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Research Priorities in Forensic Mental HealthSheilagh Hodgins aa Department of Psychology, Université de Montreal, C.P. 6128, succ. Centre-ville, Montréal,Québec, 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

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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 forensic

mental 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 others—nursing, social work, education, occupationaltherapy, pharmacology, toxicology, sociology,criminology, neurobiology—care 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

Sheilagh Hodgins

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, Université de Montreal, C.P. 6128, succ. Centre-ville, Montréal, Québec,CANADA H3C 3J7 (E-mail: sheilagh.hodgins@umontreal.ca).

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 professional’s assessment havemental health problems.

This new association and its journal focus onforensic services—all 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 (Tengström, 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, Côté, & 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,Müller-Isberner, & Jöckel, 2001; Tengström, 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; Tengström, 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;Tengström 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; Tengström 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 (Tengström, Hodgins, Grann,Langström, & 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 (Côté & 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 criminal record(Newman et al., 1996). Two follow-up studies ofgeneral psychiatric patients discharged to thecommunity have found that those with majoraffective disorders had higher rates of aggressivebehavior and offending during the follow-up periodsthan patients with schizophrenia (Hodgins, Lapalme,& Toupin, 1999; Monahan et al., 2001).

Delusional disorder. Although many suspect thatthis disorder increases the risk of violence, almost

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no evidence is available because of the difficulty ofobtaining consent from persons with this disorder toparticipate in research. One investigation hasobserved elevated rates of delusional disorder amongincarcerated offenders (Côté, Lesage, Chawky, &Loyer, 1997).

Other psychotic disorders. Almost nothing isknown about the association between these disordersand offending and violence. Many diagnostic studiesof offenders have observed elevated rates of thesedisorders (Brink, Doherty, & Boer, 2001; Gunn,2000; Hodgins & Côté, 1995).

Cluster A personality disorders. Cluster Adisorders tend to occur in individuals who arebiologically related to persons with schizophrenia.It is presumed these individuals carry genes thatrender them vulnerable to schizophrenia, but forreasons as yet unclear (perhaps because they havebetter pregnancies and births; Parnas et al., 1982),they do not develop schizophrenia but anotherdisorder that can be characterized as a milder variantof schizophrenia. As with schizophrenia, the link tooffending may be direct or indirect. Little researchis undertaken with these persons (Raine, Birhle,Venables, Mednick, & Pollock, 1999).

Cluster B personality disorders. These disordersare defined, at least in part, by behaviors that areillegal or by characteristics, such as lack ofbehavioral control, sensation seeking, insensitivityto others, and hostility, that are directly related tothe commission of illegal behavior. Most is knownabout those who present antisocial personalitydisorder. In many countries, prospective longitudinalstudies have been conducted of unbiased populationcohorts identified before birth or at a young age andfollowed into adulthood. Despite the fact that thecountries where these investigations were conductedhave very different cultures, educational, health,social, and criminal justice systems, all haveidentified 4 to 5% of males who display a stablepattern of antisocial behavior from early childhoodthrough adulthood (Hodgins, 1994; Lahey, Waldman,& McBurnett, 1999). One of the most rigorous ofthese investigations was conducted in Dunedin, NewZealand and the subjects were recently assessed atage 21. Temperament and neurocognitive abilitiesmeasured as early as two years of age, as well ascharacteristics of the parents and their parentingpractices, distinguished those who displayed this

stable pattern of behavior problems that escalatedover the life-span (Moffitt & Caspi, 2001).

Adoption and twin studies have shown thathereditary as well as environmental factors contributeto the development of antisocial personality disorder(Lahey et al., 1999). Interestingly, a recentepidemiological investigation in Norway identifieda life-time prevalence rate for antisocial personalitydisorder of 1.3% among men (Torgersen, Kringlen,& Cramer, 2001), as compared to 4.5 to 7% con-sistently reported in similar US studies (Cloninger,Bayon, & Przybeck, 1997; Robins, Tipp, &Przybeck, 1990). The variance in the life-timeprevalence rates of antisocial personality disorder isvery important for it suggests that certain environ-ments many increase the rates while others suppressthem. The search for the specific factors associatedwith low rates is a high priority.

Among men, the differences between those whomeet criteria for antisocial personality disorder inadulthood and those who meet criteria for psycho-pathy as measured by the Psychopathy ChecklistRevised (Hare, 1991), have not been studied. Bydefinition, these two groups differ as to thepersonality traits necessary for the diagnosis ofpsychopathy, but other characteristics that distinguishthe two groups are unknown. Yet, they are importantfor understanding the etiologies of these twodisorders, and for identifying targets for intervention.

