High security psychiatric/forensic wards

in Norway:
Structure; capasity; legislation
Illuminated by a forensic case

10th Nordic Symposium on Forensic Psychiatry

Kuopio, Finland,August 21-23, 2013

Yngve Ystad, psychiatrist, senior consultant

The Norwegian Psychiatric Association, Section for Forensic Psychiatry
Case with discussion - Norway
• Male, ethnic Norwegian, born 1981; one younger sister in
their parents marriage; this was fathers second marriage
(one son in first marriage)

• Father abused alcohol; abstinent for 20 years, but relapsed;

psychotic? (died 1998); parents dicorced 1997; mother was
disabled

• Sleep disturbance from infant age; uneasy and anxious

• Temper tantrums and acting out-manner at home.

Provocing behaviour; putting objects at fire; broke his
mother’s nasal bone etc.
Y. Ystad, NPF - Rettspsykiatri
Case with discussion - Norway

• Referred to hospital (Child Ward) 8 yrs. old after fathers

alleged abuse (knocking his head to the floor)

• Early put in the care of a Children’s Officer, transferred at

the age of 12 to an institution approx. 100 km from home,
partly under strengthened conditions; frequent escapes
from the institustion; 2002 transferred to reinforced
(manned) home

• From beginning of schoole career: Needed assistant

teacher from start; unconsentrated, shirked school;
completed grade 6 in a special class; was connected to
juvenile gangs involved in willful damage, tagging and
burglary; Y. Ystad, NPF - Rettspsykiatri
Case with discussion - Norway
• 1994 diagnosed with ADH -> Ritalin briefly (almost
ineffective)

• Referred to an out-patient psychiatric clininc last two yrs.

before his severe criminal act in 2004; suspicion on a
schizophrenic development, allegedly referred to
psychiatric hospital without beeing admitted.

• Discharged at the age of 18 from Child Welfare Work

without any daily public care (moved home, to mothers
care and heavy concern)

Y. Ystad, NPF - Rettspsykiatri

Case with discussion - Norway

• August 2004 (18 yrs. old), three months after having been
discharged from the Cild Welfare Work, and under the
influence of narcotic drugs, he committed a volontary
manslaughter of a rather bestial impression, by stabbing a
man he had met occasionally and had done some
”business” with. The motivation for the murder seems to
have been psychotic.

• Remanded in custody where he displayed psychotic

ideation and symptoms, transferred to Regional Security
Ward in Oslo, to his first admission (Sept. 2004 – Sept.
2006)
Y. Ystad, NPF - Rettspsykiatri
Case with discussion - Norway
• Underwent forensic psychiatric observation, which
concluded that he was psychotic (F20.0) when committing
the murder

• The court sentenced him to compulsory mental health care

(CMHC) according to The General Civil Penal Code,
section 39, with legal validity from January 2005

• Transferred to the lokal security ward in his county’s

psychiatric hospital; poor effect of antipsychotic treatment.
Was finally given Ritalin/Concerta, after having insisted in
a persevering manner

Y. Ystad, NPF - Rettspsykiatri

Case with discussion - Norway

• The CMHC-sentence has been reiterated every three years,

as there has been a rather modest improvement, if any at
all.

• Was returned to The Regional Security Ward (RSA) in

September 2010, after having taken hostage a female
nurse, threatening her with a pair of scissors. A large
muster of police was necessary to regain control over him.
Received Concerta at that time.

Y. Ystad, NPF - Rettspsykiatri

Case with discussion - Norway

• An experienced Neuropsychologist made a thorough re-

evaluation of extensive former neuropsychologigal tests,
and concluded (2011):

– MR and EEG: Normal findings

– IQ: 85 - 70
– No tests confirmed ADHD, in contrast to what had been strongly
believed
– Dx: Paranoid schizophrenia with comorbid drug dependency (with
Pervasive dveleopment disorder as a differential diagnosis)
– High risks for future violence

Y. Ystad, NPF - Rettspsykiatri

Case with discussion - Norway
Renewed risk assessment (HCR-20) performed april 2013:
H1-incidents under actual hospital stay at RSA:
– Dangerous weapen-like device found in his room
– Mapped a possible escape route
– Escaped from the airing yard
– Attacked fellow patient with homemade stab weapon
– Fighting with fellow patient
– Got hold of drugs not ment for him, using violence
– Findings under staff’s search of his room repeatedly)
– BIC-pens found in his room
– Throwing hot coffee towards fellow patient
– Crushing the WC in his bathroom
– Damaging water pipe in his bathroom
– Attempt to strangle staff member
Y. Ystad, NPF - Rettspsykiatri
Case with discussion - Norway
Renewed risk assessment (HCR-20) performed april 2013:
H1-incidents (cont.):
– Hitting and hurting staff member repeatedly
– Throwing his own urine in the face of staff member
– Got hold of a key bundle which belonged to a staff member
– Tried to assist another acting out-patient – potentially a critical
situation
– Murder threat against staff member, repeatedly
– Throwing hot tea in the face of a staff member
– Beating a staff member several times in his head
– Spitting a staff member in her eye, with need for close follow up
due to danger of infection (hepatitis C)
– Acting out, crushing window glasses
– A screw removed from his bathroom
Y. Ystad, NPF - Rettspsykiatri
Case with discussion - Norway
Renewed risk assessment (HCR-20) performed april 2013:

