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Compendium 2000 on Effective Correctional Programming

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CHAPTER 16

Treatment Approaches for Offenders with Mental Disorder

JAMES MCGUIRE1


When attention is turned to work with offenders with mental disorder, the position regarding “what works” regrettably is much less clear. There are several possible reasons for this. Whilst there has been a great deal of research on the relationship between crime and mental disorder, the quantity of data available concerning treatment outcomes is much smaller. At the same time, the explanatory models required are significantly more complex. Recently however, a number of major reviews has appeared which have enabled some progress to be made in deciphering the complexities of the field.

The overall objective of this chapter is to review evidence concerning treatment of offenders with mental disorder, and its content is organized in three main sections. First, some definitions will be considered. The field under discussion is replete with conceptual confusions and it is essential to begin by clarifying key terms. It will also be useful to consider some of the difficulties that arise in researching this field and the issues that emerge when doing so.

The second section will focus on outcomes. Some of the data relevant to this has been obtained from retrospective studies of the long-term recidivism rates of offenders with mental disorder discharged from institutions. This work is closely inter-related with research on risk assessment and prediction with this group of offenders. The number of studies available concerning treatment itself is far lower than that relating to recidivism in general. Given some of its complexities it will be divided into separate sub-groups, though there is no satisfactory way of doing this without some inevitable overlaps.

In the third section we will turn our attention to the management of offenders with mental disorder and the general question of inter-agency and multi-disciplinary working in the provision of services to them. Finally, the overall implications of the research reviewed in the chapter will be summarized. Some tentative suggestions will be assembled regarding practice, policy and future research.

PROBLEMS OF DEFINITION

The criminological literature is replete with debates over how precisely to define crime. The recording of crime is an outcome of a complex series of decisions made by citizens, police officers, lawyers, and courts. Crime statistics are now viewed as only one indicator of the rate or distribution of crime in a society, that must be supplemented by other data such as victim surveys for a more comprehensive picture to be assembled. Some criminologists contend that the process of defining crime is itself an essential subject of study. According to this argument, the language and concepts that society employs to discuss crime create its boundaries and form part of the public conception of what society is.

Similarly, in the field of mental health and disorder there are controversies regarding how to define the basic phenomena under discussion. Health is itself an extremely elusive concept. The dominance of medicine and psychiatry in the study of mental health has resulted in the primary mode of definition in the field being the use of diagnosis. Emulating the process of diagnosis in physical medicine, in psychiatry it is intended to serve four main functions: description, classification, and taxonomy; provision of a causal model for understanding a disorder; prognosis, or the prediction of the likely progress and outcome of an illness; and decision-making with regard to therapeutic interventions (Eastman, 2000).

To accomplish such objectives, elaborate systems of classification have been established. Two are of paramount interest as they are pre-eminent in influencing the work of psychiatrists and allied professionals. These are the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, and the International Classification of Diseases (ICD) of the World Health Organisation. Both have under-gone processes of revision. The current version of the APA system, DSM-IV, was published in 1994; the most recent revision of the WHO system, ICD-10, was published in 1992. There are important differences between the final set of categories used in the two systems.

Undoubtedly, some types of mental disorder have a clear and well-established underlying organic pathology (for example, toxic confusional states; degenerative brain disease; seizure disorders; traumatic brain injury; see Lishman, 1997). However, it has frequently been pointed out that in many other cases, and especially with reference to the more prevalent “functional” disorders, this is not so: and that classification systems such as the DSM are not founded on a theoretical model of the disorders they subsume (Mechanic, 1999). Indeed for the majority of the conditions identified under DSM, there is simply no known organic aetiology (Pilgrim & Rogers 1993).

The process of applying diagnostic categories to mental health problems has been a matter of some controversy for many years. Critics have included psychiatrists themselves such as Szasz (1961) who questioned whether psychiatric illnesses could be said to “exist” in the way that the word might be used with reference to physical disease. More recently, the usage of diagnosis has been questioned on several grounds. For example, Kutchins and Kirk (1997) have commented on the over-inclusiveness of concepts involved in the DSM system. To objections of this kind, Wing, Sartorius, and Üstün (1998) have replied that description and classification are merely the first stages of scientific investigation of mental disorders, which in due course will yield findings concerning the causal factors responsible for the disease (at least for some kinds of disorder).

Clark, Watson, and Reynolds (1995) have forwarded other objections to DSM-IV as a nonsological system. These authors reviewed evidence showing a high degree of comorbidity of different DSM diagnoses. In general community survey samples, very high proportions of those diagnosed as suffering from generalized anxiety disorder, panic disorder, social phobia, schizophrenia, depression, and alcohol dependence had at least one comorbid condition. This problem occurs alongside considerable heterogeneity within diagnostic categories. Many classes of diagnosis contain a wide variety of symptom patterns and patient types. In other words, two patients with the same DSM-IV diagnosis may differ very significantly from one another. For borderline personality disorder, they may share nine different personality traits in common, or alternatively, only share one, and yet still meet the criteria for the diagnosis.

Blashfield and Fuller (1996) have analyzed the political and economic context from which the DSM approach has emerged. They illustrate their argument by attempting to predict some key characteristics of the next version of the system. Extrapolating from previous manuals, they predicted that DSM-V will contain 1,026 pages and run to 415,000 words. It will define 390 disorders, encompassing 1,800 diagnostic criteria, and will yield an income of US$80 million for the American Psychiatric Association. Kutchins and Kirk (1997) have depicted the utilisation of DSM as a form of imperialist or expansionist exercise, in which virtually any behaviour might at some stage be classifiable as a form of mental disorder. Some psychiatrists such as Breggin (1991) have adduced evidence of links between the biomedical understanding of individual distress and the prescription of inappropriate somatic treatments which have given rise to major professional and ethical concerns.

