Psychopathy ≠ untreatable: Comorbid psychopathy in forensic psychiatric patients

Psychopathy is associated with greater therapy-interfering behavior, with PCL-R Factor 2 predicting institutional misconduct and PLC-R Factor 1 predicting dropout from treatment. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | International Journal of Forensic Mental Health | 2017, Vol. 16, No. 2, 149-160

Forensic Psychiatric Patients with Comorbid Psychopathy: Double Trouble?

Authors

Inge Jeandarme, Knowledge Center Forensic Psychiatric Care (KeFor)
Claudia Pouls, Knowledge Center Forensic Psychiatric Care (KeFor)
T. I. Oei, Department of Criminal Law, Tilburg University, Tilburg, The Netherlands
Stefan Bogaerts, Forensic Psychiatric Center the Kijvelanden, Rotterdam, The Netherlands

Abstract

Patients with psychopathy need intensive care and supervision. There is however reluctance to treat them because of (supposedly) limited chances of success and risk of therapy-interfering behavior. This study focused on inpatient disruptive behavior in mentally disordered offenders during medium security treatment. Patients (N = 224) were assessed using the Psychopathy Checklist- Revised total, factor and facet scores and divided into three groups depending on the presence of low, medium, and high psychopathy traits. Associations between psychopathy and criminogenic risk and need factors were analyzed. Additionally, the association between psychopathy and therapy-interfering behavior (non-compliance, drop-out, institutional misconduct) was investigated with correlational and logistic regression analyses. The results showed that psychopathy was associated with greater risk, needs, and therapy-interfering behavior. PCL-R Factor 2 predicted institutional misconduct, whereas PCL-R Factor 1 predicted drop-out from treatment. The study highlights the importance of responsive treatment climates in retaining this difficult-to-treat group in treatment.

Keywords

PCL-R, psychopathy, forensic psychiatric patients, internees, therapy-interfering behavior

Summary of the Research

“Under Belgian law, internment is a safety measure for offenders who are found not guilty for reason of insanity (NGRI). As in other countries, this specific legislation allows mentally disordered offenders (MDOs) to be transferred to (forensic) psychiatric facilities for mandatory treatment. In line with research on non-mentally ill offenders, antisocial and/or psychopathic personality traits are also strong risk factors for recidivism in MDOs. Comorbid psychopathic traits in MDOs are associated with more impulsive and coercive and less compliant interpersonal styles, premeditated aggression, and poor criminal outcomes.” (p. 149)

“Furthermore, it is generally believed that high levels of psychopathy guarantee a problematic course of treatment and thus present a serious challenge for therapists. Skeem, Manchak, and Peterson (2011) compared these patients with poor students in the classroom: verbally combative, hostile, prone to break rules, and not motivated to cooperate with treatment. According to Wong, Gordon, and Gu (2007), one of the most daunting responsivity factors in treatment is treating unmotivated, non-adherent and treatment-resistant clients such as many patients with psychopathy or (antisocial) personality disorder.” (p. 149)

“Meta-analytic research findings in different settings— including forensic psychiatric settings—have indicated that the PCL-R total score is associated with broadly defined institutional misconduct (rw = .29) and to a lesser extent, with physical violence (rw = .17). PCL-R Factor 2 was moderately predictive of institutional adjustment, whereas Factor 1 showed a less robust association. Of the PCL-R’s four facet scores, Facet 4 was the strongest and most incrementally valid predictor of institutional aggression in forensic psychiatric settings.” (p. 150)

“Given the abovementioned problems with non-compliance and institutional misconduct and the resulting security concerns, the increased treatment drop-out rates may not be surprising. A meta-analysis performed by Olver, Stockdale, and Wormith (2011) found that having an antisocial personality disorder or psychopathy (both the diagnosis and dimensional PCL-R scores) predicted attrition. In male sex offenders, PCL-R Facet 2 showed significant unique contributions to drop-out, whereas none of the other facets did. In female patients with substance abuse, a shorter treatment stay was associated with PCL-R Factor 1 personality characteristics.” (p. 150)

“The objective of this study was to investigate the relations between psychopathy measured with the PCL-R and indicators of therapy-interfering behavior, namely institutional misconduct, non-compliance and drop-out from treatment. We controlled for other risk/need factors because these may contribute to the associations of interest.” (p. 150)

