The origin of forensic mental health care is situated in the well-established identification of the fact that the existence of mental illness might exonerate someone from being assessed as morally responsible for their actions (Barnao & Ward, 2015). This point of view was established in the McNaughton rules (1983), which gave thought to the gradual development of ideas regarding criminal responsibility and the expanding knowledge regarding mental illness disorders (Barnao & Ward, 2015). During the time of the McNaughton rules and the establishment of an insanity defense, individuals who were found criminally insane by the court were admitted to asylums instead of prisons (Barnao & Ward, 2015).
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Forensic psychological care and treatment present important functions in the detention and rehabilitation of individuals suffering from serious mental health disorders, who may also present a risk to society. Professionals who work with forensic populations are faced with daunting challenges because the forensic population incorporates many different types of patients, some have committed violent acts, some non-violent acts, and some consist of trauma victims (Barnao & Ward, 2015). Each individual can possess an assortment of cognitive deficits and comorbidities like neurodevelopmental disorders, substance-related disorders, and personality disorders (Howner, et al., 2018).
In these cases, the patient is also the offender and the level of risk they acquire defines what type of method of psychological and/or psychosocial interventions they will be required to participate in. The role of interventions is to re-establish an individual’s mental well-being and the goals of the forensic psychiatric care system is to rehabilitate, help one adjust to society, and lower the risk for recidivism (MacInnes & Masino, 2019; Howner, et al., 2018). The following summarizes literature from the past five years providing information on each target population: violent offenders, non-violent offenders, and trauma victims.
Literature Review: Non-Violent Offenders
MacInnes and Masino (2019), suggests that the common psychological concerns among non-violent offenders include substance abuse disorder and mental illness disorders. Cognitive Behavioral therapies (CBT) like dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT) have been found beneficial for those suffering from substance abuse disorder (Ii, Sato, Watanabe, Kondo, Masuda, Hayes, & Akechi, 2019).
The different methods of therapy used to treat individuals with mental disorders are mostly based on research on non-offending psychiatric patients and more observation or experience is needed with the mentally disordered offenders (MDOs) populations (Barnao & Ward, 2015). For instance a standard procedure for forensic rehabilitation is the use of psychotropic medications, however, there is very little research about the effects of these psychotropic medications on MDOs (Barnao & Ward, 2015). Leaving the remaining questions about the range of the pharmacological needs of offenders differing from the needs of non-offenders with the same disorders, for instance, individuals with schizophrenia (Barnao & Ward, 2015).
Most jurisdictions use risk and/or needs assessment to help determine non-violent offender eligibility. The main model was first outlined in 1990 and taken from Andrews and Bonta’s Risk-Need-Responsivity (RNR) model of offender rehabilitation. It was created to guide those in the process of managing the risks of future violence (Barnao & Ward, 2015). The RNR approach suggests that an offender’s level of risk increases with the presence of each added risk factor and that potentially changeable factors that increase the risk of re-offending, known as dynamic factors, will reduce reoffending rates with treatment (Barnao & Ward, 2015). Researchers suggest that a mixed method using RNR principles encircling the specific needs that single out the problems of the mentally ill offenders, for example, psychotropic medications, CBT, and symptom management skills are often recommended (Barnao & Ward, 2015).
Literature Review: Violent Offenders
Care and treatment for violent offenders are often involuntary and the objective of the caregivers is complex. They not only have to rehabilitate the individual, but another concern is the person’s risk for reoffending and their potential risk they pose to society (Howner, et al., 2018). Immoral and moral actions can reference a vast array of behaviors that are viewed by traditional moral norms that are developed by human groups (Vecina, Marzana, & Paruzel-Czachura, 2015).
Experimental research using a group of men convicted of domestic violence have found a close relationship between morality and self-deception (Vecina, Marzana, & Paruzel-Czachura, 2015). It appears that self-deception, which is the viewing of one’s self in an unrealistic light, is a conciliator between moral absolutism and moral self-concept and is found in men convicted of domestic violence, but not in non-violent men (Vecina, Marzana, & Paruzel-Czachura, 2015). This is important for violent offenders because interventions are focused on the speculation that men who exhibit violence present different shortfalls and for that reason teach ways to deal with thoughts, emotions, and or control of behaviors. Research has found that these types of interventions are usually unsuccessful and cause resistance in the men because, the men do not have deficits, they usually display an absurdly positive moral self-concept and a brawny sureness about their moral beliefs (Vecina, Marzana, & Paruzel-Czachura, 2015). A promising new approach to intervention and prevention is understanding the men who use violence against their partners because this provides one to understand the perspective of the men convicted of domestic violence and their strong resistance to change (Vecina, Marzana, & Paruzel-Czachura, 2015).