- H1- H10: Full score, except H9 (personality disorder) and H4

(work/school) exluded, with the following conclusion:
All together the risk for future violence, based on history, is
extremely high

- C1 – C5: Full score, leading to the following conclusion:

Clinically an obvious lack of improvement under standard treatment
conditions.
Functional level is persistently weak, with cronic symptoms of
psychosis and (partly unpredictive) violent behaviour

- R1 – R5 (still on a ”high security” level): Partly fulfilled, (score = 5)

Y. Ystad, NPF - Rettspsykiatri
 Norway: Today’s high security - development

• Reitgjerdet Criminal Asylum (Trondheim) approx. 1880-1950

(Responsible: The Justis Department)

• 1920 - 1987: High Security Psychiatric Hospital at the same place

(Reitgjerdet) 1920, runned parallelly to the Criminal Asylum
Responible: The Health Department

• 1970s: Some ”scandals” indicated (or unveiled) clinical and

therapeutic standard which to some extent was outdated and
partly rigorous/suppressive

• One patient escaped spectacularly, assisted by a staff member

• Resulting in press headlines and severe puplic critisism

Y. Ystad, NPF - Rettspsykiatri

 Norway: Today’s high security - development

• The Parliament (Stortinget) demanded a Committee Report, which was

done by Robak et al (1980):
This report considered pros et contras for Centralization and/or
Decentraliazation.

• Gouvernmental resolution 18.05.1981: Reitgjerdet Hospital to be

closed down during 1982-1987; pasients to be returned to their county
hospitals (which not easily done, there were indeed some accusation of
”obstructions”)

• Subsequent committee reports gave additional advice for the national

clinical structure within this field (The Gunby Committee, The Skaug
Committee and other committees)

Y. Ystad, NPF - Rettspsykiatri

 Norway: Today’s high security - development

To-days result of the Robak Committee’s recommendations:

1. Decentralization of clinical treatment, later resulting in
A) 3 x Regional Security Wards (RSAs),
Capasity: Oslo 16 beds
Bergen 10 beds
Trondheim 10 beds
In total 36 beds

B) Local Security Ward (approx. 15) established in most of

the countie’s psychiatric hospitals
Approx. capasity: 170 beds all together

A and B are supposed to work together, by excanging patients

according to their varying needs
Y. Ystad, NPF - Rettspsykiatri
 Norway: Today’s high security - development

To-days result of the Robak Committee’s recommendations:

2. Establishment of three university-linked academic

centers (to-day called Competence Centres for
security, prison and forensic psychiatry, in close
cooperation with the three Regional Security
Wards

Y. Ystad, NPF - Rettspsykiatri

 Norway: Today’s high security - development

To-days result of the Robak Committee’s recommendations:

3. To-days Regional Security Wards are equivalenty

with the English term Medium High Security;

To-days Local Security Wards are equivalent with the

term Low Security

In other words: High Security Wards don’t exist in

Norway

Y. Ystad, NPF - Rettspsykiatri

Essential legislation
The General Civil Penal Code (Straffeloven, 1902):
Section 44:
A person who was psychotic or unconscious at the
time of committing the act shall not be liable to a penalty.
The same applies to a person who at the time of
commiting the act was mentally retarded to a high degree.
(= a biological principle for unaccountability)

Section 45:
Unconsciousness that is a consequence of self-induced
intoxication (caused by alcohol or other means) shall not
exclude punishment.
Y. Ystad, NPF - Rettspsykiatri
Essential legislation
The General Civil Penal Code (Straffeloven, 1902):
Section 56:
• The court may reduce the penalty below the minimum
prescribed for the act and to a milder form of penalty
a) …
b) …
c) when the offender at the time of committing the act
had a serious mental illness with a considerable reduced
capasity for making a realistic assessment of his
relastionship to his surroundings, but was not psychotic, cf.
section 44, or was slightly mentally retarded or acted under
a severe disturbance of consciousness that was not a
consequence of self-induced intoxication.
Y. Ystad, NPF - Rettspsykiatri
Essential legislation
The General Civil Penal Code (Straffeloven, 1902):
Section 39:
When it is deemed necessary for the protection of
society, an offender who is not liable to a penalty
pursuant to section 44, first paragraph, shall be
transferred to compulsory mental health care, cf.
chapter 5 of the Act relating to mental helath care.
The decisition in the case of such transfer shall be
made by a court judgement, and the transfer may
only be effected when the conditions prescribed
in No. 1 or No. 2 have been fulfilled:
Y. Ystad, NPF - Rettspsykiatri
Essential legislation
The General Civil Penal Code (Straffeloven, 1902):
Section 39:
1. The offender has committed or attempted to
commit a serious violent felony, sexual felony,
unlawful imprisonment, arson or other serious
felony, impairing the life, health or liberty of other
persons, or which may expose these legal rights to
risk. In addition there must be deemed to be an
imminent risk that the offebnder will again
commit a serious felony that …

Y. Ystad, NPF - Rettspsykiatri

Essential legislation
The General Civil Penal Code (Straffeloven, 1902):
Section 39:
2. The offender has committed or attempted to comit a less
serious felony of the same nature as is specified in No 1,
and has previously committed or attempted to commit any
such felony as is thereby specified, and it must be
presumed that there is a close connection between the
previous felony and the one now committed. In addition it
must be presumed that there is a particularly imminent risk
of relapsing into a new serious felony that will impair or
expose to riks the life, health or liberty of other persons.