An alternative approach that has been offered principally by clinical psychologists is the concept of case formulation (Bruch & Bond, 1998; Eels, 1997; Persons, 1989; Turkat, 1985). This refers to the development in individual cases of a theoretical model that will serve to explain the functional inter-connections between background, personal, and situational variables on the one hand, and long-term problems and presenting symptoms on the other. However, critics have questioned whether this can genuinely pro-vide an alternative to the use of syndromes as a method of classifying and thereby understanding the inter-relationships of disorders (Hayes & Follette, 1992).

The foregoing discussion has been included in order to emphasize that the use of terms in this area is fraught with dangers and sources of confusion. In practice, the majority of published research papers have adopted the use of psychiatric diagnosis as a means of defining study samples, and authors are likely to be criticised where this aspect of their work has not been made sufficiently clear.

Obstacles in research and evaluation

The reasons for the comparatively fewer number of outcome studies in this field probably reside in the sheer difficulty of con-ducting the required research. First, in almost any kind of research on interventions with offenders, locating appropriate comparison groups is problematic. Controlled trials are relatively uncommon. Quasi-experiments are much more typical, and many studies fall below that standard. This applies even more cogently with reference to obtaining comparative samples for groups of offenders with mental disorder. Second, mentally disordered offender clients almost by definition have severe and enduring disorders, and thus are often hospitalised for long periods. A lengthy follow-up period is therefore required for the efficacy of interventions to be judged. Third, the target behaviours of concern are acts of violence or other forms of extreme anti-social conduct. Though their impact is self-evidently very serious, they generally occur at a lower frequency than many other types of crime, and may do so only at widely dispersed intervals. In a follow-up of participants in the MacArthur Violence Risk Assessment Study, a multi-centre project in which data was collected on patients at 10-week intervals for a period of 12 months, Steadman, Mulvey, Monahan, Robbins, Appelbaum, Grisso, Roth, and Silver (1998) found that the rate of violence for study groups was no higher than that for comparison community samples in the same neighbourhoods.2 Finally, there are ethical issues in the conduct of research that arise possibly with greater potency here than in many other spheres of research. These include questions of confidentiality; of obtaining informed consent for participation; and of compliance versus coercion in provision of treatment.

THE RELATIONSHIP BETWEEN MENTAL DISORDER AND CRIME

These difficulties notwithstanding, considerable effort has been expended in trying to clarify the relationship between mental disorder and crime. The fundamental question is: Does suffering from mental disorder represent an increased risk for committing acts of violence or other forms of crime? Surveys addressing this question have taken two approaches: measurement of the prevalence of mental disorder amongst those convicted of crimes, and of criminality amongst those diagnosed as mentally disordered.

Three caveats should be borne in mind when exploring the literature in this field. First, those who already come to the attention of the correctional or mental health services are unlikely to be representative of the community as a whole. This gives rise to a distinction used by epidemiologists between underlying or true rates of pathology, and treated rates (i.e., rates as officially reported in health clinics, or recorded by the criminal justice system). Research in this area has been plagued by sampling biases and errors (Blackburn, 1993). Second, epidemiological data showing overlapping categories or even statistically significant correlations between mental disorder and criminal acts must be interpreted cautiously, and cannot in itself demonstrate that the two are causally or functionally inter-connected. Third, it is not possible to extrapolate from large-scale, aggregate-level samples to individual-level data. Whether or not relationships between mental disorder and crime are found in surveys or other studies of prevalence, they must still be assessed on a case-by-case basis with individual offenders.

Numerous investigations have been conducted in attempting to resolve these issues, and to clarify the crime-mental disorder relationship, with conclusions that have varied somewhat at different points in time. Following what has been called the “first generation” of risk assessment studies (Melton, Petrila, Poythress, & Slobogin, 1998), there was a broad consensus to the effect that mental disorder posed little if any elevated risk for committing crime. This was reinforced in literature reviews, for example, Monahan and Steadman (1983) reviewed 200 studies bearing on this question. Their conclusion was that “...rates of true and treated criminal behavior vary independently of rates of true and treated mental disorder...the correlates of crime amongst the mentally ill appear to be the same as the correlates of crime among any other group: age, gender, race, social class, and prior criminality” (p. 181).

These findings run counter to a popular misconception concerning the “dangerousness” of persons suffering from mental disorders, which as a result of comparatively rare but widely publicized incidents, remains firmly entrenched in the public imagination. Paradoxically, in the United Kingdom for example, a recent retrospective analysis has shown that the number of killings by offenders with mental disorder has actually been steadily declining over a 38-year period (Taylor & Gunn, 1999). That psychiatric patients do not in general pose an increased risk of violence in the community is further supported by the findings of the MacArthur studies cited earlier (Steadman et al., 1998).

But during the 1990s, by contrast, new evidence led to some revision of these conclusions. Wessely and Taylor (1991) sought to discern the reasons for conflicting findings in the field by explaining them in terms of differing research strategies adopted within criminological and psychiatric frameworks respectively. These authors also reviewed studies showing that in the two weeks prior to admission to hospital, many patients subsequently diagnosed as suffering from psychosis had perpetrated acts of violence.

Taking the emerging evidence into account, Monahan (1993a) commented that the conclusions of his earlier review (Monahan & Steadman, 1983) were “...at least premature, and may well be wrong” (1993a, p. 287). The key evidence influencing this came in the form of data from the Epidemiological Catchment Area studies, a large-scale survey of psychiatric morbidity (Swanson, 1994; Swanson, Holzer, Ganju, & Jono, 1990). This study employed a community sample of 10,059 respondents from three American cities. Participants were administered the Diagnostic Interview Schedule which included questions concerning whether they had engaged in any act of violence in the preceding 12 months. Whereas only 2.1% of sample members found to have no mental disorder reported violence, those diagnosed as suffering from schizophrenia reported a rate of 12.7%, and those with drug dependence 34.7%.

