MYTHS AND REALITIES OF WORKING WITH THE FORENSIC MENTAL HEALTH POPULATION

Maurizio Assandri, Ph.D.

Sylvia S. Handian, Psy.D.

MYTHS AND MISCONCEPTIONS

The quest for what it means to be “mad” has always fascinated and scared humans since early on in our history.

In working with forensically mentally ill people we often found ourselves in situations where we have to confront the different myths, misconceptions and representations of what it means to be “mentally ill.”

PURPOSE

To address some important thoughts, observations and useful tips in working with such difficult, exciting and challenging people.

We would like to tackle such issues from the angle of the professional relationship between a supervisor and a supervise, who are both involved in providing treatment and supervision to a wide range of mentally ill people who are in a forensic outpatient program.

HISTORICAL PERSPECTIVE

Human beings have always expressed a preoccupation with the pathological form of mental and psychic experience.

Throughout history the expression of madness in literature, and now in movies and mass media, both challenged and reflected the assumptions found in medicine, culture, politic and in religion

In ancient Greece, for instance, madness was regarded as a blessing, an instrument of prophecy and an initiation into poetry.

During the Enlightenment, on the other hand, reason and madness were regarded as irreconcilable opposites.

The mad God, men and women of ancient myths also reflect the actions, conflicts, sufferings and even achievements generally accepted as part of the unconscious characteristics of the insane person.

The similarities between actual symptoms of mental illness and the conduct of the mad protagonists in certain Greek myths is striking.

In Aeschylus’ Orestes madness is seen as a form of vengeance; as a “curse”, a “evil spirit”, and not as the personal affliction of an isolated individual, but as a disease that afflict and entire family.

During the Middle Ages philosophers and physicians tried to understand and provide remedies for madness.

In the fourteenth century England literature was depicting madness as a sign of inner corruption, often inspired by God, but more often by the devil.

In modern times popular literature and Hollywood cinematography have misrepresented both the reality of being mentally ill and the portrayal of professionals who work with them.

Most movies deal with psychiatric themes with extremes: psychopathic serial killers (The Silence of the Lambs), multiple personalities (The Three Faces of Eve), or with pathetic, miserable but lovable oddballs (What About Bob?).

Three mains stereotypes exist in films and popular literatures: the “evil” doctor, the “kooky’ doctor, and the “wonderful” doctor. Think of the psychologists portrayed in the previous movies as well as Good Will Hunting, Analyze This and Analyze That. The common denominator between these representations is the lack of professional boundaries.

PROFESSIONAL DEFINITIONSOF FORENSIC PSYCHOLOGY

APA Forensic Division 41 The American Psychology-Law Society,

Division 41 of the American Psychological Association, is an interdisciplinary organization devoted to scholarship, practice, and public service in psychology and law.

Goals include advancing the contributions of psychology to the understanding of law and legal institutions through basic and applied research; promoting the education of psychologists in matters of law and the education of legal personnel in matters of psychology; and informing the psychological and legal communities and the general public of current research, educational, and service activities in the field of psychology and law.

Forensic Psychology is the application of the science and profession of psychology to questions and issues relating to law and the legal system. The word "forensic" comes from the Latin word "forensis," meaning "of the forum," where the law courts of ancient Rome were held. Today forensic refers to the application of scientific principles and practices to the adversary process where specially knowledgeable scientists play a role.

THE PRACTICE OF FORENSIC PSYCHOLOGY

Psychological evaluation and expert testimony regarding criminal forensic issues such as trial competency, waiver of Miranda rights, criminal responsibility, death penalty mitigation, battered woman syndrome, domestic violence, drug dependence, and sexual disorders

Testimony and evaluation regarding civil issues such as personal injury, child custody, employment discrimination, mental disability, product liability, professional malpractice, civil commitment and guardianship

Assessment, treatment and consultation regarding individuals with a high risk for aggressive behavior in the community, in the workplace, in treatment settings and in correctional facilities

