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