 1665 41425 8187 1048 10 33 36 78 66 2 18 150 335 16 5 142 1939 589 164 1154 1557 808 34 133 179 1328 41 5987 17_Semple_Chap17.indd 685 12/7/2012 3:49:46 PM CHAPTER 17 Forensic psychiatry 686 Stalking Essence A constellation of behaviors in which an individual in \202 icts on anoth er repeated, unwanted intrusions and communications. Common stalking behaviors include: fol lowing, loitering nearby, maintaining sur- veillance, and making approaches and communicati ons in any modality, most commonly phone calls. Stalking behavior can arise as a result of an attempt to establish, re-establish, or impose a relationship on another who has either m ade clear their disinterest, or has not been consulted on the matter, or to retaliate for s ome perceived injustice. History Stalking is not a new phenomenon, but the naming of this c ourse of conduct, coupled with legal, public, and scienti \201 c interest in it is. The \201 rst state to speci \201 cally criminalize stalking was California in 1990, fol- lowin g a series of high-pro \201 le stalking cases. It was \201 rst made a speci \201 c crim inal offense in the UK by the Protection from Harassment Act 1997. This made it an offense to pursue a course of conduct which amounts to harassment of another on two or more occasio ns. Epidemiology The British Crime Survey 1998 found that 11.8% of UK adults had been subje ct to persistent and unwanted attention since age 16. Lifetime rates are signi \201 cantly higher for females (16.1%) than males (6.8%). Perpetrators are much more likely to be male (81%). Females are usually stalked by a male (90%). Men are almost as likely to be stalked by a female (43%) as a male (57%). Most victims are stalked by someone already known to th em: current or former intimate 29%; acquaintance 29%; work contact 9%; estranged friend or relative 6%. Only about of 34% victims are stalked by a stranger. Stalker typology1 Rejected stalkers Pursue victims in order to reverse, correct, or avenge rejection (e.g. divorce, separation, termination of relationship). Resentful stalkers Pursue a vendetta because of a sense of grievance against the victims. M otivated by the desire to frighten and distress. Incompetent suitors Despite poor social or courting skills, have a \201 xation on, or in some cases a sense of entitlement to, an intimate relationship with those who have attracte d their amorous interest. Predatory stalkers Initially spy on victim as a precursor to a sexual assault. However, sta lking can be sustained in this group due to stalker taking pleasure in voyeurism and fantas y about the coming attack. Erotomaniac stalkers Have the delusional belief that another person, usu- ally of higher so cial status, is secretly in love with them. The sufferer may also believe that the subject of their delusion secretly communicates their love through seemingly innocuous acts, or if they are a public \201 gure through clues in the media. The object of the delusion usuall y has little or no contact with the sufferer, who often believes the object initiated the \201 ctional relationship. Erotomaniac delusions are typically found as the pri- mary symp tom of a delusional disorder, and in schizophrenia or mania. 17_Semple_Chap17.indd 686 12/7/2012 3:49:46 PM STALKING 687 Effects of stalking on victims Stalking can have devastating conse- quences for both the vi ctim and stalker. Victims of stalking can develop depression, PTSD-like symptoms, anxiety d isorders/phobias, and substance misuse problems. Stalking of health professionals Health pr ofessionals (especially mental health professionals) are at increased risk of being stalked compared to the general public. One study found that 53% of staff in an inpatient psychiat ric unit had experienced some form of stalking harassment during their careers. Another whi ch looked at the frequency of various diagnoses in patients who were stalking mental health staff found that 45% had a psychotic disorder, 11% had a mood disorder, and 37% had a pers onality disorder. Stalking risk assessment Usually performed by a forensic psychiatrist or psychologist, a ri sk assessment tool such as the Stalking Assessment and Management (SAM) tool, can be used t o stratify stalkers into groups depending on the level of risk of harm they pose. Various f actors have been found to increase the risk of harm arising, e.g. substance misuse problems , previous criminality, persistence. The aim is to formulate a management plan to target ri sk factors to reduce risk. What to do if you are being stalked \200 Inform others (family, friends, neighbors, work, police) what is happening, as stalkers wil l use embarrassed secrecy on the part of the victim to further their stalking aims. Protect personal information (e.g. social networking sites, household garbage). Use an answering m achine (enables recording of stalker \200\231s calls). Retain all evidence of stalking. Con tact the police early, and keep contacting them whenever further incidents occur, and provi de them with any evidence of the stalking. Obtain a restraining order which, if breached, w ill result in the incarceration of the stalker. \200 \200 1 Confronting the stalker is not advised due to risk of provoking an escalation to violence . 