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.     

Child,mother, and father evaluations of depression in psychiatric inpatient children

The agreement among children and their parents in evaluating the children's depression was examined in 48 families. Newly admitted inpatient children (ages 6–13) and their mothers and fathers independently completed selfreport and interview measures to assess severity and duration of the children's depression. The results indicated that different measures of depression completed by the same rater (child, mother, or father) were highly intercorrelated. Yet there was little or no relationship between childmother and child-father ratings of the children's depression for the same or related measures of depression. Children independently diagnosed (DSM III) as depressed rated themselves and were rated by their parents as more depressed than nondepressed children. Even so, children consistently rated themselves as less depressed across the measures than did their parents. Parent ratings of the children's depression and the correspondence of child-parent ratings varied as a function of several child and family variables, including child IQ, gender, race, and family welfare status.This investigation was supported in part by a Research Scientist Development Award (1 K02 MH00353) to the first author from the National Institute of Mental Health and by a Clinical Research Center Grant for the Study of Affective Disorders (5 P50 MH30915-05) from the National Institute of Mental Health. The authors are grateful to the clinical research team of the Child Psychiatric Treatment Service.     

Psychological and theological dynamics in an inpatient psychiatric chaplaincy group

This article describes the structure and goals of chaplaincy groups in an inpatient psychiatric setting. The article also explores their therapeutic benefits for patients and offers a theological framework for thinking about the conversations that unfolded in these groups. The article focuses in particular on the value of discussion and reflection in a group setting, the significance of receiving and answering questions, and the experience of participating in a simple ritual to name hopes.     

Violence,research, and non-identity in the psychiatric clinic

Violence in psychiatric clinics has been a consistent problem since the birth of modern psychiatry. In this paper, I examine current efforts to understand and reduce both violence and coercive responses to violence in psychiatry, arguing that these efforts are destined to fall short. By and large, scholarship on psychiatric violence reduction has focused on identifying discrete factors that are statistically associated with violence, such as patient demographics and clinical qualities, in an effort to quantify risk and predict violent acts before they happen. Using the work of Horkheimer and Adorno, I characterize the theoretical orientation of such efforts as identity thinking. I then argue that these approaches lead to epistemic imperceptiveness and a subtle form of conceptual restraint on patients. I suggest a reorientation in psychiatric research, away from identity thinking and toward a more productive and just approach to the problem of violence in psychiatric clinics.     

The psychiatric inpatient treatment of children and youth in general hospitals

National attention has recently focused on the mental health needs and services of children and youth. The lack of outpatient services and their coordination has been noted, as well as the consequent press towards inpatient care. We describe the inpatient treatment of children and adolescents (ages 0-18) in short-term, non-Federal general hospitals in 1980. Nationally, 128,300 children were treated for mental disorders in general hospitals at an estimated cost of over $1.5 billion. Compared to adults, children were more likely to be treated in scatter beds (vs. specialty units); have a diagnosis of mental disorder (vs. alcohol/drug disorder); stay much longer; and pay with commercial insurance. Previous work focusing on psychiatric units of general hospitals identified less than 40% of the total episodes, a figure very similar to that for adults. The majority of psychiatric inpatient episodes for children and youth in the United States takes place in short-term general hospitals. Community psychologists need to be aware of national trends in inpatient care and be involved in the development and promulgation of alternative models of care.     

The problems of R in clinical settings and in research: suggestions for the future

It has been suggested that we control for R in the interpretation of individual Rorschach records. A related, but distinctly different issue concerns controlling for or equating R in research. I suggest we should not control for R in interpreting individual records. There are also some research paradigms in which controlling for R does not seem advisable. In other types of research, I argued that some method of controlling for or equating R appears appropriate. The distributions of many Rorschach factors are markedly non-normal, and in some cases the shapes of the distribution for a particular factor may be different among different populations. In these instances, when attempting to control statistically for R, improper model specification may lead to erroneous findings. Finally, I argue for a theory-based, empirical approach to all future Rorschach research.     

The absent body in psychiatric diagnosis,treatment, and research

Synthese - Discussions of psychiatric nosology focus on a few popular examples of disorders, and on the validity of diagnostic criteria. Looking at Anorexia Nervosa, an example rarely mentioned in...     

Child and parent evaluations of depression and aggression in psychiatric inpatient children

This investigation examined the agreement between children and their parents on measures of depression and aggression. A total of 120 inpatient children (ages 7–13) and their mothers and fathers independently completed self-report and interview measures that focused on the children's dysfunction. Children and their parents differed in their ratings of each symptom area, with children providing significantly less severe ratings than their parents. Children who met DSM III criteria for major depression or conduct disorder were significantly higher in their ratings of depression and aggression than children without these diagnoses, as reflected in both child and parent ratings. Child and parent ratings correlated in the low to moderate range on measures of children's symptoms, whereas mother and father ratings correlated in the moderate to high range. The correspondence between children and parents did not vary as a function of symptom area (depression and aggression) or assessment format (self-report and interviews). The results suggest that children are able to rate the severity of their dysfunction, although they tend to provide lowerbound estimates than do their parents.     

