Forensic Psychology

by Graham M Davies

  22.4.3 Capacity to Consent

  Capacity to consent to treatment is a complex issue and as such has legislation pertaining to it. Depending on the Section under which they are detained, an individual can be forced to take medication against their will for a period of up to three months. After this the responsible clinician has to either obtain the consent of the patient or seek a second opinion from a Second Opinion Appointed Doctor. Treatment can only be mandatorily applied in a hospital and does not apply to prisoners. A further issue to be addressed is the individual in question’s capacity to be able to give meaningful consent. The Mental Capacity Act (2005) was designed to ensure that the individual was assessed fully as to their capacity to understand, decision make and communicate their wishes regarding a specific issue. With regard to consent to treatment, the Mental Health Act can override the Mental Capacity Act so that where an individual has capacity but chooses not to have treatment this can be enforced against the person’s will.

  22.4.4 Multi-Agency Public Protection Arrangements (MAPPA)

  Due to the concern over the management of potentially risky individuals once they have been discharged into the community, and the need to ensure information sharing, multi-agency panels were set up by the Criminal Justice and Court Services Act (2000). Although the police, probation and prison services are the lead agencies, there is a duty upon healthcare services to cooperate with MAPPA. Sexual and violent mentally disordered offenders, and those thought to pose a serious risk of harm, are included under MAPPA. They are allocated to one of three levels from Level 1 (least risky) to Level 3 (most risky). For mental health professionals the disclosure of information about the patient without the informed consent of that patient breaches confidentiality and leads to professionals having to make a decision about the benefits of disclosure versus the risks.

  22.4.5 Care Pathway Approach Arrangements

  From the point of contact with forensic health services a Care Pathway Approach (CPA) is identified for the individual. The CPA is based on a multi-disciplinary treatment (MDT) model in order to provide holistic interventions to individuals with mental health problems. The MDT is typically made up of psychologists, psychiatrists, social workers, nurses and occupational therapists. In ASD services it is becoming usual to also have input from a speech and language therapist and most MDTs now have additional input from a pharmacist.

  22.5 THE ROLE OF THE PSYCHOLOGIST IN FORENSIC MENTAL HEALTH SETTINGS

  Although psychologists are uncommon within community services, they are often central to the work within residential forensic mental health settings because of their specialist skills in assessing complex needs and developing sophisticated formulations that enable services to prioritise interventions accordingly. This includes being able to assess mental health and risk and to formulate how these can be linked. Within their training they also develop a good understanding of team working and can provide relevant consultation and support to inpatient staff. Psychologists also undertake a wide variety of duties as shown below.

  22.5.1 Assessments

  Psychologists are involved in undertaking core assessments with patients upon their reception into hospital and to assess progress. These include: cognitive functioning assessments (i.e. IQ assessments, using the Weschler Adult Intelligence Scale, Version 4 (WAIS-IV); neurological test batteries; personality assessments, such as the MCMI-111; specific offence related assessments; and assessments of attitudes/schemas. Further assessments may be conducted dependent on individual risk and treatment need. Pre- and post-group assessments are routinely undertaken with both staff and patient groups dependent on the intervention delivered at the time. In order to provide an evidence base for all work carried out it is routine to use pre and post psychometric assessments alongside all interventions.

  22.5.2 Risk Assessment

  Risk management is one of the key concerns of forensic mental health professionals, and creates a need for carefully considered risk management procedures to ensure the best quality of life for the service user whilst protecting the public. It is now a requirement from the Department of Health that all mentally disordered offenders have to undergo a risk assessment using a structured risk assessment measure known as the HCR-20 (Historical, Clinical, Risk Management-20; Webster, Douglas, Eaves, & Hart, 1997) (see Chapter 18 for a description of this instrument). The HCR-20 is used to assess the risk of future violent reconviction and the items included are those that have been shown by research to be associated with increased risk of violence. As part of the completion of these risk assessments a risk management plan is drawn up. This highlights the circumstances under which risk may be increased and the likely consequences, and helps the MDT to devise an appropriate plan for the individual’s safe future management. Risk assessments are regularly reviewed and updated and are shared with other professionals involved in the care of the patient.

  22.5.3 Treatment

  Forensic mental health services have a dual responsibility in treating mental illness and/or disorder and in managing and minimising risk. In some cases the risky behaviour is directly associated with the episode of illness, and so treating mentally disordered offenders mental health problems is the first priority. If the factors that underpin an individual’s risk of reoffending are complex, specific interventions to target, these can only be effective if sufficient progress has been achieved in stabilising the individual’s mental state first. Once an individual’s mental state has been stabilised mental health professionals play a considerable role in providing psycho-education to improve insight and understanding, in order that the patient is empowered to play a greater role in maintaining their mental health in the future.

