Deinstitutionalization? Where have all the people gone?

"I don't think I have been out of fight or flight. Ever." Transgender people's experiences in inpatient psychiatric treatment

BACKGROUND

Historically, marginalized groups have been deemed unwell and deserving of correction, resulting in disproportionate use of inpatient psychiatric institutionalization. Despite changes over the last hundred years, individuals from marginalized groups continue to experience poor treatment in inpatient psychiatric settings. Transgender people are marginalized in a society where it is assumed that all individuals exist solely as woman or man with predetermined roles influenced by innate biology based on their sex assigned at birth, i.e. gender essentialism. This contributes to mental health disparities (e.g., depression, anxiety, suicidal thoughts, and suicide attempts), which may result in higher acuity symptoms, leading to overrepresentation in inpatient psychiatric settings. Yet, little is known about transgender people's experiences during inpatient psychiatric treatment.

OBJECTIVE

To describe the experiences of transgender people in inpatient psychiatric treatment.

DESIGN

A qualitative descriptive study.

SETTING

Interviews were held in person or over Zoom.

PARTICIPANTS

Adults who self-identified as transgender and had been admitted to inpatient psychiatric treatment during the last five years were recruited to participate through community organizations, social media, and word of mouth.

METHODS

Semi-structured interviews were conducted between March 2019 and June 2022. Data were analyzed using thematic analysis.

RESULTS

Participants (N = 15) described experiences within inpatient psychiatric treatment. The first theme, gender essentialism causes stigmatizing experiences through structural and enacted power, was characterized by deliberate or accidental misgendering, gender treated as irrelevant to care, pathologized gender diversity, and withholding of gender-affirming needs. The second theme, psychological and emotional strain as the price paid for enforced gender essentialism, included examples of drained emotional resources, powerlessness, and worsening of gender dysphoria. Lastly, the theme actions in disruption of the structural gender essentialist power illustrated how the gender essentialist systems in place can be interrupted and resisted by transgender patients and healthcare professionals.

CONCLUSIONS

Power structures are embedded in psychiatric hospital policies and practices, as well as the physical layout of the hospital, operating under the assumption that all patients are either man or woman based on their sex assigned at birth. Healthcare professionals may unintentionally or deliberately reinforce these structures, further marginalizing transgender patients. Healthcare professionals have the opportunity to disrupt these harmful systems by advocating for and implementing changes that challenge gender essentialism. Creating care environments that incorporate gender diversity allows transgender individuals to focus on their mental health and recovery, rather than expending emotional resources navigating a system that overlooks or invalidates their identities.

SOCIAL MEDIA ABSTRACT

Inpatient psychiatric treatment reinforces gender essentialism, subjecting transgender patients to stigma and mistreatment. Participants described experiences of frequent misgendering, dismissal of gender-affirming needs, and emotional strain from navigating a system designed for non-transgender patients, leading to worse mental health symptoms, including gender dysphoria, and feelings of powerlessness. Healthcare professionals reinforce these harmful systems deliberately or unintentionally. However, instances of disruption by healthcare professionals and transgender participants were observed leading to the creation of affirming experiences despite the prevailing gender essentialism. Future opportunities to disrupt these structures include advocating for systemic change, engaging in patient-centered care, and developing inclusive policies. By creating inpatient psychiatric environments that accommodate gender diversity, healthcare providers could allow transgender patients to focus on their mental health and recovery, rather than combating stigma. Inclusive care can shift the focus from navigating systemic transphobia to healing.

Living Dead: Trans Cooperations with Mad Necropolitics and the Mad Trans Coalitions that Might Replace Them

Trans subjectivities continue to be included in major compendia of mental illness, despite recent moves to depathologize "cross-gender identification." Regardless, the inclusion of "gender dysphoria" is often framed as a formal mechanism to support access to gender affirming care as transgender subjectivities are re-conceptualized as part of sex/gender diversity and away from madness. The latter permits trans individuals to evade sanist oppressions. However, moves to disassociate from mad individuals also often serve to condone sanism. For instance, a contemporary policy landscape often sees transgender advocates arguing for the "medical necessity" of gender affirming care for gender dysphoria as a "recognized medical condition," thereby skirting the inclusion of gender dysphoria as a psychiatric condition and implying that gender dysphoria carries a special ontological status that separates it from madness (reified as "mental illness"). More though, this framework endorses material violences toward mad individuals that are often advanced via the workings of the state to consign marginalized constituents to death by withholding the means of life, i.e., necropolitics. In the following, I argue that trans disassociations from madness often endorses or assents to mad necropolitics. Drawing from Mbembe's (Necropolitics. Duke University Press, Durham, 2019) framework, I suggest that medicalizing trans narratives, despite being used to object to anti-trans laws in contemporary context, ideologically support mad "death worlds" organized through the U.S.A. welfare state and prison industrial complex. However, I also suggest alternative strategies, i.e., intersectional collaboration, that may uplift mad and/or trans communities.

