Victimization experiences in the forensic mental health population; the impact of childhood abuse on adult psychopathology, and predictors of inpatient victimization
Background: Mental health services have undergone a paradigm shift in recognition of the widespread and long-lasting impact of trauma; changing the central question from “what is wrong with you?” to “what happened to you?” Though it has been shown that forensic mental health populations have high levels of trauma, it is a relatively under-researched population in comparison with other groups. This thesis portfolio therefore sought to add to the knowledge base considering forensic mental health populations experiences of trauma. This thesis portfolio consists of two chapters. The first is a systematic review of research exploring the association between childhood abuse and adult psychopathology in forensic psychiatric inpatients. The second presents an empirical project which aimed to explore incidents of victimization experienced by individuals whilst detained within a high secure forensic hospital, and identify potential risk factors for victimization within this environment based on existing victimization literature. Methods: The systematic review involved a comprehensive search of online databases of published research, to identify relevant papers against predefined inclusion criteria. The resulting 13 included papers were assessed for using two quality assessment tools, and their relevant findings extracted and synthesised. The empirical project consisted of a retrospective examination of a 5-year period, including all patients (n=278), and all incidents of peer-victimization recorded within this period. The victimized and non-victimized sub-samples were compared on demographic and clinical characteristics. Each individual’s history of childhood abuse, and current mental health diagnoses were extracted from their case files, and analysed to explore any association with victimization as an inpatient. Results: The systematic review found that the included studies were as generally acceptable quality, though some methodological weaknesses were identified. Prevalence of childhood abuse was found to be above that of the general population. Evidence was found of an association between childhood abuse and a range of mental health disorders; namely PTSD, personality disorders, psychopathy, suicidality and self-harming, and global psychological distress. The empirical project found that total days spent in the hospital by the end of the study period was associated with being victimized, as were diagnoses of a psychotic disorder, schizoaffective disorder, personality disorder, and intellectual impairment. Only days within the study and a diagnosis of intellectual impairment were found to be significantly associated with the number of victimizations experienced. The prevalence of PTSD within the sample was lower than expected, highlighting an ongoing under-recognition of trauma in this setting. Discussion: Both the systematic review and the empirical project highlight that this population is victimized at high levels in their childhood, and through into forensic inpatient care. Both chapters agree that screening for childhood abuse is essential within the forensic mental health population, and the empirical project highlights the need to recognise and respond to forensic inpatients as victims in the present. Those with an intellectual impairment were found to have an increased risk of victimization; this should be recognised and integrated into care planning. Limitations of both the review and empirical project are acknowledged, and recommendations for future research are provided.