3 Do Not Give Up At The First Site Of Imperfection: Treating Mental Health And Forensic Populations

No longer is it possible to assess and treat a mental health population without also interfacing with forensic problems such as legal infractions, Courts, violence, sexual behavior problems, delinquency, crime, Not Guilty by Reason of Insanity, substance abuse, and others.

What is to be done, So if a person has both problems?

The training and approaches to the mental health population is different than that for a forensic population. Of course, daily functioning is on a continuum. It’s a well mental Health population is comprised primarily Axis I disorders, just like Bipolar Disorder, Schizophrenia, Major Depression, PTSD, and Anxiety Disorders. On top of that, well controlled intermittent, mild to moderate episodes of a mood or anxiety disorder shall not necessarily interfere with daily functioning. Recovery is quick for some and slow for others and is also on a continuum. Goals for these folks are often pro social and involve being an active member of society. Someone with severe, chronic Schizophrenia or Mood Disorder requiring periodic hospitalizations and extensive community support, will have impairment in daily functioning. Although, there’re problems of trust, appropriate relationships, ego centrism, moral development, honesty, manipulation, and danger to self and others.

That said, this means that what serves the self is what matters and empathy for others and the ability to have a honest relationship with another person may not yet have developed.

Therefore this population fills the full spectrum of effective daily functioning.

Social functioning is often the most severe impairment. 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. Now look, the capacity to have a grasp of the importance of top interest of the group through laws and rules that we voluntarily follow, may not be well understood. Loads of, So if not most, have histories of childhood abuse, neglect, or exposure to domestic violence. It’s a well the therapist must separate the sincere from the manipulative moves for ‘self gain’. You should take this seriously. People with forensic problems do not always tell the truth because of their lack of trust in relationships. Normally, the therapist can not take what he/she says at face value. Anyway, the assessment and interventions with this population is necessarily different that those for a people without Axis I disorder or trait.

Actually the internal boundaries are such that they need the therapist to put external boundaries into place for them.

In a mental health population, assessment can quite effectively be done through instruments similar to the MMPI A, BASC, and MACI.

So if present, these selfreport tools are quite sufficient for this population and will elucidate psychological dynamics and mental illness. Selfreport ain’t as much of a big problem as it’s in the forensic population, where third party verification is more important. Forensic evaluation tools rely less on self report because of the trust problems and being that it is not always in the client’s best interest to be completely truthful. Third party and official reports must also be used in the evaluation phase of a forensic assessment, selfreport assessment instruments can be used. 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 was derived from statistical models will be part of the evaluation since clinical assessment of risk of future dangerousness is only a little better than chance. While often chronic, major Mental Illnesses, can often be very effectively treated with medication and therapy.

They accept responsibility for their behaviors and for making changes in their lives.

The clients are usually selfmotivated and seek therapy voluntarily.

Therapists are trained to accept what the client presents and start where the client is functioning and how the client sees the world. So, at the higher functioning end of the continuum, therapy can be supportive, psychotherapeutic, family, or cognitive behavioral. Now regarding the aforementioned fact… Their life goals are often still pro social. With major disruption in each day functioning,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, when someone is on the lower end of the continuum. However, use of a strengths model is often very effective. Loads of people recover fully and lead quite normal, ‘nondisrupted’ lives. Some degree of social and family dysfunction is generally intergenerational and lifelong.

There’re skill deficits that need to be addressed, just like social skills, anger management, and problem solving.

They do not always accept responsibility for their actions or for changing.

You can’t take what these clients say at face value. Furthermore, third party information is always needed. Essentially, in this place of intervention, different approaches are needed for the forensic population. 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. Therefore, ‘Multisystemic’ Therapy that approaches many areas that need to be addressed is often effective since This population often has multiple problems. Motivational interviewing and stages of change can be very helpful. Ok, and now one of the most important parts. Nurturing, setting good boundaries, and structure are essential in this work. This is where it starts getting interesting. Selfdirected therapy may not be effective because of the need to protect oneself from what may appear to be an unsafe world. Now look. Group work and trauma therapies are also good tools. With that said, 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 forensic/legal issue.

By the way, the approaches to these dissimilar populations is unique when clients are dually diagnosed, both approaches are needed.

The therapist or evaluator can’t accept everything the client says at face value being that not being honest is part of the disorder that the therapist is treating.

Approach for the forensic population can’t be self directed as long as the client’s goals are often antisocial and by definition counter to better interests of society. Seifert has lectured internationally on youth and family violence and trauma. Dr. Dr. She has authored the CARE and numerous articles. Kathryn Seifert has over 30 years experience in mental health, addictions, and criminal justice work.