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Research Priorities in Forensic Mental HealthSheilagh Hodgins aa Department of Psychology, Universit de Montreal, C.P. 6128, succ. Centre-ville, Montral,Qubec, CANADA, H3C 3J7 E-mail:Published online: 17 Feb 2012.
To cite this article: Sheilagh Hodgins (2002): Research Priorities in Forensic Mental Health, International Journal of ForensicMental Health, 1:1, 7-23
To link to this article: http://dx.doi.org/10.1080/14999013.2002.10471157
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International Journal of Forensic Mental Health2002, Vol. 1, No. 1, pages 7-23
2002 International Association of Forensic Mental Health Services
This article attempts to identify researchpriorities for the field of forensic mental health. It ispresumptuous to think that one person couldadequately accomplish this task. I decided to try,however, in the hope that I would provoke others toformulate a research agenda and to think seriouslyabout how to prioritize the long list of topics to study.Note please, that like the new InternationalAssociation of Forensic Mental Health Services(IAFMHS) and this journal, I use the term forensicmental health. Forensic mental health includes thestudy, treatment, and management of persons withmental disorders who engage in illegal or violentbehaviors. It is a larger and more encompassing fieldthan either forensic psychiatry or psychology. Bothof these professions, along with many othersnursing, social work, education, occupationaltherapy, pharmacology, toxicology, sociology,criminology, neurobiologycare for persons withmental disorders who have committed crimes andconduct research that advances knowledge about thispopulation, about effective treatments, and aboutfactors related to offending. The use of the termmental health is thus an attempt to acknowledge the
Research Priorities in Forensic Mental Health
This article identifies research priorities for the field of forensic mental health. What is known about
the association between mental disorders, retardation, brain damage and offending and violence is briefly
reviewed. It is noted that while some of the correlates of offending are common to both non-disordered and
disordered offenders, others characterize specific subgroups of mentally disordered offenders. The evidence
is consistent in showing that most mentally disordered offenders have multiple problems that have been
present, in many cases, since childhood. Knowledge about effective treatments for mentally disordered,
mentally retarded, and brain damaged offenders is highlighted. It is concluded that there is a lack of
information about the organization, legal powers, and content of treatment, management, and rehabilitation
programs that have been shown to impact on recidivism, relapse, and autonomous functioning. Almost
nothing is known about the impact of various social services. Future research should be designed to contribute
to (1) improving the efficacy of models of service organization; (2) improving the efficacy of treatment,
management, and rehabilitation programs; (3) improving the efficacy of the multiple components included
in treatment, management, and rehabilitation programs; (4) integrating risk assessment of violent behavior
into treatment, management, and rehabilitation programs and improving the accuracy of prediction; (5)
identifying the etiologies of offending and violence among persons with mental disorders, mental retardation,
and brain damage; and (6) preventing offending and violence among children at risk for mental disorders.
Sheilagh Hodgins is in the Department of Psychology, Universit de Montreal, C.P. 6128, succ. Centre-ville, Montral, Qubec,CANADA H3C 3J7 (E-mail: email@example.com).
contributions of different disciplines. The termmental health is also used in order to encompassmental retardation and persons who do not meetcurrent diagnostic criteria for a mental disorder butwho by their own or a professionals assessment havemental health problems.
This new association and its journal focus onforensic servicesall of the services necessary toprocess, assess, treat, manage, and rehabilitatepersons with mental disorders who have engaged inillegal behaviors. I will presume that there isagreement that services must be based on empiricalevidence of effectiveness (see Hodgins, 2000a). Thismeans that the organizational model is based onknowledge of mentally disordered offenders, theeffects of different organizational models areempirically measured, and decisions about how to(re-) organize services are made on the basis ofempirical evidence. This also means that develop-ment and modification of treatment and rehabilitationservices are based on empirical findings of the effectsof these services. Thus, even though this is primarilyan association for those who administer and provideservices for mentally disordered offenders, research
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is (perhaps should be; or even better, will be) anintegral part of the provision of services to mentallydisordered offenders.
