STSM: Ellen Vorstenbosch will visit OPGs and REMS in Italy

In April 2008, the Italian government approved a major reform of mental health care for mentally ill offenders. Up until then the six Ospedales Psichiatrici Giudiziari (OPG; Forensic Psychiatric Hospitals) fell completely under the responsibility of the Ministry of Justice and policy, regulations, staff management, careers, budget, etc. were completely organised at a national level. A census on 31 January 2012 showed that 1.264 mentally ill offenders resided in the six OPGs (Reggio Emilia, Montelupo Fiorentino, Naples, Aversa, Castiglione delle Stiviere and Barcellona Pozzo di Gotto). Apart from Castiglione delle Stiviere, the OPGs are described as obsolete 19th-century institutions, with heavy use of custodial staff. Many user associations, psychiatric societies, associations of psychiatrists working in OPGs, and also political parties demanded radical reform of the sector. However, it was not until 2006, when the Italian government received a warning of the council of Europe for violation of human rights because of the poor quality of care and living conditions, that an Italian Parliamentary Commission unanimously recommended that (except Castiglione delle Stiviere) these OPGs should be rapidly closed down.

In 2008 all resources and responsibilities for general and mental health care both in prisons and OPGs was transferred to the National Health Service (NHS), to be delivered by Regional Health Systems (RHSs). In 2012, as a consequence of another Law (9/2012), which aimed to reduce the number of prison inmates, extra financial support was given for a rapid closure of the OPGs. These changes occurred without any changes in the Criminal Code, simply stipulating that security measures be set up in ordinary psychiatric NHS settings or in newly established Residenze per la Esecuzione della Misura di Sicurezza (REMS; high-security small-size residential facilities). The REMS have been developed to better meet the needs of providing intensive and high quality mental healthcare under proper secure conditions. The REMS (for no more than 20 patients) are intended to replace admissions to OPGs. The implementation of the laws has been unsatisfactory, and in May 2014 Law 81/2014 set deadlines and operational procedures2 . Although the deadline for the final dismantlement of the OPGs was March 2015 in many regions the forensic services are currently still in the transformation phase.

As stated above the REMS are (being) developed to offer better high secure mental health care. A concept that is increasingly being used to assess (the outcome of) mental health care is quality of life (QoL). Although there is a lack of consensus about the exact definition, QoL as whole refers to an overall “sense of well-being and satisfaction experienced by people under their current life conditions”. QoL or better said the optimization of QoL could also be considered as a facilitator for forensic psychiatric treatment, as it might influence the patient’s readiness for treatment and the patient’s preparation for reintegration into society (Good Lives Model4 ). Besides, QoL also serves to monitor if patient’s basic human rights of good quality of care and living conditions are being met with the creation of new facilities.

To conceptualize QoL different approaches can be used. A first approach would be a generic conceptualization of QoL; based on research in the general population the most determining aspects of QoL are being assessed. Some of these aspects are not necessarily directly affected by the fact that patients are receiving mental health care e.g. functional status, access to resources and opportunities. These instruments are especially of value to compare QoL between different populations. A second approach is a disease-specific conceptualization of QoL; the main focus is on the aspects that are being affected by the (mental) health condition. These instruments are especially valuable when evaluating pharmaceutical interventions; e.g. medication might reduce symptoms but the side effects of the medication might actually worsen QoL.

The choice for the approach or conceptualization of QoL should be guided by the goals of the evaluation or the topic of interest that is being studied. QoL-assessment can be useful in determining needs, developing intervention strategies, and evaluating the outcomes of interventions at both the service and the individual patient level. At service level, QoL can provide an ongoing feedback from service users about the outcomes of services and thus influence further development of service and resource allocation. At the individual patient level, QoL assessment can be used to determine needs and to monitor the impact treatment interventions and services. Besides, QoL assessment can be used to guide treatment planning in (newly developed) forensic psychiatric services.