Cluster C disorders. These are the disorders thatmay well be protective against criminality. Yet, littleis known.

Mental retardation. The taboo against discussingthe criminality and violence of mentally retardedpersons limits our understanding of the vul-nerabilities associated with intellectual handicapsand prevents the development of appropriate andeffective intervention and prevention programs.Further, this neglect of the problem leads to largenumbers of mentally retarded persons beingincarcerated in correctional facilities where they aretargets for abuse and manipulation and in somecountries cut-off from mental health treatment(Mullen, 2001a; Glaser & Deane, 1999). Studieshave shown that conduct problems in childhood andadolescence are antecedents of criminality amongmentally retarded persons (Crocker & Hodgins,1997) and that such persons are unable to adequatelydefend themselves within the judicial system (Clare

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Research Priorities in Forensic Mental Health 11

& Gudjonsson, 1995). The lack of knowledge andexpertise on the association of retardation andaggressive behavior and offending is compoundedby our ignorance of appropriate, adequate, andeffective rehabilitation and prevention strategies(Müller-Isberner & Hodgins, 2000).

Brain damage. Most forensic psychiatrichospitals are required to treat brain damaged patientswho have committed violent offences, but little isknown about the specific causes of offending in thesepersons (Hodgins, 1999; Miller, 1998; Volavka,1995). Many of these persons have no history ofantisocial behavior prior to the brain injury. In theyears following the injury, important changes inpersonality develop before the violent behavioroccurs. In other cases, there is a long history ofantisocial behavior prior to the injury (Grekin,Brennan, Hodgins, & Mednick, 2001) that wehypothesize resulted from engaging in recklessbehaviors.

Conclusion. Little is known about the associa-tions between various mental disorders andcriminality. Current evidence suggests that theseassociations differ for specific mental disorders andamong subgroups with the same primary disorder.Many of these subgroups present multiple dis-orders—major mental disorders, substance misusedisorders, cluster B personality disorders, andproblems (impulsivity, aggressive behavior,sensation seeking) that have been present for manyyears and that appear to contribute to the illegalbehaviors. Antisocial behavior has been found to beassociated with personality traits among persons withand without major mental disorders (Krueger, Hicks,& McGue, 2001; Tengström et al., in press). Thestability of the traits over the lifespan(Lenzenwenger, 1999) supports the stability of theantisocial behaviors. In addition to all of thesedifficulties, many mentally disordered offenders lackthe necessary life and social skills to supportthemselves financially and to develop and maintainintimate relationships.

There is evidence that among persons with thesevarious disorders, the risk of antisocial andaggressive behavior is increased by features of thelarger social environment. For example, in theinvestigations of population cohorts the rates of crimeamong persons with major mental disorders varyfrom one country to another, but are found to be

higher than for the non-disordered persons in thesame region or country (e.g., Hodgins, 1998; Mullen,Burgess, Wallace, Palmer, & Ruschena, 2000;Wesseley et al., 1994). These findings suggest thatmany factors that influence criminality among thenon-disordered also influence criminality among thementally ill. Further, the likelihood of violentbehavior among the mentally ill is increased whenthey live in extremely poor neighborhoods (Silver,Mulvey, & Monahan, 1999) and in neighborhoodswhere violence often occurs (Swanson et al., in press;Swartz, Swanson, Wagner, Burns, & Hiday, 2001).Such influences are well known in the literature onoffenders and are described as criminogenicneighborhoods as they usually include easy accessto drugs, weapons, and criminal associates and littleaccess to socially appropriate models of behavior.Thus, the social environment that combines so manyfactors that influence antisocial and aggressivebehaviors is a powerful force. In addition, certainliving environments are associated with an increasein symptoms (Hodgins, Cyr, & Gaston, 1990) andaggressive behavior among the mentally ill (Estroff,Swanson, Lachicotte, Swartz, & Bolduc, 1998).

What Do We Know About Risk Assessment?

A good deal! Research on risk assessment hasdominated the field for many years, and notsurprisingly lead to the development of instrumentsand procedures that assess the risk of violentbehavior, relatively accurately, over short periods oftime (Bonta, Hanson, & Hanson, 1998; Borum,1996). In addition, this research has advanced ourunderstanding of mentally disordered offenders.Historical variables have been shown to be veryimportant in assessing risk for future violent behaviorin all persons, with or without mental disorders. Prioroffending, prior aggressive or violent behavior, astable pattern of prior antisocial behavior areimportant and significant predictors. Similarly, thepresence of such behaviors in childhood andadolescence and the age of onset of the behaviorsare associated with significant risk of frequent anddiverse criminal offending (Harris, Rice, & Quinsey,1993; Rice & Harris, 1995).

