Providentia

Helping the Homeless Mentally Ill

A study published in Schizophrenia Bulletin compared two contemporary approaches to linking housing and mental health services. In the integrated housing program, case management and housing services were provided by teams within a single agency and were closely coordinated. In the parallel housing condition, case management services were provided by mobile assertive community treatment teams and housing by routine community-based landlords. Adults with severe mental illness who were at high risk for homelessness (n = 121; 72.7% schizophrenia spectrum) were assigned randomly to integrated or parallel housing services and followed for 18 months. Integrated housing services led to more days of stable housing and greater life satisfaction than parallel housing services, especially for male participants. Integrated housing services were also associated with greater reductions in psychiatric symptoms. Closer integration between clinical and housing services, and greater use of supervised living settings, led to more time in stable housing for participants in the integrated housing services condition and was associated with greater gains in several outcome domains.

For the abstract.

Euthanasia Debate Re-kindled in India

Aruna Shanbaug had her entire life ahead of her. 

A pretty, vibrant 25-year old nurse, she was working at the King Edward Memorial Hospital in Mumbai, India and planning her wedding to a physician who worked at the same hospital.   All of her hopes ended on November 27, 1973 when she was attacked and sexually assaulted in the hospital basement.   Her attacker, a ward attendant named Sohanlal Bhartha Walmiki, had resented the way in which she criticized him for his work on the ward.   In the course of the attack, Walmiki choked Aruna with a dog chain and sodomized her.    The dog chain around Aruna's neck cut off the blood supply to her brain causing severe brain damage.    After stealing her earrings, Walmiki left her lying in a pool of blood and she was eventually discovered by a cleaner the following morning.   Medical examination determined that she had sustained permanent damage to her brain stem, and cervical cord.  In addition to cortical blindness, Aruna Shanbaug was left in a persistent vegetative state and has remained confined to a hospital bed at King Edward Memorial Hospital since 1973.

Sohanlal Bharth Walmiki was arrested and charged for attempted murder and robbery.  Since details of the sodomy were concealed by the attending physicians at the direction of the hospital (possibly to avoid potential social rejection of the victim), Walmiki was convicted to two-consecutive seven-year terms for assault and robbery.    Under Indian law,  he was not tried for rape or molestation which might have earned him a longer sentence.    Aruna Shanbaug's case has been the center of controversy for years.    Immediately after the attack, Mumbai nurses went on strike to ensure her continued care as well as for safer working conditions for themselves.    Following efforts to move her out of the hospital to free up the bed, nurses protested again and the plan was dropped. 

Aruna Shanbaug faded from public memory until 1998 when journalist Pinki Virani wrote a book which reignited interested in her case.  Working on Aruna's behalf, Verani filed a plea with India's Apex court to allow for euthanasia and to stop the hospital from force-feeding her.   Despite opposition from doctors and nurses at the hospital, the claim was admitted to the Supreme Court in 2009.    The plea was finally addressed on January 24, 2011 and a medical panel was set up to examine Aruna.   On March 7, the court rejected Verani's plea but, in a landmark ruling, allowed for passive euthanasia in extraordinary cases to be decided by the Supreme Court on a case-by-case basis.

As for Aruna Shanbaug, the court battle over her fate has stirred up an emotional battle with supporters on both sides expressing outrage over the facts of the case and Pinki Verani's crusade to end Aruna's life.   Since none of Aruna's family members have been involved in her care for decades, the  staff at King Edward Memorial Hospital have become her substitute family and seem willing to continue to maintain her life.   

In the meantime, Aruna remains in her hospital bed where she has survived for the past thirty-seven years.  There is no indication that she is even aware of her surroundings, or the fight to end her existence. 

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How Does Offender Treatment Affect Recidivism?

