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How Forensic Mental Health Staff Cope: Results of a Preliminary Study

Individuals working with correctional inmates on a daily basis experience high levels of job-related stress leading to burnout.(1) Stress levels among correctional staff are associated with the unpredictability of clientele, concerns for safety, the nature of the individuals they are obliged to manage, as well as co-workers and the often limited scope of their duties and working environment. These factors often lead to perceptions of being exploited, which precipitate feelings of anger and burnout.(2)

While individuals working in forensic mental health units frequently have a broader range of duties, this advantage carries along with it the potential for additional stress resulting from role ambiguity.(3)

Specifically; patients carry the ambiguous status of being "mad and/or bad." Pending the outcome of their assessment, they may be seen as chronically mentally disordered and hardly responsible for their actions; moderately impaired and partially responsible for their actions; or basically intact with some personality problems and entirely responsible for the crimes they have committed.

In response to the ambiguous status of the patient, the role of the forensic mental health worker recurrently shifts. Patients who are perceived as being ill elicit a "care giver" response from forensic staff, while those perceived as not being mentally ill invoke a more custodial and judgmental response. Forensic staff, being human, also bring certain attitudes and experiences to the work situation which may affect how they deal with patients. Such factors as patients' socio-economic status, level of intelligence, education and sophistication, mental health background, racial and religious origin and the type of crime they are charged with may affect how staff deal with their clients.

This study explored the ways in which staff at a large, urban forensic unit coped with the ongoing, conflicting demands on their professional and private selves. As this effort is the first in what is hoped to be a series of studies of staff reactions to work stress, the results should be viewed as preliminary and as a guide for future, more comprehensive analysis.

Study Method

Staff from five professional areas (psychiatrists and psychiatric assistants, psychologists and students in psychology, nurses, social workers and correctional officers) were asked to complete a questionnaire.(4) The questionnaire asked respondents to list the two coping techniques they used most frequently to deal with four basic situations with patients: mentally ill patients toward whom they are sympathetic, but for whom they see little realistic hope for improvement; personality-disordered patients whom they dislike, but who have a realistic chance of early release because of a limited criminal history; a seemingly intact patient who has committed a particularly heinous crime (such as murdering a child or infant) out of character with the individual's life history; and, last, a violent encounter with a patient requiring forced placement in a safety room.

In addition, respondents were asked to rate how stressful they found their jobs, how long they had worked at the forensic unit, how much personal satisfaction they derived from their work and their gender, age and professional group.

Results

Results relating to staff's perceived role and coping strategies for each of the four scenarios described above were examined separately. The raw data were also initially broken down by professional group, but due to the small numbers in each group, the results were grouped together.

The sample consisted of 18 staff members: 2 correctional officers, 3 registered nurses, 3 psychiatrists, 4 psychiatric assistants, 2 psychologists and 2 psychology students, 1 recreational staff member and 2 social workers.

Role Results

Five types of roles clearly emerged from the participants' written responses. They were helping, assessment, custodial, empathetic and agent of the judiciary. The distribution of these assumed roles is summarized in Table 1.


Table 1
Distribution of Perceived Roles by Situation
 
Helping
Assessment
Custodial
Empathetic Agent of
the Judiciary
Mentally Ill Patient
66.7% (12)*
22.2% (4)
5.6% (1)
0
5.6% (1)
Personality-Disordered
Patient
66.7% (12)*
11.1% (2)
22.2% (4)
0
0
Intact Patient Charged
Heinous Crime
66.7% (12)*
22.2% (4)
5.6% (1)
5.6% (1)
0
Violent Patient
52.9% (9)
0
47.1% (8)
0
0
* Figures in parentheses correspond to the number of respondents

According to Table 1, it is clear that the primary role assumed by most staff was that of helper, regardless of the situation. The second most frequently assumed role, however, fluctuated with the situation. With violent patients, the only other role chosen was the custodial role. With both mentally ill patients and individuals charged with a heinous offence, the role of assessor was assumed by about one fifth of staff -about twice as many as in the case of personality-disordered patients. With these patients, twice as many staff saw their role as custodial than as assessor. Only one staff member assumed the empathetic role, and only in the scenario of the otherwise solid citizen charged with an uncharacteristic, heinous offence. It 15 interesting that this staff member came frcm the nursing group. No other staff member saw empathy as an appropriate role in any situation. One psychiatrist assumed the role of agent of the judiciary in the scenario of the mentally ill patient. Psychologists were more prone to see themselves in the role of assessor than in any other role.

Coping Results

Answers to the questions about how staff cope revealed six different coping styles. These were distancing, intellectualization, reliance on collegial support, resignation (i.e., acceptance of the permanence of the problem), authoritarian stance, and sublimation (i.e., seeing good in one's work or patients). The distribution of these coping styles in response to the four patient situations is given in Table 2.



Table 2

In contrast to the assumed roles selection, staff showed more variety in how they coped with these different basic scenarios. In the case of mentally ill and personality-disordered patients, the preferred coping style was distancing. In the case of the intact individual charged with a single uncharacteristic, heinous crime, intellectualization was the most frequently employed coping device. As one psychologist responded,
I look at the person who has basically been a good citizen, provider, spouse and parent for 30 or 40 years. Then, under stress, in a five-minute period, the individual does something terrible, but atypical. On the basis of what am I going to judge the person - 30 years of basic decency or five minutes of frustrated evil?

In the case of dealing with a violent patient, the majority of staff responded with intellectualization.

Stress and Satisfaction Results

The figure shows the levels of stress and satisfaction among the various groups of staff. Most groups experienced approximately equivalent levels of job stress and job satisfaction. There were two exceptions to this trend: psychology staff experienced lower stress levels and higher satisfaction levels, and psychiatric assistants had marginally lower satisfaction levels. The latter finding may be related to the assistants' sense of remoteness from decision-making processes.



Figure 1
Figure 1

Discussion

This study represented an initial attempt to examine issues that are central to involved, competent and efficient management of a forensic custodial unit. Unfortunately, the size of the study sample in this one forensic unit was not large enough to justify generalizations. However, the results suggest directions for future work that should involve a multicentre design. Such a design would allow for comparison among different types of staff at various types of institutions (i.e., forensic versus detention centre versus prison). A larger study could also look at relationships among various coping styles, job stress and satisfaction. More effective coping styles could be encouraged to help alleviate stress for the betterment of management, staff and inmates or patients alike.

A final note concerns the type of individual who works in the various settings. It has been noted previously5 that people who choose to work dally with the mentally ill, criminal element of society represent a special segment of the population. The data presented here suggest that at least part of their make-up includes taking on a helping role, even when they do not empathize with their clients. It may be their ability to distance themselves and their commitment to help others that mark the forensic mental health staff.


(1)L. Gerstein, C.G. Topp and G. Correll, "The Role of the Environment and Person When Predicting Burnout Among Correctional Personnel," Criminal Justice and Behavior, 14, 3 (1987): 352-369.
(2)
J.A. Farmer, "Relationship Between Job Burnout and Perceived Inmate Exploitation of juvenile Correction Workers," International Journal of Offender Therapy and Comparative Criminology, 32, 1 (1988): 67-73.
(3)
Gerstein, Topp and Correll, "The Role of the Environment and Person When Predicting Burnout Among Correctional Personnel."
(4)A copy of the questionnaire is available from the authors at the Clarke Institute of Psychiatry in Toronto, Ontario.
(5)E. Turner, personal communication, 1987.