Sei sulla pagina 1di 8

Rehabilitation of the Mentally Disordered Offender

LORRAINE CHILDS AND PHILIP BRINDED


Medlicott Academic Unit, Christchurch, New Zealand

Psychiatric Service (CFPS) is outlined, using the principles


of a "therapeutic culture", prior to a description of specific
This article considers a number of areas significant to the psychological interventions. It is hoped that this work will
rehabilitation of mentally disordered offenders. The stimulate further research and discussion in the developing
growth of forensic rehabilitation services has area of forensic rehabilitation.
outstripped research in this area, hence it is acknowledged
that clinicians are currently working with limited guidance.
However, literature from this, and related fields, is reviewed, The Relationship Between Mental Disorder,
to outline the processes and practices of rehabilitation of Crime and Violence
mentally disordered offenders. The model of care used in the
Canterbury Forensic Psychiatric Service is described with A review of the literature into the relationship between
reference to the need for interventions to be carried out mental disorder, crime and violence is beyond the scope
within a therapeutic culture (Lindqvist & Skipworth, of this article, however, comprehensive reviews are avail-
2000).The role of a psychologist in assessment, intervention, able (Monahan & Steadman, 1994; Mullen, 1997).
training, research and organisational issues is discussed. Studies have examined the relationship between mental
There is acknowledgement of the ethical dilemmas faced by illness and crimes, including shoplifting (Gudjonsson,
clinicians working in rehabilitation, with patients who present 1987), arson (Soothill & Pope, 1973) and stalking (Mullen,
a risk to others.
Pathe, & Purcell, 2001). Violence is indicated in the major-
ity of index offences leading to referral to Forensic Mental
Health services (Taylor, 1997). Furthermore, violence com-
The last 20 years have seen a significant growth in forensic mitted by psychiatric patients is a growing concern of the
services worldwide. In New Zealand, prior to 1988 there public (Sheppard, 1996), resulting in clinicians requiring
were no designated forensic services. The country had more information and guidance for decision-making
a maximum security hospital for the most violent psychi-
purposes (Rumgay & Munro, 2001).
atric patients and psychiatrists operated in forensic capaci- While there is a substantial body of literature on the
ties on a private basis. In the last 15 years regional forensic
relationship between violence and mental illness, there are
psychiatric services have been developed. These multidisci-
limitations, which preclude direct comparisons between
plinary teams provide care to patients in inpatient units, via
community teams and services to the prisons. Reasons studies. These limitations include varying diagnostic criteria
for such rapid growth include an increase in the focus and methodology, and poor representation of populations
on community care and awareness of the prevalence in research samples. For example, there are many undiag-
of mental disorder amongst prisoners. Parallel to this has nosed and untreated people with a mental illness in prison
been a rise in public expectations regarding risk, which has (Gunn, Maden, & Swinton 1991; Brinded et al., 2001).
been driven by the media highlighting crimes committed Similarly, as discussed, due to medico-legal criteria (court
by people with mental disorders. diversion programs, insanity findings), there are people with
Service expansion and allocation of specialist resources mental illness who have committed an offence, but are not
has enabled forensic services to flourish. However, service included in "offender" statistics.
development has occurred at a faster pace than the literature Despite these limitations, it is possible to identify some
about the efficacy of treatments for forensic populations. trends in the relationships between mental disorder, crime
Literature reviews illustrate a lack of empirical research and violence. A significant body of international literature
regarding what works for mentally disordered offenders indicates a link between mental disorder and violence
(MDOs), and for whom. Hence, there are few models to (Monahan & Steadman, 1994; Mullen, 1997). The complexi-
guide clinicians involved in the rehabilitation of this group ties of this link however, have been illustrated by studies,
of offenders. which highlight confounding factors such as comorbidity of
The purpose of this article is to provide information that substance abuse and personality disorders (Steadman, et al.,
will, despite these caveats, consider a number of areas 1998; Rice & Harris, 1995). This has led to more detailed
significant to the rehabilitation of MDOs. While the clinical studies, examining specific risk factors.
outcome and research literature is utilised, so too are the The evidence that links mental disorder and violence
clinical experiences of the authors. Overall, the aim is to comes from three broad groups of studies which include
provide the reader with a conceptual framework within studies of inpatients and discharged populations (e.g.,
which the role of the psychologist and psychological inter- Lindqvist & Allebeck, 1990), prison studies (e.g., Brinded
ventions can be placed. Hence, the Canterbury Forensic et al., 2001; Taylor & Gunn, 1984), and community studies

Address for correspondence: Associate Professor Philip Bnded, Medlicott Academic Unit, Regional Forensic Psychiatric Service, Canterbury District
Health Board, Hillmorton Hospital Prvt. Bag 4733, Christchurch, New Zealand. Email: Phl.BrlndedOcdhb.govt.nz

