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International Journal of Mental Health Nursing (2012) 21, 462–470

Feature Article

_811

doi: 10.1111/j.1447-0349.2012.00811.x

462..470

Validity of assessing people experiencing mental illness who have offended using the Camberwell Assessment of Need–Forensic and Health of the Nation Outcome Scales–Secure Rana Abou-Sinna and Stefan Luebbers Centre for Forensic Behavioural Science, Monash University & Victorian Institute of Forensic Mental Health, Melbourne, Victoria, Australia

ABSTRACT: Evidence-based practices for forensic mental health services have been slow to develop, and there is a lack of measures that assess the mental health and criminogenic needs of people experiencing mental illness who have offended. The present study aimed to investigate the interrelationship between a clinician-rated forensic mental health needs assessment (Health of the Nation Outcomes Scales–Secure (HoNOS-S)), a forensic mental health needs assessment that considers both clinician and patient perspectives (Camberwell Assessment of Need–Forensic (CANFOR)), and measures of general and violent recidivism (Level Service–Case Management Inventory (LS-CMI) and HCR-20 Violence Risk Assessment Scheme (HCR-20)). Needs were assessed for 72 forensic patients aged between 20 and 62 years of age, located in a secure forensic mental health facility. The findings revealed significant positive correlations between the HoNOS-S, CANFOR, and HCR-20. Only the CANFOR was positively correlated with the LS-CMI, and uniquely contributed variance to the HCR-20. Patients and nurses differed in the total number of needs and met needs they identified as present. The findings suggest that the collaborative approach of the CANFOR might be more appropriate for measuring outcomes in the treatment of individuals experiencing mental illness who have offended. KEY WORDS: Camberwell Assessment of Need–Forensic, Health of the Nation Outcome Scales– Secure, needs assessment.

Historically, rehabilitation for people who have offended has not always been thought to ‘work’ (Martinson 1974). Today, meta-analytic reviews of thousands of interventions have reached consensus on the core components of effective treatment (Andrews & Bonta 2010; Andrews & Downden 2006; Hollin 1999; Lowenkamp et al. 2006).

Correspondence: Stefan Luebbers, Paul Mullen Centre, 505 Hoddle Street, Clifton Hill, Vic. 3068, Australia. Email: stefan.luebbers@ monash.edu Rana Abou-Sinna, BSc (Hons). Stefan Luebbers, BSc (Hons), DPsych (Clin). Accepted January 2012.

However, much of this literature has focused on the factors that directly link to reoffending (criminogenic needs). This once prominent focus has begun to shift, with the realization that both the well-being and criminogenic needs of individuals who have offended can have significant impacts on rehabilitation, particularly for those who are also experiencing mental illness and have offended. Despite this, evidence-based practices for individuals experiencing mental illness who have offended are still scarce, and forensic mental health services are without effective assessment tools and interventions on which to base their treatment and rehabilitation programmes.

© 2012 The Authors International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

