Catrin Morrissey

Predictive validity of the PCL-R for offenders with intellectual disability in a high security hospital: treatment progress

Abstract Background Among mainstream offenders, the severe personality disorder of psychopathy has considerable importance as a construct. The disorder has long been associated with failure to make treatment progress. Previous work has identified that psychopathy as a disorder occurs in samples of offenders with intellectual disability (ID), and suggests that the Psychopathy Checklist – Revised (PCL‐R: Hare, 1991, 2003) as a measure of the disorder has adequate reliability and validity (Morrissey et al., 2005). The present study aimed to compare the predictive power of the PCL‐R in relation to treatment progress with a more general assessment of violence risk, the HCR‐20 (Webster, Douglas, Eaves, & Hart, 1997). Method A sample of 73 residents in a high security intellectual disability service, who had previously been assessed using the PCL‐R and the HCR‐20, were followed up at 2 years post‐assessment, and their outcome determined in terms of two distinct dichotomous variables reflecting definite positive treatment progress and definite negative treatment progress respectively. Results In line with predictions, the PCL‐R Total score and Factor 1 score (Interpersonal and Affective aspects of psychopathy) and the HCR‐20 Total score were significantly inversely associated with a positive move from high to medium security hospital conditions within 2 years of assessment. However against prediction, the PCL‐R Total score had incremental validity over the HCR‐20. The PCL‐R Total and Factor 1, but not the HCR‐20 Total score, were also significantly associated with negative treatment progress in terms of a move to more restricted treatment conditions. Conclusion Psychopathy, and in particular its interpersonal and affective manifestations, is a construct which appears to be associated with indirect measures of treatment progress in this high security ID group. However, caution should be applied in the use of a construct with potentially negative connotations in an already devalued population.

Applicability, Reliability and Validity of the Psychopathy Checklist-Revised in Offenders with Intellectual Disabilities: Some Initial Findings

As a part of a larger study, the Psychopathy Checklist-Revised (PCL-R) was used to assess psychopathy in 203 individuals from three UK National Health Service settings for offenders with intellectual disabilities (ID): a high security hospital, a medium and low security hospital and a community based service. The PCL-R was rated from file review combined with a clinician interview. Internal consistency and inter-rater reliability were acceptable, and broadly comparable to that reported for other offender populations. The instrument was also associated in largely expected ways with level of security, and with measures of antisocial personality disorder, risk, and current behavioural functioning, providing some preliminary indications of convergent validity. However, further empirical investigation is required before the PCL-R can be used with confidence to make clinical and risk-based decisions in this population.

Antisocial and psychopathic personality disorders in forensic intellectual disability populations: what do we know so far?

Abstract Antisocial personality disorder (APD) and the more severe personality disorder of psychopathy both have particular relevance to forensic populations, but it is only recently that these constructs have begun to be explored in forensic populations who have intellectual disabilities. This paper reviews the emerging theoretical and empirical evidence in this field. Consideration is given to conceptual issues, the validity of the constructs, and emerging evidence for reliability and validity of existing measures in this particular forensic group. The lack of treatment outcome studies with respect to APD and psychopathy in this group is noted. While these constructs may be useful in understanding and treating some offenders with intellectual disability, these such labels can also result in negative outcomes for individuals. Caution is indicated in their broad application until further relevant research is completed.

Structural, item, and test generalizability of the psychopathy checklist-revised to offenders with intellectual disabilities

The Psychopathy Checklist—Revised (PCL-R) is the most widely used measure of psychopathy in forensic clinical practice, but the generalizability of the measure to offenders with intellectual disabilities (ID) has not been clearly established. This study examined the structural equivalence and scalar equivalence of the PCL-R in a sample of 185 male offenders with ID in forensic mental health settings, as compared with a sample of 1,212 male prisoners without ID. Three models of the PCL-R’s factor structure were evaluated with confirmatory factor analysis. The 3-factor hierarchical model of psychopathy was found to be a good fit to the ID PCL-R data, whereas neither the 4-factor model nor the traditional 2-factor model fitted. There were no cross-group differences in the factor structure, providing evidence of structural equivalence. However, item response theory analyses indicated metric differences in the ratings of psychopathy symptoms between the ID group and the comparison prisoner group. This finding has potential implications for the interpretation of PCL-R scores obtained with people with ID in forensic psychiatric settings.

Relationship between Assessed Emotion, Personality, Personality Disorder and Risk in Offenders with Intellectual Disability

In mainstream studies on offenders and on individuals with psychopathology, relationships have been found between personality characteristics, emotional problems and personality disorders. This study reviewed the relationships between the Emotional Problems Scale, two circumplex measures of personality, personality disorder assessments and risk assessments in 212 offenders with intellectual disability. Previous studies had established the reliability and validity of these measures with the client group. Strong relationships emerged between externalizing emotional problems and dominant and hostile personality dimensions with weaker but significant relationships between internalizing problems and submissive and hostile dimensions. Externalizing problems were strongly associated with risk for violence, while internalizing problems had a weaker but significant relationship with some historical and clinical risk scales. Dominant personality dimensions were associated with narcissistic personality disorder and nurturant personality dimensions negatively associated with anti-social personality disorder. It would seem that there are orderly, significant relationships among measures of personality, personality disorders, emotional problems and risk. We discuss the implications of emotional assessment for the evaluation of risk and prediction of treatment progress.