Cognitive Remediation to Facilitate Independent Living in Persons With Serious Mental Illness

Many people with serious mental illness (SMI) experience cognitive disabilities and poor independent living skills which limit their ability to live independently in the community. This study examined the feasibility and initial effectiveness of integrating a new cognitive remediation program, Thinking Skills for Life (TSL), into independent living skills training programs in four secure residential treatment facilities (SRTFs) to facilitate discharge to more independent living situations. Participants were 30 individuals in the SRTF, of whom 11 were forensically committed to the SRTF. Results showed the intervention was feasible to implement, with 97% of participants exposed to TSL and 67% completing the program. Initial promise of the TSL program at improving independent living was suggested by post cognitive program discharge to less restrictive living situations of 63% of participants not on forensic commitment, and 55% of those on forensic commitment. These promising findings set the stage for more rigorous evaluation of the efficacy of the TSL program.

Mental health recovery in a collectivist society: Saudi consumers, carers and nurses' shared perspectives

In 2019, the World Health Organization urged a global shift towards recovery-focused practices in mental health care. In Western nations, this transition often prioritised individualism over collectivism. In contrast, collectivist societies prioritise recovery through community and social support. This study explored mental health recovery from the perspectives of consumers, carers and registered nurses in a mainly collectivist society (Saudi Arabia) using a qualitative exploratory descriptive design. Sixteen consumers, ten carers and eight registered nurses participated in online semi-structured interviews. Inductive thematic analysis was employed to analyse English-translated versions of the 34 interviews. Consolidated criteria for reporting qualitative studies 32-item checklist were used. The study found that recovery was perceived as a process of transforming towards living a meaningful life of goals and values supported by trusted people who share moments of comfort and empowerment. A unique finding was the 'bond of recovery' a collectivist value that aid consumers' community integration in society. Saudi consumers' experiences of recovery were similar to consumers' movement narratives of recovery. Future research should establish a recovery-focused educational program that incorporates our findings into a recovery-oriented approach. This will facilitate providing a collaborative care between consumers, carers and nurses that centres around consumers' recovery goals and values.

Evaluation of a mental health service reform program, the Pathways to Community Living Initiative, for people with severe mental illness and complex needs

OBJECTIVE

The Pathways to Community Living Initiative (PCLI) aims to reform mental health care for people with severe and persistent mental illness (SPMI) and complex needs. This study reports independent evaluation findings on transitions from hospital and practice change in mental health services.

METHODS

Data for this mixed-methods evaluation were obtained from administrative collections and semi-structured interviews with PCLI program managers, teams and executive leads; aged care managers; and leaders in inpatient, community and older people's mental health services.

RESULTS

Between July 2015 and December 2020, 674 participants (67% of those eligible for the PCLI) were transitioned from hospital to community. Of those transitioned, 21 required subsequent long-stay admissions. The PCLI introduced resources, clearly defined processes, and state-wide networks to guide changes in practice which are becoming embedded in the operations and governance of mental health services across New South Wales.

CONCLUSIONS

Severe and persistent mental illness and complex needs can be managed in community settings with highly individualised planning and care, supported by specialised clinical teams in partnership with mental health, aged care and disability services. Evaluation findings highlight the importance of continued investment in rehabilitation psychiatry.

Mental health outcomes before psychotropic medications: a retrospective case series of one state hospital records from 1945 to 1954

BACKGROUND

Current outcomes for mental illness are widely regarded as poor. Since the introduction of psychotropic medications in the mid 1950's, previous psychosocial practices were minimized in favor of medication focused treatment. The majority of large U.S. state hospitals have closed with records destroyed or in storage, inaccessible to researchers. This creates barriers to studying and comparing outcomes before and after this shift in treatment practices.

