From Inside to Insight
Authors:   , van Beek Janneke 
Published: March 2024

The main objective of this thesis was to produce more tangible knowledge about how and why patients with SMI come to show violent behavior in a specialized ward in prison, specifically regarding the role of the symptoms of psychopathology that are present during these incidents.
A systematic review of empirical studies on violent incidents in European penitentiaries was performed to gain insight in the prevalence of aggressive behavior in penitentiary settings. Sixteen studies were found in which quantitative data on the nature and prevalence of violent behavior were published. The results suggest that violence is much more prevalent in a penitentiary institute than in a nonincarcerated European population. Psychiatric disorders are related to violent incidents.
Insight into the psychiatric symptoms of offenders with SMI is a prerequisite for examining the relationship between the psychiatric symptoms and violent incidents. The Brief Psychiatric Rating Scale-Extended (BPRS-E) was used to assess these symptoms in offenders with SMI. We examined the factor structure of the BPRS-E. Five factors emerged: affect, psychosis, activation, resistance, and negative emotions. Hostility appeared as a seperate entity.
The symptom profile of incarcerated patients with SMI was explores and compared that profile with profiles observed in nonforensic institutions. With the scores of 140 assessments, a symptom profile was created using the domains of the BPRS-E. This profile was compared with the clinical profiles of three nonincarcerated patient groups described in the literature with diagnoses on the same spectrum.
The results suggest that the profile of our incarcerated patients was characterized by high scores in the domains of psychosis (positive and manic psychotic symptoms), activation, and hostility (showing anger and verbal and physical aggression), and low scores for guilt, depression, and negative symptoms. Combined these scores could be indicative of a profile in which there is little awareness of or contact with the inner life; feeling, fears, grief etc., while aggression serves as an externalizing coping skill.
We proceeded with a study into the short-term dynamic risk factors for aggressive behavior in incarcerated people with SMI by investigating the relationship between acute psychiatric symptoms and violent incidents.
The results of this study show a significant positive relationship between the BPRS-E factors of hostility and antisocial traits and aggressive incidents. In other words, higher scores for these factors are related to an increased risk of aggressive incidents. Positive symptoms were not related to aggression.
To better understand possible causes of hostility and reasons for aggression, we performed qualitative analyses of incidents based on interviews with patients and staff members. We found that the restrictions and demands of the environment triggered anti-authoritarian and suspicious thoughts in the incarcerated patients. In several cases, boredom was identified as a risk factor. In addition, negative experiences, symptoms of trauma, and dysfunctional personality styles hindered the de-escalation of conflict. We concluded that often, there is no satisfactory solution to the conflict, despite mutual understanding concerning the cause of the conflict.