Research, testimony and consultation on psychological issues impacting on the legal process, such as eyewitness testimony, jury selection, children's testimony, repressed memories and pretrial publicity

Specialized treatment service to individuals involved with the legal system

Consultation to lawmakers about public policy issues with psychological implications

Consultation and training to law enforcement, criminal justice and correctional systems

Consultation and training to mental health systems and practitioners on forensic issues

Analysis of issues related to human performance, product liability and safety

Court-appointed monitoring of compliance with settlements in class-action suits affecting mental health or criminal justice settings

Mediation and conflict resolution

Policy and program development in the psychology-law arena

Teaching, training and supervision of graduate students, psychology, and psychiatry interns/ residents, and law students

Forensic psychology is the interface between psychology and the law, so all psychological services provided for the legal community are forensic psychological services. However, most forensic psychologists provide services which are both clinical and forensic in nature. When a psychologist treats an individual who was emotionally traumatized by an accident, the treatment is clinical in nature, designed to assist the individual in recovering from the trauma.

But, when the psychologist is asked to provide a report for the court, regarding the extent of the trauma, and to assess the psychological damage incurred, then the psychologist is providing forensic services.

Forensic services can and are provided in Family Court, Civil Court and Criminal Court. A common misconception is that forensic psychology applies only to the criminal population.

CLINICAL SUPERVISION

Bridges (1999) emphasized the importance of supervisor openness and candor in assisting trainees to manage intense feelings. “Ethical supervision is embedded in a clearly articulated supervisor-student relationship that monitors misuse of power and boundary crossings, yet is capable of deeply personal discourse” (Bridges, 1999, p.218).

Well intended trainees may find themselves blindly approaching ethical slippery slopes (Hamilton and Spruill, 1999; Pearson and Piazza, 1999.)

Dual roles are an inherent aspect of forensic psychology. The therapist frequently acts as a case manager, parole officer and mental health professional. APA ethics code 2002 states that although it is not unethical to enter into a dual relationship with a client, it is the therapist’s responsibility to ensure the client is not exploited or harmed by the relationship.

The ethics code further states that it is permissible for a psychologist working in forensics to act as an evaluator for parole and even release. Ethical guidelines for forensic psychologists encourages sensitivity to the ethical pitfalls inherent in this dual relationship.

One ethical concern is that the patient may not be completely honest as a therapy patient if he or she knows the therapist will be making these types of recommendations and decisions. Another concern is that informed consent is not freely given.

THE FORENSIC CLIENT

A common myth often found not only among the public but also among mental health professionals, is the notion that the “typical” forensic client is an out of control lunatic or a crazy woman who appears normal then suddenly tries to stab an unexpectent victim.

When compared to other mentally ill populations, the forensic client has striking similarities and differences.

The forensic client is diverse in his or her typology, the range is wide.

In a typical forensic outpatient program such as CONREP and the state hospitals the forensic client tends to have the following characteristics.

SIMILARITIES

They tend to be chronically mentally ill people with severe Axis I diagnoses in the schizophrenic-bipolar spectrum, with a high loading in the schizoaffective categories.

They tend to have a co-morbid substance abuse history.

They tend to have poor and/or limited social, vocational skills, often the result of the negative symptoms of their illnesses.

They tend to have a history of chronic treatment non-compliance prior to their final forensic psychiatric hospitalization.

DIFFERENCES

The ratio of male to female clients has been constant and tends to be ten to one in favor of men.

The presence of personality disorders in the Dramatic cluster of borderline, narcissistic and antisocial tends to be higher among forensic clients. However the presence of “true” psychopaths even among the forensic clients tends to be low.

Forensic clients tend to be more “stable” because more stringent control over their environment and treatment is imposed by the legal system.

SEX OFFENDERS

No major Axis I diagnosis with the exception of pedo/paraphilias.

High degree of Axis II diagnoses in the antisocial and narcissistic categories.

Tend to be “high functioning” in many aspects of their life with the exception of their ability to maintain meaningful relationships and the circumstances of their sexually deviant behaviors.