The failure of offenders to complete psychological treatment can pose significant concerns, including increased risk for recidivism. Although a large literature identifying predictors of offender treatment attrition has accumulated, there has yet to be a comprehensive quantitative review.  A paper published in the Journal of Consulting and Clinical Psychology presents a meta-analysis of the offender treatment literature that was conducted to identify predictors of offender treatment attrition and examine its relationship to recidivism. The review covered 114 studies representing 41,438 offenders. Sex offender and domestic violence programs were also examined separately given their large independent literatures. Results showed that the overall attrition rate was 27.1% across all programs (k = 96), 27.6% from sex offender programs (k = 34), and 37.8% from domestic violence programs (k = 35). Rates increased when preprogram attrition was considered. Significant predictors included demographic characteristics (e.g., age, rw = −.10), criminal history and personality variables (e.g., prior offenses, rw = .14; antisocial personality, rw = .14), psychological concerns (e.g., intelligence, rw = −.14), risk assessment measures (e.g., Statistical Information on Recidivism scale, rw =.18), and treatment-related attitudes and behaviors (e.g., motivation, rw = −.13). Results also indicated that treatment noncompleters were higher risk offenders and attrition from all programs significantly predicted several recidivism outcomes ranging from rw = .08 to .23. The authors concluded that clients who stand to benefit the most from treatment (i.e., high-risk, high-needs) are the least likely to complete it. Offender treatment attrition can be managed and clients can be retained through an awareness of, and attention to, key predictors of attrition and adherence to responsivity considerations

For the abstract.

Texas Woman Convicted in Daughter's Exorcism Death

A twenty-year old  Lake Cherokee, Texas woman has been sentenced to life in prison without parole for her role in the gruesome assault and beating death of her thirteen-month old daughter.  Jesseca  Carson was found guilty of capital murder in a unanimous jury decision relating to the December 2008 death of her daughter, Amora.   Carson's boyfriend, Blaine Milam, is on death row for beating Amora to death with a hammer in what he claimed to be an exorcism.   While it was Milam who actually beat the infant to death, Carson was conicted for aiding and abetting the crime.

In the often-graphic testimony presented to the jury, prosecutors described Carson as a woman who "sacrificed her child to a monster".    Members of the jury reacted with gasps at pictures of Amora's beaten body which were shown during the trial.  Several jury members later commented that they would be permanently affected by the testimony which was presented.   While defence attorneys attempted to portray her as someone dominated by an abusive boyfriend who convinced her that her daughter was possessed by a demon, prosecutors maintained that the exorcism was Carson's idea.  It remains unclear what had led Carson and Milam to decide that Amora was possessed and their "exorcism" involved repeatedly striking the infant with a hammer and other tools.  There were also repeated bite marks on Amora's body which had been reportedly inflicted while Milam "screamed Jesus' name" to drive out the demons.    After Amora was dead, Carson and Milam left the body on their bedroom floor while they went to a pawn shop to raise money for a professional exorcist.   Police were called in and found Amora's body at the  home where she had lived with her mother and stepfather.  According to one police source, "the child had been beaten so much we couldn’t tell how many times she had been hit. And then she had more than 20 bite marks on her body".   Although Milam and Carson repeatedly changed their story over how Amora died,  Jessica Carson finally confessed the truth although she maintained that the exorcism had been necessary.

Blaine Milam had been previously convicted of aggravated sexual assault on a fourteen-year old but had not been registered as a sex offender at the time of Amora's murder.   His probation order banned him from any contact with children outside his own family.  Friends of Jesseca Carson state that she had become increasingly withdrawn in the months leading up to Amora's death and that police had been called to their home of several previous occasions over allegations of domestic violence.

 

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Does a Change in Marital Status Affect Suicide Risk?

Research has consistently shown that abrupt changes in our personal and social life can have a disruptive impact on emotional health.  While positive life changes such as marriage can aid in recovery, negative life changees can result in increased risk of breakdown and/or suicide.  In particular, abrupt changes in marital status have been associated with different levels of suicidal risk.  A study published in a recent issue of Crisis: The  Journal of Crisis Intervention and Suicide Prevention examined the effect of marital status change in relation to suicidal behavior.   The study used a sample of 1614 suicide victims wh0 died in Slovenia between the years 2002 and 2004 and 4617 matched control who were compared for incidence and recency of marital status change during the last 5 years of their lives. Results showed that a higher percentage of suicide victims (10.7%) had a marital status change in the last 5 years compared with the controls (5.6%). All types of marital status changes (becoming widowed, getting divorced, getting married) proved to be risk factors for suicidal behavior. Almost half of all marital status changes in suicide victims occurred in the year prior to suicide, whereas marital status changes in the control group were equally distributed over the last 5 years. For recently married and divorced people, the increase in suicide risk depended on age: The risk was higher in older people.  The authors conclude that marital status change represents a risk factor for suicidal behavior.  46% of suicide victims who had suffered the loss of a spouse committed suicide in the year after becoming widowed; and that 37% of suicide victims who had got divorced committed suicide in the year following the divorce. Both events, becoming widowed and getting divorced, were probably preceded by other concurrent events such as illness (in the case of a spouse loss) or relationship and family problems (in the case of divorce), which could have facilitated the suicide process. The first year after the change is critical for elevated suicidal risk, in particular for older people.