The presence of certain personality traits havebeen consistently found to increase the risk of

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criminal offending. These traits, usually measuredusing the Psychopathy Checklist (Hare, 1991; Hart,Cox, & Hare, 1995), are described as arrogant anddeceitful interpersonal conduct and defectiveemotional experience (Cooke & Michie, 2001).

Historical factors by definition change little orslowly over time. Personality traits emerge andsolidify during adolescence and are believed to bestable. Traits that are rare, like those mentionedabove, and those that represent the extreme ends ofdimensions of personality are thought to beespecially resistant to change (Millon & Davis,1996). The extent to which the level of risk set bythe individual’s history and personality traits isthought to be altered by other attributes of theindividual and of his/her environment which changeover time. This contention, however, remains thetopic of much debate, much clinical lore, and littleempirical evidence (e.g., Skeem & Mulvey, 2001;Strand, Belfrage, Franson, & Levander, 1999). Someof the contradictory results in this field may be dueto lumping together patients with different disorders,or sub-types of disorders, for whom predictors differ.For example, the dynamic factors that contribute toincreasing or decreasing risk may differ by disorder.For a man with a history of major depression whoreacts to stress emotionally and has poor problemsolving skills, large debts may be perceived as anunbearable and unresolvable stress and lead to vio-lence against family members and self, whereas forsomeone with antisocial personality disorder such debtsmight be ignored and not be experienced as stressful.

Most of the currently used risk assessment instru-ments include many items that index a history ofantisocial and criminal behavior. Patients with a his-tory of antisocial and criminal behavior are the mostlikely to recidivate and this fact confers validity tothe assessment instruments. However, a smaller num-ber of patients have no history of antisocial andcriminal behavior before they commit a violentoffence (e.g., Erb et al., 2001). The challenge is toidentify the characteristics of such patients and theirenvironments so as to intervene before the violenceoccurs.

Factors that influence risk may also differ byenvironment. The risk of assault by a psychoticpatient in a hospital may be increased by staffrequiring participation in certain activities. The riskof assault by a personality disordered sex offender

may be increased in prison where his life isthreatened. The risk of offending among mostpersons with mental disorders is likely increased byliving in a neighborhood with high unemployment,high crime rates, and readily available drugs andweapons (Silver et al., 1999). It has been demon-strated that such neighborhoods have a more negativeeffect on individuals already at risk to offend byvirtue of certain individual characteristics such asimpulsivity (Lynam et al., 2000).

Conclusion. Risk instruments have beendeveloped that can be used in clinical milieus andthat identify the risk of violence, relativelyaccurately, over short periods of time. Generally, theresearch on risk is consistent with more basicresearch on the correlates of offending in showingthat a stable pattern of antisocial behavior includingsubstance misuse from a young age and personalitytraits of psychopathy are powerful risk factors. Thecontradictory evidence about the role of psychoticsymptoms and other fluctuating factors, bothcharacteristics of the individual and of his/herenvironment, may be due to a lack of research thattakes into account the stable patterns of behavior,personality, and context when assessing thesedynamic factors.

What Do We Know About EffectiveTreatment?

The major mental disorders. First, we know thatgeneral psychiatry is struggling to identify effectivetreatments that prevent relapse and promoteautonomous community functioning (e.g., Bauer,Kirk, Gavin, & Williford, 2001; Bowden et al., 2000;Carpenter, 2001; deJonghe, Kool, van Aalst, Dekker,& Peen, 2001; Fenton & Schooler, 2000; Gitlin etal., 2001; Mueser et al., 2001; Weller & Weller,2000). One of the major hurdles is finding strategiesthat assure adherence to prescribed treatment regimesover the long term. Given this, it is not surprisingthat current practices within general psychiatry arenot preventing crime and violence among personswith major mental disorders. For example, a Britishstudy compared intensive case management (a casemanager with 10 to 15 patients) to standard care (casemanager with 30 or more cases). Seven hundred andeight patients were randomly assigned to one or theother type of case management. Information on

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violent behavior was collected from patients, casemanagers, and files. At the end of 24 months offollow-up, 23% of the patients receiving intensivecase management and 22% of those receivingstandard case management had committed an assault(Walsh et al., 2001). Similarly, in a US study ofgeneral psychiatric patients, 14.8% of those withschizophrenia, 28.5% of those with major depression,and 22.0% of those with bipolar disorder behavedviolently as reported by themselves or an informantin the 12 months following discharge (Monahan etal., 2001). We also know that in the large majorityof cases, patients in forensic hospitals have beenpreviously treated in general psychiatry. Forexample, in a study of forensic patients fromcatchment areas in Canada, Germany, Finland, andSweden, 75% had been treated in general psychiatrybefore being admitted to forensic psychiatry(Hodgins et al., in press). These results are notsurprising when the content of treatments andservices offered by mental health services areexamined. Generally, treatments are effective onlywhen they target specific problems. Treatmentcomponents designed to reduce antisocial andaggressive behaviors and replace them with prosocialbehaviors are rarely provided in general mentalhealth services.