1 Mullen PE, Path M and Purcell R (2009) Stalkers and their victims, 2nd edn. Cambridge: Cambridge University Press. 17_Semple_Chap17.indd 687 12/7/2012 3:49:46 PM CHAPTER 17 Forensic psychiatry 688 Other offenses Arson Arson ( \201 re-setting in Scotland) is considered to be a serious of fense due to its potential to threaten life and cause massive destruction. Only a small pro portion (less than 20%) of arson offenses lead to prosecution. Classi \201 cation As with sex offenders and other offenders, typologies are fraught with problems. The following groups have been described (but they are not mutually exclusive): i nsurance fraud, covering evidence of crime, politically motivated, gang activity, revenge/a nger, cry for help, desire for power, desire to be hero, fascination with \201 re, sexual excite- ment, suicide, psychiatric disorder. Psychiatric disorder Alcohol/substance misuse and personality disorder are the most frequen t; less common are psychosis, organic disorders, and learning disability (a previously high lighted association due to studies of patients in secure hospitals). Pure \200\230pyromani a \200\231 is rare \200\224features are usually seen in individuals with personality disord ers. Assessment Full psychiatric assessment with detailed examination of cur- rent and previous offenses. Management Treatment of mental disorder if present; speci \201 c psycho- logical intervent ions have been proposed but little evidence; important to take steps to prevent access to m atches and lighters if ongoing risk in hospital setting. Outcome Rates of further arson 2 \200\22320%, rates of any reoffending 10 \200\22330%. No s peci \201 c indicators of risk. Other damage to property Acts of vandalism are common, especially in adolescence. There is little psychiatric literature on criminal damage excluding arson. Crimes of dishonesty Burglary, theft, and fraud are common offenses which are rarely asso- ciated with psychiatric disorder. Shoplifting has attracted some clinical attention. About 5% of shoplifters suffer from signi \201 cant mental disor- der (personality disorder, sub stance misuse, depression, schizophrenia, dementia). Pure kleptomania is extremely rare (se e b p. 408). Drug offenses Mental disorder rarely an issue (with the obvious exception of substance misu se/dependence and associated conditions). Car crime Impaired ability to drive may be caused by a number of disorders (see b p. 902). Occasional rare cases of people disinhibited by mania or impaired by dementia who cause ser ious injury or death. However, mental disorder is rarely an issue in car crime. 17_Semple_Chap17.indd 688 12/7/2012 3:49:46 PM MENTAL DISORDER AND OFFENDING 1: OVERVIEW 689 Mental disorder and offending 1: overview What is the relationship between mental disorder and offending? Mental disorder is common and offending is common, so it would not be surpri sing to \201 nd an individual with both. But is the relationship more than coincidental? When looking at studies of this relationship one needs to consider: \200 The nature of the sample studied (community vs. institutional; clinical vs. epidemiological ; pre-treatment vs. post-treatment; offenders vs. non-offenders). The criteria used to de \201 ne mental disorder (legal vs. clinical vs. operationalized) and the method used to det ermine its existence (case notes vs. interviews; clinically trained vs. lay interviewers). The criteria used to de \201 ne offending (types of of \201 cially recorded offenses incl uded; inclusion of unreported or unprosecuted \200\230offenses \200\231) and the method us ed to detect offenses (of \201 cial records vs. self-report vs. third-party report). Most of the research has focused on violence. The following are the main conclusions to be drawn from current evidence. \200 People with mental disorder as a broad group are no more or less likely to offend than the general population. Some speci \201 c mental disorders do increase the risk of a person ac ting violently, particularly alcohol- and drug-related disorders and personality