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Into San Pedro Prison

The following is a guest post by Allison Gamble.  You can read more of Allison's posts at forensicpsychology.net.

If you were to set foot inside the walls of San Pedro prison, you’d see that it’s unlike any other correctional facility in the world. It’s the largest prison in La Paz, Bolivia and well-known for its micro-society that dwells within its walls. The prison is divided into eight sectors, with some rooms being large and comfortable, while others are small and cramped. Approximately 1,500 inmates reside within San Pedro prison and the majority of them are jailed for drug-related charges.

Upon arriving at the facility, San Pedro appears to be like any other correctional facility, with plenty of guards, thick walls and security gates. Yet on the inside, San Pedro looks more like a poor neighborhood in Bolivia than a prison; the streets are lined with children, marketplaces, restaurants and even a hotel.

This unusual setting has received much attention on a global level, particularly from those in the field of forensic psychology, as opponents have challenged how felons, many of whom are awaiting trial, can coexist within these prison walls without much intervention from police. In fact, inside the facility there are no guards, uniforms or metal bars on the jail cells. Instead, the inmates govern the facility. It would seem as if San Pedro were a correctional facility that granted freedom.

Earning a Living

Although San Pedro offers a great deal of freedom for its inmates, this freedom comes at a price. The micro-society that exists within these prison walls operates just like any society would. Inmates must pay for their prison cells, which means the luxurious ones can only be obtained only by those who make enough money. To acquire an income, inmates work inside of the facility carrying out such tasks as selling groceries, being a hairdresser or repairing TVs and radios.

Those inmates who are fortunate enough to make decent a living within the facility have the ability to purchase the higher-end cells, which are large and contain private bathrooms and cable TV. These inmates also have access to a lively outside area, with pool tables, food stalls and kiosks that sell fresh juice. For the rest of the inmates, the prison cells rival what a cell would look like in any other prison, but worse. They’re small, cramped and several inmates have to share the space. However, it’s not just organized work that allows prison inmates to make their own money. With access to cocaine base, inmates are able to sell the cocaine and make a substantial amount of money. Indeed, the drugs are sold within the facility, but the biggest source of revenue comes from tourists who enter the prison to purchase cocaine.

Family Life

It’s not just the way this micro-society lives and works that makes them the center of attention. ABC.net.au reports that prison inmates also have the freedom to let their families live with them. Children are found playing in the streets, attending schools both inside and outside of the facility and are cared for by the nursery staff.  Although the advantages of providing a family-like environment may seem to offer security to young children, this is far from the truth.

Children often live with their fathers in San Pedro because their mothers have been sent to a different prison facility or have abandoned them. According to BBC News , the children often suffer sexual abuse and violence, causing them to fear for their safety. If the children are able to attend school outside of San Pedro, they become the source of discrimination. This less-than-ideal scenario is seen far too often, but some fathers do try to provide a stable life for their children within this micro-society.

Opposing Views

The bizarre structure of San Pedro prison has made it a frequent source of discussion. On one hand, the freedom the inmates have to run their own society makes the prison one of the safest in Bolivia. It allows the inmates to live a structured life, working, making a living and obeying certain laws. The inmates not only make their own rules, but they elect a leader and financial secretary.

Still, the prison is dangerous, with a high rate of violence and no intervention from police. Approximately four deaths a month occur due to to natural causes or accidents. Fortunately, the streets are relatively safe during the day as children play, but become more dangerous at night. Drugs are also readily accepted and done outwardly on the prison streets.

The Changing Face of San Pedro

In an effort to reduce corruption, the prison is being heavily monitored and has disallowed any of the tours which acted as a major source of revenue.  As a result, inmates at the prison fear that this will cause their lives to change for the worse. With no more tours coming in, there will be fewer ways to make money and fewer opportunities to develop relationships.  As such, inmates are worried the conditions will deteriorate and mimic a standard Bolivian jail. These fears are what make San Pedro so compelling since the inmates actually enjoy living there. In fact, inmates are often so comfortable at San Pedro, they don’t mind awaiting trial. They’ve learned to live according to a new set of laws and appreciate the mini-society that allows them to live, work and raise a family. Returning to the streets of Bolivia no longer seems a viable option.

