Simon N. Verdun-Jones

Forensic psychiatric inpatients and aggression: an exploration of incidence, prevalence, severity, and interventions by gender.

BACKGROUND Previous investigations suggest that women judged to be not criminally responsible on account of mental disorder (NCR-MD) differ markedly from their male counterparts in important ways, underscoring the necessity of subsequent study. OBJECTIVE The goal of the present study was to inform our understanding of the presenting profile of female forensic psychiatric patients and contrast their risk of inpatient aggression with their male counterparts. METHOD The population of patients assessed and/or treated at a secure Canadian forensic psychiatric hospital were available for study. In total, 527 patients had complete data and were part of intensive retrospective file reviews; inpatient aggression was evaluated using the Overt Aggression Scale. RESULTS Women were no less likely than men to have a violent index offence and to perpetrate inpatient aggression. Examining the range of aggressive behaviours and severity levels did little to increase the relevance of gender to inpatient risk. DISCUSSION Female forensic patients represent a highly selected subgroup of women with exceptional clinical and behavioural challenges and associated treatment needs.

Victim‐precipitated homicide: police use of deadly force in British Columbia

This study examines the underlying reasons for the police use of deadly force and potential deadly force, in the Province of British Columbia, Canada, during the period 1980‐94. Within this context, interactional violence and the phenomenon of victim‐precipitated homicide are examined in relation to the police use of deadly force. This study analyzes 58 separate documented incidents in which municipal and Royal Canadian Mounted Police officers, within the Province of British Columbia, have been confronted by a potentially lethal threat. In 27 of these incidents, the police responded by discharging their firearms and killing a total of 28 people. The remaining 31 cases that were examined reflect incidents in which the police responded with less‐lethal force. Through the examination of police investigations, verdict‐at‐coroner’s‐inquest reports, BC Police Commission data and interviews with police officers, this study reveals that, in roughly half of the cases examined (N = 28), the police reacted to a potentially lethal threat of victim‐precipitated homicide. These are incidents in which despondent individuals suffering from suicidal tendencies, mental illness, or extreme substance abuse, acted in a calculated and deliberate manner so as to force the police to use potential or deadly force. The study recommends that police personnel within the Province of British Columbia should be given further alternatives to the standard‐issue firearm, when responding to potentially lethal threats. Non‐lethal tools of compliance should be made readily available to the operational police officer with a view to providing alternatives to the traditional use of deadly force. In addition, the training of police personnel should emphasize non‐violent strategies in dealing with irrational individuals who are suicidal, mentally disordered and/or intoxicated.

A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff

&NA; Workplace violence, including patient‐perpetrated violence in healthcare settings, is increasingly being recognized as preventable. Staff training has been identified as a necessary component of any initiative aimed at preventing or reducing incidents of aggression and violence in the workplace. This narrative review of the literature evaluates the effectiveness of staff training programs designed to prevent and manage violence and aggression in psychiatric hospitals. An exhaustive review of the literature was performed on all articles published in English between January 1, 1990 and April 1, 2007 that evaluate an aggression management training program. Twenty‐nine studies met the inclusion criteria for a full review and were summarized using a qualitative narrative approach. Aggression management training has been proven effective in some areas, such as reducing the use of restraints and other coercive control devices, but more methodologically rigorous research is needed to firmly establish whether it is effective in reducing aggression and staff injuries. Implications: The findings of this study suggest that relying too heavily on aggression management staff training will have limited effect on addressing the range of issues related to patient‐perpetrated violence in psychiatric hospitals. Mental healthcare organizations must look beyond staff training if they are to achieve meaningful reductions in aggressive incidents and staff injuries.

Chronic Violent Patients in an Inpatient Psychiatric Hospital Prevalence, Description, and Identification

This study examines the prevalence and the individual characteristics of chronically violent patients (CVPs) in a psychiatric hospital during inpatient treatment. The study is based on a 1-year follow-up investigation of all violent episodes committed by a sample of 527 patients in a forensic psychiatric hospital in British Columbia, Canada. Sociodemographic, legal and criminological, historical, and clinical factors were analyzed using a risk assessment scheme. Approximately 10% of the sample was responsible for more than 60% for all violent episodes recorded during the study period. Those CVPs were characterized by historical, but mostly clinical, risk factors. Moderate to good predictive accuracy was achieved when defining CVPs as individuals who perpetrated 15 or more violent episodes. Important limitations of the actuarial approach were also highlighted by the presence of two qualitatively different groups of CVPs. The results are discussed in light of the scientific literature on the risk management of inpatient violence.

Perceptions and experiences of people with mental illness regarding their interactions with police.

This study examined the perceptions and lived experiences of people with mental illness in relation to their interactions with the police. A community-based participatory research approach was used and a procedural justice theoretical perspective guided the study. In-depth, semi-structured interviews were conducted by peer researchers with 60 people with mental illness who had interacted with the police and were living in Metro Vancouver, Canada. Among the study participants, contact with the police was frequent and occurred under a diverse range of circumstances. The majority of participants perceived being treated in a procedurally just manner by the police officer(s) who were involved in their most recent interaction. Almost three-quarters (n=43, 72%) of participants were generally satisfied with how the police officer(s) had handled their most recent interaction. The slight majority of participants (n=30, 51%) rated their previous contacts with the police as a positive experience overall, with 32% (n=19) indicating that their previous interactions with the police were negative life experiences. The findings paint a more balanced picture than that which is often portrayed by the media. Emphasizing a procedural justice framework for police handling of situations involving people with mental illness is a vital step toward improving how these interactions are experienced and perceived.