ASSESSMENT OF FORENSIC PATIENTS

Regular assessment of the health and social care needs of people with severe mental illness is a statutory requirement in many jurisdictions. Two particular well-established needs assessment tools designed for these purposes are the Camberwell Assessment of Need (CAN) (Phelan et al. 1995) and the Health of the Nation Outcome Scales (HoNOS) (Wing et al. 1996). The HoNOS is a 12-item scale that covers clinical problems and social functioning that can be listed into four categories: behavioural problems, organic problems, psychological symptoms, and social problems. The HoNOS is the most widely used clinical outcome measure in UK mental health services (James 2002), and has also been implemented in several hospitals in Australia and Denmark (Bech et al. 2003). The CAN conducts a more comprehensive assessment of needs for individuals with mental illness, and is based on the principle that individuals with mental illness will have specific needs, as well as similar needs to people who do not suffer from mental illness (i.e. primary human needs; Phelan et al. 1995). It assesses these needs in 22 domains of functioning. Longitudinal research conducted by Wennstrom and Weisel (2006) demonstrated the usefulness of the CAN assessments, finding significant changes in the needs status of individuals with psychoses between 1997 and 2003. The needs still remaining in 2003 were more often met than not, as compared with 1997, and many patients were no longer in need of certain care or support in these areas. Although the CAN and HoNOS are to some extent similar in purpose, one of their most notable differences is that the HoNOS is based on a model of need as a normative concept (a clinician’s view of need). The CAN, however, is based on a model of need as a subjective concept, including both the clinician and the patient views of need, accepting that frequently there will be differing, but equally valid, perceptions about the presence or absence of a specific need (Slade 1994). The incorporation of the view of the patient has important implications, and many studies using the CAN have found discrepancies in the total number of needs identified by the patient and clinician (Issakiddis & Teeson 1999; Slade et al. 1996; 1998). Furthermore, Bulten and Schoenmakers (2003) argue that identifying these discrepancies might help to understand why patients might be resistant to treatment, and also signal to the clinician that they might need to motivate and stimulate the patient to need and want care. There are differences between the extents to which certain needs influence individuals experiencing mental illness alone, and individuals experiencing mental illness

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who have offended. As individuals experiencing mental illness who have offended will differ in need domains, with more emphasis on comorbid personality disorders, substance abuse, offending behaviours, and security needs (Shaw 2002), the HoNOS and CAN might not accurately assess their needs. Addressing only the mental health needs of individuals experiencing mental illness who have offended will lead to the ‘fragmentation of care’, so that when the whole of an individual is admitted to a forensic mental health service, only part of their problem is addressed (Howells et al. 2004). In recognition of this issue, the HoNOS has been developed for users in both secure and forensic services (HoNOS–Secure (HoNOSS); Sugarman & Walker 2007), and includes an additional seven-item security scale that assesses ongoing security needs. Further to this, a forensic version of the CAN, the CAN–Forensic (CANFOR) (Thomas et al. 2003), has been developed to allow for a more in-depth and integrated needs analysis of individuals with mental illness who have offended. However, little research has investigated the adequacy with which these measures assess the broad range of needs of individuals experiencing mental illness who have offended. One recent study by Segal et al. (2010) investigated the interrelationship between the CANFOR, HoNOS-S, and the screening version of the Level of Service Inventory– Revised–Short Version (LSI-R-SV) (Andrews & Bonta 1998), a risk assessment that assesses the ‘central eight’ risk/need factors associated with criminal behaviour, known as criminogenic needs. Their findings revealed that the CANFOR and HoNOS-S were significantly associated, but neither was significantly associated with the LSI-R-SV, suggesting that the HoNOS-S and CANFOR might not be adequately assessing the criminogenic needs of individuals experiencing mental illness who have offended. However, Ferguson et al. (2009) found that while the LSI-R validly predicted recidivism in an offending population with high rates of substance use, its ability to predict reoffending in individuals who had offended, were experiencing a mental illness, and were using substances was questionable. The authors suggested that the small number of items taken from the full version of the LSI-R might not adequately assess the more extensive needs that present in forensic populations. As such, the finding of Segal et al. (2010) that the CANFOR and HoNOS-S are not associated with criminogenic needs remains questionable. In addition, contrary to some of the initial findings on subjective need in forensic mental health settings (Thomas et al. 2008), Segal et al. (2010) also revealed that clinicians and patients did not differ in total number of