“The following categorical variables were considered indicators of therapy-interfering behavior (TIB) during inpatient treatment: (1) treatment drop-out, (2) non-compliance, and (3) institutional misconduct. Non-compliance was defined as a report to the CPS that the treatment rules had not been respected (such as the use of alcohol during treatment or failure to cooperate with treatment). Institutional misconduct was defined as (1) absconding (such as escaping from the institution or absconding from supervised or unsupervised leave), (2) violating individually formulated judicial conditions, and (3) engaging in offense related behavior, which was defined as incidents coded under offending categories in the Belgian penal code, regardless of whether they led to further prosecution or sentencing.” (p. 152)

“In the current study, psychopathy was significantly associated with greater risks, needs and TIB. PCL-R Factor 2 predicted institutional misconduct, whereas PCL-R Factor 1 predicted drop-out from treatment.” (p. 155)

“Considered together, our findings support other research stating that treatment should focus on criminogenic PCL-R Factor 2 features while also carefully accounting for PCL-R Factor 1 characteristics to keep patients in treatment.” (p. 156)

“Although it is understandable that clinicians often prefer highly motivated and compliant low-risk patients, the RNR model states that most resources should be deployed to treat more difficult, less compliant patients. Forensic mental health professionals therefore face a great challenge. They must tolerate difficult interpersonal behavior, such as hostility and manipulation, and control their countertransference while still motivating forensic patients who seemingly do not want to change or even stay in treatment. This is clearly not an easy task, but as shown by international research, it is not impossible. Difficult-to-treat should not become synonymous with untreatable.” (p. 158)

Translating Research into Practice

“Therapeutic settings involved in the treatment of MDOs with psychopathic traits face major challenges. Psychopathy is linked to institutional maladjustment, lack of motivation, early drop-out from treatment, and slower progression as well as poor treatment outcomes, for example, in terms of reducing recidivism. The behavioral manifestations of these traits can significantly interfere with treatment, as they impede the formation of a good working alliance and therefore must be appropriately managed. The current study found support for the two-component model proposed by Wong, Gordon, Gu, Lewis, and Olver (2012). The Criminogenic component, or Factor 2, was significantly associated with greater criminogenic need/risk factors and institutional misconduct and reflected an established pat- tern of antisocial behavior and dysfunctional lifestyle both inside and outside the institution. While the Criminogenic component should be the focus of forensic treatment, the Interpersonal component, or Factor 1, is equally important. Factor 1 was significantly associated with drop-out and can thus also contribute to poor out- comes if TIBs are not appropriately managed. As noted by Wong et al. (2012), it is important to distinguish between using risk reduction versus personality change interventions when designing and implementing treatment programs (p. 157).

“[A]s observed, psychopathic and other personality disorder traits in MDOs may be barriers to forensic psychiatric treatment and can lead to premature interruption or discontinuation of treatment. Clinicians are advised to develop a responsive treatment climate with staff and management who are willing to invest time and effort in these personality disordered patients (for good practices, please see Bulten & Decoene, 2015). Instead of viewing poor motivation as a contraindication to treatment, motivation should be evaluated and innovative treatment studies should be designed to enhance individual’s motivation for treatment.” (p. 157)

“A meta-analysis revealed that treatment responsivity indicators such as disruptive behavior during treatment and negative treatment attitudes were among the strongest predictors of increased attrition rates, while higher levels of motivation and treatment engagement predicted decreased attrition. Therefore, it is also important to measure progress in therapy in a uniform manner, with tools specifically developed for thera-peutic measurement, such as the Instrument for Forensic Treatment Evaluation (p. 157).

Other Interesting Tidbits for Researchers and Clinicians

“When comparing the groups with low, medium, and high psychopathic traits, a small significant difference was found, indicating that patients with more psychopathic traits were less compliant. However, when investigating the correlations between the PCL-R total, factor, and facet scores and non-compliance, no significant associations were found, which contradicts other research reporting associations with PCL-R total, Factor 1, and Factor 2 scores. The differences in the operationalization of non-compliance may have contributed to these different findings. Additionally, it should be noted that in the current study, non-compliance might have been underreported.” (p. 156)

“[L]imitations of this study warrant caution when interpreting and generalizing the current findings. First, the PCL-R scores used in the current study were field validity scores with a low IRR. This finding is generally consistent with a growing body of field research that suggests that the high levels of reliability reported in many controlled research studies are not generalizable to practice. However, it calls into question how reliable clinical scores truly are.” (p. 156)

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Authored by Kenny Gonzalez

Kenny Gonzalez is currently a master’s student in the Forensic Psychology program at John Jay College. His main research interest include forensic assessment, specifically violence risk. In the future, Kenny hopes to obtain a Phd in clinical forensic psychology and pursue a career in academia and practice.

