The number of forensic psychiatric commitments has drastically increased over the last decade, now surpassing civil commitments in Texas. This uptick is a result in part of two main policy shifts during the middle of the 20th century: deinstitutionalization and over incarceration fueled primarily by the War on Drugs. Although the Community Mental Health Centers Act of 1963 was meant to replace inpatient services, few centers are adequately funded. As highlighted in the news, the combined effect is illustrated in the numbers: 1 million individuals with serious mental health disorders are booked into local jails each year and half of all incarcerated individuals are experiencing a mental health problem of some kind. To address this growing population and to prevent individuals who are criminally court-ordered to receive mental health treatment from lingering in jail for unconstitutional lengths of time, many states including Texas have been forced to find or create new forensic beds, sometimes even building new facilities. This demand for forensic beds has created opportunities for private prison companies to expand into mental health. GEO Group, one of the largest prison corporations in the world, already owns or operates five psychiatric facilities in the U.S., including one in Montgomery County, Texas, before it was acquired by Correct Care Solutions. Much like in the private prison industry, for-profit private corporations have an incentive to continue to grow the forensic psychiatric population, which contradicts best practices regarding treatment for individuals with mental illness taking place in the least restrictive environment. In order to prevent opportunities where states rely on private prison corporations because of cost savings promises, research and advocacy regarding alternatives for states attempting to curb a growing forensic psychiatric population are needed. / text

Within Canada’s federal correctional system, prison-hospitals provide both in-patient and ambulatory services to incarcerated male offenders. With at least 12% of incarcerated men being identified at intake as having a mental health disorder, the need for these services is significant (Sampson, Gascon, Glen, Louie & Rosenfeldt, 2007). While some description of the mental health services provided, internal operational reviews, and external health services accreditation surveys of these prison-hospitals are available, there has been very little attention paid to the challenge of trying to balance the dual correctional and mental health mandates of these facilities. Research in comparable facilities and services in the United States describe mental health care as a ‘non-system’ of care and state that mental health staff receive very little system-wide direction regarding the provision of services (Cruser & Diamond, 1996; Elliot, 1997). This is a study that critically analyses how mental health care has become subordinated to correctional and security priorities in a Canadian prison-hospital. Five key elements identified in the policy implementation literature are used to explicate the everyday experiences of frontline staff as they work to provide mental health services in this correctional environment. The thesis argues that the mental health work of frontline prison staff is subverted by a lack of vision for mental health care within organizational policy structures, allowing the detailed correctional policy structures to become the dominant force in implementation and decision making. Using the theory and method of institutional ethnography developed by sociologist Dorothy Smith, the analysis displays how the everyday activities of frontline staff are systematically organized by routine organizational policy structures to advance the correctional mandate of the prison-hospital while mental health care has slowly declined. The study finds that mental health care is socially organized as a ‘zero-sum game’. As policy texts have concerted and coordinated the everyday activities of frontline staff in predictable ways, gains for the correctional and security priorities of the prison-hospital have meant significant and repeated losses for mental health care. However, there are ‘windows of opportunity’ for frontline staff to advance the mental health mandate of the prison-hospital if they work together. / Thesis (Ph.D, Rehabilitation Science) -- Queen's University, 2010-04-28 14:46:36.212

