[Complex Trauma and Forensic Mental Health Services: Towards Trauma-informed Care]. / Traumatismes complexes et services psycholégaux : vers des pratiques sensibles au trauma.

Objectives Exposure to repeated traumatic events during childhood and adolescence is associated with high prevalences of mental illness, addictions, physical health conditions, and psychosocial difficulties (Felitti et al., 2019). The most common consequence of exposure to trauma is violence towards self and others (Hughes et al., 2017). The very high prevalence of complex trauma among forensic mental health service users challenges these settings to modify their practices, training approaches, policies, and service delivery approaches. The objective of this article is to contribute to such a transformation of forensic mental health services by clarifying the impacts of complex trauma on the trajectories and experiences of forensic mental health services users, as well as practices responding to complex trauma. Methods We reviewed the published and grey literature on complex trauma among forensic mental health service users. After synthesizing the findings, they were contrasted with our experiences as clinicians and researchers in the field of forensic mental health care through the development of a case vignette. Results We first identify the role of complex trauma and victimization in the development and maintenance of violent behaviours. We describe the negative experiences of services and care settings reported by individuals with complex trauma in the absence of recognition and understanding of traumatic experiences and their impacts. We highlight the fundamental principles of trauma-informed care (trust and transparency; safety; peer support; collaboration and reciprocity; empowerment and choice; sensitivity to gender, cultural and historical differences), as well as the clinical and organizational approaches emerging from those principles. Next, we describe the approaches developed internationally to apply and implement trauma-informed care in forensic mental health setting, and the opportunities and challenges associated with their implementation in the Québec context. Conclusion To date, few studies have documented and evaluated the implementation of trauma-informed care in forensic mental health settings. The literature reviewed in this paper indicates that an in-depth understanding of complex trauma among forensic mental health service users should be at the core of contemporary forensic research, policies and practices.

[Beyond Housing: The Heterogenous Effect of Housing First on Criminal Justice Outcomes Among Homeless People With Mental Illness]. / Au-delà du logement : l'effet hétérogène de Logement d'abord sur l'implication criminelle de personnes vivant avec un trouble mental.

Background Housing First does not, on average, reduce criminal justice involvement. This analysis aims to test whether the overall absence of an impact is due to intervention effect heterogeneity as a function of the pattern of lifetime criminal justice involvement, identified through latent class analysis conducted through earlier work. Methods This analysis relied on data from the Montréal, Toronto and Vancouver sites of the Canadian At Home/Chez Soi randomized controlled trial, merged with administrative records of lifetime criminal charges (N = 1,321). Negative binomial models with interaction terms were used to estimate the impact of Housing First, in comparison to treatment as usual, on violent charges, acquisitive charges (e.g., theft, sex work), and administration of justice charges (e.g., breach of probation), for each pre-identified profile. Results Participants with past criminal justice involvement associated with a chronic history of homelessness or with criminalized substance use experienced a decrease in violent charges as a result of Housing First, whereas those with no or little past criminal justice involvement experienced a marginal increase. Housing First did not affect acquisitive or administration of justice charges, regardless of profile. Conclusions Findings suggest that integrating criminological or forensic mental health tools, knowledge and approaches into the multidisciplinary teams that support Housing First service users may be an effective solution, so that all aspects of their recovery, including potential criminogenic needs, are addressed. Future research should focus on the feasibility and effectiveness of such adjunct interventions.

COVID-19 et pratiques professionnelles dans les milieux institutionnels fermés.

INTRODUCTION: While governments have focused efforts on implementing health measures such as physical distancing and confinement to protect communities from the spread of COVID-19, some researchers focused on the significant impact of these measures on mental health and well-being. Persons with mental disorders who are both institutionalized and justice-involved in psychiatric and forensic hospitals find themselves more vulnerable to these measures and more limited in their movements and activities. AIMS: The purpose of this paper is to examine the changes in practice in response to the pandemic and their potential impact on individuals in institutional settings. RESULTS: A rapid review including 69 publications identified nine major themes in the literature, which will serve as a framework to analyze the experience of one forensic psychiatry institution in Canada. These themes are: 1) population-specific vulnerability factors; 2) staff management and training; 3) early discharge, parole, and community integration; 4) management of contagion in closed spaces; 5) sanitary measures and personal protective equipment; 6) care and service continuity; 7) use of technology to maintain social ties and services; 8) legal mechanisms and individual rights; and 9) post-pandemic realities. CONCLUSION: Although this is the first pandemic of such international magnitude, experts point to an increase in epidemics over the past decade and continued growth in the coming decades. It is thus essential to learn from this health crisis in order to be prepared and minimize their potential impact on vulnerable populations in the future. The reflections presented here could be contrasted with the lived-experiences of people in institutions in order to nuance the data and propose new strategies.

Pathways to Recovery among Homeless People with Mental Illness: Is Impulsiveness Getting in the Way?

OBJECTIVE: This study investigates the association between impulsiveness and six dimensions of recovery among homeless people with mental illness. METHOD: The sample was composed of 418 participants of a randomized controlled trial of Housing First, a recovery-oriented program that provides immediate access to permanent housing. The reliable change index method was used to provide an estimate of the statistical and clinical significance of the change from baseline to 24 months (i.e., clinically meaningful improvement), on outcomes that pertain to recovery dimensions: psychiatric symptoms (clinical), physical health and substance use problems (physical), residential stability (functional), arrests (criminological), community integration (social), and hope and personal confidence (existential). We tested for the effect of impulsiveness, assessed with the Barratt Impulsiveness Scale-11, on clinically meaningful improvement on each specific outcome, adjusting for age, gender and intervention assignment, as both intervention arms were included in the analysis. RESULTS: For every increase in total impulsiveness score by one standard deviation, the odds of experiencing clinically meaningful improvement decreased by 29% (OR = 0.71, 95% CI, 0.55 to 0.91) on the clinical dimension and by 53% (OR = 0.47, 95% CI, 0.32 to 0.68) on the existential dimension. However, changes in outcomes pertaining to physical, functional, criminological, and social dimensions were not significantly influenced by impulsiveness. CONCLUSIONS: Findings highlight the importance of addressing impulsiveness in the context of recovery-oriented interventions for homeless people with mental illness. Further research may be required to improve interventions that are responsive to unique needs of impulsive individuals to support clinical and existential recovery.

