Professional Documents
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The goal of this series is to improve the quality of health care services in forensic set-
tings by providing a forum for discussing issues related to policy, administration, clini-
cal practice, and research. The series will cover such topics as mental health law; the
organization and administration of forensic services for people with mental disorder;
the development, implementation and evaluation of treatment programs for mental
disorder in civil and criminal justice settings; the assessment and management of viol-
ence risk, including risk for sexual violence and family violence; and staff selection,
training, and development in forensic systems. The book series will consider proposals
for both monographs and edited works on these and similar topics, with special con-
sideration given to proposals that promote best practice and are relevant to inter-
national audiences.
Published Titles:
How to Work With Sex Offenders: A Handbook for Criminal Justice,
Human Service, and Mental Health Professionals, Second Edition
Rudy Flora & Michael L. Keohane
Managing Fear: The Law and Ethics of Preventive Detention and Risk
Assessment
Bernadette McSherry
Case Studies in Sexual Deviance: Toward Evidence Based Practice
Edited by William T. O’Donohue
Forensic Psychological Assessment in Practice: Case Studies
Corine De Ruiter & Nancy Kaser-Boyd
Sexual Predators: Society, Risk and the Law
Robert A. Prentky, Howard E. Barbaree & Eric S. Janus
Forthcoming Titles:
Handbook of Forensic Social Work with Children
Edited by Viola Vaughan-Eden
Handbook of Forensic
Mental Health Services
Edited by
Ronald Roesch
and Alana N. Cook
First published 2017
by Routledge
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Library of Congress Cataloging in Publication Data
A catalog record for this book has been requested
PART I
Introduction 1
PART II
Forensic Mental Health Assessment 77
v
Contents
Part III
Forensic Mental Health Interventions 235
Part IV
Forensic Mental Health Systems 441
vi
Contents
Index 587
vii
Figures
viii
Tables
ix
Tables
x
Contributors
Petra Born has been a clinical psychologist at the Vitos Haina Forensic Psychiatric
Hospital since 1992. She helped develop and implement an inpatient treatment
program for psychopathic offenders. Since 2008 she has been the personal manage-
ment assistant of the director. She was instrumental in editing and implementing
the German versions of the HCR-20V3 and the START.
xi
Contributors
Sabine Eucker has worked as a psychologist at the Vitos Haina Forensic Psychiatric
Hospital since 1988. She is a licensed psychotherapist, a licensed instructor for the
Reasoning and Rehabilitation Program, and a registered forensic psychologist and
supervisor.
Beate Eusterschulte has been a forensic psychiatrist at the Vitos Haina Forensic
Psychiatric Hospital since 2001. She is a member of the advisory board of the Inter-
national Association of Forensic Mental Health Services.
Ilvy Goossens has master’s degrees in clinical psychology from the Catholic Uni-
versity of Leuven, Belgium, and in forensic psychology from Maastricht University,
the Netherlands. Her research interests include trauma-informed care in forensic
psychiatry, and victim and offender perspectives in interpersonal violence. She is
currently pursuing her PhD in forensic psychology and law at Simon Fraser Uni-
versity, Burnaby, British Columbia, Canada.
xii
Contributors
Laura S. Guy is an adjunct professor at Simon Fraser University and a licensed psy-
chologist in Canada and the U.S. Her clinical and research interests include forensic
assessment and implementation of evidence based practices in field settings.
Rebecca Jackson is Clinical Director of the Florida Civil Commitment Center. Dr.
Jackson has been working with the civilly committed sex offender population since
2003. She has experience in treatment, evaluation, program development, and research
with this population. She is the past president of the Sex Offender Civil Commitment
Programs Network, a professional organization comprised of professionals working in
sex offender civil commitment programs across the United States.
xiii
Contributors
James D. Livingston is a criminologist who studies and teaches about issues of social
inclusion and social justice for people with mental illnesses, with an emphasis on those
who are involved with the criminal justice and legal systems. His research focuses on
stigma, service improvements, and innovations in forensic mental health.
Caroline Logan is the lead consultant forensic clinical psychologist in the Specialist
Services Network of Greater Manchester Mental Health NHS Foundation Trust
(GM) in England. Her research interests include personality disorder, psychopathy,
and risk, gender issues in offending, complex case formulation and management,
and forensic clinical interviewing.
Robert D. Morgan is the John G. Skelton Jr. Regents Endowed Professor and
Chair in the Department of Psychological Sciences at Texas Tech University. His
research interests are in correctional mental health treatment, effects of incarcera-
tion, and forensic mental health assessment.
Rüdiger Müller-Isberner has been the Director of the Vitos Haina Forensic Psy-
chiatric Hospital since 1987. He was the President of the International Associ-
ation of Forensic Mental Health Services from 2003 to 2005. In 2016 the
International Association of Forensic Mental Health Services presented him with
the Award for Outstanding Contributions to Forensic Mental Health Science and
Practice.
xiv
Contributors
Randy K. Otto has been a faculty member at the University of South Florida since
1989, where he teaches in the Department of Psychology and the Department of
Criminology. His research and professional writing focus on the intersection of the
legal and mental health systems. He has authored and edited books on forensic
psychological assessment, violence risk assessment, criminal competencies, and
ethical challenges in forensic psychology practice.
Carol Schubert is a research program coordinator for the law and psychiatry program
of the Western Psychiatric Institute and Clinic. Her research interests include violence
risk and service provision to justice-involved adolescents and adults.
xv
Contributors
Simone Viljoen is a forensic evaluator for the state of Washington with the Office
of Forensic Mental Health Services. She conducts evaluations for the courts to help
address psycholegal issues such as competency to stand trial or criminal responsib-
ility. Her research focuses on the utility of violence risk assessment and manage-
ment, with a focus on the use of protective factors in these assessments; gender; and
psychopathic personality disorder.
xvi
Preface
xvii
Preface
The Handbook contains 19 chapters divided into four parts. Part I serves as an
introduction and overview of forensic mental health internationally. This review is
extensive and the first of its kind to review the history of state forensic mental
health practices around the world. Anne G. Crocker, James D. Livingston, and
Marichelle C. Leclair provide the broadest review of legal frameworks (e.g., fitness
to plead, mental disorder defenses), hospital discharge provisions, and forensic
service provision in existence in many countries. The authors go further to define
key organizing principles for forensic mental health systems, how to evaluate these
systems, and emerging approaches to organization of forensic mental health services
that can be applied cross-nationally.
Part II provides coverage of major areas of forensic mental health assessment.
Assessment and intervention are the cornerstones of forensic mental health work.
Amanda L. Reed and Patricia A. Zapf provide a comprehensive review of best
practices for criminal forensic assessments, with a particular focus on assessments of
competency to stand trial, criminal responsibility, and violence risk. Laura S. Guy
and Amanda D. Zelechoski review how forensic assessment is applied in the civil
system. The topics include assessments of child custody, fitness for duty for
employees with mental health issues, civil commitment, and civil damages. Part II
also contains a chapter by Alana N. Cook and Stephen D. Hart on the emerging
and important issues of cross-national and cross-cultural applications of risk assess-
ment. The authors include professional guidelines to inform the making of deci-
sions of when and how to use risk tools developed and validated in one country in
different jurisdictions. There is also a chapter on the quickly evolving field of
formulation. Caroline Logan uses a single case formulated in three different ways
for three different purposes to provide readers with an excellent example of ‘how
to’ formulate complex cases of risk and management. In their chapter, Simone
Viljoen and her colleagues focus exclusively on the important area of protective
factors in forensic assessment, helping readers shift from a sole focus on risk-
enhancing factors to a more balanced assessment to also include risk mitigating
factors. Part II concludes with a practice-oriented guide for forensic report writing.
Recognizing that an essential aspect of forensic assessment is writing clear and
informative reports, Richart L. DeMier and Randy K. Otto provide much sought-
after guidance on common challenges, aptly referred to as “The Tricky Parts,” in
forensic report writing that will be invaluable to readers of this book.
Part III covers a breadth of approaches and special topics related to forensic
mental health intervention. The first chapter in this section, by Lucy Guarnera and
N. Dickon Reppucci, examines models of change from a prevention and early
intervention perspective. It is well-known that the justice system places a dispro-
portionate amount of resources in interventions after an individual has already
committed a crime. Guarnera and Reppucci review two models of change that
could reduce offending, with one focusing on reducing psychiatric symptoms and
the other on reducing general causal risk factors for crime. The authors review
research on youth-focused crime prevention programs that have the potential for
reducing criminal offending, with particular attention to the role that mental illness
xviii
Preface
may play in criminal behavior. Heather M. Moulden and Casey Myers review
treatment models for justice-involved adults in forensic settings. Their focus is on
how the risk–need–responsivity (RNR) model of offender rehabilitation can be
applied to delivering empirically supported treatments to forensic populations,
including the treatment of psychopathy. Michelle Guyton and Allison Foerschner
focus specifically on the treatment of personality disorders in forensic/correctional
settings. They review empirically supported interventions for two of the most
common personality disorders found in forensic/correctional settings—borderline
personality disorder and antisocial personality disorder. Rebecca Jackson also applies
the RNR model, this time to the treatment of sexual offenders. Jackson overviews
theoretical models, including the relapse prevention and self-regulation models, but
also the biomedical model, to demonstrate how different models can inform treat-
ment approaches. An important contribution of the chapter is the discussion of
how protective factors might contribute to desistance of sex offending, and she also
shows how the good lives model can be a useful framework for treating sex offend-
ers. Kaitlyn McLachlan reviews the role that intellectual disabilities can play in
offending behavior. These disabilities include individuals who experience a range
of deficits in neurocognitive and behavioral functioning, including those who have
been formally diagnosed with intellectual disability, along with neurodevelopmen-
tal conditions, such as autism spectrum disorder and fetal alcohol spectrum disorder.
She notes that these groups are overrepresented in offending and forensic popula-
tions. Recidivism rates for these offenders is high, which highlights the need for
interventions addressing factors stemming from the ID itself, such as deficits in
social skills, impulsivity, low self-esteem, anger, and vocational and educational skill
upgrading, but also interventions designed to address criminogenic and offense-
specific needs in order to reduce offending behaviors. Vivienne de Vogel and
Marijke Louppen examine the unique needs of female offenders. They provide an
overview of specific risks and needs of female offenders and argue for gender-
responsive treatment in forensic mental health services. A case history is used to
illustrate how this approach can be applied in forensic practice. Keith Cruise, Evan
Holloway, Anthony Fortuna, and Emilie Picard review interventions with youth in
the juvenile justice system. They review community-based intervention programs
that have been shown to reduce delinquency risk factors and lessen the likelihood
of future offending. Cruise and his colleagues make a case for larger scale field-
based implementation studies that involve partnerships between researchers and
practitioners in multiple countries to more conclusively support the generalizability
of evidence-based interventions.
