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RISK ASSESSMENTS
AND THE THER APEUTICS
What is forensic psychiatry? The name abnormal offender delineates an area of OF RISK MANAGEMENT
implies a branch of psychiatry connected concern that could potentially engulf much
with, or pursued in, courts of law. Other of mental health. Offending behaviour is Risk assessment and risk management have
medical specialities
specialities have transcended the common in the whole community, and emerged as central elements not just in for-
literal meaning of their name; for example, among adolescents it approaches the uni- ensic practice but in all mental health prac-
orthopaedic surgeons no longer restrict versal. Even criminal convictions are spread tice. The long-term viability of community
their activities to crippled children. Some widely through society and even more care, which has become the central plank
would, however, constrain forensic psy- widely among people with mental disorders of most modern mental health services, is
chiatry to exactly what the name indicates: (Taylor & Gunn, 1984; Hodgins, 1993; dependent on assuaging the anxieties of
the application of psychiatry to evaluations Wessely, 1997; Wallace et al, al, 1998). The the public, and politicians, about the dan-
for legal purposes (Pollack, 1974; Wein- borders of forensic mental health need a gerousness of people with mental illnesses.
stock et al,
al, 1994). This is an impoverished clearer marker than offensive behaviour, Exaggerated and misplaced though such
vision. It constrains our speciality to acting or even criminal convictions among people public fears may be on occasion, they
exclusively as handmaidens to the courts. with mental disorders. Such boundaries are nevertheless have the capacity to damage
The forensic psychiatrist in the court in the process of being defined and seriously, or destroy, the progress made to-
process can all too often face an unequal redefined in the current phase of rapid wards less oppressive and custodial mental
struggle to maintain the dignity of a medi- change and development that is gripping health services. Mental health services have
cal expert against overwhelming pressures, forensic mental health services throughout a responsibility to do all that they can to
both institutional and fiscal, to become the Western World. provide appropriate care and support to
the lawyer's cat's-paw. Working exclu- In practice, patients often gravitate to those mentally disordered
disordered people with an
sively for, and in, the courts may increase forensic services when the nature of their increased probability of acting violently,
the practitioner's vulnerability to such use. offending, or the apprehension created by be it towards themselves or towards others.
Conversely, having an expertise and prac- their behaviour, is such as to overwhelm The aim is to identify and manage such
tice firmly rooted in a clinical practice away the tolerance or confidence of professionals risks before they manifest in violence.
from the legal arena may offer a greater in the general mental health services. The probability of there emerging diffi-
element of independence and a firmer basis Currently escalating rates of referral to cult, aggressive and socially disruptive
for the claimed expertise. forensic services are being fed, in part, by behaviour that leads to distress for patients,
Forensic mental health defined more increasing anxieties about the potential for their carers and the wider community can
broadly is an area of specialisation that, in violent behaviour in certain categories of be identified in advance and, with proper
the criminal sphere, involves the assessment patients. In part they are also driven by the management, prevented. What will never
and treatment of those who are both men- emerging culture of blame in which profes- be possible is for mental health services to
tally disordered and whose behaviour has sionals fear being held responsible for failing prevent all violent acts in their patients,
led, or could lead, to offending. In the civil to protect their fellow citizens from the fear- any more than such a perfection of preven-
sphere forensic mental health has a more inducing, or frankly violent, behaviour of tion can be obtained in the wider com-
complex remit, not only being involved in those who have been in their care. The shift munity. What will almost certainly remain
the assessment and treatment of those who to mental health services that are com- highly problematic is identifying in advance
have potentially compensatable injuries munity based and rely on general hospital that tiny minority of people with mental
but also providing advice to courts and units for in-patient facilities has tended, disorders who may go on to inflict serious
tribunals on competency and capacity. The understandably, to decrease further the con- or fatal injury on others. Only the infallible
papers in this special section of the Journal fidence that the general mental health retrospectoscope and the wisdom of hind-
will focus on the forensic mental health services have in their facilities, or even skills, sight can identify reliably the tell-tale signs