Female sex offenders tend to be rare. This may be due to the tendency to under report and under convict.

RISK FACTORS

Forensic clients in a typical forensic outpatient setting such as CONREP tend to cluster into two categories:

1. The mentally ill person who commits a crime

2. The criminal who also suffers from a mental illness.

MENTALLY ILL PERSON WHO COMMITS A CRIME

Little or very minor history of criminal activities prior to the committing offense.

The pretence of a clear and well documented (but perhaps not well recognized) major mental illness.

The presence of an Axis II disorder is not as frequent or prominent.

Substance abuse is present but in many cases it is absent

The committing offense tends to be severe and against immediate family members (often parents). High frequency of NGI commitment.

A history of treatment non-compliance, or of frustrating attempts by either the family or the client to receive treatment from local mental health clinics under the 5150 commitment.

THE CRIMINAL WITH A MENTAL ILLNESS

A lengthy and sometimes diverse criminal history that includes convictions for assaults, burglary and other related crimes.

Prior history of incarceration in state prisons. The presence of major Axis I disorders in the

schizoaffective spectrum.

The presence of Axis II disorders with a high prevalence of antisocial personality.

The presence of severe drug and/or alcohol abuse from early on.

The victim pool tends to be wider and not limited to immediate family members.

The presence of crimes against property, such as arson and burglary.

History of non-compliance with treatment and with parole/probation that resulted in several parole/probation violations.

A history of poor pre—morbid functioning, such as employment, school and interpersonal relationships.

In an outpatient treatment program forensic clients in the first category tend to do much better in terms of treatment compliance, societal re-integration, psychiatric stability and dangerousness to the community (e.g. revocation, dirty urine screen, new charges) when compared to those in the second category.

COMMON MISUNDERSTANDINGS

Exciting: This notion comes most typically from the media portrayal of the forensic client.

Dangerous: The belief that all forensic clients are maniacal, unpredictable people, who are dangerous all the time.

Different: The belief that this population is drastically different than the general outpatient client.

ORGANIZED/DISORGANIZED DICHOTOMY

Developed by the FBI Behavioral Sciences Unit after the extensive interviewing of 36 serial murderers.

Organized crimes are premeditated and carefully planned. Organized criminals are antisocial but know right from wrong, are not insane and show no remorse.

Disorganized crimes are not planned and criminals leave such evidence as blood and fingerprints at the scene of the crime. Disorganized criminals tend to be mentally ill or under the influence of alcohol or drugs or both.

Currently factor analysis is being used to group together types of offender behaviors and develop scientifically defensible descriptions and classifications of offenders.

MULTIPLE ROLESAdjustment

There is an adjustment period where the intern/trainee struggles with the idealized media portrayal of the forensic setting and the reality of it.

Just as in any adjustment period there is a struggle to make the reality and the image fit together. The greatest struggle can come from the changes and modifications the intern/trainee must make in the definition of our role as a clinical therapist.

MULTIPLE ROLESTherapeutic Relationship

The therapeutic relationship is very different in the forensic setting than in the traditional mental health setting. The first and possibly most important difference is that of confidentiality and its limits. The typical forensic outpatient client (CONREP client) does not have the same protection of confidentiality as the general outpatient client.

The therapist is frequently placed in the role of probation officer, parole agent, case manager and law enforcer. These roles make it difficult to build traditional therapeutic rapport with the client.

Given these multiple disciplinary roles, it is not surprising that client’s have conflicting feelings regarding the therapist.

In CONREP the clinician is also responsible for the client’s finances, setting up social security, making sure bills get paid and ensuring appropriate amounts of spending. The clinician is expected to conduct regular home visits, searching through a client’s belongings and confiscating things when necessary. Clinicians are expected to write reports detailing the client’s behaviors for the court and in some cases testify against clients who file for restoration of sanity.

MULTIPLE ROLESDecision Making

One important role of the CONREP clinician is making decisions for our clients; whether they can live on their own, whether they can drive, whether they can visit family for the day or spend the night, etc.