Part IV outlines various forensic mental health systems. Rüdiger Müller-Isberner
and his colleagues capture arguably the most challenging aspect of the field of for-
ensic mental health, implementation. The authors describe the process, challenges,
and potential solutions of implementation of standards of practice and new tech-
nologies in forensic services. They take lessons learned from other fields and use
their own attempts to implement a new version of a risk assessment tool into their
own services to highlight the challenges of implementation so others can learn from
xix
Preface
their experiences and insights. Robert D. Morgan, Angelea D. Bolaños, and Karen
Grabowski write about two major groups that require forensic intervention: defend-
ants found incompetent to stand trial and those who have been determined to be
not criminally responsible (or not guilty by reason of insanity) for their criminal
charges due to a mental disorder. They then turn to a review of best practices for
effective interventions with correctional and forensic populations. Tonia L. Nicholls
and Ilvy Goossens review forensic mental health interventions in inpatient forensic
hospital settings. They present a model for the delivery of forensic services that
addresses both traditional mental health needs (e.g., medications, insight) and crim-
inogenic needs. Kirk Heilbrun and his colleagues focus on community-based
alternatives to standard prosecution and incarceration. They describe the sequential
intercept model as a method to identify points of interception at which justice-
involved individuals with severe mental illness could be diverted into appropriate
treatment and alternative sanctions. The final chapter, by Richard D. Schneider,
provides an overview of the evolution of mental health and problem-solving courts.
He reviews the models that have been used to guide these courts and summarizes
the research on its effectiveness. He concludes with his perspective on the future of
these courts.
We hope that this book informs, and perhaps even inspires, improved quality of
health care services in forensic settings. While we aimed to include the most rel-
evant topics to our work as mental health professionals in assessment, intervention,
and systems, the book is limited to select topics. This book does not include
important areas of practice getting increased attention owing to changing demo-
graphics and new laws in many countries, such as the long-term care of aging for-
ensic patients and competency assessments for medical assistance in dying. We
direct readers interested in emerging areas of practice to the IAFMHS book series
as several books in the series provide coverage of areas that warrant further atten-
tion. The IAMFHS journal (the International Journal of Forensic Mental Health) also
provides coverage of other important areas of practice. This book also does not
include depth of coverage of topics to a degree that may be needed for some profes-
sionals. The authors of the book chapters have all directed readers to other recent
and high-quality resources or organizations for further information. We would like
to thank all of the authors who contributed to this book to provide what we hope
can be a key source of translating standards of practice for psycholegal issues into
applied practice globally.
xx
Part I
Introduction
1
Forensic Mental Health
Systems Internationally
Anne G. Crocker, James D. Livingston,
and Marichelle C. Leclair1
Forensic mental health systems have evolved over time as a function of legal frame-
works, health care environments, and broader social and cultural processes. The
past 20 years has seen a general increase in demand for forensic services in many
countries around the world (Jansman-Hart, Seto, Crocker, Nicholls, & Côté,
2011), a phenomenon that has sometimes been referred to as forensication (Seto
et al., 2001). This increase has been attributed to a variety of factors such as signi-
ficant changes of Mental Health Acts or civil commitment legislation, the succes-
sive downsizing of psychiatric institutions, a lack of community-based resources
and supports, the criminalization of people with mental health and substance use
problems, the increasingly complex clinical profiles of certain persons with severe
mental illness, increased media reporting of violence, and public intolerance of
nonconforming behavior (Jansman-Hart et al., 2011; Lamb, 2009; Priebe et al.,
2008; Rock, 2001; Whitley & Berry, 2013; Whitley & Prince, 2005). It is also
influenced by broader social phenomena linked to society’s handling of risk, such
as how modern societies are organized to respond proactively to risk and neoliberal
tendencies to frame risk as a problem within individuals rather than a social problem.
Authors have even suggested that, in some countries, forensic services may become
the de facto mental health services (Seto, Harris, & Rice, 2004). In addition to
posing a number of humanitarian questions as well as questions regarding the capa-
city of the regular mental health services to deal with sometimes more disruptive
patients, this trend may also come at significant economic cost. In Alberta, Canada,
the cost of forensic cases has been estimated about CAD$275,000 per year, which
is almost five times the costs for any other psychiatric inpatient (Jacobs et al., 2014).
This number compares to the cost of care in forensic psychiatric hospitals in the
Netherlands (R388 per day, or R142,000/CAD$207,000 per year: Avramenko,
Evers, Philipse, Chakhssi, & Ament, 2009) and in the United Kingdom (£131,000
per year, or CAD$243,000: Barrett et al., 2005). In England and Wales, treating
forensic patients in secure hospitals costs 15 percent of the total adult mental health
3
A. G. Crocker et al.
investment (Wilson, James, & Forrester, 2011). To date, however, there remains
relatively little research into the economic cost of forensic mental health services
over time. The immense cost of forensic services should give rise to questions about
the degree to which this is a wise investment; that is, are the potential benefits of
the forensic mental health system being optimized?
The goal of this chapter is to review the scientific and gray literatures regarding
the provision of forensic mental health services around the world. In particular, we
attempt to address the following question: What system-level characteristics are
important to consider in relation to the organization and structure of forensic
mental health services? To do so, we first examine the general legal frameworks that
provide the contours of the forensic populations and services in various countries.
We then synthesize publically accessible information to describe how forensic
systems are organized throughout the world. Following this, we examine the funda-
mental system-level principles for organizing forensic mental health systems. The
question of how to assess the performance of forensic mental health systems is
addressed before turning toward the identification of the major challenges facing
the organization of forensic services moving forward and followed by emerging
approaches in forensic mental health services.2
4
Forensic Mental Health Around the World
sources such as the World Health Organization’s Assessment Instrument for Mental
Health Systems (WHO-AIMS)5 reports, as well as stand-alone government reports
and scientific papers.
Legal Frameworks
In this section, an overview of forensic services and provisions across four general
legal frameworks is provided, including: common law, civil law, the legislation of
former Communist countries (Soviet, Soviet-controlled, and the Balkans), and
Islamic law. We summarize how they address the main issues of fitness to plead, the
mental disorder defense, diminished responsibility, hospital discharge provisions,
forensic population composition, and forensic service provision. Additionally,
information available in English, French, or Spanish is reviewed to gain insight into
issues such as the presence of dedicated forensic institutions, the degree of integra-
tion between forensic and general mental health, the centralization of services, the
continuity of services at discharge, and the presence of dedicated housing support
for the forensic population. It is important to note that the information presented
below relies exclusively on academic and nonacademic literature, and is accurate,
complete, and up-to-date to the extent that the source documents permitted.
Information was readily available for some jurisdictions (e.g., Canada, United
Kingdom), but it was scarce for many regions of the world.
Fitness to Plead
Common-law countries
Most common-law countries provide procedures for raising the issue and evalu-
ating the fitness of an accused to stand trial (see Table 1.1), which may bear a dif-
ferent name according to the jurisdiction. Although there are minor variations,
most legal tests for unfitness are based on the incapacity to understand the nature
and severity of the charges; to understand the nature, objects, or consequences of
the proceedings; and to communicate with or instruct a lawyer in a defense
(Brinded, 2000; Every-Palmer et al., 2014; Gunn et al., 2013; Mudathikundan,
Chao, & Forrester, 2014; Scott, 2007; Taylor et al., 2013). Many jurisdictions
factor in the severity of the offense as well as the probability that the accused has
committed the offense (e.g., New Zealand, South Africa) in their decisions con-
cerning dispositions following unfitness to stand trial (Taylor et al., 2013).
Jurisdictions use different settings and procedures for conducting fitness assessments
or detaining those who are found unfit. In England and Wales, forensic assessments
occur most often in prison, but treatment of those detained for reasons of fitness
occurs in a general psychiatric facility or a specialized forensic facility (Salize et al.,
2005). In South Africa, the assessment generally takes place in a forensic psychiatric
hospital (Taylor et al., 2013). In Scotland, the assessment takes place in a hospital
(Criminal Procedures Act 2016). In Canada, fitness assessments can take place in a
5
A. G. Crocker et al.
forensic hospital or jail (Criminal Code of Canada, 1992); when an individual is found
unfit to stand trial, jurisdiction is transferred from the court to a provincial or territo-
rial review board, which decides on future dispositions of the case.
It is possible for the duration of detention for persons found unfit to be indefi-
nite (see Table 1.2), but many jurisdictions have special provisions for people who
are deemed permanently unfit. In Canada, there are no time limits to the detention
in hospital of an unfit accused; however, an individual declared permanently unfit
to stand trial who is also judged to be nondangerous may be granted a stay of pro-
ceedings by a review board and, subsequently, discharged (Criminal Code of
Canada, 1992). In New Zealand, permanently unfit individuals must be brought
before court or committed civilly after serving half of the maximum custodial sen-
tence that would have been given for their index offense (or 10 years if the offense
is punishable by a life sentence; Taylor et al., 2013). In the United States, if the
competency of an accused to stand trial is not restored within a reasonable amount
of time, charges must be dropped and the individual must be either released or
civilly committed (Bloom, Williams, & Bigelow, 2000; Jackson v. Indiana, 1972). In
Australia, procedures differ from one jurisdiction to the next. Proceedings may be
discontinued in Queensland when an accused is found permanently unfit or unlikely
to regain fitness within a certain period. In New South Wales, Victoria, Tasmania,
and the Northern Territory, a special hearing to determine guilt and detention will
be held if a judge or a jury finds that the accused is unlikely to regain the capacity
to stand trial within 12 months (Hunyor, 2012; Jager, 2001; Taylor et al., 2013).
Such special hearings do not seem to exist in South Australia and Western Australia:
if the accused is found unfit, they will be held indefinitely in a secure hospital and
will be tried when they recover sufficiently (Taylor et al., 2013).
CIVIL-LAW countries
Since civil law is more inquisitorial and less adversarial in nature than common law,
thus leaving defendants with a more passive role, Continental European countries
and other jurisdictions that belong to the Roman law heritage do not tend to test
fitness to plead (Taylor et al., 2013).
Napoleonic Code legal family. In France and Brazil, accused persons may be
tried and judged despite showing symptoms of severe mental illness (Salize et al.,
2005; Taborda, Cardoso, & Morana, 2000). In Italy, if a psychiatric expert con-
siders during the inquiry or the pretrial that the accused is ill and the offense is
minor, the general attorney might not prosecute them and, instead, may prescribe
community services or general psychiatric care. If the offense is serious and the
person is considered dangerous, a trial will usually take place, despite the mental
illness (Salize et al., 2005). In Chile, an accused who is unable to stand trial will be
diverted to a forensic psychiatry network until they are ready to return to trial (Cid,
2010; St. Denis, 2008). Similarly, in Argentina, such individuals are sent to a special
institution if their behavior is considered dangerous (Folino, Montero Vazquez, &
Sarmiento, 2000).
6
Forensic Mental Health Around the World
The forensic assessment takes place in prison in France and Belgium. In Italy, it
may take place in prison, in a forensic hospital or in a psychiatric facility. In Spain, the
observation for the expert report regarding the mental disorder defense will take place
in a psychiatric penitentiary hospital or a psychiatric penitentiary. A defendant sus-
pected to be mentally ill may never be placed in a prison prior to trial in Portugal and
the assessment must, instead, take place in a specialized forensic facility (Salize et al.,
2005). In Chile, defendant assessment units (penitentiary units within civil hospitals)
were recently created to provide forensic assessments (Cid, 2010).
