Forensic Psychology

by Graham M Davies

  Personality disorder is recognised when these coping strategies have failed to mature with the individual into adulthood and thus are no longer adaptive. For example, a young child who has been separated from their mother for significant intervals as a result of illness may grow up believing that they cannot cope independently and yet are likely to be abandoned by anyone they rely upon. As a child they may have learned to look to other adults when their mother was unavailable in order to have their needs met. They may also have learned that such adults were more likely to take on a caring role towards them when they behaved well and made very few demands. As an adult this strategy for developing relationships may have become entrenched but ultimately counter-productive. Fearing abandonment has led to the adult prioritising the needs of the other person, thereby subjugating their own. Although this may maintain relationships, it is unfulfilling and can lead to significant distress, underpinned by deep-rooted resentment. This vicious circle would be typical for individuals who fulfil the criteria for a dependent personality disorder.

  Assessment of personality disorder is a very important but nonetheless a challenging area of forensic mental health. There is ongoing disagreement in diagnosis of various personality disorders and in terms of how many forms exist between DSM-5 and ICD-10. Nevertheless, appropriate identification is crucial. Diagnosis can be made in adulthood, but it is good practice not to diagnose before the age of 25 years, because of the nature of personality development up until this point. Diagnosis can arise from clinical observations, self-report assessments (for example, the third version of the Millon Clinical Multiaxial Inventory (MCMI-III, Millon, 2009), and structured clinical interviews, (e.g., the International Personality Disorder Examination, IPDE, Loranger et al., 1994).

  Sole reliance on self-report measures is not recommended for a number of reasons. They can be susceptible to problems of comprehension and poor insight. The results can also be unwittingly distorted by an individual’s mood and mental state and deliberately as a consequence of poor compliance. Within forensic mental health settings this last point is especially pertinent. It is important to maintain a healthy scepticism with regards to accepting patient’s self-report at face value because they will undoubtedly be aware that the results of assessments can have a profound impact upon their care pathway, treatment and judgments about risk. Assessment of personality disorder is further complicated by the fact that only 15% of people with personality disorders fulfil criteria for a single disorder. Most satisfy criteria for two or three forms of the disorder. Personality disorder in forensic mental health populations is also common in individuals with diagnoses of mental illness like schizophrenia. Comorbidity (the presence of more than one diagnosis) makes diagnosis difficult.

  22.3.5 Psychopathy

  Psychopathy is a highly pertinent issue in forensic mental health, but nevertheless is a very contentious one (see Chapters 3 and 18 for more discussion of this topic). Diagnosis does not form any part of DMS-5, or ICD-10. The concept of psychopathy, as a clinical entity, has been further complicated by the legal term of psychopathic disorder. This was a category by which individuals could be detained under the Mental Health Act (1983) and pertained to the broad spectrum of personality disorders. Psychopathy as a clinical term, however, is a specific type of antisocial personality disorder.

  Some clinicians view psychopathy as an extreme form of antisocial or dissocial personality disorder and so it could be argued that this would lead to duplication or considerable overlap. Thus all those deemed to be psychopaths would satisfy criteria for antisocial personality disorder (APD), or dissocial personality disorder (DPD), but only a third of those who satisfy criteria for APD or DPD would meet the threshold for diagnosis of psychopathy. In order to be diagnosed as having psychopathy an individual must be assessed by a specially trained clinician using the revised version of the Psychopathy Checklist-Revised (PCL-R; Hare, 1991, 2003) and must score above a set threshold (typically a score of 30 from a maximum score of 40). The reason that psychopathy is so relevant to the work with mentally disordered offenders is because the PCL-R (Hare, 1991) has good predictive validity as an assessment tool for violence and recidivism (Webster et al., 1997). Some critics argue that this is self-explanatory because in their view the concept of psychopathy simply medicalises criminality.

  The traditional view is that psychopaths are dangerous, manipulative and untreatable. Therefore individuals who are given this label can expect to have their stay in prison or hospital significantly extended comparative to their non-psychopathic peers, because the outcome of the PCL-R appears to have a disproportionate level of influence on their care and treatment. Admissions also become protracted because potential community services are often reluctant to accept responsibility for their care. Indeed, a number of services do not accept psychopaths as they believe they require specialist services that they are unable to provide. As a response to provide specialist services for psychopaths, four dangerous and severe personality disordered (DSPD) units were opened in 1999. Of the original four units only the two prison-based units now remain open; the Broadmoor DSPD closed in 2012 and the Rampton DSPD unit closed in 2014.

  22.3.6 Intellectual Disability and Developmental Disorders

  Intellectual disability is typically defined as a global impairment in intelligence that has arisen during the developmental period that persists across the lifespan and results in impairment in global functioning. Individuals with moderate and severe intellectual disability are not typically seen in forensic mental health settings. The nature of their day-to-day needs and functioning necessitates high levels of support and supervision that would ordinarily prevent them from engaging in serious offending (see Chapter 21 for further discussion of this area).