AIMS

The study aim was to examine discharge outcomes in relation to length of stay and diagnosis in one U.S. state hospital.

METHODS

This case series study examined 5618 medical records of participants admitted to one state hospital from 1945 to 1954, the decade prior to adoption of psychotropic medications.

RESULTS

Of the 3332 individuals who left the facility, over half (59.87%) of first episode hospitalizations were discharged within 1 year, and 16.95% were hospitalized for more than 5 years. 46.17% of all admissions were discharged from hospital with no readmission. The most common diagnoses included schizophrenia, other forms of psychosis, and alcoholism. In the decade before the introduction of psychotropic medications, participants were often admitted for a single episode and returned to their homes within several years.

CONCLUSIONS

Although limited to one site, findings suggest that discharge outcomes prior to psychotropic medication as a primary treatment for mental illness may be more positive than previously understood.

Serious Mental Illness in Nursing Homes: Stakeholder Perspectives on the Federal Preadmission Screening Program

The federal Preadmission Screening and Resident Review (PASRR) program was enacted in the 1980s amid concerns surrounding the quality of nursing home (NH) care. This program is meant to serve as a tool to assist with level of care determinations for NH applicants with serious mental illness (SMI) and was intended to limit the growth in the number of NH residents with SMI. Despite this policy effort, the prevalence of SMI in NHs has continued to increase, and little is known about the mechanisms driving the heterogeneous and suboptimal administration of the PASRR program, absent routine evaluative efforts. We conducted 20 semi-structured interviews with state and national stakeholders to identify factors affecting PASRR program administration and NH care for residents with SMI. Stakeholders expressed concern regarding fragmentation, specifically lack of clarity in the value of assessments beyond a regulatory requirement. Additionally, they cited variable program administration as contributing to fragmented communication patterns and inconsistent training across jurisdictions. Given the number of people with SMI currently residing in NHs, policy and practice should take a person-centered approach to assess how PASRR can be better used to support resident needs.

Quality of Nursing Homes Admitting Working-Age Adults With Serious Mental Illness

OBJECTIVE

This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness.

METHODS

The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates.

RESULTS

Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11.

CONCLUSIONS

These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.

An observational comparison of FACT and ACT in the Netherlands and the US

Assertive Community Treatment (ACT) is a well-defined service delivery model for the care and treatment of the most severely mentally ill in the community with American origins. The Dutch have adapted the model in order to accommodate a broader range of needs and allow more flexible implementation. Functional Assertive Community Treatment (FACT) provides the intensity of care needed to help participants sustain life in the community as well as continuity of care over time for many vulnerable client populations.

Characteristics of Working-Age Adults With Schizophrenia Newly Admitted to Nursing Homes

OBJECTIVES

Persons aged <65 years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a contemporary understanding of the characteristics and management of working-age adults (22-64 years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored.

DESIGN

This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare.

SETTING AND PARTICIPANTS

This study examines working-age (22-64 years) adults with schizophrenia at admission to a nursing home.

METHODS

Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented.

RESULTS

Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms.

CONCLUSIONS AND IMPLICATIONS

Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged <65 years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care.

An Educational Intervention for Mental Health Staff to Assess Clients' Diabetic Self-Care Skills for Self-Management and Safe Transition into the Community

The current project's objective was to increase mental health assessor's knowledge about type 2 diabetes after attending a nurse practitioner's presentation. Mental health assessors, primarily social workers, help transition individuals with severe mental illness (SMI) and comorbidities from inpatient nursing homes back into the community. The assessor's knowledge about individual comorbidities, such as diabetes, is crucial for a successful long-term community transition. Mental health assessors were given the Diabetes Knowledge Test 2 pre- and post-educational intervention. The post-test intervention revealed assessors' knowledge increased by 25% in knowledge about diabetes and 225% in ability to use a glucometer. Mental health assessors also maintained their increased knowledge 3 months post-intervention. Emboldened with this knowledge, mental health assessors are better prepared to facilitate safe transfer of individuals with diabetes and SMI back into the community. Mental health assessors may also help prevent unnecessary emergency department visits and/or hospitalizations. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Organizational Supports to Promote the Community Integration of People With Dual Diagnosis

One of the most common reasons people with intellectual and developmental disabilities (IDD) return to institutions is because of maladaptive behaviors. This study's aim was to examine the impact organizational supports can have on the community outcomes of people with dual diagnosis-those with IDD and psychiatric disabilities. We analyzed secondary Personal Outcome Measures interview data from 533 people with dual diagnosis. Findings revealed people with dual diagnosis were significantly more likely to have community outcomes present when they received individualized organizational supports. In addition, we found a number of disparities in organizational supports, including related to guardianship, communication method, and residence type. A more robust service system is necessary to ensure people with dual diagnosis are integrated into their communities.

