Individuals with dual diagnoses (intellectual disability with mental health issues) tend to represent extensive and formidable treatment challenges for clinicians. Often, they are not able to clearly articulate their internal experiences and feelings, and may be more likely to exhibit problematic or criminal behaviors. It is not surprising that some individuals with dual diagnoses come into contact with the criminal justice system. However, due to their impaired cognition, poor judgment, and lack of self-defense skills, they may falsely or quickly confess, have difficulty understanding their rights, and make decisions without counsel.
The prospect of providing appropriate care for forensic patients with dual diagnoses who may pose a risk of harm to others evokes considerable anxiety among many clinicians, including nurses. Therefore, it is important for nurses caring for this marginalized population to be aware of and equipped with the knowledge and expertise to respond to their special needs and legal issues. Nurses must also take a leading role in advocating for such clients, given inherent systemic inequalities that have historically limited client access to appropriate resources.
In this article, we describe the mental health needs of people with developmental disabilities from a nursing perspective, identify risk factors that contribute to their risk for problematic or criminal behavior, and discuss the challenges in providing client-centered care to forensic patients with dual diagnoses.
During the past 2 decades, profound changes have occurred in the provision of services to individuals with developmental disabilities. In 1987, the Ontario government released a document entitled, Challenges and Opportunities: Community Living for People with Developmental Handicaps (Ontario Ministry of Community and Social Services, 1987), which outlined key goals for the provision of services to individuals with disabilities in their home communities. Enormous optimism that individuals with developmental disabilities would benefit from shifting care away from institutions to community settings accompanied this publication. It also paved the way for the closure or downsizing of institutions and the development of comprehensive community services for these individuals (Bradley & Summers, 2003).
Although many individuals with developmental disabilities benefited from this paradigm shift, the number of individuals with developmental disabilities in the criminal justice system is a disappointing indication of the inadvertent consequences of such deinstitutionalization. In fact, it has been argued that a full evaluation of community mental health initiatives to address the mental health needs of individuals with developmental disabilities is essential to determining the success and extent of deinstitutionalization (Bradley & Summers, 2003; Minnes, Nachshen, & Woodford, 2003).
Developmental Disability and Mental Illness
In Ontario, the term “developmental disability” is used to describe individuals who have limitations in the area of intellectual functioning (IQ of ⩽70) with concurrent loss or impairment of two or more adaptive skills (e.g., communication; self-care; home, work, social, or functioning academic skills; appropriate use of community resources; self-direction; health and safety) and onset before age 18. Cutler (2001) asserted that the prevalence of mental illness among people with developmental disabilities is greater than in the general population. Morris (2003) affirmed that, in Ontario, it is estimated that 2.25% (247,000) of the general population has a developmental disability and 38% (93,000) of these individuals have a dual diagnosis.
Individuals with dual diagnoses (developmental disability and mental health issues) tend to represent extensive and formidable treatment challenges for clinicians. Frequently, these individuals have communication difficulties and often cannot relate feelings of pain or illness, which are commonly missed by their caregivers and clinicians. Therefore, they may express their physical pain and discom fort by exhibiting challenging behaviors (e.g., aggression, property destruction, self-injurious behavior) (Bradley & Summers, 2003). Characteristics of people with developmental disabilities, such as poor judgment, low frustration tolerance, and lack of impulse control, compounded by the symptoms of a mental illness, contribute to their susceptibility to problematic or criminal behaviors.
Barron, Hassiotis, and Banes (2002) contended that naïveté among individuals with dual diagnoses is a contributing factor to criminal behavior. It is not surprising that some of these individuals come in contact with the criminal justice system. In addition, due to their impaired cognition, these individuals are at risk for falsely confessing or confessing too quickly, vulnerable to suggestive questioning, may frequently change their answers, have difficulty understanding their rights, and make decisions without counsel (Barron et al., 2002).
Historically, a societal assumption was that a relationship existed between “feeble-mindedness” and criminal behavior. Such assumptions were attributed to the behaviors exhibited by individuals with developmental disabilities, which were considered “eccentric” or challenging. Consequently, these individuals were labeled deviant, and their presence tended to evoke public anxiety and fear.