NOVEMBER 2002 AUSTRALIAN PSYCHOLOGIST


VOLUME 37 NUMBER 3 pp. 229-236

229
LORRAINE CHILDS AND PHILIP BRINDED

(e.g.,Wessely, Castle, Douglas & Taylor, 1994). One of the that they are working as part of a therapeutic process, which
most comprehensive studies that contributed to an under- improves quality of life, even when task-focused change
standing of the interplay of risk factors involved the analysis appears limited. The benefits of this approach to patients are
and reanalysis of data on 10,059 subjects from a North outlined in what follows, with reference to specific examples
American Epidemiological Catchment Area (Swanson, of how these principles are addressed within the CFPS.
Holzer, Ganju, & Jono, 1990). This study indicated self-
reported levels of violence for the general population, Shared goals and values. The range of environments
people with schizophrenia and people with alcohol and and staff groups to which an individual is exposed during the
substance abuse to be 2.4%, 12% and 25% respectively. process of rehabilitation leads to possible inconsistency
When the presence of substance abuse was controlled for, in approach. It is therefore important to try to adopt
rates of violent incidents by people with mental illness a consistent culture across settings and staff so that values
dropped to 7%, which was the same as for people aged and goals are shared. In the CFPS the Recovery Approach
18-24. Subsequent research confirms the validity of this has been adopted. The principles of this state that "recovery
finding (see Soyka, 2000, for a review). Swanson and is defined ... as the ability to live well in the presence
colleagues (1990) also demonstrated an association between or absence of one's mental illness (or whatever people choose
active symptomatology and violent incidents. Research to name their experience)" (New Zealand Mental Health
findings in prison and hospital populations have confirmed Commission, 2001, p. 1). A key aim of the recovery model is
that active symptoms of psychosis do increase the risk to foster hope that "recovery" will occur through shared
of the occurrence of violent incidents (Steadman et al., effort by the patient and supporting staff team. Other philoso-
1998; Taylor & Gunn, 1984). phies and models used within the forensic service include
the Strengths model (i.e., focus and build on the strengths
of the patient; Rapp, 1998) and the psychosocial model
Rehabilitation of the Mentally (i.e., emphasis on a social rather than a medical model;
Disordered Offender Anthony & Liberman, 1986). These models emphasise
The verb "to rehabilitate" has been defined as "to restore a wider cultural goal of the service - to remain patient-
to good form or proper functioning condition" (Reber, 1995, focused, with (where possible) patients being central
p. 27). There has been debate as to whether the focus to decision-making in the delivery of care. Patients are en-
of rehabilitation with MDOs should be towards alleviating couraged to advocate for themselves, and to enroll advocacy
mental illness, or reducing offending behaviour (Blackburn, support from family, friends and staff. The Forensic Service
1996). Recently, it has been suggested that rehabilitation also employs people who have previously been patients
of MDOs should focus on "increasing personal effectiveness, within the service, to act as consumer representatives and
of which avoiding further offending is only one component advocates. Involvement of wider consumer groups is also
... this implies that the targets of intervention are those encouraged. The Pukenga Atawhai (Maori Mental Health
cognitive emotional and interpersonal disabilities which workers) are important to this process, ensuring that individ-
impede social reintegration" (Blackburn, 1996, p. 133). These ual's cultural needs are assessed and managed.
disabilities include learned behaviour, personal and social
Stffcontdnuy. Lindqvist and Skipworth (2000) emphasise
circumstances, as well as the effect of an individual's mental
the need for the patient to have the opportunity to build
illness. It is, therefore, clearly important that assessment, sustainable, trusting relationships with staff. This can help
formulation and treatment incorporate a broad range the patient to develop confidence and social skills (Perkins
of individual factors and outcomes, many of which are
& Dilks, 1992), which can later (with consistent support) be
outlined below. It can also be seen that there are inevitably
generalised to community settings. As part of this process,
broad areas of overlap between rehabilitation programs for
staff need to receive training, supervision, and feedback
MDOs and those in general psychiatric populations.
about their performance. The CFPS holds in-service training
Lindqvist and Skipworth (2000) have proposed a foren-
sessions and working groups to ensure familiarity and
sic rehabilitation assessment and treatment framework
review of adopted models and philosophies. Staff attend
which incorporates factors affecting risk of relapse or reci-
supervision, courses and conferences and share multidisci-
divism in a mentally disordered offender population. They plinary team models. Staff continuity is assured in that the
suggest four dynamic factors that need to be assessed and consultant psychiatrists, social workers, Pukenga Atawhai
addressed within forensic rehabilitation. These are the disor-
and clinical psychologists track the patient's progress
der itself, family problems and poor sociocultural circum-
through the service, whilst nurses and occupational thera-
stances, substance misuse, and antitherapeutic system pists are ward-based. To coordinate this delivery of care, the
dynamics. The authors suggest that these risk factors inter- patient is also allocated a Case Manager. This model is
act and are amenable to change (dynamic) although they flexible and staff can be changed at the patient's request, in
admit to the difficulties such a model presents for service the event that the therapeutic relationship has broken down.
evaluation. Of particular note in this model is the attention
paid to system dynamics, and how temporal and interac- Timing of the rehabilitationprocess. Lindqvist and
tional facets of the environment can facilitate or hamper Skipworth (2000) assert that rehabilitation should
rehabilitation objectives. The authors encompass these commence immediately on entry to the service, although
variables under the term "therapeutic culture", reminding us legal processes may initially hinder treatment (i.e., the
that we are working within a broad system, of which initial period of a remand assessment). Given that the litera-
specific interventions are only a part. ture suggests that rehabilitation is most effective when
The need to implement a therapeutic culture has been it takes place in the least restrictive environment (Andrews
recognised within general psychiatric rehabilitation et al., 1990), it is necessary to assist patients to develop the
(Conning, 1991), but there has been little reported applica- and self-support skills needed to progress from secure
tion of these principles in the forensic literature. This is not to open rehabilitation environments. People also need the
to say that a therapeutic culture has not been fostered. opportunity to make a gradual transition between environ-
However, explicit acknowledgement of the need for, and the ments and services to ensure expectations are clear and
principles underlying, such a culture can emphasise to staff demands are not too high. On entry to the CFPS, individuals

