Anthony A. Menditto

Effectiveness of inpatient treatment programs for mentally ill adults in public psychiatric facilities

Abstract This article updates the current state of knowledge and research on the effectiveness of inpatient treatment programs for mentally ill adults in the public sector to provide guidance for improving both research and services. National figures show inpatient facilities to still be predominant in the U.S. public mental health system; the populations and programs in these facilities are in serious need of science-based assistance. We summarize the major conceptual factors that influence the conduct and interpretation of inpatient outcome studies, clinical trials, or program evaluations (relevant domains and classes of variables, unit of analysis and effectiveness criteria, empirical findings on moderator variables). The major inpatient treatment approaches are described, and the empirical literature on effectiveness is reviewed. We conclude with a summary of the substantial accumulated evidence and recommendations for use of new assessment technology to assist with implementation of effective approaches and for advancing promising lines of research. The time seems ripe for exciting science-based advances in research and services.

Social-learning procedures for increasing attention and improving basic skills in severely regressed institutionalized patients

Seven severely debilitated and chronically institutionalized forensic psychiatric patients were enrolled in intensive shaping classes as part of a comprehensive social-learning treatment program. Results compiled over 1 year reveal that six of these patients demonstrated marked improvements in their ability to attend to basic academic tasks and five also showed consistently high rates of successful task completion or increased rates over time. Evidence for the generalization of these effects comes from the fact that all four of the residents who went on to regular academic classes demonstrated consistently high rates of successful task completion. Recommendations are made for further applications of intensive shaping procedures for such severely impaired subgroups.

Trajectories of Seclusion and Restraint Use at a State Psychiatric Hospital

OBJECTIVE This study investigated patterns of seclusion and restraint among patients hospitalized at a psychiatric facility with a large number of forensic psychiatric beds. METHODS Seclusion and restraint records were examined for 622 patients who were admitted during a five-year period (September 2001 to September 2006) and had a stay of at least 60 days. Seclusion and restraint episodes were recorded as bimonthly counts over the first two years after the initial admission. Latent class analysis was used to investigate the hypothesis that discrete seclusion and restraint trajectories exist. RESULTS Indices of model fit strongly supported the existence of three highly discrete trajectories. The low-trajectory class (71%) consisted of individuals who averaged less than .15 seclusion or restraint incidents per month over the course of their hospitalizations. Patients in the medium-trajectory class (22%) averaged approximately two incidents per month during the first two months, and rates declined to an average of about one incident per month by the end of the study period. Patients in the high-trajectory class (7%) averaged six incidents per month during the first two months, followed by a gradual decline in rates, where they then averaged two to three incidents per month by the end of the study period. The three groups differed significantly with respect to a number of diagnostic and demographic characteristics. While hospitalized, patients in the high-trajectory class were almost 30 times more likely to be named as perpetrators in incident and injury reports and 75 times more likely to be physically abused than patients in the low-trajectory class. CONCLUSIONS These findings have implications for clinical and administrative decision makers with regard to assigning new admissions to appropriate security levels, targeting patients with specialized treatment interventions, and moving low-risk patients into less restrictive treatment environments.

Functional Assessment of Independent Living Skills

Abstract Functional assessment of persons with psychiatric disabilities requires reliable and valid instruments that can be used by clinicians for planning psychosocial rehabilitation services. Two such instruments, the Independent Living Skills Inventory and the Independent Living Skills Survey are operationalized and behaviorally specific tools that can be administered as questionnaires or interviews. Both instruments have well-documented reliability and validity and are ‘user-friendly.”

The Relationship Between Seclusion and Restraint Use and Childhood Abuse Among Psychiatric Inpatients

Seclusion and restraint (S/R) is a controversial topic in the field of psychiatry, due in part to the high rates of childhood physical and sexual abuse found among psychiatric inpatients. The trauma-informed care perspective suggests that the use of S/R with previously abused inpatients may result in retraumatization due to mental associations between childhood trauma and the experience during S/R. Thus, though one would expect to see efforts on the part of inpatient psychiatric facilities to limit S/R of previously abused inpatients, research suggests that trauma victims may be more likely to experience S/R. The current study sought to clarify this possibility by examining whether presence or absence and chronicity of childhood sexual and physical abuse differed among three groups of adult inpatients (N = 622) residing at a mid-Western state psychiatric hospital. These groups are empirically derived on the basis of dramatic differences in the patterning of their exposure to S/R over the course of hospitalization. Results of Chi-square and Kruskal—Wallis tests suggest that the classes did not significantly differ in presence or absence and chronicity of childhood sexual or physical abuse when male and female inpatients were analyzed separately. However, among the class of inpatients who experienced the most instances of S/R, 70% of the members have histories of childhood abuse. Implications for inpatients, clinicians, and policy makers are discussed.