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R. ABOU-SINNA AND S. LUEBBERS

needs they identified on the CANFOR, but did differ on the number of unmet needs they identified. The research on subjective needs assessment in forensic mental health settings is still in its infancy, particularly in relation to the link that clinician- and patient-rated needs might have with the risk of reoffending for individuals experiencing a mental illness who have offended. To extend research by Segal et al. (2010), the present study employed more comprehensive measures of the criminogenic needs associated with general offending, the Level Service–Case Management Inventory (LS-CMI; Andrews et al. 2004), and violent offending, the HCR-20 Violence Risk Assessment Scheme (HCR-20) (Webster et al. 1997). Therefore, the first aim of this study was to investigate the interrelationship between the CANFOR, HoNOS-S, and measures of criminogenic needs (i.e. the LS-CMI and HCR-20). The second aim of this study was to explore the overlap (i.e. shared variance) between the HoNOS-S, CANFOR, and measures of criminogenic needs (LS-CMI and HCR-20). The final aim of this study was to investigate whether there were differences between patient and clinician ratings of need on the CANFOR. The first hypothesis was that the CANFOR would have a positive correlation with the HoNOS-S. The second hypothesis was that CANFOR and HoNOS-S would have a positive correlation with the LS-CMI and HCR-20. The third hypothesis was that while the patient and clinician ratings would show a positive correlation, patients would identify more unmet needs and less met needs compared to clinicians on the CANFOR.

METHOD Setting The study took place at the state secure forensic mental health facility in Victoria, Australia, the Thomas Embling Hospital (TEH). The hospital treats forensic psychiatric patients, known as forensic patients, who are ordered by the courts to be detained in a secure forensic psychiatric facility. Forensic patients have been found either not guilty on account of mental impairment or unfit to stand trial under the Victorian Crimes (Mental Impairment and Fitness to be Tried) Act 1997. The TEH has acute, continuing care and subacute and rehabilitation programmes across seven units, with a total of 116 beds.

Participants Participants of this study were 72 adult forensic patients (66 males and 6 females), aged between 20 and 62 years of age (mean (M) = 37.78, standard deviation (SD) = 8.98), who had committed serious violent offences

(i.e. murder, attempted murder, serious assault). Participants were located on two rehabilitative and two continuing care units of the TEH. Sixty-eight percent of participants had a diagnosis of schizophrenia (predominantly paranoid type, n = 49), including nine with comorbid axis-I disorders (e.g. depression, paraphilia, and posttraumatic stress disorder), 14 with identified comorbid substance abuse, and a further five participants with a recorded comorbid personality disorder (i.e. schizoid, narcissistic, borderline, and dissociative). A further 2.8% (n = 2) of participants had a diagnosis of schizoaffective disorder, one had a diagnosis of bipolar disorder and intellectual disability, and one participant had a primary diagnosis of personality disorder (narcissistic).

Materials The CANFOR–short version (CANFOR-S) (Thomas et al. 2003) was used to assess both the patient and nurse views of total, met, and unmet needs of individuals experiencing mental illness who have offended. The short version of the CANFOR is a brief, one-page version of the full version of the CANFOR that assesses 25 domains of functioning (accommodation, food, looking after the living environment, self-care, daytime activities, physical health, psychotic symptoms, information, psychological distress, safety to self, safety to others, alcohol, drugs, company, intimate relationships, sexual expression, childcare, basic education, telephone, transport, money, benefits, treatment, sexual offences, and arson) and can be used for clinical and research purposes. In completing the CANFOR-S, the rater must first decide whether a need is present (rating of 0), and if present, whether that need is met (rating of 1) or unmet (rating of 2) by the service. A met need is defined as an area of difficulty for which an appropriate intervention is currently being received. An unmet need is defined as an area of difficulty for which no interventions are currently being received, or that interventions received are not helping. The CANFOR-S test–retest reliability is 0.80 for patient-rated needs, and 0.85 for clinician-rated needs. In addition, the development study (Thomas et al. 2008) also showed adequate construct validity, but this has not been replicated in independent studies. The HoNOS-S (Sugarman & Walker 2007) was also used to assess the needs of individuals experiencing mental illness who have offended. It comprises amended versions of the original 12 HoNOS items and an additional seven-item security scale. The security items include risk of harm to adults or children, risk of selfharm, need for building security to prevent escape, need for a safely staffed living environment, need for escort on



