Rehabilitation of the Mentally Disordered Offender
LORRAINE CHILDS AND PHILIP BRINDED
Medlicott Academic Unit, Christchurch, New Zealand
This article considers a number of areas significant to the
rehabilitation of mentally disordered offenders. The
growth of forensic rehabilitation services has
outstripped research in this area, hence it is acknowledged
that clinicians are currently working with limited guidance.
However, literature from this, and related fields, is reviewed,
to outline the processes and practices of rehabilitation of
mentally disordered offenders. The model of care used in the
Canterbury Forensic Psychiatric Service is described with
reference to the need for interventions to be carried out
within a therapeutic culture (Lindqvist & Skipworth,
2000).The role of a psychologist in assessment, intervention,
training, research and organisational issues is discussed.
There is acknowledgement of the ethical dilemmas faced by
clinicians working in rehabilitation, with patients who present
a risk to others.
The last 20 years have seen a significant growth in forensic
services worldwide. In New Zealand, prior to 1988 there
were no designated forensic services. The country had
a maximum security hospital for the most violent psychi-
atric patients and psychiatrists operated in forensic capaci-
ties on a private basis. In the last 15 years regional forensic
psychiatric services have been developed. These multidisci-
plinary teams provide care to patients in inpatient units, via
community teams and services to the prisons. Reasons
for such rapid growth include an increase in the focus
on community care and awareness of the prevalence
of mental disorder amongst prisoners. Parallel to this has
been a rise in public expectations regarding risk, which has
been driven by the media highlighting crimes committed
by people with mental disorders.
Service expansion and allocation of specialist resources
has enabled forensic services to flourish. However, service
development has occurred at a faster pace than the literature
about the efficacy of treatments for forensic populations.
Literature reviews illustrate a lack of empirical research
regarding what works for mentally disordered offenders
(MDOs), and for whom. Hence, there are few models to
guide clinicians involved in the rehabilitation of this group
of offenders.
The purpose of this article is to provide information that
will, despite these caveats, consider a number of areas
significant to the rehabilitation of MDOs. While the clinical
outcome and research literature is utilised, so too are the
clinical experiences of the authors. Overall, the aim is to
provide the reader with a conceptual framework within
which the role of the psychologist and psychological inter-
ventions can be placed. Hence, the Canterbury Forensic
Address for correspondence: Associate Professor Philip Bnded, Medlicott Academic Unit, Regional Forensic Psychiatric Service, Canterbury District
Health Board, Hillmorton Hospital Prvt. Bag 4733, Christchurch, New Zealand. Email: Phl.BrlndedOcdhb.govt.nz
Psychiatric Service (CFPS) is outlined, using the principles
of a "therapeutic culture", prior to a description of specific
psychological interventions. It is hoped that this work will
stimulate further research and discussion in the developing
area of forensic rehabilitation.
The Relationship Between Mental Disorder,
Crime and Violence
A review of the literature into the relationship between
mental disorder, crime and violence is beyond the scope
of this article, however, comprehensive reviews are avail-
able (Monahan & Steadman, 1994; Mullen, 1997).
Studies have examined the relationship between mental
illness and crimes, including shoplifting (Gudjonsson,
1987), arson (Soothill & Pope, 1973) and stalking (Mullen,
Pathe, & Purcell, 2001). Violence is indicated in the major-
ity of index offences leading to referral to Forensic Mental
Health services (Taylor, 1997). Furthermore, violence com-
mitted by psychiatric patients is a growing concern of the
public (Sheppard, 1996), resulting in clinicians requiring
more information and guidance for decision-making
purposes (Rumgay & Munro, 2001).
While there is a substantial body of literature on the
relationship between violence and mental illness, there are
limitations, which preclude direct comparisons between
studies. These limitations include varying diagnostic criteria
and methodology, and poor representation of populations
in research samples. For example, there are many undiag-
nosed and untreated people with a mental illness in prison
(Gunn, Maden, & Swinton 1991; Brinded et al., 2001).
Similarly, as discussed, due to medico-legal criteria (court
diversion programs, insanity findings), there are people with
mental illness who have committed an offence, but are not
included in "offender" statistics.
Despite these limitations, it is possible to identify some
trends in the relationships between mental disorder, crime
and violence. A significant body of international literature
indicates a link between mental disorder and violence
(Monahan & Steadman, 1994; Mullen, 1997). The complexi-
ties of this link however, have been illustrated by studies,
which highlight confounding factors such as comorbidity of
substance abuse and personality disorders (Steadman, et al.,
1998; Rice & Harris, 1995). This has led to more detailed
studies, examining specific risk factors.
The evidence that links mental disorder and violence
comes from three broad groups of studies which include
studies of inpatients and discharged populations (e.g.,
Lindqvist & Allebeck, 1990), prison studies (e.g., Brinded
et al., 2001; Taylor & Gunn, 1984), and community studies
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LORRAINE CHILDS AND PHILIP BRINDED
(e.g.,Wessely, Castle, Douglas & Taylor, 1994). One of the
most comprehensive studies that contributed to an under-
standing of the interplay of risk factors involved the analysis
and reanalysis of data on 10,059 subjects from a North
American Epidemiological Catchment Area (Swanson,
Holzer, Ganju, & Jono, 1990). This study indicated self-
reported levels of violence for the general population,
people with schizophrenia and people with alcohol and
substance abuse to be 2.4%, 12% and 25% respectively.
When the presence of substance abuse was controlled for,
rates of violent incidents by people with mental illness
dropped to 7%, which was the same as for people aged
18-24. Subsequent research confirms the validity of this
finding (see Soyka, 2000, for a review). Swanson and
colleagues (1990) also demonstrated an association between
active symptomatology and violent incidents. Research
findings in prison and hospital populations have confirmed
that active symptoms of psychosis do increase the risk
of the occurrence of violent incidents (Steadman et al.,
1998; Taylor & Gunn, 1984).
Rehabilitation of the Mentally
Disordered Offender
The verb "to rehabilitate" has been defined as "to restore
to good form or proper functioning condition" (Reber, 1995,
p. 27). There has been debate as to whether the focus
of rehabilitation with MDOs should be towards alleviating
mental illness, or reducing offending behaviour (Blackburn,
1996). Recently, it has been suggested that rehabilitation
of MDOs should focus on "increasing personal effectiveness,
of which avoiding further offending is only one component
... this implies that the targets of intervention are those
cognitive emotional and interpersonal disabilities which
impede social reintegration" (Blackburn, 1996, p. 133). These
disabilities include learned behaviour, personal and social
circumstances, as well as the effect of an individual's mental
illness. It is, therefore, clearly important that assessment,
formulation and treatment incorporate a broad range
of individual factors and outcomes, many of which are
outlined below. It can also be seen that there are inevitably
broad areas of overlap between rehabilitation programs for
MDOs and those in general psychiatric populations.
Lindqvist and Skipworth (2000) have proposed a foren-
sic rehabilitation assessment and treatment framework
which incorporates factors affecting risk of relapse or reci-
divism in a mentally disordered offender population. They
suggest four dynamic factors that need to be assessed and
addressed within forensic rehabilitation. These are the disor-
der itself, family problems and poor sociocultural circum-
stances, substance misuse, and antitherapeutic system
dynamics. The authors suggest that these risk factors inter-
act and are amenable to change (dynamic) although they
admit to the difficulties such a model presents for service
evaluation. Of particular note in this model is the attention
paid to system dynamics, and how temporal and interac-
tional facets of the environment can facilitate or hamper
rehabilitation objectives. The authors encompass these
variables under the term "therapeutic culture", reminding us
that we are working within a broad system, of which
specific interventions are only a part.
The need to implement a therapeutic culture has been
recognised within general psychiatric rehabilitation
(Conning, 1991), but there has been little reported applica-
tion of these principles in the forensic literature. This is not
to say that a therapeutic culture has not been fostered.
However, explicit acknowledgement of the need for, and the
principles underlying, such a culture can emphasise to staff
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230
that they are working as part of a therapeutic process, which
improves quality of life, even when task-focused change
appears limited. The benefits of this approach to patients are
outlined in what follows, with reference to specific examples
of how these principles are addressed within the CFPS.
Shared goals and values. The range of environments
and staff groups to which an individual is exposed during the
process of rehabilitation leads to possible inconsistency
in approach. It is therefore important to try to adopt
a consistent culture across settings and staff so that values
and goals are shared. In the CFPS the Recovery Approach
has been adopted. The principles of this state that "recovery
is defined ... as the ability to live well in the presence
or absence of one's mental illness (or whatever people choose
to name their experience)" (New Zealand Mental Health
Commission, 2001, p. 1). A key aim of the recovery model is
to foster hope that "recovery" will occur through shared
effort by the patient and supporting staff team. Other philoso-
phies and models used within the forensic service include
the Strengths model (i.e., focus and build on the strengths
of the patient; Rapp, 1998) and the psychosocial model
(i.e., emphasis on a social rather than a medical model;
Anthony & Liberman, 1986). These models emphasise
a wider cultural goal of the service - to remain patient-
focused, with (where possible) patients being central
to decision-making in the delivery of care. Patients are en-
couraged to advocate for themselves, and to enroll advocacy
support from family, friends and staff. The Forensic Service
also employs people who have previously been patients
within the service, to act as consumer representatives and
advocates. Involvement of wider consumer groups is also
encouraged. The Pukenga Atawhai (Maori Mental Health
workers) are important to this process, ensuring that individ-
ual's cultural needs are assessed and managed.
Stffcontdnuy. Lindqvist and Skipworth (2000) emphasise
the need for the patient to have the opportunity to build
sustainable, trusting relationships with staff. This can help
the patient to develop confidence and social skills (Perkins
& Dilks, 1992), which can later (with consistent support) be
generalised to community settings. As part of this process,
staff need to receive training, supervision, and feedback
about their performance. The CFPS holds in-service training
sessions and working groups to ensure familiarity and
review of adopted models and philosophies. Staff attend
supervision, courses and conferences and share multidisci-
plinary team models. Staff continuity is assured in that the
consultant psychiatrists, social workers, Pukenga Atawhai
and clinical psychologists track the patient's progress
through the service, whilst nurses and occupational thera-
pists are ward-based. To coordinate this delivery of care, the
patient is also allocated a Case Manager. This model is
flexible and staff can be changed at the patient's request, in
the event that the therapeutic relationship has broken down.
Timing of the rehabilitationprocess. Lindqvist and
Skipworth (2000) assert that rehabilitation should
commence immediately on entry to the service, although
legal processes may initially hinder treatment (i.e., the
initial period of a remand assessment). Given that the litera-
ture suggests that rehabilitation is most effective when
it takes place in the least restrictive environment (Andrews
et al., 1990), it is necessary to assist patients to develop the
and self-support skills needed to progress from secure
to open rehabilitation environments. People also need the
opportunity to make a gradual transition between environ-
ments and services to ensure expectations are clear and
demands are not too high. On entry to the CFPS, individuals

are assisted to understand the legal processes. Key clinicians
(including cultural workers) are appointed early on to facili-
tate development of trusting relationships. The process
of gaining increased autonomy and reduced imposition
of restrictions is made transparent, and staff and patient
hopes and expectations are discussed and negotiated.
Transition between environments, (i.e., between wards
or from hospital to the community) is managed via a
process of increased day and overnight leaves (Mohan,
Jamieson, & Taylor, 2001), with gradual introduction of
new case managers, and maintenance of contact with other
professionals as appropriate.
Family relationships. Violence is most likely to occur in
patient's homes, especially when they are exposed to
relationship stress (Bullard, 1994). Hence, the patient's
relationship with their family is an important factor in
rehabilitation. However, after years of failure to bring
improvement, families are often disillusioned with services.
Lindqvist and Skipworth (2000) suggest that "forensic
services must expect some of this frustration to be voiced
before solid alliances can be forged between the patient, the
family and the psychiatric service" (p. 322). The CFPS
seeks permission from the patient to include the family in
the assessment and rehabilitation process. Specifically,
Pukenga Atawhai assist in fostering relationships between
the patient, whanau (family) and service, even when
patients have lost contact with their family. In this way,
family and partners can help with assessment and identifica-
tion of previous service failures, and be included in the
rehabilitation plan and educational programs. Specifics of
family intervention are discussed later in this article.
Social networking/peers. The patient must have a social
network beyond the boundaries of paid staff when they
move back into the community. In the CFPS, patients are
assisted to contact friends and family who will provide
positive support and esteem to the patient throughout the
inpatient and community rehabilitation process. In particu-
lar, cultural and patient support workers assist with this
process and act as role models.
Process insight. Lindqvist and Skipworth (2000) suggest
that if a patient regards their hospital stay as "a sentence"
and is discharged having "served their time" one can predict
a poorer outcome. Hence, they indicate that a major part of
rehabilitation is to increase the self-determination of the
patient, so that they are able to recognise and respond to
factors pertinent to relapse and recidivism. The CFPS
provides illness education and addresses relapse-prevention
by helping individuals establish the factors that will help
them stay well. Community follow-up is also provided to
the patient as a way of helping them to build upon and
maintain the progress they have made in hospital. Families
and partners are helpful in this process.
The future. As stated earlier, the CFPS has adopted the
Recovery Approach, which focuses on fostering hope
via the establishment of realistic future goals. These
are determined by the patient (as far as possible), who
is then encouraged to work towards these goals and assisted
in developing the necessary skills. Lindqvist and Skipworth
(2000) also emphasise the importance of helping the patient
to establish hope and planning for the future. In this way,
people's actions can be guided by their own goals and percep-
tions of success. This is important, since a lack of social
support and achievable goals has been clearly identified
MENTALLY DISORDERED OFFENDERS
as a factor that increases the chance of recidivism in MDO
populations (Webster, Douglas, Eaves, & Hart, 1997).
The Role of the Psychologist in Rehabilitation
The role of a clinical psychologist has been described
as involving "specialised knowledge of psychological
functioning and psychological methods, which provides
particular expertise in carrying out psychological assess-
ments such as psychometric tests, psychological treatments
and psychological methods of research and evaluation"
(Hall & Marzillier, 1992, p. 9).' Whilst psychologists have
traditionally been employed to work with individuals, there
is increasing recognition that their role is also one of train-
ing, consultation, planning and research at environmental
(i.e., ward-based) and broader service levels (Conning,
1991). The heterogeneity of the patient base and the broad
remit of forensic services gives the psychologist in these
environments an opportunity to work at all of these levels.
The role of the psychologist in forensic rehabilitation will
therefore be described according to Liddell's (1983) sugges-
tion of the core skills of the psychologist - assessment;
therapy/intervention; and research and teaching (as cited in
Conning, 1991).
Assessment
Psychological assessment involves asking questions and
using scientifically-based methods to gather information,
and to formulate a model of factors that may be contributing
to a particular circumstance. Individuals who present to the
forensic service will, in the medico-legal process, have
received a diagnosis. In terms of planning rehabilitation,
diagnoses are limited in their utility. Often people have
more than one diagnosis. Furthermore, diagnoses do not
highlight psychological and social disabilities that may be
related to offending. Hence, psychologists can assist with
complex multidisciplinary formulation via assessment of
neuropsychological deficits (Gillespie & McKenzie, 2000);
cognitive factors (i.e., dysfunctional cognitive processing
and deviant interpersonal beliefs); affective factors
(i.e., anxiety and depression); and lifestyle (interpersonal
skills, substance abuse) (Browne & Howells, 1996).
The assessment of the individual may identify broad
needs or specifically focus on a particular problem or risk
factor (Conning, 1991). A range of techniques may be used
including interviews with the patient and significant others
(including getting the patient's view of the problem); previ-
ous file information on social, psychiatric and forensic
factors; psychometric assessment and measures of function-
ing (i.e., cognitive, adaptive); and observation. Test instru-
ments can be used to increase objectivity in formulation and
outcome evaluation. For example, a test battery may include
neuropsychological assessment, measures of affect, motiva-
tion for change and personality. It is important that the
practitioner interprets the results of such instruments
cautiously, as forensic patients may differ significantly from
the population for whom the instruments were developed
and normed. For example, as cultural minorities tend to be
over-represented in forensic populations (Coid, Kahtan,
Gault, & Jarman, 2000), tests may lack cultural validity
with some patients. In Australia and New Zealand, this is
particularly pertinent to those from Aboriginal and Maori
backgrounds respectively.
Risk assessment. The increasing attention given to the
"dangerousness" of psychiatric patients means that all services
need to pay more attention to risk assessment. Recently
the focus of assessment has changed from dangerousness as a
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 LORRAINE CHILDS AND PHILIP BRINDED
static phenomena to the treatability of dynamic and change-
able risk factors (Lindqvist & Skipworth, 2000). Similarly,
there have been changes in professional perspectives of
methods of risk assessment, with recent agreement that
careful collaborative use of clinical and actuarial measures,
is likely to provide the most accurate assessment of future
risk (Blackburn, 1996; Rice & Harris, 1997).
"Risk" is a broad concept that may relate to the effect of
the individual on the self (i.e., deliberate self-harm, suicide
or neglect) or on others (i.e., violence). These principles
apply in the community and in the institution. Whilst there
are limitations in accuracy (Mossman, 1994), a risk assess-
ment attempts to predict the likelihood of an individual
committing further antisocial acts. The psychologist can
assist in risk assessment by using methods already outlined
(i.e., file reviews, interviews with patient and family). Aims
of assessment may include: identifying themes and patterns
of previous offending; examining the interplay of mental
illness with broader psychosocial factors; assessing the
individual's insight and understanding of their problems
(i.e., motivation for change); identifying judgemental biases
and attitudes; and examining the contribution of neuropsy-
chological deficits. Identification of specific risk factors
requiring more in-depth assessment and/or formulation can
be acquired by using a formal risk assessment tool, such
as the Historical/Clinical Risk Management scheme (HCR-
20; Webster et al., 1997) or the Violence Risk Appraisal
Guide (VRAG; Harris, Rice, & Quinsey, 1993). These
actuarial tools focus on identified risk factors that have been
shown to increase the risk of future violence. Risk assess-
ment in MDO populations must always lead to risk manage-
ment as part of an overall care plan.
Assessment of the environment and service. Most forensic
patients are subject to at least a short period of incarceration.
It is therefore important that the environment and the broader
service facilitates the rehabilitation process. Psychologists are
equipped with the research skills to evaluate models of care
(Lavender, 1985) and to encourage evidence-based practice
(Weisz, Hawley, Pilkonis, Woody, & Follette, 2000). Quest-
ions relevant to organisational assessment may be explorative
(i.e., who are we admitting and how does this compare
to other psychiatric services?) or more specific (i.e., are we
meeting specified standards of care?). Psychological
techniques can then be applied to improve service delivery
(Manpower Planning Advisory Group, 1990) through consul-
tancy, where the focus is on the formulation and development
of interventions to improve services for staff and patients
(Brunning, Cole, & Huffington, 1990). Research and service
development are closely linked and may be pursued simulta-
neously, providing one is mindful of issues such as confiden-
tiality and use of data. Open feedback to stakeholders and
participants in such projects is likely to sustain support for
future work (Rice & Harris, 1997).
Therapy
In the last 20 years the emphasis on community rather than
institutional care has shifted the focus of psychiatric treat-
ment of people with severe mental illness from a curative
model to one of reducing disability and maximizing quality
of life (New Zealand Mental Health Commission, 2001).The
same applies to the rehabilitation of MDOs. Whilst medica-
tion still remains an integral part of treatment for most
patients, psychosocial and psychological interventions have
become more salient (Mueser & Bond, 2000).
In forensic settings, where intervention needs to target
offending behaviour, as well as illness and psychosocial
variables, psychologists have demonstrated the effectiveness
NOVEMBER 2002 V AUSTRALIAN PSYCHOLOGIST
232
of these psychosocial treatment approaches (Quayle
& Moore, 1998; Renwick, Black, Ramm, & Novaco, 1997).
The remainder of this section focuses on specific
psychological interventions used in forensic rehabilitation.
Behaviour theay. The basic premise of behaviour therapy
with MDOs is to positively reinforce prosocial behaviours
and to reduce antisocial behaviours. Behavioural programs
are extremely effective interventions when they are specific,
structured and part of a multimodal treatment package
(Lipsey, 1992). This structure and clarity is particularly
useful when working with people with learning disabilities
and/or active psychotic symptoms, with the techniques
successfully applied in community and inpatient settings
(Beck, Menditto, Baldwin, Angelone, & Maddox 1991).
In their review; Rice and Harris (1997) suggested that
behavioural interventions provided a means of monitoring
behaviour and building skills. Specifically, they recom-
mended using behavioural approaches alongside social
skills training. The latter will be discussed separately, as it
also relates to cognitive-behavioural interventions.
At the CFPS, contingency-based behavioural programs
aim to increase patients' awareness of and responsibility for
their behaviour and its consequences. The approach
is framed in terms of encouraging people to develop the
skills and atitudes necessary to survive in the community
in the future. Patients assist with the development and
choice of rewards and consequences for specific behaviours,
and goals are regularly reviewed. Initial areas of focus
include reducing aggressive acts, reducing substance abuse,
encouraging the taking of medication, improving personal
care and encouraging participation in ward or community
activities. Behavioural reinforcers are generally delivered by
nursing staff, who are encouraged to deliver positive
reinforcement for appropriate behaviours, rather than focus-
ing on the negatives. Monitoring levels of achievement as
the patient progresses through their rehabilitation, provides
information to aid decision-making of the multidisciplinary
team (i.e., regarding future leaves).
CognitIve-behaviouraltherapy. Randomised controlled
trials indicate that cognitive-behavioural therapy (CBT)
is an effective treatment, alongside medication for people
who have psychotic experiences. Follow-up trials indicate
that treatment effects can be enduring (Haddock, et al.,
1998). However, most trials utilised outpatients or people
in the early stages of schizophrenia (Sensky, et al., 2000;
Kuipers et al., 1998). These populations are likely to be less
socially disabled than many of those within forensic
environments. Hence, whilst there is informative literature
about CBT with people who have psychosis (Chadwick,
Birchwood & Trower, 1996), the first author has found
it particularly useful to adopt simplified approaches to CBT
when treating MDOs, inline with those approaches
suggested for use with people with learning disabilities (i.e.,
Stenfert Kroese, Dagnan, & Loumidis, 1997).
Literature relating to CBT in forensic settings suggests
that these interventions are usually applied in conjunction
with social skills training. Aims of programs cited include
helping people to improve coping strategies, problem-
solving, anger management, development of self-control
skills, self-management and adaptation of antisocial
attitudes (Rice & Harris, 1997). Groupwork has been tried
in larger forensic settings with mixed results (McMurran,
Charlesworth, Duggan, & McCarthy 2001). However, in
smaller settings, the diversity of patient needs may preclude
CBT being carried out in groups.

CBT can be a useful tool in assisting the patient
to develop insight and awareness of relapse prevention
requirements, for example, the need to comply with medica-
tion (Brondolo & Mas, 2001). However, more research on
this application of CBT is needed with forensic populations.
Social skills training. Onset of psychotic illness during
adolescent years, institutionalisation, and psychotic experi-
ences themselves can lead to a lack of confidence
or ability to cope with day-to-day social routines, such as,
going shopping or to a cafd. Social skills training (SST)
aims to teach interpersonal skills by dividing social behav-
iours into steps. Specifically, the processes of modelling,
shaping, role-play, feedback and in vivo practice are used to
aid acquisition and generalisation of skills (Mueser & Bond,
2000). SST has been found to be effective with forensic
populations for reducing impulsivity, increasing problem
solving skills (McMurran, Egan, Richardson, & Ahmadi,
1999); improving anger management (Renwick, et al.,
1997); and making friends (Rice, 1983). SST has also been
used to increase medication compliance of psychiatric
patients (Cramer & Rosenheck, 1999). Whilst many studies
report positive results, one review has indicated that the
results of SST may not always be long lasting or generalis-
able (Benton & Schroeder, 1990). However, research to date
has indicated that "maintenance" (ongoing) support in the
use of previously learned social skills can increase longevity
and generalisation (Dobson, 1996).
Cognitive rehabiliaion/ cognitive remediation. Cognitive
rehabilitation aims to help people to remediate problems
with information-processing skills, such as attention,
memory and concentration, which can result from having
a psychotic illness. Compensatory strategies are taught
to the patient using frequent sessions of practice and
rehearsal (Brenner et al., 1994). There are mixed findings
regarding its effectiveness (Hogarty & Flesher, 1992). It has
been found to lead to improvements in problem-solving
abilities and social adjustment in forensic settings (Donnelly
& Scott, 1999). However, a randomised control trial found
that after a 6-month follow-up, people with schizophrenia
who had received intensive cognitive rehabilitation did not
differ from controls who had received intensive occupa-
tional therapy, in measures of symptoms or social function-
ing (Wykes, Reeder, Corner, Williams, & Everitt, 1999).
Whilst they had better cognitive functioning and self-
esteem, the study did little to suggest that cognitive remedi-
ation had any real benefits over meaningful activity,
vocational rehabilitation or employment, which are positive
prognostic indicators in serious mental illness (Harding,
Strauss, Hafez, & Lieberman, 1987).
Vocational rehabilitation. Vocational rehabilitation is not
primarily the domain of psychologists, but it is an important
aspect of a rehabilitation program, particularly in forensic
rehabilitation where the effects of institutionalisation must
be counterbalanced with occupational/ recreational pursuits.
Most people who have a psychiatric illness want competitive
employment (Bebout, Becker, & Drake, 1998) which has
been associated with improved clinical outcome (Mueser,
et al., 1997). However, only 8 to 40% of psychiatric patients
achieve this aim, with people exhibiting psychosis falling
at the lower end of this range, compared to people
with other diagnoses (Cook & Razzano, 2000). This trend
has also been found within forensic inpatient facilities
(Evans, Souyma, & Maier, 1989). Whilst psychologists may
not be directly involved in the delivery of vocational
rehabilitation, they have an important role to play in the
assessment of patient abilities (i.e., cognitive and adaptive
MENTALLY DISORDERED OFFENDERS
functioning) and identification of potential barriers
to patient vocational pursuits. In this way they can help
to identify suitable work placements and can continue
to provide support and encouragement to help the patient
achieve success (Cook & Razzano, 2000).
Family intervention. Trials for family intervention programs
for people with serious mental illness have tended to be of at
least 6 months duration, offering psychoeducation, illness
management, empathy and support, problem-solving devel-
opment and crisis management (Dixon, Adams, & Lucksted,
2000; Mueser & Bond, 2000). Whilst these programs have
been well utilised by families of forensic patients (Lefley,
2001), literature reviews reveal mixed findings regarding
their efficacy. In their review, Mueser and Glynn (1999)
concluded that family interventions significantly reduced
future relapse and rehospitalisation rates. However, Dixon
and colleagues (2000) indicated that the effect of intensive
family interventions was less pronounced where enriched
individual models were provided. They suggested three
important elements in working with families - providing
information, assisting with communication and problem
solving, and providing support. Ways of doing this include
brief family therapy, workshops and helping people
to contact self-help organisations. Psychologists can take
an active role in identifying the need for and delivery of
family interventions, and in the event that services are
pressured, psychologists can ensure that these interventions
are utilised in an efficient and time-limited manner.
