Sectioned offenders presenting with enduring mental illness: a study exploring behaviors indicative of bullying

Logit and logistic regression analyses were employed to explore the nature, extent and predictors of behaviors indicative of "being bullied" and of "bullying others" in a sample of 125 adult male offender-patients sectioned for enduring mental illness and detained within a high-secure psychiatric hospital. The study addresses the lack of research into this specialized population to date, with a subsidiary aim of comparing the results directly with a previous study conducted with a population of adult male personality-disordered offender-patients (n = 53). Participants were required to complete a self-report behavioral checklist (Direct and Indirect Patient behavior Checklist-Hospital version Revised). The prediction that indirect (subtle) aggression would be reported more frequently than direct aggression was supported in relation to perpetration estimates, with evidence such aggression was also more prevalent among personality-disordered than mentally ill offender-patients. As predicted verbal aggression was the most commonly reported direct behavior. Although it was predicted that those perpetrating aggression would present with increased experience with secure settings this was only supported with regard to bully-victims. Contrary to the prediction made, those victimized did not present with less experience of secure settings. Consistent with the hypothesis, bully/victims were predicted by increased negative behavior toward staff and hospital rules. The results are discussed in relation to the environment in which the aggression is taking place with the implications for practice and future research outlined.     

The predictive validity and practical utility of structured schemes used to assess risk for aggression in psychiatric inpatient settings

There has been increased interest in structured schemes for the assessment of risk for aggression within inpatient psychiatric settings. The most commonly utilized schemes are those previously developed to assess risk for prisoners being considered for release on parole and for forensic psychiatric patients being considered for discharge from the hospital to the community. Few structured schemes have been developed with the explicit aim of assessing risk for aggression in the inpatient setting. Recent research utilising a variety of risk assessment schemes has revealed reasonable predictive validity. This narrative review summarizes and appraises this expanding literature within the context of risk assessment decision making tasks typically undertaken by psychiatric unit staff. It is concluded that a number of structured risk assessments schemes do have acceptable predictive validity. Unfortunately, many of the schemes tested are compromised by a lack of practical utility, and only a few are capable of contributing to the entire range of risk assessment decision making tasks required. Options for the application of structured risk assessment schemes are raised.     

The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients

Considerable research has attempted to delineate the demographic and clinical characteristics of high-risk psychiatric patients and identify salient modifiable aspects of aggression prone environments. Recently, there has also been increased interest in the development and testing of structured schemes for the assessment of risk for aggression within inpatient psychiatric settings. Although some of these methods show acceptable predictive validity, their ability to inform day-to-day treatment and management decisions is limited. The current research was designed to identify existing and novel risk factors that would assist staff to identify and manage the risk for aggression in psychiatric inpatient populations. Results showed that assessments supported by structured risk measures were more accurate than unaided clinical judgements based only on nurses' clinical experience and knowledge of the patient alone. Seven test items emerged that were maximally effective at identifying acute psychiatric patients at risk for engaging in inpatient violence within 24 hours; these items have been combined in the development of the Dynamic Appraisal of Situational Aggression. Empirical analyses and clinical experience support the efficacy of the instrument in assisting clinical staff in the identification and management of inpatient aggression.     

Therapeutic Assessment With Child Inpatients

Growing evidence supports Therapeutic Assessment (TA), a collaborative and therapeutic approach to psychological assessment, as an effective method for enhancing motivation for and engagement with psychotherapy across a variety of clinical populations and treatment settings. However, to date there are no known studies assessing the use of TA in child psychiatric inpatient settings. This article briefly reviews the structure of child and family TA, enumerates the challenges and risks associated with short-term inpatient stays, and proposes a path for integrating TA into these units as a way to enhance the quality of care and reduce the risk of rapid rehospitalization. The authors provide three case examples from a child psychiatric inpatient unit, each using a modified version of TA and each integrating assessments into brief family interventions. The authors conclude with suggestions for best practice for child psychiatric inpatient TAs.     

A taxometric analysis of MMPI-2 Infrequency scales [F and F(p)] in clinical settings

The typology of overreporting, which is a deliberate attempt to amplify symptoms, simulate psychopathology, or understate coping capacities, was examined using taxometric procedures with Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Infrequency scales [F and F(p)] in psychiatric inpatient and Veterans Affairs (VA) medical center treatment settings. Overreporting was identified as a taxon using several taxometric procedures, and the multiple estimates of the taxon base rate were consistent within each sample. Mean base-rate estimates were .27 and .19 for the psychiatric inpatient and VA medical center settings, respectively. Overall classification rates ranged from .80 to .97 across the 2 settings, which supports the use of F and F(p) in the identification of overreporting on the MMPI-2 in psychiatric inpatient and VA medical center settings.     

Staff survey results and characteristics that predict assault and injury to personnel working in mental health facilities

The purpose of this study was to complete a mental health staff opinion survey to identify patient and staff characteristics associated with staff assault and injury in psychiatric treatment settings and to develop a model of prediction for staff assault and injury utilizing these survey variables. The data consisted of opinion surveys sent to staff of 15 child, adolescent, and adult psychiatry inpatient units in the United States. Multivariate logistic regression was used to determine the level of assault and staff‐reported injury prediction that could be obtained from the staff‐completed opinion survey. Responses indicated a high prevalence of reported aggression, with 62.3% of staff endorsing verbal and physical aggression, property destruction, and self‐injurious behavior as being prevalent at their site, whereas only 4.1% rated none of these as prevalent. Staff working with children and adolescents in settings with high rates of psychiatric diagnoses reported increased frequency of assault and injury compared with those working with adults. Younger, less experienced staff reported higher rates of assault and injury. Staff working with female patients reported similar rates of assault and injury to those working with males. A logistic regression analysis using staff‐reported survey results of both staff and patient characteristics predicted assault correctly 73.7% of the time and injury 66.1% of the time. Resources for violence prevention and staff training programs in violence prevention are needed in child and adolescent psychiatry wards. Results are consistent with theories emphasizing the importance of negative emotions and affects, impulsivity, and frustration in goal‐directed activities in human aggression. Aggr. Behav. 29:31–40, 2003. © 2003 Wiley‐Liss, Inc.     

Behavioral assessment of imipramine effects in a depressed child

A 7-year-old boy was diagnosed as suffering from childhood depression by two independent psychiatric evaluators who employed the Research Diagnostic Criteria. Multifaceted behavioral observations were performed on target behaviors which were identified as major problematic areas of functioning related to the child's depression. The behavioral assessment strategy included daily monitoring of on-task and disruptive behavior in the classroom, enuresis, and overall hygienic, social, and compliance behaviors as a means of identifying the specific drug-induced effects of an anti-depressant, imipramine. The assimilation and application of behavioral assessment strategies within child psychiatry have been slow and tenuous. Reasons for the resistance include theoretical differences and misconceptions among psychiatric personnel, who, although open to objective evaluations, may wish to employ nonbehavioral treatments such as pharmacologic agents. The primary purpose of this study was to demonstrate the viability of behavioral assessment as an integral adjunct to pharmacologic treatment in a psychiatric setting as a means of gauging the efficacy of a psychiatric intervention. Issues regarding the role of behavioral assessment in psychiatry and, in particular, pharmacologic interventions with depressed children are examined and discussed.This study was supported, in part, by NIMH Grant MH 30915.     