Germanic legal family. Germany uses criteria similar to common-law jurisdic-
tions to determine competence to participate in the trial. In addition, an accused
can be found to have ‘limited fitness to stand trial,’ in which case the trial may
proceed in such a way that allows the accused to participate, such as in the presence
of a specialist (such as a psychologist), with extended breaks, or with limits on the
duration of the proceedings (Edworthy, Sampson, & Völlm, 2016; Rothschild,
Erdmann, & Parzeller, 2007). The forensic assessment will be carried out in a public
psychiatric hospital or on an ambulatory basis if possible.
Nordic legal family. Sweden, Denmark, and Finland do not have the concept of
fitness to plead; however, Finland does have provisions allowing for a forensic psy-
chiatric assessment to determine whether an accused can be heard at the trial (Salize
et al., 2005; Taylor et al., 2013).
In Denmark, forensic assessments may take place in a forensic psychiatric facility or
in the community. In Finland, it can be carried out in a forensic psychiatric hospital,
in forensic psychiatric wards, or in a prison psychiatric ward—rarely, the assessment
can be performed based solely on the patient’s record (Salize et al., 2005).
Other civil-law jurisdictions. In the Netherlands, fitness to stand trial does not
exist in practice (de Ruiter & Hildebrand, 2003; van der Wolf, van Marle, Mevis,
& Roesch, 2010). In Taiwan and Japan, fitness to stand trial exists as a legal concept,
but is rarely successful. In Japan, mentally disordered offenders are generally not
prosecuted, but are rather referred to the forensic mental health services (MTSA
process; Every-Palmer et al., 2014; Fujii, Fukuda, Ando, Kikuchi, & Okada, 2014).
In China, mentally ill accused may be found unfit to stand trial, in which case they
will be referred to a psychiatric hospital or released into the care of the family
(Every-Palmer et al., 2014).
The legal concept of fitness to stand trial was mentioned in the literature for Russia,
the Czech Republic, and Bulgaria (Ciszewski & Sutula, 2000; Every-Palmer et al.,
2014; Tătaru, Marinov, Douzenis, Novotni, & Kecman, 2010; Vevera et al., 2009).
In Russia, if the accused is found unable to stand trial—that is, if they are unable to
understand the course of the proceedings or mount a defense—the trial will be
suspended and the accused will be hospitalized. If the accused does not regain the
capacity to stand trial within a reasonable time, there will be no trial and the accused
will remain hospitalized.
7
A. G. Crocker et al.
Table 1.1 A
vailability of Fitness to Plead, Mental Disorder Defense, and Diminished
Responsibility in Law by Legal Framework and Country
Common Law
Australia Yes Yes No: SA, TAS, VIC, WA
Yes: NSW, QLD, ACT, NT
Botswana n/a Yes n/a
Canada Yes Yes No
England and Wales Yes Yes Yes
Ghana Yes Yes n/a
Hong Kong Yes Yes Yes
India Yes Yes Yes
Ireland Yes Yes Yes
Israel Yes Yes No
Kenya n/a Yes n/a
New Zealand Yes Yes No
Pakistan Yes Yes No
Scotland Yes Yes Yes
Singapore Yes Yes Yes
South Africa Yes Yes Yes
Tanzania n/a Yes No
Uganda n/a Yes n/a
United States Yes Most states Most states
8
Forensic Mental Health Around the World
Former Communist
Bulgaria Yes Yes n/a
Croatia n/a Yes n/a
Czech Republic Yes Yes Yes
Hungary n/a Yes n/a
Poland n/a Yes Yes
Russia Yes Yes Yes
Ukraine n/a Yes n/a
Note
n/a indicates that the information was unavailable or not expressly specified in the literature.
Common-law countries
9
A. G. Crocker et al.
as a general rule, they do not qualify either in Australia and the United States;
although the fact that states are autonomous on this matter gives rise to exceptions
and ambiguities (Greenberg & Felthous, 2007). Personality disorders are excluded
in the American states that have adopted the ALI test, as well as in a handful of
other states, including Arizona, Colorado, California, New Mexico, and Oregon
(Greenberg & Felthous, 2007). In New Zealand, the Mental Health Act excludes
personality disorders, but this may differ in practice (Brinded, 2000). Most jurisdic-
tions do not restrict the mental disorder defense to serious or violent offenses;
however, in many countries the forensic populations are comprised mainly of
people who have committed violent offenses (e.g., New Zealand, South Africa,
India, Zimbabwe: Chadda, 2013; Marais & Subramaney, 2015; Mellsop et al.,
2016; Menezes, Oyebode, & Haque, 2009; Skipworth, Brinded, Chaplow, &
Frampton, 2006; Strydom et al., 2011), but this is not reflected in the forensic
populations of other countries (e.g., Canada: Crocker, Nicholls, Seto, Charette, et
al., 2015b).
Dispositions available to the accused found not criminally responsible due to
mental disorder vary from absolute discharge to hospital detention. In several Amer-
ican states a treatment order is mandatory (Bureau of Justice Statistics, 2004). In
England and Wales, forensic services may be provided for individuals with person-
ality disorders or mental impairments who have been found guilty of an offense and
sentenced to mandatory treatment, known as a hospital order (Salize et al., 2005).
Some jurisdictions adapt the dispositions to the seriousness of the offense. In the
Australian Capital Territory, for example, if the offense is serious (i.e., involving
actual or threatened violence or endangering life) the court must give a custodial
order. If the offense is minor, the court can make other orders, as appropriate
(Williams, 2000).
CIVIL-LAW countries
10
Forensic Mental Health Around the World
requires mandatory assessment prior to release (Salize et al., 2005). Similarly, coun-
tries such as Portugal detain all convicted mentally ill offenders lacking criminal
responsibility in specialized facilities (e.g., forensic units: Cartuyvels, Champetier,
& Wyvekens, 2010; Salize et al., 2005). Brazil and Chile offer outpatient treatment
to mentally ill offenders who are not considered harmful, in replacement of inpa-
tient forensic detention (Cid, 2010; Taborda et al., 2000). In Spain, forensic patients
may be placed under security arrangements, such as being detained in a psychiatric
penitentiary hospital (Salize et al., 2005).
Germanic legal family. In Germany, mentally disordered accused persons can be
considered not criminally responsible if they are “incapable of recognizing the
injustice of the criminal act or unable to act according to this insight” (Müller-
Isberner, Freese, Jöckel, & Gonzalez Cabeza, 2000). Austria, Switzerland, and
Greece have also adopted a test based on cognition and volition (Code pénal suisse,
1937; Salize et al., 2005; R. J. Simon & Ahn-Redding, 2006; Tătaru et al., 2010).
In Austria and Germany, mentally ill offenders with lack of criminal responsibility
will be acquitted; however, if they are still dangerous due to their illness they will
receive a criminal commitment (Edworthy et al., 2016; Schanda, Ortwein-
Swoboda, Knecht, & Gruber, 2000). In Switzerland, mentally ill offenders are also
acquitted but they can be given a hospital disposition only if (1) there was a direct
connection between the illness and the offense; (2) they are at high risk of relapse;
(3) their disorder is treatable; and (4) their prognosis is likely to improve with treat-
ment. If they are not socially dangerous, the treatment may take place on an out-
patient basis (Graf & Dittmann, 2007). In Greece, if the person is a danger to the
public they will receive guardianship in a public hospital (Salize et al., 2005).
Severe personality disorders are included in the insanity defense in Germany,
Austria, and Greece. In Germany, nearly 37 percent of the patients in forensic psy-
chiatric hospitals have a primary diagnosis of personality disorder (Konrad, 2005),
and around 85 percent have committed a serious offense (Müller-Isberner et al.,
2000). In Austria, 40 percent of people found NGRI had committed an offense of
homicide or severe bodily injuries (Schanda et al., 2000).
Nordic legal family. Denmark and Sweden are similar in that criminal respons-
ibility does not exist as a legal concept. Rather, the mental state at the time of the
offense is taken into consideration at the time of the sentencing (Taylor et al.,
2013). In Iceland, the mentally disordered offender is found innocent (Pálsson,
n.d.). The Norwegian legal system adopts a medical principle where the mere pres-
ence of psychosis at the time of the offense is sufficient to find an offender not
criminally responsible (Måseide, 2012). In Finland, a person cannot be held crimi-
nally responsible if they were unable to understand the nature of the act or to
control their behavior. Dispositions that are available for mentally ill offenders vary
according to the risk they pose to society and the severity of the offense. In
Denmark, a mentally ill offender found guilty can be given psychiatric treatment on
an outpatient basis, on an inpatient basis, or as a patient in a psychiatric maximum-
security institution, depending on whether they are given a treatment order or a
placement order,6 whereas in Sweden offenders are sentenced to forensic care with
11
A. G. Crocker et al.
12
Forensic Mental Health Around the World
murder (Wang, Livingston, Brink, & Murphy, 2006). In the Netherlands, for a
judge to impose a TBS-order the offense committed must result in an imprison-
ment sentence of at least four years in cases where the offender is fully responsible
(Edworthy et al., 2016).
Diminished Responsibility
Common-law countries
The availability of diminished responsibility for offenses other than homicide is not
widespread in the common-law legal system. Generally, a plea of diminished
responsibility can be effective when the defendant argues that, while they did
commit the offense, they should not be held fully criminally liable owing to the
13
A. G. Crocker et al.
partial impairment of their mental state (Every-Palmer et al., 2014). Since the only
sentence available for murder in many common-law jurisdictions is life imprison-
ment, reducing the category of crime from murder to manslaughter allows to
impose a lighter sentence to those whose mental disorder played a substantial role
in their offense (Salize et al., 2005).
CIVIL-LAW countries
14
Forensic Mental Health Around the World
In Russia, diminished responsibility may be argued when an individual was not able,
on account of mental disorder, to completely realize the nature of his or her actions
or to completely control them. In this situation, the court must take into account the
mental disorder when ordering a sentence, and, if they are still considered a danger to
others or to themselves, they may receive an outpatient treatment order (Ruchkin,
2000). In Poland, mentally ill offenders with seriously limited accountability may
receive lighter penalties, but may only receive treatment in prison (Ciszewski &
Sutula, 2000). In the Czech Republic, individuals with diminished responsibility will
be sentenced to both prison and forensic protective treatment, with the forensic care
occurring most often after the imprisonment (Vevera et al., 2009).
Discharge Provisions
Common-law countries
Napoleonic Code legal family. Discharge can be the responsibility of the court (e.g.,
Spain, Portugal, Brazil, Argentina: Salize et al., 2005; R. J. Simon & Ahn-Redding,
15
Table 1.2 Hospital Discharge Provisions by Legal Framework and Country
Common Law
Australia State-specific State-specific (ministerial assent or Mental
Health Review Tribunal)
Canada Unlimited, reviewed every year (every three years if ‘high-risk accused’) Provincial/Territorial Review Board
England and Wales Six months (must be renewed after six months, then annually) Treating psychiatrist/hospital (unless restriction
order)
India Reviewed every six months Court
Ireland Related to seriousness of the offense, reviewed every six months Mental Health Review Board
Israel Reviewed every six months Regional psychiatric board
New Zealand n/a Ministerial assent
Scotland Six months (must be renewed after six months, then annually) Mental Health Tribunal
Singapore Reviewed every six months Visitors board of independent psychiatrists and
members of the public
South Africa n/a Treating hospital (ministerial assent if index
offense was violent)
United States n/a Court (most states)
continued
Table 1.2 Continued
Finland Unlimited, reviewed every six months Final decision by the Authority of Medico-
Legal Affairs (TEO)
Iceland Depends on psychiatric state, reviewed after a year Court
Norway Unlimited n/a
Sweden Reviewed every six months Court
Former Communist
Bulgaria Every six months Court
Croatia Depends on psychiatric state, should not exceed upper limits of n/a
imprisonment
Czech Republic Unlimited n/a
Poland Unlimited, reviewed at least every six months Court
Russia Limit is duration of the sentence, reviewed after six months, then annually Court
Ukraine Related to nature of the offense n/a
Note
n/a indicates that the information was unavailable.
