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Focusing on violence from assessment, through underlying neurobiology, to treatment and other recommendations for practice, this book will be of interest to forensic psychiatrists, general adult psychiatrists, psychiatric residents, psychologists, psychiatric social workers and rehabilitation therapists.
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A catalog record for this publication is available from the British Library
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Chapter 7 Prevalence of physical violence in a forensic psychiatric hospital system during 2011–2013: patient assaults, staff assaults, and repeatedly violent patients Charles Broderick, Allen Azizian, Rebecca Kornbluh and Katherine D. Warburton
Evidence has accumulated that shows that patients with a mental illness in a hospital setting have higher rates of violence in comparison to people with mental illness living in the community [1–3]. Investigations into patient violence in psychiatric hospitals have typically examined variables such as sex, age, ethnicity, and diagnosis. These investigations have typically found higher prevalence of violence among inpatients who are female [4–7], younger [8–10], and of ethnic minority status [11,12]. However, these findings have not been universal across all studies, as noted in the review by Bowers et al. [13] Their review found that of the 26 studies of psychiatric inpatients that specifically investigated the roles of age and aggression, 13 reported no significant relationship and 13 reported that aggressive patients were significantly younger.
Likewise, with regard to diagnosis, their review again found discrepancies; across 19 studies, nine reported no significant differences in diagnosis between the aggressor and non-aggressor groups, and only one study directly addressed the issue of personality disorder among aggressive and non-aggressive groups [9]. The presence and number of contradictory findings raises questions regarding methodological issues, such as the setting of the study (and subsequent generalizability to other settings), along with issues of statistical power related to the sample size of the study, which may have limited the ability of the investigators to find significance when the impact of a variable was small.
In the decade or more since many of these studies were conducted, there have been significant changes in the state psychiatric hospital system; these include a simultaneous reduction in hospital beds with an increase in the demand for beds by the criminal court system (i.e., forensic patients) [6,14]. Nationwide, as of 2012, expenditures by state psychiatric hospitals for forensic patients had grown to 36% of the total budget, with an additional 4.7% of expenditures dedicated for persons committed under sex offender commitment statutes. While several states now have a forensic population over 50% of the total inpatient population, perhaps nowhere has this impact been felt more than in the California State Hospital system, where shifts over the past decade have resulted in criminal-related, forensic inpatients comprising over 92% of the hospitalized patients.
The increasing number of forensic patients admitted to state hospitals creates a number of concerns, chief among these the concern of risk for violence. Because commitment to a state hospital in California requires an assessment of whether the patient can be safely treated in the community as an alternative to hospitalization, a patient can only be committed if the court finds that person too dangerous to treat in the community. Since the only distinguishing feature between those treated as outpatients or committed to a state hospital is that of dangerousness, in essence patients are hospitalized by courts primarily due to the issue of dangerousness and secondarily due to mental illness. Also considering the requirements of the commitment criteria in California, as the patients committed by the courts are presumed to be dangerous, they cannot be discharged solely by the treatment team’s recommendation; the court must evaluate any treatment team discharge recommendation and can choose to follow or not follow any such recommendation based on the relevant legal issue(s) brought up at the hearing or trial. This potentially can increase the length of stay of these patients, beyond what would reasonably be expected for simple treatment of their mental illness needs. In view of previous research findings that patients who were more violent in the community are more likely to be violent while hospitalized, and those patients diagnosed with schizophrenia with recent violence or law enforcement contact have increased violence risk, there are concerns that violence by forensic patients in state hospitals may be both quantitatively and qualitatively different from violence in other psychiatric facilities that do not treat forensic patients [2,4]. Owing to these issues, and a need to develop effective methodologies to decrease violence, we decided to enumerate both the prevalence of violent assaults, as well as investigate details of the assaults that may warrant further evaluation.
Previous studies that examined prevalence of inpatient violence in psychiatric facilities typically followed one of several common methodologies. Studies conducted before 2000 routinely used questionnaire-type surveys administered to staff, asking about previous violence – a technique methodologically subject to under-reporting [15,16]. Another methodology was to conduct a one-year “look-back” at the violence committed by all patients resident in the hospital, which could systematically overlook patients resident during any part of the year but discharged prior to the study initiation [6,16]. In one such study, it is estimated that potentially up to 25% of all patients resident at any point during the year were not included [6]. More recent studies have commonly followed inpatients for a prescribed length of time and had nursing staff fill out standardized aggression surveys immediately after aggressive/violent events [7]. An issue for some of these studies is that nursing time resources are needed, if aggression ratings forms are not a routine part of nursing duties, resulting in a more limited duration for the study period.
