No longer is it possible to assess and/or treat a mental health population without also interfacing with forensic issues such as legal infractions, Courts, violence, sexual behavior problems, delinquency, crime, Not Guilty by Reason of Insanity, substance abuse, and others. The training and approaches to the mental health population is different than that for a forensic population. So what is to be done, if a person has both issues? We must be cross trained for dually affected clients.
How Are the Populations Different
A Mental Health population is comprised primarily Axis I disorders, such as Bipolar Disorder, Schizophrenia, Major Depression, PTSD, and Anxiety Disorders. Daily functioning is on a continuum. Recovery is quick for some and 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 folks are often pro-social and involve being an active member of society. A therapist can be fairly sure that the mental health client without forensic issues will be relatively honest in his or her interactions and the therapist can take most of what he/she says at face value. An emphasis on a strengths model works well when no personality disorder is involved.
A forensic population can be defined as having personality disorders, interpersonal difficulties, behavioral problems, multiple problems and life long courses of various levels of dysfunction or difficulty. Again, this population fills the full spectrum of effective daily functioning. However, social functioning is often the most severe impairment. There are issues of trust, appropriate relationships, ego centrism, moral development, honesty, manipulation, and danger to self and others. They often have a negative view of themselves and others, especially authority figures. Moral development is often delayed leaving them at the egocentric stage of development. This means that what serves the self is what matters and empathy for others and the ability to have an honest relationship with another person may not yet have developed. Their goals are often self-serving.
The capacity to understand the importance of the best interest of the group through laws and rules that we voluntarily follow, may not be well understood. Many, if not most, have histories of childhood abuse, neglect, or exposure to domestic violence. The assessment and interventions with this population is necessarily different that those for a people with no Axis II disorder or trait. The people with forensic issues do not always tell the truth because of their lack of trust in relationships. The therapist cannot take what he/she says at face value. The therapist must separate the sincere from the manipulative moves for self-gain. The internal boundaries are such that they need the therapist to put external boundaries into place for them. Information must be checked with other sources of information.
How Assessment Tools Differ
In a mental health population, assessment can quite effectively be done through instruments such as the MMPI-A, BASC, and MACI. These self-report tools are quite sufficient for this population and will elucidate psychological dynamics and mental illness, if present. Self-report is not as much of an issue as it is in the forensic population, where third party verification is more important. However when a youth has multiple problems, both mental health and forensic, a combination of tools is preferred.
Forensic evaluation tools rely less on self-report because of the trust issues and because it is not always in the client’s best interest to be completely truthful. Self-report assessment instruments can be used, but third party and official reports should also be used in the evaluation phase of a forensic assessment. Courts are concerned with public safety, therefore, the need for tools that assess future risk of dangerousness to others. Risk of future aggression and sexual behavior problems that have been derived from statistical models (actuarial tools) should be part of the evaluation since clinical assessment of risk of future dangerousness is only a little better than chance. While risk assessments are not perfect, they are better than clinical judgment in this area.
How are Interventions Different?
Major Mental Illnesses, while often chronic, can often be very effectively treated with medication and therapy. At the higher functioning end of the continuum, therapy can be supportive, psychotherapeutic, family, or cognitive behavioral. Therapists are trained to accept what the client presents and start where the client is functioning and how the client sees the world. The clients are usually self-motivated and seek therapy voluntarily. They accept responsibility for their behaviors and for making changes in their lives. Use of a strengths model is often very effective. Many people recover fully and lead quite “normal,” non-disrupted lives. When someone is on the lower end of the continuum, with major disruption in every day functioning (work and family),despite medication and therapy, major supports for housing, jobs, and activities of daily living and medication are needed for a very long time, perhaps a life time. However, their life goals are often still pro-social. Serlf-directed care works well with the mental health population without Axis II diagnoses.
In the area of intervention, different approaches are needed for the forensic population. Some level of social and family dysfunction is generally intergenerational and lifelong. These clients are often Court ordered to an assessment or therapy or they are having significant problems at work or within the family causing others to seek assessment or therapy for them. They do not always accept responsibility for their actions or for changing. There are skill deficits that need to be addressed, such as social skills, anger management, and problem solving. You cannot take what these clients say at face value. Third party information is always needed. This is because you need to trust someone in order to be honest with them and most of these folks have been abused, neglected, or exposed to domestic violence and a suspicious arm’s length treatment of others is a coping strategy that is difficult to give up.
This population often has multiple problems so that Multi-systemic Therapy that approaches many areas that need to be addressed is often effective (treating the whole person). Group work and trauma therapies are also good tools. Self-directed therapy may not be effective because of the need to protect oneself from what may appear to be an unsafe world. Nurturing, setting good boundaries, and structure are essential in this work. Motivational interviewing and stages of change can be very helpful. When clients have issues in the mental health and forensic arenas, both approaches must be used to the extent possible.
Clients in a mental health setting range from the single diagnosis of a major mental Illness to the dual diagnosis of a major mental illness and a personality disorder and/or forensic/legal issue. The approaches to these dissimilar populations is unique when clients are dually diagnosed, both approaches are needed. Assessments and treatment for a mental health population can be self-directed and strengths based.
However, the approach for the forensic population cannot be self-directed because the client’s goals are often antisocial and by definition counter to the best interests of society. The therapist or evaluator cannot accept everything the client says at face value because not being honest is part of the disorder that the therapist is treating. Motivational interviewing seems to blend the views of traditional mental health and forensics in a way that is beneficial for the client and society.