Longitudinal HCR‐20 scores in a high‐secure psychiatric hospital

BACKGROUND The HCR-20 is a widely used 20 item structured professional judgement aid to risk assessment and management, but longitudinal studies of its value are rare, particularly with people at high risk of reoffending. AIMS To investigate whether the HCR-20 discriminates between patient subgroups in one high-security hospital in England, whether scores reduce with hospital treatment and whether lower scores predict discharge. METHODS Repeated HCR-20 ratings were made by clinical teams across five services within the hospital, two of them (women and men with intellectual disability) national services. A database of 3337 HCR-20 ratings, from 532 patients over a period of 5 years, was examined using mixed effects models. RESULTS As expected, HCR-20 scores were high overall, but there were differences between services in the ratings obtained. Female patients and men with intellectual disability had the highest total score. There was a significant relationship between discharge and lower clinical risk score, but not between total and risk scale scores and discharge. There were significant changes in scores over time, although these were small and may not be clinically meaningful. Differences between services were observed, with women evidencing greater change. CONCLUSIONS It is unsurprising that patients in two national services (for men with intellectual disability and women) have the highest HCR-20 scores; however, the finding of relatively greater risk reduction in women needs further investigation. Although we did not find ceiling effects in this sample, the clinical value of frequently repeated HCR-20 ratings may be limited for high-risk populations where any change is likely to be slow.

A systematic review and synthesis of outcome domains for use within forensic services for people with intellectual disabilities

Background There is limited empirical information on service-level outcome domains and indicators for the large number of people with intellectual disabilities being treated in forensic psychiatric hospitals. Aims This study identified and developed the domains that should be used to measure treatment outcomes for this population. Method A systematic review of the literature highlighted 60 studies which met eligibility criteria; they were synthesised using content analysis. The findings were refined within a consultation and consensus exercises with carers, patients and experts. Results The final framework encompassed three a priori superordinate domains: (a) effectiveness, (b) patient safety and (c) patient and carer experience. Within each of these, further sub-domains emerged from our systematic review and consultation exercises. These included severity of clinical symptoms, offending behaviours, reactive and restrictive interventions, quality of life and patient satisfaction. Conclusions To index recovery, services need to measure treatment outcomes using this framework. Declaration of interest None. Copyright and usage

Outcomes from the National High Secure Learning Disability Service: findings and challenges

Purpose – The “outcomes revolution” in healthcare has yet to impact strongly on secure intellectual disability (ID) services in the UK. The purpose of this paper is to review the service-level outcome studies that exist for this population, and to explore some of the challenges of conducting such research. It further describes some illustrative routine outcome data from the National High Secure Learning Disability Service. Design/methodology/approach – Routinely collected outcome measures (length of stay; violent incidents; Emotional Problem Scale (EPS) Behaviour Rating Scale and EPS Self-Report Inventory) were analysed for two overlapping cohorts of patients resident in the high-secure service between 2008 and 2013. Findings – The median length of stay of those discharged during the study period (n=27) was around 9.9 years (range one to 40 years). A significant proportion (25 per cent) of discharges resulted in an eventual return to high security. There did not appear to be a treatment effect over two to...

Structure, fit and coherence of two circumplex assessments of personality in a population with intellectual disabilities

BACKGROUND Little research has been conducted investigating the way in which personality constructs relate to people with intellectual disabilities. The small amount of research that does exist suggests that underlying personality structure may be considerably different to that found in mainstream research. This hypothesis is, however, untested because so little work has been conducted with this population. METHOD Two circumplex models, the Interpersonal Adjective Scales and the CIRCLE, were employed to explore the factor structure, coherence and fit of these models with this population. One hundred and twenty-three participants from forensic intellectual disability services were rated by staff on the assessments, although not all assessments were completed for all participants. RESULTS The factor structures for both assessments conform broadly with a theoretical structure. Hypotheses concerning the magnitude and direction of Spearmans correlations both within and between assessments were generally confirmed. CONCLUSION While results would support the applicability of mainstream personality assessments to this client group, cautions were expressed in relation to the source of the sample and to the method of data collection.

Treatment outcomes from forensic intellectual disability services: The perspectives of patients and their family/carers

Introduction: Research investigating the treatment outcomes of forensic intellectual and developmental disability (FIDD) services has largely focused on the perspectives of clinicians and researchers. This study sought the perspectives of patients and family/carers on the outcomes important to them. Methods: Semi-structured consultation groups were conducted with patients in FIDD services (n = 21) and family carers (n = 6). Interview data were content analysed, and outcomes identified fell into three main domains (effectiveness, safety and patient experience). Results: The consultations identified outcome domains not considered in the published literature. Patients and carers also had differential perspectives on treatment outcomes commonly reported within literature. Illustrative quotes are used to evidence the domains. Discussion: This study is the first to investigate the outcomes of relevance to patients and their families. These views have been incorporated into an outcomes framework which will form the foundation of future prospective outcome studies.