Encouraging new findings have emerged froma randomized trial of involuntary outpatient treatmentthat shows positive effects on violent behavior,especially when combined with depot medications(Swartz et al., 2001; Swanson et al., 2000; Torrey &Zdanowicz, 2001). The importance of using courtorders to promote treatment compliance is consistentwith the results of evaluations of specialized forensiccommunity treatment programs that demonstrate lowrates of recidivism among patients with a history ofcriminality and violence (Hodgins et al., 1999;Luettgen, Chrapko, & Reddon, 1998; Müller-Isberner, 1996; Wilson, Tien, & Eaves, 1995; forreviews see Heilbrun & Peters, 2000; McGuire,2000). This evidence, however, is limited. These arenaturalistic follow-up studies with no randomizationof patients to different treatment conditions, smallsamples, and follow-up periods that differ and oftendo not extend beyond two years. As well, details ofthe organization of the program, various treatmentcomponents, and services are poorly described inmost of the reports.

Despite the fact that these programs have beenconducted in different countries with different legaland health and social service systems, severalfeatures are common to the forensic after-careprograms that appear to prevent recidivism. One, theprograms are highly structured and include multipletreatment components designed to meet the needsof multi-problem patients. Two, the staff accept thattheir job is to treat mental illness and to prevent crimeand violence. Three, court orders can be obtained torequire compliance with the treatment program. Four,clinicians have the legal power to rehospitalizepatients quickly for short periods, against their willif necessary. Five, staff accept responsibility forensuring compliance with all aspects of the program.

To conclude, there is little research on effectivetreatment programs for persons with major mentaldisorders who commit crimes or behave violently.Consequently, knowledge of what works to preventillegal behaviors is scarce but a basis for future workdoes exist (e.g., Bloom, Mueser, & Müller-Isberner,2000; Hollin, 2001; Müller-Isberner & Hodgins,2000). The existing evidence suggests that: (1)current practices in general psychiatry do not preventassaultive behaviors among more than one in fivepatients; (2) court mandated community treatmentcoupled with depot medications increases com-pliance with treatment; and (3) recidivism may beprevented even among high risk patients using multi-modal, highly structured and intense, specializedforensic community programs that include specifictreatment components that target the problems ofmentally ill offenders.

Personality disordered offenders. Meta-analyticreviews have shown that highly structured cognitivebehavioral programs offered in the community tohigh-risk offenders lower recidivism (Andrews &Bonta, 1998; Cooke & Phillip, 2001). Further, thislarge literature (e.g., McGuire, 1995), often ignoredby forensic mental health clinicians, has succeededin identifying treatment needs that must be targetedin order to reduce future offending. The complexityand stability of the disorders and of needs of personswith these disorders are not to be underestimated(Blackburn, 2000; Lenzenweger, 1999).Twoimportant questions need to be answered. One, doesthe presence of specific personality disorders alterthe effectiveness of the different programs? Two,how can the effective programs be integrated into

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mental health services so that relapse prevention canbe undertaken on a long-term basis?

Conclusion

Persons with certain mental disorders are morelikely than those without these disorders to commitcriminal offences and to behave violently. Conse-

quently, with these persons, intervention must always

be two-pronged, aiming to treat or manage the

mental disorder and to prevent offending and

violence.

The mental disorders associated with offendingand violence are pervasive, involving cognitive,emotional, and behavioral deficits, and typicallypersist throughout the adult lives of those who areafflicted. Offenders with these disorders spend timein correctional facilities belonging to the criminaljustice system, as well as inpatient (forensic, general,and psychiatric hospitals) and outpatient clinicsbelonging to the health care system, and they usemany social services including welfare payments,housing, and job training. Consequently, services and

treatment must be integrated, or at least coordinated,

during many decades and across multiple agencies.

There are associations between specific mentaldisorders, and subgroups among persons with thesame disorder, and criminal offending. The specificnature of these associations continue to elude us.Descriptive studies of mentally disordered offendersconsistently identify multiple characteristics (forexample, antisocial attitudes and behaviors, a lackof behavioral control, a lack of prosocial skills,substance abuse) of the offender and his/herenvironment (living in high crime neighborhoods,not working, spending long hours in bars, living withparents) that are associated with offending andaggressive behavior. Each of these multiple problems

associated with offending and aggressive behavior

must be targeted by a specific intervention.

