Forensic Community Programs: Recommendations for the ... Commu… · disordered male offenders, 28%...

AREA REVIEW

Forensic Community Programs:Recommendations for the Managementof NCRMD Patients in the Community

Mike Woodworth, MScKristine A. Peace, MScCedar O’Donnell, MSc

Steve Porter, PhD

ABSTRACT. Recent trends towards community support and rehabilita-tion for individuals found Not Criminally Responsible due to a MentalDisorder (NCRMD) has led to the development of forensic communityprograms (FCP). The authors of the present paper were contacted by pro-fessionals involved with an FCP established at a hospital in Nova Scotia,Canada. The professionals involved with this FCP were interested in im-proving the overall functioning (in terms of client management and treat-ment, and risk reduction) of the program. The current article will discussthe eight main considerations and recommendations that were provided

Mike Woodworth and Kristine A. Peace are affiliated with Dalhousie University, Hali-fax, Nova Scotia. Cedar O’Donnel is affiliated with Acadia University, Halifax, Nova Sco-tia. Steve Porter is Chair of Forensic Psychology, Dalhousie University, Department ofPsychology, Halifax, Nova Scotia, Canada, B3H 4J1 (E-mail: [email protected]).

The first and second authors were supported in part by grants from the AmericanPsychology-Law Society (AP-LS). The first and fourth authors were supported by anoperating grant from the Social Sciences and Humanities Research Council of Canada(SSHRC).

Journal of Forensic Psychology Practice, Vol. 3(4) 2003http://www.haworthpress.com/store/product.asp?sku=J158

! 2003 by The Haworth Press, Inc. All rights reserved.10.1300/J158v03n04_01 1

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by the authors after an extensive review of the literature as well as a con-sideration of the current structure of the Nova Scotia FCP. These recom-mendations are generalizable to most community treatment programsavailable for NCRMD individuals. [Article copies available for a fee fromThe Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com> © 2003 byThe Haworth Press, Inc. All rights reserved.]

KEYWORDS. NCRMD, mental disorder, forensic community pro-grams, treatment and management recommendations, mental health issues

Recent trends within the criminal justice system towards communitysupport and rehabilitation have led to the development of forensic com-munity programs (FCP). These FCPs have been used, in conjunctionwith psychiatric hospital services, as a management strategy for men-tally ill offenders. Specifically, these outpatient programs have beencreated to both assist and monitor mentally ill offenders who have beenfound not criminally responsible, and who have been granted a condi-tional discharge into the community. Additionally, some individualsparticipating in FCPs may have been discharged directly into the com-munity following their finding of Not Guilty by Reason of Insanity(NGRI) or Not Criminally Responsible due to a Mental Disorder(NCRMD),1 and were never inpatients at a forensic psychiatric facility.In general, FCPs are responsible for providing client treatment plans,medication and symptom management, assessment and management ofrisk, client supervision, and rehabilitation measures to NCRMD clientsin the community. Further, the directives of forensic community ser-vices are to ensure public safety while addressing the client’s individualrehabilitation needs (e.g., Lamb, Weinberger, & Gross, 1999).

Prior to the establishment of FCPs, services available for NCRMDindividuals in the community were deemed to be inadequate; with sup-port, supervision, and follow-up being minimal or non-existent. For ex-ample, Golding, Eaves, and Kowaz (1988) studied 188 NCRMDpatients released into the community after psychiatric hospitalization.Longitudinal follow-up with these patients revealed an average of 2.4rehospitalizations per individual, and a 63% rate of community supervi-sion violations over a period of approximately 9.5 years. Similarly,McNamara and Andrasik (1982) evaluated recidivism rates in NCRMDpatients released into the community. In their sample of 64 mentally

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disordered male offenders, 28% were reincarcerated within approxi-mately 2 years of release due to technical parole violations or the com-mission of new crimes. These researchers suggested that dischargeassessments should include information on the post-release environ-ment, and anticipated reactions to that environment, in order to providea better prediction of community adjustment (McNamara & Andrasik,1982). Although these studies demonstrated the potential for poor out-comes for NCRMD patients, they did not clearly identify problem areasin community service delivery. More recently, a study by Solomon,Draine, and Meyerson (1994) reported that the recidivism of mentallyill offenders was related to diminished services available to individu-als-even when self-requested (as opposed to mandated) by clients. Intheir study, approximately 33 of 105 NCRMD clients were reincarceratedwithin 6 months of release into the community. Rehabilitative serviceswere deemed to be lacking for the majority of these patients, in whichcase management programs monitored mentally ill offenders rather thanoffering comprehensive community services to enable successful reinte-gration (Solomon et al., 1994). It was noted that this situation was furthercomplicated by fact that many NCRMD offenders were unlikely to seekhelp themselves, and may have felt marginalized and controlled bycommunity workers due to the deterioration of services (e.g., Vaughan &Stevenson, 2002). Research on mentally ill offenders, such as theabove, demonstrates the need for development and planning of effec-tive FCPs in order to address shortcomings in the services and treat-ments allocated for NCRMD patients. In fact, the need for FCPs andtheir importance to the individual, local community, and the public as awhole is evident.

