Susan Velasquez, Andrea Bauchowitz, David Pyo, and Megan Pollock
Changing Trends in Forensic Populations
The California Department of State Hospitals (DSH) manages the psychiatric care of almost 7,000 patients admitted to any of its five hospitals. Over 90% of these patients have forensic commitments, meaning they have been charged with, or convicted of, a crime. Treating patients with mental illness and criminal behavior reflects a general trend within state psychiatric facilities.1,2 An increase in physical violence towards staff and patients has been attributed to this mandate to care for patients with both severe mental illness and criminal backgrounds.1,3,4 Addressing violence is a pressing need within state hospital systems, as a safe treatment environment is essential to the delivery of effective care.
Treating psychiatric symptoms alone has not been effective in reducing violence associated with severe mental illness.5 Furthermore, treating patients without considering their violent behaviors is apt to complicate their timely discharge into the community. In addition to symptoms of severe mental illness, criminogenic risk factors perpetuate criminal thinking and behavior.6 These risk factors include, but are not limited to, association with antisocial peers, antisocial attitudes, substance abuse, poor family relations, and difficulties with employment. Research demonstrates that addressing the criminogenic as well as mental health needs of justice-involved patients significantly improves outcomes in terms of criminal behaviors and psychiatric symptoms.5 Traditionally, criminogenic risks were addressed in correctional treatment settings and the generalizability to other settings is recently being explored in detail.7 A study of the DSH patient population revealed that criminogenic risk clearly exists in many state psychiatric hospital patients.8 These findings expose a necessary paradigm shift in treatment planning within state psychiatric facilities.
Historically, state psychiatric hospitals were tasked with providing humane psychosocial care for persons diagnosed with severe mental illness, a mindset and practice remaining predominant today. Traditionally, addressing violence risk was not routinely implemented in treatment planning. Given the current and growing forensic patient population, outdated practices to address violent behaviors for the wellbeing of patients and staff must be amended.
A key struggle in these efforts is lack of continuum of care in the state psychiatric system.