professional's activities related directly to to manage the more challenging and poten- of the future killer. This being so, cam-
violent and criminal behaviour. tially frightening patient. Compounding paigns of blaming mental health profes-
Defining forensic psychiatry in terms of these influences are changes in our societies sionals for failing to prevent such rare and
the assessment and treatment of the mentally that tend to decrease the tolerance for diffi- essentially unforeseeable tragedies as homi-
cult and intrusive behaviour and to increase cide can only lead to injustice and be a spur
the demand that professionals, rather than to defensive and increasingly coercive prac-
{
See pp. 312^350, this issue. neighbours and family, control such tices. Conversely, there is much to be
307
MU L L E N
gained from the open discussion of im- public mental health services of most subsequent offending behaviour. Nothing
proved methods of identifying and mana- British, European or Australasian coun- can be done to change an existing history
ging potentially aggressive patients, as tries, the diagnostic mix would be dramati- of abuse but a lot can be done about the
well as from programmes for analysing cally different. Does this imply then that the subsequent social, psychological and be-
and learning from the inevitable incidents MacArthur actuarial tool will not travel havioural difficulties that may manifest in
and failures (however minor). Such quality well? Not necessarily. What it does imply adult life. By disaggregating a history of
assurance practices only work, however, if is that it will require validating and poten- child abuse into the components of adult
they focus on improving future clinical prac- tially modifying for use in different clinical disorder to which the abuse may have con-
tice and training rather than on assigning and sociocultural contexts. tributed, you transform an unchangeable
blame and criticising individuals. Like any project that aspires to pro- piece of history into a group of current pro-
The paper by Monahan et al (2000, duce a risk assessment instrument, the blems to which therapeutic efforts can be
this issue) offers some of the early fruits MacArthur collaboration is concerned with directed. The signpost to future dangerous-
of the MacArthur collaboration, aimed at establishing robust correlations between ness is in the process transformed into an
elucidating the factors relevant to assessing measurable factors and the later target out- agenda for prevention. The focus is shifted
the risks of violent behaviour in people come, in this case violence. Correlations from controlling or incarcerating those
with mental disorders. The collaboration here, as everywhere, are not necessarily re- destined to be dangerous to an agenda of
brought together some of the finest minds flective of causal connections. They do not prevention by care and support. It is only
in psychology, medicine, sociology and have to be to be useful actuarially. If, how- the latter form of prevention for which
law to design and carry through a research ever, we wish to move from risk assessment the skills and knowledge of mental health
protocol that would generate the data from to a risk management strategy that is not professionals are appropriate.
which actuarial predictions could be made content to rely solely on incarceration and Risk assessments, I would assert, are
about the probability of future violence in containment, then attempting to articulate the proper concern of health professionals
people with mental disorders. The data the causal nexus that may underlie the pre- to the extent that they initiate remedial
from this MacArthur study deserve to com- dictive correlations becomes critical. The interventions that directly or indirectly
mand respect and will repay detailed con- challenge for forensic mental health profes- benefit the person assessed. Decreasing a
sideration. Equally, the study has to be sionals is to move from risk assessment to mentally disordered individual's chance of
approached with caution, particularly the therapeutics of risk management. This injuring others is a benefit to them as well
when its results are to be generalised to theme is clearly developed by Lindqvist & as to the future victim. Such prevention is
patient populations that may differ signifi- Skipworth (2000, this issue). part of a health professional's legitimate
cantly from those studied. Risk factors represent significant statisti- activity if, and only if, it is part of therapy
For example, it may surprise clinicians cal associations subject only to the proviso for a mental disorder or for psychological
that in Monahan et al's al's actuarial tool for that the risk factor precedes the predicted or emotional dysfunction. Confining and
assessing the risk of violence, the diagnosis outcome. They present themselves as inno- containing offenders as punishment, or sim-
of schizophrenia places a subject into a cent of cultural and social assumptions, but ply to prevent further offending, may be
low-risk category. The evidence is now this is just an appearance. In some risk assess- legitimate for a criminal justice system but
virtually overwhelming that a diagnosis of ment schedules, being male or giving a his- should have no place in a health service.
