Abstract
The dedication of an edition of the Journal to forensic mental health and to the mentally disordered offender reflects broad cultural changes and alterations in mental health services: forensic psychiatry is now a distinct subspecialty rather than a practice of dilettantes, and most mental health services now grapple daily with the issues raised by criminal and violent behaviours. Although providing opinions to civil and criminal courts remains part of forensic practice, it is now but a small part. The core business of a forensic mental health professional is now:
not just assessing but managing mentally abnormal offenders; not just assessing but managing the psychological impact of victimization; not just assessing but managing risk; and not just containing and caring for the mentally ill who have committed serious crimes, but working with general mental-health services to prevent the offending ever occurring.
The emerging roles for forensic mental health are sustained by an increasing body of systematic research – some aspects of which are reflected in this issue of the Journal. The term mental health is used by us in preference to simply forensic psychiatry. This reflects the multidisciplinary nature of forensic practice, relying on specialized nursing staff, a close working relationship with psychology colleagues, and the evolving development of occupational therapy and social work practice with a distinct forensic focus. These partnerships are welcomed and are evident, for example, in the number of papers in this edition from psychologists or using psychological research methodology.
Aspects of forensic mental health exist at the uneasy interface between community safety and patient-centred practice. While forensic services have long had the reputation of being coercive, correctional, punitive or ambivalent, the future of forensic mental health remains firmly grounded in effective and evidence-based models of treatment and service delivery. We would argue that the role of psychiatric interventions in promoting community safety is best developed through effective treatment, not just assessment and containment. Good forensic practice is embedded in all specialties through provision of management rather than abandonment of difficult or unpleasant patients [1].
Forensic services frequently find themselves in positions which apparently demand compromise on ethical positions, asserted as necessary to mitigate the extreme risk posed by odious people. Such ethical slippage is demanded in information-sharing arrangements such as the Multi-agency Public Protection Panels in the UK [2]; in legislation which couches involuntary treatment in terms based upon public protection as the primary goal [3]; and in correctional mental-health service provision which is not clearly boundaried from the detaining authority, most evident in military and immigration detention settings internationally [4].
Thus, a primary focus of forensic mental health is, curiously enough, close attention to issues of civil rights and ethically grounded practice. Regular dealings with mandated patients, prisoners and those subject to longterm psychiatric inpatient care breeds a clear awareness of the need to be scrupulous in ensuring that international and local standards are upheld. In addition, advocacy for the needs of the most stigmatized of psychiatric patients – mentally disordered offenders – is crucial. This population is often denied accommodation after release and at times, generic services are markedly reluctant to accept a role in treatment. The consequences of such rejection are reflected in the appalling morbidity and mortality statistics of both offenders and their victims [5, 6]. All too often the needs for effective care and supervision are sacrificed to populist agenda of retribution and control – a sacrifice which is inflicted not just on the offender subjected (on the basis of actual or supposed mental disorder) to indefinite detention or draconian conditions after the expiry of their sentence – but also on those who fall victim unnecessarily to those who might have been managed therapeutically but instead were left untreated, alienated and enraged.
Regarding mentally abnormal offenders, community safety is best addressed not by escalating sentences and reinventing preventive detention but by provision of excellent dedicated forensic services spread across diverse points of intervention – in correctional settings, in secure and general psychiatric units, and above all, in community units. The gradual development in Australia over the last 15 years of multifaceted forensic services provides increased opportunities for more effective interventions.
Research into links between mental disorder and offending has in the last 15 years dispelled the shibboleths about the pacific nature of those with psychosis, and established a clear association between psychosis and violence, together with synergistic risk amplification from substance use and personality variables [7, 8]. The next significant task is to refine our understanding, in order to determine who warrants most intervention, the other task of course being how best to do so!
There remain significant threats to forensic mental health. Stigmatization of mentally disordered offenders may lead to estrangement of forensic patients, with forensic and generalist services developing in parallel rather than in a linked fashion. Leadership in forensic mental health and policy development must focus on opportunities for rapprochement, liaison and forging alliances with mainstream services. Certainly forensic hospitals are frequently the last remaining asylums, and prisons the largest – and most poorly resourced – psychiatric institutions in the early 21st century.
Among forensic services, some patient groups remain poorly served. Adolescents tend to receive post ipso facto interventions, and – in their infancy themselves – adolescent forensic mental health services have few opportunities for well-provisioned and sustained intervention [9]. Elderly mentally disordered offenders – both ‘graduates’ and new patients – are poorly served by existing aged care and forensic services [10]. The projected numbers warrant a dedicated response to minister to the complex psychiatric and medical needs of this group.
Furthermore, narrow operationalized definitions of mental disorder may prevent access to treatment for those whose conditions are best considered as behavioural disorders rather than mental disorders. In our experience, the benefits of multidisciplinary, skilled mental health interventions are often denied to those without Axis I disorders but whose behaviours pose significant problems. Stalkers, sexual offenders, threateners and arsonists are all examples of people whose offending is usually driven by their difficult personalities, irrespective of any co-occurring psychosis [11].
The further development of forensic mental health is critically dependent on clinical and epidemiological research, both to shape future treatments and also to refine understanding of outcomes and support funding. All too frequently the basis of funding is the prevention of adverse publicity and risk containment, which is at best a form of tertiary prevention. What is required is both primary prevention through improved management of high-risk patients when they first come into contact with mental health services, and secondary prevention in the form of better management of mentally disordered offenders and those evincing persistent problem behaviours.
This edition of the Journal, and recent articles on prison psychiatry, are proof that forensic mental health is revitalized and offers exciting potential for the near future –not just a good income churning out reports and an inexhaustible store of dinner party stories.