Based on the above, the Italian forensic services would be served by a more generic QoL approach in order to compare QoL in different facilities. A well-known generic QoL instrument is the World Health Organisation Quality of Life assessment and its´ abbreviated version the WHOQoL-Bref. Although the WHOQoL is health related, it is not sufficiently disease-specific and assesses a broad range of aspects related with QoL. However, what is lacking in the WHOQoL is to take into account liberty deprivation and a restrictive context, as is the case in forensic mental health services. In forensic services QoL is being influenced by generic, disease-specific and context-specific aspects. These three aspects come together in the Forensic Psychiatric inpatient Quality of Life questionnaire (FQL) and its abbreviated version the FQL-SV. The FQL has been developed as a tool for every day practice, containing life domains that can be of guidance for (individual) treatment in forensic psychiatric services. Therefore, also the FQL could be of additional value in the reorganisation of forensic psychiatric services in Italy.

The first aim of the STSM was to gain insight in the conceptualization of QoL for assessment in forensic psychiatric services in Europe. This was done by further exploring the concept of QoL against the background of newly developed forensic psychiatric services in Italy.

A secondary aim was to increase the knowledge of QoL as an outcome measure for service evaluation and (individual) treatment planning in the host institutions of the STSM. This was among others done by providing a seminar for staff about QoL within a forensic psychiatric context.

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A STSM comparing patients and services in long term forensic psychiatry in Germany (Vitos-Haina) & Ireland (Dundrum, Dublin).

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.


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TRAINING SCHOOL 2015 – Koper, Slovenia – 14-17th July 2015

Written by Ana Cristina Neves (Forensic Psychology Assistant Professor at Instituto Superior de Ciências da Saúde Egas Moniz, Portugal) and Valentina Campani (Psychology Master Student, trainee at Reggio Emilia Forensic Unit, Italy)

The Training School (TS) was focused on the concepts of quality of life (QoL) and needs within a long-term forensic psychiatric context, how to assess them and how to improve conditions of long-term patients while meeting their needs. As one of the aims of the TS was the interaction between participants, we were just 18, what allowed the experience of a friendly and functional environment. Treatment realities vary substantially within Europe according to different legal frameworks and resources, so group work and discussion was actively stimulated by the trainers. They also provided valuable advises on how to integrate both concepts into everyday practice.


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Training School 2015 – Quality of Life and Needs in a Forensic Psychiatric Context

Training School 2015 will focus on ‘Quality of Life and Needs in a Forensic Psychiatric Context’ 

Rationale: Treatment in forensic psychiatry is focused on improving mental health and reducing the risk of recidivism of mentally disordered offenders. In long-term forensic psychiatric care this focus shifts. Instead of aiming at re-entry into society, treatment is principally aimed at psychiatric and medical care and optimizing quality of life.

In order to offer adequate psychiatric and medical care, the needs of service users residing in long-term term forensic psychiatric care must be addressed. This might be a variety of mental and general health problems, as well as aging and psychosocial functioning. Mentally disordered offenders with an above average length of stay may well require a different type of treatment. For instance, a study on forensic service users over 55 years of age or residing for longer than 10 years, showed high rates of physical illness, mobility impairment, sensory impairment and polypharmacy (Lightbody et al., 2010). Shaw (2002) suggests that long term forensic service users have needs across a variety of domains including quality of life, personality disorder, psychotic symptoms, and alcohol and drug misuse. Furthermore, Shaw found that certain individuals do not benefit from particular interventions and that their needs in those domains remain unmet but that there is progress in other domains e.g. an improved quality of life.

Some authors stress that in a high secure context, with long-term involuntary liberty deprivation, aspects like autonomy, lack of freedom, sense of control, restriction of movement and constraint of sexual relations will negatively influence the quality of life of service users (Coid, 1993; Mercier & King, 1994). Empirical research in this area is scarce and has so far been single-centered, decreasing the generalizability of the findings (Swinton, Carlisle, & Oliver, 2001; Van Nieuwenhuizen, Schene, & Koeter, 2002; Saloppé & Pham, 2006). Besides, the instruments used in these studies to assess quality of life are either based on the norms for the general public or psychiatric service users, ignoring the restrictive context of long-term forensic psychiatric care and its influence on quality of life (Van Nieuwenhuizen & Nijman, 2009; Swinton, Oliver, & Carlisle, 1999; Walker & Gudjohnson, 2000). The conceptualization of quality of life, based on perceptions of service users in long-term forensic psychiatric care, differs from that required for use in general forensic psychiatric studies (Vorstenbosch et al., 2010).