Forensic Mental Health Around the World
19
A. G. Crocker et al.
average stay is one to three months before they are released under the care of their
family (Chen, Ou, & Wang, 2013; Topiwala, Wang, & Fazel, 2012).
The decision to discharge from forensic services belongs to the court in Russia and
Poland (Ciszewski & Sutula, 2000; Ruchkin, 2000; Vevera et al., 2009). In Russia,
the duration of the detention is restricted to the duration of the sentence. In Croatia,
it depends on the mental state of the patient, with the maximum duration of treat-
ment not exceeding the upper limits of imprisonment unless there is a serious risk
of recidivism. In Ukraine, the duration of treatment is mostly related to the nature
of the offense instead of the patient’s mental state or social risk (Douw et al., 2015;
Margetić et al., 2012; Ruchkin, 2000). The duration of forensic treatment is
unlimited in Poland and the Czech Republic (Ciszewski & Sutula, 2000; Vevera
et al., 2009).
Common-Law Countries
In England and Wales, forensic services are organized by level of security and are
provided by the National Health Service (NHS) or the private sector. Hospitals and
wards are not divided into forensic and nonforensic; as such, offenders and aggres-
sive nonoffenders may be treated on the same wards. There are three high-security
hospitals (sometimes called ‘special hospitals’). They provide services to individuals
who are formally detained under the mental health legislation and who present a
grave and immediate danger to the public (McMurran, Khalifa, & Gibbon, 2009).
Medium-security units receive patients who present a risk to others. Patients who
have committed minor offenses are treated in general psychiatric hospitals, where
about 3,700 beds belong to the NHS (National Health Service, 2013). Forensic
services are delivered through five distinct forensic care pathways, which have been
developed in order to ensure that patients’ needs are met at the right time and that
care decisions are evidence-based (Care Pathways and Packages Project, 2009).
In Ireland, forensic services are organized by levels of risk and security, and
admit mentally ill offenders and nonoffenders. High-security forensic units provide
treatment to patients who pose a grave and immediate danger to others. The
National Forensic Mental Health Service (NFMHS) is based at the Central Mental
Hospital Dublin, with a capacity of about 90 secure beds, some of which are avail-
able to women offenders, distributed across three levels of security. Other mentally
ill offenders may be treated in psychiatric centers and in district or private psychiat-
ric hospitals. Regional forensic mental health teams are established to support con-
tinuity of care. Housing support is put in place by the NFMHS recovery and
20
Forensic Mental Health Around the World
rehabilitation team, as patients first move to a low-security hostel situated near the
Central Mental Hospital (Mental Health Commission, 2006; O’Neil, 2012; Salize
et al., 2005; Taylor et al., 2013).
In Scotland, forensic services are also organized by level of security and are pro-
vided by the National Health Service (NHS), under the coordination of the For-
ensic Mental Health Services Managed Care Network. Offenders and nonoffenders
are treated on the same wards. High-security services, for those who present a grave
and immediate danger to others, are provided nationally at the State Hospital in
Carstairs (Forensic Network, 2016; McMurran et al., 2009; Thomson, 2016).
Medium-security services, for patients who pose a serious but less imminent danger
to others, are delivered regionally (Crichton et al., 2004; Forensic Network, 2016;
Thomson, 2016). Finally, low-security services and community services are offered
locally. Women requiring high-security services are transferred to England and are
detained at Rampton Hospital, while women requiring medium-security services
may be treated at the Rowanbank Clinic and at the Orchard Clinic.
In Australia, the jurisdiction of mental health services belongs to each state and,
hence, the organization of forensic services varies from one region to the next.
For example, New South Wales’s forensic facilities are under the authority of
the Justice and Forensic Mental Health Network. Forensic services are delivered
in correctional, inpatient, and community settings with one high-security facil-
ity as well as medium-security facilities that are operated by local health districts
(Mental Health Coordinating Council, 2015). In South Australia, forensic serv-
ices are delivered in a forensic hospital by Forensic Mental Health Services, a
component of the Statewide Mental Health Service, but all patients are under
the administrative control of the Department of Correctional Services (Jager,
2001). In Victoria, Forensicare7 provides forensic psychiatric services at the
Thomas Embling Hospital (Jager, 2001; Mullen et al., 2000). Continuity of care
is ensured by transferring discharged service users to the Community Forensic
Mental Health Services, where they receive assertive follow-up and the support
of a case manager for approximately two to three years (O’Donahoo & Simmonds,
2016). In the Australian Capital Territory, forensic mental health services are
under the responsibility of the Corrections Health Board and they are provided
in dedicated, secure beds of a psychiatric unit. In the Northern Territory, inpa-
tient forensic services are primarily delivered within the prison system (Jager,
2001).
In New Zealand, forensic services are decentralized, regionally configured, with
no overarching organization and are entirely integrated to civil mental health serv-
ices. All regions provide medium-security services and most also operate low-
security units. Most of these forensic services offer outpatient services for those that
have been discharged but are not ready yet to be transferred to general mental
health services, with the exception of Auckland Regional Forensic Service, which
21
A. G. Crocker et al.
transfers discharged service users to general mental health services with liaison serv-
ices from the forensic system (Brinded, 2000; Ministry of Health, 2007).
Canada is much like Australia, in that there is no national structure of forensic
services and the organization of forensic and general mental health is a provincial or
territorial responsibility and part of the public health system (Crocker, Nicholls, Seto,
Charette, et al., 2015a; Livingston, 2006). In addition to their core services, most for-
ensic services also offer support and treatment to mentally disordered offenders in
provincial prisons.8 Models for organizing forensic services in Canada vary from a
highly centralized, integrated network of forensic mental health services in British
Columbia (BC Mental Health & Substance Use Services, 2013; Livingston, 2006), to
a small number of dedicated forensic facilities in Ontario to highly distributed regional
services in Québec (Crocker, Nicholls, Côté, Latimer, & Seto, 2010). All provinces
have a high-security facility, or forensic units in psychiatric hospitals for less populous
provinces. Supportive housing is available but limited across the country (Livingston,
Wilson, Tien, & Bond, 2003; Salem et al., 2015).
In the United States, forensic service provision varies widely from one state to
the other; however, they are all part of the public mental health systems. A survey
conducted by the National Association of State Mental Health Program Directors
indicates that approximately two-thirds of the states have a dedicated forensic facil-
ity, with the remaining states treating forensic patients in either forensic or nonfo-
rensic units located in general psychiatric facilities. Eighty percent of states have
established conditional release programs that aim to facilitate the reentry and reinte-
gration of forensic service users into the community (Fitch, 2014).
Asia
Many Asian countries have a number of dedicated forensic beds in psychiatric hos-
pitals or forensic inpatient units (World Health Organization, n.d.). Hong Kong’s
forensic services are under the authority of the Department of Forensic Psychiatry.
Inpatient treatment is delivered in forensic wards and a Community Reintegration
Unit offers predischarge services to ensure successful community reintegration for
mentally ill offenders. Community services for discharged forensic service users are
provided by forensic outpatient clinics, forensic community services, and a multi-
activity center (Every-Palmer et al., 2014). In India, patients found not guilty by
reason of insanity may be detained in ‘safe custody,’ which most often results in
being detained in a prison, but sometimes includes detention in a psychiatric hos-
pital or under the charge of family members. In Bangalore, forensic inpatient treat-
ment is delivered in a male forensic psychiatric ward embedded within the National
Institute of Mental Health and Neurosciences in Bangalore, or in psychiatric hos-
pitals, where forensic and civil psychiatric patients are treated together (Kumar et
al., 2014; Sarkar & Dutt, 2006). In Israel, forensic services are provided by four
departments of a designated maximum secure unit of the Sha’ar Menashe Mental
Health Center; there are no medium- or low-security units (Bergman-Levy, Bleich,
Kotler, & Melamed, 2010). In Pakistan, some psychiatric hospital beds are dedicated
22
Forensic Mental Health Around the World
to forensic patients, but they are distinct from general psychiatric services and
administrated by the prisons (Hassan et al., 2015). In Singapore, the Institute of
Mental Health Department of Forensic Psychiatry (originally named Woodbridge
Hospital), under the authority of the Ministry of Health, receives mentally dis-
ordered offenders (Chan & Tomita, 2013; Every-Palmer et al., 2014). Information
for Bangladesh, Kyrgyzstan, and Myanmar is provided in Table 1.3.
Civil-Law Countries
Europe
The Austrian forensic system is centralized and forensic institutions are under the
responsibility of the Ministry of Justice. Mentally ill offenders may be treated in a
high-security forensic hospital (male only), in small forensic departments within
civil psychiatric hospitals, or in closed wards of regional psychiatric hospitals. For-
ensic outpatient services are available after discharge in a large forensic aftercare
institution in Vienna and in forensic outpatient clinics, but continuity of care
depends mostly on civil psychiatric services (Salize et al., 2005; Schanda et al., 2000;
Stompe, Frottier, & Schanda, 2007).
In Belgium, forensic services are federalized and, as such, there are large disparities
between the organization of care in Wallonia (primarily French-speaking), and
23
A. G. Crocker et al.
24
Forensic Mental Health Around the World
are not treated there. When there are forensic bed shortages, forensic patients are
sometimes placed in general psychiatric facilities, alongside both voluntarily placed
and involuntarily placed nonoffenders. Some of these are high-security hospitals
that take specifically the most serious and dangerous offenders. But, in most of the
German states, a single forensic hospital comprises all levels of security (e.g., Haina
Forensic Psychiatric Hospital: Edworthy et al., 2016; Kamara & Müller-Isberner,
2010). As probation conditions, the court can order a person to present themselves
to outpatient treatment or receive aftercare from forensic outpatient centers. All 16
states operate forensic outpatient centers (Edworthy et al., 2016; Konrad & Lau,
2010; Müller-Isberner et al., 2000; Salize et al., 2005).
Greece has a high-security forensic psychiatric hospital in Athens for male
offenders and high-risk nonoffenders detained under civil legislation; those who are
judged less dangerous are held in one of the six general psychiatric hospitals with
forensic beds. Women have no forensic facilities, so they are either treated in the
female prison or in psychiatric hospitals. The Greek forensic setting is not con-
sidered to be integrated with the national health system (Salize et al., 2005).