leave (beyond secure perimeter), risk to individual from others, and need for risk management procedures. Each item is rated on a five-point Likert scale (range: 0–4). A security scale item rated at 1 or above indicates that a risk management intervention is needed, and for items on the clinical scales, a rating of 2 or above indicates that a care or treatment intervention is needed. The HoNOS-S has an acceptable level of internal consistency, with a Cronbach’s alpha of 0.73 for the security scale, and 0.79 for the HoNOS scale (Dickens et al. 2007). While the security scale of the HoNOS-S has not been validated, the HoNOS-S clinical scale resembles the items of the original HoNOS, which has been validated in numerous studies (e.g. Wing et al. 1996). The LS-CMI (Andrews et al. 2004) was used as a measure of criminogenic needs associated with general offending. The LS-CMI is a semistructured interview and coding system that assists in obtaining a detailed survey of a particular individual’s criminogenic needs. Only Section 1 of the LS-CMI, which contains 43 items coded to yield scores on eight subcomponents or the ‘central eight’ risk/ need factors for offending (history of antisocial behaviour, antisocial cognitions, antisocial personality pattern, antisocial associates and peer groups, family and/or relationship circumstances, school and/or work functioning, lack of leisure and/or recreation pursuits, and substance abuse) was used to identify participants’ criminogenic needs. The LS-CMI Cronbach’s alpha value in the normative correctional female sample is 0.91, similar to the normative correctional male sample of 0.89 (Andrews et al. 2004). The HCR-20 (Webster et al. 1997) was used as a measure of criminogenic needs that are associated with violence for individuals experiencing mental illness who have offended. The HCR-20 is a set of structured professional guidelines that are used to assess the risk of violence in people with mental illness. It considers and codes for 20 factors grouped into three domains, namely the historical domain, the clinical domain, and the risk management domain. The historical domain includes 10 items concerning factors of the past that relate to violence. The clinical domain contains five items that are meant to reflect current, dynamic correlates of violence. The risk management domain is future orientated and focuses attention on situational post-assessment factors that might aggravate or mitigate risk. For each item, a score is given based on whether these factors are present (rating of 2), partially present (rating of 1), or absent (rating of 0) for the individual. The HCR-20 has been shown to be a valid predictor of violence in psychiatric (Douglas et al. 1999) and forensic psychiatric populations (Douglas et al. 2003).

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Procedure The study was presented at the morning meeting (including patients and nursing staff ) on four different units of the TEH, involving 106 potential participants during the study period, with the sample representing a 70.1% response rate. Patients interested in participating in the study approached the researchers to express their interest. The researchers informed the patients about the nature of the study before participants were invited to consent to participation. Participants provided the researcher with written consent to access clinical documentation, so that the HCR-20 and section one of the LS-CMI could be coded. In addition, the HoNOS-S and CANFOR-S outcome data, routinely completed between patients and their primary nurse, were obtained.

RESULTS Relationship between the CANFOR-S, HoNOS-S, LS-CMI, and HCR-20 Pearson’s product moment correlational analysis was used to examine the relationship between the HCR-20, LS-CMI, HoNOS-S, and CANFOR-S patient and nurse ratings of total, met, and unmet needs. The correlation matrix showing the significant relationships between these variables is presented in Table 1. Results summarized in Table 1 showed that the CANFOR-S nurse and patient ratings of total needs were significantly and positively correlated with the HoNOS-S clinical and security scales, as well as the HCR-20 clinical and risk management scales. These correlations indicated that increases in the number of rated needs on the CANFOR-S were associated with increases in items rated on the clinical and security scales of the HoNOS-S, and the clinical and risk management scales on the HCR-20. In addition, significant, positive correlations between the CANFOR-S nurse rating of total needs and unmet needs and the LS-CMI indicated that increases in the number of nurse-rated unmet needs, as well as the total number of needs on the CANFOR-S, were associated with increases in the presence of criminogenic needs on the LS-CMI. As with the CANFOR-S, significant, positive correlations between the HoNOS-S clinical scale and the clinical and risk management scales on the HCR-20 also indicated that increases in items rated on the clinical scale of the HoNOS were associated with increases in items rated on the clinical and risk management scales of the HCR-20.