Tools for Moving On: Adapting an Evidence-Based Housing Curriculum for Individuals Receiving Services in an Inpatient Psychiatric Setting to Prepare for Community Living

Individuals with serious mental illness transitioning from state psychiatric hospitals to community living need specialized skills to enter community housing programs. There are few examples of best practice hospital group programs to improve community living skills. To address this gap, the authors developed a community skills training and discharge readiness program, Tools for Moving On (TFMO), adapted from materials from the Substance Abuse and Mental Health Services Administration Permanent Supportive Housing: Tools for Tenants toolkit. The new program uses facilitator and participant handouts, implementation recommendations, and covers four topics, including housing choices, housing preferences, tenancy skills, and support needs. Adapting existing evidence-based practices for individuals in state psychiatric hospitals may aid in successful discharge and community living and support nurses in their efforts for discharge. [Journal of Psychosocial Nursing and Mental Health Services, 57(8), 23-29.].

Satisfaction, safety, and supports: Comparing people with disabilities' insider experiences about participation in institutional and community living

BACKGROUND

Legislation and court decisions in the United States mandate the right to least restrictive community living and participation for people with disabilities, yet little research has examined differences in participation across institutional and community settings, or over time in the community post-transition.

OBJECTIVE

As part of a multi-site participatory action research project examining participation, we examined the differences in quality of life in institutional and community living environments among people with disabilities.

METHODS

We conducted surveys with adults with disabilities between 18 and 65 years-old that transitioned from institutions to the community in the United States within the last five years. This paper reports on findings for a diverse sample of 150 participants.

RESULTS

We found significant differences between ratings of institutional and community experiences, with increased reports of satisfaction, personal safety, service access, and participation in community settings. We also found significant improvements in community integration and inclusion after transition to community living, although barriers to transportation and activity access often remained.

CONCLUSIONS

This study of insider experiences of previously institutionalized people with disabilities illuminates important understandings of community participation, integration, and quality of life for the disability community in the United States.

Comparison of schizophrenia outpatients in residential care facilities with those living with someone: Study of mental and physical health, cognitive functioning, and biomarkers of aging

This paper aims to compare mental and physical health, cognitive functioning, and selected biomarkers of aging reflecting metabolic pathology and inflammation, in outpatients with schizophrenia from two residential settings: residential care facilities (RCFs) and living with someone in a house/apartment. This cross-sectional study examined community-dwelling adults with schizophrenia either in RCFs (N = 100) or in a house/apartment with someone (N = 76), recruited for two NIH-funded studies in San Diego. Assessments included measures of mental/physical health, cognitive function, and metabolic (glycosylated hemoglobin, cholesterol) and inflammatory (C-Reactive Protein, Tumor Necrosis Factor-alpha, Interleukin-6) biomarkers of aging. General logistic models were used to analyze factors associated with residential status. RCF residents had several indicators of worse prognosis (never being married, higher daily antipsychotic dosages, increased comorbidities and higher Framingham risk for coronary heart disease) than individuals living with someone. However, RCF residents had better mental well-being and lower BMI, as well as comparable biomarkers of aging as those living with someone. While the cross-sectional nature of the study does not allow us to infer causality, it is possible that the supportive environment of RCFs may have a positive impact on mental and physical health of persons with schizophrenia. Longitudinal follow-up studies are needed to test this hypothesis.