Further research by Link and his colleagues (Link, Andrews, & Cullen, 1992; Link & Stueve, 1993) showed that almost all the difference in rates of violence between patient and non-patient samples could be accounted for by psychotic symptomatology. The specific symptoms most closely associated with violence risk were paranoid delusions, and especially those in which individuals feel threatened because their own self-controls are being invaded by external forces. Link and Stueve (1993) called this pattern of phenomena threat/control-override (TCO) symptoms. When the basis of these perceptions and feelings was understood, the reasons why an individual might become violent became understandable. They called this the principle of rationality-within-irrationality. Quinsey and his colleagues (1998) also obtained evidence of temporal linkage between these symptoms and violent offences. Other research has shown that depending upon their content, and on aspects of the situation, command hallucinations may also be associated with the occurrence of acts of violence (McNiel, 1994).

The most recent and thoroughly conducted research suggests that mental disorder may pose an increased risk of some serious crimes, but only in specific ways or certain circumstances. As we will see in the next section, a clinical diagnosis of psychotic illness is unrelated to, and has been found to be negatively correlated with, risk of future general recidivism (Bonta, Law, & Hansen, 1998). Indeed globally, there is little evidence to suggest that a diagnosis of mental disorder in itself is clearly linked to increased occurrence of any specific type of crime. Furthermore, as pointed out by some authors, individuals suffering from schizophrenia are a significantly greater risk to themselves than to anyone else. But certain indicators of psychosis, most notably TCO symptoms, are associated with an increased risk of violence.

Although these kinds of findings pertain to symptoms of serious mental disorder and their links to criminal offending, in some respects they are not unlike other results obtained by Zamble and Quinsey (1997) from their study of recidivist offenders returning to Canadian prisons after a further re-conviction. Part of this work involved exploration of the circumstances of offenders across a period of one month prior to new offences. For the majority of the sample there was evidence of dysphoric states, personal instability, stressful events, and failure of coping mechanisms during that period, and particularly in the 48 hours leading up to the offence. If we accept that mental disturbance can be conceptualized as occurring on a continuum of severity, then personal and emotional upheaval due to stress or difficulties in coping can be considered as one point on it. The sense of personal disintegration that is characteristic of delusional states may be a more extreme manifestation of similar processes.

In a review of the most recent research in this area from a psychiatric standpoint, Crichton (1999) concluded that “... the relationship between mental disorder and crime is small and easily obscured by more influential criminological factors” (p. 670). There is evidence that a dual diagnosis of psychosis and substance abuse disorder is associated with an increased risk of violence (Swanson, Estroff, Swartz, Borum, Lachicotte, Zimmer, & Wagner, 1997). Beyond this, the causal links are likely to be highly specific: it is only certain symptoms of psychoses, such as persecutory delusions or command hallucinations, that are associated with heightened risk of violence (O'Kane & Bentall, 2000).

There is evidence that these links are moderated by social and contextual factors (See Hiday, 1997). In a recent follow-up study of rates of violence amongst patients discharged to different neighbourhoods differing in levels of affluence, Silver (2000) found that environment was a better predictor of violence risk than clinical or psychological variables. This study also clarified the inter-action effects of ethnic group, neighbourhood and occurrence of violent incidents. Stratified by socio-economically equivalent neighbourhoods, there were no differences between ethnic groups (caucasian vs. black) in rates of violence. However, there were differences in rates of violence between neighbourhoods at different levels of affluence. As is often found, black populations were over-represented in more deprived neighbourhoods. The net effect of this was that when comparisons were made across the entire sample, a spurious relationship appeared between ethnic group membership and violence.

Mental disorder in offender populations

It is important in correctional services to have information concerning the mental health problems of offenders. Particularly in prison, stress may activate underlying problems or exacerbate existing ones, with accompanying risks of deterioration, and potentially of self-harm or even suicide. This is of course a major healthcare issue in its own right and should form part of a needs assessment in any correctional setting, quite apart from any relevance it may have for understanding potential mental disorder-crime relationships.

In studies carried out in custodial settings, numerous researchers have found sizeable levels of mental health problems amongst inmate populations. This has emerged in several North American studies. For example, amongst penitentiary inmates in Canada both Hodgins and Côté (1990), and Motiuk and Porporino (1991) found significant proportions of inmates suffering from major mental disorders. The latter study involved the administration of the Diagnostic Interview Schedule to a large, stratified and representative sample from institutions in each of the five regions of the Correctional Service of Canada. In Ontario, for example, proportions of those meeting DSM criteria for various disorders were as follows: psychosis, 8.6%; major depression, 11.9%; generalized anxiety disorder, 27.9%; drug dependence, 36.7%; anti-social personality disorder, 5 9.0%; and alcohol dependence, 69.1%. Note that here, as in other surveys of this type, and as indicated in broader context above, there was a sizeable degree of comorbidity within the samples studied.

Similar findings have been obtained in the United Sates. Steadman, Fabisiak, Dvoskin, and Holohean (1989) conducted a survey of 3,332 inmates in New York State. Of this group, 8% were found to suffer from severe psychiatric disorders, with an additional 16% being found to suffer from other disorders requiring less intensive but nevertheless periodic treatment. Amongst a random sample of 728 male admissions to a county jail, Teplin (1990) found that 6.4% met diagnostic criteria for major mental disorders such as schizophrenia, mania, or clinical depression. In a parallel study with women inmates, Teplin, Abram and McClelland (1996) found that an even higher rate (15%) met diagnostic criteria. Comparable findings have also been obtained in the United Kingdom, amongst both convicted inmates (Gunn, Maden, & Swinton, 1991) and those held on remand awaiting trial (Brooke, Taylor, Gunn, & Maden, 1996).

Lamb and Weinberger (1998) recently reviewed this field. Overall, these authors found that the proportion of inmates held in local US jails diagnosed as suffering from severe mental disorders ranged from 6% to 15%, with a still higher average pro-portion (10% to 15%) so diagnosed in state prisons. Further, several studies suggested that “...a large proportion of mentally ill persons who commit criminal offences tends to be highly resistant to psychiatric treatment” (1998, p. 487).

Inmates with mental disorders, particularly psychosis, appear to have fewer opportunities in their prospects of release. Porporino and Motiuk (1995) compared a group of mentally disordered inmates with a matched non-disordered group. Though their criminal histories were in other respects equivalent, the former group was given fewer opportunities for parole or early release. They were also more likely to have their parole revoked as a result of violating conditions of supervision; yet the non-disordered group were more likely to commit a new offence while under supervision.