Background: High levels of dissociation have been found in recent studies involving psychiatric inpatients. Proponents of the ‘dissociative psychoses’ have found that trauma-focused intervention strategies can improve outcomes of patients with major mental illness. Despite this, levels of dissociation have not been measured in forensic inpatients in Scotland. This study investigates levels of dissociative symptoms (DES-II) within a sample of male patients in secure forensic psychiatry settings in Scotland. It explores levels of psychosis (PANSS) and self-reported childhood trauma (CTQ), current PTSD symptoms (IES-R), levels of depression (BDI-II) and broad attachment style (RQ). Four groups were arbitrarily defined based on presence or absence of psychosis and childhood trauma. It was hypothesised that levels of dissociation would be predicted by presence of childhood trauma. Methods: A quantitative cross-sectional design was used in which 56 mentally disordered offenders were interviewed across three different secure hospitals in Scotland: The State Hospital – a maximum security psychiatric hospital, and two medium secure facilities. Attempts are made to clarify the relationship of dissociation with different types of childhood trauma and psychosis symptom clusters. By splitting the data into groups the study seeks to discern whether the groups differ significantly on dissociation scores in relation to the childhood experiences they reported and presence of psychosis they are experiencing. Results: Childhood traumatic experiences were frequent where median CTQ total score = 47.0 (IQR: 42-70.5). Physical neglect was reported by 58.9% of the sample closely followed by emotional neglect (55.4%). 46.4% of the sample reported physical abuse of significant levels, 44.6% reported being emotionally abused and almost a third reported being sexually abused (28.6%). DES-II (dissociation) scores were significantly associated with delusions and hallucinatory behaviour from PANSS. Emotional abuse and sexual abuse were significantly associated with dissociation scores. Mann Whitney tests revealed that dissociation was significantly higher in the groups which reported childhood trauma. Kruskal-Wallis results indicated no significant differences between groups within the data and dissociation scores. Conclusion: Patients with clinically significant levels of dissociative symptoms were identified. This indicates that dissociation is a key characteristic, warranting further consideration in this sample. Levels and severity of reported childhood trauma were higher than expected. The findings add weight and support to the importance of dissociation and trauma in formulations of male, mentally disordered offenders. Clinical implications of these findings are considered and further directions are discussed.

People who are mentally unwell and have committed a criminal offence are cared for by forensic mental health services. Their treatment is provided in secure hospitals so that any risks to the public are minimised. The complex nature of the mental health difficulties experienced by this clinical population means that they are typically treated in secure hospitals for several years, incurring high economic and personal costs. The need for meaningful approaches to treatment and management of these individuals is therefore paramount. The first paper systematically reviewed eighteen qualitative research papers that explored stakeholder perspectives on the personal recovery approach to care in forensic contexts. Principles of personal recovery were perceived to be meaningful and applicable in forensic contexts if adaptations were made to overcome inherent barriers such as restrictions due to risk management. Methodological quality of the reviewed studies was limited by shortcomings in the transparency of study procedures. The second paper explored the experiences of a significant subpopulation of forensic service users who were discharged to the community subject to conditions including ongoing monitoring, then recalled back to a secure hospital due to a relapse in their mental state or other indicators of increased risk. Using grounded theory, a theoretical model was developed of how these individuals make sense of being recalled. This was found to be a recursive process influenced by their perceptions of events before their recall, during the recall itself, and their subsequent experiences.

Aims: The aims of this thesis were focused on the social climate of inpatient forensic mental health settings. Firstly, the study reviewed the literature of qualitative studies of staff and patient experiences of social climate. Secondly, the utility of a case study methodology to examine innovations to practice in forensic mental health settings are discussed. Thirdly, a longitudinal case study aimed to examine the impact of a Mentalization based treatment (MBT) training and case consultation intervention on the functioning of a low secure ward. Method: A systematic review and qualitative synthesis of social climate in forensic mental health settings was completed using the ‘best-fit’ framework approach. Secondly, a critical analysis of case study methodology was presented based on key decision points. A longitudinal ward case study with staff (n=37) and patient (n=7) participants examined the impact of staff MBT training and MBT based case consultation sessions. MBT based case consultation sessions ran on the ward over an eight month period. Data was collected through a range of methods including questionnaires, semi-structured interviews, ward observations and routinely reported data. The case study data was tested through a pattern matching approach with reference to rival explanations. Results: The systematic review identified 20 papers that met the inclusion criteria. The framework synthesis identified 22 themes related to social climate, which were organised in a conceptual model. Ten themes were seen to represent the experience of social climate. Consideration of the applicability of the case study method to forensic settings found the method to be feasible and acceptable to staff though a limitation is that outcomes are tentative and open to rival explanations. Positive impacts of the training and case consultation intervention included an increase in enthusiasm for working with patients with a personality disorder diagnosis and evidence of some increased team cohesion. The main rival explanation identified was the impact of changes to the composition of the staff and patient group. Conclusions: The systematic review findings highlight that current quantitative measures of social climate may not fully represent the construct. The conceptual model developed allows for generation of potential interventions to improve social climate. In the case study, staff reported positive perspectives of both MBT training and the case consultation sessions. The intervention did not appear to impact on patient motivation, though patients reported positive changes in staff behaviour. The case study method was seen as applicable to forensic mental health settings and provided interpretable data useful for analytical generalisations, and clinically in considering innovations to practice.