schizophrenia, at least in males, is asso- tory of child abuse contributes to the
ciated with higher rates of reported inter- prediction of future dangerousness. Leaving
personal violence and convictions for aside the moral and ethical implications of IMPROVING FORENSIC
violent offences (Taylor & Gunn, 1984; potentially disadvantaging people because MENTAL HEALTH SERVICES
Lindqvist & Allebeck, 1990; Swanson et of gender and past victimisation, these two
al,
al, 1990; Hodgins, 1992; Eronen et al, al, risk factors present as a biological (well The history of forensic mental health ser-
1996; Wallace et al,
al, 1998). This association almost) and a historical fact. Both are effec- vices, until recently, was marked and
has been established by comparing violence tively immutable but the links between, on marred by isolation: geographical isolation
measures in those with schizophrenia with the one hand, maleness or being abused as in the insane asylums and prisons; profes-
similar measures in the general population. a child and, on the other hand, violent sional isolation, which was particularly
Monahan et al, al, however, are concerned proclivities are likely to be mediated by a marked for nursing staff who, for example,
with differentiating between levels of wide range of factors, of which some at least in some forensic hospitals in the UK chose
violence in a population of admissions to will be open to influence and therapeutic to identify themselves with prison officers
acute psychiatric facilities in urban public intervention. rather than primarily as members of the
hospitals in the USA. It becomes less Among the potential associations with nursing profession; and institutional isola-
counter-intuitive for schizophrenia to be a having a history of child abuse are pro- tion, with forensic services all too often
factor contributing to a lower-risk categor- blems with interpersonal and sexual adjust- organisationally fragmented and isolated
isation when you realise that this is com- ment, increased risks of substance misuse, from general mental health services. One
pared with a population in which an high rates of personality problems and effect of such isolations has been that much
admission diagnosis of alcohol or drug increased anxiety and depressive symptoms of the progress in the organisation and
abuse was made in 59.3% and of a person- (Fergusson & Mullen, 1999). It would seem delivery of general mental health services
ality disorder in 36.6%, with schizophrenia plausible that one or more of such factors has passed forensic services by. The
being diagnosed in only 26% (Steadman et contributes to mediating the reported asso- anachronistic and unforgivable giant
al,
al, 1998). In acute admission wards in the ciation between a history of child abuse and high-security
high-security hospitals still dominate not
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F O R E N S I C M E N TA L H E A LT H
309
MU L L E N
Making available mental health exper- failure to maintain accepted standards still (a) substance use inducing violent
tise to relieve perceived social problems plays a central role in establishing legal behaviour in people with mental disor-
should not conflict with traditional medical liability. That being said, trends in the ders (a direct causal relationship);
practice if its aim is, through identifying USA have a tendency to influence medical (b) substance use disrupting the effective
and relieving disorder, to benefit primarily and legal practice throughout the English- treatment of these disorders, via exacer-
patients and, through their more adequate speaking world and beyond. Risk assess- bation of symptoms and/or decreasing
care and management, to benefit those they ments of the type discussed by Fletcher compliance, with resulting increased
potentially threaten. One of the problems of et al will become an increasingly import- disturbance and consequent violence
the current fashion for substituting `client' ant aspect of the work of forensic mental (an indirect causal relationship).
or `consumer' for `patient' is that in this health professionals, and not just in the
(c) that people with mental disorders who
situation, as in so many, it obfuscates the USA.
are prone to violent behaviour also
clinician's ethical and therapeutic responsi- The knowledge generated by forensic
happen to be prone to substance
bilities. Using the term `client' facilitates mental health professionals, both through
misuse (a non-causal association based
substituting a different client for the indivi- their practice and through research, can be
on chance or, more likely, on a
dual actually assessed, thus employers, the of potential relevance to a range of organ-
common origin in a third factor such
courts, police, etc. become the health profes- isations and social agencies. It is right and as personality).