Promising preliminary results for DBT in a forensic psychiatric setting

Dialectical behavior therapy (DBT) shows promising results in reducing aggressive behavior in a forensic psychiatric sample. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | International Journal of Forensic Mental Health | 2017, 1-12

The Potential for a Skills-Based Dialectical Behavior Therapy Program to Reduce Aggression, Anger, and Hostility in a Canadian Forensic Psychiatric Sample: A Pilot Study

Authors

Monica F. Tomlinson, The University of Western Ontario
Peter N. S. Hoaken, The University of Western Ontario

Abstract

Dialectical behavior therapy (DBT) is designed to target maladaptive behaviors, such as aggression. The present pilot study assessed whether DBT reduces aggression, anger, and hostility in a forensic psychiatric sample (N D 15). A randomized waitlist control pre-post/follow-up crossover design was employed. Group-level findings indicated a reduction in hostility during and following DBT. Individual- level findings indicated some reductions in aggression during and following DBT. Individual-level findings indicated that participants in DBT improved more on measures of aggression compared to participants in treatment as usual. These results are preliminary. Implications and future directions in research are discussed.

Keywords

Dialectical behavior therapy, forensic psychiatric patients, aggression, anger, hostility

Summary of the Research

“The forensic mental health care system in Canada is responsible for rehabilitating individuals who have engaged in criminal behavior and been found Not Criminally Responsible on Account of a Mental Disorder. Given that these individuals both suffer from severe mental disorders and have histories of criminal behavior, forensic psychiatric hospitals are tasked with the dual responsibility of treating their mental disorders and reducing their risk to society. Treatment in these settings primarily focuses on pharmacotherapy, which is less expensive, resource-intensive, and time consuming than psychotherapy. Pharmacotherapy also has more evidence than psychotherapy for treating primary psychotic disorders, which 70.9% of Canadian forensic psychiatric patients have as their primary diagnosis.” (p. 1)

“While pharmacotherapy is an evidence-based treatment for the primary psychotic diagnoses in these settings, there is little evidence that pharmacotherapy is effective in reducing antisocial behavior either in the hospital or out in the community. There is also little evidence that pharmacotherapy is effective for treating the secondary diagnoses that are equally prevalent among forensic psychiatric populations (e.g., personality disorders, substance use disorders). These secondary diagnoses are highly related to antisocial behavior both in the hospital and the community. The National Trajectory Project in Canada recently reviewed the diagnoses most related to recidivism among 1,800 forensic psychiatric patients and found that a primary psychiatric diagnosis had no influence on risk of recidivism, a substance use disorder increased risk by 1.41 and a personality disorder diagnosis increases risk by 1.48 (when the index offence was against a person as opposed to property). Therefore, the current pharmacotherapy focused approach to rehabilitation in forensic psychiatric hospitals is neither addressing the safety issues in these settings, nor is it addressing the diagnoses or behaviors most related to ongoing antisocial behaviors.” (p. 1)

“Recent research has suggested that evidence-based psychotherapeutic approaches which explicitly target aggressive behavior be incorporated into general psychiatric care in this population. Dialectical behavior therapy (DBT) has surfaced as among the most promising and theoretically appropriate group therapy programs for developing pro-social skills and decreasing antisocial behaviors.” (p. 2)

“DBT has been widely implemented with forensic psychiatric and correctional populations diagnosed with BPD and has been recently recommended to treat individuals with antisocial personality disorder, substance use disorders, and psychopathy. Importantly, DBT has also been deemed one of the most promising therapies for reducing treatment-interfering behaviors, such as physical aggression among individuals with BPD in forensic psychiatric and correctional settings.” (p. 2)