Some patients with mental disorders have littleinsight into their disorder and refuse to comply withtreatment. Court orders, and other strategies that

increase compliance with all necessary components

of a treatment program may be necessary for some

patients.

Features of the community and the immediateliving situation have been shown to increase thelikelihood of offending. Consequently, decisions

about where patients live and with whom must take

account of these influences on levels of antisocial

and aggressive behavior.

A RESEARCH AGENDA

To Improve the Efficacy of OrganisationalModels of Service

Research is needed to identify organizationalmodels of service that prevent relapse and recidivismamong mentally disordered offenders. This impliescoordination, over many decades, of servicesprovided within the criminal justice, mental health,and social service systems. The only strategy foridentifying the most effective way of organizing allthe necessary services is to test various models thatare based on current knowledge of both the offendersand of interventions that have been shown to beeffective for them. Sadly, there is not much relevantresearch. For example, if interventions withpersonality disordered offenders aimed at reducingantisocial attitudes and behaviors, inappropriatesexual behaviors, and substance abuse are carriedout in correctional facilities, what organizationundertakes follow-up care to ensure that new skillsare not lost? To be realistic, given what is knownabout these offenders, follow-up may be critical topreventing recidivism and relapse to a former life-style. Offenders with major mental disorders requirestable care over many decades, regardless of whetherthey are in jail or prison, a forensic or generalhospital, or in a group home. Detailed knowledgeabout the individual’s history of aggressive behavior,medication compliance, and substance misuse arecritical for planning appropriate services andpreventing recidivism, and a stable relationship witha care-giver over the long-term may contribute topreventing offending, violence and relapse. Theevidence reviewed above, although sparse, doessuggest that specialized forensic programs may bemore effective in preventing offending and violencethan are different forms of out-patient treatmentprovided within general psychiatry. One advantageof integrating or coordinating services for mentallydisordered offenders across multiple agencies wouldbe the possibility of primary prevention. Forexample, patients with major mental disorders being

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Research Priorities in Forensic Mental Health 15

treated within general psychiatry with many riskfactors for offending and violence could be treatedin long-term specialized community programsprovided to mentally ill offenders. Although therehave been studies on these issues (e.g., Steadman,Cocozza, & Veysey, 1999), implementation ofsuccessful programs and research aimed at refiningthe interventions have not been forthcoming.

Services provided to offenders with mentalretardation need to be integrated and coordinatedwith those for mentally disordered offenders. Manyof the components of the services for the mentallydisordered can be modified for use with mentallyretarded and with brain damaged offenders, and theireffectiveness evaluated and enhanced.

To Improve the Efficacy of Treatment,Management and Rehabilitation Programs

Research is needed to evaluate the effectivenessof programs of treatment and services designed toprevent offending and violence, to increaseautonomy, self sufficiency, and overall quality if life.We also need to use this information to improve theefficacy of each program and organization. In otherwords, we have to discover what works for whom,under what circumstances, provided by what typeof practitioner. This is a huge task! Current evidencesuggests that individualized programs are requiredto target the multiple problems presented by mentallydisordered offenders. Many of these programs wouldinclude the same components (for example, cognitivebehavioral programs aimed at modifying substanceabuse, antisocial attitudes and behaviors, andincreasing medication compliance), but the effective-ness of each component will be significantlyenhanced if each is adapted to a specific type ofoffender. The level of specificity of this pairing oftype of patient and treatment component required toachieve efficacy is largely unknown. For example,do male offenders with schizophrenia who havedisplayed antisocial behavior since childhood andpresent many traits of psychopathy benefit from thesame substance abuse prevention program as maleoffenders with schizophrenia with a long history ofalcohol abuse but with no history of antisocialbehavior prior to committing a homicide? Further,evaluations of programs of treatments and servicesneed to examine the timing and sequencing of

different components associated with the greatestefficacy.

Given the high cost of such evaluation studiesand the multiple methodological challenges that theypresent, it is essential that the participating subjectsare well described so that results can be accuratelyunderstood. This is especially important, becausemany relevant studies are undertaken in differentfields. For example, much research conducted withincorrectional facilities has shown that importantnumbers of offenders benefit from specific be-havioral and cognitive programs. The impact onrecidivism is well documented in meta-analyticstudies (Andrews & Bonta, 1998). The offenders thatbenefited from these interventions and those whodid not, are poorly, if at all, described. Are the failuresthose with antisocial personality disorder and thesuccesses those without? Were offenders with lowintelligence, or a history of depression or psychosesor anxiety disorders excluded from participating inthe programs? Offenders with mental disorders havethe right to the most effective treatments for theirmental disorder and the most effective rehabilitationprograms to prevent recidivism. Knowledge oftreatments and programs is difficult to access as it ispublished in specific domains relative to either themental health or criminal justice fields. Yet, suchknowledge is required to design, set-up, and evaluatecomprehensive programs for mentally disorderedoffenders.