A recent article from Guardian.co.uk discusses the inmates’ concerns over the changing dynamics of San Pedro prison. This has raised awareness that inmates hardly view the prison as such and instead consider San Pedro to be an acceptable society. Authorities worry that with this approach; inmates will struggle to integrate into Bolivian society again. The social order that takes place at San Pedro is compelling. Inmates are left to fend for themselves, while learning to adapt to a new society. Even with the violence, crime and drug use, San Pedro is home to many families and offers a safer and more tolerable living arrangement than the streets of Bolivia. This unique set-up may actually decrease psychological damage in the long run for these inmates and their families.

Do Socioeconomic Factors Affect Pain?

Socioeconomic disparities in pain may be attributable to both greater frequency in stressful financial events as well as greater vulnerability to economic hardship for those at the lower end of the socioeconomic spectrum. A study published in a recent issue of Health Psychology investigated the effects of economic hardship and daily financial worry on daily pain among women with a chronic musculoskeletal condition.  The sample consisted of 250 women with osteoarthritis (N = 105), fibromyalgia (N = 46), or both (N = 99). During an initial assessment, participants' chronic pain diagnosis, level of economic hardship, and demographic information were ascertained. For a period of 30 days, daily diary assessments recorded daily financial worries and daily pain severity. Statistical analysis of results showed that conditions of economic hardship and daily ratings of financial worry both had significant detrimental effects on daily pain. Participants with greater levels of economic hardship reported greater pain severity in response to daily financial worries than their counterparts with little or no economic hardship. Further, participants in the sample who were not employed and who reported higher levels of economic hardship exhibited the most pain reactivity in response to daily financial worries. The authors concluded that economic hardship was associated not only with greater exposure to daily financial worries but also with greater vulnerability to pain on days when daily financial worries were experienced

For the abstract.

Mental Health Concerns Mount in Japan

Mental health experts warn that the continuing humanitarian crisis in Japan is taking a heavy psychological toll on survivors.  With an estimated 27,500 dead or missing following the devastating March 11 earthquake and tsunami, thousands remain homeless in makeshift camps with minimal resources available.  Despondency and depression are becoming increasingly common as survivors recognize that their plight will likely continue for an indefinite period of time.   According to one volunteer doctor at a shelter in the heavily effected Iwate Prefecture, 

"For a lot of people who, up until this point, have been able to ignore reality and what actually happened, as they get back on their feet they realize that, for instance, their house is gone or their children are dead and they're being forced to confront these facts.  A lot of them are extremely uncertain as to what they can do".    

Despite a massive humanitarian relief effort to house, feed, and clothe survivors, there are few resources available for mental health services.  Posttraumatic symptoms remain common with many survivors being afraid to sleep at night out of fear of earthquakes.   This fear is compounded by the hundreds of aftershocks recorded since March 11 and the continuing nuclear crisis at the Fukushima reactor site.   Survivors often report sleeping fully clothed and are easily startled by even routine noises in their environmet.  While psychological counseling centres have been set up at many disaster evacuee sites, with posters describing possible symptoms of posttraumatic stress,  there are an inadequate number of  counselors.   Survivors often report being unable to find volunteer counselors when needed and are forced to cope on their own as a result.  

Inadequate mental health services has been a common feature of similar disasters in other countries around the Pacific ring of fire.  The psychological aftermath of previous earthquakes, including the Kobe earthquake in 1995, the 2004 Indian Ocean earthquake and tsunami, and the 2008 earthquake in China's Sichuan province have all left scars on survivors which continue to this day.   Children and the elderly are particularly vulnerable to physical problems resulting from mental stress.  To assist child evacuees, the Japanese government is working to reopen schools in areas affected by the tsumani.  Officials remain confident that  school will be open for children by the time classes begin on April 12 to help children resume their normal life.   While teachers and school administers are aware of the psychological problems their children face, the road to recovery is likely to be long. 