466


TABLE 1: Correlation matrix of the relationships between the HONOS-S, CANFOR-S, LS-CMI, HCR-20 Scale 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Total CANFOR (nurse) CANFOR met (nurse) CANFOR unmet(nurse) Total CANFOR (patient) CANFOR met (patient) CANFOR unmet (patient)a Total HoNOS-S HoNOS-S security scale HoNOS-S clinical scale Total HCR-20 HCR-20 historical scale HCR-20 clinical scale HCR-20 risk management LS-CMI

1

2

3

4

5

6

7

8

9

10

11

12

13

– 0.77* 0.76* 0.80* 0.32 0.67* 0.79* 0.67* 0.76* 0.79* 0.31 0.68* 0.73* 0.57*

– 0.10 0.64* 0.51* 0.32 0.40 0.43* 0.31 0.42 0.05 0.31 0.71* 0.25

– 0.55* -0.01 0.71* 0.75* 0.51* 0.80* 0.68* 0.49* 0.66* 0.34 0.55*

– 0.64* 0.68* 0.57* 0.49* 0.59* 0.65* 0.22 0.45* 0.69* 0.38

– -0.17 0.30 0.30 0.26 0.21 -0.07 0.22 0.45 -0.04

– 0.39 0.21 0.39 0.62* 0.45 0.37 0.38 0.53*

– 0.89* 0.97* 0.63* 0.12 0.75* 0.51* 0.30

– 0.73* 0.50* 0.04 0.67* 0.47* 0.21

– 0.65* 0.15 0.71* 0.45 0.32

– 0.65* 0.83* 0.77* 0.75*

– 0.17 0.06 0.67*

– 0.74* 0.53*

– 48*

14

*P < 0.01 (two tailed). Spearman’s rank order correlation was reported for this variable; Nurse ratings on the CANFOR-S and HoNOS-S, n = 60; All HCR-20 and LS-CMI, n = 71; All patient ratings on the CANFOR-S, n = 59 (one patient did not provide a response for this measure). CANFOR-S, the Camberwell Assessment of Need–Forensic–short version; HCR-20, HCR-20 Violence Risk Assessment Scheme; HoNOS-S, the Health of the Nation Outcomes Scales–Secure; LS-CMI, Level Service–Case Management Inventory.

TABLE 2: Summary of the hierarchical regression CANFOR-S and HoNOS-S for predicting HCR-20 b

Sr2

t

Step 1 CANFOR-S

0.74

0.59

6.1*

Step 2 CANFOR-S HoNOS-S

0.69 0.12

0.22 0.01

3.6* 0.68

Predictor

R2

for

the DR2

0.59* 0.60*

0.01

*P < 0.01; n = 60. CANFOR-S, the Camberwell Assessment of Need–Forensic–short version; HCR-20, HCR-20 Violence Risk Assessment Scheme; HoNOS-S, the Health of the Nation Outcomes Scales– Secure; LS-CMI, Level Service–Case Management Inventory.

However, the HoNOS security scale was only positively correlated with the clinical scale of the HCR-20, indicating that increases in ratings of security items on the HoNOS-S were associated with increases in items rated on the clinical scale of the HCR-20.

Relationship of the CANFOR-S and HoNOS-S with criminogenic needs As the HCR-20 was the only criminogenic need measure that both the HoNOS-S and CANFOR-S were correlated with, a hierarchical regression analysis was conducted to determine whether the HoNOS-S accounted for additional variation in the HCR-20 above that of the CANFOR-S; that is, if the CANFOR-S has been completed, does the HoNOS-S provide additional information about criminogenic needs? Table 2 reports the results of the hierarchical multiple regression analysis.