Today, because of their limited ability to advocate for their own needs, most individuals with dual diagnoses are financially and socially disadvantaged, live in impoverished surroundings, and lack necessary treatment (Holland, Clare, & Mukhopadhyay, 2002). Labeling and rejection increase their marginalization and likelihood of either being admitted to hospital or incarcerated. Institutionalization or incarceration may further hamper any independent living skills individuals with developmental disabilities may have gained from group care facilities or outpatient skill-oriented treatment programs.
The following example will highlight the unique nursing role in the provision of client-centered care to a forensic patient with a dual diagnosis.
Josh (name changed for anonymity purposes), a 28-year-old, single man, lives with his father and receives government financial assistance. He was significantly delayed in his developmental milestones, and a psychological assessment suggested he had a moderate developmental disability (i.e., IQ 35–40 to 50–55) with speech and motor delays. Josh had difficulties in school. He displayed an inability to follow school rules and regulations, and was frequently uncooperative with his teachers and schoolmates.
As an adolescent, his behavior at home became more problematic and difficult to manage. This prompted his aunt to place Josh in a group home. However, his behavior deteriorated further. After several months in the group home, Josh moved in with his father. Since he left the group home and returned to his father's care, his aggressive behavior was a constant concern. Josh's father also has a developmental disability. His aunt had assumed the role of Josh's primary caregiver.
His aunt was unable to offer as much support to Josh because of her own physical illness. This led to Josh's marked physical and emotional deterioration. In addition, Josh and his father had difficulties restraining their behavior and often became verbally and physically aggressive toward each other. Finally, Josh's family and the outpatient treatment team made the decision to hospitalize Josh for psychiatric stabilization.
In the fall of 1999, Josh allegedly entered an apartment building to pursue an 8-year-old boy. Josh grabbed the boy's hat and pushed him against the wall. The boy went home very upset and told his parents what had happened. His parents called the police, and Josh was charged with robbery and assault. A psychiatric assessment was performed at the request of the court, preceding the fitness hearing. Josh was found unfit to stand trial and was placed under the jurisdiction of the Ontario Review Board (ORB). The ORB ordered that Josh be discharged, with conditions that he should reside with his family, keep the peace, and exhibit good behavior.
Since that disposition, Josh was admitted twice to the hospital. With little supervision, structure, and support in the community, as described above, Josh experienced significant deterioration in his physical and mental status and became a community risk.
Admission to the Inpatient Unit
On the day of his admission, Josh appeared disheveled and anxious, smelled of urine, had been shouting and crying, and spat at one of the nurses. On several occasions, Josh was found screaming, arguing, and involved in physical altercations with other patients. He frequently spent hours on the telephone with his father, and when he was asked to leave by one of the other patients, he threw the telephone book on the floor. He kicked the nursing station door and hit or punched staff members when his needs were not immediately met. Occasionally, Josh would require p.r.n. dosages of lorazepam and locked seclusion to help calm him. He also had difficulty understanding personal-space boundaries. The other patients reported that he was invading their personal space by constantly hugging them, despite their resistance.
After several months in a general forensic unit without noticeable improvement in his behavior, Josh was referred to a specialized program in which staff could assess and address his needs. Subsequently, Josh was admitted to the dual diagnosis unit.
Specialized Dual Diagnosis Unit
To achieve success with individuals with dual diagnosis, clinicians need an accurate diagnosis, appropriate treatment strategies, and understanding of the environmental and developmental factors that caused the crisis to occur. In formulating clients' diagnoses, experienced clinicians give more weight to nonverbal clinical manifestations of behavior and information from the clients' caregivers. Clinicians who are unfamiliar with normal manifestations of behavior in individuals with development disabilities may inaccurately attribute observed psychiatric symptoms to a developmental disability, rather than to mental illness (the phenomenon of diagnostic overshadowing). Therefore, inexperienced clinicians may overmedicate or undertreat these individuals (Bradley & Summers, 2003).
Evidence indicates that readily available resources and specialized expertise in the area of dual diagnosis (e.g., assessment of individuals and their behaviors, promoting behavioral change) are necessary to provide the best quality of care to this vulnerable group. These specialized services can also provide relief and support for caregivers (Griffith, Taillon-Wasmund, & Smith, 2002).
