As of this writing in September 2017, DSH-Napa provides psychiatric treatment to approximately 1,250 patients. Patients at DSH-Napa can be divided into two broad categories. Approximately 75% of our patients are hospitalized under criminal commitments, while 25% have civil commitments.
Patients with criminal commitments can be divided into three groups. These include patients who are:
- Not Guilty by Reason of Insanity (NGRI)
- Incompetent to Stand Trial (IST)
- Mentally Disordered Offenders (MDO)
These patients are admitted to DSH-Napa in several ways:
- Committed to the California Department of State Hospitals (DSH) by county superior court under one of the three penal code designations noted above.
- Transferred from a more secure facility for treatment in a less restrictive setting.
- Returned from Community Outpatient Treatment (COT) for noncompliance when the county conditional release program (CONREP) advises the county superior court that the patient may not be safely managed in the community.
Not Guilty by Reason of Insanity (NGRI)
DSH-Napa provides treatment for the largest population of NGRI patients of any facility in the country. Approximately 47% of the 1,250 patients at DSH-Napa were hospitalized on NGRI commitments. The overall goal for these patients is improvement to the point where they gain admission or re-admission to CONREP, which coordinates return to the community. There is one NGRI Admissions Unit, where the focus is on initial assessments and initiation of behavioral stabilization. Following the admissions unit, NGRI patients are treated on approximately 17 different units. These units are graded in step-wise fashion from more structured “stabilization units” to less structured “discharge units,” where patients have jobs, or attend partial hospitalization treatment, away from their home unit. On the journey from the admission unit, through the continuum of care from stabilization to discharge, some patients may receive specialized treatment on our “Specialty Units.” These include the Geropsychiatric Unit, Sex Offender Treatment Unit, Substance Abuse Treatment Unit, and two Comprehensive Dialectical Behavior Therapy Treatment Units. Several of the NGRI units are co-ed. Psychologists on generic NGRI and specialty units all serve as members of a multidisciplinary treatment team. They provide individual psychotherapy and group treatment services (e.g., process and support groups, chemical dependency groups, etc.) and consultation services. In addition, psychologists write and implement behavior plans, prepare court letters, provide crisis intervention services, and testify at writ and extension hearings. A major component of group treatment on NGRI units is the Forensic Issues Group, where patients are encouraged to come to terms with their mental illness, understand the role their illness played in their instant offense, and learn relapse prevention skills. A broad range of rehabilitative and recreational therapy services is also offered by other disciplines.
Interns who are interested in working on an NGRI unit will spend 20 hours per week working as a member of a multidisciplinary treatment team. In addition to providing clinical services to all patients on the unit, each intern will have their own caseload of 3-5 patients. In this capacity, they have primary responsibility for all treatment services provided to these patients, under the supervision of the unit psychologist. This means that interns conduct suicide risk assessments. They also conduct violence risk assessments using primarily the History-Clinical-Risk Management-20 (Version 3) (HCR-20) but might include additional measures as needed. Interns conduct cognitive screens on patients with evidence of cognitive dysfunction. The results of cognitive testing is incorporated into patients’ treatment plans so that appropriate diagnostic steps and interventions can be pursued. We primarily use the Montreal Cognitive Assessment (MoCA) but may use other measures as indicated. Interns are responsible for participating in all quarterly and annual treatment planning conferences, and for updating all Forensic Relapse Prevention Plans. When behavioral incidents occur, interns attend the Program Review Committee. This is a meeting of all disciplines including senior psychiatrists and psychologists where behavioral incidents (e.g., verbal or physical aggression) are reviewed and plans developed to address these issues. On discharge and transition units, interns work closely with our Forensic Services Department. Forensic Services conducts the Forensic Quality Review Panel evaluation, to determine if the hospital is in support of release to the community, or if “action items” still need to be addressed before discharge. Interns are also required to write court letters, developing and defending their opinion regarding whether a patient is ready for release or requires continued hospital treatment. In the court letter, interns must describe each patient’s current psychiatric symptom status, the patient’s understanding of the “instant offense” and insight into their mental illness, in formulating their opinion. Finally, interns are required to write progress notes on each patient on their caseload, detailing progress on goals, effectiveness of interventions and plan for the coming month. Interns on NGRI units provide a minimum of 3 hours of groups per week and may see several short-term individual therapy patients in addition to the minimum of 3 long-term clients.
Incompetent to Stand Trial (IST)
Approximately 30% of the 1,250 patients at DSH-Napa were hospitalized on IST commitments. These individuals have committed a criminal offense but are unable to go to trial or plea-bargain because of mental impairment. The county superior courts have determined that these defendants are unable to understand the criminal charges against them and/or assist their attorneys in preparing a rational defense. The focus of treatment for these patients is to regain competency so that they can return to court and face charges. As on NGRI units, psychologists on IST units also serve on a multidisciplinary team and provide the range of clinical treatment services noted above. However, treatment for these patients is more psycho-educational in nature. Patients attend competency groups designed to enable them to understand the nature of the criminal charges against them and to meaningfully participate in their own defense. These patients must also pass a competency evaluation before they are returned to court. The IST patients are treated on approximately 7 locked units.