NOVEMBER 2002 VAUSTRALIAN PSYCHOLOGIST

230
MENTALLY DISORDERED OFFENDERS

are assisted to understand the legal processes. Key clinicians as a factor that increases the chance of recidivism in MDO
(including cultural workers) are appointed early on to facili- populations (Webster, Douglas, Eaves, & Hart, 1997).
tate development of trusting relationships. The process
of gaining increased autonomy and reduced imposition The Role of the Psychologist in Rehabilitation
of restrictions is made transparent, and staff and patient The role of a clinical psychologist has been described
hopes and expectations are discussed and negotiated. as involving "specialised knowledge of psychological
Transition between environments, (i.e., between wards functioning and psychological methods, which provides
or from hospital to the community) is managed via a particular expertise in carrying out psychological assess-
process of increased day and overnight leaves (Mohan, ments such as psychometric tests, psychological treatments
Jamieson, & Taylor, 2001), with gradual introduction of and psychological methods of research and evaluation"
new case managers, and maintenance of contact with other (Hall & Marzillier, 1992, p. 9).' Whilst psychologists have
professionals as appropriate. traditionally been employed to work with individuals, there
Family relationships. Violence is most likely to occur in is increasing recognition that their role is also one of train-
patient's homes, especially when they are exposed to ing, consultation, planning and research at environmental
relationship stress (Bullard, 1994). Hence, the patient's (i.e., ward-based) and broader service levels (Conning,
1991). The heterogeneity of the patient base and the broad
relationship with their family is an important factor in
remit of forensic services gives the psychologist in these
rehabilitation. However, after years of failure to bring
environments an opportunity to work at all of these levels.
improvement, families are often disillusioned with services. The role of the psychologist in forensic rehabilitation will
Lindqvist and Skipworth (2000) suggest that "forensic therefore be described according to Liddell's (1983) sugges-
services must expect some of this frustration to be voiced tion of the core skills of the psychologist - assessment;
before solid alliances can be forged between the patient, the therapy/intervention; and research and teaching (as cited in
family and the psychiatric service" (p. 322). The CFPS Conning, 1991).
seeks permission from the patient to include the family in
the assessment and rehabilitation process. Specifically, Assessment
Pukenga Atawhai assist in fostering relationships between
Psychological assessment involves asking questions and
the patient, whanau (family) and service, even when using scientifically-based methods to gather information,
patients have lost contact with their family. In this way, and to formulate a model of factors that may be contributing
family and partners can help with assessment and identifica- to a particular circumstance. Individuals who present to the
tion of previous service failures, and be included in the forensic service will, in the medico-legal process, have
rehabilitation plan and educational programs. Specifics of received a diagnosis. In terms of planning rehabilitation,
family intervention are discussed later in this article. diagnoses are limited in their utility. Often people have
Social networking/peers. The patient must have a social more than one diagnosis. Furthermore, diagnoses do not
network beyond the boundaries of paid staff when they highlight psychological and social disabilities that may be
move back into the community. In the CFPS, patients are related to offending. Hence, psychologists can assist with
assisted to contact friends and family who will provide complex multidisciplinary formulation via assessment of
neuropsychological deficits (Gillespie & McKenzie, 2000);
positive support and esteem to the patient throughout the
cognitive factors (i.e., dysfunctional cognitive processing
inpatient and community rehabilitation process. In particu-
and deviant interpersonal beliefs); affective factors
lar, cultural and patient support workers assist with this
(i.e., anxiety and depression); and lifestyle (interpersonal
process and act as role models. skills, substance abuse) (Browne & Howells, 1996).
Process insight. Lindqvist and Skipworth (2000) suggest The assessment of the individual may identify broad
that if a patient regards their hospital stay as "a sentence" needs or specifically focus on a particular problem or risk
and is discharged having "served their time" one can predict factor (Conning, 1991). A range of techniques may be used
a poorer outcome. Hence, they indicate that a major part of including interviews with the patient and significant others
rehabilitation is to increase the self-determination of the (including getting the patient's view of the problem); previ-
patient, so that they are able to recognise and respond to ous file information on social, psychiatric and forensic
factors pertinent to relapse and recidivism. The CFPS factors; psychometric assessment and measures of function-
provides illness education and addresses relapse-prevention ing (i.e., cognitive, adaptive); and observation. Test instru-
by helping individuals establish the factors that will help ments can be used to increase objectivity in formulation and
them stay well. Community follow-up is also provided to outcome evaluation. For example, a test battery may include
the patient as a way of helping them to build upon and neuropsychological assessment, measures of affect, motiva-
tion for change and personality. It is important that the
maintain the progress they have made in hospital. Families
practitioner interprets the results of such instruments
and partners are helpful in this process.
cautiously, as forensic patients may differ significantly from
The future. As stated earlier, the CFPS has adopted the the population for whom the instruments were developed
Recovery Approach, which focuses on fostering hope and normed. For example, as cultural minorities tend to be
via the establishment of realistic future goals. These over-represented in forensic populations (Coid, Kahtan,
are determined by the patient (as far as possible), who Gault, & Jarman, 2000), tests may lack cultural validity
is then encouraged to work towards these goals and assisted with some patients. In Australia and New Zealand, this is
in developing the necessary skills. Lindqvist and Skipworth particularly pertinent to those from Aboriginal and Maori
(2000) also emphasise the importance of helping the patient backgrounds respectively.
to establish hope and planning for the future. In this way, Risk assessment. The increasing attention given to the
people's actions can be guided by their own goals and percep- "dangerousness" of psychiatric patients means that all services
tions of success. This is important, since a lack of social need to pay more attention to risk assessment. Recently
support and achievable goals has been clearly identified the focus of assessment has changed from dangerousness as a