The present study endeavored to overcome these limitations encountered by past investigations by using a computerized violent incident reporting system that is routinely used by staff to record the occurrence of every violent incident. Use of other available patient databases enabled us to cross-reference patient information with the violent incident data, and determine who was and was not violent. Additionally, the use of these databases allowed us to track and record every patient and every violent incident for three years, allowing a sufficient time period to ensure a representative portrayal of violent incidents over time. To the best of our knowledge, this is the single largest study on violent assaults in a state psychiatric hospital system.
Mario Amore
Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genoa, Italy
Allen Azizian
Coalinga State Hospital, Coalinga, and Department of Criminology, California State University, Fresno, California, USA
Shannon M. Bader
California Department of State Hospitals, and Patton State Hospital, California, USA
Michael W. Barsom
Department of State Hospitals (DSH) – Metropolitan, Norwalk, California, USA
Nicole R. Bartholomew
Psychology Services, Federal Bureau of Prisons, Big Spring, Texas, USA
Amlan Basu
Broadmoor High Secure Hospital, West London Mental Health NHS Trust, and Institute of Psychiatry, King’s College, London, UK
Charles Broderick
California Department of State Hospitals, Sacramento, California, USA
Rosalie S. Brooman-White
Medical Sciences Division, John Radcliffe Hospital, University of Oxford, Oxford, UK
Darcy Brown
The School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
Leslie Citrome
Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, New York, USA
Emil F. Coccaro
Clinical Neuroscience & Psychopharmacology Research Unit, Department of Psychiatry (MC#3077), Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
Michael A. Cummings
Department of State Hospitals–Patton, Department of Psychiatry, Patton, California, USA; Department of Psychiatry and Human Behavior, University of California, Irvine, Orange, California, USA
Stephen E. Cummings
Department of Psychiatry, San Mateo Medical Center, San Mateo, California, USA
Pál Czobor
Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
Laura J. Dardashti
California Department of State Hospitals, and Metropolitan State Hospital, California, USA
Mrigendra Das
Broadmoor Hospital, West London Mental Health Trust, Berkshire, amd School of Psychiatry, Oxford Deanery, Oxford, UK
Darci Delgado
California Department of State Hospitals, and Vacaville Psychiatric Program, California, USA
Sean E. Evans
Psychology Department, Department of State Hospitals, Patton, California, and Psychology Department, La Sierra University, Riverside, California, USA
Thomas Fahy
Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Jennifer R. Fanning
Clinical Neuroscience & Psychopharmacology Research Unit, Department of Psychiatry (MC#3077), Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
Alan R. Felthous
Division of Forensic Psychiatry, Department of Neurology & Psychiatry, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
E. Fuller Torrey
Department of Psychiatry, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA; Stanley Medical Research Institute, Chevy Chase, Maryland, USA
David Goldman
Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
Jordan H. Grafman
Rehabilitation Institute of Chicago, Chicago, Illinois, USA
Nitin Gupta
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
Margaret Guyer
Central Office Research Review Committee, Massachusetts Department of Mental Health, Massachusetts Mental Health Center Division of Public Psychiatry, and Harvard Medical School/Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
Colin A. Hodgkinson
Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
Brian J. Holoyda
Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA
Matthew J. Hoptman
Schizophrenia Research Division, Nathan Kline Institute for Psychiatric Research, Orangeburg, Department of Psychiatry, New York, USA, and University School of Medicine, and Department of Psychology, City University of New York, New York, USA
Deborah Horowitz
Office of Training and Development, Massachusetts Department of Mental Health, Westborough, Massachusetts, USA
James E. Hotham
Medical Sciences Division, John Radcliffe Hospital, University of Oxford, Oxford, UK
Sharon A. Humphreys
Broadmoor High Secure Hospital, West London Mental Health NHS Trust, London, UK
James L. Knoll IV
Division of Forensic Psychiatry, Department of Psychiatry, SUNY Upstate Medical University, Syracuse, New York, USA
Rebecca Kornbluh
California Department of State Hospitals, Sacramento, California, USA
Frank Krueger
Molecular Neuroscience Department, George Mason University, Fairfax, and Department of Psychology, George Mason University, Fairfax, Virginia, USA
Fintan Larkin
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Royce Lee
Clinical Neuroscience & Psychopharmacology Research Unit, Department of Psychiatry (MC#3077), Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
