VOL: 96, ISSUE: 38, PAGE NO: 40
Nicola Evans, BSc, CertEd, Cert Family Therapy, RMN, is lecturer/practitioner, Caswell Clinic, Glanrhyd Hospital, BridgendNicola Evans, BSc, CertEd, Cert Family Therapy, RMN, is lecturer/practitioner, Caswell Clinic, Glanrhyd Hospital, Bridgend
With all referrals to a medium-secure unit, careful attention is paid to the nature of the so-called 'index' offence - the one that led to the patient's detention - and to any history of offending behaviour pre-dating the charge or conviction.
Throughout this process, attention is also paid to the wider issues of the developmental history, family composition, health status, life events, and medical and psychiatric history. Also important is an understanding of the family's attitude to the patient, particularly where there has been an escalating series of threatening or violent occurrences within the home before the index offence.
The distress seen in the forensic patients is experienced but often hidden by the family in their efforts to prevent further distress befalling their ill relative (Rose and James, 1996). Helping families work through their feelings ultimately enables them to support the patient more effectively.
Assessment of risk
Where possible, it is useful to invite family members to describe their recollections of the patient's behaviour, symptoms, presentation and lifestyle at the point of relapsing mental health or before the index offence.
This is clearly an emotive process, with the family searching their memories for clues they might have missed, or blaming themselves for not having noticed any significant events.
It is essential to include early life events when history-taking, in order to determine an effective diagnosis and treatment plan. Significant factors may include head injuries, prolonged periods of drug or alcohol use, or involvement with educational psychology services during their schooldays.
Patterns of deviancy within the family can affect the likelihood of predicted recidivism (Lilly, 1995). For example, if intrafamilial violence is condoned, work on reducing offending behaviour needs to allow the patient to recognise and challenge beliefs that he or she has grown up with (Bates, 1995).
Frequently, within the context of discussions with family members, new information about the potential for high-risk behaviour becomes evident. Coercive or threatening behaviour experienced by family members but not reported to the police may not feature in any clinical or social reports. This extra information can help clinical teams' grasp of the risk behaviour, when it is more likely to occur, what helps to reduce it, what exacerbates it and for how long there has been a problem.
Many families are caught in the vulnerability/risk dilemma. Family members will usually have differing views on how imminent the patient's risk behaviour is. It may be difficult for some family members to voice opinions that are different from the rest of the family's perception of the truth. Discussion of these views is vital to allow individual family members to feel that they have contributed in a meaningful way to the treatment plan and risk formulation.
This vulnerability/risk dilemma can even be seen within the same person. For example, in one recent family session the sister of a patient admitted to her family that she was frightened that her brother would be bullied if he were moved to a hostel.
She remembered how she had seen her brother bullied by a babysitter throughout their teenage years, but had been unable to talk to her parents about this. Of equal concern to her was that her brother would re-offend if placed in a hostel where there was inadequate supervision.
Ambivalence of this type is a feature of many family discussions, and is also replicated within clinical teams when discussing the future. Helping families manage ambivalence not only assists in achieving general collaboration with the family, but also allows the patient and family to appreciate the complexities of clinical decision-making.
Working collaboratively with the patient and family assists ultimately in the plan for the patient's discharge into the community.
Following a homicide by a patient with mental illness living in the community an inquiry team noted that not enough regard was given to the observations made by those family and friends who knew the patient best (Blom-Cooper, 1995). Family involvement in prodromal monitoring could be extremely helpful in averting a full relapse, and preventing a crisis situation.
Ensuring that family members are familiar with the action they should take in the event of a crisis enables them to feel supported, helps to contain a patient when life is becoming stressful or difficult for them and, just as importantly, alerts the community care team to respond as agreed in the pre-crisis plan.
Geelan and Nickford (1999) conducted a telephone survey investigating the extent of family work offered by medium-secure units in England and Wales. They discovered that very little family therapy is available for this group of patients, despite their need for it. Where there is evidence of this approach being applied, it is found to benefit the patient, their family, and clinicians working with them.
More evidence is found of the use of behavioural interventions, but indications for this form of treatment are narrow, mainly focused on people diagnosed with schizophrenia. This excludes large groups of forensic patients. Other diagnoses such as depression, post-traumatic stress disorder, and borderline personality disorder are often excluded.
Despite there being little research-based evidence to qualify the usefulness of family-focused interventions with these other groups of patients, feedback from relatives indicate that they are felt to be valuable.
Family work with mentally disordered offenders is a clinically effective intervention that currently appears to be under-used in forensic services. Systemic, behavioural and psychodynamic approaches to family work can be used interchangeably to achieve different outcomes for the patient and family.
Further exploration of innovative practices is essential to develop this aspect of the service to its full potential.