As above, interns interested in working on a competency to stand trial unit will join an existing treatment team consisting of a psychologist, psychiatrist, rehabilitation/recreation therapist, and carry a caseload of individual patients. On an IST unit, an intern provides competency restoration interventions, including individual and group treatment, assesses safety risks, and provides therapeutic interventions to target treatment goals. Interns may complete a rotation working with new admissions from the county jail who need rapid stabilization. Interns on an admission team will complete admission psychology assessments, which includes determining a new patient’s diagnosis, screening for cognitive impairment, determining trial competence and assessing for relevant risks (violence, suicide). Interns who work on a long-term IST team may conduct brief psychological assessments and/or psychological screens to inform treatment planning, seek additional services and/or determine trial competence (including ultimate likelihood of restoration). Interns will have the opportunity to administer, score, and interpret several measures and instruments used when evaluating a patient’s competency to stand trial. These measures include the Revised - Competency Assessment Instrument and Georgia Court Competency Test, the MacArthur Competence Assessment Tool - Criminal Adjudication and Evaluation of Competency to Stand Trial – Revised and the Evaluation of Competency to Stand Trial, among others. Interns often participate in evaluating malingering, utilizing measures such as the Inventory of Legal Knowledge and Structured Inventory of Reported Symptoms – 2nd Edition, as well as assessing a patient’s cognitive functioning. Interns participating in a competency to stand trial rotation often complete a number of suicide risk assessments, develop behavioral plans, consult with the hospital’s Forensic Services department, and participate in treatment planning conferences. Interns are also encouraged to participate in unit dispositional staff meetings, where clinical staff evaluate a patient’s competency in a group format. Many interns choose to participate in Mock Trial, a weekly group where patients are evaluated in a simulated trial setting.
Mentally Disordered Offenders (MDO)
Approximately 6 percent of the 1,250 patients at DSH-Napa were hospitalized on MDO commitments. The Mentally-Disordered Offenders Act provides for a mandatory mental health commitment as a condition of parole for all prisoners “who have a treatable, severe mental disorder that was one of the causes of, or was an aggravating factor in the commission of the crime for which they were incarcerated” who are “not in remission or cannot be kept in remission at the time of their parole or upon termination of their parole,” creating a danger to society.
MDO patients have been committed to the Department of State Hospitals (DSH) for continued treatment. MDO patients are the smallest of the 3 forensic patient groups. They receive treatment on NGRI units.
Interns can work with MDO patients on several of our NGRI units and will provide the services described above.
Specialized Treatment Programs
For the most part, patients are treated on units organized around penal code status (e.g., NGRI). However, there are several specialty units/programs that address the special needs of forensic patients. Interns who work on specialty units will provide essentially the same clinical services as on “generic” NGRI units (e.g., HCR-20, treatment planning conferences). The exception is that each of these units may have additional types of assessments (e.g. Static-99-R, Stable-2007) and will have specialized treatment programs (DBT Skills Groups) that address the specific needs of patients on these units.
A. The Dialectical Behavior Therapy (DBT) Treatment Program
There are 3 comprehensive DBT treatment units at DSH-Napa. These units were established to treat a group of patients who were engaging in significant dangerous behaviors, including episodes of self-injurious behavior, physical assaults on others, and episodes requiring seclusion and restraint. These patients receive both individual and group treatment, and are housed and treated in a DBT-informed therapeutic milieu.
At DSH-Napa, we provide patients with the “standard” DBT program. Patients obtain the full “skills training” module, DBT individual therapy and staff coaching on the unit. All unit staff have been trained in DBT principles and unit staff as well as ancillary staff attend weekly DBT consultation groups.
As noted above, the role and responsibilities of interns who work on a comprehensive DBT unit are the same as those described for any NGRI unit. However, the services that an intern provides would be DBT-informed. As such, interns would conduct at least one skills group, a mindfulness group or homework group. On some units, these groups have been modified for special needs patients. For example, we offer DBT groups for developmentally disabled patients and special groups for patients who have graduated from the comprehensive program.
In addition, components of the DBT program are provided on other units. Usually these are therapy groups, such as DBT skills group, without the individual therapy component, and without the structured milieu where unit staff are trained in DBT principles and interventions.
B. The Sex Offender Unit and Hospital-Wide Sex Offender Treatment Program
The Sex Offender Unit provides treatment for patients who meet the following criteria:
- Any patient who is required to register as a sex offender pursuant to section 290 of California Penal Code
- A sexual offense is a component of the patient’s instant offense, or sexual offending is one of the patient's primary risks for re-offense and thus, is a core focus of treatment
- Any patient who has a history of sexually inappropriate behavior and/or sexual offending behavior regardless of whether there is a formal adjudication
- Referrals from Forensic Services and/or CONREP
- Self-referral for intensive services related to discharge criteria
The services provided on this unit include the following:
- A focused specialized assessment process to determine the appropriate level of service needs guided by the Risk-Need-Responsivity Principle
- Multi-Modal Group Sex Offender Treatment to Target Dynamic Risk Factors and Criminogenic Needs as identified by assessment. Treatment services will be adjusted to meet the level of cognitive functioning of patients
- Non-Sex Offender Specific Group Treatment as clinically indicated and as resources allow (e.g., leisure skills, anger management, mood regulation, managing psychotic symptoms, cognitive skills training.)