Teaching and Research
A psychologist's role in the multidisciplinary team
also includes teaching and educating other staff, either
informally (i.e., in meetings, case discussions and through
sharing complex formulations) or formally (i.e., through
lectures and/or inservice education). Areas of education
commonly include behavioural techniques and theories
of offending and rehabilitation. As discussed, psychologists
can also become involved in service development, monitor-
ing of staff knowledge and the application of philosophical
principles.
Psychologists are trained in research methods, therefore
they can apply these skills in a number of ways, such as,
via service evaluation, testing hypotheses based on clinical
observations, and developing theory-practice links
(Conning, 1991). Research in the area of mentally disor-
dered offenders can fall into two categories - evaluating
effectiveness of treatment components or describing charac-
teristics of patients to develop typologies relevant to both
treatment and etiology (Hodgins, 1998). For further
examples of psychological research in a forensic setting see
the special edition of Criminal Behaviour and Mental
Health (Taylor, Heads, Hill, & Perkins, 1998).
Ethical Issues in Delivering Psychological
Services to Mentally Disordered Offenders
The lack of guidance from the literature is one of a number
of dilemmas that face clinicians working in the area
of rehabilitation of MDOs. Another major issue is the need
to balance the rehabilitation of the individual with the risk
that they pose to society. At times, the clinical team may
exercise over-caution, particularly in a climate of increasing
legal, social and political pressures. Hence, psychologists
may find themselves a part of an uncomfortable process,
focusing more on assessment than management of risk
(Rice & Harris, 1997), and consequently detaining people
for what they might do, rather than what they have done
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LORRAINE CHILDS AND PHILIP BRINDED
(British Psychological Society, 1999). Furthermnnore, there
may be organisational factors, which impede an individual's
progress through the rehabilitation process. For example,
the individual may be in prison, where access to psychiatric
services is very limited. Also community services may not
wish to accept responsibility for the care of an individual
with a forensic history, as they may believe that they would
have difficulties in meeting their complex needs (Vaughan,
Pullen, & Kelly, 2000).
Unlike other fields of psychology, confidentiality may
be limited as information may be required for legal
decision-making and ongoing risk assessment. To some
extent, this can be countered by regularly reviewing the
boundaries of confidentiality with patients and by clearly
stating the reasons for referrals and reports, thereby limiting
inappropriate disclosure of information (McGuire, 1997).
Furthermore, psychologists may find themselves working
in environments unsupportive of psychological and thera-
peutic principles (i.e., in prisons, where staff are untrained
in mental health needs). Rice and Harris (1997) suggest that
this can be partially overcome by "applying established
behavioural principles to the organisation" (p. 163). Such
principles include targeting management for education
about behavioural principles; identifying enthusiastic,
motivated people to oversee programs; jointly initiating and
developing intervention programs; obtaining funding from
the agency, so they have a vested interest in its success;
and reporting success to reinforce the positive efforts of the
staff and agency.
Future Research
While there is a regular flow of research about MDOs, more
is needed on treatment outcomes and long-term follow-up
of criminal, clinical and psychosocial variables. Research
could further differentiate outcomes of MDOs, compared
to non-offending clinical populations or non mentally-ill
offenders (Rice & Harris, 1997). However, as Lindqvist and
Skipworth (2000) state, difficulties in trying to do research,
especially randomised control trials, with MDOs include
the complexity of the systems in which treatment is carried
out and the number of factors outside of clinical control
(i.e., patients moving between prison and hospital environ-
ments). The challenge for psychologists is to try to design
studies that will overcome some of these difficulties,
in order to provide meaningful, generalisable data that will
assist us in offering effective interventions to meet the broad
needs of this population and the wider society.
Endnote
I In future, the term "psychologist" refers to psychologists who
have received sufficient postgraduate training to carry out the
functions described.
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