Post on 26-Dec-2015
June 2008/Kristiansson
Mentally disordered offenders – The need for integration and
smart design of services
Marianne Kristiansson, M.D., Ph.D., Ass ProfHead and Medical Director
Dept of Forensic Psychiatry in StockholmNational Board of Forensic Medicine and
Karolinska institutet,Stockholm, Sweden
e-mail: marianne.kristiansson@rmv.se
June 2008/Kristiansson
VIOLENCE - a universal challenge
THE PUBLIC HEALTH APPROACH
WHO - 2002
June 2008/Kristiansson
Several cases of unprovocedLethal ViolenceSweden, 2003
The Minister for Foreign Affairs
June 2008/Kristiansson
Psychiatric Services
Forensic Psychiatry
Crisis?
June 2008/Kristiansson
Need for a better way?Wolff N. (New) public management of mentally
disordered offenders.Int J Law and Psychiatry 2002;25:427-444.
• Systems-level dysfunction– Mismatch between individual needs and
system capacities
• Services-level dysfunction– Mismatch between individual needs and
services due to management barriers• Lack of integration of various services
June 2008/Kristiansson
New mental models –investment in innovation!
Building cross-system and intraservice partnerships
June 2008/Kristiansson
Lien L.Economic factors influencing the implementation of community care for severely ill schizofrenic patients.
World Hospitals and Health Services2005;41:1:21-24
• A balance between hospital and community care• Incentives that serve the need of the patients
– Economic incentives• Demand for mental health care
– Different as compared to somatic care• Demander: society, relatives• Lack of information on what is good quality care
• Price elasticity– Higher as compared to somatic care
June 2008/Kristiansson
Lien 2005What works?
• Multidisciplinary teams
• Continuous responsibility
• High staff-to-client ratio
• Brief frequent contacts
• Collaboration with other parts of the patient’s support system
• Costs and Benefits?
June 2008/Kristiansson
Organizations - Complexity various parts are integrated
into an adaptive function – how to apply in mental health care?
Anderson and McDaniel Jr
Managing Health Care Organizations: Professionalism meets Complexity Science
Health Care Management Review 2000;25:83-92
June 2008/Kristiansson
Mentally disordered offenders
Complex needsMany services
Psychiatry, Substance abuse treatment,Housing, Daily activities
June 2008/Kristiansson
Substance abuse*Do not comply to medication
No housing**
* Grann & Fazel, Br Medical Journal 2004;328:1233-1234
**Tsemberis et al, Am J Public Health 2004;94:651-656
June 2008/Kristiansson
The Swedish designthe Swedish Penal Code,
• ”a person who has committed a crime under the influence of a severe mental disorder must not be sentenced to prison”
• Sentence to compulsory forensic psychiatric care– with or without special court assessment
before discharge
June 2008/Kristiansson
Compulsory forensic psychiatric care
Not limited in time
June 2008/Kristiansson
however
There is a lack of specialised housing environments for
mentally disordered offenders and need for integration of forensic psychiatric and
social services.
June 2008/Kristiansson
National Board of Health and Social Welfare
2006 – launched a national project
Intermediate treatment
Three models
June 2008/Kristiansson
Aim of the project
Design models that facilitate patients’ re-entry into community –
Beneficial for patients and also for society
June 2008/Kristiansson
Half-way house –located just near the hospital
• Run by Mental Health Care– Forensic Psychiatric Care– Four small apartments
• Short to medium term transitory phase from inpatient care to outpatient care
• Assessment with regard to social skills and compliance
• 6 – 12 months
June 2008/Kristiansson
Forensic Psychiatric outpatient residential facility– home-design
located in community
• Run by forensic psyhiatry (75 %) in close collaboration with staff from social services (25 %)
• Four to six small apartmens
• Intensive rehabilitation services
June 2008/Kristiansson
Outpatient forensic psychiatric residential facility
• Accommodation
• Case manager
• Occupational therapy– Social skills training
• Vocational training
• Physical exercise
• Relaxation centre
• Forensic psychiatric outpatient services
• Probation services• Social services• Outpatient substance abuse
treatment• Primary somatic care• Work related activities• Unit for information
– Media– Public
June 2008/Kristiansson
Group living –located in community
• 6 – 8 apartments
• Run by social services (75 %) but with staff from forensic psychiatry (25 %)
• Always possible to provide short periods of inpatient care
June 2008/Kristiansson
Cost – Benefit Analysisfrom hospital to
Facilities in community
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June 2008/Kristiansson
Financial aspectsthe three models
costs per patient/year• Inpatient care 170 000 – 180 000 euro
• Half-way house 110 000 euro
• Forensic psychiatric outpatient residential facility – 140 000 euro
• Group living with expert forensic psychiatric services – 120 000 – 100 000 euro
June 2008/Kristiansson
Forensic Psychiatric Management
(leadership, organization, innovation)
A new concept
We cannot change the patients but
we can change