Violence Among Insanity Acquittees: Criminogenic Risks and Psychiatric Symptoms

CNS Spectrums | 2020, Vol. 25, No. 5, p. 714-722

Examining violence among Not Guilty by Reason of Insanity state hospital inpatients across multiple time points: the roles of criminogenic risk factors and psychiatric symptoms

Darci Delgado; California Department of State Hospitals, Sacramento, California, USA
Sean M. Mitchell; Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA; Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA
Robert D. Morgan; Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA
Faith Scanlon; Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA

Objective: Institutional violence in state hospitals is a public health problem that has been severely understudied. Given the personal (ie, staff and patients) and fiscal harms associated with institutional violence, more research into contributing factors for violence is needed. The overarching aim of this study then was to examine associations among psychiatric symptoms, criminal risk factors, and institutional violence.

Methods: Participants were 200 male, female, and transgender forensic mental health inpatients adjudicated Not Guilty by Reason of Insanity and committed to the California Department of State Hospitals. Participants completed a psychiatric symptom measure, and measures of and associated with criminal risk. Institutional violence was recorded from file review and includes physical violence toward staff or patients for 6 months prior to and post-patient participation in this study.

Results: After adjusting for previous institutional violence, results indicated that psychiatric symptoms were not associated with follow-up institutional violence; however, criminal risk was associated with follow-up institutional violence. Unexpectedly, 2 aspects of criminal risk, antisocial cognitions and associates, were not associated with follow-up institutional violence after adjusting for previous institutional violence. Results also provided a tentative cutoff score on the Self-Appraisal Questionnaire for predicting follow-up institutional violence.

Conclusions: These results have important implications for treating and managing patients at risk for institutional violence, including the need to assess criminogenic risk and leverage treatments that target these risk factors as a best practice approach.

Violence; criminal risk; psychiatric symptoms; state hospital; NGRI; inpatient

“Institutional violence and associated risk factors within state hospitals have largely remained unexamined in the literature in spite of high violence prevalence rates: almost one-third (31.4%) of state hospital inpatients will engage in a violent assault during their hospitalization course. This dearth of research is particularly true for state hospital inpatients adjudicated Not Guilty by Reason of Insanity (NGRI)...  The current study aimed to evaluate both psychiatric symptoms and criminogenic risk (ie, risk factors that, when present, increase an individuals’ risk of engaging in criminal activity and/or violence) as they relate to institutional violence over time during NGRI inpatients’ hospitalization.” (p. 715). 

“The relationship between severe mental illness and violence is complex. It was long assumed that criminal justice involvement for individuals with mental illness was due to untreated mental illness; however, in the past 15 years, it has been recognized that criminogenic risk significantly contributes to criminal justice involvement to a greater degree than does psychopathology. Research has identified eight central criminogenic risk factors including: antisocial personality, antisocial attitudes, antisocial peers, substance abuse, history of antisocial behavior, relationship/familial problems, vocational difficulties, and lack of leisure activities. There is concordance between these criminogenic risk factors and factors that have been associated with institutional violence within forensic settings” (P. 715).

This study utilized a mixed-method approach with participants consisting of “ 164 male (82%), 33 female (16.5%), and 3 transgender (1.5%) forensic mental health inpatients adjudicated NGRI and hospitalized under California Penal Code 1026 in the California Department of State Hospitals (DSH)” (p. 717). The measures used included the Self-Appraisal questionnaire, the Brief Symptom Inventory, and the measure of Criminal Attitudes and Associates. 

“Our study elucidated patterns in institutional violence among NGRI inpatients. Data indicated that 16.5% and 10% of this sample of NGRI inpatients engaged in institutional violence toward other patients or staff in the 6 months prior to and 6 months following the self-report assessments, respectively. Additionally, most patients who were not previously violent did not go on to be violent during the follow-up period; only 33.3% of those who were previously violent also engaged in violence during the follow-up period” (p. 719).

“The results in the current study also partially supported our hypotheses. That is, one of our assessments of criminogenic risk (the SAQ Total score) was significantly higher among NGRI inpatients who engaged in institutional violence during the follow-up period compared to those who did not, after controlling for previous institutional violence. However, our findings did not support significant differences between the follow-up institutional violence groups on specific aspects of criminogenic risk” (p. 719). 

“There were no significant differences between the follow-up institutional violence groups on our assessment of psychiatric symptoms distress severity (the BSI GSI scores) after controlling for previous institutional violence. Although research has indicated that psychiatric symptoms are significantly associated with violence among other psychiatric patients, including inpatients,6,7 our results do not support this association among NGRI inpatients after considering their previous violence. Perhaps NGRI state hospital inpatients—particularly in our sample—are more psychiatrically stabilized given their length of hospitalization compared to participants in previous studies that may include acute inpatients in other settings” (p. 720). 

“Clinical utility of risk assessments should not be limited to prerelease assessments, but also as an important treatment-planning tool with NGRI inpatients who are at an intermediate stage of their treatment pathway and inpatient hospitalization. Some of the major hurdles to an NGRI inpatient’s successful release from a state hospital include institutional rule violations and violence. These results show that criminogenic risk factors play a key role in violence, thereby greatly influencing eventual treatment success. By assessing criminogenic risk, a clinician would identify treatment targets—that is, substance abuse, criminal thinking, or anger management—as a focus of treatment. Importantly, holistically integrating criminogenic risk in treatment of mental illness may result in the even greater treatment success.37-39 Leveraging treatments that target these criminogenic needs could a beneficial addition to the traditional psychiatric symptom-focused approach to treatment of NGRI inpatients” (p. 721).

“This study is not without limitations. First, we assessed criminogenic risk and psychiatric symptom severity at one time point and our follow-up violence records from the 6 months following our self-report assessments. Therefore, our study could not detect potentially important short-term changes in psychiatric symptoms or criminal risk that could impact violence, as indicated in previous studies.40 This could possibly explain some of our nonsignificant findings. Additionally, participants were in the DSH system, and they were required to have at least a 6th grade English reading level and demonstrate the capability for informed consent to participate. Our sample was also largely male and had been hospitalized for several years. Therefore, these findings may not generalize to other state hospital systems, NGRI inpatients with greater demographic heterogeneity, or those who do not meet our inclusion criteria. In addition, these findings may not generalize to patients who are earlier in their hospitalization course. Given the participants’ length of hospitalization, our participants were likely more psychiatrically stabilized than more recently admitted patients; therefore, they may not have been experiencing as severe psychiatric distress measured by the BSI. It is possible that newer patients who are less psychiatrically stabilized would demonstrate a different relation between their psychiatric symptoms and future violence. Furthermore, our study used self-report measures as our primary predictors, which are subject to recall bias and false reporting. Alternative measures of psychiatric symptom distress and criminal risk should be considered. Although we had data on institution violence reported in the patients’ hospital records, which provided objective violence data, it is possible that there was institutional violence that was not observed by staff or that was not recorded, which could impact the effect sizes of our results. Similarly, the observed power statistics (ie, the probability of detecting an effect if there is one) for our analyses were low, especially for nonsignificant results; however, it should be noted that the effect sizes for nonsignificant results were also very small (eg, ηp2 = .01). Thus, a very large sample would be necessary to detect such small effect sizes, which would likely lack clinical meaning. Nevertheless, the low power in the current study could have produced a false negative finding. Therefore, further replication of our work is warranted” (p. 721-722).