Remoteness and its impact on the potential for mental health initiatives in criminal courts in Nunavut, Canada

Remoteness in the isolated communities of Nunavut, Canada adversely affects access to mental health services. Mental health initiatives in criminal courts exist in many cities to offer healthcare alternatives to regular criminal court processing for people affected by mental illness. These initiatives do not exist in Nunavut. A qualitative multiple-case study in 3 Nunavut communities involving 55 semi-structured interviews and 3 focus groups explored perceptions by health, justice and community stakeholders of the potential for criminal court mental health initiatives in the territory. Findings suggest remoteness is perceived to hinder mental healthcare support for court responses to people affected by mental illness, creating delay in psychiatric assessments and treatment. While communication technologies, such as tele-mental health, are considered an effective solution by most health professionals, many justice-sector participants are sceptical because of perceived limits to accessibility, reliability and therapeutic value. These perceptions suggest remoteness is a significant hurdle facing future criminal court mental health initiatives in Nunavut. Additionally, remoteness is viewed as affecting decisions by lawyers to bypass legislated mental health avenues, possibly resulting in more people with mental illness facing criminal justice sanctions without assessment and treatment.

The relationship between disability prejudice and medicaid home and community-based services spending

BACKGROUND

Medicaid is one of the most important health care safety nets for people with disabilities in the United States. Yet, from the beginning Medicaid only covered long-term services and supports (LTSS) through institutional care. In 1981 changes to Medicaid allowed states to provide home and community-based services (HCBS) instead so people with disabilities could receive LTSS in their own homes or in the community. As a result of these changes, there has been a significant decline in institutionalization of people with disabilities in favor of HCBS in the United States. However, the priority of HCBS can be impacted by ideas about community living and disability attitudes, among others. How these attitudes may trickle down to impact Medicaid funding decisions is unknown.

OBJECTIVE

The aim of this study was to examine the relationship between HCBS and disability prejudice in the United States.

METHODS

We used secondary data about state LTSS expenditures from across the nation in fiscal year (FY) 2015, as well as disability prejudice data (Disability Attitudes Implicit Association Test) from 325,000 people residing in all 50 states and the District of Columbia.

RESULTS

Findings revealed regardless of the state size or wealth, states with more disability prejudice direct less of their LTSS funding towards HCBS.

CONCLUSIONS

Biases and prejudice in disability policy decision-making are obstacles to equality of opportunity and full participation in society, as promised by civil rights.

Intimate Relationships of People With Disabilities

Despite the difficulties people with disabilities may have garnering intimate relationships, intimate relationships may be particularly beneficial for people with disabilities as they result in greater self-acceptance, less internalized stigma, and more camaraderie. The aim of this study was to explore the intimate relationships of adults with disabilities (n = 1,443) in its many forms (from intimate friendships to romantic relationships). We particularly explored what factors increased the odds of adults with disabilities having intimate relationships, what supports resulted in increased likeliness to have intimate relationships, and what factors resulted in the presence of favorable intimate relationship outcomes. Our analysis revealed service organizations are key to enhancing the social and intimate relationships of adults with disabilities.

Community residential facilities in mental health services: A ten-year comparison in Lombardy

Residential mental health services grew steadily since 2000 in Italy. A reorganisation of residential facilities was implemented in 2007 in Lombardy, introducing supported housing in addition to staffed facilities. We compare the provision and characteristics of residential facilities in the 2007 and 2016. In 2007 there were 3462 beds (35.9/100,000 population) in 276 facilities. In 2016 beds were 4783 (47.8/100,000) in 520 facilities. The increase were unevenly distributed in the public and private sector, and the overall increase was due to a higher increase in the private sector. 72% of beds were in highly supervised facilities in 2007 and 66% in 2016. The public sector managed more facilities with a rehabilitation goal, while the private sector more for long-term accommodation. Mean numbers of beds were higher in facilities managed by the private sector in both years. The 2007 reorganisation and the stop to opening new facilities in the last years were not enough to correct the imbalance between highly supervised and flexible solutions. A wider and more diverse offer might have triggered off an increased demand, rather than a more rational use. Given the costs of highly staffed facilities, and the risk of reproducing custodial models, close evaluation of the use of residential facilities should inform policies.

