Forensic Psychology

by Graham M Davies

  Central to effective working in this area is good cooperation between criminal justice and health services. Ultimately this means that such offenders receive appropriate care and treatment for their mental disorders at various stages of them coming into contact with the CJS. This could be from the point of arrest, through to diversion to hospital, as part of the sentencing process via a hospital order, or post-sentence by way of a prison transfer1. Parallel to the criminal justice route into forensic mental health services is the generic psychiatric route. In such instances the risky behaviours that require specialist forensic management and intervention develop after the onset of mental illness. Although these patients could be convicted of offences, such as violence, these prosecutions are not always supported by the CJS because of the debates about criminal responsibility in the context of severe mental illness.

  Psychologists who work within forensic mental health services have historically tended to be clinical, or counselling, psychologists who have specialised in working with offenders. However, more recently forensic psychology as a distinct specialism has increasingly been recognised. However, this is a broad field and can include a number of areas that pertain to the legal system without necessarily incorporating mental illness. Therefore, forensic psychologists who work with mentally disordered offenders typically have had additional training in the field of mental health. This chapter will provide an overview of the area and will describe:

  The history of services to this population

  The range of illnesses commonly seen in mental health settings

  The mental health legislation associated with the duty of care for these patients

  The role of psychology when working with this client group.

  A final section of the chapter outlines the role of the psychology assistant, which is a typical first job for a psychology graduate wishing to embark a career in forensic and/or clinical psychology.

  22.2 HISTORY OF FORENSIC MENTAL HEALTH SERVICES

  Although specialised forensic services have expanded greatly in the last 30 to 40 years, legislation and provision pertaining to this population has been in existence for far longer. In the UK individuals with mental illness were typically “looked after” in large asylums, later called psychiatric hospitals. Those who were considered dangerous to themselves or others would be restrained but there was no specific provision made for them.

  22.2.1 Hospital Provision for Mentally Ill Offenders (in Special Hospitals, Medium and Low Secure Units)

  The first purpose-built hospital for mentally disordered offenders was Broadmoor Hospital in Berkshire, UK. It was completed in 1863, and was built under an Act of Parliament to reform the inadequate conditions of psychiatric institutions such as the Bethlem Hospital in London. Broadmoor is one of four high-security special hospitals in the UK; the others are Ashworth (previously Moss Side and Park Lane), Rampton, and Carstairs in Scotland. The role of the special hospitals has been to house and provide treatment for the most serious mentally disordered offenders assessed as needing a high level of security. As a result of there only being four special hospitals, mentally ill offenders were typically a long distance from their home area, which posed difficulties for family visits and rehabilitation when they were ready to leave high security. A further problem was the huge difference between high security and returning to the community, which created difficulties for the patients in adjustment, and for professionals in identifying if individuals would be able to cope safely in the community.

  In response to these difficulties the Glancy Report (Department of Health and Social Security, 1974) and the Butler Report (Department of Health and Social Security, 1975) outlined the need for more regionally based medium secure units, which would both enable patients to be nearer to home, and also to be treated in conditions of lesser security than special hospitals. The Butler Report (1975) was particularly concerned with the gradual rehabilitation of patients from high security. The Glancy Report (1974) focussed on the needs of patients in general psychiatric hospitals who were behaving in a dangerous way that indicated that they required conditions of security, but were not sufficiently dangerous to warrant admission to a special hospital. These initiatives were envisaged to enable gradual rehabilitation into the community whilst being able to observe the patient’s behaviour and retain control over the individual’s treatment in a secure environment.

  As a result of the Butler and Glancy reports it was recommended that regional secure units offering a level of medium security should be opened throughout England and Wales. These units came to be known as medium secure units (MSUs). Following on from the opening of MSUs came the advent of low secure services to offer a more complete care pathway and a gradual reduction of levels of security for the individuals being rehabilitated. It was also recognised that patients should be managed in the least restrictive environment possible, and thus low security offered an alternative to medium security when this was not warranted. Over time psychiatric intensive care units have tended to cater for patients who present in an acute stage of their mental illness, while low secure units have tended to cater for patients with more long-standing illnesses who respond poorly to treatment. In addition to these specialised units (such as the special hospitals, MSUs and LSUs), there are also other settings in which mentally disordered offenders are catered for, in the community and in prison settings. The Centre for Mental Health reported in April 2011 that: “secure services cost the NHS about £1.2 billion and treat about 8,000 patients at a time, mostly in medium and low-secure hospital units. Spending on secure services more than doubled between 2002 and 2010, taking up 30% of all new money for mental health services during that period.”