NOVEMBER 2002 VAUSTRALIAN PSYCHOLOGIST

231
LORRAINE CHILDS AND PHILIP BRINDED

static phenomena to the treatability of dynamic and change- of these psychosocial treatment approaches (Quayle
able risk factors (Lindqvist & Skipworth, 2000). Similarly, & Moore, 1998; Renwick, Black, Ramm, & Novaco, 1997).
there have been changes in professional perspectives of The remainder of this section focuses on specific
methods of risk assessment, with recent agreement that psychological interventions used in forensic rehabilitation.
careful collaborative use of clinical and actuarial measures,
is likely to provide the most accurate assessment of future Behaviour theay. The basic premise of behaviour therapy
risk (Blackburn, 1996; Rice & Harris, 1997). with MDOs is to positively reinforce prosocial behaviours
"Risk" is a broad concept that may relate to the effect of and to reduce antisocial behaviours. Behavioural programs
the individual on the self (i.e., deliberate self-harm, suicide are extremely effective interventions when they are specific,
or neglect) or on others (i.e., violence). These principles structured and part of a multimodal treatment package
apply in the community and in the institution. Whilst there (Lipsey, 1992). This structure and clarity is particularly
are limitations in accuracy (Mossman, 1994), a risk assess- useful when working with people with learning disabilities
ment attempts to predict the likelihood of an individual and/or active psychotic symptoms, with the techniques
committing further antisocial acts. The psychologist can successfully applied in community and inpatient settings
assist in risk assessment by using methods already outlined (Beck, Menditto, Baldwin, Angelone, & Maddox 1991).
(i.e., file reviews, interviews with patient and family). Aims In their review; Rice and Harris (1997) suggested that
of assessment may include: identifying themes and patterns behavioural interventions provided a means of monitoring
of previous offending; examining the interplay of mental behaviour and building skills. Specifically, they recom-
illness with broader psychosocial factors; assessing the mended using behavioural approaches alongside social
individual's insight and understanding of their problems skills training. The latter will be discussed separately, as it
(i.e., motivation for change); identifying judgemental biases also relates to cognitive-behavioural interventions.
and attitudes; and examining the contribution of neuropsy- At the CFPS, contingency-based behavioural programs
chological deficits. Identification of specific risk factors aim to increase patients' awareness of and responsibility for
requiring more in-depth assessment and/or formulation can their behaviour and its consequences. The approach
be acquired by using a formal risk assessment tool, such is framed in terms of encouraging people to develop the
as the Historical/Clinical Risk Management scheme (HCR- skills and atitudes necessary to survive in the community
20; Webster et al., 1997) or the Violence Risk Appraisal in the future. Patients assist with the development and
Guide (VRAG; Harris, Rice, & Quinsey, 1993). These
choice of rewards and consequences for specific behaviours,
actuarial tools focus on identified risk factors that have been and goals are regularly reviewed. Initial areas of focus
shown to increase the risk of future violence. Risk assess-
include reducing aggressive acts, reducing substance abuse,
ment in MDO populations must always lead to risk manage-
encouraging the taking of medication, improving personal
ment as part of an overall care plan.
care and encouraging participation in ward or community
Assessment of the environment and service. Most forensic activities. Behavioural reinforcers are generally delivered by
patients are subject to at least a short period of incarceration. nursing staff, who are encouraged to deliver positive
It is therefore important that the environment and the broader reinforcement for appropriate behaviours, rather than focus-
service facilitates the rehabilitation process. Psychologists are ing on the negatives. Monitoring levels of achievement as
equipped with the research skills to evaluate models of care the patient progresses through their rehabilitation, provides
(Lavender, 1985) and to encourage evidence-based practice information to aid decision-making of the multidisciplinary
(Weisz, Hawley, Pilkonis, Woody, & Follette, 2000). Quest- team (i.e., regarding future leaves).
ions relevant to organisational assessment may be explorative
(i.e., who are we admitting and how does this compare CognitIve-behaviouraltherapy. Randomised controlled
to other psychiatric services?) or more specific (i.e., are we trials indicate that cognitive-behavioural therapy (CBT)
meeting specified standards of care?). Psychological is an effective treatment, alongside medication for people
techniques can then be applied to improve service delivery who have psychotic experiences. Follow-up trials indicate
(Manpower Planning Advisory Group, 1990) through consul- that treatment effects can be enduring (Haddock, et al.,
tancy, where the focus is on the formulation and development 1998). However, most trials utilised outpatients or people
of interventions to improve services for staff and patients in the early stages of schizophrenia (Sensky, et al., 2000;
(Brunning, Cole, & Huffington, 1990). Research and service Kuipers et al., 1998). These populations are likely to be less
development are closely linked and may be pursued simulta- socially disabled than many of those within forensic
neously, providing one is mindful of issues such as confiden- environments. Hence, whilst there is informative literature
tiality and use of data. Open feedback to stakeholders and about CBT with people who have psychosis (Chadwick,
participants in such projects is likely to sustain support for Birchwood & Trower, 1996), the first author has found
future work (Rice & Harris, 1997). it particularly useful to adopt simplified approaches to CBT
when treating MDOs, inline with those approaches
Therapy suggested for use with people with learning disabilities (i.e.,
In the last 20 years the emphasis on community rather than Stenfert Kroese, Dagnan, & Loumidis, 1997).
institutional care has shifted the focus of psychiatric treat- Literature relating to CBT in forensic settings suggests
ment of people with severe mental illness from a curative that these interventions are usually applied in conjunction
model to one of reducing disability and maximizing quality with social skills training. Aims of programs cited include
of life (New Zealand Mental Health Commission, 2001).The helping people to improve coping strategies, problem-
same applies to the rehabilitation of MDOs. Whilst medica- solving, anger management, development of self-control
tion still remains an integral part of treatment for most skills, self-management and adaptation of antisocial
patients, psychosocial and psychological interventions have attitudes (Rice & Harris, 1997). Groupwork has been tried
become more salient (Mueser & Bond, 2000). in larger forensic settings with mixed results (McMurran,
In forensic settings, where intervention needs to target Charlesworth, Duggan, & McCarthy 2001). However, in
offending behaviour, as well as illness and psychosocial smaller settings, the diversity of patient needs may preclude
variables, psychologists have demonstrated the effectiveness CBT being carried out in groups.
NOVEMBER 2002 V AUSTRALIAN PSYCHOLOGIST