“The following study aims to provide initial evidence that offering a skills-only (i.e., without the individual therapy component) DBT group to a small, diagnostically diverse, forensic psychiatric sample can have both a statistically and clinically meaningful impact on reducing aggression. In this pilot study, the 1993 manual was closely followed. Typically, it takes approximately eight weeks to complete each of the four modules, and then all four modules are repeated. In this pilot, the DBT leaders covered all modules in 6 months (approximately 24 sessions), rather than the prescribed 32 sessions. The transition of patients into outpatient care happened too frequently to repeat all skills modules twice and still retain group members. Therefore, this pilot study will discuss the potential for a six-month, skills-only DBT group to reduce aggression in this sample.” (p. 3)

“Participants’ ages ranged from 28 to 63 years old. Twelve participants identified as Caucasian (80%), one identified as Aboriginal (7%), one as Asian/Pacific Islander (7%), and one as East Indian (7%). Participants had been under the supervision of the forensic mental health care system for an average of 3.6 years. Seven participants had less than a high school education (47%), five participants had a high school diploma (33%), and three participants (20%) had completed some post-secondary education.” (p. 6)

“While these data are preliminary, they demonstrate several interesting trends. First, among the participants who were improving during TAU, there is some indication that they either continued to improve during DBT or maintained their gains. Second, among the participants who were declining during TAU, many of them either continued to decline or moved into the “improvement” or “no change” groups during DBT. Third, among the individuals who remained stable during TAU, most of these individuals moved into the “improvement” group during DBT or remained stable throughout DBT. For example, the two participants who improved on anger during TAU moved into the “no change” group, and two of the three participants in the “no change” group moved into the “improvement” group and one stayed in the “no change” group during DBT. On the hostility measure, no patients improved in the six months before DBT, four patients remained stable, and three declined. During DBT, two patients moved into the “improvement” group, the majority remained stable, and one person continued to decline. During DBT, between 2 and 4 of the 13 participants clinically reliably improved on at least one measure.” (p. 8)

“Important trends were also noted in the six months following DBT. While the percentage of participants who improved was greater on most measures in DBT compared to TAU, it appears that the most improvements occurred in the months following DBT. For example, on impulsive aggression, no participants improved during TAU. In DBT, two participants improved, and during the six months following DBT, four participants showed clinically reliable improvement. In the six months following DBT, only one person declined on a measure of premediated aggression. No other patients declined on any of the measures in the six months following DBT. On measures of impulsive aggression, four participants from the “no change” group clinically reliably improved following DBT. These results suggest that the effects of DBT are most noticeable in the months following DBT, perhaps because patients are able to consolidate and synthesize their skills.” (p. 9)

Translating Research into Practice

“These preliminary findings offer an important starting point for future research. The paramount goal in forensic psychiatric hospitals is rehabilitation and successful, sustainable, reintegration back into society. This goal cannot be met with pharmacotherapy alone. Individuals in these settings need concrete skills with which to cope with the inevitable challenges of inpatient care and reintegration into society. Further, staff need evidence-based therapies for targeting behaviors that threaten safety within the hospital. Future research with larger sample sizes and a more stringent methodology are needed. With these very preliminary findings, the authors are hopeful that future, more methodologically rigorous studies, can help support the use of DBT for reducing aggression, anger, and hostility among forensic psychiatric patients both in forensic facilities and in society.” (p. 10)

Other Interesting Tidbits for Researchers and Clinicians

“When comparing the TAU and DBT groups during the first six months of the study, there is some indication that participants are improving during DBT, or are maintaining their pre-DBT scores. Given that several participants declined during TAU and no participants declined during DBT in the first six months, these results provide no suggestion that DBT is harmful for patients who are declining during TAU. These are important trends that, with a larger sample size, may be detected using more traditional statistical analyses.” (p. 9)

Join the Discussion

As always, please join the discussion below if you have thoughts or comments to add!

Authored by Kenny Gonzalez

Kenny Gonzalez is currently a master’s student in the Forensic Psychology program at John Jay College. His main research interest include forensic assessment, specifically violence risk. In the future, Kenny hopes to obtain a Phd in clinical forensic psychology and pursue a career in academia and practice.