Results summarized in Table 2 show that the CANFOR-S accounted for a significant proportion of variance in the HCR-20 (R2 = 0.59, F(1, 56) = 37.27, P < 0.01), explaining 59% of the variation in scores on the HCR-20. However, the addition of the HoNOS-S at step 2 did not account for any additional variance in the HCR-20 (DR2 = 0.01, F(1, 55) = 0.43, P = 0.53).

Differences between nurse and patient perspectives of need The correlations in Table 1 show that nurse ratings on the CANFOR-S total needs, unmet needs, and met needs were significantly and positively correlated with the respective CANFOR-S patient ratings. Figure 1 shows the average number of total needs, met needs, and unmet needs rated by the nurse and the client. Three independent t-tests were performed to test for any significant differences between patient and nurse ratings on CANFOR-S total needs, met needs, and unmet needs. The results showed that there was a significant difference between nurse and patient ratings of total need (t(58) = 3.85, P < 0.01, d = 0.98), indicating that the total number of needs identified by nurses (M = 9.26, SD = 4.69) were higher than the total number of needs identified by patients (M = 5.48, SD = 2.71). A significant difference was also found for met needs (t(58) = 4.35, P < 0.01, d = 1.12), where the number of met needs identified by nurses (M = 6.87, SD = 3.20) was higher than the number of met needs identified by patients (M = 3.86, SD = 2.07). There was no significant difference between



467

the number of unmet needs identified by the patient and nurse (t(58) = 1.12, P = 0.27). Table 3 presents the proportion of needs (met and unmet) rated by nurses and patients as being present. Nurses most commonly reported needs in the areas of daytime activities, physical health, psychotic symptoms, company, psychological distress, and food. Similarly, patients commonly reported needs in the areas of physical health, psychological distress, and company, but also commonly rated needs in the areas of information about treatment and condition, and accommodation. The main discrepancies between nurses and patients regarding what needs they viewed as met or unmet were in the areas of daytime activities, company, and psychotic symptoms.

14

Average no. needs

12 10 8 6 4 2 0 Nurse

Patient

FIG. 1: Average number of total needs, met needs, and unmet needs, as rated by the nurse and the client on the Camberwell Assessment of Need–Forensic–short version (CANFOR-S). Error bars indicate ⫾2 standard error. ( ), total needs, ( ), met needs, ( ), unmet needs.

TABLE 3:

DISCUSSION As hypothesized, the CANFOR-S and HoNOS-S were significantly and positively associated. This finding was consistent with the findings of Segal et al. (2010), who found associations between the HoNOS-S and nurserated total needs on the CANFOR-S. This finding is likely

Number and percentage of nurse and patient ratings of total, met, and unmet needs on each domain of the CANFOR-S Nurse ratings Met needs

Unmet needs

Patient ratings Total needs

Met needs

CANFOR-S item description

%

n

%

n

%

n

%

n

Unmet needs %

n

%

n

Accommodation Food Looking after the living Self-care Daytime activities Physical health Psychotic symptoms Information about condition Psychological distress Safety to self Safety to others Alcohol Drugs Company Intimate relationships Sexual expression Child care Basic education Telephone Transport Money Benefits Treatment Sexual offences Arson

23.3 48.3 35.0 20.0 66.7 55.0 43.3 51.7 33.3 13.3 16.7 15.0 31.7 46.7 13.3 0.0 5.0 20.0 1.7 6.7 35.0 16.7 48.3 8.3 5.0

14 29 21 12 40 33 26 31 33 8 10 9 19 28 8 0 3 12 1 4 21 10 29 5 3

23.3 6.7 3.3 8.3 10.0 20.0 25.0 1.7 5.0 0.0 1.7 10.0 20.0 15.0 26.7 25.0 8.3 3.3 0.0 0.0 8.3 0.0 3.3 3.3 1.7

