The indistinguishables: determining appropriate environments for justice involved individuals.

Criminalizing those with mental illness is a controversial topic with a long and complex history in the United States. The problem has traditionally been dichotomized between criminals (i.e., "bad") in need of placement in jails and prisons and the mentally ill (i.e., "mad") who are need of treatment in psychiatric facilities. Recent trends demonstrate significant increases in the rates of mental illness in jails and prisons, as well as increased rates of violence within psychiatric hospitals. This would suggest that there are a group of justice involved individuals who are "indistinguishable" within the traditional dichotomous categories of dangerousness and mental illness. The authors argue for a more nuanced model that dimensionally conceptualizes dangerousness and mental illness; increased attention to situational factors that create facilities appropriate for those who are dangerous and mentally ill and more diversion programs for those inappropriate for incarceration or hospitalization.

Implementing an ecological approach to violence reduction at a forensic psychiatric hospital: approaches and lessons learned.

Existing literature on aggression within psychiatric hospitals suggests that treating an aggressive patient's symptoms could be complemented by (a) milieu environments that mitigate violence and (b) hospital-wide policies and procedures that focus on creating a safe environment. Described as an ecological approach, examples of how this broader, situational approach can reduce inpatient violence in psychiatric settings are provided throughout. The authors identify potential barriers to focusing on wards and institutional rules as well as patient treatment. Last, details of how this ecological approach has been implemented at one state hospital in California are provided.

Aggression Among Psychiatric Inpatients: The Relationship Between Time, Place, Victims, and Severity Ratings.

BACKGROUND: The rate of aggressive acts perpetrated by psychiatric inpatients remains a pressing issue. To date, few studies have distinguished between incident severities. OBJECTIVE: The aims of the current study were to identify rates of inpatient aggression in an inpatient forensic psychiatric facility and describe the severity of the aggression reported for aggressive incidents. DESIGN: All documented acts of aggression at a 1,500-bed forensic hospital between 2009 and 2013 provided data about the time, location, and victims of aggressive acts. In total, 52,109 unique incidents were analyzed. RESULTS: The findings showed an increase in violence rates during meal, medication, and shift change times. Patients (n = 3,436, 62%) were victimized more often than staff members (n = 2,103, 38%). Fall and winter months showed more acts of aggression than summer and spring, but there were no mean differences between severity ratings by season. The results showed that the swing shift saw more severe aggressive incidents than the morning or overnight shifts, p = .001, and significantly more serious incidents occurred when there were staff members working over time, p = .050. CONCLUSIONS: The current study reports some key findings about aggression rates with a very large sample and presents some valuable data regarding the severity of aggressive acts.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guideline.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines.

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

Recidivism among female child molesters.

During recent years, research about female sexual offender recidivism rates using official criminal justice records has increased. Although informative, rearrest or conviction rates may be insufficient for this population. This study examines two potential outcome measures for accurately studying recidivism among 57 female sexual offenders; a criminal recidivism measure based on formal legal charges and a reported recidivism measure based on child welfare reports. Based on the criminal recidivism outcome measure, 10(17.5%) women were charged for a subsequent sexual crime. The broader reported recidivism measure identified six additional women with subsequent contact with police or child welfare agencies for sexually inappropriate behaviors. There were no significant differences found between the 41 nonrecidivists and the 16 recidivists. The implications of these findings are discussed.

Female sexual abuse and criminal justice intervention: a comparison of child protective service and criminal justice samples.

OBJECTIVE: The current study compared a sample of female perpetrators reported to Child Protective Services (CPS) to a sample of women from the criminal justice system. Instead of examining a clinical or criminal justice sample in isolation, this comparison allows a more accurate description of female sexual offending. METHODS: Cases were drawn from a Midwestern state's child abuse registry, law enforcement records, and sex offender registry. The CPS sample consisted of 179 women, and the criminal justice system sample consisted of 57 women. All cases were reported to the agencies between 1994 and 2004. RESULTS: Victims ranged in age from 1 to 18 years old (M=9.98, SD=4.37). As hypothesized, there were statistically significant differences between the CPS and criminal justice samples. Specifically, the CPS sample had a majority of victims under age 12 (74.9%), while the criminal justice sample had a majority of victims between ages 13 and 19 (73.8%). The CPS sample had predominantly intrafamilial victims (97.8%), while the criminal justice sample had a majority of extrafamilial victims (63.3%). The CPS sample also showed significantly more female victims (63.7%), while the criminal justice sample had mostly male victims (62.1%). CONCLUSIONS: There were significant differences in the victim's age, the victim's gender and the perpetrator-victim relationship between cases managed in the CPS and the criminal justice system. The results highlight the need for further research into child welfare and law enforcement collaboration.

Exhibitionism: findings from a Midwestern police contact sample.

This study used a police sample to examine offense characteristics, recidivism rates, and other types of sexual offending among individuals suspected of exhibitionism. The sample consisted of 202 incidents of indecent exposure perpetrated by 106 identified individuals. Demographic information showed that one quarter of the sample had symptoms of a mental illness and one quarter had a history of substance abuse. More than 84% of the sample had other nonsexual criminal charges. Approximately 30% of the perpetrators were charged for more than one exposure incident. Masturbating during the offense, exposing to child victims, and speaking to the victim did not show any relationship to the occurrence of more sexually aggressive behaviors. However, individuals who had subsequent rape or molestation charges (16.9%) were more likely than those who did not to have had multiple exposure incidents and a history of physical assault charges.

A gender-based incidence study of workplace violence in psychiatric and forensic settings.

Limited data exist analyzing the role of gender in workplace violence in health care settings. This study examined whether different types of threatening incidents with patients (physical, verbal, sexual, or posturing) were salient to male versus female staff across psychiatric settings (inpatient forensic, inpatient acute/chronic psychiatric, and outpatient psychiatric). Results indicated that although women disproportionately experienced sexualized threats, they were not more likely to report such incidents as salient and threatening. The study also assessed the extent to which situational variables contributed to staff's feelings of threat. Results showed that rapport with the patient, quality of relationships with coworkers, and presence of coworkers in the area were not significantly related to how threatened staff felt in a recent threatening incident. Findings are discussed within the context of staff training and organizational benefits.