WHAT DO WE KNOW?
What is Known About the AssociationBetween Mental Disorder and Crime?
Not much! It is seems realistic to assume, untilthe opposite is shown to be true, that the associationdiffers across disorders, as well as across individualssuffering from the same disorder.
Schizophrenia. Most persons with schizophreniado not commit criminal offences (Brennan, Mednick,& Hodgins, 2000). Among those who do commitcrimes, some begin offending long before they aresymptomatic and would be diagnosed with schizo-phrenia, others commit their first offence as theybecome psychotic for the first time, and otherscommit their first offence after a long course ofillness (Tengstrm, 2001). These differences in thetemporal relationships of the onsets of schizophreniaand offending suggest that the disorder is notnecessary for engaging in illegal behaviors. But, itis essential to remember that persons who willdevelop schizophrenia are different from those whodo not develop this disorder from conceptiononwards. They carry specific genes and haveexperienced specific complications during the pre-and peri-natal periods that affect neurobiologicalfunctioning. This conclusion, that the presence ofthe disorder is not necessary in all cases for offendingto occur, is further supported by the contradictoryfindings about the role of psychotic symptoms inoffending and violent behavior. Whereas somestudies show that specific symptom patterns areassociated with violent behavior (Junginger, 1996;Junginger, Parks-Levy & McGuire, 1998; Link,Stueve, & Phelan, 1998; Taylor et al., 1998), othersfail to identify any elevation in symptoms or specificpatterns of symptoms associated with violentbehavior (Appelbaum, Robbins, & Monahan, 2000).Both results may be correct, but each may apply to adifferent subgroup of persons with schizophrenia.
Recent research has shown that a stable patternof antisocial behavior present from at least earlyadolescence and personality traits of psychopathy
characterize a subgroup of offenders with schizo-phrenia who begin offending in adolescence andpersist until incapacitated (Hodgins, Ct, & Toupin,1998; Hodgins, 2000b). Another subgroup ofoffenders with schizophrenia about whom almostnothing is known includes those with no history ofantisocial behavior and a long history of alcoholabuse who begin behaving violently in their late 30sor early 40s. Many of these subjects commithomicide, and like most homicide offenders withschizophrenia they have no prior history of offendingand a low risk of recidivism (Erb, Hodgins, Freese,Mller-Isberner, & Jckel, 2001; Tengstrm, 2001).Thus, recent evidence strongly suggests that it isnecessary to divide offenders with schizophrenia intosubgroups in order to accurately identify character-istics associated with offending. If this is true, itwould suggest that these different subgroups requiredifferent types of treatments and services.
Exploring the hereditary (Heston, 1966; Kay1990; Silverton, 1985) and obstetrical factors(Hodgins, Kratzer, & McNeil, in press) associatedwith illegal behaviors among persons with schizo-phrenia may contribute to understanding the specificcognitive, behavioral, and emotional vulnerabilitiesthat are present early in life and that may beantecedents of violent behavior. Prospectivelongitudinal investigations have shown that amongchildren at risk for schizophrenia by virtue of havingclose relatives with the disorder, those who displaydifficult temperaments (Silverton, 1985) andbehavior problems are at increased risk for offending(Hodgins, 2000b; Tengstrm, Hodgins, & Kullgren,2001). Similarly, retrospective studies of offenderswith schizophrenia indicate that a sizeable proportionof the men presented behavior problems from ayoung age (Hodgins, 2000b; Hodgins et al., 1998;Tengstrm et al. 2001; Hodgins et al., in press b). Inaddition, many offenders with schizophrenia reporthaving been physically abused as children and havingwitnessed violent behavior between their parents(Hodgins et al., in press). These findings need to bereplicated and extended in order to further ourunderstanding of the developmental mechanismsleading to offending and windows of opportunity forchildhood prevention.
