Fluent Essays

Please Note: Using a minimum of 4 recent scholarly peered reviewed articles less than 5yrs old for DQ 1 and 2. Must be cited using APA format, 750 words for each topic AND include the HTTP or DOI for all references used. Written separately Week 8 DQ 1 What advancements in the field of psychology that have occurred in the last 10 years have you found to be most interesting or startling? Can or does this advancement apply to the field of psychopathology? Use scholarly resources to support your explanations. Week 8 DQ 2 One solution for deviant or criminal behavior that continues to be developed is the treatment of mental illness with medications. Why are these medications treated as cure-alls rather than remedying the underlying psychological issues? Should we continue to pursue drugs as solutions to psychological conditions? Is there a negative aspect to our dependence on medications in our society? Use scholarly resources to support your explanations.  Note: Please see attached reading assignments Understanding Persons With Mental Illness Who Are and Are Not Criminal Justice Involved: A Comparison of Criminal Thinking and Psychiatric Symptoms Nicole R. Gross and Robert D. Morgan Texas Tech University Research has begun to elucidate that persons with mental illness become involved in the criminal justice system as a result of criminality and not merely because of their mental illness. This study aims to clarify the similarities and differences in criminal thinking and psychiatric symptomatology between persons with mental illness who are and are not criminal justice involved. Male and female (n � 94) participants admitted to an acute psychiatric facility completed measures to assess criminal thinking (i.e., Psycho- logical Inventory of Criminal Thinking Styles and Criminal Sentiments Scale–Modified) and psychiatric symptomatology (Millon Clinical Multiaxial Inventory–Third Edition). In addition to the inpatient sample, 94 incarcerated persons with mental illness from a previously conducted study were selected based on their match with the current sample on several key demographic and psychiatric variables. The results of this study indicated that hospitalized persons with mental illness with a history of criminal justice involvement evidenced similar thinking styles to persons with mental illness who were incarcer- ated. Persons with mental illness without criminal justice involvement evidenced fewer thinking styles supportive of a criminal lifestyle than the incarcerated sample. Furthermore, the persons with mental illness sample with no history of criminal justice involvement showed significantly lower levels of psychopathology shown to be risk factors for criminal justice involvement (e.g., antisocial personality, drug dependence, alcohol dependence). These findings have implications for offender-type classification, development of targeted treatment interventions, and program placement. Keywords: criminal thinking, offender, criminal justice involvement, mental illness Persons with mental illness (PMI) are 3 times more likely to be incarcerated than admitted to a psychiatric facility (Abramsky & Fellner, 2003; Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010). Consequently, correctional institutions have become the largest providers of mental health treatment in the United States (Abram- sky & Fellner, 2003). Notably, 14.5% of male and 31% of female offenders in jails have a serious mental illness (i.e., schizophrenia spectrum disorder; schizoaffective disorder; schizophreniform disor- der; brief psychotic disorder; delusional disorder; psychotic disorder not otherwise specified [NOS]; bipolar disorder I, II, and NOS; major depressive disorder; and depressive disorder NOS; Steadman, Osher, Robbins, Case, & Samuels, 2009). PMI are disproportionally repre- sented in correctional institutions because less than 6% of the general population is estimated to suffer from a severe mental illness (Amer- ican Psychiatric Association, 2000; Kessler, Chiu, Demler, & Walters, 2005). It appears that PMI are involved in and affected across criminal justice (CJ) and mental healthcare systems; however, it remains un- clear how PMI involved in the mental healthcare system compare to PMI involved in the CJ system. When compared to offenders without mental illness, PMI who are placed in community supervision (i.e., probation and parole) after being released from a correctional facility are significantly more likely to recidivate (continued criminal behavior resulting in arrest and reincarceration; Messina, Burdon, Hagopian, & Prendergast, 2006). Likewise, it is estimated that 37–53% of PMI released from mental health facilities psychiatrically recidivate (decompensate and are con- sequently readmitted to a mental health facility) within 1 year of being discharged (Hillman, 2001; Segal & Burgess, 2006). Commonalities