To assess both needs and quality of life two different approaches can be used: 1. a normative approach that considers the clinician as most capable of assessing the service user’s needs/quality of life or 2. a subjective approach that includes the service user’s own perspective and that of their family members or carers. A combination of both approaches facilitates intervention in a tailored manner and constitutes ´best practice´ in long-term forensic psychiatric care.

Aim: This Training School is being organized to draw attention to the importance of the concepts ´needs´ and ´quality of life´ within long-term forensic psychiatric care and to give an incentive to the inclusion of these concepts in future research projects in forensic psychiatry in Europe.  It will include: a) lectures/presentations on needs and quality of life, b) provide training in the use of assessment instruments, c) advice on how to incorporate both concepts in every day practice and d) result in constructive contributions for the COST Action IS1302 (reports and/or publications/networking).

Expected Outcomes: Improved outcomes for service users, due to better met needs and an improved quality of life.

This years training school will take place in Koper, a coastal city in Slovenia, on the 14th till the 17th of July 2015. The program will include a visit to the forensic psychiatric facility in Maribor.

For more details and registration please click here. Also if you´d like to apply for reimbursement, please subscribe here. The eight researchers with the best motivation letters will get reimbursed.

The registration deadline ends at the 25th of June.

In case you have any questions, please do not hesitate to contact us.

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How do Dutch LFPC-patients experience their quality of life and are their case managers aware of these experiences?

Written by Sandra Schel
Junior Researcher, Pompefoundation, The Netherlands

Quality of life is seen as an important treatment goal in Dutch LFPC. Since 2007 QoL has been measured on a yearly basis at the LFPC-wards of the Dutch Pompefoundation, using the Forensic Inpatient Quality of Life Questionnaire (FQL; Vorstenbosch, Bulten, Bouman, & Braun, 2007). The FQL is a setting- and disease-specific questionnaire for QoL-assessment in long-care forensic psychiatry, which is based on patients’ and forensic psychiatric nurses’ experiences and their perceptions on quality of life (Vorstenbosch, Bulten, Bouman, & Braun, 2010). In Dutch LFPC every member of the forensic psychiatric nursing staff is linked to specific patients. Therefore, additionally, Vorstenbosch and colleagues developed a proxy version of the FQL, which consists of exactly the same questions, but then rephrased as to how the forensic psychiatric nurse assigned to the patient (henceforth: case manager) thinks the patient would answer.


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Training School 2015 – Quality of Life and Needs in a Forensic Psychiatric Context


The first Training School of 2015 will take place in Koper (Slovenia, 14-17 July) and will focus on quality of life and meeting needs within a forensic psychiatric context as well as on how to assess both concepts within the restrictive context of LFPC.

More specifically, this Training School will focus on the needs brought about by (severe) psychiatric symptoms and long-term residence in a highly restrictive setting, and how meeting these needs might optimize quality of life of patients in LFPC. For more details and a complete overview of the program please click here.

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Patient Involvement

Written by Franco Scarpa, Patient Involvement Coordinator of the COST Action and, Psychiatrist and Director of  Unità Operativa Complessa of USL 11 in Tuscany.

A key recommendation of our COST Action is the involvement of patients in the activities of the Action. This involvement may come from patients and their relatives individually, or from patient boards, where such boards exist. The aim of Patient Involvement here is to provide users of long term forensic psychiatric care services a platform for input, where they can express their ideas and opinions on our two objectives, 1) reducing the length of treatment for long term forensic psychiatric patients and 2) improving the in-care life experience for long term forensic psychiatric patients, measured through the use of Quality of Life (QoL) indicators. To begin with, we will be collecting written contributions from patients, their families, industry experts, and others with ties to long term forensic psychiatric patients. This will provide foundations for continued patient involvement.


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