Josh was able to mask the severity of his impairment and draw from his strengths (i.e., create a “cloak of competence,” by which he presented himself as higher functioning or more competent than he actually was), which led to high expectations of him from others. He presented himself with confidence related to the independent management of his daily tasks, but after further assessment by the interdisciplinary team, it was determined that Josh needed extensive supervision and follow up to be able to do so. Psychological testing confirmed he had significant cognitive delay, was limited in his receptive and expressive communication, and had inadequate, if any, understanding of the court system and its ramifications, despite efforts to teach him.
Individuals with dual diagnoses need more resources, extra clinical time, interpreters, and advocates. In addition, they tend to have longer lengths of hospital stay and are difficult to discharge due to the severity of their problems, nonadherence to treatment regimens, increased rule infractions, and lack of suitable placement and support systems to which to discharge (Benner, 2001; Griffith et al., 2002).
Josh's nurse crafted a flexible, realistic, efficient, individualized treatment plan that provided adequate structure and less restrictive and intrusive supervision. Treatment goals were established, such as life skills and risk management (prevention of reoffense). Josh's treatment plan was properly documented and communicated to team members, thus promoting consistency (e.g., defining risk behavior). Perseverance, creativity, and the capacity to adapt treatment strategies to Josh's abilities were important in helping him achieve his goals. Collaboration and coordination among team members was needed, particularly related to decision making about the appropriate level of supervision. The individualized treatment plan was periodically reviewed and revised according to Josh's needs (e.g., managing risk factors) (Benner, 2001).
The therapeutic alliance plays a crucial role in achieving optimal client outcomes. Setting boundaries; displaying firmness, consistency, and perseverance; and demonstrating positive regard and empathy are vital to ensuring forensic clients' adherence to their treatment plans (Martin & Street, 2003). However, it would be imprudent not to acknowledge that one of the characteristics of people with dual diagnoses is dependence on others for support. Developing a collaborative relationship with members of their support systems can help such clients achieve improved functioning and quality of life. Considerable evidence indicates that suitable, coordinated, and progressive supports reduce the degree of client disability, help maintain mental status stability, and prevent reoffense (Cutler, 2001; Griffith & Gardner, 2002).
Role of the Family
The dynamic role of the family throughout the lives of people with dual diagnoses cannot be overstated. Some families assume the role of advocates for the individuals' needs, but all families are different and have diverse needs. Much of Josh's aunt's time and energy were spent caring for him, while trying to meet other family members' needs. It was essential for Josh's nurse to provide psychoeducation and adequate, accurate information about respite services, listen to his family's concerns, teach basic relapse prevention strategies, and prioritize and respect the family's wishes in planning and implementing Josh's treatment plan (Benner, 2001; Minnes et al., 2003). The enormous responsibility of families in caring for individuals with dual diagnoses who are involved in the criminal justice system is often both physically and emotionally exhausting. Linking Josh's aunt to professional and social agencies and support groups was extremely beneficial in attending to her own needs and mitigating her stress.
In a dual diagnosis unit, it is not unusual for members of the interdisciplinary team to consider clients' families or primary health care providers as a source of frustration and perceive them as challenging. Families and providers sometimes demonstrate overt hostility toward staff members, such as sarcasm and verbal abuse (Dale Munro, 2003).
Josh's father's behaviors had a negative effect on Josh's treatment and care. He was overprotective of Josh and frequently threatened to take his son away from the hospital. He also once advised Josh not to take his medications and gave him a bottle of his own prescribed medication. After careful analysis of the situation, a family meeting was arranged, and an agreement was reached that his father's bags would be checked and searched prior to his visits with Josh.
Nurses found the practice of self-reflection and objectivity valuable, particularly when they felt provoked toward defensiveness (Dale Munro, 2003). Accordingly, Josh's nurse avoided power struggles, set boundaries, and maintained professional perspectives by focusing on Josh's needs. In addition, she drew support from other members of the interdisciplinary team by discussing her disappointments and frustrations during clinical team reviews and primary patient care meetings, thus lessening her risk for burnout.
