June 2008/Kristiansson Mentally disordered offenders – The need for integration and smart design...

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: [email protected]


VIOLENCE - a universal challenge

THE PUBLIC HEALTH APPROACH

WHO - 2002


Several cases of unprovocedLethal ViolenceSweden, 2003

The Minister for Foreign Affairs


Psychiatric Services

Forensic Psychiatry

Crisis?


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


New mental models –investment in innovation!

Building cross-system and intraservice partnerships


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


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?


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


Mentally disordered offenders

Complex needsMany services

Psychiatry, Substance abuse treatment,Housing, Daily activities


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


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


Compulsory forensic psychiatric care

Not limited in time


however

There is a lack of specialised housing environments for

mentally disordered offenders and need for integration of forensic psychiatric and

social services.


National Board of Health and Social Welfare

2006 – launched a national project

Intermediate treatment

Three models


Aim of the project

Design models that facilitate patients’ re-entry into community –

Beneficial for patients and also for society


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


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


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


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


Cost – Benefit Analysisfrom hospital to

Facilities in community

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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


Forensic Psychiatric Management

(leadership, organization, innovation)

A new concept

We cannot change the patients but

we can change

June 2008/Kristiansson Mentally disordered offenders – The need for integration and smart design...

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