What Influences Perceptions of Procedural Justice Among People with Mental Illness Regarding their Interactions with the Police

According to procedural justice theory, a central factor shaping perceptions about authority figures and dispute resolution processes is whether an individual believes they were treated justly and fairly during personal encounters with agents of authority. This paper describes findings from a community-based participatory research study examining perceptions of procedural justice among sixty people with mental illness regarding their interactions with police. The degree to which these perceptions were associated with selected individual (e.g., socio-demographic characteristics), contextual (e.g., neighborhood, past experiences), and interactional (e.g., actions of the officer) factors was explored. The results of regression analyses indicate that the behavior of police officers during the interactions appears to be the key to whether or not these interactions are perceived by people with mental illness as being procedurally just. Implications of these findings for improving interactions between the police and people with mental illness are discussed.

Geographic Risk Management: A Spatial Study of Mentally Disordered Offenders Discharged from Forensic Psychiatric Care

We investigated the impact of neighborhood and community factors on the reintegration of forensic patients leaving custodial care in British Columbia, Canada. Using geographic information systems (GIS) techniques, the residential locations of a sample of forensic patients were tracked over time and mapped in relation to each other. The frequency of a patients return to hospital was monitored and the reasons for these returns were recorded after each unsuccessful community placement. The analysis of the findings suggested that patients who were released to certain, socially disorganized neighborhoods returned to inpatient care at a higher frequency. These neighborhoods exhibited many destabilizing features that may have significant influence on the long-term success or failure of discharge patients, such as low income, high unemployment, poor educational achievement, and concentrated rental accommodation. Further research is needed in order to explore not only the influence of neighbourhood destabilizers on the length of community placements for forensic mental health patients, but also the underlying rationale for locating patient services in socially disorganized areas.

Using social bonding theory to examine ‘recovery’ in a forensic mental health hospital: A qualitative study

BACKGROUND For people living with mental illness, recovery involves learning to overcome and manage their symptoms and striving to live fulfilling lives. The literature on achieving recovery emphasises the importance of social connections and positive role models. Hirschis social bonding theory posits that an individuals attachment to others, belief in social norms, and their commitment and involvement in conventional activities are the major contributors to normalising social behaviour. AIMS The aim of this study is to understand the qualities of service identified by patients in a forensic hospital as being important and meaningful to recovery. METHODS Semi-structured interviews with 30 inpatients in a forensic mental health hospital in British Columbia, Canada, were audio recorded, and the transcriptions were analysed using thematic analysis. RESULTS Five themes emerged: involvement in programmes, belief in rules and social norms, attachment to supportive individuals, commitment to work-related activities and concern about indeterminacy of stay. CONCLUSIONS The first four themes map closely onto Hirschis criminologically derived social bonding theory; however, indeterminacy of stay also arose as a common theme. In addition, the theory was too simple in its separation of elements; our data suggested the complex integration of themes. Our findings may be useful for informing evaluation of forensic mental health services.

2. The Impact of the Canadian Charter of Rights and Freedoms upon Canadian Mental Health Law: The Dawn of a New Era or Business as Usual?

Canadian mental health law has traditionally held many themes in common with the mental health law of other Commonwealth countries such as Britain, Australia, and New Zealand. Until recently, this b o d y of law bore only a passing resemblance to the system of mental health law that has emerged in the United States. T h e existence of an entrenched Bill of Rights in the United States has meant that many major issues relating to the rights of mental health patients have been dealt with as constitutional matters of great import. Consequently, the 1960s and 1970s witnessed the burgeoning of an exciting body of case law establishing a number of critical rights for a constituency that had hitherto been powerless and tragically neglected.’ While many of the rights established in the so-called landmark cases were subsequently limited in their scope or were just not affirmed by the appellate courts,’ the widespread use of constitutional challenges by mental health advocates wrought wholesale changes in both federal and state legislation and permanently altered the balance of power between mental health professionals and their patients.’ In countries such as Britain, Australia, New Zealand, and Canada, on the other hand, developments in mental health law have, of necessity, occurred largely as the result of legislative reform and judicial interpretation, rather than the courts’ application of constitutional imperatives. As a consequence, the structure of mental health law in these Commonwealth countries is very different from that which has emerged in the United States4

Privatization and protective services for the elderly: Some observations on the economics of the aging process

Various analysts of both social control and social welfare policies and practices have identified a major shift in the management of groups such as the mentally ill, the mentally retarded and the mentally infirm elderly in advanced capitalist countries (Emerson, 1981; Lerman, 1982; Scull, 1977, 1981; Warren 1981). Until relatively recently, reliance upon state-operated and financed institutions and services used to lie at the very heart of social control and welfare policies. However, since the early 196Os, the trend has been towards deinstitutionalization and the reprivatization of alternative care and treatment facilities (Lerman, 1982; Scull, 1977, 1981). This general development has been referred to as the “privatization and profitization of social control” (Spitzer & Scull, 1977), and, in the specific context of mental health systems, the ‘recommodification’ of the mental health patient (Scull, 1981). There is a growing interest in the way in which a private sector, social welfare and social control marketplace is being created and how, following a variety of financial initiatives on the part of the state, the incentive to engage in social welfare and social control entrepreneurship has been developed. The goal of this article is to identify and delineate another feature of this general trend. The focus of inquiry will be turned upon one specific group,of persons, who have been affected by the policies of deinstitutionalization and privatization: namely, the mentally infirm elderly. While a policy of reprivatization is unfolding in relation to care and treatment facilities, the reverse trend seems to be forming in relation to the provision of the guardianship and trusteeship (or “conservatorship”) services, which are an important adjunct to the policy of deinstitutionalization. Scull has contended that one notable consequence of deinstitutionalization has been “a much greater involvement of the private sector in spheres