Örebro Forensic Psychiatry Service, Eken, Örebro, Sweden
Regional Forensic Psychiatry Service, Auckland, New Zealand
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See editorial pp.
307311, this issue.
Correspondence: Per Lindqvist, Director, Örebro Forensic Psychiatry Service, Eken, S-70185 Örebro, Sweden. e-mail: per.lindqvist{at}orebroll.se
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ABSTRACT |
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Aims To highlight some essential features of a forensic psychiatric rehabilitation system, and to discuss risk assessment in this context to create a conceptual framework for risk research and practice.
Method The applicability of risk assessment instruments to forensic psychiatric rehabilitation was examined. Core processes and elements considered essential in this type of rehabilitative work were reviewed.
Results Current risk research has limited application to rehabilitation. Future research aimed at analysing forensic psychiatric rehabilitation will be hampered by the complexity of the treatment systems and the number of methodological issues relevant to this type of research.
Conclusions Novel research approaches are suggested to analyse further the risk factors and processes important in forensic psychiatric rehabilitation.
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INTRODUCTION |
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THE EVOLUTION OF RISK RESEARCH |
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One risk is that some patients, falsely associated with a high actuarial risk score (false positives), will be locked up because of guilt by statistical association. The equally unacceptable risk is that those patients with a falsely reassuring low actuarial risk score (false negatives) may persuade judges or review panels that they are ready to be released despite clinical concerns. Finally, the correctly identified group with a high probability of future violence is in danger of having the label dangerous attached. This risks their being treated as if they have an immutable quality of viciousness rather than possessing a range of properties and predispositions, many open to modifications.
There is evidence, although disputed, that mental health professionals' predictions of violence are substantially better than chance (Mossman, 1994). It appears that the addition of actuarial risk assessment tools to clinical judgement alone improves the accuracy of determining a patient's risk of recidivism (Borum, 1996; Gardner et al, 1996; Bonta et al, 1998). However, the currently used predictor variables of recidivism are similar in different offender groups, irrespective of any contribution from mental illness, and are often regarded as largely immutable. This does not obviate the task of psychiatric rehabilitation, nor render the treating team jail wardens awaiting the expiry of a sentence to indicate that community placement is appropriate. That forensic psychiatric populations compare favourably with matched criminal populations with respect to recidivism is not surprising, given the vastly disparate nature of their treatment and rehabilitation. Better questions to pose then may be what is there to treat, and what is it about forensic psychiatric rehabilitation that works?
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FUTURE RISK RESEARCH |
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The need for more and better scientific evaluations of treatment programmes is therefore overdue in the evolution of risk research, because successful interventions to reduce risk will need to be founded on both reliable and valid assumptions. There is an inherent risk in the clinical setting that in viewing the notion of risk assessment purely within a quantitative paradigm based on static and historical factors we will potentially dilute the effectiveness of other rehabilitative endeavours that aim to change the mental state and behaviour of an offender.
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DYNAMIC RISK VARIABLES |
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Risk assessment can be linked to at least four dynamic features of the individual patient and their treatment setting, each with varying resistance to change, and necessitating a different therapeutic task:
Many forensic patients have multiple and complex diagnoses and are subjected to treatment that varies widely in quality and efficacy. This may be one reason for the dearth of literature on treatment evaluation. What we are to analyse is almost as difficult as capturing the wind. What is evident, however, is that any assessment that looks only at the patient and neglects to analyse the forensic system within which the individual lives will reveal only part of the answer to what will constitute optimal treatment for that individual. In the past, there has been insufficient analysis of those factors external to the patient and of their influence on the prognosis. It is, therefore, essential to focus therapeutic rehabilitative endeavours on factors within both the person and the rehabilitative environment in which they live.
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FORENSIC PSYCHIATRIC REHABILITATION |
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Shared values and goals
Viewing forensic rehabilitation as a process infers that different parts
within the forensic setting make their own unique contributions to promoting
the health of the individual. The culture of the treatment setting submits
patients to the values, ideals and goals prevailing in the system. If this
culture is not consistent, trustworthy, competent and caring, a good outcome
is jeopardised. Inconsistencies and unpredictability are recurrent features in
the personal history of many forensic patients, and consequently dysfunctional
system dynamics and diffuse expectations will reinforce previous life
experiences. Experiences of unity, collaboration, solid agreements and
foresight would be novel for these patients.
Staff continuity
A system in which the staff come and go will not be able to promote the
formation of solid treatment alliances. In our experience, trust is one of the
most important foundations upon which rehabilitative work can be built. A
trusting relationship takes time to nurture, especially in forensic
populations. The ability of the system to provide patients with a broad
variety of staff, enabling such trust and alliances to emerge and be
sustained, is vital for the long-term effect of treatment. On the other hand,
a system where staff never leave their job but for retirement or attrition is
most likely counter-productive; like living in a stagnant pool with stale,
anaerobic water, only nourishing parasites.
A fresh stream of therapeutic integrity is essential to counteract this process. Staff training and skills-building should mirror rehabilitative work with patients. Staff need to examine their skills base and address any deficits through supervision, education, ongoing monitoring and feedback of their professional growth and performance. Thus, the need to become more actively involved in the process of rehabilitation becomes established in the culture.
Residents in health-promoting rehabilitative settings find themselves in what for some is a strangely supportive and nurturing setting. The fostering of such an environment and culture can allow the patient to build confidence and self-esteem, initially in the context of the therapeutic community. Thereafter, these skills can be generalised to contact with the wider community. The personal experience can be brought back to the therapeutic community and, with staff and peer support, re-internalised to enhance the patient's concept of self and of competence.
