| No longer is it possible to assess and/or treat a | | | | problems that have been derived from statistical |
| mental health population without also interfacing with | | | | models (actuarial tools) should be part of the |
| forensic issues such as legal infractions, Courts, | | | | evaluation since clinical assessment of risk of future |
| violence, sexual behavior problems, delinquency, | | | | dangerousness is only a little better than chance. |
| crime, Not Guilty by Reason of Insanity, substance | | | | While risk assessments are not perfect, they are |
| abuse, and others. The training and approaches to | | | | better than clinical judgment in this area.How are |
| the mental health population is different than that for | | | | Interventions Different?Major Mental Illnesses, while |
| a forensic population. So what is to be done, if a | | | | often chronic, can often be very effectively treated |
| person has both issues? We must be cross trained | | | | with medication and therapy. At the higher |
| for dually affected clients.How Are the Populations | | | | functioning end of the continuum, therapy can be |
| DifferentA Mental Health population is comprised | | | | supportive, psychotherapeutic, family, or cognitive |
| primarily Axis I disorders, such as Bipolar Disorder, | | | | behavioral. Therapists are trained to accept what the |
| Schizophrenia, Major Depression, PTSD, and Anxiety | | | | client presents and start where the client is |
| Disorders. Daily functioning is on a continuum. | | | | functioning and how the client sees the world. The |
| Recovery is quick for some and slow for others and | | | | clients are usually self-motivated and seek therapy |
| is also on a continuum. Well controlled intermittent, | | | | voluntarily. They accept responsibility for their |
| mild to moderate episodes of a mood or anxiety | | | | behaviors and for making changes in their lives. Use |
| disorder will not necessarily interfere with daily | | | | of a strengths model is often very effective. Many |
| functioning. Someone with severe, chronic | | | | people recover fully and lead quite "normal," |
| Schizophrenia or Mood Disorder requiring periodic | | | | non-disrupted lives. When someone is on the lower |
| hospitalizations and extensive community support, will | | | | end of the continuum, with major disruption in every |
| have impairment in daily functioning. Goals for these | | | | day functioning (work and family),despite medication |
| folks are often pro-social and involve being an active | | | | and therapy, major supports for housing, jobs, and |
| member of society. A therapist can be fairly sure | | | | activities of daily living and medication are needed for |
| that the mental health client without forensic issues | | | | a very long time, perhaps a life time. However, their |
| will be relatively honest in his or her interactions and | | | | life goals are often still pro-social. Serlf-directed care |
| the therapist can take most of what he/she says at | | | | works well with the mental health population without |
| face value. An emphasis on a strengths model works | | | | Axis II diagnoses.In the area of intervention, different |
| well when no personality disorder is involved.A | | | | approaches are needed for the forensic population. |
| forensic population can be defined as having | | | | Some level of social and family dysfunction is |
| personality disorders, interpersonal difficulties, | | | | generally intergenerational and lifelong. These clients |
| behavioral problems, multiple problems and life long | | | | are often Court ordered to an assessment or |
| courses of various levels of dysfunction or difficulty. | | | | therapy or they are having significant problems at |
| Again, this population fills the full spectrum of | | | | work or within the family causing others to seek |
| effective daily functioning. However, social functioning | | | | assessment or therapy for them. They do not |
| is often the most severe impairment. There are | | | | always accept responsibility for their actions or for |
| issues of trust, appropriate relationships, ego | | | | changing. There are skill deficits that need to be |
| centrism, moral development, honesty, manipulation, | | | | addressed, such as social skills, anger management, |
| and danger to self and others. They often have a | | | | and problem solving. You cannot take what these |
| negative view of themselves and others, especially | | | | clients say at face value. Third party information is |
| authority figures. Moral development is often delayed | | | | always needed. This is because you need to trust |
| leaving them at the egocentric stage of | | | | someone in order to be honest with them and most |
| development. This means that what serves the self | | | | of these folks have been abused, neglected, or |
| is what matters and empathy for others and the | | | | exposed to domestic violence and a suspicious arm's |
| ability to have an honest relationship with another | | | | length treatment of others is a coping strategy that |
| person may not yet have developed. Their goals are | | | | is difficult to give up.This population often has multiple |
| often self-serving.The capacity to understand the | | | | problems so that Multi-systemic Therapy that |
| importance of the best interest of the group through | | | | approaches many areas that need to be addressed is |
| laws and rules that we voluntarily follow, may not be | | | | often effective (treating the whole person). Group |
| well understood. Many, if not most, have histories of | | | | work and trauma therapies are also good tools. |
| childhood abuse, neglect, or exposure to domestic | | | | Self-directed therapy may not be effective because |
| violence. The assessment and interventions with this | | | | of the need to protect oneself from what may |
| population is necessarily different that those for a | | | | appear to be an unsafe world. Nurturing, setting good |
| people with no Axis II disorder or trait. The people | | | | boundaries, and structure are essential in this work. |
| with forensic issues do not always tell the truth | | | | Motivational interviewing and stages of change can |
| because of their lack of trust in relationships. The | | | | be very helpful. When clients have issues in the |
| therapist cannot take what he/she says at face | | | | mental health and forensic arenas, both approaches |
| value. The therapist must separate the sincere from | | | | must be used to the extent |
| the manipulative moves for self-gain. The internal | | | | possible.ConclusionsClients in a mental health setting |
| boundaries are such that they need the therapist to | | | | range from the single diagnosis of a major mental |
| put external boundaries into place for them. | | | | Illness to the dual diagnosis of a major mental illness |
| Information must be checked with other sources of | | | | and a personality disorder and/or forensic/legal issue. |
| information.How Assessment Tools DifferIn a mental | | | | The approaches to these dissimilar populations is |
| health population, assessment can quite effectively | | | | unique when clients are dually diagnosed, both |
| be done through instruments such as the MMPI-A, | | | | approaches are needed. Assessments and treatment |
| BASC, and MACI. These self-report tools are quite | | | | for a mental health population can be self-directed |
| sufficient for this population and will elucidate | | | | and strengths based.However, the approach for the |
| psychological dynamics and mental illness, if present. | | | | forensic population cannot be self-directed because |
| Self-report is not as much of an issue as it is in the | | | | the client's goals are often antisocial and by definition |
| forensic population, where third party verification is | | | | counter to the best interests of society. The |
| more important. However when a youth has multiple | | | | therapist or evaluator cannot accept everything the |
| problems, both mental health and forensic, a | | | | client says at face value because not being honest is |
| combination of tools is preferred.Forensic evaluation | | | | part of the disorder that the therapist is treating. |
| tools rely less on self-report because of the trust | | | | Motivational interviewing seems to blend the views of |
| issues and because it is not always in the client's best | | | | traditional mental health and forensics in a way that is |
| interest to be completely truthful. Self-report | | | | beneficial for the client and society.Dr. Kathryn Seifert |
| assessment instruments can be used, but third party | | | | has over 30 years experience in mental health, |
| and official reports should also be used in the | | | | addictions, and criminal justice work. She has |
| evaluation phase of a forensic assessment. Courts | | | | authored the CARE and numerous articles. Dr. Seifert |
| are concerned with public safety, therefore, the need | | | | has lectured internationally on youth and family |
| for tools that assess future risk of dangerousness to | | | | violence and trauma. |
| others. Risk of future aggression and sexual behavior | | | | |