Many offenders with schizophrenia abusealcohol and/or drugs. In many cases, the abuse beginsin adolescence, especially among those whose fathers
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Research Priorities in Forensic Mental Health 9
and brothers also have substance abuse problems(Hodgins et al., in press; Tengstrm et al., 2001).Studies indicate that persons with schizophrenia aremore likely than non-disordered persons living inthe same region to abuse alcohol or drugs (Rach-Beisel, Scott, & Dixon, 1999). Thus, schizophreniamay be related to offending because it increases thevulnerability for substance misuse and abuse. Theassociation cannot be this simple however, becauselarge numbers of patients with schizophrenia misuseand abuse alcohol and drugs and do not commitcriminal offences. In our international study of foren-sic after-care being conducted in Canada, Finland,Germany and Sweden (Hodgins et al., in press c),we have found that among male patients with schizo-phrenia, 74% of those treated in general psychiatryand 70% of those treated in forensic psychiatry meetDSM-IV criteria for abuse or dependence. Further,the role of intoxication at the time of the offence hasnot yet been separated from that of a diagnosis ofabuse or dependence. We have hypothesized that therole of substance misuse is secondary to personalitytraits of psychopathy (Hodgins, 2000b), and haverecently shown that substance use disorders did notincrease the risk of offending in the presence of thetraits of psychopathy (Tengstrm, Hodgins, Grann,Langstrm, & Kullgren, in press). Among men withschizophrenia who did not have these traits,substance use disorders were associated with anincrease in the risk of offending.
To conclude, although current evidence is scanty,it does suggest that the association betweenschizophrenia and offending differs for specificsubgroups with this disorder. In some of these groups,the factors associated with the development ofschizophrenia may also contribute to the develop-ment of certain characteristics, for example,antisocial behavior in childhood and adolescence,or alcoholism, that in turn increase the risk ofengaging in illegal behaviors. Alternately, in othersubgroups, aspects of the disorder such as symptomsor an inability to tolerate close emotionally chargedrelationships may lead to violent behaviors. Patientswith schizophrenia frequently are victims of violence(Brekke, Prindle, Bae, & Long, 2001; Swanson,Borum, Swartz, & Hiday, 1999). Victimization inadulthood, as in childhood, may be associated withaggressive behavior (Monahan et al., 2001).
Major affective disorders. The same conclusionlikely applies to the association between majordepression, bipolar disorder, and offending.Longitudinal studies have shown that conductdisorder or behavior problems in childhood oftenprecede the onset of major affective disorders(Hodgins, 2000b; Hodgins, Faucher, Zarac, &Ellenbogen, in press), and that they are associatedwith a severe course of disorder, impaired psycho-social functioning (Carlson, Bromet, Driessens,Motjabai, & Schwartz, submitted), and suicide(Harrington, Rutter, & Fombonne, 1996). Empiricalevidence on whether or not this subgroup of personswho develop major affective disorders has increasedrates of offending is sparse. Both major depressionand bipolar disorder are associated with very highrates of substance abuse (Grant & Harford, 1995;Weissman et al., 1996; Goodwin & Jamison, 1990),and in some studies this co-morbid pattern ofdisorders has been found to be associated with severeviolence (Ct & Hodgins, 1992). In contrast, thehopelessness of depression has been associated withhomicide-suicides in which the perpetrator felt it wasnecessary to take others, usually family members,away from their current life situation. Thus again, itmay be that there are specific subgroups of offenderswith major affective disorders for whom theassociation between the mental disorder and illegalor violent behaviors differ.
Few studies have focused on criminality andviolence among persons with major affectivedisorders. The finding that conduct problems oftenprecede these disorders suggests the importance ofinvestigating this topic further, as does recentevidence on the offending of persons with majoraffective disorders. For example, in a prospectivelongitudinal investigation of a New Zealand birthcohort followed to age 21, it was found that 31.6%of the young adults with mania had a...