Detecting back irrelevant responding on the Personality Assessment Inventory in a psychiatric inpatient setting

The present studies focus on strategies for detecting back irrelevant responding (BIR) on the Personality Assessment Inventory (PAI; L. C. Morey, 1991). Moderate BIR levels can greatly affect the clinical scales of the PAI. Further, the PAI's Inconsistency and Infrequency validity scales are less than optimal for detecting BIR. L. C. Morey and C. J. Hopwood (2004) developed an alternative strategy for detecting BIR that involves comparison of 2 scales from the PAI short-form with the same 2 scales from the PAI full-instrument. The present study examines how different BIR levels affect the clinical, treatment, and interpersonal scales of the PAI in 2 psychiatric inpatient samples. The effectiveness of various strategies for detecting BIR in an inpatient setting is also discussed. Consistent with previous research, moderate rates of BIR impacted several PAI scales in a meaningful way. The Inconsistency and Infrequency validity scales of the PAI were relatively ineffective for detecting low-to-moderate BIR levels. Conversely, the short-form full-instrument comparison strategy was much more sensitive to BIR. Finally, a new BIR detection indicator is presented that improves sensitivity rates for detecting all BIR levels in an acute setting. The implications of these results for detecting BIR in inpatient settings are discussed.     

Parent and child MMPI responses: Characteristics among families with adolescents in inpatient and outpatient settings

The relationship of parent personality to child psychopathology has been investigated in numerous MMPI studies over the past three decades. Very few of these studies, however, have directly analyzed MMPI response patterns of both parents and offspring. The current study included the MMPI responses of 199 families with adolescents entering inpatient and outpatient psychiatric setting (N = 542). Inpatient parents and adolescents had significantly higher mean scores across a variety of MMPI scales than did their outpatient counterparts. The linear combination of adolescent and maternal MMPI scale data, in a stepwise discriminative function analysis, resulted in accurate classification of 75% of all children in inpatient treatment and 74% of all children assigned to outpatient treatment. Findings were discussed in terms of salient MMPI differences between inpatient and outpatient families and shared psychopathological characteristics among family members with offspring in psychiatric treatment settings.     

Do hospital treatments represent a 'teachable moment' for quitting smoking? A study from a stage-theoretical perspective

Hospital treatments are assumed to be a 'teachable moment'. This phenomenon, however, is only poorly conceptualised and untested. A stage-theoretical perspective implies that a cueing event such as hospital treatments is a teachable moment if a stage progression, change of cognitions, or both occur. This concept is examined in a cross-sectional study by comparing smokers in two treatment settings, an emergency department (ED) and inpatient treatment after elective surgery, with smokers in a control setting. Setting differences were hypothesised in stage distribution, and levels of and stage differences in social-cognitive factors under control for possible confounders. Stage, social-cognitive factors and possible confounders were assessed in 185 ED smokers, 193 inpatient smokers and 290 control smokers. Compared to control smokers, ED and inpatient smokers were in higher stages; they perceived fewer risks and cons; inpatient smokers reported more concrete plans. Stage differences in self-efficacy among ED and inpatient smokers differed from those among control smokers, but the former corresponded more strongly to the theoretical stage assumptions. The results suggest that hospital treatments lead to a stage progression and change of corresponding cognitions, and thus represent a 'teachable moment'. Stage-matched interventions should be provided but consider differences in cognitions to be effective.     

Do hospital treatments represent a ‘teachable moment’ for quitting smoking? A study from a stage-theoretical perspective

Hospital treatments are assumed to be a ‘teachable moment’. This phenomenon, however, is only poorly conceptualised and untested. A stage-theoretical perspective implies that a cueing event such as hospital treatments is a teachable moment if a stage progression, change of cognitions, or both occur. This concept is examined in a cross-sectional study by comparing smokers in two treatment settings, an emergency department (ED) and inpatient treatment after elective surgery, with smokers in a control setting. Setting differences were hypothesised in stage distribution, and levels of and stage differences in social-cognitive factors under control for possible confounders. Stage, social-cognitive factors and possible confounders were assessed in 185 ED smokers, 193 inpatient smokers and 290 control smokers. Compared to control smokers, ED and inpatient smokers were in higher stages; they perceived fewer risks and cons; inpatient smokers reported more concrete plans. Stage differences in self-efficacy among ED and inpatient smokers differed from those among control smokers, but the former corresponded more strongly to the theoretical stage assumptions. The results suggest that hospital treatments lead to a stage progression and change of corresponding cognitions, and thus represent a ‘teachable moment’. Stage-matched interventions should be provided but consider differences in cognitions to be effective.     