disorders (especially those with predominant cluster B characteristics). Schizophrenia has a modest a ssociation with violence, but the overwhelming majority of people with schizophrenia are ne ver violent, being more likely to be victims than perpetrators of violence. In people with mental disorders the factors most strongly associated with offending are the same as for no n-mentally disordered offenders: male gender, young age, substance misuse, disturbed childh ood, socioeconomic deprivation. When considering an offense perpetrated by a person with me ntal disorder, one should bear in mind that, as with any offense, there is interplay betwee n the perpetrator, the victim, and the situational circumstances. Although mental disorder may play a part it is rarely the only factor that leads to an offense. 17_Semple_Chap17.indd 689 12/7/2012 3:49:46 PM CHAPTER 17 Forensic psychiatry 690 Mental disorder and offending 2: speci \201 c disorders and offending1,2,3 Schizophrenia T he lifetime risk of violence in people with schizophrenia is about 5 times that in the gene ral population. People with schizophrenia account for less than 10% of all violent crime in Britain. The factors most commonly associ- ated with violence in people with schizophrenia are those associated with violence in people without psychosis. Alcohol and drug misuse ar e particu- larly important. Speci \201 c symptoms may be important but clearly are not eno ugh in themselves, otherwise virtually every person with schizophrenia would be violent. Th reat control-override symptoms (delusions regarding being threatened or being controlled) h ave been found to be associated with violence, but again, most patients with these symptoms are never violent. The role of command auditory hallucinations is unclear. When people wit h psychosis are violent the victim is more likely to be known to them (particularly relativ es) than when violence is committed by non- psychotic individuals. Delusional disorders Delusional disorders are probably over-represented among patients deta ined in secure psychiatric hospitals; however, the research on the association between delu sional disorders and violence is dif \201 cult to inter- pret as the samples are usually s elective and uncontrolled, and in many studies patients with delusional disorders are lumpe d in with patients with other psychoses, especially schizophrenia. Increased risk of violen ce has been reported to be associated with persecutory delusions, misidenti \201 - cation delusions, delusions of jealousy, delusions of love, and querulous delusions. Jealousy may be dangerous whether it is delusionally based or not. In some cases it is dif \201 cult to differentiate between premorbid per- sonality disorder (perhaps with paranoid and/or narci ssistic features) and delusional disorder. The relevant beliefs are probably no less risky if they are over-valued ideas than if they are delusional. Affective disorders Affective disorders have a far less strong relationship with offending and violence than schizophrenia. Mania commonly leads to minor offending due to grandiosity and disinhibition, but rarely leads to serious violence or sexual assaults. Depression is very rarely associated with violence or offending. Extended suicide (also known as altruist ic homicide), in which a depressed parent (usually the father) kills members of their famil y before attempting and perhaps succeeding in killing themselves, is extremely rare and imp ossible to predict. In some cases it occurs in depressive psychosis associated with nihilis tic delusions, but more commonly there is a history of marital breakdown in people who are depressed and suicidal but not psychotic. A historical association between shoplifting and depression has been highlighted, but is probably insigni \201 cant. 17_Semple_Chap17.indd 690 12/7/2012 3:49:46 PM MENTAL DISORDER AND OFFENDING 2: SPECIFIC DISORDERS 691 Alcohol- and drug-related disorders Alcohol- and drug-related problems are more strongly li nked to offending and violence than any other mental disorders. A number of aspects of alco hol and substance misuse may be relevant: direct effects of intoxi- cation or withdrawal; f unding the habit; the personal and social conse- quences of dependence; the neuropsychiatri c sequel of prolonged misuse; the social context (peer group, socio-economic deprivation, c hildhood mistreatment), and personal characteristics (impulsivity and sensation seeking), w hich may lead to substance misuse, may also be associated with offending. Personality disorders Personality disorder is more strongly related to offending and violen ce than mental