  It is beyond the scope of this chapter to describe the vast array of interventions that may be used with mentally disordered offenders. As with any mental health client the intervention used is based on an assessment of the individual’s needs and abilities to ensure engagement and motivation. Interventions can be individual or group-based. Although generally based on a cognitive-behavioural treatment (CBT) approach, other approaches may be used such as: dialectical behaviour therapy (DBT); mindfulness; cognitive analytic therapy (CAT); eye movement desensitisation and reprocessing (EMDR); acceptance and commitment therapy (ACT); and compassion focused therapy (CFT). (See Glossary for a brief description of these approaches.)

  It is usual for programmes aimed at specific offence behaviours also to be available (i.e. sexual offending, anger management, substance misuse, firesetting) along with programmes aimed at improving problem-solving abilities, such as enhanced thinking skills, general social and relationship skills and relapse prevention/preparation for discharge groups (see Chapter 18 for a review of these interventions with mainstream offenders). Box 22.3 shows the types of problems in treating psychotic disorders (i.e. schizophrenia, major affective disorders), while Box 22.4 shows some indicative treatments for personality disorders.

  BOX 22.3 THE DIFFICULTIES OF TREATING PSYCHOTIC OFFENDERS

  Lack of insight, poor motivation, poor compliance with treatment and frequent additional problems such as substance misuse, present a challenge in effectively treating psychotic offenders.

  The positive symptoms of schizophrenia (with the exception of delusions) generally respond well to the wide variety of antipsychotic medications that have been developed. Negative symptoms can be persistent by virtue of the fact that they are less amenable to pharmacological treatments. Nevertheless, they are an important target of interventions because of the way in which they can lead to significant disability by impairing an individual’s day-to-day functioning.

  Major advancements have been made in the field of pharmacology that have enabled clinicians to stabilise affective disorders. Poor compliance with mood stabilisers is a common precursor to relapse in major affective disorders. This can present a particular challenge to mental health services, because the early stages of a manic episode, characterised by increased energy, hopefulness and positive self-bel
ief, can be so enticing to the patient that they do not want to lose these features.

  Patients with the dual diagnosis of both schizophrenia and substance misuse show poorer compliance with medication and other care, reduced stability of social functioning and increased hospitalisation rates, and increased reconviction rates following discharge from medium security. It is therefore a key area for intervention for service users in secure settings in order to support recovery, improve functioning and reduce offending.

  BOX 22.4 THE DIFFICULTIES OF TREATING PERSONALITY DISORDER

  There is growing evidence for some pharmacological treatments having some efficacy for treating symptoms that stem from personality disorder, particularly emotional lability. However, the majority of targeted treatments for personality disorder are based on psychological models.

  In a review of cognitive behavioural treatment (CBT) interventions by Rice and Harris (1997) a number of themes emerged regarding the efficacy of particular treatment strategies for particular categories of personality disorder, based on the clusters from DSM-IV:

  Social skills programmes targeted at individuals with Cluster A, (dependent personality disorders) were found to be most effective. Emotional management skills training was also found to be most effective with individuals with anxious and depressive/dependent personality disorders as well as those with pronounced affective liability as is the case with borderline personality disorder.

  Individuals with Cluster B (independent personality disorders), whose difficulties are often characterised by impulsivity and hostile reactions, have been shown to respond best to life skills training.

  Substance misuse often coexists with personality disorders. By virtue of the fact that the basis of personality disorder is characterised by pervasive and entrenched patterns of responding, progress in moderating the impact of this in forensic mental health settings can be slow. Thus personality disorder per se can be a marker for a poorer prognosis. For this reason, there is a need for the application of sophisticated treatments, but these depend on the correct identification of the disorder in the first place.

  Such interventions are underpinned by research from evidence-based practice, including the National Institute of Clinical Excellence (NICE) guidelines (http://guidance.nice.org.uk/Topic/Public Health). However, the complexity of the cases, including comorbidity and the chronic nature of some mentally disordered offenders’ mental disorder, demonstrates that the evidence-base is inadequate. Forensic mental health services also need to take account of competing agendas, when developing intervention plans for mentally disordered offenders, in terms of the rights of the individual and the protection of the public.

  A further tier of intervention may include individual or group-based sessions to promote self-awareness and impart psycho-education to patients. An example of this may include assisting patients to understand the link between physical tension and mental activity via biofeedback sessions or using mindfulness practice to reduce rumination and help them learn to cope with and tolerate distressing experiences. Patients are thus encouraged to utilise these skills in everyday life and/or stressful situations, enhancing their abilities to observe and monitor themselves to control their tension and anxiety-based arousal levels.