In one sense, the question of whether there is a relationship between mental disorder and crime might seem to be of academic interest only. A prime concern of managers and practitioners in correctional services is with assessment and pre-diction of risk of future reoffending. Considerable effort has been expended in attempting to discern those features of offenders that may be used as indicators in this respect.

OUTCOME RESEARCH

Retrospective studies of long-term recidivism

Numerous retrospective studies have been reported which can be described as “naturalistic”, in that they consisted of follow-up of samples of patients discharged from secure conditions. Their subsequent rates of “failure”, defined as re-arrest, re-conviction, relapse, or re-admission to institutions (prison or hospital) were monitored for varying periods up to several years afterwards. In some instances, it has been possible to use multivariate statistics to disentangle factors predictive of differential outcomes.

In the United States, studies of this kind were undertaken of groups collectively known as the “Baxstrom” and “Dixon” patients. These were sizeable numbers of patients who, against psychiatric advice, were discharged from hospital following a 1966 ruling by the Supreme Court to the effect that Johnny Baxstrom, a resident of a long-stay hospital, had been wrong-fully detained. Follow-up studies in several states (e.g., Steadman & Keveles, 1972; McGarry & Parker, 1974) showed the rates of re-arrest and re-incarceration of these groups were surprisingly low. Of a sub-sample followed up by Steadman and Keveles, only 17% had been arrested during a four-year period after discharge. Only 2.2% were returned to secure hospitals and less than one per cent to prison. Similar figures emerged from other studies of comparable patient groups.

However, the mean age of the Baxstrom sample was 47, while that of the proportion of the sample who reoffended was much lower. In Canada, Quinsey, Warneford, Pruesse, and Link (1975) obtained parallel findings from a sample of 91 patients released from Oak Ridge (a maximum security facility in Ontario) between 1967 and 1971. The mean age of these patients on discharge was 32. A total of 38% of the sample committed new crimes, though the proportion re-convicted of violent offences was 16.5%. Factors associated with greater likelihood of reconviction included being diagnosed as suffering from a personality disorder, and being unmarried. The only variable associated with subsequent violence was a history of prior violence. A broadly consistent pattern emerges from later follow-up studies of this type with respect to both men (Hodgins, 1983; Hodgins & Gaston, 1989) and women offenders (Hodgins, Hébert, & Baraldi, 1986) in Canada, and in studies with similar designs conducted elsewhere (Bieber, Pasewark, Bosten, & Steadman, 1988; Bogenberger, Pasewark, Gudeman, & Beiber, 1987; Pasewark, Bieber, Bosten, Kiser, & Steadman, 1982).

A total of eight follow-up studies of this kind has been carried out with patients discharged from high-security units (known as “special hospitals”) in the United Kingdom (Bailey & MacCulloch, 1992a, 1992b; Black, 1982; Brewster, 1998; Buchanan, 1998; Dell, 1980; Gathercole, Craft, McDougall, Barnes, & Peck, 1968; Tennent & Way, 1984; and Tong & Mackay, 1958). In all these studies, the re-admission or reoffending rates amongst the samples studied are lower than might be expected, given what may be assumed to be the seriousness of offences which warranted incarceration, and the likely severity of other problems (including marked mental disorders) amongst the populations studied. When contrasted with criminological data concerning non-mentally disordered samples (for example, released inmates), the observed recidivism rates are comparatively low.

All these reports were published and based on data collected over a lengthy span of time between the 1950s and 1990s. Consequently, it is difficult to make valid comparisons between them, given the probable dissimilarities between the types of patients detained in secure hospitals during these successive decades. None of the studies incorporates an appropriate control group with which a meaningful comparison can be made, nor are there any predictor scales (as have been developed for general offending populations) with which the impact of hospitalization and treatment can be properly evaluated.

Yet some notable patterns emerged after further analyses. In the studies by Bailey and MacCulloch (1992a, 1992b), there are higher recidivism rates amongst those classified as suffering from psychopathic disorder; and the differences between members of this group given conditional and absolute discharges provides some indications concerning better and poorer risk categories for release and follow-up. The latter findings accord with others reviewed by Lösel (1998) concerning this category of clients.

Buchanan (1998) carried out a more elaborate analysis of data on a sample of 425 discharged patients followed for a period of up to 10 years. Overall, the findings suggested that those more likely to recidivate were younger, more heavily convicted prior to admission, and likely to be classed as suffering from psychopathic disorder in terms of relevant legislation (the Mental Health Act, 1983). There were weaker associations with gender (women less likely to be re-convicted) and discharge destination (reconviction rates were lower amongst those discharged to other hospitals than amongst those sent home or to a community setting).

Overall, when searching for evidence concerning factors associated with success or failure with this offender group, it is necessary to make inferences on the basis of retrospective analyses in which details of follow-up histories are linked to prior characteristics of samples. There are no well-designed, properly controlled prospective studies of treatment regimes or of mentally disordered offender-patients given different types of treatment whilst detained in secure settings.

With regard to the overall debate on the feasibility of predicting recidivism and the accuracy with which this can be accomplished, Bonta, Law, and Hansen (1998) recently reported important findings. These authors conducted a meta-analytic review of long-term follow-up studies, to establish which factors were the best predictors of criminal and violent recidivism amongst this offender group. The set of studies they found incorporated 68 independent samples (a total sample size of 15,245). Predictors were classed into four groups: demographic; criminal history, deviant lifestyle and clinical factors (including psychiatric diagnosis). The general finding, as shown in Table 16.1, was that the most accurate predictors were demographic or criminal history variables: indeed the overall pattern obtained was a close parallel to that typically found with non-mentally-disordered offender populations.