There are almost no studies that evaluate theimpact of various types of social services on mentallydisordered offenders (Høyer, 2000). But, as notedabove, social factors play a role in antisocial andaggressive behavior. The evidence seems clear thatproviding housing in non-criminogenic neighbor-hoods is necessary to reduce violence and crime. Theconsequences of placing mentally ill patients withtheir families of origin needs study in light of findingssuggesting that this practice may increase the risk ofaggressive behavior (Estroff, Swanson, Lachicotte,Swartz, & Bolduc, 1998) and that the victims ofviolent offending by the mentally ill are often familymembers. Similarly, there is evidence that groupingtogether offenders increases antisocial skills(Andrews & Bonta, 1998).

Investigations are required to identify the typesof patients that can live together, for example, ingroup homes without the contact leading to an

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16 Hodgins

increase in antisocial behavior. Also, under whatconditions and with what type of patients arepensions and welfare payments adequate andcontributing to improving the quality of life? Underwhat conditions and with what type of patients arethese payments contributing to substance misuse?Depending on the type of patient, is it the amount ofmoney that matters or the way in which it isdisbursed?

Pioneering work by, for example, Bloom andWilliams (1994) and Dvoskin and Steadman (1994)unfortunately has not become the basis for evidencedbased practice nor for much continuing research onefficacy. The reasons for this situation requirethought and analyses.

To Improve the Efficacy of Components ofTreatment, Management, and RehabilitationPrograms

Theoretically, each component of treatment orservice targets a specific need, a specific problem,presented by the offender. Thus, detailed descriptivestudies and the development of treatment relevanttypologies of offenders are necessary. The com-ponents will come from what have historically beenconsidered as distinct fields of study and practice,such as psychiatry, psychology, addictions, crimin-ology, law, nursing, occupational therapy, socialwork. Empirical evidence of effectiveness needs tobe demonstrated for each of the components thatcomprise a treatment and service program. Theseevaluations should be designed as randomized trialswhen at all possible (for a discussion, see Høyer,2000; for a concrete example of a strategy to adoptwhen this is not always possible, see Swartz et al.,2001). This is an overwhelming task, but recentstudies show that it is being attended to at least insome quarters. For example, a recent US study usedboth a randomized design and a follow-up ofmentally ill offenders with a recent history ofviolence, to show that court ordered communitytreatment and depot medications contributed tocompliance (Swartz et al, 2001).

To Integrate the Assessment of Risk of ViolentBehavior Into Treatment, Management, andRehabilitation Programs and to ImproveAccuracy

Research is needed on how to use validated riskassessment instruments to guide treatment efforts andto identify community placements that in concertwith on-going treatments and services will eliminateoffending and aggressive behavior. Assessments ofthe risk of offending or behaving violently need tobe conducted at regular intervals and to be used bythose directing programs to identify patient needsfor specific treatment components and services.Improving the accuracy of risk assessment instru-ments can be built into studies evaluating programsof treatments and services.

The transfer of knowledge of how to assess therisk for violence to general mental health servicesrequires thought and study. Many patients have ahistory of aggressive behavior, and sometimes evencriminality, before their first contact with generalmental health services. Perhaps if they wereidentified as high risk patients and provided withspecific components of treatment designed to reduceantisocial behavior, an escalation of the frequencyand severity of their antisocial behaviors could beprevented.

Whether we like it or not (for a discussion, seeMullen 2001b), assessing the future risk of violenceof offenders with mental disorders is often requiredby law of mental health professionals in an effort toassure public safety. When it is required, it shouldbe conducted using scientifically validated instru-ments. Research needs to focus on refining theseinstruments and improving their accuracy ofprediction. The disproportionate effort put into riskassessment by researchers and clinicians, is notjustified on scientific grounds, nor is it justified as itengages the ‘brightest and the best’ keeping themaway from research focused on treatment. The useof risk assessment to identify targets of interventionsaimed at lowering the risk has already begun(Douglas, Webster, Eaves, Hart, & Ogloff, in press;Monahan & Appelbaum, 2000; Webster, Douglas,Belfrage, & Link, 2000).