such as high criminal recidivism and psychiatric hospitalization rates between PMI who are and are not CJ involved may indicate common risk factors such as criminal thinking, poverty, homelessness, and unemployment (Draine, Salzer, Culhane, & Hadley, 2002; Mgust- shini, 2010) between the two groups. Such results would identify a neglected treatment area for PMI regardless of setting (CJ or mental health) that, if addressed, may improve treatment outcomes (e.g., symptom reduction, reduced criminal recidivism, and psychiatric hos- pitalizations). Investigating the role of mental illness in the provoca- tion and exacerbation of criminal behavior is thus warranted. PMI who are CJ involved may have unique mental health needs and criminal risk factors when it comes to offending behavior. Addition- ally, similarities in criminal thought patterns may affect psychological functioning and mental health recovery (e.g., symptom management, rehospitalization) of PMI who are not CJ involved. Although it may seem plausible that PMI enter the CJ system as a result of their mental health symptoms, it has been suggested that some PMI have comorbid criminal dispositions that result in their This article was published Online First October 29, 2012. Nicole R. Gross and Robert D. Morgan, Department of Psychology, Texas Tech University. Correspondence concerning this article should be addressed to Robert D. Morgan, Department of Psychology, Texas Tech University, Box 42051, Lubbock, TX 79409-2051. E-mail: [email protected] T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al li ed pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. Law and Human Behavior © 2012 American Psychological Association 2013, Vol. 37, No. 3, 175–186 0147-7307/13/$12.00 DOI: 10.1037/lhb0000013 175 mailto:[email protected] http://dx.doi.org/10.1037/lhb0000013 CJ involvement (Hiday, 1999). Elbogen and Johnson (2009) found that severe mental illness did not predict future violence if not paired with historical, clinical, and dispositional contextual factors (e.g., past violence, unemployment, low socioeconomic status, victimization; Draine et al., 2002). Although violence does not necessarily result in CJ involvement, the aforementioned contex- tual factors that are related to the prediction of violence are also commonly associated with crime in general. Furthermore, Draine and colleagues (2002) noted that the relationship between mental illness and crime is weak, and they suggest that poverty, lack of education, unemployment, and limited prosocial relationships likely serve as moderating variables in this relationship. Mental illness appears to predispose individuals to reside in environments that foster criminal behavior (Draine et al., 2002; Fisher, Silver, & Wolff, 2006). For example, offenders and PMI often live in low- income areas, are single, have limited social and family support, and have a history of unemployment (Fisher et al., 2006). Home- lessness and a family history of incarceration have been found to be more prevalent among PMI who are CJ involved than offenders without mental illness (Ditton, 1999). Additionally, PMI who are CJ involved were more likely to be unemployed before their arrest when compared with offenders without mental illness (Ditton, 1999), and male PMI with substance abuse disorders were twice as likely to have a criminal record as those without a substance abuse disorder. This is likely due to the role of substance abuse as a prominent risk factor for criminal behavior (Andrews & Bonta, 2006). Among a sample of hospitalized veterans, substance abuse accounted for most of the variance in the risk of incarceration despite the presence or absence of mental illness (Erickson, Rosen- heck, Trestman, Ford, & Desai, 2008). Additionally, the link between mental illness and violent behavior was weak if the individual did not have comorbid substance use issues (Elbogen & Johnson, 2009; Swartz et al., 1998). PMI appear to experience multiple risk factors that strongly influence CJ involvement. With regards to the number and inten- sity of risk factors experienced by PMI, Girard and Wormith (2004) found that PMI evidenced higher scores on the Levels of Service Inventory/Case Management Inventory (LSI/CMI; a com- monly used measure of risk assessment for predicting criminal recidivism) than persons without mental illness, suggesting that PMI experience more criminal risk factors than individuals with- out mental illness. Many of these criminal risk factors measured by the LSI (e.g., education, employment, housing, substance abuse) correspond to poverty, joblessness, and other factors that Draine and colleagues (2002) identified as factors that predispose PMI to engage in criminal behavior. The criminal risk factors measured by the LSI/CMI are positively correlated with criminal recidivism. In a study examining PMI perceived risk for psychiatric