A Social-Learning Approach to the Rehabilitation of Individuals with Severe Mental Disorders who Reside in Forensic Facilities

Abstract With steadily growing populations of individuals with severe mental illnesses in forensic hospitals and correctional institutions, there is a need for effective rehabilitation services in these facilities. Individuals in such facilities have many of the same rehabilitation needs as people with severe mental illnesses in other settings. This paper describes the use of a comprehensive social-learning approach to rehabilitation that has been implemented in forensic facilities with documented success. The effectiveness of the social-learning approach has been well established for individuals with the most severe mental illnesses in public psychiatric hospitals. The application of this approach within the Forensic Services of the Missouri Department of Mental Health is outlined, and some of the challenges associated with implementing psychosocial rehabilitation technologies within highly secure facilities are discussed.

Factors Influencing Length of Hospitalization for NGRI Acquittees in a Maximum Security Facility

Analyzing personal-social characteristics of mental patients for the purpose of developing an equation to predict length of hospitalization has received considerable attention in the psychiatric and psychological literature. Severity of crime, gender, race, marital status, education and occupation have all been identified at one time or another as salient predictor variables. A lack of clearly defined procedures to operationally define variables, particularly crime severity, and a failure to cross-validate findings have resulted in widely disparate conclusions that appear ambiguous and idiosyncratic. The current investigation attempted to correct these two methodological limitations and discovered a three-variable prediction model accounting for 34% of the variance in length of hospital stay, nearly three times that which has been accounted for in any previous study. Despite this significant improvement, the use of a prediction model should be limited to providing information regarding hospitalization prognosis and should not be used as a discharge decision-making instrument.

Shaping Procedures as Cognitive Retraining Techniques in Individuals with Severe and Persistent Mental Illness

Abstract Many persons with schizophrenia are characterized by cognitive impairments that interfere with their ability to benefit from traditional rehabilitation interventions, including some forms of cognitive rehabilitation. To date, shaping procedures, a form of social-learning based intervention, have demonstrated effectiveness in several reports in improving the attention spans and lengths of continuous work performance among people severely impaired by schizophrenia. Despite this encouraging data, shaping as a form of cognitive rehabilitation remains underutilized. In this paper, we review the conceptual foundations for shaping, the rationale for the use of shaping as a form of cognitive rehabilitation, and future tasks necessary to refine this intervention.

Statewide implementation of recovery support groups for people with serious mental illness: a multidimensional evaluation.

This study evaluated a statewide demonstration project to implement a group-based intervention called Procovery in selected inpatient and community mental health centers. Procovery is a facilitated mutual support group designed to build hope and a sense of social inclusion by raising consciousness and helping people develop an understanding of the ways one can move toward recovery in their own lives. This evaluation sought to determine both consumer outcomes and perceptions of the program and implementation efforts held by consumers and the facilitators of the intervention. A multidimensional approach was used, including a quasi-experimental design with consumers, questionnaires and focus groups with the intervention facilitators, and individual interviews with administrators. The Procovery model was shown to have a positive impact on consumers’ recoveries and was viewed favorably by consumers, facilitators, and administrators. Several barriers to effective implementation were identified. These findings and their implications for future practice and research are discussed.

The Use of Logistic Regression to Enhance Risk Assessment and Decision Making by Mental Health Administrators

Development of policies and procedures to contend with the risks presented by elopement, aggression, and suicidal behaviors are long-standing challenges for mental health administrators. Guidance in making such judgments can be obtained through the use of a multivariate statistical technique known as logistic regression. This procedure can be used to develop a predictive equation that is mathematically formulated to use the best combination of predictors, rather than considering just one factor at a time. This paper presents an overview of logistic regression and its utility in mental health administrative decision making. A case example of its application is presented using data on elopements from Missouris long-term state psychiatric hospitals. Ultimately, the use of statistical prediction analyses tempered with differential qualitative weighting of classification errors can augment decision-making processes in a manner that provides guidance and flexibility while wrestling with the complex problem of risk assessment and decision making.