TABLE 16.1 Predictors of recidivism amongst offenders with mental disorder (from Bonta, Law, & Hansen, 1998)

.
Category of predictor
General recidivism
Violent recidivism
.
Demographic
0.12
0.12
Criminal history
0.08
0.15
Deviant lifestyle
0.07
0.08
Clinical
-0.02
-0.03
.

Bonta et al. also found that the poorest predictors of recidivism were clinical variables. Most notably, although a DSM diagnosis of anti-social personality disorder was associated with a greater risk of future criminality, no other diagnostic category, including that of psychosis, emerged as significant: the latter was in fact negatively correlated with future recidivism. If these findings are correct, the intervention approaches adopted in work with offenders in general may be equally applicable to clients with mental disorders. It is highly likely that such clients would also require further services in addition: including both therapies for other mental health problems, and potentially, additional treatments focused upon alcohol abuse (Rice & Harris, 1995), or on symptoms associated with risk of relapse (Greenwood, 1995; O'Kane & Bentall, 2000).

As noted earlier, the quantity of evidence with a direct bearing on treatment of offenders with mental disorder is considerably less than that available on offender treatment in general. Similarly, the amount of mental health outcome research with this group is also fairly limited. To make headway in addressing this problem, one possibility is that we attempt to chart the anticipated outcomes of treatment with this group of offenders through a process of “triangulation”. Several sets of evidence might form the cornerstones of such an inquiry. They consist of evaluative studies of psychological therapies for treatment of mental health problems, including major mental disorders; the research literature on treatment of offenders and reduction of general recidivism; and a smaller quantity of direct evidence concerning the impact of interventions with this group. The latter however remains extremely difficult to interpret. The objective of this process is to extract any pattern of evidence that might provide indications as to “what works” with mentally disordered offenders.

General effectiveness of psychological therapies

Several major reviews have confirmed overall positive effects of psychological therapies for many types of mental health problems (Lambert & Bergin, 1994; Roth & Fonagy, 1996). In a panoramic review of 302 meta-analyses of outcome studies of psychological interventions, Lipsey and Wilson (1993) found positive mean effects for a large number of treatment methods with a wide range of specified targets. For many years it was believed that if psychotherapy did have effects, they were probably due to underlying common factors (such as the creation of a supportive therapeutic relationship) and no differential effects could be discerned to support a claim that some treatments were better than others. But more recent reviews of controlled-trial studies have indicated that it is possible to identify superior outcomes following application of some types of therapies with some types of clinical problems. This has led to the emergence of what have been called empirically supported treatments (Dobson & Craig, 1998; Nathan & Gorman, 1998; Kendall & Chambless, 1998). This term designates interventions that are supported by consistent evidence from controlled trials, and that could therefore be recommended to practitioners as “treatments of choice” for a given disorder. However, powerful counter-arguments have also been made against such claims. For example, it has been stated that the circumstances of treatment in most mental health clinics are so dissimilar to the conditions achieved in controlled trials that they render it almost impossible to translate the findings of such studies into practice. Therefore, the implications of research for delivery of therapy services in ordinary clinical settings remain highly controversial (Fishman, 1999; Persons & Silbersatz, 1998).

Treatment approaches with mentally disordered offenders

The standard and most widely used treatment approaches with many mental health problems involve psychopharmacological therapies. Since the discovery of the major tranquillizers (neuroleptics) in the 1950s, significant advances have been made in the development of chemical agents for reduction of symptoms amongst a wide range of clinical disorders. The use of medication for the treatment of anxiety, depression, obsessive-compulsive disorder, bipolar disorder, psychoses, substance abuse and many other mental health problems is now widespread. Reviews of outcome studies have indicated the value of these therapies for some major mental disorders. Neuroleptic medication is widely used for reduction of the more severe symptoms of psychosis, such as delusions, hallucinations, and thought disorder (Nathan & Gorman, 1998). Simultaneously, a meta-analytic review of 22 controlled trials has shown that there is no simple, direct relationship between severity of symptoms and dosage effects (Bollini, Pampallona, Orza, Adams, & Chalmers, 1994). This study showed that, beyond a certain dose level, there were no additional therapeutic benefits but a significant increase in unwanted side-effects (such as tardive dyskinesia). The new generation of neuroleptics (e.g., Clozapine) has more specific symptom-relieving effects and reduced risk of adverse reactions. These drug regimes however require careful, individualized modulation and a proportion of those administered them are “treatment-resistant”.

Psychosocial methods have also been used for treatment of many of these problems and have met with considerable success. Often, patients prefer them as they do not have associated side effects, avoid risks of dependence and place more control in the hands of the service user. Successful psychological treatments include a number of behavioural, cognitive and cognitive-behavioural therapies; interpersonal therapy; family systems interventions and therapeutic communities. In the majority of work with mentally disordered offenders, the commonest pattern is for a mixture of pharmacological and psychological interventions to be employed.

Psychological treatment of psychotic symptoms

A number of treatment studies have shown that it is feasible to apply cognitive-behavioural interventions to the reduction of delusional belief, but most have entailed single-case experimental designs (Hartman & Cashman, 1983; Milton, Patwa, & Hafner, 1978; Watts, Powell, & Austin, 1973). However, some have reported on the application of such methods in group settings (Garety, Kuipers, Fowler, & Chamberlain, 1994; Tarrier, Beckett, Harwood, Baker, Yusupoff, & Ugarteburu, 1993). During the mid-1990s this literature was assembled with additional studies in the edited books by Fowler, Garety and Kuipers (1995) and Chadwick, Birchwood and Trower (1996).

The presence of paranoid symptomatology and feelings of being threatened or controlled is understandably associated with experience of anger, which may be a direct precursor of aggression and precipitation of acts of violence (Novaco, 1994; O'Kane & Bentall, 2000). Reviews of the relevant literature have also suggested that effective interventions exist or can be developed for individuals with low self-control of anger problems (Edmondson & Conger, 1996; Novaco, 1997). While indications have been given of the potential value of this intervention with mentally disordered offenders (Stermac, 1986), only limited outcome studies on the use of this strategy with mentally disordered offenders have appeared (Renwick, Black, Ramm, & Novaco, 1997). There is also firm evidence of treatment gains from the application of social skills training and allied methods to help overcome “negative” symptoms of schizophrenia such as social withdrawal and isolation, flatness of affect and emotional inexpressiveness. In a meta-analysis of 27 studies concerning this, Benton and Schroeder (1990) found a mean effect size of 0.76.