sional's client. It is more difficult to regard proper that such knowledge be applied to
organisations such as the criminal justice benefit the community. How this is to In practice all three relationships may
system as the patient. There are manifest occur, and to what extent health profes- play a role in mediating the association
ethical and professional dangers for mental sionals should be directly involved in the between misusing substances, having a
health professionals who assess patients at wider applications of such knowledge, mental disorder and acting violently. Irre-
the behest of employers or social agencies needs to be considered by the various pro- spective of what causal relationship, if
when the main beneficiary of such assess- fessional groups involved. In our own any, exists, the presence of substance mis-
ments is the organisation, with potentially narrow experience in the State of Victoria use is a robust risk factor for violent
the loser being the patient. Prior consent in Australia, it has been our forensic ser- behaviour. Given, however, that it is unli-
and the waiving of claims to confidentiality vices' work with stalkers and with persis- kely that the relationship is entirely
by the individual being assessed in no way tent claimants that has generated the accounted for by a common origin in
mitigates these dilemmas, given that such widest community and interdisciplinary something like personality factors, then
undertakings can hardly be considered interest. The work has also led to calls from the effective management of substance
uncoerced if the examination is, for ex- a remarkably diverse range of organisations misuse in people with mental disorders
ample, a condition of acquiring or retaining for advice and input on how to cope with also becomes central to preventing future
employment. Further, by focusing on indivi- the problems created in the workplace, antisocial behaviour (as, for that matter,
dual psychopathology as the cause of con- and the wider community, by such behav- it is in the non-disordered population).
flict and violence in the workplace, there is iour. Knowledge generated by forensic One of the most obvious impacts of the
a danger of overlooking the organisational mental health professionals through research over recent years on mental
contributions to creating the conditions for research and clinical experience can, I disorder and offending behaviour has been
such conflict, as well as providing an excuse believe, inform improvements in practices the increased emphasis on preventing and
for management to abrogate to professional aimed at ensuring safer workplaces and a managing substance misuse in the
advisors their responsibilities to maintain a safer community. The challenge is to medi- patients of forensic mental health services.
safe workplace (Mullen, 1997). ate that knowledge and enlarge our profes- Whether we use the term comorbid or co-
The American context of Fletcher et al's
al's sional roles without becoming salespeople, existing, the challenge is the same: how to
work is one in which, as they note, the civil pundits, instant experts or ersatz police reduce substance misuse by people with
law is the primary regulator of conduct officers and also without compromising mental disorders.
aimed at curbing workplace violence. The our role as clinicians.
law, in the US context, operates through The presence of significant substance CONCLUSION
placing employers at hazard of being held misuse in those mentally disordered indivi-
liable for injuries resulting from violence duals who behave violently has been The papers in this special section of the
in the workplace. Given such a context, it reported repeatedly. This literature is ably Journal aim to provide a glimpse into
becomes understandable that there is an reviewed by Soyka (2000, this issue). In research and practice internationally in the
attempt to shift at least some responsibility those with schizophrenia, for example, such area of forensic mental health. Inevitably
back to the perpetrators or potential per- a high level of offending behaviour is there are yawning gaps in the coverage,
petrators. Similarly, the search by organisa- reported in those who also misuse alcohol both of topics and of countries. Some gaps
tions for insurance in the form of or drugs that it appears to account for were due to my editorial failures and some
professionally performed risk assessments all, or virtually all, of the elevated rates to those who promised contributions but
is encouraged by the drive to limit potential in schizophrenia as a whole (Soyka were not able to deliver. Conspicuous by
liability. The issue of workplace violence et al,
al, 1993; Ra
Rasanen
È saÈnen et al,
al, 1998; Swartz their absence are papers dealing with the
calls forth different responses in juris- et al,
al, 1998; Wallace et al,
al, 1998). The asso- management of personality disorders in of-
dictions where the law is less eager to ciation, in theory, between substance fenders and any consideration of the impact
endorse implied duties to rescue, and where misuse, mental disorder and offending of offending on victims. Next to managing
demonstrating negligence, recklessness or could reflect: substance misuse, the problems created by
31 0
F O R E N S I C M E N TA L H E A LT H
311
Forensic mental health
PAUL E. MULLEN
BJP 2000, 176:307-311.
Access the most recent version at DOI: 10.1192/bjp.176.4.307
References This article cites 16 articles, 9 of which you can access for free at:
http://bjp.rcpsych.org/content/176/4/307#BIBL
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