Mental Health Treatment

Treating Mental Health and Forensic Populations

It is no longer possible to assess and/or treat a mental health population without also facing forensic issues such as legal violations, courts of law, violence, sexual behaviour issues, delinquency, crime, not guilty by reason of insanity, substance abuse, and others. The training and approach of the mental health population is different from that of a forensic population. So what should happen if a person has both problems? We must be trained to deal with doubly affected clients.

How do the populations differ?

A mental health population mainly includes axis I disorders, such as bipolar disorder, schizophrenia, major depression, PTSD, and anxiety disorders. Daily functioning is on a continuum. Recovery is fast for some, slow for others, and is also on a continuum. Well-controlled, intermittent, mild to moderate episodes of a mood or anxiety disorder will not necessarily interfere with daily functioning. Someone with severe, chronic schizophrenia or mood disorder requiring periodic hospitalizations and extensive community support will have impairment in daily functioning. Goals for these people are often pro-social and involve being an active member of society. A therapist can be fairly confident that the mental health client without forensic problems will be relatively honest in his or her interactions, and the therapist can take most of what he/she says without hesitation. The emphasis on a strengths model works well when there is no personality disorder involved.

A forensic population can be defined as a person with personality disorders, interpersonal problems, behavioural problems, multiple problems, and a lifelong course of varying levels of dysfunction or difficulty. Again, this population fills the full spectrum of effective daily functioning. However, social functioning is often the most serious limitation. There are issues of trust, appropriate relationships, self-centeredness, moral development, honesty, manipulation, and danger to self and others. They often have a negative image of themselves and others, especially those in authority. Moral development is often delayed, leaving them in the egocentric stage of development. This means that what serves the self is the most important thing, and empathy for others and the ability to have an honest relationship with another may not yet be developed.

The ability to understand the importance of the group’s interests through laws and regulations that we voluntarily follow may not be well understood. Many, if not most, have a history of child abuse, neglect, or exposure to domestic violence. The assessment and interventions in this population are necessarily different from those for those without an Axis II disorder or trait. People with forensic problems don’t always tell the truth because of their lack of trust in relationships. The therapist cannot simply accept what he or she says. For the therapist’s own benefit, he must separate the sincere from the manipulative movements. The internal boundaries are such that they need the therapist to set external boundaries for them. Information should be checked with other sources of information.

How assessment tools differ?

In a mental health population, assessment can be done quite effectively through tools such as the MMPI-A, BASC, and MACI. These self-report tools are sufficient for this population and, if present, will elucidate psychological dynamics and mental illness. Self-reporting is not as much of a problem as in the forensic population, where third-party verification is more important. However, when a young person has multiple problems, both psychological and forensic, a combination of instruments is preferred.

Forensic assessment tools rely less on self-reports because of trust issues and because it is not always in the client’s best interest to be completely truthful. Self-report tools can be used, but third-party reports and official messages should also be used in the evaluation phase of a forensic investigation. Courts are concerned with public safety, so there is a need for tools that assess future risks of danger to others. Risk of future aggression and problems with sexual behaviour derived from statistical models (actuarial instruments) should be part of the evaluation, as the clinical assessment of the risk of future danger is only slightly better than chance. While risk assessments are not perfect, they are better than clinical judgement in this area.

How are interventions different?

Serious mental illness, while often chronic, can often be treated very effectively with medication and therapy. At the higher-functioning end of the continuum, therapy can be supportive, psychotherapeutic, familial, or cognitive-behavioural. Therapists are trained to accept what the client presents and start with how the client functions and how the client sees the world. Clients are usually self-motivated and seek therapy voluntarily. They accept responsibility for their behaviour and for making changes in their lives. Using a strength model is often very effective. Many people make a full recovery and lead quite “normal” undisturbed lives. When someone is at the bottom of the continuum, with major disruption to daily functioning (work and family), despite medication and therapy, significant support for housing, jobs, and activities of daily living and medication is needed for a very long time, maybe a lifetime. However, their life goals are often still pro-social. Self-directed care works well in the mental health population without Axis II diagnoses.

In terms of intervention, different approaches are needed for the forensic population. Some degree of social and familial dysfunction is generally intergenerational and lifelong. These clients are often ordered by the court for assessment or therapy, or they have major problems at work or in their family that cause others to seek assessment or therapy for them. They do not always take responsibility for their actions or for change. There are certain skills that need to be addressed, such as social skills, anger management, and problem solving. You can’t take what these customers say at face value. Information from third parties is always necessary. This is because you have to trust someone to be honest with them, and most of these people have been abused, neglected, or exposed to domestic violence and a suspicious arm ‘

This population often has multiple problems, so multisystemic therapy that addresses many areas that need to be addressed is often effective (treating the whole person). Group work and trauma therapy are also good tools. Self-directed therapy may not be effective due to the need to protect yourself from what appears to be an unsafe world. Nurturing, setting good boundaries and structure are essential in this work. Motivational interviewing and phases of change can be very helpful. When clients have mental health and forensic issues, both approaches should be used whenever possible.

Conclusion

Clients in a psychiatric setting range from the single diagnosis of a serious mental illness to the dual diagnosis of a serious mental illness and a personality disorder and/or forensic/legal issue. As soon as a person has a double diagnosis, both approaches are needed.They can be done on their own and based on their own strengths when it comes to mental health assessments and treatment.

However, the approach for the forensic population cannot be self-directed because the client’s goals are often antisocial and, by definition, contrary to the interests of society. The therapist or evaluator cannot simply accept everything the client says, because being dishonest is part of the disorder the therapist is treating. When motivational interviewing comes together with traditional mental health and forensics, it seems to help both the client and society.

Dr. Kathryn Seifert has more than 30 years of experience in mental health, addiction, and criminal justice work. She is the author of CARE and numerous articles. Dr. Seifert has lectured internationally on violence and trauma in youth and families.