rehospital- ization, individuals endorsed risk factors such as unemployment, lack of education, lack of housing, and economic difficulties (Mgustshini, 2010) that correspond to those used in the prediction of criminal behavior. Thus, it is reasonable to suggest that criminal risk factors may also play a role in the frequency of psychiatric hospitalizations. These predisposing environmental factors are im- portant in terms of treatment and recidivism (criminal and psychi- atric) given that they increase the potential for the presence of criminal attitudes and thought patterns in PMI, even if they are not currently engaging in criminal behavior. Carr and colleagues (2009) examined criminal thinking styles in a sample of civil psychiatric patients and compared the results to findings from a previously published study using offenders with- out mental illness. Results indicated that the civil psychiatric patients scored significantly higher on five of eight criminal think- ing style scales. Morgan and colleagues (2010) examined criminal thinking and psychiatric symptomatology in a sample of 416 incarcerated PMI. It was found that incarcerated PMI exhibited criminal thinking patterns similar to those of incarcerated offend- ers without mental illness. Additionally, the psychiatric symptom- atology of the incarcerated PMI was similar to that of inpatient psychiatric samples. These comparisons were made with preva- lence rates known from other published samples of offenders without mental illness (criminal thinking comparison) and nonof- fender psychiatric patients (psychiatric symptomatology compari- son). Furthermore, a recent study conducted with 4,204 incarcer- ated male and female participants found results consistent with Carr and colleagues (2009) and Morgan et al. (2010) such that incarcerated PMI evidenced similar criminal thinking styles when compared with those without mental illness (Wolff, Morgan, Shi, Fisher, & Huening, 2011). Additionally, those with severe mental illness (i.e., schizophrenia or bipolar disorder) displayed higher levels of criminal thinking than those without mental illness and those with less severe mental illness (i.e., depression, posttrau- matic stress disorder, and anxiety; Wolff et al., 2011). Although these three studies provided valuable information for understand- ing PMI that are and are not CJ involved, significant research design and methodological problems limited conclusive interpre- tations. Specifically, Carr and colleagues (2009) and Morgan and colleagues (2010) lacked a direct comparison group, and Wolff et al. (2011) was limited in that there was no mental health sample that was not CJ involved as a control. The proposed study aims to extend these prior studies by examining criminal thinking with PMI who are and are not CJ involved and provide a direct com- parison group for Morgan et al. (2010). Results from Morgan et al. (2010) suggested that PMI who are CJ involved may have different psychiatric needs and features when compared with PMI who are not CJ involved. Furthermore, general criminal thinking has been shown to partially mediate the relationship between mental illness and institutional violence for incarcerated PMI (Walters, 2011), suggesting that the behavior of PMI who act violently should be considered a product of more than mental illness. It appears that PMI who are CJ involved are not merely criminals because of their mental illness but are “crim- inals who happen to be mentally ill” (Morgan et al., 2010). This assertion has important implications for PMI who are CJ involved, but the applicability of these results to PMI who are not CJ involved has yet to be empirically examined. Thus, the exploration of criminal thinking in PMI is warranted. If criminal thought patterns are found within PMI, or a subset of PMI, who are not CJ involved, what effects do such dispositions have on other aspects of functioning (e.g., mental health functioning)? To expand on Morgan et al. (2010), criminal thinking and psychiatric symptom- atology data from PMI admitted to a short-term psychiatric facility were gathered to examine potential differences between this group and incarcerated PMI. Because mental illness and criminal pro- pensities are conceptualized as comorbid disorders (Morgan et al., 2010; Wolff et al., 2011), the presentation and effects of such comorbidity may manifest differently in PMI who are not CJ T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al li ed pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 176 GROSS AND MORGAN involved. Additionally, the data collected from PMI who are not CJ involved will allow for the examination of criminal thinking as a risk factor in predicting the number of psychiatric hospitaliza- tions and relapse. The purpose of this study was to further examine differences and similarities in psychiatric symptoms and criminal