In Iceland, Sogn is the only forensic psychiatric hospital; two or fewer people
are sentenced to forensic care each year. It was recently administratively incorpor-
ated to the psychiatric ward of the Landsspitalinn University Hospital. As of 2010,
a psychiatric hospital at Kleppur was attempting to establish a closed ward with
additional beds that could serve as a low-security ward. At discharge, the court
orders a strict follow-up, which may involve regular visits to the psychiatrist or
medication adherence (Ilorleifsson, 2010; Pálsson, n.d.; Sigurjónsdóttir, n.d.).
Prior to 2008, there were six forensic psychiatric hospitals in Italy, with around
1,000 to 1,200 beds. They were entirely separated from the civil health system and
were run, except for one, by the Ministry of Justice. In April 2008, the Italian gov-
ernment introduced a program to progressively downsize and/or close the forensic
hospitals and to refer patients to the national health system. The forensic hospitals
were closed completely in the spring of 2015, and were replaced by smaller com-
munity facilities located in each of the 20 Italian regions, each with about 20 beds
that were adapted for socially dangerous offenders. Offenders who are less socially
dangerous may be transferred to a civil psychiatric facility (Barbui & Saraceno,
2015; Carabellese & Felthous, 2016; Peloso, D’Alema, & Fioritti, 2014; Salize et
al., 2005; Traverso et al., 2000). In Luxembourg, forensic services are highly cen-
tralized: mentally ill offenders may only be treated in the Neuropsychiatric Hospital
Center in Ettelbruck. They may not be placed in general mental health institutions
and they are not treated alongside nonoffenders (Salize et al., 2005).
Forensic services are federalized in the Netherlands; thus, each district has its
own service system. TBS-patients may either be treated in specialized forensic facil-
ities, such as one of the nine TBS-hospitals (as of 2005), or in one of the three
forensic psychiatric hospitals, or in forensic units of general psychiatric hospitals.
TBS-hospitals are under the authority of the Ministry of Justice, while forensic
psychiatric hospitals are under the authority of the Ministry of Health and receive
TBS-patients with psychiatric disorders (instead of personality disorders) along with
25
A. G. Crocker et al.
In Argentina, forensic services are provided either by the public health system when
the unimputable9 patients are considered low risk (Folino et al., 2000) or by the
26
Forensic Mental Health Around the World
penitentiary service in one of its forensic psychiatric hospitals (Almanzar, Katz, &
Harry, 2015; World Health Organization, n.d.). In the province of Buenos Aires,
there are at least three institutions treating unimputable patients, one of which is
dedicated to women. Another institution has been established in the province of
Córdoba (J. F. Folino, personal communication, August 21, 2016). Postdischarge
outpatient services are often delivered by the forensic hospital where the patient
had received inpatient care (Folino et al., 2000; Taborda et al., 2007). In Brazil,
forensic services differ from one region to the next, owing partly to legal differences
and partly to socioeconomic differences. The 31 forensic hospitals and units in the
country are not distributed uniformly and many states have no forensic facilities
(Almanzar et al., 2015; Taborda et al., 2007; World Health Organization, n.d.). In
the latter case, forensic patients are either detained in general psychiatric hospitals
or in prisons (Taborda et al., 2007). Ties to the forensic system are severed when
forensic service users receive a hospital discharge (Taborda et al., 2000). In Chile,
forensic services are under the authority of the New Forensic Psychiatry Network,
which comprises forensic facilities across the country, including one high-
complexity forensic unit in the Philippe Pinel Hospital and three medium-
complexity units in three hospitals (Cid, 2010). In less than 10 years, the number of
forensic beds has increased fourfold (World Health Organization, n.d.). Informa-
tion about Cuba, Ecuador, El Salvador, Guatemala, Mexico, Paraguay, Peru, and
Uruguay is summarized in Table 1.3.
Asia
27
Table 1.3 Forensic Service Provision by Country
Countries and Their Adult Location of Forensic Services Forensic Beds Forensic Beds per 100,000 Adult
Resident Population Estimates Population Rate
(18 and Over, Unless Specified)
continued
Table 1.3 Continued
Countries and Their Adult Location of Forensic Services Forensic Beds Forensic Beds per 100,000 Adult
Resident Population Estimates Population Rate
(18 and Over, Unless Specified)
England and Wales Secure hospitals 795 high secure HS: 1.8
(44,812,000 in 2013) 3,192 medium MS: 7.1a
secure (2013)
Finland Psychiatric hospitals, some of which have a forensic ward 450 (2013) 10.4a
(4,338,000 in 2013)
France Secure units in psychiatric hospitals or psychiatric 486 (2005) 1.0a
(48,410,000 in 2005) hospitals
Germany Forensic hospitals and psychiatric hospitals, with or 10,471 (2013) 15.5a
(67,596,000 in 2013) without forensic department
Greece Forensic hospital or psychiatric hospital (also prison for 250–330 2.7–3.6a
(9,109,000 in 2005) women) (estimate, 2005)
Hungary n/a n/a 1.9 (2009, crude population)
(8,185,000 in 2009) 2.3e (estimated, adult population)
Iceland Forensic hospital or psychiatric units 7–8 (2010) 3.0–3.4a
(237,000 in 2010)
Ireland Forensic facilities and psychiatric facilities 89 (2006) 2.6a
(3,440,000 in 2011)
Latvia Forensic units n/a 0.7 (2009, crude population)
(1,769,000 in 2009) 0.9e (estimated, adult population)
Macedonia Psychiatric hospitals 123 (2009) 7.7b
(1,591,000 in 2009)
Netherlands Forensic facilities (TBS-hospitals or forensic hospitals) or 1,867 (2013) 14.2a
(13,154,000 in 2011) forensic units in psychiatric hospitals
Norway Secure units administered by counties and health regions 180 (2014) 4.5a
(3,983,000 in 2014)
Poland Psychiatric wards or secure institutions n/a 3.8 (2009, crude population)
(30,825,000 in 2009) 4.7e (estimated, adult population)
Portugal Forensic units, often attached to psychiatric hospitals 189 (2005) 2.2a
(8,532,000 in 2005)
Romania Psychiatric hospitals or penitentiary psychiatric hospital n/a 7.2 (2009, crude population)
(17,506,000 in 2009) 8.8e (estimated, adult population)
Russia Secure hospitals and psychiatric hospitals 5,440 high HS: 4.7
(116,486,000 in 2012) secure MS: 5.7a
6,582 medium
secure (2014)
Scotland Secure hospitals 140 high secure HS: 3.3
(4,293,000 in 2015) 160 medium MS: 3.7a
secure (2016)
Slovenia n/a n/a 1.2 (2009, crude population)
(1,685,000 in 2009) 1.4e (estimated, adult population)
Spain Psychiatric penitentiary hospitals 593 (2005) 1.7a
(35,630,000 in 2005)
Sweden Forensic facilities, psychiatric facilities, or general 1,113 (2011) 14.7a
(7,564,000 in 2011) hospitals
Switzerland Forensic facilities or prisons n/a 1.3 (2005, crude population)
(5,973,000 in 2005) 1.6f (estimated, adult population)
Ukraine Secure hospitals, psychiatric hospitals 709 high-security 1.9a
(37,382,000 in 2013) (2015)
continued
Table 1.3 Continued
32
Countries and Their Adult Location of Forensic Services Forensic Beds Forensic Beds per 100,000 Adult
Resident Population Estimates Population Rate
(18 and Over, Unless Specified)
Asia
Armenia Forensic unit in psychiatric hospital 60 (2009) 2.6b
(2,323,000 in 2011)
Azerbaijan Forensic unit n/a 3.6 (2009, crude population)
(6,286,000 in 2009) 5.1e (estimated, adult population)
Bahrain Forensic unit in psychiatric hospital 18 (2010) 2.0b
(943,000 in 2010)
Bangladesh Forensic unit 15 (2007) 0.02b (15+)
(94,162,000 in 2011, 15+)
China Ankang hospitals, run by the public safety system 7,000 (2012) 0.7a
(1,054,898,000 in 2010)
Hong Kong Forensic wards in psychiatric hospital 220 (2016) 3.4a (15+)
(6,437,000 in 2014, 15+)
Iraq High-security unit of psychiatric hospital 250 (2006) 0.9b (per total population)
(28,750,000 in 2006, total
population)
Israel Maximum-security unit of psychiatric hospital 200 (2007) 4.2a
(4,793,000 in 2007)
Japan Forensic units 666 (2011) 0.6a
(107,438,000 in 2011)
Jordan Forensic unit in psychiatric hospital 78 (2011) 2.7b
(2,863,000 in 2004)
Korea Forensic units 1,000 (2006) 2.8b
(36,201,000 in 2005)
Kyrgyzstan Special forensic facilities and psychiatric hospitals 249 (2008) 7.4b
(3,382,000 in 2009)
Myanmar Forensic units 120 (2006) 0.4b
(33,126,000 in 2014)
Oman Psychiatric hospital and prison 5 (2008) 0.4b
(1,387,000 in 2003)
Pakistan Psychiatric hospitals administered by prisons n/a 0.02d (2009)
(87,509,000 in 2007, 15+)
Philippines Psychiatric hospital 400 (2007) 0.7b
(55,720,000 in 2010)
Saudi Arabia Forensic units 50 (2013) 0.2a
(21,199,000 in 2014)
Singapore Forensic hospital 140 (2013) 4.7a
(2,959,000 in 2010)
Sudan Prison medical facilities 200 (2009) 1.0b
(19,709,000 in 2015)
Tajikistan Forensic units 25 (2009) 0.6b
(4,357,000 in 2010)
Uzbekistan Psychiatric hospitals 890 (2007) 4.5b
(19,932,000 in 2013)
Vietnam Forensic units 300 (2006) 0.5b
(59,617,000 in 2009)
Oceania
Australia State-specific 616 (2013–14)a 3.4g
(18,205,000 in 2014)
New Zealand Forensic units 221 (2005) 7.4a
(2,974,000 in 2006)
Africa
Ghana Psychiatric hospital or general hospital 79 (2011) 0.6b
(13,627,000 in 2010)
Nigeria Forensic units or prisons 22 (2006) 0.02b (15+)
(104,268,000 in 2006, 15+)
33
continued
Table 1.3 Continued
Countries and Their Adult Location of Forensic Services Forensic Beds Forensic Beds per 100,000 Adult
Resident Population Estimates Population Rate
(18 and Over, Unless Specified)
South Africa Forensic wards in psychiatric hospitals 1,676 (2007) 4.6b (15+)
(36,670,000 in 2011, 15+)
Tunisia Psychiatric hospital 60 (2008) 0.7b (15+)
(8,372,000 in 2014, 15+)
Uganda Psychiatric hospital 116 (2006) 0.8b
(14,267,000 in 2002)
Zambia Psychiatric hospital 120 (2009) 1.9a
(6,222,000 in 2010)
Notes
n/a indicates that the information was unavailable. When multiple sources of information were available for a country, the most recent was used. Adult population estim-
ates were retrieved or calculated from governmental websites, the United Nations Statistics Division, or the Organisation for Economic Co-operation and Development.
a Total number of beds was retrieved from various sources (Almanzar et al., 2015; Bergman-Levy et al., 2010; Bjørkly, Hartvig, Roaldset, & Singh, 2015; Chan & Tomita,
2013; Department of Mental Health and Substance Abuse – World Health Organization, n.d.; Douw et al., 2015; Edworthy et al., 2016; Every-Palmer et al., 2014; Ilor-
leifsson, 2010; Koskinen, Likitalo, Aho, Vuorio, & Meretoja, 2014; Livingston, 2006; Mental Health Commission, 2006; Ministry of Health, 2007; Nakatani, 2012;
National Association of State Mental Health Program Directors Research Institute, 2015; National Health Service, 2013; Ngungu & Beezhold, 2009; Nielsen, van Mas-
trigt, & Wobbe, 2016; Pálsson, n.d.; Qureshi et al., 2013; Salize et al., 2005; Sigurjónsdóttir, n.d.; Thomson, 2016; Topiwala et al., 2012; World Health Organization,
2005; Yee Ho & Kwan Yan, 2016) and the number of beds per 100,000 population was hand-calculated.
b Total number of beds was made available by the WHO-AIMS reports on mental health systems and the number of beds per 100,000 population was hand-calculated.
c This number represents a minimum.
d The number of beds per 100,000 population was made available by the WHO-AIMS reports on mental health systems. It is not known whether this number was calcu-
lated using the adult population or the total population.
e The number of beds per 100,000 crude population was retrieved from Mundt et al. (2012). The number of beds per 100,000 adult population was estimated using the
total population retrieved from the United Nations Statistics Division.
f The number of beds per 100,000 crude population was retrieved from Priebe et al. (2008). The number of beds per 100,000 adult population was estimated using the
total population retrieved from the United Nations Statistics Division.
g Total number of beds and beds per 100,000 population retrieved from the Australian Institute of Health and Welfare (Australian Institute of Health and Welfare, n.d.).