232
MENTALLY DISORDERED OFFENDERS

CBT can be a useful tool in assisting the patient functioning) and identification of potential barriers
to develop insight and awareness of relapse prevention to patient vocational pursuits. In this way they can help
requirements, for example, the need to comply with medica- to identify suitable work placements and can continue
tion (Brondolo & Mas, 2001). However, more research on to provide support and encouragement to help the patient
this application of CBT is needed with forensic populations. achieve success (Cook & Razzano, 2000).
Social skills training. Onset of psychotic illness during Family intervention. Trials for family intervention programs
adolescent years, institutionalisation, and psychotic experi- for people with serious mental illness have tended to be of at
ences themselves can lead to a lack of confidence least 6 months duration, offering psychoeducation, illness
or ability to cope with day-to-day social routines, such as, management, empathy and support, problem-solving devel-
going shopping or to a cafd. Social skills training (SST) opment and crisis management (Dixon, Adams, & Lucksted,
aims to teach interpersonal skills by dividing social behav- 2000; Mueser & Bond, 2000). Whilst these programs have
iours into steps. Specifically, the processes of modelling, been well utilised by families of forensic patients (Lefley,
shaping, role-play, feedback and in vivo practice are used to 2001), literature reviews reveal mixed findings regarding
aid acquisition and generalisation of skills (Mueser & Bond, their efficacy. In their review, Mueser and Glynn (1999)
2000). SST has been found to be effective with forensic concluded that family interventions significantly reduced
populations for reducing impulsivity, increasing problem future relapse and rehospitalisation rates. However, Dixon
solving skills (McMurran, Egan, Richardson, & Ahmadi, and colleagues (2000) indicated that the effect of intensive
1999); improving anger management (Renwick, et al., family interventions was less pronounced where enriched
1997); and making friends (Rice, 1983). SST has also been individual models were provided. They suggested three
used to increase medication compliance of psychiatric important elements in working with families - providing
patients (Cramer & Rosenheck, 1999). Whilst many studies information, assisting with communication and problem
report positive results, one review has indicated that the solving, and providing support. Ways of doing this include
results of SST may not always be long lasting or generalis- brief family therapy, workshops and helping people
able (Benton & Schroeder, 1990). However, research to date to contact self-help organisations. Psychologists can take
has indicated that "maintenance" (ongoing) support in the an active role in identifying the need for and delivery of
use of previously learned social skills can increase longevity family interventions, and in the event that services are
and generalisation (Dobson, 1996). pressured, psychologists can ensure that these interventions
Cognitive rehabiliaion/ cognitive remediation. Cognitive are utilised in an efficient and time-limited manner.
rehabilitation aims to help people to remediate problems
with information-processing skills, such as attention, Teaching and Research
memory and concentration, which can result from having A psychologist's role in the multidisciplinary team
a psychotic illness. Compensatory strategies are taught also includes teaching and educating other staff, either
to the patient using frequent sessions of practice and informally (i.e., in meetings, case discussions and through
rehearsal (Brenner et al., 1994). There are mixed findings sharing complex formulations) or formally (i.e., through
regarding its effectiveness (Hogarty & Flesher, 1992). It has lectures and/or inservice education). Areas of education
been found to lead to improvements in problem-solving commonly include behavioural techniques and theories
abilities and social adjustment in forensic settings (Donnelly of offending and rehabilitation. As discussed, psychologists
& Scott, 1999). However, a randomised control trial found can also become involved in service development, monitor-
that after a 6-month follow-up, people with schizophrenia ing of staff knowledge and the application of philosophical
who had received intensive cognitive rehabilitation did not principles.
differ from controls who had received intensive occupa- Psychologists are trained in research methods, therefore
tional therapy, in measures of symptoms or social function- they can apply these skills in a number of ways, such as,
ing (Wykes, Reeder, Corner, Williams, & Everitt, 1999). via service evaluation, testing hypotheses based on clinical
Whilst they had better cognitive functioning and self- observations, and developing theory-practice links
esteem, the study did little to suggest that cognitive remedi- (Conning, 1991). Research in the area of mentally disor-
ation had any real benefits over meaningful activity, dered offenders can fall into two categories - evaluating
vocational rehabilitation or employment, which are positive effectiveness of treatment components or describing charac-
prognostic indicators in serious mental illness (Harding, teristics of patients to develop typologies relevant to both
Strauss, Hafez, & Lieberman, 1987). treatment and etiology (Hodgins, 1998). For further
examples of psychological research in a forensic setting see
Vocational rehabilitation. Vocational rehabilitation is not the special edition of Criminal Behaviour and Mental
primarily the domain of psychologists, but it is an important Health (Taylor, Heads, Hill, & Perkins, 1998).
aspect of a rehabilitation program, particularly in forensic
rehabilitation where the effects of institutionalisation must
be counterbalanced with occupational/ recreational pursuits. Ethical Issues in Delivering Psychological
Most people who have a psychiatric illness want competitive Services to Mentally Disordered Offenders
employment (Bebout, Becker, & Drake, 1998) which has The lack of guidance from the literature is one of a number
been associated with improved clinical outcome (Mueser, of dilemmas that face clinicians working in the area
et al., 1997). However, only 8 to 40% of psychiatric patients of rehabilitation of MDOs. Another major issue is the need
achieve this aim, with people exhibiting psychosis falling to balance the rehabilitation of the individual with the risk
at the lower end of this range, compared to people that they pose to society. At times, the clinical team may
with other diagnoses (Cook & Razzano, 2000). This trend exercise over-caution, particularly in a climate of increasing
has also been found within forensic inpatient facilities legal, social and political pressures. Hence, psychologists
(Evans, Souyma, & Maier, 1989). Whilst psychologists may may find themselves a part of an uncomfortable process,
not be directly involved in the delivery of vocational focusing more on assessment than management of risk
rehabilitation, they have an important role to play in the (Rice & Harris, 1997), and consequently detaining people
assessment of patient abilities (i.e., cognitive and adaptive for what they might do, rather than what they have done