As therapists we are trained to encourage client’s to make their own decisions, to guide them in making independent choices and to never foster dependency upon us or enable them in any way. Many interns/trainees struggle with this large discrepancy between what is expected in the forensic setting and what is taught in graduate school.

The decision making role places many forensic clinicians in a psuedo-parent role that can be uncomfortable for the clinician and confusing for the client. This role requires blurring boundaries and often leads to transference issues for the client.

MULTIPLE ROLESLosses in the therapeutic relationship

 The threats to rapport The crossing of classically identified boundaries Threats to and lack of confidentiality Loss of open disclosure Resistance due to involuntary treatment

Resistance due to the multiple roles the clinician plays in the client’s life

Difficulty establishing and maintaining therapeutic trust

The constant threat of rehospitalization

MULTIPLE RELATIONSHIPSSupervisors Role

In order to help the supervisee navigate through the different roles, it is important to keep in mind that such dual roles are an inherent aspect of forensic mental health work. The 2002 APA ethics code states that it is not unethical to enter into a dual relationship with a client, it is the therapist’s responsibility to ensure that the client is not harmed by such relationship.

Keep your boundaries intact: Because working with forensic clients implies assuming roles that are potentially contradictory, it is very crucial that well-defined and clear boundaries are established and followed. Discuss the potential pitfalls of violating such an important rule.

Avoid dual relationships with client: Although this problem might seem similar to the boundaries one, this is a different set of issues. The risk with not well defined boundaries is to confuse the different roles that a therapist has toward the client (e.g. therapist, case manager, “glorified” probation officer, court evaluator), while the issue with dual relationships is more a personal one: to see the client as a “friend”, or as a person who is different from the other clients.

Be open and candid in managing intense feelings: Help supervisee become aware and frankly address countertranference issues that are often common when working with this people.

COUNTERTRANSFERENCE

The case of NJ The mentally ill person who happened to

commit a crime. Treatment issues and approach Specific countertransferance issues Strong reactions to the instant offense

The case of MB The criminal who happens to have a mental

illness Treatment issues and approach Specific countertransferance issues Strong reactions to the instant offense

The case of JD The incompetent to stand trial Treatment issues and approach Specific countertransferance issues Strong reactions to the instant offense

COMMON DILEMMAS

How do I balance being the law enforcer and the empathic clinician?

- Separate as much as possible, includingphysically where you do things. Be the therapist in the session and not the case manager. - This separation communicates the two roles to the client as well. -Different yet integrated.

These duties are out of my scope of practice.

-Explore. Is this a misunderstanding of what the position entails? Is it counter-

transference? Is it an issue of

professional development?

-Educate. Evaluate expectations.

-Explore whether forensics is the right fit.

This client scares me.-Listen and elicit from the supervisee

what makes the person afraid.-Help do a risk assessment.-Encourage appropriate safety

precautions. -If the fear persists, re-evaluate and take action if necessary.

-If the fear interfere with job performance

then address it directly in supervision and

help the supervisee look at counter-

transference issues, and reactions.

-Help the supervisee come up with and

implement a plan of correction.

Self doubt. How do I know I am cut out for this line of work?

- Why is the supervisee asking this

question?

-What are the personal feelings? Expectations? Level of experience?

Feeling overwhelmed by the responsibilities.

- Is this an issue of being overly involved

with the client and not drawing appropriate boundaries?

-Is it a question of time management?

-Is the supervisee stepping into the role

of an overprotective parent?

Strong reactions to the crime.- Try to separate the crime from the

person to a certain extent. - Encourage the supervisee to take care of themselves outside of the setting and not take their work home with them.-Continue to seek supervision and

professional support.

Never had experience working with the chronically mentally ill population. The “Oh My! He’s really crazy!” reaction.

-Encourage the supervisee to evaluate the client’s baseline functioning and symptoms

and use it as a yard stick.

-Encourage case management, containment and reframing of expectations. What is

success for this client?

QUESTIONS?

THANK YOU