Y. Ystad, NPF - Rettspsykiatri

Essential legislation
The General Civil Penal Code (Straffeloven, 1902):
Section 39a:
Refers to felonies of the same type mentioned
under section 39, committed by persons who are
mentally retarded at a high degree; They will be
transferred to a central ward in Trondheim
(Brøset) and examined prior to a later transfer to
his or her own municipality.

Y. Ystad, NPF - Rettspsykiatri

Essential legislation
The General Civil Penal Code (Straffeloven, 1902):
Section 39c:
Refers to felonies of the same type mentioned under
section 39, but committed by persons that were not
psychotic or mentally retarded to a high degree, when a
sentence for a specific term is deemed to be insufficient to
protect society.
These persons get a sentence of preventive detention in an
institution under the correctional services.
Should usually not exceed 15 yrs; may not exceed 21 yrs.

Y. Ystad, NPF - Rettspsykiatri

Essential legislation
The Criminal Procedure Act (Straffeprosessloven,1981):

Section 165:
Regulates and defines the ordinary forensic psychiatric
obeservation; explains when it is essential to have it done

Y. Ystad, NPF - Rettspsykiatri

Essential legislation
The Criminal Procedure Act (Straffeprosessloven, 1981):

Section 167:
If it is necessary in order to judge the mental state of
the person charged, the court may, after hearing counsel
for the defence and the appointed experts, order the person
charged to be committed for observation at a psychiatric
hospital or other suitable place for observation. The court
shall at the same time fix a time-limit for the duration of
the commitment.
If the person charged is sentenced, the period of
commitment shall be deducted from the sentence…

Y. Ystad, NPF - Rettspsykiatri

Essential legislation
The Mental Health Act (Psykisk helsevern-loven, 1999):
Chapter 3
About the admission to establish compulsory psychiatric observation
and compulsory mental health care

Chapter 4
About the accomplishment of compulsory mental health care

Chapter 4A (a recent supplement)

About the accomplishment of compulsory mental in high security
psychiatric institutions

Chapter 5
About the accomplisment of sentence to compulsory mental health care
Y. Ystad, NPF - Rettspsykiatri
Subjects for discussion (I):
• Treatment ”chain” within the security field in Norway lacks
continuity, there are difficulties in exchanging patients, and
lokal security level is too heterogeneous

• Results in a poor capasity for the high security level

• Institutions are small and vulnerable – one single patient may

consume a relatively high proportion of resources,

Y. Ystad, NPF - Rettspsykiatri

Subjects for discussion (I):
• Physical conditions are insuffient (old buildings, lacking
breadth of outlook, inconvenient seclusion areas etc.)

• Lack of ”in-between-institutions” for permanent stay (some

patients remain psychotic and highly violent for years)

• Incoherent ”chain” of public authorities; hospitals ”negotiate”

with municipalities for permanent stay in an suitable
institution

Y. Ystad, NPF - Rettspsykiatri

Subjects for discussion (II):

• Small and vulnerable institutions for the high and medium

high security an obstacle to research and professional
development

• The ”fragmentation” into small and distant units may

contribute to an explanation of why the academic activities
within the common field of security, prison and forensic
psychiatry has been so ”modest” - till recent years (it is
improving!)

Y. Ystad, NPF - Rettspsykiatri

Subjects for discussion (IV):

• Legislation, and admission to establish and practice ”house

order”, has become rather suitable and adequate, partly as a
concequence of the latest supplements (some would say
that is a sort of ”Lex Breivik”)

Y. Ystad, NPF - Rettspsykiatri

Subjects for discussion (V):
• Forensic psychiatry in Norway obviously facing a change.

• Committee reports are already presented, others will follow

• More expert examinations and evaluations are belived to

take place in institutions in the future (ref.: strpl. § 167)

Y. Ystad, NPF - Rettspsykiatri

Subjects for discussion (V):

• Autorization of forensic psychiatrists/psychologists under

consideration

• Forensic psychiatry will probably not become a speciality

of its own in Norway

Y. Ystad, NPF - Rettspsykiatri

Subjects for discussion (VI):
Ideology:

• The heavy weight on ”ordinary” or ”normal” psychiatry

(people to be treated near home, beds no longer necessary
with few exceptions, all patients restore to health etc) could
result in a sort of ”criminalization” of the psychiatric
institustions

• More patients will get sentenced to some sort of

compulsory mental healt care, as in-patients or out-patients

• A common Western phenomenon?

Y. Ystad, NPF - Rettspsykiatri