What Factors Influence the Decision to Share Suicidal Thoughts? A Multilevel Social Network Analysis of Disclosure Among Individuals with Serious Mental Illness

Nondisclosure of suicidal thoughts limits suicide risk management. Consistent with disclosure models for other stigmatized statuses, understanding suicidal disclosure requires accounting for features of the discloser (individual factors) and the discloser-recipient relationship (relational factors). In a sample of 30 adults with schizophrenia, bipolar disorder, or major depressive disorder (Level 2) who nominated 436 social network members (Level 1), we examined disclosure patterns and identified individual and relational correlates of disclosure intent. Most individuals disclosed in the past (77%; n = 23) and all intended on disclosing (100%; n = 30). Disclosure was highly selective, with 14% (n = 62) of network members identified as prior confidants and 23% (n = 99) identified as intended confidants. Multilevel modeling indicated that relational factors were more central to disclosure than individual factors. Network members who were prior confidants and who provided social support were attractive targets for intended disclosure. Our findings suggest that "targeted" gatekeeper training may be a promising strategy and reveal relational characteristics to identify "high-probability confidants."

After the Asylum? The New Institutional Landscape

During the last decades services to people with severe mental health problems have gone through important changes. Terms as de-, trans-, reinstitutionalisation and dehospitalisation has been used. The objective of the study was to collected data about the changes in a welfare society about the new institutional landscape after the mental hospital area. Data about interventions from social welfare agencies, psychiatric care, and prisons were collected from local and national register as well as data about cause of death and socio-economic status for 1355 persons treated with a diagnosis of psychosis in a Stockholm area 2004-2008. Psychiatric in-patient care and prisons are marginalized. Different interventions in open care touched a very large number of persons. Social welfare agencies play an increasing role in this context. The total institutions have been replaced by a network of micro-institutions sometimes offering help but also control.

"Symptoms of something all around us": Mental health, Inuit culture, and criminal justice in Arctic communities in Nunavut, Canada

RATIONALE

Rehabilitation-oriented criminal court mental health initiatives to reduce the number of people with mental illness caught in the criminal justice system exist in many North American cities and elsewhere but not in the mainly Inuit Canadian Arctic territory of Nunavut.

OBJECTIVE

This study explores whether the therapeutic aims of these resource-intensive, mainly urban initiatives can be achieved in criminal courts in Nunavut's resource constrained, culturally distinct and geographically remote communities.

METHOD

A qualitative multiple-case study in the communities of Iqaluit, Arviat and Qikiqtarjuaq involved 55 semi-structured interviews and three focus groups with participants representing four sectors essential to these initiatives: justice, health, community organizations and community members. These interviews explored whether the therapeutic jurisprudence (TJ) principles that guide criminal court mental health initiatives and the component objectives of these principles could be used to improve the criminal court response to people with mental illness in Nunavut.

RESULTS

Interviews revealed 13 themes reflecting perceptions of Inuit culture's influence on the identification of people with mental illness, treatment, and collaboration between the court and others. These themes include cultural differences in defining mental illness, differences in traditional and contemporary treatment models, and the importance of mutual cultural respect.

CONCLUSION

The findings suggest Inuit culture, including its recent history of cultural disruption and change, affects the vulnerability of Nunavut communities to the potential moral and legal pitfalls associated with TJ and criminal court mental health initiatives. These pitfalls include the dominance of biomedical approaches when identifying a target population, the medicalization of behaviour and culture, the risk of "paternalism" in therapeutic interventions, and shortcomings in interdisciplinary collaboration that limit considerations of Inuit culture. The pitfalls are not fatal to efforts to bring the rehabilitative benefits of these initiatives to Nunavut, but they require careful vigilance when employing TJ principles in an Indigenous circumpolar context.

Re: Mental health rehabilitation in therapeutic jurisprudence: Theoretical improvements

Legal scholarship relevant to criminal court mental health initiatives that divert people with mental illness from prosecution to treatment has created the concept of therapeutic jurisprudence (TJ), an approach that seeks to maximize the law's potential for therapeutic outcomes. Despite recognition that TJ includes a rehabilitative response as a key animating principle and that it advocates for interdisciplinary synthesis, TJ has developed mainly from within the practice and discipline of law and without reference to the discipline of rehabilitation science, in which approaches to mental health rehabilitation (MHR) have witnessed significant developments in recent decades. In particular, concepts of MHR have shifted from a biomedical focus to a psychosocial approach, such as the recovery model, that incorporates values of self-determination, independence, and empowerment. It is argued that greater consideration of MHR will improve the theoretical validity of TJ by 1) helping define what 'therapeutic' means; 2) constructing a normative framework; and 3) broadening the scope of TJ as an interdisciplinary approach. More research is needed to ensure concepts from MHR rehabilitation science are considered in TJ legal scholarship and criminal court mental health initiatives.