Community management of offenders with major mental disorders

The paucity of well-controlled treatment trials in this area does not mean that there is no evidence that might indicate the usefulness of interventions. Heilbrun and Griffin (1998) reviewed a series of 15 evaluative studies that fell roughly into two groups. The first included studies of community-based psychiatric treatment with mentally disordered offenders (patients found Not Guilty by Reason of Insanity) . The second comprised evaluative studies of supervision of clients with mental disorders placed on probation or parole. The methodology in several of these studies consisted of post-hoc analyses of factors that appeared to be predictive of differential outcomes for patients. The principal criteria employed were re-arrest for new offences or re-admission to hospital; though other indicators too were sometimes utilized, such as symptom reduction, clinical progress, community adjustment, and rates of revocation of parole conditions. Eight of the studies included comparison groups. Heilbrun and Peters (2000) have reported an extension and updating of this review. In these reviews, the authors noted that the results that are available come from a relatively small number of sites; and only two studies were located that approximated the methodology of a con-trolled trial, so precluding the use of meta-analysis (Silver, Cohen, & Spodak, 1989; Wiederanders, 1992).

Some follow-up studies allowed the making of comparisons between discharged patients allocated to different forms or levels of intensity of community supervision (Bloom, Bradford, & Kofoed, 1988; Bloom, Rogers, Manson, & Williams, 1986; Bloom, Williams, & Bigelow, 1991; Bloom, Williams, Rogers, & Barbur, 1986; Tellefsen, Cohen, Silver, & Dougherty, 1992; Wiederanders, Bromley, & Choate, 1997). However the findings are often very difficult to interpret (McGuire, 2000). One reason is that in many evaluations, comparisons are made between dissimilar jurisdictions (for example, different American states) in which it is not known whether staff practices regarding case management and recall were equivalent. Another is that, in some instances in which patients are allocated to an Assertive Case Management service, there has been evidence that the case managers are more likely to re-incarcerate clients for less serious violations of their release conditions. From other, less well-controlled or single sample studies, some indications emerged that intensive case management has beneficial effects. Generally, re-arrest rates on conditional release were found to be comparatively low (ranging from 2% to 16%). An average of 3.9 reasons was given when clients were made subject to parole revocations (recalled to hospital).

In some respects these findings are not dissimilar to those obtained by Petersilia and Turner (1993) from their evaluation of intensive supervision programs in probation or parole. Higher levels of surveillance or scrutiny were associated with higher levels of technical violation and therefore resulted in higher apparent rates of failure amongst experimental samples. Despite such misgivings, for mentally disordered offenders the evidence concerning the usage of aggressive or assertive case management has been generally regarded as positive (Dvoskin & Steadman, 1994; Heilbrun & Peters, 2000).

Treatment as a variable

It is disappointing that, in their meta-analysis, Bonta et al. (1998) found only 14 studies that included treatment as an independent variable. There was no overall positive evidence of treatment effects on general recidivism within these studies; the mean effect size was just below zero (-0.03) based on a combined sample of 3,747 participants. Problems of design and methodology, for example the absence of appropriate comparison groups, once again made the findings difficult to interpret in this respect. Nevertheless, while some studies reported negative results, others obtained findings that showed institutionally-based intervention had positive effects. Such results have come from a number of countries including Italy (Russo, 1994), Sweden (Belfrage, 1991), the United Kingdom (Reiss, Grubin, & Meux, 1996) and the United States (Hartstone & Cocozza, 1983; Jew, Kim, & Mattocks, 1975). It remains problematic, however to give any-thing other than preliminary indications of what might con-tribute to “success” with this group. Research suggests that the most “likely-to-succeed” interventions will be broadly similar to those applied with non-disordered offender groups.

Offenders with personality disorders

The group of offenders who not uncommonly cause the greatest concern are those diagnosed as suffering from personality disorders, and especially anti-social personality disorder or psychopathy. This collection of attributes consistently emerges as one of the most accurate predictors of future risk of violence. Reviewers of relevant research have contended that some combined measure incorporating structured assessment of it “... might be necessary for the prediction of violent recidivism” (Quinsey, Harris, Rice, & Cormier, 1998, p. 168). While there continues to be disagreement over the precise meaning of these labels and on the nature of any underlying clinical entity, a sizeable volume of evidence links the proposed features of such a syndrome to greater risk of recidivism. Serin (1995) has discussed issues of responsivity and treatment resistance with this group, but also noted longitudinal evidence concerning decreasing proportions of study samples that retain diagnostic features as time progresses. This is amplified in a recent study by Sanislow and McGlashan (1998) who reviewed 44 studies of the natural course of personality disorders including anti-social personality disorder. Rather than finding a fixed, immutable pattern as was previously expected, this review showed a pattern of changeability over time. These authors and others (Bateman & Fonagy, 2000; Blackburn, 2000; Lösel, 1998; Perry, Banon, & Ianni, 1999) have also reviewed available evidence concerning the possibility of effective treatment of this group. Most studies have focused on borderline or avoidant personality disorder where the aver-age treatment effect sizes are much higher than anticipated (Perry, Banon, & Ianni, 1999). However, with reference to anti-social personality disorder, very few controlled evaluations could be found on which to base firm conclusions.

There are tentative suggestions that some behavioural, cognitive-behavioural, and therapeutic community programs may be successful in reducing anti-social behaviour amongst personality-disordered individuals. While to date, little evidence has been found of treatment effects with “primary psychopaths”, this is an absence of pertinent data rather than a firm finding that “nothing works” with this group. Lösel (1998) recommends first, that much more and much better research is needed if the treatment issues in this area are to be clarified and advanced. Second, rather than identifying any preferred treatment approaches, he advocated instead the application of a set of principles based more broadly on the large-scale research findings on offender treatment in general, briefly cited above.