10 4 2 5 6 12 15 1 3 0 1 6 12 9 16 15 5 2 0 0 5 0 2 2 1

40.0 55.0 38.3 28.3 76.7 91.7 68.3 53.3 60.0 13.3 18.3 25.0 51.7 61.7 40.0 25.0 13.3 23.3 1.7 6.7 43.3 16.7 51.7 11.7 6.7

24 33 23 17 46 55 41 32 36 8 11 15 31 37 24 15 8 14 1 4 26 10 31 7 4

32.2 28.8 6.8 0.0 16.9 42.4 22.0 35.0 40.0 3.4 3.4 5.1 11.9 32.2 5.1 1.7 3.4 13.6 1.7 3.4 13.6 10.2 32.2 1.7 1.7

19 17 4 0 10 25 13 21 24 2 2 3 7 19 3 1 2 8 1 2 8 6 19 1 1

13.6 1.7 0.0 0.0 25.4 23.7 5.1 10.2 8.5 0.0 1.7 1.7 1.7 16.9 32.2 20.3 6.8 1.7 0.0 0.0 1.7 0.0 5.1 0.0 0.0

8 1 0 0 15 14 3 6 5 0 1 1 1 10 19 12 4 1 0 0 1 0 3 0 0

45.8 30.5 6.8 0.0 42.4 66.1 27.1 45.8 49.2 3.4 5.1 6.8 13.6 49.2 37.3 22.0 10.2 15.3 1.7 3.4 15.3 10.2 37.3 1.7 1.7

27 18 4 0 25 39 16 27 29 2 3 4 8 29 22 13 6 9 1 2 9 6 22 1 1

Patient ratings, n = 59. CANFOR-S, the Camberwell Assessment of Need–Forensic–short version.


Total needs

468


due to the considerable overlap between items on the CANFOR-S and HoNOS-S, and suggests that these needs assessments might assess the same underlying areas of need. The findings also highlight that both the nurse and patient have valid perspectives of need, as both perspectives were significantly associated with nurse ratings of the HoNOS-S clinical scale. This signals to health service providers, and in particular, nursing staff, the validity in obtaining their patients’ perspectives of need and adopting a collaborative approach to care planning. These findings also offer preliminary evidence of the concurrent validity of the CANFOR-S as a forensic mental health needs assessment tool. Furthermore, the hypothesis that the CANFOR-S and HoNOS-S would have positive associations with the LS-CMI and HCR-20 was partially supported. The HoNOS-S was not associated with the LSCMI. However, as hypothesized, the HoNOS-S and CANFOR-S had moderate to strong associations with the HCR-20, and the CANFOR-S was moderately associated with the LS-CMI. These findings contrast with previous research (Segal et al. 2010) that did not find significant associations between the CANFOR-S and the LSI-R-SV. The conflicting findings might be explained by the current study’s use of a comprehensive risk assessment tool, the LS-CMI, instead of the LSI-R-SV, which, as Ferguson et al. (2009) found, might not incorporate all criminogenic needs that are relevant for individuals experiencing mental illness who have offended. These findings also provide some support for the conclusions drawn by Ferguson et al. highlighting the importance of using comprehensive needs assessments to be able to cater for the complex needs of individuals experiencing mental illness who have offended. The current findings suggest that the CANFOR-S is an adequate forensic mental health needs assessment that incorporates both criminogenic and noncriminogenic needs relevant to individuals experiencing mental illness who have offended. Therefore, it might be a valuable needs assessment tool for forensic mental health services to utilize for monitoring treatment progress. Alternatively the HoNOS-S was only associated with the HCR-20, and specifically those violence risk factors associated with mental illness, rather than more broader criminogenic needs. In evaluating these measures, the current findings help inform health professionals about the differences between these two measures in what they can contribute to care planning and in providing effective treatment. One of the aims of this study was to explore whether the HoNOS-S provided additional information about