- Routine assessment of sexual offending dynamic risk factors to monitor treatment progress
The core groups offered include:
- Overview: Confidentiality/boundaries/what is consent
- Offense Chain: Lay Out, Relapse Prevention, Autobiography
- Cognitive Self-Regulation
- Victim Awareness
- Deviant Sexual Interests
- Sexual Risk Management (SO WRAP)
- Mental Illness and Sexual Offending
- Healthy Sexuality
Other relevant treatment areas that are associated with reducing risk of sexual offense offered on the Sex Offender Unit include:
- Criminal Thinking
- Emotional Self-Regulation
- Problem Solving
- Leisure Skills
- Substance Use
- Vocational Training
- Psychoeducational treatment designed for patients who are not ready for core treatment groups, designed to introduce them to sex offender treatment concepts and to work on coping strategies that may decrease risk.
C. The Geropsychiatric Treatment Program
This program provides treatment to elderly individuals hospitalized under NGRI and IST commitments. Treatment on this unit is geared to the special medical and neuropsychiatric needs of this population. A major focus is the impact of medical issues on psychological functioning. Clinical staff provide age appropriate treatment that takes into account the cognitive changes that may be related to mental illness, history of brain trauma and, for some, a history of significant substance abuse.
D. The Intensive Substance Recovery Unit (ISRU)
Many DSH-Napa patients hospitalized under forensic commitments have histories of substance use/dependence. Many of these patients’ crimes/charges occurred in the context of substance use/misuse or dependency. It is clear that patients’ mental illnesses are either exacerbated by substance abuse issues or for a smaller group primarily caused by their substance use. Some patients have experienced very serious on-going substance use/misuse/diversion/dependency even after admission, including those who developed even more serious drug problems after admission to the hospital than they had in the community. Aggression data suggests that many patients with non-psychotically driven aggression are struggling with substance abuse. There is significant evidence that some of the self-injury and other medical problems leading to costly outside hospitalization is the direct result of substance use. Many patients cannot be discharged because of their ongoing substance use and its behavioral and mental health sequelae. DSH-Napa provides treatment for these patients in our Intensive Substance Recovery Unit (ISRU).
Service and Treatment Offered:
a) The ISRU provides evidence-based treatment services that are consistent with the National Institute for Drug Abuse (NIDA). Three complementary models of treatment are offered:
- Clinical Model – Intervention services are provided by trained licensed and/or certified practitioners. These include cognitive behavioral, behavioral medication and motivational interviewing interventions.
- Social Model – Peer counseling, support groups, 12-step philosophy
- Medical Model – Use of medical interventions addressing physiological aspects of use and/or prevention of use. Inclusive of detoxification medications and drug antagonists such as Antabuse.
The treatment program offers the following groups as resources allow:
- An educational series that covers topics such as the medical aspects of substance abuse
- 12-step or alternative self-help recovery group with the expectation that patients graduating from service will have completed Step Four or equivalent by completion of service.
- Recreational skills group
- Criminal thinking group
- Self-care group
- Dual Diagnosis group
- Physical exercise group
- Individual therapy
- Peer mentoring
- Anger Management
- Psychiatric consultation
- Pain management with pain management consultation as applicable.
- Relapse prevention
- Recovery birthday celebration
- Family Intervention as possible
Approximately 17% of the 1250 patients at DSH-Napa are hospitalized under civil commitments. Patients who represent a danger to themselves or others, but who have committed no crime, are committed to DSH-Napa pursuant to civil commitment statutes. Typically, all patients are county conservatees who are too severely disturbed to be treated in locked facilities or board and care homes in their county of origin. Unlike the forensic units, these patients are not treated as a function of penal code status. Patients on civil commitments are treated on different units as a function of their age, gender, level of functioning, acuity, or special needs. There are currently 8 in-patient units. These include an acute/receiving, acute medical, skilled nursing and 5 long-term units. Five of these units are co-ed. Treatment programs for these patients are similar to those of the forensic patients, without a focus on criminal behavior. Like the forensic units, the treatment program on each civil unit is grounded in a needs assessment of the particular patients it serves. Psychologists offer the same range of clinical services as provided on forensic units.
As on all units, interns who are interested in working on a civil commitment unit will spend 20 hours per week working as a member of a multidisciplinary treatment team. In addition to providing clinical services to all patients on the unit, each intern will have their own caseload of 3-5 patients. In this capacity, they have primary responsibility for all treatment services provided for patients, under the supervision of the unit psychologist. This means that interns conduct suicide risk assessments and cognitive screens as needed. Interns on civil units assess risk using the Short-Term Assessment of Risk and Treatability (START) measure. The START is a behavioral checklist that uses structured professional judgment to identify an individual's risk factors over the next 3 months. They also attend Program Review Committee meetings (see above).