In a number of countries steps have been taken towards the identification of populations of offenders with severe personality disorders, thought to constitute a high risk of committing the most serious types of crime including homicide, or grievous physical or sexual assaults. This includes for example Canada's Dangerous Offenders Act (1997) which allows indeterminate detention of certain offenders; the advent of Sexual Predator Commitment legislation, enacted in a number of US states; and proposals for detention of Dangerous People with Severe Personality Disorder in the United Kingdom (Home Office, 1999). Most of these departures are based on the premise that, given the problems of treating such groups and the lack of any firm evidence concerning treatment effects, there is an identifiable clinical sub-group who for all practical purposes can be regarded as untreatable. According to this argument, the only option for their management is that of incapacitation.

Blackburn (2000) has reviewed evidence that calls into question the concept of untreatability of persons diagnosed as suffering from such disorders. Evidence is available from several studies suggesting that those designated as “psychopaths” are capable of forming therapeutic alliances; and are amenable to a number of treatments such that short-term improvements in mental health status have been observed. Longer-term treatment studies to test the hypothesis that the risk levels posed by this clinical group can be reduced, have simply not been carried out.

SERVICE DELIVERY AND INTER-AGENCY WORKING

Community-based services

As neither the technology of risk prediction nor the evidence from treatment research is yet sufficiently refined to allow precise guidance to be given, some agency practice focuses pre-dominantly on the simple avoidance of catastrophe. Following upon the ramifications of the Tarasoff case, and the conflict between client-practitioner confidentiality and the duty to warn, Monahan (1993b) provided useful advice on risk containment. The proposed framework revolves around five principles: use of the best-validated procedures for risk assessment; provision of staff training in risk management; preparation of relevant documentation and standardization of practices concerning its usage; development and implementation of policies with respect to these initiatives; and when calamities occur, recourse to effective strategies for damage control.

The patterns which have emerged in attempting to provide effective community care can vary immensely between services, agencies, and localities, both within and between regions of one country, and across national boundaries. In the United Kingdom, the Care Programme Approach was developed to address the difficulty of combining community care with public safety and risk management. This comprises a set of principles and procedures for assessment of clients, setting targets, monitoring progress, recording goal achievement or the reverse, and communicating information between professionals involved in an individual's care. Its implementation is intended to avert many of the previously all too familiar problems of monitoring of risk and of obstacles to inter-agency communication of information. Properly enacted, it could enable agencies to work collaboratively to the maximum benefit of clients and the minimization of risk. Thus, it is widely felt amongst practitioners -- and the findings of inquiries lend support to this expectation -- that the key to rehabilitation or community maintenance resides not in individually focused interventions, but in the assembly and delivery of well co-ordinated support services.

Such a development underlines the potentially immense importance of multi-disciplinary teams. Recently Tyrer, Coid, Simmonds, Joseph, and Marriott (1999) have reported on an extensive review of available literature on the impact of Community Mental Health Teams (CMHTs) on persons with comorbid severe mental illness and personality disorders. Though initially identifying a potential 1,200 studies for review, only five satisfied inclusion criteria. Within these studies, there was tentative evidence of some positive impact of the teams in reducing suicide rates and hospital re-admissions. By contrast, no conclusions were permissible regarding the effects of teams on clinical indicators such as mental state or social functioning of clients.

It was concluded some time ago that “...the keys to reducing the risk of violence by persons with mental disorder in the community are aggressive case management and a comprehensive array of support services” (Dvoskin & Steadman, 1994, p. 684). Other evidence underlines the importance of both of these elements being present in any comprehensive package of community based care services.

For regrettably, innovations in services alone do not appear to be conducive to effectiveness in the absence of sound clinical intervention with individual clients. There are several well-documented studies of intervention projects in which considerable extra resources were invested in services for clients with long-term mental health problems (Bickman, 1996; Lehman, Postrado, Roth, McNary, & Goldman, 1994; Morrissey, Calloway, Bartko, Ridgeley, Goldman, & Paulson, 1994). In these studies, services were designed such that significant changes were made in the their mode of delivery and in the degree of integration between them. Planned improvements in service functioning were systematically monitored; the evidence so obtained showed they had been effectively established and maintained. There was therefore clear evidence of what should have been meaningful improvement in service systems.

However, controlled comparisons failed to discover measurable “client-level improvements” on such indicators as subjective well being, symptom levels, or community adjustment. Reviewing these experiments, Morrissey (1999) held that enhanced case management and allied service improvements were “...a necessary but not sufficient condition for positive out-come effects for clients” (p. 462). Perhaps disappointingly then, integration is an essential feature of good services; but it does not in itself appear to be enough to result in a genuine impact on clients' psychological welfare. All the contributing services or constituents of them must also be of high quality (Morrissey, 1999). Whilst services clearly cannot meet clients' requirements where resources are inadequate, it appears that re-organisation of services alone will be insufficient unless it also contains well-tested clinical input.

Implications of research for practice and policy

Changes in systems of care such as those just discussed have been associated with a number of well-publicized difficulties. Given their complexity, it is impossible to disentangle any clear links between causes and effects. In the United Kingdom the transfer of large numbers of patients to community care raised concerns that vulnerable and potentially dangerous persons were inadequately supervised. When tragedies such as homicides occurred, they received possibly disproportionate media attention, and in 1994 following a particularly horrific murder public inquiries into such incidents were placed on a mandatory footing by the Department of Health. Between then and the year 2000 there were approximately 90 such inquiries, costing an estimated average of £1 million each. Recently commentators on this field have suggested that there is little more to be learned from such inquiries (Peay, 1996; Reith, 1998).

