Challenges in the mental health care of older incarcerated persons

Background: The number of older incarcerated adults has exponentially risen within the past two decades. Even though they still represent a minority amongst the general prison population, they require vast amount of resources from prison mental health services. Their health needs are higher compared to the general population and to younger incarcerated adults. At the same time, we lack detailed knowledge on their needs and the applicability of current interventions to this particular subgroup. We therefore systematically explored their mental health needs profile with a specific focus on substance use issues. Moreover, a major limitation in the integration of literature on older incarcerated adults is the missing shared definition of this age group. For this reason, we assessed the problems of defining the older population and compared current understandings and arguments provided to support these choices. In addition, in the Swiss prison context, the number of older adults mandated to psychotherapeutic treatment has risen the most drastically. The overall goal of these court-mandated treatment orders is to reduce risk of recidivism by treating mental health disorders that stand in direct connection with the crime committed. Such interventions come with specific challenges due to aspects such as the coercive and restrictive nature of prison environment, the involuntary admission to psychotherapeutic treatment, as well as the therapist’s dual role to care and control. To date, we lack research exploring these factors on psychotherapeutic interventions, which could support mental health professionals in integrating these challenges into their clinical practice. This thesis therefore investigated the experiences of older incarcerated adults and mental health professionals with court-mandated treatment orders to explore current challenges and shortcomings in the delivery of psychotherapeutic and psychiatric treatment. Methods: Systematic reviews of current literature were performed with the aim to investigate prevalence rates of mental health disorders with a specific focus on substance use issues as well as to shed light into current ways of defining this older age group, arguments used to support this choice, and the empirical evidence to back these definitions. This research project further used a mixed-methods approach, collecting qualitative and quantitative data from incarcerated persons as well as mental health professionals working in Swiss and Canadian correctional contexts. Quantitative data collection mainly encompassed data extraction from medical records. Additionally, pilot studies for the applicability of the routine outcome measure HoNOS-secure, the screening tool PHQ-9, and the structural diagnostic interview MINI were conducted. For qualitative data collection, semi-structured interviews were performed with older incarcerated adults receiving mental health care as well as mental health professionals working with patients who offended. Results: Systematic review methodology revealed that definitions of the older age group vary and hamper the integration of already limited research. Based on our findings, we suggest the use of age 50 as cut-off to define the older age group for research and health care planning on national levels. Additionally, we confirmed the high rates of mental health disorders amongst this subgroup with psychiatric diagnoses of cognitive issues, alcohol misuse, and affective disorders being relatively more common in comparison to younger incarcerated adults. Qualitative interviews showed that patients and mental health professionals likewise struggled with integrating the involvement of the justice system into their psychotherapeutic work. In particular, limits to confidentiality needed to be handled transparently. Patients accepted mental health professionals sharing information with judicial authorities, as long as their private details were protected that were of no relevance to authorities’ decision-making. Additionally, when mental health professionals accomplished to emphasize their caring role over their controlling responsibilities, patients reported beneficial treatment experiences. This was achieved by a supportive and respectful attitude that aimed at promoting the patient’s well-being and progress in life. Therapists needed to master the balancing act between responding to patient’s individual needs within the predefined framework of mandated interventions. When therapist managed to respond to these personal needs, relief from psychological burden and therefore positive effects from treatment participation motivated them to remain and engage in therapy. This psychological burden frequently originated in their difficulties in dealing with deprivation of freedom, harshness of prison environments, as well as accepting and understanding their crimes committed and their psychiatric diagnoses. Last, external pressures imposed by judicial authorities strongly affect patients’ experiences with psychotherapeutic treatment. Predefined goals and authorities’ decision-making currently lacks clarity and transparency. To augment patients’ motivation to participate in treatment, the application of these external motivators should be used more favorably. Discussion: This research project contributes to much-needed research on mental health of older incarcerated adults and their experiences with court-mandated interventions. We confirmed high prevalence rates of older incarcerated persons’ mental health issues and outlined current definitions applied to this subgroup. This to advance a shared understanding of this population to facilitate the integration of available literature. Further, we showed that the involvement of the justice system substantially affects psychotherapeutic processes. We confirmed previous assumptions that the way MHPs integrate coercion and control in their clinical work, alters patients experiences with psychotherapy. We outline some pressing shortcomings of current treatment delivery and propose some strategies in alleviating the negative impact of external pressures. By this, we can potentially enhance patient motivation and alliance quality to improve clinical and criminal outcomes of incarcerated persons mandated to treatment. By increasing the effectiveness of such court-mandated treatments, we consequently not only enhance well-being of the individual patient but concurrently increase public’s safety