Prevalence of traumatic brain injury in an inpatient psychiatric population

This study investigated the prevalence of traumatic brain injury (TBI) in an inpatient psychiatric population. We hypothesized increased prevalence of TBI relative to the general population due to a variety of risk factors observed in psychiatric patients. One hundred (mean age = 34) psychiatric inpatients completed the revised Head Injury Questionnaire. Chart review of 17 subjects reporting injuries established whether injuries were documented in medical records. Sixty-eight percent of this psychiatric population reported one or more injuries in which they were unconscious or dazed. This number is higher than the prevalence in the general population. Injuries were generally of mild to moderate severity; multiple injuries were common. Chart review of 17 subjects reporting TBI indicated that histories of TBI had not been noted in the medical record. Finally, 63% of TBI subjects reported that their injury predated the onset of their psychiatric symptoms. These results suggest a possible role of TBI in psychiatric symptomatology and have implications for psychiatric treatment in this population.     

Mental health policy and the psychiatric inpatient care of children

Recent changes in psychiatric inpatient treatment of children and youth are placed in the more general context of, first, the inpatient treatment of adults and, second, multiple public policies affecting children. For adults, the experimental evidence shows that the majority of psychiatric inpatients could be treated in programs outside the hospital more effectively and less expensively. For children, no such data base exists. Contrary to policy intent, between 1980 and 1985 inpatient care of children and youth increased substantially in residential treatment centers, private psychiatric hospitals, and scatter hospitals (general hospitals without any formal specialized units). Thus, psychiatric inpatient care of children and youth is increasing, dramatically so at largely uninvestigated and more expensive sites. The failure of children's mental health policy is placed in the context of the multiple policy failures for children regarding health, welfare, education, and housing. Recent positive efforts by federal agencies are described, but the need is great for data on efficacy and cost-effectiveness of inpatient treatment of children.     

Behavioral knowledge among direct care staff in an inpatient psychiatric setting

Despite demonstrations of the utility and cost effectiveness of behavioral programming, such techniques are not commonly employed in psychiatric inpatient settings. Several explanations for this have been proposed, including inadequate levels of training and competence in behavioral programming among prevalent treatment staff. This study employed a multiple choice inventory to assess behavioral knowledge among subjects representing several direct care disciplines commonly found in inpatient psychiatric settings. The results support assertions of relatively low levels of behavioral knowledge among disciplines that are most prevalent in such settings. The implications of these results for initiatives to enhance behavioral knowledge and skills are discussed.     

Rorschach predictors of therapeutic outcome in a child psychiatric inpatient service

This study tested the hypothesis that Rorschach indicators of psychological instability and perceptual sensitivity are predictive of therapeutic outcome in a child psychiatric inpatient service. Thirty-four children, matched for age, were divided into two groups, Improvers and Decliners, based on changes in behavioral problems over 60 days of hospitalization. The groups were not distinguishable by scores on intellectual tests, sex, or the initial quality or severity of psychological disturbance. Analyses of Rorschach protocols indicated that children who obtained higher ep, ep-EA, Blends, Zf, and Z sum and lower Lambda had improved in treatment. The results suggest that children who are less stabilized and manifest perceptual sensitivity do achieve the greatest gains.     

Group-as-a-whole concepts and the therapeutic milieu on the inpatient psychiatric unit

This paper focuses on large group process on the inpatient psychiatric unit. General systems theory and group-as-a-whole concepts are used to understand the dynamics of the therapeutic milieu. Using this information as a tool, the therapist can make various interventions on an individual and group level that will help patients understand and deal with their own psychopathology. Another benefit of this process is that it will develop a community on the psychiatric unit where patients help each other to get well. Three clinical examples are used to illustrate the relevance of this concept. With the advent of short-term psychiatric hospitalization, the therapeutic milieu has shown a drastic decline. Emphasis has been placed on the individual as opposed to the group and a valuable therapeutic tool has been lost. Using a group-as-a-whole concept can help reverse this trend and make the milieu on the inpatient psychiatric unit instrumental in the recovery of the patient.     

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.     

Behavioral assessment and analysis of mechanical restraint utilization on a psychiatric,child and adolescent inpatient setting

A behavioral assessment and analysis of mechanical restraint utilization on a child and adolescent psychiatric inpatient unit was performed to identify contextual variables associated with implementation. The most frequent antecedent conditions correlated with restraint were when staff initiated physical contact towards a patient and when a patient refused to go to, or remain in, the “quiet room” when instructed. These interactions were seen as staff-initiated encounters that elicited aggressive responses from patients and increased the likelihood of restraint because the physical intervention and “quiet room” procedures were implemented in the absence of a comprehensive treatment formulation, and without reference to behavior-specific guidelines. Recommendations to reduce the use of mechanical restraint with child and adolescent inpatients by isolating functionally controlling variables are presented. © 1998 John Wiley & Sons, Ltd.