  22.2.2 Community Service Provision

  Community forensic services were set up following the recommendations of the Reed Report (Department of Health and Home Office, 1992), which recommended that for an individual patient the level of control and security should be the least restrictive possible, in order to best manage that individual’s risk to themselves and others. Community forensic teams began to be set up and by 2006 there were 37 services across England and Wales. Their remit is to provide a service both to patients who have been discharged from secure units and to those who have never been sent to a secure unit in the first place. These tend to be offenders being managed by the Probation Service, who have received a community order. Such offenders may be subject by the court to a mental health treatment requirement, which can last for up to three years and requires a named responsible clinician who will be responsible for overseeing the treatment of the offender. We will now examine the profiles of mentally disordered patients in these settings.

  22.2.3 Mentally Ill Offenders in Prison

  There are a large number of offenders with mental health problems in the prison system. When mental health problems are suspected within a prison setting, assessments of mental health are undertaken by visiting forensic professionals such as psychiatrists and psychologists. Prisons have their own hospital wing and will look after the most disturbed patients until they can be assessed and transferred to an appropriate secure unit. Despite this a significant number of individuals with mental health problems remain in the prison system.

  Hassan et al. (2011) in their prospective study of more than 3,000 newly convicted prisoners admitted to five UK prisons found that nearly one third screened positive for mental illness, with 10% suffering from psychosis, 32% from a major depressive disorder, 12% from other mental illnesses, 67% from drug misuse and 52% from alcohol misuse. They found that rates of mental disorder remained stable over the first and second months with symptom severity gradually decreasing over time in male but not female prisoners. The finding that mental illness symptoms did not worsen in prison is consistent with previous research (Taylor, Walker, Dunn, Kissell, Williams, & Amos, 2010).

  22.3 TYPES OF MENTAL ILLNESS/FORENSIC BEHAVIOURS SEEN IN FORENSIC MENTAL HEALTH SERVICES

  Forensic mental health services work with indi
viduals who suffer from a range of mental illnesses and disorders. There are also high rates of comorbidity, that is to say, patients who fulfil diagnostic criteria for more than one disorder (dual diagnosis). Although the vast majority of mentally disordered offenders are male, there are a small but significant number of females. Specialist services exist for them. There are also a small number of specialist services for adolescents. There are two major nosological systems currently in use to classify mental illnesses and disorders. The International Classification of Diseases and Causes of Death (ICD-10) is used in the UK (World Health Organization, 1992); and the Diagnostic and Statistical Manual of Mental Disorders, Version Five (DSM-5) is used in the United States (American Psychiatric Association, 2013). A consultation process in respect of developing ICD-11 is currently underway (see: http://www.who.int/classifications/icd/revision/en/) in preparation for its release in 2018. We will now examine the most common forms of mental illness found in the settings outlined above, based on ICD10/DSM-5 criteria.

  PHOTO 22.1 Forensic mental health services have a dual responsibility in treating mental disorder and in managing and minimising risk.

  Source: © Geoff Manasse/SuperStock

  22.3.1 Schizophrenia

  Schizophrenia is the most common diagnosis within forensic mental health settings. It is a severe and chronic illness that is characterised by episodes of significant perceptual disturbance (the positive symptoms of hallucinations, delusions and thought disorder), which may or may not be accompanied by the negative symptoms (including flattened affect, avolition, anhedonia etc.), that result in major changes in an individual’s thinking, emotions and behaviours. While none of these specific symptoms are exclusive to schizophrenia or are essential to diagnosis, symptoms must have been present for at least a month and should not be accounted for by other conditions such as organic brain injury and substance misuse. For diagnosis there is also a need for evidence of social dysfunction that has persisted for at least six months. The episodic nature of schizophrenia is often characterised by disturbances in people’s hearing, sight, sense of touch, taste and smell and significant changes in their thinking and beliefs (positive symptoms). In this context the term “positive” denotes psychotic experiences that can be viewed as having been “added to” an individual’s day-to-day experiences, which under normal circumstances would not be present. This could range from hearing voices that other people present cannot experience to the unwavering conviction with which they may hold fixed beliefs known as delusions, without reasonable evidence to support them.

  During or following a psychotic episode, negative symptoms are also common. In this context “negative” is a term used to denote symptoms that represent something being taken away from the person, such as their drive, energy and enthusiasm. Negative symptoms can mirror a depressive episode and indeed reactive depression can be triggered by the trauma and sense of loss often experienced after a psychotic episode and following an initial diagnosis. Generally schizophrenia is considered to have a poor prognosis in spite of advancements in antipsychotic medication and thus 80% of patients will experience more than one psychotic episode after a formal diagnosis has been made. Nevertheless, there are extremely wide variations in individual outcomes. Relapse behaviours can be triggered by poor medication compliance, and/or psychosocial stressors.

