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The State of Commitment: An Embedded Ethnography of Court Mandated Psychiatric Treatment at a Forensic Hospital


Background: This study explores the relationship between hospital organization, therapeutic treatment, and court commitment for persons with mental illness at a California state forensic hospital. I structure the narrative of this dissertation in the context of psychiatric institutionalization (and deinstitutionalization), mass incarceration, and welfare retrenchment for clarification, grounding, and to explain the known interactions between the criminal justice and mental health systems for persons living with mental illness. The criminal justice system is the primary point of contact for many individuals with severe mental illness; therefore, it is necessary to understand how individuals gain access to long-term psychiatric treatment within the criminal justice system via the state hospital system, the terms to which they are committed, and the types of psychiatric treatment they are entitled to based on those terms. As pressing an issue as this is, little is known about the psychiatric treatment provided to persons that are civilly and criminally committed outside of the state hospital system and little critical inquiry is extended to the interdependent nature of the criminal justice and state hospital systems in California.

Method: This dissertation is an institutional ethnography that uses a mixed method design. It follows in the long tradition of institutional ethnographies by examining a hard to reach population in a locked forensic facility. The administration of this study included intensive, close-up observations and interviews in addition to accessing agency documents, reports, and implementing a survey of patient satisfaction. As an embedded ethnographer and employed social worker, I had access to multiple sources of organizational documentation, including administrative directives, internal notices, and training materials. As a result of my direct employment and position as a doctoral researcher, I attended daily treatment team meetings, therapeutic treatment groups, monthly program meetings, and department meetings, in addition to bioethics, program review committee meetings, pain management, and mortality review committee meetings. The qualitative data were analyzed in an ongoing and iterative fashion throughout the data collection period for thematic connections. Additionally, the mixed methodology and multiple data sources allowed for triangulation and clarification as unexpected hypothesis emerged over the course of this study.

Findings: The findings from this study are based on four years of direct observation; semi-structured interviews (N= 62) with psychiatric patients, front-line clinicians, and hospital administrators, and an analysis of patient satisfaction survey data (N=611). After examining the psychiatric treatment and care provided to patients mandated to treatment at the state psychiatric hospital, I determined that patients at the hospital that are committed as not guilty by reason of insanity receive more opportunities for therapeutic treatment, recreation, leisure, vocational training, and educational opportunities. Patients committed as not guilty by reason of insanity are more satisfied with their overall treatment and care in comparison to patients who are incompetent to stand trial, or patients who are civilly committed due to a grave disability. In contrast, patients deemed incompetent to stand trial receive psychiatric treatment that is solely based on trial restoration competency and ignores other psychiatric and medical needs. Further, administrators, clinicians, and patients all expressed frustration with the treatment provided to patients found incompetent to stand trial, asserting that trial competency restoration treatment did not amount to the comprehensive standard of care they want to provide or receive, nor did trial competency restoration treatment adequately meet the needs of the population committed as incompetent to stand trial; lastly, clinicians and administrators disliked or feared the societal use of the incompetent to stand trial commitment as a mechanism for providing mental health treatment, often describing the phenomenon as a failure of community mental health systems and asserting a need for more comprehensive welfare services in the community. Remarkably, during the data collection period, the hospital received a mandate from the courts to accelerate the treatment of patients found incompetent to stand trial threatening the precarious balance of treatment at the hospital and strengthening the implications of the study’s findings.

Discussion: The findings in this study have implications for scholarship across the domains of law and society, community mental health practice, organizational studies, and policy research, suggesting the need for further investigation and promotion of mental health policies that are independent of the criminal justice system. This study provides new information about the nature of mental health treatment within the criminal justice system and important insights into the accessibility of effective or comprehensive mental health treatment in the community. This dissertation is based on a single case study. More studies are needed that use the critical lens of commitment and court regulation to understand the accessibility and production of therapeutic treatment for persons with mental illness and how judicial thinking shapes the nature and distribution of psychiatric care.

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