  Some individuals with mild intellectual disability who exhibit relatively minor offending behaviour may also escape prosecution because other people excuse their behaviour on account of their disability. This can lead to under-reporting. The danger with failing to identify or define some individuals’ behaviour as offending is that they do not receive timely interventions that could prevent more frequent, or more serious, offending from occurring. However, it is also possible that individuals with a mild intellectual disability are over-represented in offender populations because they are more likely to be apprehended. Individuals with intellectual disabilities have been shown to be more susceptible to mental illness. This risk is dramatically increased with the level of intellectual disability, and if there are comorbid diagnoses such as autistic spectrum disorder (ASD).

  Over recent years increases in referrals of individuals with ASDs have been observed within forensic mental health services. This is likely to have come about by a combination of a greater awareness and identification of ASD. It is also likely that specific characteristics of the disorder may contribute to increased instances of risky behaviour comparative to the general population. For example, individuals with ASD can be prone to poor impulse control and have deficits with regards to interpersonal skills that undermine their ability to interpret social situations and to empathise with others. This has led to the development of specialist ASD forensic mental health units.

  PHOTO 22.2 The term “autistic spectrum disorder” reflects the wide variation in challenges and strengths possessed by each person with autism.

  Source: © Andrii Kondiuk/Shutterstock

  22.3.7 Acquired Brain Injury

  Measuring the prevalence of acquired brain injury (ABI) in forensic populations and drawing conclusions about the links between acquired brain injury and offending is complex. This is because many incidences of head injury are not reported and the adverse impact can be underestimated. It is also apparent that the factors that make an individual susceptible to offending behaviour are similar to those that increase the risk of acquired brain injury, especially when individuals misuse substances.

  ABI can be associated with impulsive reactions and antisocial behaviour because of the significant impact upon cog
nitions, emotions and personality functioning. Common problems in cognitive functioning following acquired brain injury can be impairments in concentration, memory and executive functioning. These problems can lead to reduced information processing, processing speed and reduced ability to plan, organise, think flexibly and solve problems. Corresponding changes in personality can include egocentricity, tactlessness, impulsivity, lack of concern, lack of insight and poor judgment.

  PHOTO 22.3 Acquired brain injury can be associated with antisocial behaviours because of its impact upon cognitions, emotions and increase in impulsivity.

  Source: © Puwadol Jaturawutthichai/Shutterstock

  Pertinent to the problem of mentally disordered offenders with ABI is reduced emotional regulation skills, and how these can manifest in terms of increased irritability, hostility and aggression. Specialist forensic mental health services exist for mentally disordered offenders with significant ABI. Nevertheless, professionals need to be mindful of the high incidence of less serious ABI within mentally disordered offender populations and the potential impact that this can have on their functioning.

  22.3.8 Substance Misuse Disorders

  Substance misuse disorders are highly prevalent in this population for a number of reasons. As a diagnosis, substance misuse disorder is not used as a primary disorder with regards to justifying detention, but it is typically comorbid with other mental health conditions and has an enormous impact upon prognosis. According to the Department of Health between one-third and one-half of all people with severe mental health problems have comorbid problematic substance misuse (Department of Health, 2000). There is a wealth of evidence that among psychiatric populations, substance misuse is the most significant risk factor for relapse and associated violence. The association between substance misuse and offending more generally has been widely supported by research.

  22.3.9 Poorly Controlled Anger (with Resultant Aggression and Violence)

  Poorly controlled anger with resultant aggression and violence is the most common “risk” that necessitates a patient’s transfer to forensic mental health services, irrespective of whether individuals come through the mental health or criminal justice care pathway and irrespective of the nature of the mental health problem. Management of violence is also viewed as a priority by the general public and as such the media are understandably quick to highlight when services have been inadequate in this regard. It should be noted that violence to the self in respect of serious self-harm and suicidal behaviour can also lead to admission to forensic services.

  Management of violence within secure settings includes the threat of imminent violence and violence that is predicted within the medium and long-term and within different contexts including the community. Therefore, services need to take account of immediate and distal factors that could have a bearing on an individual’s risk. Other offending behaviours, such as sexual offending and firesetting, are also the focus of forensic mental health services and have started to feature more prominently within specialist intellectual disability, and women’s services in particular. We will now examine the legislation involved in governing work with mentally ill offenders.

  22.4 LEGISLATION PERTAINING TO MENTALLY DISORDERED OFFENDERS

  Due to the fact that mentally disordered offenders present a threat to themselves or others they frequently require supervision, monitoring and detention until it is deemed that they no longer present a risk. In order to enable authorities to have the power to supervise, monitor and detain individuals, appropriate legislation is required which outlines the range of powers the relevant authorities have and the circumstances under which these powers can be used. In addition to legislation providing powers to detain and treat individuals there is also legislation to ensure the rights and humane treatment of those who are detained. We will now examine these legislative arrangements in more detail.