Whatever the details of the national or local framework, several pressures have remained constant. One is to conduct more thorough assessments of individuals such that they may be directed towards the most appropriate channels of the mental health, criminal justice, or community care systems. Such work should have both a clinical and a forensic focus. Clinical assessment should include direct interviews, structured assessments using, for example, the Minnesota Multiphasic Personality Inventory, the Millon Inventories, or Symptom Check List (SCL-90) and scrutiny of available reports from all professionals involved. Forensic assessment will focus on risk using instruments such as the Psychopathy Check List (PCL-R), the HCR-20, or the Violence Risk Appraisal Guide but should also take account of anticipated destinations of clients and associated situational factors. Useful source texts providing background that will assist this process include the books by Melton, Petrila, Poythress, and Slobogin (1998); Quinsey, Harris, Rice, and Cormier (1998); and Rogers and Shuman (2000). Assessment and any resultant recommendations are not value-free processes and attention must be paid to ethical dimensions arising in such work (Grisso & Appelbaum, 1992; Zinger & Forth, 1998).

A second demand is to develop improved methods of risk assessment and prediction. Broadly speaking, risk assessment strategies have traditionally been classified into two principal types: actuarial or empirically-driven (involving measurement of a specified set of factors derived from an systematic research base); and clinical (founded on the subjective judgement of individual clinicians drawing on their own experience). A lengthy history of research clearly demonstrates the superiority of the former over the latter for purely predictive purposes. Yet clinical judgement still has a valuable contribution to make (Monahan, 1997). Thus it has been argued that a focus on the distinction between static and dynamic risk factors, and on the relation between statistical and clinical prediction, could enhance our ability to conduct systematically informed risk assessments (Monahan, 1997; Serin, 1993). To the two long-standing approaches Melton, Petrila, Poythress, and Slobogin (1997) have suggested adding a third, which has been entitled anamnestic risk assessment. This entails compilation of a checklist of risk factors on an actuarial basis, supplemented by clinical judgement. That information is then conjoined to the assembly of an inventory of situations in which individuals may be at risk of manifesting the target problem behaviour, together with a set of procedures for estimating the probabilities of such circumstances occurring.

The search for empirically supported treatments for offenders with mental disorder is evidently fraught with difficulty. In the absence of clear and definitive findings concerning the dimensions of effective interventions with offenders with mental disorder, a number of authors have resorted instead to the provision of a tentative framework or set of service guide-lines. These currently represent the best advice that can be given to service providers until fuller, more detailed and better validated conclusions are available from systematic research.

Frameworks such as these are inevitably a form of compromise. That may sound fairly negative; looked at more positively, they comprise a synthesis of three sets of ideas. The first is findings from available research evidence, to the extent that these show consistent trends. The second consists of lessons that can be distilled from practitioner experience (including, for example, reports of public inquiries or service audits). The third is a set of principles concerning ethically acceptable practice. The objective is to resolve issues of community safety and appropriate risk assessment and management with a concern for the civil rights of individuals subject to mental health legislation.

Heilbrun and Griffin (1998; Heilbrun & Peters, 2000) have forwarded a set of such principles for effective community-based forensic services, combining guidelines for sound ethical practice with such recommendations as can be extracted from the limited evidence base. They include an emphasis on the importance of communications between agencies; an explicit balance between individual rights, the need for treatment, and public safety; an awareness of the range of treatment needs of clients; the usage of a demonstration model in assessing risk of harm and treatability; clarification of legal requirements such as confidentiality and duty to protect; application of sound risk management procedures; and the practice of principles for promoting healthcare adherence.

These principles are valuable in providing a framework for service delivery within agencies, and as such they are also resonant of guidelines for risk containment proposed earlier by Monahan (1 993b). It is unfortunate that the research base is not yet available to furnish more specific directions in which to develop or arrange provision of treatment and support.

CONCLUSIONS

There are many studies on the prevalence of mental disorders amongst persons found guilty of crimes, and conversely of criminality amongst persons diagnosed as mentally disordered. There are also numerous follow-up studies of such groups following their discharge from institutions. Similarly, much research has been reported on the outcomes of psychological therapies for mental health problems, and on reduction of offender recidivism. In sharp contrast, there are far fewer studies with a direct bearing on the question of effective treatment for mentally disordered offenders. It might therefore be concluded that we know very little about how to work with this client group.

On the other hand, this could appear to be a much larger problem than it actually is. It only seems insurmountable if the target group is regarded as somehow categorically different from other groups of offenders, or from other groups of persons with mental health problems. That offenders with mental disorder are perceived as forming a distinct group may be a by-product of popular stigma, or of the medicalisation of this field and its location within the domain of psychiatry.

As an alternative, consider that offenders with mental disorder are basically (and self-evidently) persons who manifest two types of problems: respectively, mental disorder and criminal behaviour. Obviously in relation to both, many questions remain to be answered. At an individual level, the connection between the two has to be assessed and understood. But our knowledge of effective interventions in adjoining fields has advanced considerably in recent years. Rather than seeking a new solution that will somehow be uniquely applicable to this group, provision of proper correctional services for them entails a focus on both types of problems they present, with realistic expectations regarding outcomes for each.

Based on the very limited treatment literature that is avail-able, no specific conclusions are possible regarding the efficacy of any specific type of intervention with any specific array of problems posed by offenders with mental disorder. However, given consistent linkages found with adjacent fields of treatment in which there are sizeable volumes of positive evidence, there are no reasons why those interventions that have proved beneficial with other groups should not be offered to this group also. On the contrary, there are strong reasons for research and evaluation studies employing similar types of programs as are used elsewhere in correctional services. They would, of course be targetted upon factors linked to recidivism, without any expectation that they would reduce problems arising from mental disorder. Adaptations of materials and methods may be necessary to address responsivity issues, and additional help should be available to focus on symptoms of mental disorder per se. For ethical and practical reasons such work should be organized through and conducted within healthcare rather than penal settings. But in terms of its basis in background research, treatment of offenders with mental disorder has much to gain from being more effectively integrated with the field of correctional intervention as a whole.


1 University of Liverpool, UK

2 This pattern changed for patients with substance abuse problems. For patients with substance abuse problems and community members reporting substance abuse there was an increased rate of violence; and overall a higher proportion of patients reported substance abuse.


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