NOVEMBER 2002 AUSTRALIAN PSYCHOLOGIST

233
LORRAINE CHILDS AND PHILIP BRINDED

(British Psychological Society, 1999). Furthermnnore, there Beck, N.C., Menditto, A.A., Baldwin, L., Angelone, E.,
may be organisational factors, which impede an individual's & Maddox, M. (1991). Reduced frequency of aggressive
progress through the rehabilitation process. For example, behaviour in forensic patients in a social learning program.
the individual may be in prison, where access to psychiatric Hospitaland Community Psychiatry, 42, 750-752.
services is very limited. Also community services may not Benton, M.K., & Schroeder, H.E. (1990). Social skills training
wish to accept responsibility for the care of an individual with schizophrenics: A meta-analytic evaluation. Journal
with a forensic history, as they may believe that they would of Consulting and Clinical Psychology, 58, 741-747.
have difficulties in meeting their complex needs (Vaughan, Blackburn, R. (1996). Mentally Disordered Offenders. In C.R.
Pullen, & Kelly, 2000). Hollin (Ed.), Working with offenders: Psychologicalpractice
Unlike other fields of psychology, confidentiality may in offender rehabilitation.(pp. 119-149). Chichester. Wiley.
be limited as information may be required for legal Brenner, H., Roder, V., Hodel, B., Kienzle, N., Reed, D. & Liber-
decision-making and ongoing risk assessment. To some man, R. (1994). Integrated psychological therapyfor schizo-
extent, this can be countered by regularly reviewing the phreniapatients. Toronto: Hogrefe &Huber.
boundaries of confidentiality with patients and by clearly Brinded, P.M.J. (2000). Forensic psychiatry in New Zealand.
stating the reasons for referrals and reports, thereby limiting InternationalJournalof Law and Psychiatry, 23, 453-465.
inappropriate disclosure of information (McGuire, 1997). Brinded, P.M.J., Simpson, A.I.F., Laidlaw, T., Fairley, N., &
Furthermore, psychologists may find themselves working Malcolm, F. (2001). Prevalence of psychiatric disorders in
in environments unsupportive of psychological and thera- New Zealand Prisons: A national study. Australian and New
ZealandJournalof Psychiatry, 35, 166-173.
peutic principles (i.e., in prisons, where staff are untrained
in mental health needs). Rice and Harris (1997) suggest that British Psychological Society. (1999). British Psychological
this can be partially overcome by "applying established Society's Response to managing dangerouspeople with severe
personality disorders. Leicester. Author.
behavioural principles to the organisation" (p. 163). Such
principles include targeting management for education Brondolo, E., & Mas, F. (2001). Cognitive-behavioural strategies
about behavioural principles; identifying enthusiastic, for improving medication adherence in patients with i-polar
disorder. Cognitive and BehaviouralPractice, 8, 137-147.
motivated people to oversee programs; jointly initiating and
developing intervention programs; obtaining funding from Browne, K., & Howells, K. (1996). Violent Offenders. In C.R.
the agency, so they have a vested interest in its success; Hollin (Ed.), Working with offenders: Psychologicalpractice
in offender rehabilitation. (pp. 188-210). Chichester Wiley.
and reporting success to reinforce the positive efforts of the
staff and agency. Brunning, C., Cole, P., & Huffington, C. (1990). The change direc-
tory: Key issues in organisationaldevelopment and the manage-
ment of change. Leicester The British Psychological Society.
Future Research Bullard, H. (1994). Management of violent patients. In J. Shepherd
While there is a regular flow of research about MDOs, more (Ed.), Violence in health care: A practical guide to coping with
is needed on treatment outcomes and long-term follow-up violence and caring for victims. New York, NY: Oxford
of criminal, clinical and psychosocial variables. Research University Press.
could further differentiate outcomes of MDOs, compared Chadwick, P.D.J., Birchwood, M., & Trower, P. (1996). Cognitive
to non-offending clinical populations or non mentally-ill therapy with delusions and voices. Chichester Wiley.
offenders (Rice & Harris, 1997). However, as Lindqvist and Coid, J.W., Kahtan, N., Gault, S., & Jarmnan, B. (2000). Ethnic
Skipworth (2000) state, difficulties in trying to do research, differences in admissions to secure forensic psychiatry services.
especially randomised control trials, with MDOs include British Journal of Psychiatry, 177,241-247.
the complexity of the systems in which treatment is carried Conning, A.M. (1991). The role of the psychologist in psychiatric
out and the number of factors outside of clinical control rehabilitation. InternationalReview of Psychiatry, 3, 83-93.
(i.e., patients moving between prison and hospital environ- Cook, J.A., & Razanno, L. (2000). Vocational rehabilitation
ments). The challenge for psychologists is to try to design for persons with schizophrenia: Recent research and implica-
studies that will overcome some of these difficulties, tions for practice. Schizophrenia Bulletin, 26, 87-103.
in order to provide meaningful, generalisable data that will Cramer, J.A., & Rosenheck, R. (1999). Enhancing medication
assist us in offering effective interventions to meet the broad compliance for people with serious mental illness. Journal
needs of this population and the wider society. of Nervous and Mental Disease, 187, 53-55.
Dixon, L., Adams, C., & Lucksted, A. (2000). Update on family
Endnote psycho-education for schizophrenia. Schizophrenia Bulletin,
26, 5-20.
I In future, the term "psychologist" refers to psychologists who
have received sufficient postgraduate training to carry out the Dobson, D. (1996). Long term support and social skills training
for patients with schizophrenia. Psychiatric Services, 47,
functions described.
1195-1199.
Donnelly, J.P., & Scott, M.F. (1999). Evaluation of an offending
References behaviour program with a mentally disordered population.
Andrews, D.A., Zinger, I., Hoge, R.D., Bonta, J., Gendreau, P., British Journal of Forensic Practice, 1, 25-32.
& Cullen, F.T. (1990). Does correctional treatment work? Evans, B., Sonyma, A., & Maier, A. (1989). A vocational assess-
A clinically relevant and psychologically informed meta-analy- ment and training program for individuals in an inpatient
sis. Criminology, 28, 369-404. forensic mental health centre. Psychosocial Rehabilitation
Anthony, W.A., & Liberman, R.P. (1986). The practice of psychi- Journal, 13,61-69.
atric rehabilitation: Historical, conceptual and research base. Gillespie, N.K., & McKenzie, K. (2000). An examination of the
SchizophreniaBulletin, 12, 542-559. role of neuropsychological deficits in mentally disordered sex
Bebout, R.R., Becker, D.R., & Drake, R.E. (1998). A research offenders. Journalof SexualAggression, 5, 21-29
induction group for clients entering a mental health research Gudjonsson, G.H. (1987). The significance of depression in the
project: A replication study. Community Mental Health mechanism of compulsive shoplifting. Medicine, Science and
Journal,34, 289-295. the Law, 27, 171-176.