A pilot study of "post-seclusion and/or restraint review" intervention with patients and staff in a mental health setting.

PURPOSE: To develop and evaluate a "post-seclusion and/or restraint review" (PSRR) intervention implemented in an acute psychiatric care unit. DESIGN AND METHODS: Twelve staff members and three patients were enrolled in a participatory case study. To evaluate PSRR intervention, qualitative analysis was carried out. Seclusion and restraint use 6 months before and after the PSRR implementation was compared. FINDINGS: Nurses reported that they were able to explore the patient's feelings during the PSRR intervention with patients, which led to restoration of the therapeutic relationship. PSRR with the treatment team was perceived as a learning opportunity, which allowed to improve the therapeutic intervention. Both the use of seclusion and the time spent in seclusion were significantly reduced 6 months after the implementation of PSRR intervention. PRACTICE IMPLICATION: Our results suggest the efficacy of PSRR in overcoming the discomfort perceived by both staff and patient and, in the meantime, in reducing the need for coercive procedures. Systematic PSRR could permit to improve the quality of care and the safety of aggressiveness management.

Justice involvement among homeless individuals with mental illnesses: Are self-report and administrative measures comparable?

Individuals with mental illnesses who experience homelessness have frequent interactions with the criminal justice system. Correctly measuring this involvement is essential to develop and evaluate the efficacy of intervention programs. Criminal justice involvement is typically assessed through administrative records or self-reported accounts. The aims of this study are to: 1) assess agreement between self-report and administrative data related to court appearances, and 2) identify individual characteristics that affect discrepancies between sources. Participants were 468 homeless persons with mental illness from the Montreal site of the At Home/Chez Soi randomized controlled trial, in Canada. Self-reported data was collected through an interviewer-administered questionnaire. Administrative data was collected through provincial and municipal court databases. Overall, agreement was good. Discrepancies were more common among those with a diagnosis of mood disorder with psychotic features, and those with a criminal history. Increased age and interviewer's perception of sincerity and interest increased likelihood of concordance. Generally, high agreement between self-report and administrative data suggests that either source can provide reliable information. Further work to understand predictors of discrepancies could further enhance the quality of data collected through these different sources.

Persisting Barriers to Employment for Recently Housed Adults with Mental Illness Who Were Homeless.

Adults with mental illness who are homeless experience multiple barriers to employment, contributing to difficulties securing and maintaining housing. Housing First programs provide quick, low-barrier access to housing and support services for this population, but their success in improving employment outcomes has been limited. Supported employment interventions may augment Housing First programs and address barriers to employment for homeless adults with mental illness. The present paper presents data from qualitative interviews to shed light on the persisting barriers to employment among people formerly homeless. Once housed, barriers to employment persisted, including the following: (1) worries about disclosing sensitive information, (2) fluctuating motivation, (3) continued substance use, and (4) fears about re-experiencing homelessness-related trauma. Nevertheless, participants reported that their experiences of homelessness helped them develop interpersonal strength and resilience. Discussing barriers with an employment specialist helps participants develop strategies to overcome them, but employment specialists must be sensitive to specific homelessness-related experiences that may not be immediately evident. Supported housing was insufficient to help people return to employment. Supported employment may help people return to work by addressing persisting barriers.

Do romantic partners' responses to entry dyspareunia affect women's experience of pain? The roles of catastrophizing and self-efficacy.

INTRODUCTION: Entry dyspareunia is a sexual health concern which affects about 21% of women in the general population. Characterized by pain provoked during vaginal penetration, introital dyspareunia has been shown by controlled studies to have a negative impact on the psychological well-being, sexual function, sexual satisfaction, and quality of life of afflicted women. Many cognitive and affective variables may influence the experience of pain and associated psychosexual problems. However, the role of the partner's cognitive responses has been studied very little. AIM: The aim of the present study was to examine the associations between partners' catastrophizing and their perceptions of women's self-efficacy at managing pain on one side and women's pain intensity, sexual function, and sexual satisfaction on the other. METHODS: One hundred seventy-nine heterosexual couples (mean age for women = 31, SD = 10.0; mean age for men = 33, SD = 10.6) in which the woman suffered from entry dyspareunia participated in the study. Both partners completed quantitative measures. Women completed the Pain Catastrophizing Scale and the Painful Intercourse Self-Efficacy Scale. Men completed the significant-other versions of these measures. MAIN OUTCOME MEASURES: Dependent measures were women's responses to (i) the Pain Numeric Visual Analog Scale; (ii) the Female Sexual Function Index; and (iii) the Global Measure of Sexual Satisfaction scale. RESULTS: Controlled for women's pain catastrophizing and self-efficacy, results indicate that higher levels of partner-perceived self-efficacy and lower levels of partner catastrophizing are associated with decreased pain intensity in women with entry dyspareunia, although only partner catastrophizing contributed unique variance. Partner-perceived self-efficacy and catastrophizing were not significantly associated with sexual function or satisfaction in women. CONCLUSIONS: The findings suggest that partners' cognitive responses may influence the experience of entry dyspareunia for women, pointing toward the importance of considering the partner when treating this sexual health problem.