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More Research Needed on Stigmas Faced by Forensic Psychiatric Patients

Forensic-Training-AcademyForensic psychiatric patients face three stigmas—mental illness, race, and criminal history—and there is a dearth of research focusing on these areas. This is the bottom line of a recently published article in International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

ijfmhFeatured Article | International Journal of Forensic Mental Health| 2014, Vol. 13, No. 1, 75-90

Triple Stigma of Forensic Psychiatric Patients: Mental Illness, Race, and Criminal History

Authors

Michelle L. West, John Jay College of Criminal Justice
Philip T. Yanos, John Jay College of Criminal Justice
Abby L. Mulay, Long Island University

Abstract

Stigma involves negative beliefs and devaluations of people in socially identified groups, which some people internalize. Research has increasingly explored mental illness self-stigma, when people with mental illness believe society’s negative beliefs are true of them (e.g., they are hopeless due to mental illness). Self-stigma predicts poorer functional and treatment outcomes. Forensic psychiatric patients experience multiple stigmas, yet no research has explored how stigmas due to mental illness, race, and criminal history influence each other. This review discusses relevant stigma research, which suggests that self-stigma in forensic psychiatric populations likely interferes with rehabilitation and avoiding re-arrest. Forensic psychiatric stigma is particularly relevant given increasing social attention on violence, incarceration, mental illness, and race. Conclusions discuss targets for future research.

Keywords

forensic psychiatric patients, mental illness, offenders, race, self-stigma, stigma

Summary of the Research

Individuals with a mental illness and a criminal history, labeled forensic psychiatric patients, endure stigmatization. Research has skimmed over stigmatizations and their influence on the wellbeing of these individuals; however, “expanding self-stigma research to a forensic psychiatric population could provide an opportunity to examine how different stigmas influence each other and the relative impact of these stigmas on self-concept and outcomes” (p .75).

The goal of this review was to “overview theory and research on stigma, self-concept, and how stigma impacts self-concept, as well as research on three stigmas that are particularly relevant in

forensic psychiatric populations” (p. 75). The three stigmas discussed are mental illness, racial stigma, and criminality stigma. Reactions to each stigma and self-stigma are discussed.

Mental Illness

People with mental illness are often seen as being inferior, violent, vulnerable, and unable to have romantic experiences or to contribute to society. Although Western cultures have attempted to minimize the stigma by attributing mental illness to biological factors, surveys have found that adults (in the United States and Australia) still view mental illnesses as dangerous and some have stated that they would prefer to minimize interactions with people who have a mental illness. However, research “indicates that the great majority of people (90% or more) with severe mental illness do not engage in any violent behavior and the remaining violence risk attributable to mental illness is small in contrast with more common characteristics such as age and gender” (p. 78).

People with mental illness face many challenges like finding adequate shelter and treatment. Stigmatization may also cause difficulties in developing a good mental health professional-patient relationship. Research has provided “evidence that mental health and medical professionals commonly exhibit negative attitudes towards people with mental illness. Stigmatization is likely particularly harmful coming from such caregivers” (p. 79).

Reactions to Mental Illness Stigma People who have mental illness are aware of the stigma. “Research indicates that about 90 percent of people with mental illness are aware of stigmatizing

views about mental illness, but stereotype consciousness by itself is generally unrelated to self-esteem and depression” (p .79). This may cause some individuals to be in denial of the diagnosis since it would mean “integrating the diagnosis into their self-concepts” (p. 79). Some individuals accept the illness as part of their identity in a positive manner, while others adopt the “illness identity.” The way that a person copes with the mental illness can play a strong influence in motivation, behavioral changes, and creating goals in therapy.

Self-stigma of Mental Illness-“One consequence of stigma is that people with mental illness may internalize stigmatizing beliefs” (p. 79). The stigma endorsement scale evaluates agreement with common negative attitudes towards mental illness, and the discrimination experience scale focuses on experiences with discrimination due to mental illness” (p. 80). Scales such as this and past research suggests there is self-stigma in individuals with mental illness. Self-esteem, self-efficacy, quality of life, individuals’ likelihood of becoming depressed and their ability to cope with mental illness are all factors that can be affected by their self-stigma.

Racial Stigma

Reactions to Racial Stigma– Racial stigmatization occurs through “its impact on the emotions, beliefs, and behaviors of racial minorities” (p. 81). Some individuals have come to expect racial discrimination, even from the government. Alas, it also results in emotional consequences such as individuals’ experiencing anger and the feeling of being disrespected. “Discrimination can have an emotional impact…and has been linked to negative consequences including mental and physical health problems, which in turn can negatively impact functioning” (p. 82). Stigmatization can also influence how a group perceives discrimination. Research has found that it could lead to drug use, fights, stereotype activation, and impaired performance on assessments of abilities.