Background: Evidence suggests that the recovery focused approach provides a new conceptual framework for modern rehabilitation practice; encouraging a movement away from traditional medical treatment, towards a more person-centred, social approach to patient care. Mental health services are increasingly focused on supporting the recovery approach to patient care, with government policies continuing to encourage local teams to develop recovery focused services. In relation to the recovery focused approach, this thesis had two aims. Firstly, to systematically analyse literature which explores the impact of recovery-oriented training on staff knowledge and attitudes toward recovery practice, and secondly, to explore nursing staff perceptions and experiences concerning moving towards and using a recovery focused approach within a low secure forensic mental health setting. Methods: Aims were addressed in two separate pieces of work. The first journal article presents a systematic review. Literature searches of six computerised databases, hand searching of selected journals, and the contacting of key authors of identified papers identified nine papers which explored the impact of recovery-oriented training programmes on increasing staff knowledge and changing attitudes towards practice. In journal article 2, interviews were conducted with eleven forensic mental health nurses in relation to service changes and analysed using Framework Analysis. Results: The systematic review found that all nine studies demonstrated significant positive changes in mental health practitioners’ self-reported recovery-based knowledge, recovery-consistent attitudes and attributions, and optimism following completion of a recovery-oriented training programme. In journal article 2, five themes were identified: managing risk; patient engagement; service developments; development of job role and ward environment. Conclusions: The systematic review demonstrated the effectiveness of recovery-oriented training programmes at facilitating positive changes in staff knowledge, attitudes and attributions towards recovery oriented practice in clinical populations. Limitations of the papers included the relatively small sample sizes, the complex nature of the populations reviewed and the high rate of demographic confounding variables identified. The results of the original study provided insight into the views and understandings of forensic mental health nursing staff, specifically, into factors which were perceived to promote and impede the recovery focused approach within a low secure forensic mental health setting. In both articles, results are discussed in relation to clinical implications, strengths and limitations, and directions for future research.

Purpose: The systematic review summarised the research investigating potential risk factors for impulsive behaviours in forensic populations. The empirical study examined the predictive utility of clinician rated, self-report and behavioural measures of impulsivity in detecting violence and antisocial behaviour in forensic mental health inpatient settings. Method: The review is comprised of 9 studies identified through electronic database searches using a structured search strategy and predetermined inclusion criteria. The empirical study employed a cross-sectional design using retrospective and prospective statistical analysis. Forty-three participants were recruited from secure forensic mental health inpatient settings across Scotland and data collected from clinician rated, self-report and behavioural measures of impulsivity. Results: The review found original evidence to suggest that traumatic brain injury, substance and alcohol misuse, trauma and sleep as possible predictors of impulsive behaviour in forensic populations. The empirical study found a relatively consistent relationship between impulsive behaviour and violent or antisocial behaviour in a sample of forensic mental health inpatients. Conclusions: The systematic review identified a limited number of risk factors thought to influence impulsive behaviour in forensic populations. The review highlights the need for future research with improved methodological design to further explore contributory factors for increased levels of impulsivity. Findings from the empirical study reveal clinician rating of impulsive behaviour to be the most sensitive in predicting future incidents of violent and antisocial behaviour, which may be supplemented by the addition of a self-report measure.