Forensic Mental Health Around the World
general mental health care system. This outpatient treatment usually lasts three years
(Every-Palmer et al., 2014; Fujii et al., 2014; Nakatani, 2000, 2012; Nakatani,
Kojimoto, Matsubara, & Takayanagi, 2010). Information for Korea, Vietnam, and
the Philippines is provided in Table 1.3.
Africa
In Algeria, the Frantz Fanon Hospital is the designated forensic hospital, but a
regionalization process has recently been taking place (El Hamaoui et al., 2009;
Ogunwale et al., 2012). Information for Tunisia is provided in Table 1.3.
As published by the World Health Organization’s AIMS Report on Mental
Health Systems, there are no forensic facilities in Benin, Bolivia, Burundi, Djibouti,
Dominican Republic, Eritrea, Guyana, Haiti, Honduras, Laos, Lebanon, Suriname
(where patients are treated in the long-stay unit of a psychiatric hospital), Panama,
or Venezuela.
35
A. G. Crocker et al.
the Federal Ministry of Health, that receive highly socially dangerous patients.
Nonoffenders may not be admitted to these hospitals. The tendency in the last year
has been to centralize the forensic services. When the patients are discharged, they
are followed-up by outpatient psychiatric clinics, ensuring continuity of care
(Every-Palmer et al., 2014; Ruchkin, 2000).
In Ukraine, forensic services are also offered at different levels of security.
Mentally ill offenders are often first treated in the Special Psychiatric Hospital in
Dnepropetrovsk, which is the only high-security forensic hospital. Eventually, they
are transferred to medium-security units of general psychiatric hospitals. However,
there is a critical lack of continuity of care between levels of security (Douw et al.,
2015). Information for Armenia, Azerbaijan, Belarus, Hungary, Latvia, Macedonia,
Romania, Slovenia, Tajikistan, and Uzbekistan is provided in Table 1.3.
Summary
The review above clearly shows the wide variation in legal frameworks around
such issues as fitness to plead and criminal responsibility, as well as the absence of
clear processing patterns, both within and across large legal systems. No straight-
forward conclusion about the organization of forensic services and the actual com-
parability across nations can be made. Despite these limitations, some trends do
emerge. Fitness to stand trial is much more common in common-law countries in
comparison to civil-law countries, where it is nearly nonexistent, with the excep-
tions of Germany, Chile, Argentina, Japan, China, and Taiwan. This could be
explained by the fact that common law is more adversarial in nature, whereas civil
law adopts an inquisitorial approach. The concept of fitness was also available in
some former Communist countries. The insanity defense, on the other hand, is a
legal concept that is both deeply embedded in countries of civil-law tradition and
of common-law tradition, despite being rarely used in England. The Nordic coun-
tries of Denmark and Sweden instead sentence criminally responsible offenders to
treatment.
In most countries, a defendant found unfit could be either detained in a hospital
(either forensic or general) or released, depending on the risk level and on the
severity of the offense. Many common-law countries have put in place safeguards
36
Forensic Mental Health Around the World
37
A. G. Crocker et al.
38
Forensic Mental Health Around the World
to be designed. However, there are guidelines for organizing general mental health
and substance use systems (Hogan et al., 2003; McDaid & Thornicroft, 2005;
National Treatment Strategy Working Group, 2008; Organization of Services for
Mental Health, 2003; Roberts & Ogborne, 1999; Rush, 2010; Thornicroft &
Tansella, 2004; U.S. Department of Health and Human Services, 2009). With
some adaptation to the unique role and function of forensic services (i.e., involun-
tary, public safety-focused), these system-level principles are transferable to the for-
ensic mental health arena.
According to these guidelines, an effectively organized forensic mental health
system would include elements such as: (1) providing a comprehensive and bal-
anced continuum of services, (2) integrating services within and between systems,
(3) matching services to individual need, (4) adhering to human rights, (5) respond-
ing to population diversity, and (6) using the best available evidence to make
system-wide improvements. Though all of these system-level principles are
important, the discussion below will focus on how the first three (service contin-
uum, system integration, and service matching) may be applied to the organization
of forensic mental health services.
39
A. G. Crocker et al.
from unnecessarily becoming involved in the criminal justice system. It would also
ensure that high-quality services reach those with mental health needs who are in
the criminal justice system (e.g., arrested by police, detained or incarcerated, on
parole or probation) in order to prevent further criminalization (Munetz & Griffin,
2006).
One conceptual framework that is used to portray what balanced care systems
look like is the ‘tiered model’ (National Treatment Strategy Working Group,
2008; Organization of Services for Mental Health, 2003; Rush, 2010). A funda-
mental aspect of the tiered model is that mental health and substance use systems
contain logical groupings of services that have comparable levels of intensity,
specialization, and restrictiveness. Comparable services can be clustered into tiers
that are most appropriate for meeting the needs of distinct groups of people based
on the acuity, complexity, and chronicity of their mental health and substance
use problems. For instance, highly specialized and intensive (and costly) services
are most suitable for people with severe (i.e., highly acute, complex, and chronic)
problems, and least appropriate for people experiencing low to moderate levels
of distress or impairment. Another feature of the tiered model is that the distribu-
tion of services should align with the population distribution of problem severity.
Those with lower-level problem severity are more numerous in the population
and, as such, the demand (i.e., volume) for less intensive, less specialized services
is great. Conversely, severe mental health and substance use problems are less
common in the population and the demand for highly specialized, highly inten-
sive services is small. The shape of service systems should correspond with the
demand for different service levels.
According to the principles of the tiered model, a balanced forensic mental
health care continuum would resemble the figure below.
Drawing from other frameworks (e.g., Kennedy, 2002; Mullen, 2000;
O’Dwyer et al., 2011; Thornicroft & Tansella, 2013; World Health Organiza-
tion, 2003), this conceptual model is designed with six tiers that contain three
clusters of custodial-based forensic mental health services (Tiers 4–6) and three
clusters of community-based services (Tiers 1–3). Each service cluster would
contain evidence-based interventions corresponding with the particular function
of that cluster. The menu of interventions available within each cluster will vary
between jurisdictions. Compared with other tiered service models designed for
general mental health and substance use systems, the model depicted here is
weighted more heavily toward institutional services in order to reflect the dis-
tinct nature of forensic populations and the risk management function of for-
ensic systems. Nonetheless, striking a balance between custodial- and
community-based services is vital for forensic mental health systems (Mullen,
2000), with some suggestion that the investment in community services should
be equal to or greater than the amount being spent on custodial care (Thornicroft
& Tansella, 2013).
As was revealed by our review of forensic systems, the upper half of the
pyramid (Tiers 4–6) parallels with how parts of the world currently distribute
40
Forensic Mental Health Around the World
High High
Tier 6.
High-security
custodial services
Tier 5.
Forensic specialization
Medium-security
Deprivation of liberty
custodial services
Tier 4.
Low-security
custodial services
Tier 3.
High-intensity
community services
Tier 2.
Moderate-intensity
community services
Tier 1.
Low-intensity
community services
Low Low
41
A. G. Crocker et al.
42
Forensic Mental Health Around the World
on their risk and need profile, as is depicted in the table below. Others have pro-
posed similar strategies for distributing resources based on the needs of adults with
behavioral health problems who are under correctional supervision (Osher et al.,
2012). Additionally, the ‘stratified risk and care’ model described by Pillay and col-
leagues (2008) outlines a similar way that forensic service users are distributed across
security levels according to their level of clinical need and risk for violence and
crime.
Custodial forensic services (Tiers 4–6) are most appropriate for forensic service
users who are assessed as being at moderate to high levels of criminogenic risk, as
well as those with severe mental health and substance use problems. The Prins and
Draper (2009) model suggests that persons with higher levels of criminogenic needs
accompanied by more serious mental health and substance use problems would be
the most likely to benefit from a highly specialized forensic mental health service,
with its integration of risk assessment, risk management, and mental health and sub-
stance abuse treatment. Community forensic services (Tiers 1–3) may be most
appropriate for forensic service users assessed as being at low to moderate levels of
criminogenic risk and have low to moderate mental health and substance use treat-
ment needs. The needs of forensic service users who have lower levels of crimino-
genic, mental health, and substance use needs are likely to be met by services with
lower levels of forensic specialization. Those with higher criminogenic needs who
are living in the community may be best served by highly specialized forensic serv-
ices, such as forensic assertive community treatment.
Much of the literature in this area focuses on criminogenic risk and need factors,
but a recent body of scholarship has cast doubt on the validity of using crimino-
genic risk to inform decisions regarding the assignment of service users to different
security levels in a forensic mental health care continuum (O’Dwyer et al., 2011).
43
A. G. Crocker et al.
Integrating Systems
Forensic service users need to access different systems and subsystems to have their
intersecting needs appropriately met. Many obstacles prevent services from achiev-
ing optimal levels of integration and coordination, such as fragmented funding
mandates. The complexity of the criminal justice, psychiatric, and social problems
existing within the forensic mental health population present challenges for coord-
inating and integrating services for this group—especially since forensic service
users are undesired, unwanted, and rejected by other service systems (Wolff,
2002).
Receiving care from different systems, or different components of a system, is
very problematic in a population with co-occurring, complex needs, and that has
experienced severe social ruptures and interrupted care trajectories. A fundamental
principle for effectively organizing mental health and substance use services is that
systems should be integrated (Craven & Bland, 2006; Thornicroft & Tansella,
2003). In the forensic mental health context, system integration refers to bridging
the service delivery gaps that exist within and between mental health, substance
use, criminal justice, corrections, housing, and other essential service sectors. The
purpose of systems integration is to encourage seamless service delivery, to promote
efficiency, to optimize the use of scarce resources, and to improve outcomes.
