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PubMed1996

Outpatient treatment of mentally disordered offenders in Austria.

The mental health system is faced with a growing number of MDOs with treatment orders. For more than 90% of our sample of 157 discharged irresponsible MDOs a mandatory outpatient treatment was ordered. Considering the fact that half of these patients are transferred after discharge to institutions like psychiatric hospitals or nursing homes (Leygraf, 1988), institutional as well as outpatient treatment options are needed (Silver & Tellefsen, 1991). Within the Austrian mental health system here is an enormous lack of post-discharge treatment facilities for forensic patients (Meise, Rossler, & Hinterhuber, 1994). Furthermore, the existing structures obviously do not meet the special needs of forensic patients. Although this point of view is shared by the psychiatric hospitals and their contentment with the settings for forensic outpatient treatment was low, only one hospital intended conceptional change and modifications. Facing the reality that the same psychiatric hospital authorities complained that they could not release MDOs from an inpatient status because of inappropriate outpatient facilities, the responsibility for forensic patients seems to be projected from the medical to the legal system. This can be seen as a symptom of the tendency to a step wise and long-standing exile of forensic patients from the mental health system. Actually, forensic patients were for various reasons refused by mental health professionals and could not get psychotherapy, medication or adequate psychosocial care. A possible answer to these problems is to establish institutionalized outpatient facilities in the "hybrid" gap between the legal and mental health system (Lamb, Weinberger, & Gross, 1988). The new outpatient clinic in Vienna deals with rejected treatment-order patients, most of them with additional treatment problems such as impulsivity, substance abuse, and mental impairment (Cote & Hodgins, 1990). The special structure of the institution (i.e., a multiprofessional team that offers a wide and easily accessible spectrum of interventions, the realization of individual treatment programs with psychotherapeutic and psychosocial as well as biological aspects, and the long-term personal continuity of care by staff members with forensic psychiatric skills) promoted the experience that after some time half of the patients came on a voluntary basis (Fenell, 1992; Winick, 1994). Some pressure by the court was an efficient way to guarantee regular treatment for patients with personality disorders and perversions. The model of a special, structured, multiprofessional outpatient clinic is successful, but the role of such complementary pilot institutions is ambiguous. Simultaneously, the deficit of adequate outpatient care for MDOs has to be opposed by stopping the unacceptable withdrawal of general psychiatry from the forensic sector.

Aftercare↗
PubMed1996

Criminality of the mentally ill in sheltered care: are they more dangerous?

The sample of mental patients in sheltered care has a lower arrest rate than the general population in California in all categories of crimes, except for violent crimes. For violent crimes, the sheltered-care population is likely to be arrested at 1.33 times the rate of the state population, even when the heterogeneity of aggravated assault was taken into consideration. This indicates empirically that the mentally ill in sheltered care are more dangerous than the general population. For prediction of criminality, four factors are found to be significant predictors of resident criminality after 1973: (a) prior crime history, (b) age, (c) use of alcohol and drugs, and (d) sex (male). Among these factors, prior crime history is the single most powerful predictor of resident criminal activity. This is another confirmation of most of the previous research findings. Although there have been controversies over the issue of the dangerousness of the mentally ill, the results of this study, overall, support the most recent findings of studies in which the mentally ill population pose greater threats to the community than the general population. Now it is time to consider more specific and practical measures to monitor and carefully follow up the discharged population, especially those with prior crime history, and prevent further violent crimes. This will in turn help to promote the reintegration of the mentally ill in the community.

Adolescent↗
PubMed1985

The nature and effectiveness of general hospital psychiatric services.

Inpatient psychiatric episodes in general hospitals represented 58% of the total for the United States by the end of the 1970s. Given this growth, recent studies of the nature and effectiveness of general hospital psychiatric care are reviewed. Surprisingly, the data base continues to be largely descriptive rather than experimental. Evidence is particularly needed about the relative clinical and cost-effectiveness of general hospital treatment vis-a-vis that of other inpatient and community alternatives. Future research must also consider the effect of a general hospital's organizational characteristics upon the manner in which it structures and delivers psychiatric care.

Cost-Benefit Analysis↗
PubMed1987

Involuntary hospitalization: an issue for the consultation-liaison psychiatrist.

Little has been written about the issue of involuntary hospitalization in consultation-liaison psychiatry. Nevertheless, patients frequently seen in medical and surgical settings may be judged to be a danger to themselves or others because of psychiatric disorders that cloud cognition, impair judgment, or modify insight, and judicial or administrative proceedings leading to involuntary commitment may be needed. The C-L psychiatrist will be the physician most knowledgeable about the concepts of involuntary hospitalization, competency and informed consent. Clinical examples illustrate issues that may arise.

Adult↗
PubMed1993

A prospective study of psychiatry patients' attitudes toward the seclusion room experience.

The seclusion room is an integral component of hospital psychiatry. This study prospectively surveyed 50 patients shortly after each was released from an isolation room in a voluntary general hospital psychiatric unit. Fifty-eight percent of the sample were diagnosed with mood disorders. Previous studies found generally negative attitudes toward seclusion. These data revealed that patients often found seclusion to be restful and therapeutically helpful. The clinical implications of these data are discussed.

