Are mentally disordered offenders oriented towards appropriate care settings according to security needs? A cross-sectional study
(2018) 13th ENMESH Congress — Location: Lisboa (6.June.2019)
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- Abstract
- Background: Internationally acknowledged standards of mental health care delivery favour community-based and recovery-oriented mental healthcare systems. However, this approach raises specific issues when applied to Mentally Disordered Offenders (MDOs). MDOs combine mental illness and a criminal history. In most countries, there is a debate to decide whether MDOs should be placed in generic or specific forensic mental health care settings. Community-based, recovery-oriented care suppose that MDOs are placed in the lowest possible secured setting according to their security needs. This requires the assessment of MDOs' security needs. Until recently, Belgium lacked appropriate care settings and guidelines for MDOs' placement. However, a reform process has been ongoing since 2016. Within an evaluation of the reform policy, we firstly assessed how MDOs' placement to care settings was related to their security needs, and secondly, which were the main clinical, social, and custodial predictors of MDOs' placement. Methods: Routinely collected data on MDOs placement to care settings were retrieved in 2017 (n=3529). Care settings include in- and outpatient, forensic and generic mental health care across the country. Settings were classified in three security levels, in addition to mobile teams that act as liaison teams between services. Data included socio-demographics, diagnosis groups, criminal categories, and custodial status. Security needs were assessed using the HoNOS-Secure. This scale evaluates the need of MDOs of a secure environment and procedures as well as individual and environmental risks. It returns a score from 0 (no need) to 28 (highest security needs). Placement appropriateness to security levels was assessed using multinomial regressions controlling for MDOs' individual characteristics. Results: Of the 3529 MDOs' placements, 16% were registered in low-security settings, almost half (45%) in medium-security, 2% in high-security settings, and 37% in mobile teams. The mean score of security need was respectively 4.7 (±4.3) in low-security, 7.5 (±4.8) in medium-security, 18 (±3.6) in high-security settings, and 6.1 (±4.7) in mobile teams. MDOs security need scores overlap between low and medium secure settings, while there was a major cut-off between those settings and high secure settings. Security need scores were significantly and positively correlated to security levels after controlling for individual characteristics (OR=1.29, 95% IC: 1.23-1.37, p<0.0001). Another significant predictor of MDOs' placement was having a diagnosis of personality disorder (OR=3.41, 95% IC: 2.22-5.24, p<0.0001). However, having a higher severity of symptoms (OR= 0.91, 95% IC: 0.87-0.94, p<0.0001), and having committed a substance-related offence (OR= 0.49, 95% IC: 0.26-0.92, p=0.03) were negatively correlated to the level of security. Conclusion: Despite the lack of formal process, MDOs’ placement was globally appropriate according to their security needs. This finding suggests a good level of professional expertise of those involved in placement. However, low and medium secure settings should clarify their roles to avoid overlapping and better address MDOs with moderate security needs. Further research is still needed to understand better the impact of clinical and legal determinants.
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Nicaise, P., & et al. (2018). Are mentally disordered offenders oriented towards appropriate care settings according to security needs? A cross-sectional study. 13th ENMESH Congress, Lisboa. https://hdl.handle.net/2078.5/125805