thinking between PMI who are incarcerated and psychiatric inpatients. The aim of the proposed study was to identify distinguishing features of PMI who are and are not CJ involved. It was hypothesized that all three groups would evidence similar overall levels of psychi- atric symptomatology and produce similar symptom profiles. Such results would coincide with the results from Morgan et al. (2010). It was hypothesized that PMI admitted to the short-term psychi- atric hospital without a history of CJ involvement would evidence less criminal thinking, as measured by the Psychological Inventory of Criminal Thinking Styles (PICTS) and the Criminal Sentiments Scale–Modified (CSS-M), than the PMI who were incarcerated or admitted to the short-term psychiatric facility with a history of CJ involvement. Lastly, it was expected that criminal thinking would be positively correlated with psychiatric hospitalizations such that those evidencing higher levels of criminal thinking would also have a greater number of lifetime psychiatric hospitalizations. Methods The following method section is a replication of that found in Morgan et al. (2010). The procedure and all measures used, with the exception of a modified demographic form, are the same as those used in Morgan et al. (2010). This replication was nec- essary to allow for a direct comparison between the PMI sample admitted to a short-term psychiatric hospital in this study with the incarcerated PMI sample in Morgan et al. (2010). Participants Participants consisted of 94 short-term psychiatric male (n � 53, 56.4%) and female (n � 41, 43.6%) patients from an acute psychiatric hospital located in West Texas. Participants were at least 18 years old (M � 38.55, SD � 11.35) and were admitted to the facility for at least 5 days (M � 8.24, SD � 7.02). We incorporated a 5-day minimum for the length of time admitted to the facility to increase the likelihood that the participant would be experiencing chronic and enduring psychiatric problems and not transient, crisis-type issues. Over half of the sample (n � 51, 54.3%) had been convicted of a crime in the past; for that reason, the inpatient sample was split into two groups (i.e., with and without past CJ involvement) for the completion of data analysis. Approximately 80% (n � 76) of the inpatients had been admitted to a psychiatric facility before their admission at the time of participation. Additionally, the Structured Clinical Interview for DSM–IV Axis I Disorders (SCID-I) was administered by a doctoral-level counseling psychology student (who received supervision and training from a licensed psychologist) to approximately 20% of the sample to assess the reliability of the participant’s diagnosis as reported by the institutional file. It appears that the institutional file provided a reliable diagnosis for the participants because there was a 77.8% agreement rate between the diagnosis found in the insti- tutional file and the diagnosis determined by the administration of the SCID-I. On the basis of the diagnoses recorded for each participant from institutional records, the inpatient sample had a primary Axis I diagnosis of bipolar disorders (n � 37, 39.4%) followed by major depressive disorder (n � 24, 25.5%), schizo- phrenia (n � 11, 11.7%), schizoaffective disorder (n � 9, 9.6%), other mood disorders (e.g., drug-induced, NOS; n � 8, 8.5%), adjustment disorder (n � 2, 2.1%), psychosis NOS (n � 1. 1.1%), acute stress disorder (n � 1. 1.1%), and Asperger’s syndrome (n � 1. 1.1%). Participants were also drawn from those who participated in the Morgan et al. (2010) study. This sample was composed of 94 incarcerated male (n � 53, 56.4%) and female (n � 41, 43.6%) adults with mental illness. Participants were selected based on their match with participants in our sample on sex, Axis I diagnosis, age, ethnicity, years of formal education, and relationship status when possible. Analyses revealed no significant differences among significant demographic characteristics of Axis I diagnosis, age, race, and relationship status. However, the two groups differed significantly with regards to the number of years of formal edu- cation completed, t � 2.81, p � .005, with the inpatient mental health sample having completed more years of formal education (M � 12.46, SD � 2.13) than the incarcerated mental health sample (M � 11.52, SD � 2.44). Demographic characteristics of both groups along with the results of the between-group analyses of the demographics of each sample are shown in Table 1. Materials A written informed consent form was used to inform potential participants of the purpose of the study, the potential risks, confi- dentiality, and their rights as human subjects. A self-report demo- graphic form was used to gather information regarding age, eth- nicity, relationship status, time hospitalized, CJ involvement, psychiatric history (e.g., treatment, number of hospitalizations), mental health diagnoses, employment status, and public assistance received. The PICTS (Walters, 1995), a self-report measure composed of 80 items and designed to assess thought patterns associated with criminal behavior (Walters, 2006), was used. For example, the PICTS contains items such as “The more I got away with crime the more I thought there was no way the police or authorities would ever catch up with me”; “The way I look at it, I’ve paid my dues and am therefore justified in taking what I want”; and “I have justified selling drugs, burglarizing homes, or robbing banks by telling myself that if I didn’t do it someone else would.” Responses to the items on the PICTS are provided using a 4-point Likert scale (1 � disagree, 4 � strongly agree; Walters, 2006). The PICTS produces two content scales (i.e., Current Criminal Thinking and Historical Criminal Thinking), two composite scales (i.e., Proac- tive Criminal Thinking and Reactive Criminal Thinking), eight thinking style scales (i.e., Mollification, Cutoff, Entitlement, Power Orientation, Sentimentality, Superoptimism, Cognitive In- dolence, and Discontinuity), and five Factor and Special Scales (i.e., Problem Avoidance, Interpersonal Hostility, Self-Assertion, Denial of Harm, and Fear of Change; Walters, 2006). There are no cutoff scores distinguishing the presence or absence of each of the eight criminal thinking scales, but guidelines are provided for interpreting the criminal thinking style T-scores as low (�40), T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al li ed pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 177UNDERSTANDING PERSONS WITH MENTAL ILLNESS average (�40, �60), high (�60, �70), and very high (�70; Walters, 2006). The PICTS has acceptable validity when compared with other means of assessing criminality (i.e., criminal history such as arrests, diversity of offenses, age of first offense, and psychopathy) (Walters, 2006; Walters & Schlauch, 2008). The PICTS has demon- strated moderate to high levels of internal consistency and test-retest reliability in offender samples. The internal consistency for the sub- scales ranged from .54 to .88 for male and female offenders (Walters, 1995; Walters, Elliott, & Miscoll, 1998). Test-retest reliability was .68 –.85 after 2 weeks and .57–.72 after 12 weeks (Walters, 1995; Walters et al., 1998). The PICTS has not been normed on a clinical sample. The internal consistency for the PICTS in this study was high, yielding a Cronbach’s � of .95. The CSS-M (Simourd, 1997), a self-report measure composed of 41 items, designed to assess “attitudes, values, and beliefs related to criminal behavior” (Wormith & Andrews, 1984), was used. The CSS-M measures the content of criminal thoughts whereas the PICTS measures the process of criminal thinking (Simourd & Olver, 2002). For example, the CSS-M contains items such as “The police are as crooked as the people they arrest,” “Pretty well all laws deserve our respect,” and “You cannot get justice in court.” Responses to the items on the CSS-M are pro- vided using a 3-point Likert-type scale (Simourd, 1997; Simourd & Olver, 2002). The CSS-M yields a total score and five subscale scores (attitude toward the law [Law], attitude toward the court [Court], attitude toward the police [Police], tolerance for law violations [TLV], and identification with criminal others [ICO]; Simourd, 1997; Simourd & Olver, 2002; Simourd & van de Ven, 1999). The Law, Court, and Police subscales are then combined to form the Law-Court-Police (LCP) subscale that assesses the level of respect an individual has for the criminal and legal system (Simourd & Olver, 2002). Additionally, the TLV subscale assesses the degree to which an individual justifies their criminal behavior, and the ICO subscale assesses how the individual perceives the criminal behavior of others (Simourd & Oliver, 2002). Scores greater than 19 indicate clinical significance whereas scores of 30 or higher are considered “high” (Simourd, 1997). The CSS-M has not been normed on a clinical sample; however, it has been shown to be a valid and reliable measure with offender populations (Andrews, Wormith, & Kiessling, 1985; Roy & Wormith, 1985; Wormith & Andrews, 1984). Internal consistency ranged from .73 to .91 (Simourd, 1997; Simourd & Olver, 2002). Additionally, when compared with other criminal risk assessment measures (i.e., Hare Psychopathy Checklist–Revised and Level of Service Inventory–Revised), the convergent validity ranged from .25 to .37 (Simourd, 1997). The internal consistency for the CSS-M in this study was high, yielding a Cronbach’s � of .88. The Millon Clinical Multiaxial Inventory–Third Edition (MCMI-III; Millon, 1994) was used. MCMI-III is a self-report measure composed of 175 true/false items, providing an integrated understanding of a respondent’s personality and clinical