criminogenic needs once the CANFOR-S was taken into account. In investigating these relationships, it was found that the CANFOR-S provided unique information about criminogenic needs, as measured by the HCR-20, above that of the HoNOS-S. While neither the CANFOR-S nor the HoNOS-S should replace a comprehensive risk assessment of violence using the HCR-20, the CANFOR-S might be a more appropriate outcome measure than the HoNOS-S for use with individuals experiencing mental illness who have offended. The hypothesis that there would be no significant difference between the total number of needs identified by the nurse and patient was not supported. Although this is contrary to findings by Segal et al. (2010), it is consistent with earlier research by Thomas et al. (2008), who also found differences between the total number of needs identified by clinicians and patients. The hypothesis that patients would identify more unmet needs compared to nurses on the CANFOR-S was also not supported. Contrary to previous research (Segal et al. 2010), there was no significant difference between nurse and patient views of unmet need. While nurses and patients identified the same number of unmet needs, in some cases, they did not rate the same needs as unmet. Additionally, nurses tended to rate more needs as met compared to patients. These findings highlight the impact of not incorporating patients’ perspectives of need, such that, if these perspectives are excluded, health professionals will miss opportunities to better understand the need domains and perspectives of their patients. In turn, this limits their ability to work with their patients to aid them in reflecting on and understanding the treatment they are receiving, ultimately impacting on patient engagement and treatment effectiveness.

LIMITATIONS AND FUTURE DIRECTIONS Although this study has revealed some important findings, several limitations must be acknowledged. The first of these limitations is that some of the risk assessments had been conducted a couple of months before the needs assessments had been conducted. This means that the criminogenic needs identified by the risk assessments might not have been considered as needs when they were assessed later with the forensic mental health needs assessments, and this in turn might have reduced any apparent relationships observed. In addition, most of the risk assessments were completed by psychologists, while the needs assessments were completed by nurses. As previous research has suggested that there might be differences in the perceptions and ratings of people from



different professional backgrounds (Davies et al. 2006), needs might not have been consistently rated by nurses and psychologists across all patients. Again, this might have reduced the observed relationship between measures. Another limitation is in relation to the sex and patient composition of the sample; the sample mainly consisted of males, the majority of whom were diagnosed with paranoid schizophrenia. Although this sample is generally representative of the forensic mental health population, the findings might not be generalizable to females who are experiencing mental illness and have offended, or forensic patients who are experiencing other mental illnesses. Future research can investigate differences between the needs of female and male individuals experiencing mental illness who have offended on the CANFOR-S, and can also assess whether discrepancies between nurses and patients differ according to sex. Future research can also assess whether the CANFOR-S, alongside risk assessment, can predict some external criteria, such as institutional violence.

CONCLUSION The current study revealed that the CANFOR-S is a forensic mental health needs assessment that assesses the criminogenic, mental health, and non-criminogenic needs relevant for the treatment of individuals experiencing mental illness who have offended. While the HoNOS-S assesses similar underlying domains of need to the CANFOR-S, it does not incorporate a broad range of criminogenic aspects that are related to general reoffending for these individuals. To avoid fragmentation of care, and to provide effective treatment and rehabilitation for individuals experiencing mental illness who have offended, forensic mental health services would benefit from utilizing assessments, such as the CANFOR-S, for measuring outcomes. In particular, nurses should consider the potential it gives them to incorporate the patient’s perspective into treatment planning. The findings revealed that it is not always the case; that a patient will perceive the same need for care in a particular domain of functioning as a treating nurse. Nurses should be mindful of this and work collaboratively with patients to help develop a mutually-agreed and comprehensive assessment of needs that can be used to develop a collaborative treatment plan, ultimately improving patient engagement and treatment outcomes.

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