Social skill performance among normal and psychiatric inpatient children as a function of assessment conditions

The present investigation examined the effects of varying the standard assessment conditions on performance of social skills among normal and psychiatric inpatient children. Sixty children (30 normals, 30 patients), ages 6–12, completed behavioral and self-report measures of social skills on two separate occasions. During the second assessment, half of the children received feedback and incentives for performance; the other half did not. The testing conditions consistently altered social skill performance. Children who received the incentives during assessment showed significantly higher levels of social skills, as reflected in concrete behavior (e.g. eye contact, facial expressions), and molar responses (e.g. giving compliments, responding to provocation). The results suggest that social skills performance varies considerably as a function of the assessment conditions. Training programs should not assume that persons do not have the responses in their repertoires merely because of low pretest performance unless more extensive efforts are made to evoke appropriate responses.     

A behavioral observation method for differentiating hyperactive and aggressive boys

This study employed a playroom observation technique to examine the behavioral differences between hyperactive and aggressive boys. Subjects were clinic-referred boys assigned to Hyperactive, Aggressive, or Hyperactive plus Aggressive goups on the basis of behavior checklists and ratings of psychiatric chart information. While significant discrimination was obtained in all three settings (free play, restricted play, and restricted academic), behavioral differences among the subject groups were most pronounced during the restricted academic period. Discriminant function analysis for the restricted academic period resulted in accurate classification of 86% of the subjects as hyperactive, aggressive, or hyperactive plus aggressive. The present findings suggest that children with externalizing disorders can be distinguished in light of their observed clinic behavior in the restricted academic setting.This was conducted as part of the author's dissertation. The author wishes to express thanks to Jan Loney, Richard Milich, and Richard Roberts for their assistance in completion of this study and preparation of this article.     

Penn State Worry Questionnaire: Findings Form Normative and Clinical Samples in Denmark

Anxiety disorders are among the most prevalent psychiatric disturbances in childhood. None-the-less, they often go unrecognized and untreated, which puts the child at risk for developing additional difficulties, such as academic difficulties, depression, and substance abuse. Further knowledge and valid assessment tools are essential to identify at-risk children. The present study investigates (i) the factor structure of the Penn State Worry Questionnaire for Children (PSWQ-C) using a large Danish community sample (N?=?933), and (ii) its treatment sensitivity in clinically anxious children (N?=?30) treated with cognitive behavioral therapy. Results from the community sample replicated previous findings supporting the strong psychometric properties of the PSWQ-C, and yielded Danish norms and clinical cut-offs for the measure. Clinically anxious children with a generalized anxiety disorder (GAD; N?=?10) diagnosis reported significantly higher levels of worry than anxious children without GAD (N?=?20). At post treatment, worry levels in children with GAD but not in anxious children without GAD were normalized. Findings regarding worry in the community sample are discussed in light of normal child development. Implications for the use of the PSWQ-C as a useful and important tool in clinical assessment by psychiatrists and psychologists in their treatment of anxious children and adolescents are also discussed.     