NOVEMBER 2002 V AUSTRALIAN PSYCHOLOGIST

234
MENTALLY DISORDERED OFFENDERS

Gunn, J., Maden, A., & Swinton, M.(1991). Treatment needs of Mossman, D. (1994). Assessing predictions of violence: Being
prisoners with psychiatric disorders. British Medical Journal, accurate about accuracy. Journal of Consulting and Clinical
303, 338-341. Psychology, 62,473-492.
Haddock, G., Tarrier, N., Spaulding, W., Yusupoff, L.,Kinney, C., Mueser, K.T., Becker, D.R., Torrey, W.C., Xie, H., Bond, G.R.,
& McCarthy, E. (1998). Individual cognitive-behaviour Drake, R.E. et al. (1997). Work and nonvocational domains of
therapy in the treatment of hallucinations and delusions: functioning in persons with severe mental illness: A longitudi-
A review. Clinical Psychology Review, 18, 821-838. nal analysis. Journal of Nervous and Mental Disorders, 185,
Hall, J., & Marzillier, J. (1992). What is clinical psychology? 419-426.
In J. Marzillier & J. Hall (Eds.), What is clinical psychology? Mueser, K.T., & Bond, G.R. (2000). Psychosocial treatment
Oxford: Oxford Medical Publications. approaches for schizophrenia Current Opinion in Psychiatry,
Harding, C.M., Strauss, J.S., Hafez, H., & Lieberman, P.B. (1987). 13, 27-35.
Work and mental illness I: Toward an integration of the Mueser, K.T., & Glynn, S.M. (1999). Behaviouralfamily therapyfor
rehabilitation process. Journal of Nervous and Mental Disease, psychiatricdisorders (2nd ed.). Oaldand, CA: New Harbinger.
175, 317-326. Mullen, P.E. (1997). A reassessment of the link between mental
Harris, G.T., Rice, M.E., & Quinsey, V.L.(1993). Violent disorder and violent behaviour, and its implications for clinical
Recidivism of mentally disordered offenders: the development practice. Australia and New Zealand Journal of Psychiatry,
of a statistical prediction instrument, Criminal Justice and 31,3-11.
Behaviour, 20, 315-335.
Mullen, P.E., Pathe, M., & Purcell, R. (2001). Stalking: New
Hodgins, S. (1998). Research in forensic hospitals: Possibilities constructions of human behaviour. Australia and New Zealand
and limitations. Criminal Behaviour and Mental Health, Journal of Psychiatry, 35, 9-16.
8,7-12.
New Zealand Mental Health Commission. (2001). Recovery
Hogarty, G., & Flesher, S. (1992). Cognitive remediation in schizo- competencies for New Zealand Mental Health Workers. New
phrenia: Proceed ... with caution! Schizophrenia Bulletin, Zealand: Author.
25,291-307.
Perkins, R., & Dilks, S. (1992). Worlds apart: Working with
Kuipers, E., Fowler, D., Garety, P.A., Chisholm, D., Freeman, D.,
severely socially disabled people. Journal of Mental Health,
Dunn, G. et al. (1998). London-East Anglia randomised
1, 3-17.
controlled trial of cognitive-behavioural therapy for psychosis
mII: Follow-up and economic evaluation at 18 months. British Quayle, M., & Moore, E. (1998). Evaluating the impact of struc-
Journalof Psychiatry, 173, 61-68. tured groupwork with men in a high security hospital. Criminal
Lavender, A. (1985). Quality of care and staff practices in long stay Behaviour and Mental Health, 8, 77-92.
settings. In F.N. Watts (Ed.), New developments in clinical Rapp, C.A. (1998). The active ingredients of effective case
psychology. (pp. 70-83).Chichester: British Psychological management: A research synthesis. Community Mental Health
Society in Association with John Wiley & Sons Ltd. Journal, 34, 363-380.
Lefley, H.P. (2001). Helping Families of criminal offenders with Reber, A.S. (1995). Dictionary of psychology. London: Penguin
mental illness. In G. Landsberg and A. Smiley (Eds.), Forensic Books.
mental health: Working with offenders with mental illness. Renwick, S.J., Black, L., Ramm, M., &Novaco, R.W. (1997). Anger
Kingston, NJ: Civic Research Institute. treatment with forensic hospital patients. Legal Criminological
Liddell, A. (1983). The training and function of a clinical psycholo- Psychology, 2, 103-116.
gist. In A. Liddell (Ed.), The practice of clinicalpsychology in Rice, M.E. (1983). Improving the social skills of males in a
Great Britain. (pp. 13-24). Chichester: John Wiley & Sons Ltd.
maximum security psychiatric setting. Canadian Journal
Lindqvist, P., & Allebeck, P. (1990). Schizophrenia and crime. of BehaviouralScience, 15, 1-13.
A longitudinal follow-up of 644 schizophrenics in Stockholm.
British Journalof Psychiatry, 157, 345-350. Rice, M.E., & Harris, G.T. (1995). Psychopathy, schizophrenia,
alcohol abuse and violent recidivism. International Journal
Lindqvist, P., & Skipworth, J. (2000). Evidence-based rehabilita- of Law and Psychiatry, 18, 333-342.
tion in forensic psychiatry. British Journalof Psychiatry, 176,
320-323. Rice, M.E., & Harris, G.T. (1997).The treatment of mentally disor-
dered offenders. Psychology, Public Policy and Law, 3, 126-183.
Lipsey, M.W. (1992). Juvenile delinquency treatment: A meta-
analytic inquiry into the variability of effects. In T.D. Cook, Rumgay, J., & Munro, E. (2001). The lions' dens: Professional
H. Cooper, D.S. Cordray, H. Hartmann, L.V. Hedges, R.J. defences in the treatment of dangerous patients. Journal
Light (Eds.), Meta-analysis for explanation (pp. 83-127). of Forensic Psychiatry, 12, 357-378.
New York: Sage. Sensky, T., Turkington, D., Kingdon, D., Scott, J.L., Scott, J.,
Manpower Planning Advisory Group. (1990). Clinical psychology Siddle, R. et al. (2000). A randomised control trial of cognitive-
project: Full report. London: HMSO. behaviour therapy for persistent symptoms in schizophrenia
McGuire, J. (1997). Ethical Issues in forensic clinical psychology, resistant to medication. Archives of General Psychiatry, 57,
Legal and CriminologicalPsychology, 2, 177-192. 165-172.
McMurran, M., Charlesworth, P., Duggan, C., & McCarthy, L. Sheppard, D. (1996). Learning the lessons: Mental Health enquiry
(2001). Controlling angry aggression: A pilot group interven- reports published in England and Wales between 1969-1996
tion with personality disordered offenders. Behavioural and and the recommendationsfor improving practice. London: Zito
Cognitive Psychotherapy, 29,473-483. Trust.
McMurran, M., Egan, E., Richardson, C. & Ahmadi, S. (1999). Soothill, K.L., & Pope, PJ. (1973). Arson: A 20-year cohort study.
Social problem solving in mentally disordered offenders: Medicine, Science and the Law, 13, 127-138.
A brief report. Criminal Behaviour and Mental Health, Soyka, M. (2000). Substance Misuse, psychiatric disorder and
9, 315-322. violent and disturbed behaviour. British Journal of Psychiatry,
Mohan, D., Jamieson, E., & Taylor, P.J. (2001). The use of trial 176, 345-350.
leaves for restricted special hospital patients. Criminal Steadman, H.J., Mulvey, E.P., Monahan, ., Robbins, P.C.,
Behaviour and Mental Health, 11, 55-62. Appelbaum, P.S., Grisso, T. et al. (1998). Violence by people
Monahan, J., & Steadman, H.J.(1994). Violence and mental discharged from acute psychiatric inpatient facilities and
Disorder:Developments in risk assessment. Chicago and by others in the same neighbourhoods. Archives of General
London: University of Chicago Press. Psychiatry, 55, 393-401.