  22.4.1 Mental Health Legislation/Arrangements

  Mental health legislation has been in existence in one form or another for centuries and is continually being revised and updated to remain relevant to the demands of the current population. The Mental Health Act (1983) applies only to England and Wales, with Scotland and Northern Ireland having their own legislation. The Act was amended in 2007 and introduced significant changes. Mental disorder is defined very broadly under the 2007 amendment as “any disorder or disability of the mind”. Mental Health care is regulated by a body known as the Care Quality Commission, established in 2009, whose role is to inspect and regulate health and social care services in England and Wales.

  The Mental Health Act covers every aspect pertaining to mentally disordered offenders and their care and detention. It lays out the criteria that enable an individual to be “sectioned” and detained, in order to be assessed and treated against their will. It also empowers certain professional groups with the powers to enforce the Act. Under the 2007 amended Act a range of professionals can become the responsible clinician who carries the ultimate responsibility for the decisions made about the care and detention of the individual. The criteria for compulsory hospital admission are shown in Box 22.1. It is of note that “medical treatment” is broadly defined as being to alleviate, or to prevent a worsening of, the disorder or one or more of its symptoms or manifestations. This includes nursing care, psychological interventions and rehabilitation alongside medical care and treatment.

  BOX 22.1 CRITERIA FOR COMPULSORY HOSPITAL ADMISSION

  The individual must have, or be suspected to have, a mental disorder.

  The mental disorder must be of a nature or degree to warrant detention in or to receive medical treatment in hospital.

  Detention must be in the interests of the patient’s health and safety or for the protection of others.

  Appropriate treatment must be available.

  The individual must have, or be suspected to have, a mental disorder.

  The mental disorder must be of a nature or degree to warrant detention in or to receive medical treatment in hospital.

  Detention must be in the interests of the patient’s health and safety or for the protection of others.

  Appropriate treatment must be available.

  In order to detain an individual against their wishes and enforce assessment and treatment a range of sections are available that enable detention for differing periods of time. After this they have to be reviewed and the responsible clinician can renew the section in specific circumstances. It is beyond the scope of this chapter to describe all the sections, but Box 22.2 shows some examples of those most common sections used in forensic units. Other sections provide “holding powers” to registered mental health nurses, enable transfers from prison to hospital and enable the police to remove an individual to a place of safety.

  BOX 22.2 COMMONLY USED MENTAL HEALTH ACT SECTIONS

  Section 3: This is a six-month order that enables the individual to be detained for treatment. It can then be renewed for a further six months, and then annually. The application has to be made by at least two doctors, and another approved mental health professional.

  Section 37: This is known as a “Hospital Order” and only applies to those who have been convicted of an imprisonable offence. It is imposed by the Court on the recommendation of at least two doctors. It enables detention for six months, renewal for six months, and then on an annual basis.

  Section 41: This is known as a Restriction Order and can only be imposed by the Crown Court. It is used where the individual is thought to pose a risk of serious harm to others. Decisions regarding leave from the hospital, transfer and discharge can only be made by the Ministry of Justice, which limits the power of the responsible clinician to make such decisions. Individuals can also be subject to conditional discharges whereby certain conditions are imposed upon them, such as the requirement to continue taking medication and to maintain contact with their mental health team. If the individual does not comply or their mental health deteriorates they can be compulsorily recalled to hospital.
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br />   Community Treatment Order: The 2007 Mental Health Act amendment introduced this order, which allowed for individuals who had been subject to either Sections 3 or 37, to be discharged into the community under certain conditions, similar to those imposed on Section 41. Individuals who do not comply can then be recalled. The purpose of this order is to ensure compliance from those individuals who were not on Restriction Orders.

  22.4.2 Legislation to Safeguard the Patient

  In order to safeguard the rights of patients, and ensure their appropriate care, there is additional legislation specific to ensuring that individuals are not detained unnecessarily. As mentioned above, the Care Quality Commission regulates and inspects all forensic healthcare provision for mentally disordered offenders. In addition, individuals sectioned under the Mental Health Act are entitled to apply to a Mental Health Review Tribunal, an independent judicial body, who will review their case and can override the recommendations of both the clinical team and the Ministry of Justice and discharge the individual if they think continued detention in hospital is no longer warranted.

  The Mental Health Review Tribunal is made up of a panel comprising a legal representative, a medical representative and a layperson. It is an independent judicial body. The panel hear the evidence presented by the clinical team and the individual’s solicitor may also examine the evidence of the team. Detained patients in hospital are also entitled to a Hospital Manager’s Hearing where again they can be discharged. A more recent development for safeguarding patients is the mental health advocacy system, which has been endorsed by the Mental Health Act (2007). This ensures that all detained patients can have access to a mental health advocate who can sit in on meetings between the mental health professionals and the patient (such as ward rounds and Care Programme Approach (CPA) reviews) and speak on the patient’s behalf if required.