Written by Padraic O’ Flynn (Senior Occupational Therapist, Central Mental Hospital, Dundrum, Ireland).
This short term scientific mission explored two forensic psychiatric services in Ireland (Central Mental Hospital, Dundrum, NFMHS) and Germany (Vitos Haina) which cater for long term forensic psychiatric patients. The completed report detailed the overall model and design of the two services, the patient characteristics (diagnosis, average length of stay, index offence, “step”, nationality, IQ) on long stay wards, procedures in both services for identifying patient need for psychosocial treatment, comparisons of what psychosocial interventions are offered on long stay units/ with long stay patients, and finally comparisons on quality of life from self reported measures on long stay wards in Ireland and Germany. The report also detailed recommendations for future research in this area. Below the points from the main report are summarised with graphs and diagrams included. Further exploration of comparisons of descriptive characteristics, service models etc. are available in the full report.
Brief description of legal pathways to Vitos Haina & Central Mental Hospital Dundrum:
Figure 1: Brief overview of pathway to becoming a long stay patient in Vitos Haina (adapted from the “hope for the hopeless” – Nursing in long term forensic care – Cholibois, Heil & Kamara (2010)).
Figure 2: Brief overview of becoming a long stay patient in the NFMHS, Central Mental Hospital, Dundrum, Ireland.
Overarching pathways and service models:
Figure 3- Basic outline of pathway at Vitos Haina
Figure 4- Basic outline of pathway at the Central Mental Hospital, Dundrum
Descriptive characteristics of long stay patients:
Figure 5: Comparison of primary diagnosis within long stay wards.
Figure 6: Average IQ from a sample of patients in long stay wards in Vitos Haina (N= 20).
Figure 7¹: Average Matrics score for a sample of long stay patients in Central Mental Hospital, Dundrum (neurocognitive Ax; N= 21).
Figure 8: Comparison of categorised offences with long stay patients in Ireland & Germany.
Figure 9: Comparison of length of stay in years (mean & median calculated) in Ireland & Germany.
Figure 10: Escorted and Un-escorted community leave comparisons in % in Ireland & Germany.
There are marked differences with patients that have unescorted leave and escorted leave with more patients having community staff escorts in Dundrum compared to Vitos Haina. This is explored in more detail in the main report.
Provision of psychosocial interventions for patients:
Data was collected on which psychosocial interventions were offered to long stay patients on both sites.
Figure 11: Programme of activities and therapies on long stay ward in Vitos Haina (provided by Jessica Jamrowski, psychologist on long stay ward in Haina).
In Dundrum psychosocial needs are identified and interventions are developed under the overarching model within the hosptial. We call these the pillars of care:
And below examples of specific psychosocial interventions are shown within each pillar:
Figure 13: Psychosocial interventions as guided by the pillars of care in Central Mental Hospital Dundrum.
Psychosocial interventions in both forensic psychiatric hospitals (Vitos Haina & Central Mental Hospital Dundrum):
Quality of life:
Figure 15: Comparison of scores on FQL in Vitos Haina and WHOQOL Bref in Central Mental Hospital Dundrum.
Figure 16: Comparison of community residents in New York normative values with WHOQOL bref scores for long stay patients in Central Mental Hospital Dundrum.
The above graph gives an overview of the comparison between long stay patients in Central Mental Hospital Dundrum and normative values with community residents in New York. As derives from the graph, the WHOQoL-Bref domain for physical well-being is almost similar but psychological well-being, social relationships and environment scores are remarkable lower.
Conclusion & recommendations for further research:
There are many interesting comparisons and differences between the two sites. Diagnosis across both sites are relatively homogonous. Cognitive impairment and low IQ is a distinguished feature amongst this patient group across both sites. Differences in offending profiles across both sites was evident with more sex offenders amongst the group in Germany and homicide as an offence which is more prevelant amongst the group of patients in Ireland. Differences between unescorted and escorted leave access across both sites was also evident. There were differences in length of stay. There were similarities in quality of life scores but the data that was used from Haina was from 2010 with a different population. Also different measures were used in capturing QOL. Psychosocial interventions were similar and a needs led approach is taken in both services. It is evident that quality of life for these patients on both sites is lower than the general population as per normative data.
A greater understanding of patient characteristics, needs, treatment approaches/ treatment priorities is needed. The most powerful platform to do this is on an international, multicentred level. Future research should focus on understanding what variables and factors are associated with QOL for these patients. QOL data should be collected over a regular basis to account for confounding factors like low mood. Proxy instruments should also be used due to the limitations of self report instruments within this population. Further research into the impact of QOL on recidivism and other treatment outcomes should be considered.
Cholibois, Heil & Kamara (2010). Hope for the hopeless. Nursing in long term forensic psychiatric care. Presentation from the 10th Annual Conference IAFMHS – Vancouver.
Coid, J.W. (1993). Quality of life for patients detained in hospital. British Journal of Psychiatry, 162, 611-620.
Janicki, P., Jamrowski, J., & Eucker, S. (2011) Are longstay patients really untreatable? A follow-up study. Presentation from the 11th Annual Conference IAFMHS - Barcelona.
Kamara, R. & Müller-Isberner, R. (2010). Step by Step – Different levels of security in the Haina Vitos Forensic Psychiatric Hospital. Presentation from the 10th Annual Conference IAFMHS Vancouver.
Palijan, T.Z., Muzinić, L., & Radeljak, S. (2009). Psychiatric comorbidity in forensic psychaitry. Psychiatr Danub., Sep. 21 (3), 429-36.
Vorstenbosch (2010). Quality of Life in Longterm Forensic Psychiatric Care. A comparative study between three different locations in the Netherlands and Germany. Presentation from the 10th Annual Conference IAFMHS – Vancouver.
Hawthorne, G. Herrman, H & Murphy B. (2006) Interpreting the WHOQOL-Bref: Preliminary Population Norms and Effect Sizes. Social Indicators Research Vol. 77, No. 1, 37-59.
Gill P, McKenna P, O’Neill H, Thompson J, Timmons D (2010): Pillars and pathways: foundations of recovery in Irish mental health care. B J Forensic Practice, 12(3), 29-35.
¹ The MATRICS Consensus Cognitive Battery (MCCB) is a standardized battery for use with adults with schizophrenia and related disorders. Advancements in the past decade suggest that there may be opportunities for developing effective medications for improving cognition in people with schizophrenia. The MCCB was developed to help researchers and clinicians measure cognition in individuals who have been diagnosed with schizophrenia and related disorders.