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Research Priorities in Forensic Mental Health 17

To Identify the Etiology of Offending

Etiological research is undertaken in an effortto unravel the processes that occur over the courseof the life-span that lead to illegal or violentbehaviors. These factors and processes identify thetargets of prevention programs and the times duringthe course of development when preventativeintervention is likely to have maximum positiveeffectiveness. Again, current knowledge suggeststhat whereas some of the factors and processes arecommon to most types of offenders, others are highlyspecific to a particular type of offender. For example,pre- and perinatal factors have been found to play aminor role and family factors a major role in theoffending of men who do not have major mentaldisorders (Hodgins, Kratzer, & McNeil, 2001), butthe opposite was found to be true for offenders withmajor mental disorders (Hodgins et al., in press b).Given the cost of longitudinal, prospective investiga-tions of high risk populations and the lack ofunderstanding of the associations between mentaldisorders and offending and violence, it is essentialthat such studies be conducted as part of largerprospective, longitudinal investigations of thedevelopment of specific mental disorders andantisocial behavior.

To Prevent Offending Among Persons WithMental Disorders

Although other disciplines conduct research andintervention trials to identify how to preventoffending generally, there is no research, to myknowledge, on preventing aggressive and antisocialbehavior among children known to be at risk formental disorders. These children are at risk for mentaldisorders by virtue of the presence of the disorder inthe parents, who may confer a vulnerability to mentaldisorder through genetic transmission but alsoincrease the risk of disorder in the child through theirparenting practices. Children at risk for mentaldisorders can be identified. Consequently, they couldbe the object of interventions that target the problemsthat they present as children, such as aggressivebehavior, difficulty in controlling their behavior,problems in learning to read and write, and emotionalreactions to parental illness or substance abuse. Mostpersons who end up in prisons and forensic

psychiatric hospitals did not suddenly developproblems in the weeks or months preceding thecommission of an offence. Their problems developedover many years, each one compounding the others.Interventions focused on these problems as theyemerge in childhood would be more humane thanthe current practice of intervening only after theindividual has committed a criminal offence ordeveloped a serious mental disorder. Further, targetedinterventions in childhood and adolescence mightactually prevent the development of violence andoffending. Finally, some mentally disorderedoffenders have children. Who has the mandate toprevent these children from becoming like theirparents?

Neglected Populations

All of the above research priorities need to beundertaken with respect to all types of mentallydisordered offenders. Knowledge is particularlylacking on women, persons with mental retardation,and those with brain damage.

Conclusion

There is much to do!

COMMON OBSTACLES TO OVERCOME

Research using scientific methodology producesobservations. These observations are presented in theresults sections of reports. Although the authors ofthe research interpret their results, the reportedobservations and description of the method shouldbe sufficiently clear and detailed to permit others toevaluate the authors’ interpretations, to draw alternateconclusions, and to replicate and extend the findings.In addition, researchers have a responsibility tocommunicate the results of their investigations toadministrators and clinicians. For researchers thismeans taking time out from doing research andpublishing reports of studies, to writing compre-hensive reviews of recent results on a specific topicthat are accessible to busy administrators andclinicians. Thus, the results of research have to bepresented so that they can be challenged by otherscientists and implemented by practitioners.

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Sample bias. Sample bias is one of the mostimportant obstacles confronting researchers in thisfield. Different samples will be appropriate to answerdifferent research questions. The characteristics ofthe sample will determine the generalizability of thefindings. Further, the intactness of the sample at theend of the study as at the beginning has majorimplications for the interpretation of the results. Howdo we overcome this obstacle? First, attempt toidentify the most appropriate sample given theobjectives or hypotheses of the study. In the case ofevaluation studies of treatment programs, this maymean difficult negotiations with those who havedeveloped and provide the service. In the case ofstudies of mental disorders among convictedoffenders, it may mean convincing prison authoritiesof the necessity of approaching inmates who areisolated 24 hours a day in high security cells. Second,as no sample is perfect, it is essential to describe indetail the population from which the sample is drawn,the characteristics of those who refused to participate,and the biases of the sample. This is often not easy,and has to be included in the original design of thestudy. Usually, approval of the research ethicscommittee is required to collect information onindividuals who refuse to participate in a study. Suchinformation may be absolutely critical to interpretingthe results.

Some unknown proportion of persons withmental disorders who commit crimes do not permitmental health professionals to assess, treat, or studythem. Although we think that most suffer from someform of paranoid disorder, we have no evidence tosupport this proposition. Sometimes, for shortperiods, such persons are assessed or treated orstudied, often under court order. Our lack ofknowledge of this subgroup of mentally disorderedoffenders may result in misleading conclusions aboutthe role of mental disorder and particularly ofparanoid symptoms in violent offending. Original,creative, ethical solutions to this situation are needed.