Loneliness and social isolation among the older person in a Swiss secure institution: a qualitative study

Background A pandemic of loneliness is hitting the aging population. As COVID19 forced us to isolate ourselves, we are in a better position to understand consequences of social distancing. The recent literature showed that older incarcerated adults are particularly at risk of health-related complications due to isolation in the prison environment, reducing their social capital. Mental and physical health can be severely affected by loneliness and social isolation, especially in prison. Methods Our qualitative study investigates the view of older persons deprieved of their liberty on loneliness and social isolation pertaining to their mental health. We interviewed 57 older participants, including imprisoned individuals and forensic patients, following a semi-structured interview guide. During the data management and data analysis process, we excluded 7 interviews which were of poorer quality. Thereafter, we analyzed the remainders following a thematic approach. Results Most interviewees experience loneliness following lack of significant human relationships in prison. Making friends appears to be a challenge for all the participants, because, for one thing, they do not find people with similar interests. Also, secure institution setting aggravates isolation due to the restrictions of movement placed such as rules concerning movement between floors, hindering intimate relationship, and separation between friends. Moreover, contact with prison personnel is limited and lack social capital (e.g. trust). Conclusion To our knowledge, this study is one of the first to present incarcerated persons’ perspective on loneliness, social isolation and poor social capital in the Swiss prison setting. These has been reported to cause health problems both somatic and psychological. Our participants experience these deleterious factors in detention. As prisons have the possibility to become a health-promoting environment through connectedness, friendship, and trust promotion, stakeholders need to better their social capital

What characterizes a good mental health professional in court-mandated treatment settings?: Findings from a qualitative study with older patients and mental health care professionals.

BACKGROUND Therapist-related activities and characteristics such as empathy and genuineness are factors that significantly contribute to psychotherapy outcome. As they play a role in psychotherapy more generally, it can be expected that they are equally important in the treatment of court-mandated patients more specifically. At the same time, these treatment settings come with specific challenges-e.g. due to coercion and control-and it could thus be that some therapist-related characteristics might have a different empathy on the therapy. This interview study sought to investigate service providers' and users' perspectives on therapist-related characteristics in the context of detention. METHODS We conducted a qualitative interview study with 41 older incarcerated persons mandated to treatment, and 63 mental health professionals (MHP). The data analysis followed thematic analysis. RESULTS Patients and experts both emphasized the importance of treating patients with respect by taking a humanistic approach, that is, condemn the deeds but embrace the person and display genuine interest in supporting patients with any issue or concern that is of relevance to them. Furthermore, interviewees underscored that the coerciveness of the therapy context required to incorporate patients' wishes into treatment planning, recognize and respond to the patients' needs, and allow some choice within the given framework. Such inclusive attitude was deemed critical to engage and motivate patients to participate in treatment. In addition, it was emphasized that feedback and advice by the therapists need to be concrete, detailed and applied to each person's current situation. Lastly, patients questioned MHP's qualification when they did not progress in therapy. DISCUSSION Our findings indicate that some therapist-related activities and characteristics are of particular importance in court-mandated settings. These include genuine interest in the patient, a respectful and positive attitude, as well as the capacity to target sensitive issues in a directive but non-confrontational manner. Further research needs to identify specific expressions and behaviors that are linked to the aforementioned characteristics in the forensic context. Our study therefore contributes to much-needed empirical research on clinician and patient perspectives on therapist characteristics and activities in the treatment of court-mandated patients

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine