The Need for the Development and Evaluation of Preventive Psychosocial Forensic Interventions in Mainstream Adult Community Mental Health Services

THE IMPLICATIONS FOR COMMUNITY MENTAL HEALTH

Leaving aside the causes of the increase in the rate of convictions among registered psychiatric patients, the trend highlights significant challenges for policymakers, researchers and mental health and welfare services in identifying and responding to the specific needs of this population, their carers and the community. In addition, important preventive opportunities in relation to criminal offending and mental illness now prevail.

First, there are challenges for consumers with forensic issues who leave forensic institutions or prisons for the community (frequently crisis accommodation services), where life stressors, in the absence of appropriate supports in combination with access to substances, may lead to recidivism and deterioration in mental health. 12 These consumers are often stigmatized in the wider community 15 and possibly by mental health clinicians, who may be frightened or horrified by the heinous or perverse nature of some crimes. These consumers may require programmes which facilitate their adjustment and reduce their suffering (and thereby their re-offending). Mental health clinicians may require corollary programmes to sensitize them to the problems these consumers face, including the aetiology of their offences, and the possibilities of offence reenactments. Unfortunately, such programmes have very rarely been developed or evaluated internationally, 16 , 17 and some, including intensive case management, have not always proven to be effective in reducing rates of violence compared with standard care. 18 For patients and their families, there is also often an absence of adequate resources which could stabilize many of the underlying problems which can contribute to a criminogenic lifestyle, especially appropriate levels of supported accommodation programmes or services geared for the homeless. 19 , 20 In short, there is a critical need to accumulate further evidence to guide the development of appropriate and efficacious psychosocial interventions in the mainstream community mental health setting for this growing subgroup of 21 consumers.

Second, there are challenges posed for community mental health services in terms of providing safe care for both consumers and staff. Critically, this increased demand is occurring in the absence of specific forensic expertise in the workplace or available evidence-based risk-prevention interventions and secure facilities. 3 In the absence of a coherent, evi-dence-based and adequately resourced model of intervention, community mental health staff may experience fear, low morale and danger in the workplace. 22

Some researchers have attempted to address gaps in knowledge regarding the clinical pathways of consumers who offend. A recent multi-site study across four countries matched a group of patients diagnosed with schizophrenia who were treated through forensic services with a group treated through general psychiatric hospitals. The findings demonstrated that 24% of patients who were treated solely within the general psychiatric system had a criminal record; importantly 78% of those who were eventually treated within a forensic service were initially treated within a general psychiatric hospital and, of those, 40% had a criminal history preceding their initial admission to a general psychiatric hospital. 21 , 23 This study highlights the potential for preventing the progression to more serious offences if effective risk assessment programmes and treatment interventions can be designed and evaluated for the mainstream adult mental health context. Factors which were predictive of a criminal history before the initial admission included behavioural problems during childhood, substance misuse before the age of 18 years, alcohol dependence and a comorbid diagnosis of antisocial personality disorder. 21

In a study including the same cohort of patients, when antisocial personality problems were controlled for, severe positive symptoms of psychosis and socalled ‘threat’ and ‘control over-ride’ symptoms were associated with a risk of violence over a 12 month follow-up period in patients diagnosed with schizo-phrenia. 14 This is consistent with findings from research into the development of specific actuarial risk assessment tools specific for the mainstream community mental health setting which have been applied to both formal forensic patients and patients with a history of offending to inform risk manage-ment. 24 However, as some reviewers have noted, there are differences between patient groups in forensic and mainstream mental health services, for example, in the overall rates and history of offending, which may limit applicability of existing actuarial tools. 25 Notwithstanding these limitations, it is unfortunate that many mental health clinicians have not received evidence-based training in these tools or in forensic risk assessment or had the clinical experience of forensic clinicians. 26 Similarly, it is our experience that many clinicians in mainstream mental health are unfamiliar with relevant clinical outcome research from the forensic context relating to problems such as anger, psychopathy and related criminogenic factors.

SOME POTENTIAL GUIDING PRINCIPLES FOR DEVELOPING PSYCHOSOCIAL INTERVENTIONS

Of course, many of the potential approaches to these issues are likely to be found in the policy sphere, in better overall resources for community mental health services, and in improved protocols between the mental health and justice systems. 22 However, one component of the solution, firmly within the domain of community mental health services, is also likely to be the development and evaluation of appropriate psychosocial forensic interventions. While there is much data regarding the efficacy of pharmacological interventions for acute agitation, 27 there is little consensus or research data from well-designed trials of specific psychosocial interventions for reducing or preventing the risk for re-offending or in optimizing clinical and functional outcomes for patients with a history of criminal offences which could be delivered safely and economically within mainstream community mental health settings. This includes outcome studies which evaluate programmes to manage the transition of forensic patients into the commu- 12 , 16 and specific therapeutic interventions within mainstream services for patients including patients with anger and adjustment problems, 28 which Szmukler has recently argued should be the initial research priority for mainstream mental health ser-vices. 3 Although psychosocial interventions exist in continuing care programmes in community mental health services, specific focus needs to be given to psychosocial precipitants of offending, such as poverty, domestic violence, homelessness, substance usage and so on. The interaction between these stressors and offending may shape appropriate psychosocial forensic interventions. To date, little has been documented at all about the nature of treatments received in community mental health settings by consumers with serious mental illness who engage in violent behaviour, 1 and even fewer evaluation outcome studies have been reported. 29

The challenge in designing interventions is, of course, that they would need to be flexible enough to cater for a broad range of clinical and forensic issues presenting in a heterogeneous group. For example, Hodgins has recently highlighted that there are at least two subgroups –those with a history of offending which precedes the onset of serious mental illness and those whose offences were committed post-onset of illness. 1 Effective interventions are therefore likely to be multifaceted, address a range of clinical and forensic issues, based upon idiographic formulations, and even gender-specific. 28 Treatment outcome may also be moderated by legal status and motivation for engagement, which differ as patients move from forensic to mainstream community mental health settings.

Prospective follow-up studies of recidivism in consumers with severe mental illness provide a useful starting point in informing guiding principles for psychosocial interventions. 30 This research has employed actuarial statistics, such as iterative classification tree approaches and receiver operator characteristics analysis 24 in order to identify predictive factors of re-offending, based upon data from standardized risk assessment instruments.

Findings can help guide the selection of assessment tools and sensitize clinicians to the importance of matching interventions to distinct and varied factors associated with violence. For example, Skeem et al. recently utilized the actuarial approach to validate three distinct clusters of consumers who are at increased risk of re-offending –alpha, beta and delta. 31 The alpha group was described as the primary psychopathic group who was the most violent and who held core psychopathic traits of callousness and emotional detachment. The beta group was prone to emotionally driven violence in the context of prominent borderline personality traits and perceived stress; substance abuse, not surprisingly, was found to be a significant problem in this group. The delta group, who often had lengthy histories of intensive psychiatric treatment, was found to commit violent acts primarily in the context of active psychotic symptoms. Given the emerging evidence base 32 for psychological therapies for treatment-resistant psychosis, it could be argued that the delta group is a logical priority for the development and evaluation of specific preventive interventions. While there is a paucity of research on the alpha and beta group in the community, it could also be argued that interventions for these groups could be timely to develop because they represent an increasing number of dangerous clients who present at mainstream services and who do not fulfil the treatment criteria of forensic facilities.

In designing appropriate psychotherapeutic interventions, the identification of subgroups of mentally ill consumers at risk of re-offending can be combined with a well-established literature regarding factors associated with successful correctional programmes for reducing recidivism.^33–36 Research has consistently highlighted that four principles underlie successful programmes. These include first an adherence to a focus upon so-called criminogenic needs which entail aspects of individuals’ lives which are conducive to, or supportive of, offence acts including antisocial activities, antisocial attitudes and substance abuse. These are conceptualized as dynamic and malleable risk factors which, when reduced, ameliorate the risk of recidivism. Of course, in mental health settings, significant progress has been made in interventions for comorbid substance abuse, 37 but significant pessimism arguably needs to be addressed in relation to antisocial personality traits, despite recent reviews which have concluded that therapeutic nihilism is not supported empirically, and that both cognitive behavioural therapy and insight-orientated psychotherapies have shown promise, albeit in less than ideally designed trials. 38 , 39 The second identified principle has been the matching of style and modes of interventions to the learning styles of offenders. 40 The principle seems particularly pertinent to severe and enduring psychotic disorders where the idiographic assessment of well-known neuropsychological problems 41 could significantly enhance the tailoring of psychoeducation regarding anger and violence.

The third principle is that the level of intensity of prevention programmes should be matched to the identified risk level of the offender and programmes may need to address the offence-related and offencespecific issues of offending. 40 However, in order to execute this principle, sustainable training and supervision programmes in both appropriately validated actuarial tools and in clinical risk assessment and treatment need to be more widely disseminated among community mental health clinicians. The responsivity principle highlights that the most effective interventions are those that are based upon modelling, graduated practice, rehearsal, role playing, reinforcement and detailed verbal guidance and explanations, including cognitive restructuring. These skills are of course well established among many mental health clinicians who are trained in cognitive behavioural therapy.

Fourth, a prime therapeutic task may be to ascertain what specific needs are met by offending, including power and control, affiliation needs, esteem needs, social needs and so on. 42 Recent intervention programmes in correctional settings assist clients in reframing their needs to achieve ‘the good life’ but not a crimogenic life. 43 Major components of these programmes can include problem-solving, selfmanagement, education of values and social interaction training, because most offending occurs in an interpersonal setting. 44

Finally, we recommend the adoption of a comprehensive and flexible treatment programme containing a range of strategies, in individual and group formats, targeting specific clinical and forensic factors, and which is tailored to clients with specific forensic issues and diagnoses. It may be possible to target subcategories of clients in accordance with typologies of re-offending risk in keeping with the research by Skeem et al. 31 Their classifications gave emphasis to the nature of violence as the key distinguishing feature of each group and they stressed that diagnosis may overlap. For clients who have been diagnosed with antisocial traits or psychopathy, core components of a treatment programme may include victim empathy, problem-solving, conflict resolution, anger identification, provocation management, and so on. These clients are most likely to commit serious crimes of violence against the person, for example assault. The major treatment goals for those who have borderline traits or personality may include stress inoculation, problem solution, social competency, emotional regulation, and so on. These clients are most likely to commit income-generating crimes against property to support substance usage or minor assault or property damage in the context of interpersonal distress. The major treatment goals for the psychiatric patients who have been diagnosed with active psychotic symptoms may include intensive symptom control of command hallucinations, management of perceptions of threat, and so on. These clients may commit violent crimes against people.

The components of the treatment programme can be used by each subtype of patient and can be group or individual. Each of these client subcategories may need intensive case management and corollary attention can be given to the psychosocial aspects of their lives which may contribute to a criminogenic lifestyle. We also think it is important to situate these treatment interventions in a conceptual framework which emphasizes the positive, life-giving, healthy potential, and relationships of these clients in keeping with the treatment interventions which promote the ‘good life’ attitudes and perspectives on offenders and the mentally unwell. 43 As Skeem et al. noted, while these patients may not always comply with traditional treatment programmes, the existence of specific programmes may at the very least sensitize health practitioners to the treatment needs of these patients. 31 The task for community mental health professionals is to develop clinical treatment programmes which address the specific forensic needs of psychiatric patients who are being treated in a community rather than a forensic setting. Of course, in order to achieve this, the skills and knowledge of practitioners will need to be extended, and some modifications to existing interventions designed in the forensic setting may be required, such as integration with assertive outreach and case management models. 45 Any innovations would need to be evaluated within well-controlled studies. Finally, as illustrated by the international emergence of dual diagnosis treatments, additional resources and new collaborations will be required to develop, evaluate and sustain innovative and evidence-based approaches to a growing unmet need. 46

CONCLUSION

In order to develop appropriate systems, training, assessment and treatment, and preventive programmes, more fine-grained prospective follow-up research regarding the forensic, clinical and psychosocial needs of consumers treated within mainstream mental health system, who have a history of offences, is required. Further, data is needed regarding the nature, intensity and effectiveness of interventions currently provided to these consumers within mainstream community mental health. Subcategories of clients may be identified according to their psychological and offence characteristics and tailored psychosocial interventions developed accordingly. Evidence-based research is necessary to validate the usefulness of programmes which are designed to meet the specific needs of psychiatric forensic clients and potential forensic patients. Unique and vital opportunities exist in community mental health to utilize existing psychosocial interventions in an intensive and specialist context, allowing the extension and development of existing resources and skills. The unmet needs of these consumers, the risks of recidivism and the dangers of the workplace are compelling, and require urgent attention from mental health practitioners, service providers and policy-makers.