Adult↗
PubMed1995

The ethical limits of confidentiality in the therapeutic relationship.

The author explores the moral underpinnings of psychiatric confidentiality in an attempt to define its ethical limits. Knowledge of this standard assumes growing importance as third party incursions into the patient-therapist dyad become increasingly common in day-to-day practice. The APA's AIDS policy on confidentiality and disclosure is offered as an illustrative example of the profession's ability to successfully translate moral deliberation into clinical policy.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Violence counseling in the routine health care of adolescents.

Intentional violence is a leading cause of mortality among teenagers and young adults. Whereas violence-related mortality is fairly well recognized among medical practitioners, the literature contains little information regarding violence-related morbidity or medically oriented approaches to preventing violence. Violence-related morbidity data for adolescents from one community revealed that 50% of the male respondents experienced at least one pushing or shoving fight per year, and that by age 16 25% had already been threatened by a weapon. These findings provided the impetus to incorporate regular violence counseling into the routine health care maintenance of adolescents at one health center. Our approach to violence-prevention counseling, obtaining a history of violence, and devising a treatment plan is described and advocated.

Adolescent↗
PubMed1985

Deinstitutionalization and public policy.

Deinstitutionalization, originally hailed as a major advance in public policy towards mental illness, has recently become increasingly controversial. This paper reviews the implementation of this policy in the United States, providing a critical examination of some of the central issues and problems that are the focus of current debates. It concludes with a pessimistic assessment of the likelihood of substantial improvements occurring in the lot of the chronic mental patient in the contemporary United States.

Chronic Disease↗
PubMed1986

Divided loyalties in adolescent psychiatry: late adolescence.

The paper discusses problems that arise in psychotherapy with late adolescent patients when other individuals somehow become indirectly involved in ways that require or suggest some exchange of information. These individuals may be parents or administrative and teaching personnel within an institution. The differences between confidentiality, privileged communication, and privacy are discussed, and specific difficulties discussed in the therapy of late adolescents who are in the process of psychologically (as well as legally) attempting to achieve the independent status of a young adult.

Adolescent↗
PubMed1987

A measure of the 'sick' label in psychiatric disorder and physical illness.

Persons with psychotic disorders receive devalued labels. Despite considerable theorizing, the proposition that these labels affect the course of psychotic illness has rarely been subjected to investigation. The lack of an adequate operational measure for the labeling construct has hampered research. The present report describes the development of the Social Response Questionnaire (SRQ), a measure of the 'sick' label which incorporates moralistic attitudes, fear of dangerousness and negative expectations attached to the role of the severely psychiatrically ill. This 32-item scale, a multidimensional measure of informal labeling, which may be administered in a self-report format or to significant others, permits the study of dose-response relationships. The SRQ is internally stable. It also exhibits construct validity. Schizophrenics and persons with affective psychosis label themselves and are labeled by others more harshly than persons with Crohn's disease or normals. While self-percepts and the perceptions of significant others are fairly congruent for normals and persons with a significant physical illness, there is no agreement between the self-ratings of psychotics and their significant others. Psychotic persons view themselves more negatively than Crohn's disease sufferers or normals, but not as negatively as their therapists, families and friends. Potential uses for the SRQ in longitudinal research are addressed.

Adolescent↗
PubMed1988

Statutory change and 'street-level' implementation of psychiatric commitment.

This paper assesses the impact of a statutory change in psychiatric commitment laws on the dangerousness of involuntarily committed civil patients in one metropolitan area. More restrictive local guidelines for commitment emphasizing assaultiveness were replaced by a new state law which expanded the criteria to those whose health might deteriorate from neglect. Using an interrupted time-series analysis, we find that changes in the proportion of persons hospitalized as dangerous (or assaultive) occurred more among normally less assaultive groups such as older, white and female patients than among normally more assaultive categories of younger, black and male patients. The less assaultive groups contained an increasing proportion of dangerous patients under the period of restrictive guidelines but the proportion dropped dramatically following the implementation of the less restrictive law. Groups typified by higher rates of assaultiveness remained at a relatively high level, unaffected by changes in the statutes or time. Given the relative stability in the numbers of OTA patients committed over time, the results suggest that changes in the proportion of patients said to be dangerous may be an artifact of the way petitioners for patients and providers make use of the mental health system.

Adult↗
PubMed1992

Mad, bad and dangerous to know: dimensions and measurement of attitudes toward injecting drug users.

Attitudes toward injecting drug users were assessed using a 53-item questionnaire which was administered to 143 workers at a drug and alcohol research unit and an AIDS treatment facility. Factor analysis revealed three interpretable dimensions: intravenous drug use as a matter of both public concern and personal inadequacy; intravenous drug users as criminals who should be removed from society; and social avoidance of, and personal distaste for, intravenous drug users. The scale and subscales had good test-retest reliability and internal consistency. Its potential use as a measure of attitudes toward injecting drug users for both treatment research and AIDS research is discussed.

Acquired Immunodeficiency Syndrome↗