illness. Personality disordered offenders are heterogeneous: only a small nu mber are psychopathic (see b p. 496). Various aspects of personality disorder may be relate d to offending: impulsivity, lack of empathy, poor affect regulation, paranoid thinking, po or relationships with others, problems with anger and assertiveness. Learning disability Offending occurs more often in people with milder forms of learning dis - ability than in those with severe learning disability. Offenses are broadly similar to th ose in non-learning disabled offenders and are associated with family and social disadvanta ge. Evidence for increased rates of sex offend- ing and \201 re-raising is based on highl y selected patient samples in secure hospitals and is therefore questionable. In some learn ing disabled offend- ers poor social development, poor educational achievement, gullibility , and impaired ability to communicate may be important factors. Profound and severe learnin g disability may be associated with disturbed behavior, including aggression, but would rar ely come to the attention of the crimi- nal justice system. Organic disorders Aggression is well recognized in dementia, but rarely leads to serious vi o- lence. Delirium and brain injury may lead to aggression. In head injury cases it may be dif \201 cult to differentiate the effects of the head injury from premorbid personality. Epilepsy is twice as common in offenders as in the general population, but this is probably due to shared environmental and biological disadvantages that predispose individuals to bo th. Violence resulting from epileptic activity is extremely rare. 1 Higgins J (1995) Crime and mental disorder II. Forensic aspects of psychiatric disorder. In Chiswick D and Cope R (eds), Seminars in practical forensic psychiatry. London: Gaskell. 2 Walsh E, Buchanan A and Fahy T (2002) Violence and schizophrenia: examining the evidence . Br J Psychol 180: 490 \200\2235. 3 Chiswick D (1998) The relationship between crime and p sychiatry. In: Johnstone EC, Freeman CPL and Zealley AK (eds), Companion to psychiatric stu dies. Edinburgh: Churchill Livingstone. 17_Semple_Chap17.indd 691 12/7/2012 3:49:47 PM CHAPTER 17 Forensic psychiatry 692 Assessing risk of violence1,2,3 Context Risk of violence to others is assessed by psychiatr ists in a range of situations, (e.g. acute assessments in casualty, allowing patients leave , court reports, determining whether a patient should progress from a secure setting; see B ox 17.4). Types of violence risk assessment \200 Clinical: guided by the research literature. Clinical risk assessment criticized due to lac k of reliability, validity, and transparency. Actuarial approaches based on multivariate an alyzes of factors in samples of forensic patients or prisoners to determine which predict f urther violence. Variables predictive of recidivism given weightings and combined to give s core. From this score a probability of recidivism can be calculated. Criticized as factors identi \201 ed invariably historical unchangeable attributes. Considered by some to be in \202 exible and unable to inform risk management. Structured clinical approach. Combines h istorical factors of actuarial approach with dynamic factors in structured way. Clinically the consideration of each factor is more important than the actual scores, so act as useful aides- m moires. The approach here is based on this method. Traditionally carried out in an unstructured manner, perhaps (e.g. violence risk appraisal guide [VRAG]): Statistical (e.g. historical, clinical and risk [HCR-20]): Intermediate Information Sources of information determined by nature and context of assessment, using as many sources of information as possible: records (psychiatric, general practice, social wo rk, prison, school, criminal), inter- views (patient, relatives, staff), psychometric (e.g. PCL-R). Factors to consider (based on HCR-20) \200 Historical motivation, victims, context); relationships (lack of relationships, unstable re lationships); employment (poor employment record, disciplinary problems); substance misuse; mental illness (noting its relationship to previous aggression); personality disorder (dis social, emotionally unstable, paranoid, psychopathy); childhood problems (behavioral distur bance, mistreatment); previous dif \201 culties with supervision (absconding, lack of atte ndance, lack of compliance). Current (internal) Symptoms (delusions, hallucinations); threa ts (towards particular victim or group); fantasies (violence, sexual); attitudes (pro-crimi nal, minimization, denial); impulsivity; insight (into illness, into personality, into prev