Mounting evidence suggests that a repertoire of skills is needed to provide effective and competent care to people with dual diagnoses. Knowledge and acceptance of personal limitations is necessary and allowed Josh's nurse to become cognizant of numerous resources available within the interdisciplinary team. Josh's nurse was open to the experiences of her colleagues, acknowledged their clinical expertise, and recognized that each professional is a valued, equal partner within the team. She was able to pool the skills of her team members to achieve positive patient outcomes.
Given the complexity of needs inherent in this underserved client population, nurses must have a certain degree of clinical proficiency and be able to move beyond traditional nursing skills to include approaches that involve detection and management of risk for problematic or criminal behavior. Risk assessment entails ascertaining the presence of past or current risk factors for such behavior, as well as the likelihood of reoffense. Nurses should also know that conducting risk assessments for this patient population may take time and could involve modifying risk assessments to the clients' abilities (Benner, 2001). Determining risk for problematic or criminal behavior requires detailed attention to each individual's cognitive ability, physical condition, personality, social functioning, communication ability, psychiatric history, previous criminal offenses, and the nature of the index offense. It is significant to consider that there is a propensity for individuals with dual diagnoses to be impulsive and misread social cues that predispose them to aggression and interpersonal conflicts with staff and other patients (Johnston, 2002).
The importance of helping people with dual diagnoses, including Josh, to understand the contributing factors that lead to offending behavior must not be overlooked. Knowledge of risk factors can assist in the provision of appropriate treatment and the prevention of recidivism. Because of Josh's moderate to severe level of disability and limited intellect, he will continue to have some difficulties with impulse control and frustration tolerance. His legal history indicated that strong attachment to his father and lack of structure in the home contributed to his problematic behavior.
Effective clinical treatment, risk management, and habilitation of individuals with dual diagnoses require multimodal treatment strategies (Griffith et al., 2002). Such strategies may be implemented concurrently or consecutively, and may have a number of goals, including minimizing the effects of or reducing the incidence of problematic or criminal behaviors, maintaining the individuals' and others' safety, and improving clients' quality of life (Johnston, 2002). A brief discussion of some of these strategies follows.
Milieu Management. Environment plays a key role in helping people with dual diagnoses develop prosocial behaviors. Because of Josh's developmental disability and coping skill deficits, he was prone to psychological problems associated with anxiety and frustration, and was sensitive to environmental changes (e.g., noise, overcrowding, heat, smells). By proactively addressing the milieu and maintaining a well-defined, consistent, structured, and safe environment, Josh gradually developed positive coping and social skills (Griffiths & Gardner, 2002).
A pleasant environment was created, as much as possible, in which Josh could communicate his concerns. The nurse was flexible and acted appropriately in conveying messages to Josh in a way that he understood (i.e., using simple words and short sentences) and which fit the circumstance. Josh's nurse did not consider her interactions with Josh complete until she received feedback that he understood the message.
Individual and Group Psychotherapy. Some authors maintain that individual and group psychotherapy are effective in helping people with dual diagnoses, particularly in coping with issues of stigma, anger, aggression, grief, and depression (Cutler, 2001). The benefits of helping these individuals validate their feelings, positively express their emotions, and develop coping strategies related to prevention of further difficulties cannot be disputed (Esbensen & Benson, 2003).
An important aspect of the one-to-one interaction with Josh was helping him understand court proceedings (e.g., court strategy), the roles of court officials, and the acts of pleading and giving testimony, but the team met with little success. Some authors have argued that fitness to stand trial may never be achieved by many individuals with a developmental disability who are involved in the justice system (Griffiths et al., 2002).
Nurses play a pivotal role as advocates for their clients, particularly because of inherent systemic inequities that have historically limited access to appropriate resources for people with dual diagnoses. Through knowledge of available resources within and outside the organization, Josh's nurse was able to obtain a legal aid lawyer for Josh, who represented him in the ORB hearing.