Common measurements and definitions. In orderto advance knowledge, it is essential to understandthe participants in any investigation. Who are they?Consequently, it is preferable to use concepts andmeasures that are widely used and validated. Forexample, even if we are unsure of the validity ofcertain DSM diagnoses, the careful use of thesecriteria facilitates communication and understanding

of the study and in no way prevents the use of othermeasures that the researchers consider to be morevalid. For example, Quinsey Cyr, and Lavallée(1988) used cluster analyses of behaviors andsymptoms to describe needs and treatment targetsfor patients within forensic psychiatric hospitals intwo Canadian provinces. A complementary descrip-tion of the patients within each cluster may havefacilitated recognition of the patient population andunderstanding of the importance and use of such anapproach for organizing treatment programs. Evenif, and perhaps correctly, researchers conceive ofpersonality as dimensional, describing the person-ality disorders of participants in a rehabilitationprogram may facilitate a more accurate and profoundunderstanding of the results by colleagues aroundthe world. For example, a number of behavioral-cognitive programs have proven to be effective inreducing recidivism among inmates (Andrews &Bonta, 1998; McGuire, 1995; Hollin, 2001).Unfortunately, little information is provided aboutthe differences between the inmates who benefitedand who did not benefit from the programs. Had theybeen described using concepts and measures familiarto mental health professionals, the results would havebeen easier to interpret, have had greater impact, andmore likely lead to the implementation of similarprograms.

Not only do patients have to be described, so dotreatment programs and components. In order toadvance knowledge about what works, studies needto provide precise descriptions of all aspects, bothformal and informal, of a treatment program. Suchdescriptions need to include details about treatmentcomponents and how they were administered.Indices of the integrity of each component and theoverall program are essential.

Two steps can be taken to facilitate communica-tion. One, as noted above, concepts and measurescommonly used by clinicians and researchers canbe used. Two, provide descriptions of the criteria usedto define subject groups especially if they are notoften used, and also the criteria used to define keyvariables, for example the definitions of violent crimeand violent behavior.

Finally, as some proportion of illegal, and evenviolent behavior, does not lead to criminal charges,it is important to add reports from subjects andcollaterals of these behaviors. Otherwise, results

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Research Priorities in Forensic Mental Health 19

based exclusively on official criminal records willbe misleading. Further, the use of subject andcollateral reports facilitates communications acrossnational borders, as it overcomes differences in theefficiency of police and judicial systems in accuratelyprosecuting offenders.

Adequate measurement of substance use. Assubstance use and misuse is so common amongmentally disordered offenders, and according tomany, the trigger of much violent behavior, it isessential to become more sophisticated in definingand measuring what we are talking about, and in itsrelation to offending. It is essential, although not easy,to distinguish intoxication at the time of offending,which can be measured objectively from blood orurine, or by reports from subject or collaterals. Next,a lifetime diagnosis of abuse or dependence needsto be distinguished from a current diagnosis of abuseor dependence. Self-reports of use differ fromcollateral reports of use, which differ from objectivemeasures, for example from urine, blood, or hair.The inclusion of several of these measures in thesame study, will contribute to increasing ourunderstanding of the role of alcohol and drugs inoffending among different types of offenders andhow to adequately intervene with each group.

CONCLUSION

More research is needed to further our under-standing of the association between various mentaldisorders, mental retardation, brain damage, andoffending and violence. As we do not understandwhy persons with these disorders and conditions aremore likely than those without these disorders andconditions to behave violently and commit offences,it is essential that such research is undertaken in thecontext of research on the etiologies of thesedisorders. Organizational models that offer effective,affordable treatment and management of personswith mental disorders and retardation who havebehaved violently or committed crimes need to beidentified, implemented, and refined. Similarly,studies are needed to identify the elements—components of treatment, supervision, legal orders,social services—necessary for effective treatmentand management programs. New research can profit

from published work, that is limited, but that doesprovide a solid basis for future studies.

Forensic mental health practitioners andresearchers have traditionally been isolated fromgeneral mental health practice and research. Thisimpoverishes practice and research. Both general andforensic mental health practice and research couldbenefit from closer involvement. Forensic mentalhealth practitioners and researchers do need, inaddition, contact and exchange with others who dailyconfront the same problems. Learning how othersorganize treatment services, use the courts to promotecompliance with treatment, integrate social servicesinto treatment programs, provide specific trainingprograms, monitor substance abuse, deal with themedia when a patient recidivates, attract, select, andtrain competent and dedicated staff, is enriching andstimulating. The new association can play a majorrole in fostering such learning and exchanges and inpromoting the use of scientific research as a tool toimprove the efficacy of treatment.

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