A study was conducted to investigate and identify differences inherent in two subtypes of psychosis driven or mentally disordered homicide: matricide versus any other biological intrafamilial homicide or attempted homicide. Matricide was further investigated through the exploration of offence specific details, as well as demographic and diagnostic characteristics of persons who had committed (or attempted) homicide against the mother and were subsequently found not criminally responsible and detained by the Ontario Review Board between 1992 and 2012. Matricidal accused were more often diagnosed with childhood disorders and paranoid schizophrenia. As adults, they failed to mature sexually and socially, and continued to live at home, dependent on the mothers that were the ultimate victims of their violence. Attachment theory is offered as a proposed explanation for the matricidal impulse.

Experiences of trauma and maltreatment are frequent predictors of poor physical and mental health outcomes in adulthood. Existing literature also suggests an impact of developmental adversity on criminality and aggressive behavior, though little research exists describing the effects of cumulative adversity in forensic mental health samples. In the current study of 381 forensic mental health inpatients, rates of trauma, neglect, and parental substance abuse are reported in comparison with community norms. Cumulative adversity and the occurrence of foster care placement are examined via linear and logistic regression analyses in relation to age at first arrest, first psychiatric hospitalization, and onset of aggression, as well as history of suicide attempts and non-suicidal self-injury. Results revealed that experiences of developmental adversity were more common among participants than have been reported in community samples using the ACE survey, and that there were differential effects of gender on the prevalence of traumas experienced. Cumulative adversity scores were significantly associated with all outcomes, though the addition of foster care placement to the model significantly contributed to understanding outcomes, and in some cases, removed the effect of cumulative adversity. Implications and direction for future study are discussed.

While forensic psychiatric inpatient violence is a serious problem, research on risk assessment for this outcome is limited; the current research investigated the predictive validity of a number of structured risk/forensic instruments for inpatient violence. Research objectives included: 1) observing the profile of dynamic changes in violence risk detected by existing violence risk assessment instruments; 2) assessing whether existing violence risk assessment instruments could be used to assess risk for inpatient violence; 3) evaluating the contribution of dynamic risk measures to the prediction of inpatient violence; and 4) assessing the relationship between dynamic changes in risk and inpatient violence. Instruments included: the Historical Clinical Risk Management 20 - Version 3 (HCR-20V3), the Psychopathy Checklist Revised (PCL-R), the Short-Term Assessment of Risk and Treatability (START), the Revised Violence Risk Appraisal Guide (VRAG-R), and the Violence Risk Scale (VRS). Two studies were conducted on a maximum-security forensic psychiatric unit at Alberta Hospital Edmonton. Study 1 was a pseudo-prospective archival investigation (n = 99), while Study 2 was a prospective investigation (n = 19); all risk assessment scores were based on information available in institutional files. Instruments designed to capture dynamic/clinical risk variables (HCR-20V3, START, VRS) detected dynamic changes in risk in this setting over longer follow-ups (i.e., between admission and discharge), but not over shorter follow-ups (i.e., 28 day periods). Predictive validity analyses indicated that specialized measures designed to capture relevant dynamic/clinical variables were significant predictors of inpatient violence; instruments that were not designed for this purpose (PCL-R and VRAG-R), did not demonstrate predictive validity for inpatient violence. Dynamic measures consistently demonstrated incremental predictive validity for inpatient violence, beyond the static measures. Additionally, change scores demonstrated incremental relationships with decreased inpatient violence, beyond pretreatment scores. Put another way, positive risk change was associated with decreased violence over the course of the patients’ stays in hospital. Reliable and valid risk assessments are a necessary component of effective offender programming (Risk-Need-Responsivity Model) and the current results indicated that valid violence risk assessments for forensic psychiatric inpatient violence are possible. Implications for clinical practice and the reduction/mitigation of inpatient violence are discussed.