ious violence and precursors); response to treatment (pharmacological and psychosocial); pl ans (realistic). Current (external) Weapons; access to victims; support (formal and informa l); destabilizers (alcohol, drugs, homelessness, victimization); stress (relationship probl ems, debt, life events). Previous violence (convicted and non-convicted, nature, Formulation Anchored by historical factors with current factors indicating immediate/short- term risk. Risk of what, to whom, when, under what cir- cumstances? Acknowledge uncertainti es and information gaps. Emphasize context(s) in which person may be at increased/decreased risk. If using 17_Semple_Chap17.indd 692 12/7/2012 3:49:47 PM ASSESSING RISK OF VIOLENCE 693 actuarial methods: are they applicable to this person/risk? Are normative values from an ap propriate sample? Communication The assessment must be communicated in an appropriate and understandable way to others. It must also be documented. Use of scores, percentages, or terms such as low, me dium, or high should be explained. Risk management The factors identi \201 ed in the risk assessment should indicate areas to be addressed in management. They may point to the need for speci \201 c treatments (pharm acological or psychological), supervi- sion, support, or detention. Box 17.4 Risk assessment instruments A number of risk assessment instruments have been developed. Some are structured clinical m ethods, while others are actuarial. The following list indicates the type of risk assessed and whether the tool is actuarial or structured clinical in nature. Most of these tools req uire speci \201 c train- ing and all require familiarity with the tool and the risk being assessed. There is no consensus as to which tools should be used and when, and some argue t hat risk assessment tools should not be used at all. Historical, clinical and risk 20 \200\224(HCR-20) Violence/structured clinical Violence ris k appraisal guide (VRAG) Violence/actuarial Psychopathy checklist \200\224revised (PCL-R) V iolence/actuarial Risk assessment, management, and audit systems (RAMAS) Risk assessment gu idance framework (RAGF) Offender assessment system (OASys) Reconviction prediction score (R PS) Risk of reconviction (ROR) score Offender Group Reconviction Scale (OGRS) Risk of sexua l violence protocol (RSVP) (previously SVR-20) Sexual offending risk appraisal guide (SORAG ) Rapid risk assessment of sex offender recidivism (RRASOR) Static 99 SONAR1 Matrix 2000 (p reviously structured anchored clinical judgment [SACJ]) Spousal assault risk assessment (SA RA) Spouse abuse/structured Violence/structured clinical Violence/structured clinical Violence/structured clinical Violence/actuarial Violence/actuarial Violence/actuarial Sex offending/structured clinical Sex offending/actuarial Sex offending/actuarial Sex offending/actuarial Sex offending/actuarial Sex offending/actuarial clinical 1 Sex Offender Needs Assessment Rating (SONAR) 1 Quinsey VL, Harris GT, Rice ME, et al. (1998) Violent offenders: appraising and managing risk. Washington, DC: American Psychological Association. 2 Webster CD, Douglas KS, Eaves D , et al. (1997) HCR-20 Assessing risk for violence (version 2). Vancouver: Simon Fraser Uni versity. 3 Royal College of Psychiatrists (1996) Assessment and management of risk of harm to other people. Council report CR53. London: Royal College of Psychiatrists. 17_Semple_Chap17.indd 693 12/7/2012 3:49:47 PM CHAPTER 17 Forensic psychiatry 694 Secure hospitals and units1 Within the health service there are psychiatric hospitals and u nits that offer varying degrees of security. The terms high, medium, and low secu- rity are used to categorize these services, and give some indication of the level of risk that can be managed within a particular unit. However, there are no clear de \201 nitions of these levels of security; different units at the same security level may operate in very differen t ways; there is blurring between the different levels; and rather than thinking of patient s in terms of level of security required it is better to consider a particular patient \200 \231s risk, how this should be managed, and how a particular unit may or may not be able to manage the risk. The network of secure services for a par- ticular area varies considerabl y from region to region. Security does not just rely on the physical barriers and monitoring, although these are imp ortant. Knowing patients well (from studying their backgrounds and interacting with them) a nd developing good relationships with them contribute to \200\230relational security \200 \231. Multidisciplinary risk assess- ment and management