  22.3.2 Paranoid Schizophrenia

  Paranoid schizophrenia (see Case Study 22.1) is the most common form of schizophrenia found in forensic mental health settings. It is characterised by persecutory and sometimes grandiose delusions (positive symptoms). In some cases individuals’ offending behaviour can be directly linked to psychotic experience, for example, in a case where a patient stabbed his partner during a psychotic episode in which he believed that she was poisoning him and their children. In other cases, symptoms are best understood as being linked indirectly, by virtue of the way that they might interfere with an individual’s capacity to think clearly and make rational decisions.

  CASE STUDY 22.1 PARANOID SCHIZOPHRENIA

  Mr B. is a 45-year-old man with a diagnosis of paranoid schizophrenia. He first became mentally ill in his late teens and has had repeated admissions to psychiatric hospital. In response to delusional beliefs he had become increasingly aggressive towards others and could no longer be safely contained at his local psychiatric hospital. He was admitted to the low secure forensic service where he responded well to the stricter boundaries, and the frequency of his aggressive outbursts diminished. Psychological formulation suggested that his aggressive outbursts were in response to his fixed delusional beliefs. Unfortunately his mental illness has not responded well to medication and he falls within the “treatment resistant” category. He is not amenable to psychological treatment due to his disturbed mental state and limited ability to engage, along with poor motivation. For him quality of life is a key issue and the primary treatment aims are to prevent deterioration and to engage him in as many activities as possible to keep him occupied and provide him with some enjoyment and purpose in life. If he remains settled the plan is to move him to a locked rehabilitation unit with increased access to the community. If this is successful he may then be rehabilitated back to his local area.

  22.3.3 Major Affective Disorders

  Major affective disorders are characterised by dramatic fluctuations in mood states, as is the case for bipolar disorder or persistent and extreme mood states, such as depression, that interfere with an individual’s functioning. In extreme cases psychotic symptoms can be present during episodes of illness, such as auditory and visual hallucinations and delusions. However, what assists clinicians in distinguishing these from a schizophrenic episode is that the psychotic experiences are always mood congruent, that is to say they reflect the mood being experienced. For example, an individual may believe that they own a property empire or that they are a music celebrity, in association with a manic episode.

  22.3.4 Personality Disorder

  Personality theory suggests that individuals exhibit stable characteristics across a range of situations. These characteristics are shaped by a combination of temperamental and environmental factors (Millon, 1990). It is likely that a number of individuals are born with a biological propensity to develop personality disorders whilst in others it appears to be due to adverse life events. Hence, when an individual is considered to be “personality disordered” the normal developmental process has been derailed in some way. This is because some individuals with personality disorder have had difficult life experiences that have prevented one or more fundamental emotional needs from being met. This results in the child developing quite extreme coping strategies necessary for psychological survival, and having attachment difficulties (see Chapter 11 for a brief description of these).

  Individuals with personality disorder commonly experience a variety of mental health problems and psychological distress. The distinction between “disorder” and “illness” is important though because it conveys the stable nature of the condition in contrast to an episodic mental illness. For example, individuals with schizophrenia typically experience periods of being mentally well but can relapse into periods of being mentally unwell. Individuals with personality disorder may experience crises when their difficulties seem more pronounced but in general terms their emotional and behavioural problems are persistent. See Case Study 22.2 for a description of an individual with a particularly intractable personality disorder – borderline personality disorder.

  CASE STUDY 22.2 BORDERLINE PERSONALITY DISORDER

  Ms A. is a 25-year-old woman who was sent to a medium secure unit for assessment prior to sentencing for arson. She had a previous history of self-harm and a diagnosis of borderline personality disorder. She disclosed a history of sexual abuse by her father and was estranged from her family as a result of this disclosure. Her father has never been prosecuted. Psychological assessment and interview confirmed her diagnosis of borderline personality disorder. Furthermore, psychometric testing showed that s
he had very low self-esteem, was emotionally lonely, had an external locus of control, and was impulsive. A psychological formulation suggested that her arson and self-harm behaviours were associated with a need to feel in control and were triggered by negative life events, particularly problems in interpersonal relationships. She was assessed as being suitable for treatment in a medium secure unit and was placed on a Section 37 of the Mental Health Act (1983) (see Box 22.2). Treatment involved including her in a dialectical behaviour therapy (DBT) programme, which was made up of both group and individual sessions covering “distress tolerance, skills training and mindfulness” (see Linehan, 1993). Following this, Ms A. underwent individual work to address her victimisation issues with a focus on developing self-compassion before more specific offence-focussed work on her firesetting. As the work progressed, and she gained more control of her behaviour, she moved from medium security to low security before finally being discharged to supported accommodation in the community, under the care of her community team.