syn- dromes (Millon, 1994). The MCMI-III yields 14 Personality Dis- order Scales that coincide with Diagnostic and Statistical Manual– 4th Edition (DSM–IV; American Psychiatric Association, 1994) Axis II disorders, and there are 10 Clinical Syndrome Scales that coincide with DSM–IV Axis I disorders (Millon, 1994). A Correc- tion Scale detects careless or random responding, and the Modi- fying Indices and the Validity Index assess validity and response style (Millon, 1994). MCMI-III is strongly correlated with the MCMI-II, with correlations ranging from .59 to .88 (Millon, Davis, & Millon, 1997). The MCMI-III has been designed for use with clinical populations and has been normed on a clinical population. Table 1 Between-Sample Comparison of Demographic Results Psychiatric inpatient sample Morgan et al., (2010) sample �2 pn % n % Ethnicity 10.16 0.07 Caucasian 54 58.1 51 54.3 Hispanic 20 21.5 13 13.9 African American 8 8.6 22 23.4 Asian 1 1.1 0 0.0 American Indian 1 1.1 0 0.0 Other 9 9.7 8 8.5 Diagnosis 0.57 0.90 Schizophrenia/Other Psychotic Disorder 21 22.3 20 21.3 Bipolar I and II 38 40.4 38 40.4 MDD/Other Mood Disorder 29 30.9 32 34.0 Other Mental Health Disorder 6 6.4 4 4.3 Relationship Status 8.15 0.15 Single 34 42.5 43 45.7 Partnered/Common Law 5 6.3 4 4.3 Divorced 21 26.3 23 24.5 Separated 8 10.0 9 9.6 Married 7 8.8 15 15.9 Widowed 5 6.3 0 0.0 M SD M SD t p Age 38.55 11.35 36.83 10.61 1.08 0.28 Education (Years) 12.46 2.13 11.52 2.443 2.81 0.005 T hi s do cu m en t is co py ri gh te d by th e A m er ic an P sy ch ol og ic al A ss oc ia ti on or on e of it s al li ed pu bl is he rs . T hi s ar ti cl e is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. 178 GROSS AND MORGAN Validity of the MCMI-III with relation to the diagnostic determi- nation from clinicians was low to moderate, and the correlations ranged from .07 to .37 (Millon, 1994). Internal consistency reli- ability ranged from .66 to .90 whereas test–retest reliability ranged from .82 to .86 at 5–14 days from the original test date (Millon, 1994). The internal consistency for the MCMI-II in this study was high, yielding a Cronbach’s � of .92. SCID-I (First, Spitzer, Gibbon, & Williams, 1997), a semistruc- tured interview used to assist in diagnosing DSM–IV Axis I dis- orders that is composed of six modules that assess mood episodes, mood disorders, psychotic symptoms, psychotic disorders, sub- stance abuse disorders, and anxiety and other disorders (First et al., 1997), was used in this study. During administration, various questions regarding mental health symptoms are posed to the examinee, and on the basis of their response the examiner deter- mines the presence or absence of the symptom (First et al., 1997). The positive and negative ratings of symptoms within a diagnostic category are combined to determine if DSM–IV diagnostic criteria for the disorder have been satisfied (First et al., 1997). In terms of Kappa ratings, interrater reliability for the SCID-I ranges from .57 to 1.0, and test–retest reliability over a 7- to 10-day period ranges from .35 to .78 (Zanarini, et al., 2000). SCID-I has been developed as a means of improving the diagnostic accuracy of clinicians; thus, most comparisons with unstructured interviews or the best estimate diagnosis procedure have demonstrated superior validity for the SCID-I (Basco et al., 2000). Procedure Individuals admitted to the psychiatric hospital were identified and recruited for participation in this study using a bed locator sheet (an updated record that identified the names, admission dates, cautionary ratings, and room assignments for all current inpatients). Consumers were considered eligible for participation if they had been admitted to the facility for a minimum of 5 days, were able to communicate in English, were not admitted to the facility after being adjudicated not competent to stand trial and not restorable, were not receiving competency restoration ser- vices, and were at least 18 years of age. Participants were selected in the order of their presentation on the bed locator sheets such that the first available consumer (e.g., met inclusion criteria, had not already participated or refused participation) was contacted by a research assistant for recruitment into the study presented here. Research assistants approached the iden- tified consumers either in the day room of the facility or in their assigned rooms and asked them to meet with a research assis- tant regarding participation. During this meeting, consumers were verbally informed about the purpose of the study, the tasks they would be asked to com- plete, and of their rights as a research participant (i.e., confiden- tiality, right to withdraw) should they decide to participate. Addi- tionally, risks and benefits of participation were also verbally explained. Consumers willing to participate were provided with a written informed …