are also important. High-security hospitals There are \201 ve high-security hospitals in the British Isles: \200 English special hospitals Hospitals. Serve England and Wales and are each part of a local N HS Trust. Each has about 500 beds. State hospital (Carstairs) special health board. About 2 50 beds. Central mental hospital (Dundrum) Eastern Health Board. About 80 beds. \200\224Ashworth, Broadmoor, and Rampton . Serves Scotland and NI. Managed by a . Serves the RoI. Managed by the Patients are admitted from prisons, courts, or less secure hospitals. Patients must be deta ined under mental health or criminal procedure legislation. Majority of patients have commi tted offenses, but a substantial minor- ity are transferred from other hospitals where they are unmanageable. Patients should pose a grave immediate danger to the public. Admissions are usually for several years. Medium-security units Medium-security units are not as virtually escape-proof as high-secur ity hospitals but are more secure than locked wards. Vary in size from 30 \200\223100 beds. Each region in England and Wales has one or more medium-security unit, there is one in Sco tland (with current plans to develop more), and one in NI. Patients are admitted from priso ns, courts, and less secure units, and also from high-security hospitals. Admissions are no t usually for more than 2yrs. Patients may move on to low-security units, open wards, or th e community, being managed by general or forensic services depending on local service provi sion, patients \200\231 backgrounds, and clinical needs. Some specialist units have developed for personality disordered patients, learning disabled patients, women, and adolescents. The State hospital, Carstairs, and the central mental ho spital, Dundrum, admit many patients who would be admitted to medium-security units in Engl and and 17_Semple_Chap17.indd 694 12/7/2012 3:49:47 PM SECURE HOSPITALS AND UNITS 695 Wales due to the under-development of local secure forensic provision in Scotland, NI, and the RoI. Low-security units Low-security units and wards have locked doors but do not usually have a secure perimeter. Some regional forensic services have a combination of low- and medium-se curity wards; in areas of Scotland and NI there are low-security forensic wards without med ium-security units. Intensive Psychiatric Care Units (IPCUs) are low-security short-stay wa rds pri- marily for the care of acutely disturbed general psychiatry patients. In a few are as they also take patients from courts, prisons, and more secure units, but they are not we ll-suited to providing longer-term assessment or treatment. Referring a patient to secure forensic services \200 A comprehensive assessment should be made and details of this should be sent with the refer ral. Particular attention should be given to the risk the person poses (b p. 692) and why t his risk cannot adequately be managed in less secure services. Patients should meet the cri teria for compulsory detention in hospital under relevant legislation. 1 Kennedy HG (2002) Therapeutic uses of security: mapping forensic mental health services b y stratifying risk. Adv Psychiat Treat 8: 433 \200\22343. 17_Semple_Chap17.indd 695 12/7/2012 3:49:47 PM CHAPTER 17 Forensic psychiatry 696 Police liaison 1 Prevalence of psychiatric disorder 2 \200\2235% of people held in custody by the police suffer from mental disorder. About 1 \200\2232% suffer from severe mental ill ness. Liaison and diversion \200 Diversion of people with mental disorders from the criminal justice system to health care c an operate at any stage of the criminal justice process. The term is often used to refer to early diversion, the transfer of mentally disordered people from police custody or at thei r \201 rst court hearing. Diversion schemes is provided to the police and/or courts to he lp identify and divert mentally disordered individuals. These schemes may also be known as police or court liaison schemes. Police or court liaison health services provide assessment and/or diversion for people with mental disorder at an early stage of the criminal justice process. In some areas there are formal diversion schemes, but from area to area there are differences. operate in some areas whereby a speci \201 c service is the process or system by which mental In many cases where a person is diverted, the police, prosecutor, or court will discontinue the criminal justice process. This will be particu- larly appropriate in most cases where individuals with mental disorder will have committed relatively minor offenses. However, di version does not necessitate this, and where