Timing of the initiation of the rehabilitation process
It can be hypothesised that the patient's long-term risk will decrease most
significantly if rehabilitation commences soon after admission, because this
will allow maximal exposure to the rehabilitative process. The therapeutic
tasks will change through the course of confinement, and one should not
underestimate the magnitude of the initial task of dealing with the legal
process when facing serious charges, and the uncertainty that this can create
in developing treatment approaches.
Institutional life inevitably counteracts autonomy and self-support. It is not surprising that the most successful rehabilitative endeavours occur in the least restrictive environment (Andrews et al, 1990; Test, 1992). Although legal sanctions and/or individual risk appraisal may necessitate institutional care, it is essential that institutional attitudes, which may be convenient for the staff and the patients, are intensively challenged. The problem with forensic work is seldom to succeed in making the patients adjust to the institution. Rather, the task is to enable them to live peacefully outside an institution in a less-structured and supervised milieu, with neighbours who are not on the payroll.
Failures of a patient in transition to the community may well be the product of a system failure. Being too briskly exposed to new demands in new settings, and denied access, overnight, to the security and familiarity of the preceding treatment environment will invite failure. For some, the treatment setting and fellow patients will have been their home and family for many years.
Family relationships
Even though a hospital admission will be a decisive event for any forensic
patient, relationships with family members often remain what matters most, for
better and for worse.
However, because many forensic patients are severely disturbed with multiple and grave diagnoses and a history of offending, many families are burned out and disillusioned. They may have experienced poorly resourced hospital and community-based psychiatric services and, not unfairly, apportion blame for the offending on these deficits. Forensic services must expect some of this frustration to be voiced before solid alliances can be forged between the patient, the family and the psychiatric service. This will take more than an average effort, but when it happens, in our experience, the process of recovery is commonly greatly enhanced. This, therefore, appears to be a factor of great importance.
Social networking/peers
The patient's keyworker or nurse, therapist and doctor are important people
in the treatment process, but they walk alongside the patient for a limited
period of time. Their loyalty is professional, linked to their position and
restricted to time and place. The patient has little choice in these
alliances. In our experience, the patients are more aware of this than most
professionals. Social contacts and friends outside the institution have other,
seemingly more genuine, reasons to spend time with the patient. Therefore,
personal friends outside the hospital are often at least as important as those
who are working on the inside. Who is waiting outside? Who will visit and
care? Who will open their door on the day of the first leave and eventually at
the time of discharge? Different welcome scenarios will be created by a peer
who has managed to leave a life of offending and substance misuse, a fragile
but stern and loving grandmother and a criminal mob. Without doubt these
different scenarios will be associated with different outcomes.
Process insight
Most forensic patients view their involuntary commitment/hospital orders as
a punishment, a sentence to serve. Some professionals unfortunately share this
view. We argue that if the patient is discharged with this opinion
unchallenged and unaltered, a good outcome is less likely. Thus, a major task
for forensic treatment will be to attack the idea of penance through serving
time. The purpose of hospitalisation is secondary prevention, that is, to
treat a disorder and keep it under control, resulting in fewer hospital
admissions, greater autonomy and a better self-understanding. We teach the
patient with diabetes what to eat, to exercise and to medicate with the
purpose of reducing the complications of the disorder but also to return
responsibility to the patient, increasing his or her competence for
self-determination. A forensic patient should, ideally, ask for continuous
out-patient care on a voluntary basis at the time of discharge. If this
happens the rehabilitation has been successful, and experience suggests that
the risk of relapse and recidivism is diminished.
The future
The hopes and fantasies of the patient about his or her future are probably
decisive for recovery. At a stretch one might say that it is not what we
actually offer the patient on an everyday basis that works, but what lies
ahead, beyond our reach: future events that have not happened and may never
happen. It is our belief that we should ask far more frequently "what is
the rehabilitative task?" rather than "why did he or she do
it", because planning determines to a large degree what we do today,
whether we are patients with mental disorders or not. Within that perspective,
rehabilitation should deal with the patient's preparations and perceptions of
post-discharge life with the ultimate goal of forming a realistic, productive
and hopeful future. This future is one in which the patient is safe from real
or imagined threat from others and has no desire to self-harm. There is always
one part of every patient that wants to live a decent social life in peace
with fellow human beings.
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RESEARCH ON TREATMENT |
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Measuring the post-discharge effect of forensic rehabilitation is fraught with difficulty, whether one works within a quantitative or a qualitative paradigm. However, the description and analysis of the treatment system requires recognition as an important variable in the scientific analysis of outcomes in this area of research. Gottfredson (1984) proposed programme development evaluation as a way of measuring the quality and internal integrity of interventions, and this approach has been usefully applied to forensic treatment settings (Rice et al, 1990).
Another way to circumvent the temptation to launch reductionistic studies that focus on one easily-measured item at a time would be to organise a number of separate forensic psychiatry services into a joint collaboration, creating a situation that resembles a natural experiment. The legal and professional practices vary within and between countries and states, whereas in our experience patient characteristics and the nature of offences do not know national borders. With this design, pre-admission data, treatment factors and post-discharge information could be collected and configured uniformly at several sites simultaneously, creating the possibility for comparative research. Such a collaborative approach would allow both qualitative and quantitative research endeavours, leading to the development of more valid and reliable measures of prognostic significance in rehabilitation with these populations. Hopefully, this will capture some core elements of good forensic psychiatric practice, which will enable us to throw away some bad practices and begin to create a more solid scientific, evidence-based practice in forensic psychiatric rehabilitation.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication May 19, 1999. Revision received November 29, 1999. Accepted for publication December 7, 1999.