Also as part of the treatment plan, Josh was given opportunities to make more informed choices and was encouraged to participate in structured groups and ward activities, such as an anger management group. Josh's participation in the anger management group helped improve his self-control skills. He learned to articulate when he was upset without swearing or yelling by taking time to quietly settle down and then process the issue that angered him (see the Sidebar on page 33 for more detailed information). Linking Josh to a community workshop with educational activities greatly enhanced his self-esteem and had positive effect on his ORB status. In addition, as Josh's behavior improved, he was granted indirectly supervised and unsupervised hospital ground privileges and was able to actively participate in community outings.
Behavioral Approach to Manage Josh's Inappropriate Behavior
- Be consistent.
- If his inappropriate behavior is minor, ignore, distract, or redirect him.
- Teach him to walk away from uncomfortable or distressing situations.
- Send him to his room or the therapeutic quiet room to calm down.
- Ask for p.r.n. medication.
- Place him in locked seclusion (as a last resort).
Inappropriate Behavior During Day Program Groups or Activities
- If he is rude, loud, verbally abusive, or disruptive, prompt him to terminate his inappropriate behavior.
- Ask him to leave the group.
- Tell him he will miss the group the following day if the behavior continues.
- Restrict his fluid intake in the evening.
- Remind him to use the washroom every 2 hours.
- Give him a chocolate bar if he was dry the whole night.
- Assign a morning task he finds enjoyable, such as turning on the light in the dining room before breakfast.
Behavioral Treatment Intervention. During his stay in the dual diagnosis program, Josh benefited from behavioral assessments and interventions. The interdisciplinary team formulated a comprehensive behavioral treatment plan with Josh, aimed at developing his adaptive skills, mitigating his aggressive behavior, increasing his independence, and improving his quality of life. To accomplish these goals, Josh was gradually provided with increased responsibility for his actions, consistent expectations, and reinforcement for positive behavior. The team also helped Josh understand that inappropriate responses to redirection would result in consequences, such as not allowing him to participate in the day program (Barron et al., 2002; Griffiths & Gardner, 2002).
Urinary incontinence, both at night and in the late morning (if he stayed in bed past breakfast time), was another concern for Josh. A behavioral program that involved restriction of fluid intake in the evening, scheduled time to use the washroom at night, assignment of an enjoyable morning task to encourage him to get up early, and positive reinforcement after dry nights helped resolve this problem.
Psychopharmacology. Some authors have asserted that pharmacological agents, in combination with behavioral and environmental management and education, can enhance the mental and functional status of individuals with dual diagnoses, and thus improve their quality of life (Griffiths & Gardner, 2002). However, use of such agents must be carefully evaluated because of individuals' limited understanding of and difficulty in communicating experienced side effects and their different responses to medications, compared to the general population. In addition, some side effects or toxicity could be masked by the individuals' behavioral changes and functional disabilities. Therefore, it is vital to carefully monitor the effects and side effects of any medications (Stavrakaki, Antochi, Summers, & Adamson, 2002).
Josh adhered to his medication regimen, which improved his psychotic symptoms and helped him with his impulse control difficulties. After several months, he reached the stage of remission.
Transferring Care to the Community
Providing appropriate care for this vulnerable population is challenging. However, there is growing understanding that a long-term, flexible, interdisciplinary approach and quality community support services (e.g., respite services) are needed. Specifically designed treatment interventions that focus on comprehensive and ongoing assessment, including risk for reoffense, promotion and maintenance of physical and mental well-being, development of skills, crisis intervention, and reduction of any factors that may lead to criminal behavior (e.g., impulsivity, financial insecurity, negative peer influence, poor housing conditions) are required to meet the complex needs of this population (Griffiths et al., 2002). Many advocates have asserted that receiving services closer to their communities could help individuals with dual diagnoses maintain family and other supportive relationships. In addition, finding a setting in which the individuals are familiar and comfortable should be a consideration in discharge planning and transferring care to community services (Cutler, 2001; Holland et al., 2002).
Josh was placed in a structured group home environment with constant supervision. Arrangements were made to allow Josh's father limited and supervised access to Josh, but prevent him from taking Josh home. Josh continues to attend the community workshop and a forensic outpatient program in the community, and has a good relationship with his case manager, who provides clinical care, case management, and service coordination, including crisis intervention, health improvement, and risk management, depending on the intended outcome (Johnston, 2002).