  22.5.4 The Assistant Psychologist

  In many secure mental health settings it is also usual for qualified psychologists to have assistants working with them under their direct supervision. It is common for those intending to train as chartered clinical or forensic psychologists to work at assistant level and gain experience in a clinical setting prior to commencing their full training. The types of work often undertaken by assistant psychologists are shown in Box 22.5.

  BOX 22.5 PSYCHOLOGICAL ASSISTANT ROLES IN FORENSIC MENTAL HEALTH SETTINGS

  In secure forensic mental health settings, assistant psychologists may be involved in differing levels of psychological therapeutic interventions with patients (subject to their level of motivation, responsivity and mental state) including:

  Assessing a patient’s needs, abilities or behaviour using a variety of methods, including psychometric tests, interviews and direct observation of behaviour

  Assisting in the devising and monitoring of appropriate programmes of treatment

  Delivering therapy for difficulties relating to anxiety, depression, addictions, social and interpersonal problems and challenging behaviour

  Evaluating service provision

  Assisting in carrying out research

  Having key involvement in setting up and delivering low-level interventions that aim to introduce appropriate communication and interaction skills in a group setting

  Collating information for completion of risk assessments, which are required to be used routinely with all forensic patients as part of risk assessment and risk management.

  22.6 SUMMARY

  Psychologists working in forensic mental health settings are typically involved in the care pathway approach, risk assessment, general assessment and formulation of problem behaviours and treatment of patients.

  Psychologists work closely with staff members from other disciplines including psychiatry, occupational therapy and nursing within secure mental health settings. Together these professionals form the multi-disciplinary team.

  Such work is to stabilise and maintain an individual’s mental health and to manage and minimise the risk of reoffending behaviour in the least restrictive environment possible.

  This poses an interesting challenge to psychologists and other mental health professionals who work in forensic settings. Clearly they have a duty of care to treat and rehabilitate their patients. Nevertheless, they have the additional role of protecting the public from risks presented by their patients.

  ESSAY/DISCUSSION QUESTIONS

  Describe the primary considerations for a psychologist working in a forensic mental health setting.

  Mental illness can be a key factor in leading to crime. Discuss.

  How might the rehabilitation process differ in forensic settings compared to general mental health settings?

  Describe the range of treatment approaches that might be specific to forensic settings.

  What might be the advantages of multi-disciplinary working in forensic mental health settings?

  ANNOTATED READING LIST

  Dickens, G., Sugarman, S., & Picchioni, M. (Eds.) (2015) Handbook of secure care. London: Royal College of Psychiatrists. This book provides an up-to-date and comprehensive summary of clinical practice and good risk management within secure psychiatric settings. It covers the full range of mental disorders for both male and female patients regardless of age and considers clinical, academic and ethical aspects of secure psychiatric care.

  Fazel, S., Gulati, G., Linsell, L., Geddes, J. R., & Grann. M. (2009). Schizophrenia and violence: Systematic review and meta-analysis. PLoS Medicine, 6(8):e1000120 This paper reports a meta-analysis on data from 18,423 patients with schizophrenia and other psychoses. The link of schizophrenia and other psychoses with violence and offending may be mediated by subtance abuse comorbidity.

  Gibbon, S., McMurran, M. & Khalifa, N. (2009). Forensic mental health. Cullompton, Devon: Willan. This book provides “a clear overview of both the key concepts in forensic mental health as well as the way the discipline operates in the broader context of criminal justice and mental health care systems”. It is an excellent starting point for an introduction to the main issues and describes the working of the multi-disciplinary team, the legislation involved and the care pathway taken by the patient.

  Hodgins, S. (2008). Criminality among persons with severe mental illness. In K. Soothill, P. Rogers, & M. Dolan (Eds.), Handbook of forensic mental health (pp. 400–423). Cullompton, Devon: Willan. This chapter provides an excellent overview of the association between crime and mental illness and considers the prevalence of crime among the severely mentally ill.

  International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10
). Geneva: World Health Organization. This is the World Health Organization coding used in Europe by clinicians concerned with diagnosing and classifying all known diseases and disorders, including mental health problems. It contains the criteria for diagnosis for each disorder. It is worth looking at this to obtain an idea of the types of symptomatology for the various disorders classified under the Mental Health Act (1983).

  Mental Health Act 1983 and 2007. It is worth looking at the Mental Health Acts in order to gain an understanding of the legislation covering forensic mental health patients and the duties and responsibilities of the mental health teams who care for them. An alternative reference that provides a guide to the Act is: Jones, R. (2008). The Mental Health Act Manual. London: Sweet and Maxwell.