K. Luan Phan
Department of Psychiatry, University of Illinois College of Medicine, Mental Health Service Line, Jesse Brown Veterans Administration Medical Center, and Departments of Psychology, and Anatomy and Cell Biology, University of Illinois at Chicago, Chicago, Illinois, USA
Barbara E. McDermott
Department of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine, Sacramento, California, USA
Jonathan M. Meyer
Department of Psychiatry, University of California–San Diego, San Diego, California Department of State Hospitals, and Patton State Hospital, California, USA
John Monahan
School of Law, University of Virginia, Charlottesville, Virginia, USA
Robert D. Morgan
Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA
Debbi A. Morrissette
Neuroscience Education Institute, Carlsbad, California, Department of Biology, California State University, San Marcos, California, and Department of Biology, Palomar College, San Marcos, California, USA
Jennifer A. O’Day
California Department of State Hospitals, and Metropolitan State Hospital, California, USA
Mark E. Olver
Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Matteo Pardini
Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, and Magnetic Resonance Research Centre on Nervous System Diseases, University of Genoa, Genoa, Italy
Debra A. Pinals
Law and Psychiatry Program, Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts, USA
George J. Proctor
California Department of State Hospitals, and Patton State Hospital, California, USA
Cameron D. Quanbeck
Department of Psychiatry, San Mateo Health System, San Mateo, California, USA
Vanessa Raymont
Department of Medicine, Imperial College London, London, UK
Phillip J. Resnick
Division of Forensic Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
Jose L. Romero-Ureclay
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Benjamin Rose
California Department of State Hospitals, and Napa State Hospital, California, USA
Daniel R. Rosell
Department of Psychiatry, Icahn Medical School, Mount Sinai, New York, and Special Evaluation Program of Mood and Personality Disorders, Icahn Medical School, Mount Sinai, New York, USA
Callum C. Ross
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Kathy Sanders
Clinical and Professional Services, Massachusetts Department of Mental Health, and Harvard Medical School/Massachusetts General Hospital, Boston, Massachusetts, USA
Robert J. Schaufenbil
California Department of State Hospitals, Sacramento, California, USA
Marie Schur
California Department of State Hospitals, and Atascadero State Hospital, California, USA
Eric H. Schwartz
California Department of State Hospitals, and Vacaville Psychiatric Program, California, USA
Charles L. Scott
Division of Psychiatry and the Law, Department of Psychiatry and Behavioral Sciences, University of California–Davis School of Medicine, 5 Sacramento, California, USA
Samrat Sengupta
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Larry J. Siever
Department of Psychiatry, and Special Evaluation Program of Mood and Personality Disorders, Icahn Medical School, Mount Sinai, New York, and Department of Psychiatry and the VISN3 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, New York, USA
Patrick J. D. Simpson
Medical Sciences Division, John Radcliffe Hospital, University of Oxford, Oxford, UK
Jennifer L. Skeem
School of Social Welfare & Goldman School of Public Policy, University of California–Berkeley, Berkeley, California, USA
Stephen M. Stahl
California Department of State Hospitals, Sacramento, University of California San Diego, California, USA, and University of Cambridge, Cambridge, UK
Maren Strenziok
Department of Psychology, George Mason University, Fairfax, Virginia, USA
Katalin A. Szabo
Department of Psychiatry, San Mateo Health System, San Mateo, and Behavioral Health and Recovery Services, San Mateo, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
John Tully
Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Richard A. Van Dorn
Research Triangle Institute International, Research Triangle Park, Durham, North Carolina, USA
Susan Velasquez
California Department of State Hospitals, and Patton State Hospital, California, USA
Morris Vinestock
Broadmoor Hospital, West London Mental Health Trust, Berkshire, UK
Jan Volavka
Department of Psychiatry, New York University School of Medicine, New York, USA
Raziya S. Wang
Behavioral Health and Recovery Services, San Mateo, California, USA
Katherine D. Warburton
California Department of State Hospitals, Sacramento, and Division of Psychiatry and the Law, University of California, Davis, California, USA
Eric M. Wassermann
Behavioral Neurology Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
Christopher L. White
Department of Psychiatry, San Mateo Health System, San Mateo, and Behavioral Health and Recovery Services, San Mateo, California, USA
Stephen C. P. Wong
Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, School of Medicine, University of Nottingham, Nottingham, UK, and Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Australia