Setting up inpatient behavioral treatment programs: The staff needs assessment

Despite the success that behavior therapy has demonstrated in treating severely mentally ill adults, widespread impact of behavioral treatments on this population has been limited because the staff of many inpatient settings do not routinely utilize these strategies. Surveying staff regarding their perception of programatic and organizational needs is proposed as a valuable first step for selecting behavioral strategies to be introduced in these settings. Goldfried and D'Zurilla (1969) developed a behavioral assessment survey that is especially useful for identifying staff needs vis-à-vis behavioral rehabilitation. Using these strategies, survey questions addressed five problem areas: Administrative, Staff, Patient, Resource, and Programatic. Results using this survey with 40 clinicians on the extended care unit of a state hospital showed that staff members had greatest concern with the Patient Problem Area (i.e., aversive patient behaviors that are not sufficiently addressed by treatment plans). Further analyses showed staff members were interested in addressing Patient concerns using incentive procedures. The needs assessment in this study not only provided useful information that might be generalized to other treatment settings, but also showcased a reliable survey approach that program developers might implement prior to designing training curricula for behaviorally naive staff in inpatient settings.     

Development and preliminary validation of the Concise Neuropsychological Screening Inventory (CNSI): A clinical tool for use in psychiatric settings

We describe the development and preliminary validation of the Concise Neuropsychological Screening Inventory (CNSI), designed to afford clinical psychologists working in psychiatric settings a simple, rapid, and objective assessment of 10 vital left- and right-hemisphere brain functions: (1) Receptive and Expressive Language, (2) Orientation, (3) Attention/Concentration/Immediate Memory, (4) Recent Auditory and Visual Memory, (5) Remote Memory, (6) Motor/Sensory/Tactile Functioning, (7) Visual/Spatial/Motor Integration, (8) Academic Functioning, (9) Intellectual Processes, and (10) Judgment and Reasoning. Preliminary findings suggest that the CNSI can discriminate patients diagnosed with organic mental syndrome from patients with various psychiatric disorders, including chronic schizophrenia (i.e., specificity in screening). Moreover, with regard to predicting neuropsychological differences among various diagnostic groups, the CNSI is superior to some of the most commonly employed tests by psychologists in psychiatric settings (e.g., WAIS-R Digit Span, Digit Symbol, and Bender-Gestalt).     

A Longitudinal Analysis of Psychiatric Severity upon Outcomes Among Substance Abusers Residing in Self-Help Settings

A longitudinal analysis of psychiatric severity was conducted with a national sample of recovering substance abusers living in Oxford Houses, which are self-run, self-help settings. Outcomes related to residents' psychiatric severity were examined at three follow-up intervals over one year. Over time, Oxford House residents with high versus low baseline psychiatric severity reported significantly more days using psychiatric medication, decreased outpatient psychiatric treatment, yet no significant differences for number of days abstinent and time living in an Oxford House. These findings suggest that a high level of psychiatric severity is not an impediment to residing in self-run, self-help settings such as Oxford House among persons with psychiatric comorbid substance use disorders.     

Relationships between patients' perceived improvement and their evaluations of treatment components in a behaviorally-oriented psychiatric inpatient unit

Patients on a behaviorally-oriented inpatient psychiatric unit were asked to rate their perceptions of treatment outcome and the value of 16 program components in producing that outcome. Significant correlations were found between perceived outcome and positive evaluations of the overall behavioral treatment plan, individual meetings with nursing staff, individual meetings with team psychologists, assertion group training, and daily group therapy. Patients perceived individual meetings with the nursing staff to be the single most valuable program component among those related to favorable outcome. Implications for the increased utilization of nursing staff during a time of dwindling resources for mental health are discussed.     

Short-Term Psychiatric Treatment

With the increasing prevalence of short-term psychiatric hospitalization, brought about in part by reduced inpatient insurance coverage, decisions must be made concerning both the nature of treatment and who will provide services. The impracticality of traditional rehabilitative services in these settings has serious implications for the future role of occupational therapists in psychiatric health care. It is proposed that necessary modifications to treatment approaches must and can be made without abandoning fundamental theories of practice. Recommendations are made to upgrade the current level of practice via improved communication of information concerning short-term methodologies, to develop long-range plans to strengthen professionalism, and to make greater use of community-based alternatives for the delivery of services no longer practical in short-term treatment settings.