Vecina, Marzana, and Paruzel-Czachura (2015) suggest that psychological treatment for men convicted of violence against their partner should identify the individual’s extremely high levels of self-deception concerning their personal moral perspective (Vecina, Marzana, & Paruzel-Czachura, 2015). The new focus should be on helping them enhance awareness of the point to which functional becomes dysfunctional (Vecina, Marzana, & Paruzel-Czachura, 2015).
Literature Review: Trauma Victims
There are many concerns involving veterans and veterans can suffer from invisible wounds and scars that impact their lives, families, friends, and society as a whole negatively (Koven, 2018). Post-traumatic stress disorder (PTSD), is evidence of invisible wounds that occur during military service. There are many negative side effects of traumatic stress and they include unemployment, homelessness, depression, divorce, drug abuse, alcoholism, mental health disorders (MDOs), and criminal activity (Koven, 2018).
Similarly to violent offenders, soldiers are at high risk of developing a pang of hunger for aggression and trauma-related disorders preventing them from succeeding in integration back into society (Hecker, Hermenau, Crombach, & Elbert, 2015). It has been reported that the experience of combatants and veterans have slowly changed their perception of violence, due to repeated experience it became acceptable and normal, and also became arousing and exciting to them, referring to violence like an addiction (Hecker, Hermenau, Crombach, & Elbert, 2015).
Steenkamp et al. (2015), evaluated results from clinical trials of psychotherapies for PTSD in veteran and military populations, and they found that cognitive processing therapy and prolonged exposure were studied the most but are in need of improvements because the majority of PTSD patients kept their diagnosis after completion of treatment (Koven, 2018).
Narrative exposure therapy (NET) is a short-term, evidence-based, and culturally universal intervention for trauma victims and has proven to be successful in multiple populations like those convicted of violent acts (Hecker, Hermenau, Crombach, & Elbert, 2015). NET entails the therapist helping the client in building a chronological narrative of their entire life, placing memories into words, with the main focus being on the traumatic experiences (Hecker, Hermenau, Crombach, & Elbert, 2015). Veterans suffering from PTSD is a noteworthy issue for individuals, families, friends, and society (Koven, 2015). Similarly to the other populations, there is still more research that needs to continue in the exploration of treatment options.
Barnao, M., & Ward, T. (2015). Sailing uncharted seas without a compass: A review of interventions in forensic mental health. Aggression and Violent Behavior, 22, 77–86. doi: 10.1016/j.avb.2015.04.009
Hecker, T., Hermenau, K., Crombach, A., & Elbert, T. (2015). Treating Traumatized Offenders and Veterans by Means of Narrative Exposure Therapy. Frontiers in Psychiatry, 6. doi: 10.3389/fpsyt.2015.00080
Howner, K., Andiné, P., Bertilsson, G., Hultcrantz, M., Lindström, E., Mowafi, F., … Hofvander, B. (2018). Mapping Systematic Reviews on Forensic Psychiatric Care: A Systematic Review Identifying Knowledge Gaps. Frontiers in Psychiatry, 9(452), 1–9. doi: 10.3389/fpsyt.2018.00452
Ii, T., Sato, H., Watanabe, N., Kondo, M., Masuda, A., Hayes, S. C., & Akechi, T. (2019). Psychological flexibility-based interventions versus first-line psychosocial interventions for substance use disorders: Systematic review and meta-analyses of randomized controlled trials. Journal of Contextual Behavioral Science, 13, 109–120. doi: 10.1016/j.jcbs.2019.07.003
Koven, S. (2018). Veteran Treatments: PTSD Interventions. Healthcare, 6(3), 94. doi: 10.3390/healthcare6030094
MacInnes, D., & Masino, S. (2019). Psychological and psychosocial interventions offered to forensic mental health inpatients: a systematic review. BMJ Open, 9(3). doi: 10.1136/bmjopen-2018-024351
Vecina, M. L., Marzana, D., & Paruzel-Czachura, M. (2015). Connections between moral psychology and intimate partner violence: Can IPV be read through moral psychology? Aggression and Violent Behavior, 22, 120–127. doi: 10.1016/j.avb.2015.04.013