NOVEMBER 2002 t AUSTRALIAN PSYCHOLOGIST

235
LORRAINE CHILDS AND PHILIP BRINDED

Stenfert Kroese, B., Dagnan, D., & Loumidis, K. (1997). Webster, C.D., Douglas, K.S., Eaves, D., & Hart, S.D. (1997).
Cognitive-behaviourtherapyfor people with learning disabili- HCR-20: Assessing Risk for Violence - Version 2. Canada:
ties. London: Routledge. Mental Health Law and Policy Institute, Simon Fraser
Swanson, J., Holzer, C., Ganju, V., & Jono, R. (1990). Violence University, British Columbia Forensic Psychiatric Services
and psychiatric disorder in the community: Evidence from the Commission.
epidemiological catchment area surveys. Hospital and Weisz, J.R., Hawley, K.M., Pilkonis, P.A., Woody, S.R.,
Community Psychiatry, 41, 761-770.
& Follette, W.C. (2000). Stressing the (other) three Rs in the
Taylor, P.J. (1997). Damage, disease and danger. Criminal search for empirically supported therapies: Review procedures,
BehaviourandMentalHealth,7, 19-48. research quality, relevance to practice and the public interest.
Taylor, P., & Gunn, J. (1984). Violence and psychosis: 1. Risk ClinicalPsychology- Science and Practice, 7, 243-258.
of violence among psychotic men. British Medical Journal,
288, 1945-1949. Wessely, S.C., Castle, D., Douglas, A.J., & Taylor, P.J. (1994).
The criminal careers of incident cases of schizophrenia.
Taylor, P.J., Heads, T.C., Hill, M. & Perkins, D. (1998).
PsychologicalMedicine, 24, 483-502.
Illustrating psychological research in a forensic setting [Special
Issue]. CriminalBehaviour andMental Health, 8. Wykes, T., Reeder, C., Corner, J., Williams, C., & Everitt, B.
Vaughan, P.J., Pullen, N., & Kelly, M. (2000). Services for (1999). The effects of cognitive remediation on executive
mentally disordered offenders in community psychiatry teams. processing in patients with schizophrenia. Schizophrenia
Journalof ForensicPsychiatry, 11, 571-586. Bulletin, 25, 291-307.
M

NOVEMBER 2002 V AUSTRALIAN PSYCHOLOGIST

236