Racial self-stigma– “Mental illness self-stigma may be more common than racial self-stigma, although no research directly compares them” (p. 82). Contrary to the strong evidence found in mental illness self-stigma, racial self-stigma has a low prevalence. “Possible reasons for lower

prevalence of this explicit racial self-stigma include the current rejection, at least overtly, of the legitimacy of racial discrimination, the relatively more positive racial minority role models, the relatively younger age at which race becomes integrated into self-concept, and the increased likelihood that children will learn coping skills for racial discrimination from family members. However, racial minorities may also internalize stigmatizing attitudes towards their racial group, perhaps especially the more implicit type of self-stigma” (p. 82).

Criminality Stigma

There is a dearth of research on stigmatization in criminality, “despite evidence of stigma against this group” (p. 83). Although it could be argued that hiding one’s criminal history is easier than hiding one’s race, criminal stigmatization can exist. For example, in the workforce past offenders are required to inform an employer of their criminal history. In a competitive job market, the chances of being hired with a criminal history are unlikely. More research on criminal stigmatization is needed, especially with adults. However, “there is evidence that stigma against offenders can limit social networks and supports. For instance, a longitudinal study of adolescents concluded that being labeled a criminal and the resulting stigma impacts peer networks, which in turn impacts future criminal involvement (p. 83).

Responses to Stigma of Criminality– “A large study of inmates near release found a general consensus of anticipated rejection by others in multiple social contexts, and participants in a qualitative study of stigma experiences of ex-offenders in higher education described fears about social and employment discrimination, and exhibited secrecy through attempts to hide their offense history and selectively choosing who to tell” (p. 83). Stigma against criminals may also affect their health, in terms of stress, coping, and social support. These factors “likely contribute to elevated suicide rates among recently released prisoners” (p. 83).

Self-stigma of Criminality-“Although the impact of stigma on offenders has been explored somewhat, research has largely not addressed the role of self-stigma in these outcomes” (p. 83). Research has studied the Labeling Theory as a means to explore the self-concept of criminality; however, this theory has remained unsupported in its claims about criminals changing identity due to being labeled offenders.

Translating Research into Practice

“Despite the multidimensionality of self-concept, less research has investigated the experiences of individuals with multiple stigmatized identities, including how they may affect each other, become internalized, and affect outcomes” (p. 83). Preliminary research has found that individuals with multiple stigmatized identities experience a unique set of difficulties in the real world. Forensic psychiatric patients are especially vulnerable to multiple stigmatized identities. Aside from being stigmatized for having a mental illness, they have to struggle with an “offender” label.

The present review found that research is beginning to focus on these three stigmas; however, it also underscored that “there is no research on self-stigma related to criminal offense history, nor is there an existing measure of this construct” (p. 84). There is also growing concern for mental health care providers and whether they hold these same stigmas for the patients they treat as this could be detrimental to the successful treatment of these patients, resulting in weak provider-patient relationships. Stigmatizations can damage an individual’s self-esteem and emotional balance. Providing empirical data to inform the mental care field and the general population about stigmas and of their negative influence could help forensic psychiatric patients navigate the outside world with more ease.

This review remains optimistic by concluding that “there is a growing body of research separately investigating stigmatizing attitudes towards relevant groups: people with mental illness, racial/ethnic minorities, and criminal offenders, including labeled individuals’ reactions to stigma ranging from empowerment to self-stigma. There is growing research on the impact of stigma on self-concept, particularly for mental illness stigma” (p. 84).

Other Interesting Tidbits for Researchers and Clinicians

Future research could focus on investigating self-stigma on mental illness, race, and criminality in the forensic population. Special attention should be paid to factors that could be affected by stigmatization such as depression, coping skills, social functioning, treatment-adherence, etc. In addition, research on addressing stigmatization and how to minimize its effects could prove to be beneficial for forensic psychiatric patients.

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Special Contributor

GaliciaBetsy-pictureContributions to this post were made by Betsy Galicia.

Betsy E. Galicia is a graduate student born and raised in Houston, Texas pursuing her MA in Forensic Psychology at John Jay College of Criminal Justice. She is interested in cultural differences in forensic assessments and cultural competency. She plans to write a thesis on these topics and go on to earn a doctoral degree. Other interests include traveling and exploring the world, going to parks, riding her bike, and re-reading The Giver by Lois Lowry.