Increasing the Coherence of Forensic Mental Health Services: An Introduction
Stephen L. Golding, Ph.D.
Professor and Director of
Clinical Training
Department of Psychology
University of Utah
Salt Lake City, Utah
This Special Section concerns the complex interdependencies that mark the interactions among the network of "systems" that are subsumed under the rubric of "forensic mental health services." The lead paper, by Hafemeister(1), is a valuable starting point in understanding the often conflicting goals of the interactive systems. Unfortunately, our very use of the term "systems" is misleading because it implies a rather high level of organization and coherence. Many of the papers in this section can, indeed, be viewed as attempts to provide a much needed framework for increasing the coherence of service delivery in several critical subsystems, e.g., pretrial evaluations(2) and services(3), training and quality control for evaluators(4), and treatment of insanity acquittees(5)-(6). But, why is this "system" so difficult to conceptualize, administer, study, or change? Several factors need to be added to the excellent observations already presented in this set of papers.
First, forensic systems have never been constructed, from a mental health perspective, on the basis of a consensual, much less empirically tested, theory of human behavioral development and change; nor, from a legal perspective, have the laws, which govern the actors in the system and the recipients of services, been based upon a consensual theory of social policy or jurisprudence. As a result, many of the elements of the system contradict each other because they are implemented ad hoc, or worse, on the basis of transient political or financial considerations.
Second, the individuals who work in the forensic system, which is inherently inter-disciplinary, tend to come from diverse mono-disciplinary training programs. Mental health professionals rarely understand the theories or methods of their own allied professions (e.g., psychiatry, psychology, social work) much less the theories and methods of the justice system (e.g., corrections, law enforcement, legal regulation, probation/parole). The converse is also obviously true.
Third, most forensic systems are not organized in a fashion designed to maximally facilitate their goals. As many of the following papers demonstrate, forensic systems require a great deal of coordination and control among a set of diverse agencies in order to provide continuity of care, the tracking of individuals as they cross the boundaries of many sub-systems, the coordination of information across agencies and longitudinally-based program impact and evaluation initiatives. It is the rare forensic system that is designed in such a fashion. As a result, forensic systems usually do not have direct and coordinated control over applicable budgets, policies and procedures in the complex web of agencies that are responsible for the delivery of services within the system.
The interaction and importance of these factors can be seen in the set of topics addressed by the papers in this section. Consider the issues surrounding the assessment and treatment (both inpatient and outpatient) of individuals found not guilty by reason of insanity (NGRI). In Jones v. United States(7), the United States Supreme Court made it clear that "A verdict of not guilty by reason of insanity is sufficiently probative of mental illness and dangerousness to justify commitment of the acquittee for the purposes of treatment and the protection of society. ... The purpose of ... commitment is to treat ... mental illness and protect ... (the acquittee) and society from ... potential dangerousness." (pp. 354-355) The papers by Griffin5, Silver6 and their colleagues go a long way in discussing the complexities inherent in models for the coordination of outpatient services for such individuals. If, however, we look at the entire "NGRI system" from a longitudinal perspective, a series of additional complexities, contradictions and problems emerge. In one such study(8), a large cohort of NGRI acquittees was followed both retrospectively and prospectively with respect to both criminological and psychopathological status as they entered and left various systems during their "NGRI careers." Several findings are of direct relevance to our discussion of coherence and coordination of forensic mental health services. First, while it is no suprise that most of this cohort would have significant mental health histories (approximately 80% had one or more prior hospitalizations), it is notable that the vast majority of the hospitalizations just prior to the NGRI offense occurred for legally relevant reasons (modally, civil commitment for dangerousness to self or others) and within one year of the NGRI offense. Thus, a large proportion of those ultimately found NGRI were already in the forensic mental health system and had been identified as suffering from legally relevant mental disorder. Second, a large proportion of the NGRI cohort (approximately 60%), not suprisingly, had been found unfit to stand trial prior to their ultimate disposition as NGRI. What was surprising was that, by monitoring their clinical status at various points in time, the researchers were able to infer that most of the significant clinical change in psychopathology which occurs does so before the adjudication as NGRI. Thus, while the average NGRI acquittee was under supervision and treatment for 114.7 months (49.9 months initial hospitalization, 47.7 months outpatient supervision, 17.1 months re-hospitalization), most of the significant clinical change occurred even before that time period. Finally, the data implied that most individuals had repetitive cycles of deterioration, even though they were constantly under supervision and psychotropic medication. Thus, the "NGRI" time-frame was a legally imposed "window" on a much longer time-series.
Data such as these clearly need to be replicated, but they are provocative nonetheless. Can the limited resources of the forensic system be more specifically targeted towards high-risk individuals before they enter the NGRI system? Which treatment modalities (both inpatient and outpatient) are most effective and cost-efficient? How does the Jones standard relate to the realities of treatment, life-time course of serious mental disorder and the predictions of future dangerousness? Restructuring forensic mental health systems so that they can routinely take a coordinated and longitudinal approach to the NGRI population, based upon articulated and coherent goals, and a meaningful database, is a clearly indicated direction.
The papers in this section which concern pre-trial2 and jail services3 as well as the training of forensic examiners4 provide another "window" on a related aspect of the forensic system and also contain the theme of increased coordination and control. Since pre-trial evaluators or therapists work at the "front end" of the system, and hence have a great deal of influence on the flow of clients through the forensic system itself, it is critical that these individuals be highly trained and skilled in an interdisciplinary context. As Poythress and his colleagues2 demonstrate in their paper in this issue, considerable cost-efficiencies can also be realized by careful attention to the training and co-ordination of pre-trial evaluations, especially when evaluations take place on an out-patient basis when feasible. Unfortunately, the types of training and monitoring programs discussed in these papers are the exception to the rule.
The reader of this special section should think about the degree of coherence and coordination of their own systems as they evaluate the ideas presented by these papers. While all papers agree that the vast jurisdictional and local variations in administrative structure, legal regulation and political realities make the advocacy of a single model inappropriate, there is an overarching theme that can be applied across jurisdictions. Forensic professionals and mental health administrators can produce significant improvements and cost-efficiencies in their systems by adopting a broader interdisciplinary view of the interactive components, by instituting better coordination and control mechanisms, by challenging the assumptive bases of their programs, and by building in longitudinally based evaluation and feedback mechanisms.
1. Hafemeister RL: Goals to guide the interactions of the mental health and justice systems. Journal of Mental Health Administration 1991; in press.
2. Poythress NG, Otto RK, & Heilbrun K: Pre-trial evaluations for criminal courts: Contemporary models of service delivery. Journal of Mental Health Administration 1991; in press.
3. Ogloff JRP, Tien G, Roesch R, & Eaves D: A model for the provision of jail mental health services: An integrative, commpunity based approach. Journal of Mental Health Administration 1991; in press.
4. Fein RA, Appelbaum KL, Barnum R, Baxter P, Grisso T & Leavitt N: The designated forensic professional program: A state government-university partnership to improve forensic mental health services. Journal of Mental Health Administration 1991; in press.
5. Griffin PA, Steadman HJ & Heilbrun K: Designing conditional release systems for insanity acquittees. Journal of Mental Health Administration 1991; in press.
6. Silver SB & Tellefsen C: Administrative issues in the follow-up treatment of insanity acquittees. Journal of Mental Health Administration 1991; in press.
7. Jones v. United States. 463 U.S. 354 (1983).
8. Golding SL, Eaves D & Kowaz AM: The assessment, treatment and community outcome of insanity acquittees: Forensic history and response to treatment. International Journal of Law and Psychiatry 1989; 12:149-179.