appropriate, particularly where more serious o ffenses have been committed, a prosecution may be pursued in parallel with diversion for ca re and treatment. Powers allowing police to take a person to a place of safety (Box 17.5) \200 The police have powers under mental health legislation to convey a person whom they believe is suffering from mental disorder to a place of safety. (Speci \201 c powers are set out in Box 17.5.) The purpose of these powers is to allow for a psychiatric assessment. The use by the police of these powers does not oblige mental health services to admit the person. \200 Arrest and detention in custody Where an offense has been committed, a mentally disordered offender may be arrested and taken into police custody. \200 Issues to be addressed when assessing a person in police custody: \200 \200 \200 Is there evidence of mental disorder? Is treatment in hospital required? If so, how urgentl y? What is the nature of the alleged offense and is there any evidence of a serious risk to others? Is the person \201 t to remain in police custody? Is the person \201 t to be i nterviewed by the police? Do they require an appropriate adult? Would they be \201 t to p lead if they appeared in court (see \200 b p. 716)? 17_Semple_Chap17.indd 696 12/7/2012 3:49:47 PM POLICE LIAISON 1 697 Options following assessment if person appears to be mentally disordered: \200 \200 \200 \200 Admission to hospital informally or under mental health legislation. Treatment in the commu nity. Recommend admission on remand following \201 rst court appearance. Recommend furthe r assessment on remand in custody or on bail following \201 rst court appearance. Fitness to remain in police custody There are no legal criteria to determine whether a person is \200\230 \201 t to remain in police custody \200\231. A person may be un \201 t to remain in police custody due to physical illness or mental disorder. Where a person is mentally d isordered such that there would be a serious immediate risk to their own health if they rem ained in the police cells, then they would be un \201 t to remain in police custody, and s hould usually be admitted to hospital. Box 17.5 Powers allowing the police to take a mentally disordered person to a place of safe ty England and Wales Section 136 MHA 1983 allows the police to appre- hend a person who appear s to be mentally disordered found in a public place, and convey them to a place of safety w here they may be detained for up to 72hrs. The place of safety should be a mental health se tting, but often a police station is used. The purpose of section 136 is to allow for the p erson to be assessed by mental health services. Following the assessment the person may be diverted to mental health services (infor- mally or under compulsion), arrested and taken i nto police custody, or released. Scotland Section 297 MH(CT)(S)A 2003 allows similar provis ions in Scotland, but detention may only be for up to 24hrs. NI Article 130 MH(NI)O 1986 al lows similar provisions in NI, but deten- tion may only be for up to 48hrs. RoI Under secti on 12 MHA 2001, if a garda has reasonable grounds for believing that a person is suffering from a mental disorder and that, because of the disorder, there is a serious likelihood of the person caus- ing harm to himself/herself or another person, the garda may take the pers on into custody. If necessary, the garda may use force to enter the premises where it is be lieved that the person is. The garda must then go through the normal application procedure for involuntary detention in an approved center. If the garda \200\231s application is refu sed, the person must be released immediately. If the application is granted, the garda must remove the person to the approved center. Note: in England and Wales, Scotland, and NI the se powers do not allow the police to enter premises if they want to remove a person who app ears to be suffering from mental disorder. Under these circum- stances powers are available under s135 MHA 1983, s293 MH(CT)(S)A 2003, and article 129 MH(NI)O 1986. 17_Semple_Chap17.indd 697 12/7/2012 3:49:47 PM CHAPTER 17 Forensic psychiatry 698 Police liaison 21,2,3 Police interviews: \201 tness, false confessions, and appropriate a dults Mental disorder may affect a police interview by: impairing the ability of a person t o communicate; leading to the person giving unreliable evidence; or making a person vulnera ble to becoming distressed. In some cases men- tal disorder may be so severe that a person is un \201 t to be interviewed. \200 \201 tness to be interviewed, but the following There is no legal basis for issues may be relevant: \200 