Systems integration is promoted through structures and processes that facilitate col-
laborations, partnerships, and communication between professionals and agencies.
Models of systems integration between mental health, criminal justice, and com-
munity support services have been developed (Lamberti, Deem, Weisman, &
LaDuke, 2011; Osher et al., 2012; Weisman, Lamberti, & Price, 2004). Our review
of forensic systems also shows various ways in which different jurisdictions through-
out the world have tried to build systems integration in order to meet the needs of
forensic service users. One aspect of systems integration focuses on linkages and
coordination among the various components of the mental health, substance use,
44
Forensic Mental Health Around the World
and correctional service continuum. Integration between the custodial and com-
munity settings is also essential for the efficient and effective delivery of forensic
mental health services. Opportunities for multi-system collaboration and system
integration exist throughout the tiered model. For instance, the needs of forensic
service users at the lower tiers (e.g., 1 or 2) could be effectively met by the general
mental health system, since the need for specialized forensic services may no longer
exist (Humber et al., 2011), an approach that has been adopted by many countries.
Integrating risk management strategies and transferring forensic skills into the
general mental health system, or transitioning forensic service users to the general
mental health system when appropriate has a number of advantages (Jansman-Hart
et al., 2011), including freeing up space in the forensic system but also avoiding
unnecessarily restricting the liberty of forensic service users.
As our international review of frameworks demonstrated, numerous options
exist for organizing forensic mental health systems. In addition to population differ-
ences, the models vary in the degree to which services are integrated with the other
sectors, such as the general, nonforensic mental health system as well as the cor-
rectional system. One approach, which we call a ‘specialized’ model, offers special-
ized forensic services to all forensic services users throughout their care pathway in
custody (e.g., forensic hospital) and the community (e.g., forensic outpatient care).
In contrast, a ‘mixed’ model provides access to specialized care based on need
whereby only some forensic service users (e.g., moderate–high risk) receive special-
ized forensic services, while others receive hospital- or community-based services
in the general mental health system. This model’s focus on tailoring care (special-
ized or integrated) based on individual need is consistent with the principles of the
tiered model. Lastly, in a ‘general’ model, forensic service users receive services
either entirely (i.e., hospital and community) or partly (i.e., community only) in the
general mental health system—an arrangement that is primarily based on the avail-
ability of resources rather than people’s needs. There are theoretical strengths and
weaknesses of these different ways of integrating systems, but their relative effec-
tiveness requires further study.
45
A. G. Crocker et al.
Parameswaran, Spaeth-Rublee, Huynh, & Pincus, 2012). Very little substantive doc-
umentation about performance measurement is currently available in the gray liter-
ature and even less so in the scientific literature. We were able to locate variable
degrees of information from Canada (Ontario and British Columbia), England and
Wales, Scotland, Germany, the Netherlands, and Australia. A few key initiatives are
being disseminated, particularly through the International Association of Forensic
Mental Health Services’ special interest group of service development, organization,
strategy, and delivery, which meets regularly at the association’s annual conference.
As was clearly illustrated by Müller-Isberner et al. (2016), forensic mental health
services are complex organizational structures embedded in an elaborate mesh of
media and public scrutiny, legal frameworks, administrative contexts, institutional
contexts, and general risk management interventions. Managing all of these com-
ponents is an important and challenging endeavor. The development of quality
standards can help organizations in measuring outcomes, standardizing procedures,
and facilitating the integration of evidence-based practices into services. Whether
organizations choose to follow the guidelines of the International Organization for
Standardization (Müller-Isberner et al., 2016), quality standards developed by
accrediting bodies for general health care organizations,11 or their own quality
standard network approaches (Barbaree & Goering, 2007; Haque, 2016; Thomson,
2016), it is becoming increasingly clear that forensic mental health services can and
should implement systematic quality management processes.
The United Kingdom’s Quality Network for Forensic Mental Health services
has been particularly active.12 From recent reports, they now have participants from
100 percent of all English, Irish, and Welsh medium-security units and 88 percent
of English low-security units (Haque, 2016). This network has produced a series of
accessible documentation booklets on standards for medium-security units, low-
security units, community forensic mental health, prison mental health services,
and a series of supplementary aids on such themes as intellectual disabilities and sub-
stance misuse (Haque, 2016). For medium-security units, the standards focus on
four main themes: (1) Patient safety, which includes physical security,13 procedural
security,14 relational security,15 and the safeguarding of children and vulnerable
adults; (2) patient experience, which includes patient focus, family and friends, and
environment and facilities; (3) clinical effectiveness, which is comprised of patient
pathways and outcomes, physical health care, and workforce; and, finally, (4) gov-
ernance, which includes such indicators as accountability processes, incident
reporting, and accessible complaints procedure (Quality Network for Forensic
Mental Health, 2007). For low-security units, the quality network has developed
standards around six main themes: (1) Models of care, including admission, recov-
ery, physical health care, and discharge; (2) a safe therapeutic environment building
on physical security, relational security, and procedural security; (3) service environ-
ment, which includes environmental design, risk assessment and management, de-
escalation and seclusion, access to external spaces, and facilities for visitors; (4)
workforce, which includes capacity and capability as well as training and continuing
professional development; (5) governance, such as reporting and managing adverse
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Forensic Mental Health Around the World
47
A. G. Crocker et al.
main goals of forensic mental health services. As with mental health services in
general, other intervention attributes need to be taken into account (Thornicroft &
Slade, 2014). These may include accessibility, acceptability, efficiency, cost-
effectiveness, and evidence-informed practices. It is also suggested that outcome
measurement be comprehensive and multidimensional—evaluating humanitarian,
psychosocial, health, and public safety outcomes—and take into account the per-
spectives of multiple stakeholder groups (e.g., patients, caregivers, clinicians: Cohen
& Eastman, 2000; Epperson et al., 2014). All of the abovementioned attributes may
pose some challenges in forensic mental health as there are delicate balances to
maintain between meeting the needs of the individual service users, in terms of
both well-being and human rights, and satisfying the needs of other interest groups,
including victims, the public, and the state. Very little research to date has exam-
ined these issues and together.
Many outcomes will be shaped by factors outside the control of the forensic
mental health system, particularly institutional forensic mental health services, unless
strong continuing links are created and care pathways are maintained in community-
based services. In a recent meeting of mental health, justice, and safety stakeholders
in Canada, the chronic lack of appropriate housing for forensic service users was
identified as a major challenge for forensic services to transition people safely and
promptly into the community (Crocker, Nicholls, Seto, Roy, et al., 2015c).
Although there is ongoing debate, the available research argues against the develop-
ment of parallel forensic mental health community services, but rather supports
investing in better integration with general mental health services (Coid, 2007).
Others have also called for a retooling or scaling up of practices in the general
mental health care system in order to better address the needs, goals, and capabilities
of forensic service users (Hodgins, 2009). It is hypothesized that a more integrated
approach would foster a better understanding of forensic issues among general
mental health care practitioners and would help reduce the stigma of receiving
services from specialized forensic programs. It could also facilitate dissemination and
adoption of quality standards across the continuum of care for forensic service users.
We must also acknowledge that distal outcomes, such as recidivism and mental
health recovery, are strongly associated with social and environmental factors, such
as trauma exposure, environmental stressors, deprivation, poverty, and inequality,
as well as access to and continuity of meaningful care and support in the community
(Epperson et al., 2014; Seto, Charette, Nicholls, & Crocker, n.d.; Tew et al., 2012).
Increased attention to these determinants in regards to assessing forensic mental
health outcomes, including the processes that influence outcomes, is essential for
better organizing the continuum of care and addressing the balance between public
safety and individual rights and freedoms.
Despite a clear interest and need in implementing quality management strategies
and developing cultures of outcome measurement in forensic mental health services,
one must remain aware of potential invariance in the measurements; that is, the same
outcome is measured for everybody irrespective of its importance for a particular
person (Thornicroft & Slade, 2014). What is considered to be ultimate positive
48
Forensic Mental Health Around the World
outcome, such as recidivism reduction, may not be what is perceived as most important
for the people who receive or provide forensic services (Livingston, 2016), or for
other stakeholder groups, such as families. Reduction of symptoms may be important
and helpful for the service users to start engaging in more meaningful activities, but
perhaps the most important components of risk reduction or strengths development
for a particular service user may be the possibility of developing significant relations
with others. We must, therefore, remain cognizant of the recovery path of each indi-
vidual service user and integrate the appropriate recovery components in the quality
of care assessment process, which can be a challenge in light of some risk and crimi-
nogenic attributes that must be addressed. In their review on recovery in mental
health, Tew and colleagues (Tew et al., 2012) propose a paradigm shift from “indi-
vidualized ‘treatment-oriented’ practice to one in which working with family and
friends, and promoting social inclusion, are no longer optional extras” (p. 455), focus-
ing on enabling people to reach their aspirations by working not only with the indi-
vidual but his or her social environment. The performance of modern forensic systems
should be systematically evaluated with respect to their alignment with recovery-
oriented or patient-centered principles (Livingston, Nijdam-Jones, & Brink, 2012), as
is evident in the quality frameworks of England and Wales and Scotland, or their
adherence to whichever model (e.g., the balanced care approach depicted in Figure 1.1)
has been chosen to guide the organization and delivery of services.
Risk-Averse Society
The concept of risk refers to the probability of an event and the magnitude of its
consequences; risk and probabilities can be difficult to grasp and can lead to a
variety of responses in society. “Risk events interact with psychological, social and
cultural processes to heighten or attenuate public perceptions of risk and related risk
behavior” (Kasperson et al., 1988, p. 178). Sociologists argue that modern society
is increasingly being structured around risk, with social institutions constituted to
protect the population from perceived dangers (e.g., terrorism, climate change,
infectious diseases, and financial crises: Beck, 1992). Some very low-risk phenom-
ena, such as violent behavior toward a stranger by a person with a mental illness,
can elicit strong public concern and insecurity (Monahan & Steadman, 2012). A
fearful and anxious public turns to their government for protection, and, in turn,
government officials (e.g., politicians) maintain social order by convincing the
public of their capability to manage and control risk. Some politicians strategically
use such opportunities to gain popularity and political advantage by promoting
punitive and coercive measures (e.g., incarceration) to suppress ‘risky problems’
(Pratt, 2007). These harsh punitive measures are problematic in that they are largely
symbolic and undermine the rehabilitative objectives of the criminal justice,
forensic, and correctional systems.
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A. G. Crocker et al.