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The Bedridden Activist (Part 2)

Continued from Part 1

Aside from the health reforms and support for public nursing that were her main causes in life, Florence Nightingale also involved herself in a number of side causes, including economic reform to relieve poverty.  She often cajoled legislators into passing legislation that she supported (both in terms of lending her support and threatening unfriendly politicans with adverse publicity if they failed to see things her way).    Despite being a public figure, she remained an intensely private person and often preferred to act anonymously whenever possible.    Her chronic illness (which remain undiagnosed during her lifetime) made her feel old before her time and, in her letters, she often described herself as elderly even at a relatively young age.   Being an invalid didn't prevent her from caring for herself though and she often did many of her own household chores. 

Florence Nightingale also never accepted payment for her activism and remained dependant on inherited money to support herself.  This may have been one of the reasons for her adamant opposition to the registration of  nurses (she considered nursing to be a calling rather than a profession).  Arguing that nursing required a special aptitude that could not be effectively taught was not a popular position to take.  Even after nursing registration became mandatory, she emphasized that nursing was continually evolving and encouraged lifelong learning so that nurses could keep their skills up to date.   Her "Nightingale system of education" proved to be popular and she encouraged the founding of nursing schools throughout the British Empire and in the United States. 

That wasn't to say that her life was entirely given to public service.  She had a longstanding feud with the owner of a pub across the street from her modest home in London.  The "disgraceful" behaviour of the pub's patrons and the noise of their antics which continued late into the night was a constant source of vexation for her.  Florence Nightingale's status as a public heroine didn't seem to deter the pubowner and his customers in the least.  Her strong Victorian attitudes regarding the evils of alcohol probably didn't help either.  She was also an absolute perfectionist and insisted on cleanliness and order in her household and in the various homes and public building that she visited.   Despite her strong views on many issues, she remained fiercely loyal to her small circle of family members and friends and often provided financial support when she could.  She was also devoted to animal welfare (she owned cats all her life) and many of her surviving letters show her concern about the poor  veterinary care available at the time.

By 1900, Florence Nightingale was completely blind and more dependent on her personal staff than ever.   When financial problems forced her to "retrench" and let her nurse go, it was a personal blow for her but she managed to live her remaining years in comfort.   For the last ten years of her life, she was an almost total invalid with little real writing completed.   Her memory had become so poor that she needed to be briefed on any new visitor that she received.   The India Office was instructed to stop sending her material in 1906 since she could no longer understand them.  When Florence Nightingale died on August 13, 1910,  she left behind an amazing legacy of public service and writing (although many of her papers were destroyed at her death as she had requested).    While she also left behind instructions that her body be used for medical research, her wishes were ignored and she was buried in her family church in East Wellow.   The grave marker simply states, "F.N. Born 12 May 1820, Died 13 August 1910.”

Aside from her achievements,  Florence Nightingale also left behind a medical mystery.   What was the disease that left her an invalid for much of her life?   Given the lack of proper diagnostic tests at the time and the variable nature of her symptoms,  many of her later biographers suggested that her illness was largely psychosomatic.   Given the number of soldiers in her care who had died as a direct result of her reluctance to recognize the need for proper sanitation (which she freely admitted in her commission work), the theory that her symptoms stemmed from depression became popular for a time.   Even up to 1899, the Encyclopedia Britannica article on her stated that "it has never been shown that Florence Nightingale had any organic illness; her invalidism may have been partly neurotic and partly intentional."    Her tendency to worsen whenever she experienced emotional turmoil also resulted in accusations of deliberate malingering  (she was often referred to as  a "strategic invalid").   

The current medical consensus seems to be that her  symptoms stemmed from a serious attack of brucellosis (also known as "Crimean fever") during her time in Turkey.   Believed to be the result of her exposure to infected meat or unsterilized milk,  the acute phase of the disease can be marked by severe headaches, anemia, depression, and weakness.   Although she recovered enough to carry on her nursing work,  the damage left behind by the disease would stay with her for the rest of her life.   Considering that brucellosis is still rare in industrialized countries, it's hardly surprising that her condition was never properly diagnosed in her lifetime.  There has also been speculation that she suffered from chronic fatigue syndrome or myalgic encephalomyelitis and the Nightingale Research Foundation continues to fund research into those two diseases in her name.

Whatever the actual diagnosis, there is no doubt that Florence Nightingale's ability to carry on her reform work while dealing with such a debilitating disease remains inspirational.  The annual International Nurses Day is stll celebrated each year on her birthday.