Deinstitutionalised patients, homelessness and imprisonment: systematic review

BACKGROUND

Reports linking the deinstitutionalisation of psychiatric care with homelessness and imprisonment have been published widely.

AIMS

To identify cohort studies that followed up or traced back long-term psychiatric hospital residents who had been discharged as a consequence of deinstitutionalisation.

METHOD

A broad search strategy was used and 9435 titles and abstracts were screened, 416 full articles reviewed and 171 articles from cohort studies of deinstitutionalised patients were examined in detail.

RESULTS

Twenty-three studies of unique populations assessed homelessness and imprisonment among patients discharged from long-term care. Homelessness and imprisonment occurred sporadically; in the majority of studies no single case of homelessness or imprisonment was reported.

CONCLUSIONS

Our results contradict the findings of ecological studies which indicated a strong correlation between the decreasing number of psychiatric beds and an increasing number of people with mental health problems who were homeless or in prison.

Trajectories of recovery among homeless adults with mental illness who participated in a randomised controlled trial of Housing First: a longitudinal, narrative analysis

OBJECTIVES

This study used longitudinal, narrative data to identify trajectories of recovery among homeless adults with mental illness alongside the factors that contribute to positive, negative, mixed or neutral trajectories over time. We expected that participants who received Housing First (HF) would describe more positive trajectories of recovery than those who were assigned to Treatment as Usual (TAU; no housing or support provided through the study).

DESIGN

Narrative interview data were collected from participants at baseline and 18 months after random assignment to HF or TAU.

SETTING

Participants were sampled from the community in Vancouver, British Columbia.

PARTICIPANTS

Fifty-four participants were randomly and purposively selected from the larger trial; 52 were interviewed at baseline and 43 were reinterviewed 18 months after randomisation.

METHOD

Semistructured interviews were conducted at both time points. For each participant, paired baseline and follow-up narratives were classified as positive, negative, mixed or neutral trajectories of recovery, and thematic analysis was used to identify the factors underlying different trajectories.

RESULTS

Participants assigned to HF (n=28) were generally classified as positive or mixed trajectories; those assigned to TAU (n=15) were generally classified as neutral or negative trajectories. Positive trajectories were characterised by a range of benefits associated with good-quality, stable housing (eg, reduced substance use, greater social support), positive expressions of identity and the willingness to self-reflect. Negative, neutral and mixed trajectories were characterised by hopelessness ('things will never get better') related to continued hardship (eg, eviction, substance use problems), perceived failures and loss.

CONCLUSIONS

HF is associated with positive trajectories of recovery among homeless adults with mental illness. Those who did not receive housing or support continued to struggle across a wide range of life domains. Findings are discussed with implications for addressing services and broader social change in order to benefit this marginalised population.

Housing First improves subjective quality of life among homeless adults with mental illness: 12-month findings from a randomized controlled trial in Vancouver, British Columbia

PURPOSE

This study used an experimental design to examine longitudinal changes in subjective quality of life (QoL) among homeless adults with mental illness after assignment to different types of supported housing or to treatment as usual (TAU, no housing or supports through the study). We hypothesized that subjective QoL would improve over time among participants assigned to supported housing as compared to TAU, regardless of the type of supported housing received or participants' level of need.

METHODS

Participants (n = 497) were stratified by level of need ("high" or "moderate") and randomly assigned to Housing First (HF) in scattered-site apartments, HF in a congregate setting (high needs only), or TAU. Linear mixed-effects regression was used to model the association between study arm and self-reported QoL at baseline and at 6 and 12 months post-baseline by need level.

RESULTS

Based on the adjusted overall score on the QoL measure, participants randomized to HF reported significantly greater overall QoL as compared to TAU, regardless of need level or type of supported housing at both 6 and 12 months post-baseline. Scores on the safety and living situation subscales were significantly greater for both high and moderate need participants assigned to supported housing regardless of type at both 6 and 12 months post-baseline as compared to TAU.

CONCLUSIONS

Despite multiple health and social challenges faced by homeless individuals with mental illness, HF in both scattered-site and congregate models results in significantly greater perceived QoL as compared to individuals who do not receive HF even after a relatively short period of time.