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Forensic Mental Health Around the World
has not always been clear about this relationship (Monahan, 1992) and researchers
have not effectively communicated what is known about justice-involved mentally ill
persons in general (Crocker et al., 2015c). It may also be partially reinforced by an
emphasis on a deterministic biomedical model of mental illness that can create dualis-
tic thinking between individual recovery and public safety, in the eyes of the public
and politicians. In fact, when it comes to violence and mental illness, there is a general
tendency to view recovery and public safety as opposites, when the evidence has
shown that it is through rehabilitation and recovery that one can achieve a reduction
in risk (Dvoskin, Skeem, Novaco, & Douglas, 2012). The risk–need–responsivity
model research also shows that excessive intervention that is disproportionate to risk
can actually have the inverse effect of increasing risk (Andrews, 2012) and, con-
sequently, decreasing public safety. Research has clearly shown that punitive policies
and coercive practices tend to, in the long term, exert a negative effect on public
safety. Some of the best examples were observed in the United States through the
tough on crime legislation of the 1990s (Blumstein, 2012). Traditionally, conservative
governments have argued for more incarceration/punitive approaches, while liberals
tend to promote crime prevention strategies based on social development (Blumstein,
2012). The resurgence of conservative, right-wing governments around the globe
will continue to pose challenge for forensic mental health services in striving for
recovery-oriented approaches despite increasing pressures to be punitive, often fueled
by highly mediatized cases to use punitive and coercively driven approaches. It will
become increasingly important to develop clear messaging around short-, medium-,
and long-term outcomes and programs that reduce recidivism rates in forensic popu-
lations and improve public safety in order to guide policy-making and reduce stigma.
Future research could explore what are the most effective strategies for educating
policy-makers and the general public around justice-involved persons with mental
illness (Crocker et al., 2015c).
51
A. G. Crocker et al.
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Forensic Mental Health Around the World
53
A. G. Crocker et al.
2015). The model also enables the creation of a list of interventions that could
enhance the staff modifiers (i.e., actions of the staff as individuals or teams) that can
influence the frequency of conflict and containment, thereby reducing conflict and
containment rates (Bowers et al., 2015).
A body of research supports the domains in the Safewards model. Eggert et al.
(2014) examined the person–environment interaction effects of environmental
design on ward climate, safety, job satisfaction, and treatment. With regards to
treatment outcomes, as perceived safety increased so did patient discharges, although
only to a small degree. This result suggests that, when people feel safe in the treat-
ment environment, treatment is more likely to have a positive impact, resulting in
earlier discharge from the hospital. In another study, conducted by van der Schaaf
et al. (2013), the ‘presence of an outdoor space,’ ‘special safety measure,’ and a large
‘number of patients in the building’ increased the risk of being secluded. On the
other hand, design features such as ‘total private space per patient,’ a higher ‘level
of comfort’ and greater ‘visibility on the ward’ decreased the risk of being secluded.
Some support was also found in a literature review by Alexander and Bowers (2004)
on ward rules, providing evidence that service users were in fact calmer and less
disruptive on wards with clear, consistent rules, and clear roles for staff. Finally,
service users’ perceptions about the social climate of the ward were found to have
a significant relationship with their satisfaction with forensic services. However, the
variables most strongly associated with satisfaction with forensic services were their
perceptions about the nature of therapeutic relations with staff (Bressington,
Stewart, Beer, & MacInnes, 2011). Moreover, in a study of participant observation
coupled with interviews of 131 staff collected over 38 months on four acute and
two chronic wards, Katz and Kirkland (1990) concluded that violence was in fact
more common in wards with unclear staff functions. Violence was less frequent in
wards with strong psychiatric leadership, clear staff roles, and events that reflect the
Safewards model’s main principles.
Bowers et al. (2015) conducted a large-scale clustered randomized controlled
trial over a three-month period to test a series of interventions to increase safety and
reduce coercion. The results indicate that simple interventions aiming to improve
staff relationships with patients can reduce the frequency of conflict and contain-
ment. Furthermore, relative to the control intervention, when conflict events
occurred, the Safewards intervention reduced the rate of conflict events by 15
percent and containment events by 26 percent (Bowers et al., 2015). Price, Burbery,
Leonard, and Doyle (2016) used a service evaluation incorporating a nonrand-
omized controlled design to analyze the effects of Safewards on conflict and con-
tainment between and within wards. Informal feedback sessions with staff were
conducted to explore views on the acceptability of the interventions and the adher-
ence to the interventions was measured. The benefit of using the Safewards inter-
vention in a between-ward analysis by measuring conflict and containment rates
failed to reach significance. However, there was a significant association between
ward, conflict, and containment. Furthermore, overall views of the interventions
were valued more highly on female wards than on male wards. Staff from female
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Forensic Mental Health Around the World
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A. G. Crocker et al.
56
Forensic Mental Health Around the World
Casey, 2015; Ware & Bright, 2008). Early research with forensic populations has
found that GLM helped forensic service users discover their motivation for change
through supporting the development of personally meaningful goals (Barnao et al.,
2015) and has allowed practitioners to integrate various treatment theories into
their work with patients (Barnao & Ward, 2015). Bouman, Schene, and de Ruiter’s
(2009) study of the short- and long-term effects of subjective well-being among
forensic service users in the community found that satisfaction with health and
fulfillment of life goals were associated with decreased offending (self-reported) in
the short term. Moreover, in the long term, satisfaction with health and general life
satisfaction were associated with reduced reconvictions for violence among those
who were assessed as high risk. These findings support the notion that fulfillment
of primary goods is associated with reduced recidivism as well as desistance. In sum,
GLM has demonstrated preliminary effectiveness in enhancing treatment engage-
ment, fostering desistance, and paying increased attention to environmental con-
texts. GLM has the promise to supply forensic mental health practitioners with the
tools needed to engage difficult patient populations, and to strengthen the capacity
of forensic service users to overcome tremendous challenges in their lives.
57
A. G. Crocker et al.
implementation of these tools will they be widely implemented and used (Scullion,
2002). Stronger partnerships between forensic and general mental health services
could increase the cross-pollination of evidence-based risk assessment and manage-
ment strategies with the aim of preventing the involvement of people with mental
illnesses, especially those at risk for criminality and aggressive behavior, in the crim-
inal justice, forensic, and correctional systems. In turn, these partnerships can
provide increased opportunities for general adult mental health services to infuse
forensic mental health services with recognized evidence-based practices such as
integrated concurrent disorder (severe mental illness and substance use disorder)
treatment strategies (Mueser, Noordsy, Drake, & Fox, 2003) and progressive thera-
peutic approaches (e.g., recovery-oriented). In turn, this would lead to increased
continuity of care between the systems.
58
Forensic Mental Health Around the World
2011). The service user movement in some jurisdictions, such as the United
Kingdom, is particularly strong and has made substantial gains in the forensic
system (Bowser, 2012; Spiers, Harney, & Chilvers, 2005). In order to support
patient engagement at a systems level, organizations must place value on the lived
experiences of service users and meaningfully involve them in the planning and
delivery of services. Forensic service users would be supported to collaborate in
their own care and to help others in similar situations (e.g., co-facilitation, peer
support). They can also be integrated into quality improvement processes,
involved in the hiring and training of staff, and engaged as peer researchers
(Bowser, 2012; Livingston, Nijdam-Jones, & Team P.E.E.R., 2012; Livingston,
Nijdam-Jones, Lapsley, Calderwood, & Brink, 2013).
Studies in this area are demonstrating that, despite the challenges, forensic service
users can be engaged in ways that are consistent with recovery-oriented, patient-
centered care approaches (Livingston, Nijdam-Jones, & Brink, 2012; Staley, Kabir,
& Szmukler, 2013). Enhancing patient engagement in a custodial setting has the
potential to enhance forensic service users’ experiences of care (Livingston et al.,
2013) and improve safety (Polacek et al., 2015). Greater research is needed to better
understand how patient engagement and related approaches (e.g., recovery) influ-
ence forensic mental health processes (e.g., risk management) and outcomes (e.g.,
recidivism).
6 Conclusion
This review has exposed the breadth and variety of legal frameworks, processes, and
pathways through forensic mental health services around the world. The term for
ensic contains many different kinds of services, populations, and systems, depending
on where they are located in the world. Understanding that such heterogeneity
exists is important for researchers to consider in relation to the generalizability of
their findings to other contexts, and for administrators and clinicians to consider in
relation to evidence-based practices. With this in mind, there is an obvious need to
assess the performance of different models for organizing forensic mental health
systems, fostering international comparisons, and controlling for population
characteristics.
This review also demonstrated the interest of bringing forensic mental health
research, practice, and administration closer to current trends in general adult
mental health care, which is increasingly strengths-based, consumer participation-
based, quality measurement-based, and community-oriented. We further propose
a balanced care approach to the organization of forensic services, in line with
general mental health services. Moreover, we also identified significant gaps in the
literature in the area of community integration services for justice-involved people
with severe mental health problems. A great deal can be learned by looking at com-
plementary systems within nations, but also by looking outward—across nations—
to find solutions for the urgent, transnational problems shared by forensic mental
health service providers and administrators around the world.
59
A. G. Crocker et al.
Beyond the system-level characteristics identified in this review, the field would
benefit from greater interdisciplinary (e.g., history, sociological, political science,
social psychology, cultural studies) work to understand how the organization and
structure of forensic mental health systems are influenced by, and reproduce, histor-
ical and ongoing social, economic, political, and cultural factors. A robust body of
scholarship exists to understand the connection between punishment (and penal
institutions) and society, and to trace this through history and compare it between
different nations (Simon & Sparks, 2013). Connecting this body of theory and
research to the context of forensic mental health systems would allow us to reach a
deeper understanding of contemporary trends. There are, therefore, many future
opportunities to expand the field of forensic mental health services by growing
international, interdisciplinary collaborations.
Notes
1 The authors are grateful to Precilia Hanan, research assistant at the Douglas Mental
Health University Institute and McGill University in Montreal, as well as Zach MacMillan,
research assistant at Saint Mary’s University in Halifax, for their help in preparing the
documentation and summarizing studies for this book chapter. Many thanks also to Dr.
Quazi Haque, chair of the U.K. Quality Network for Forensic Mental Health Services
and executive medical director of Partnerships in Care, and Dr. Lindsay Thomson,
medical director of Forensic Network in Scotland, for sharing their knowledge and
insights on the development of quality standards in forensic mental health services. We
would like to thank as well Dr. Phil Klassen, vice president medical services at the
Ontario Shores Centre for Mental Health and member of the Ontario Forensic Quality
Initiative in Canada, and Dr. Jorge Folino, professor at the National University of La
Plata in Argentina.
2 Although we focus our review on adult forensic mental health services, we acknowledge
a growing need for research and thought into the youth forensic population. Further-
more, we do not specifically address the issue of forensic intellectual disabilities services,
most of which are under forensic mental health services with some specialized services
particularly prominent and well documented in the United Kingdom (Lindsay et al.,
2010).
3 Equivalent of not guilty by reason of insanity in other jurisdictions.
4 A court-ordered detention of a convicted individual for treatment (e.g., www.nes-mha.
scot.nhs.uk/people1e.htm).
5 The World Health Organization has published reports on the mental health systems of
over 80 countries. They may be accessed here: www.who.int/mental_health/who_
aims_country_reports/en
6 The difference between a placement order and a treatment order lays in the level of
security: patients under placement orders are admitted to a forensic facility and may only
be discharged by a court order. They are nearly always unlimited in duration and are
most often given to patients who have committed a severe offense against a person. A
patient under a treatment order is treated largely like a civil patient.
7 Also called the Victorian Institute of Forensic Mental Health.
8 In Canada, provincial correctional facilities are for individuals whose sentence is less than
two years.
9 Most South American countries use the word unimputable to describe not criminally
responsible offenders.
10 www.cost.eu/COST_Actions/isch/IS1302
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