For several decades now, community programs designed for the man-agement of NCRMD patients has gradually been established on an inter-national scale. As mentioned above, this has become more and morenecessary with the move towards decentralization of mental health ser-vices for forensic patients from the prisons to community agencies(Laben & Spencer, 1976; Rothbard & Kuno, 2000). For example, in theUnited Kingdom, several programs have been devised that use a gradualrelease system from secure psychiatric detention facilities to reliance oncommunity services have been devised (e.g., see Blackburn, 1996). Inone such program, an outpatient hostel in London began to treat NCRMDoffenders in 1974 and continues to service this population (e.g., the EffraTrust; Robertson & Gunn, 1998). Another example is the forensic out-reach team (FOT) at the Maudsley Hospital, established in 1994. Thisteam is comprised of community forensic nurses and psychiatrists, who

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provide assessment, management, and treatment of NCRMD patients inconjunction with local community psychiatric agencies in London(Whittle & Scally, 1998). In this case, linkage between psychiatric hospi-tal and community resources was used to provide an integrated serviceprogram for mentally ill offenders in the community (Whittle & Scally,1998). Dale and Storey (2001) have suggested that programs forNCRMD patients in the U.K. need to address key issues in communityservices such as risk assessments and management, crisis interventionand relapse prevention, assertive follow-up procedures, establishingcompliance with patients, providing comprehensive care, and applying amultidisciplinary/multiagency approach. The integration of such forensicspecialist and local services is deemed essential in the successful reinte-gration of NCRMD patients discharged into the community (Dale &Storey, 2001; Sugarman, 1999).

The trend towards community based models of care for NCRMD pa-tients also has been initiated by legal reform in Eastern European coun-tries such as Germany (e.g., Mueller-Isberner, Freese, Joeckel, &Cabeza, 2000), Sweden (e.g., Belfrage & Fransson, 2000), and Finland(e.g., Eronen, Repo, Vartiainen, & Tiihonen, 2000). For example, re-structuring of the Swedish forensic psychiatric services from inpatient tooutpatient and community management of mentally ill individuals hasbeen modeled after FCPs in Canada and the United States (Belfrage &Fransson, 2000). However, the treatment of mentally ill offenders insome Western European countries remains under the mandate of correc-tional and secure psychiatric facilities (Ruchkin, 2000), lacking neces-sary integration of community resources and management. For example,countries such as Russia and Poland have been relatively resistant to theimplementation of international reform in the treatment of NCRMD pa-tients (e.g., Ciszewski & Sutula, 2000; Ruchkin, 2000). In addition, legalreforms in Austria have now transferred responsibility for treatment andmanagement of NCRMD patients away from mental health services (pri-marily psychiatric inpatients) to the Ministry of Justice, granting correc-tional control over this population of offenders (Schanda, Ortwein-Swoboda,Knecht, & Gruber, 2000). In contrast, large demands on correctional andpsychiatric resources prompted legislation changes and the establishment ofa community based mental health system in Japan, which functions inpart to divert NCRMD offenders from prisons and hospitals (Kuno &Asukai, 2000; Nakatani, 2000).

The development of different models of FCPs has also been wide-spread in the United States, largely due to the prevalence of mentallydisordered offenders and the limited correctional services that are avail-



able. A survey conducted with criminal justice professionals in Floridain 1983 highlighted the limitations of prisons and mental hospitals indealing with mentally ill individuals (Nuehring & Raybin, 1986). Ingeneral, community support of this population was considered manage-able as long as sufficient levels of monitoring, residential care, andtreatment were implemented (Nuehring & Raybin, 1986). In line withthis, it was estimated that 35-38% of NCRMD patients could be treatedeffectively in the community rather than in state psychiatric facilities ifcommunity services for evaluation and treatment were enhanced(Schutte, Malouff, Lucore, & Shern, 1988).

Mental health and correctional professionals in Massachusetts deviseda forensic transition program to provide assistance for community reinte-gration and 3 months of follow-up after NCRMD patients were dis-charged (Hartwell & Orr, 1999). This program addressed the need toprovide such community support, with 57% of mentally ill individualsdischarged living in the community and requiring mental health services.In addition, psychiatric facilities in Wisconsin have implemented the useof a community preparation service (CPS) to aid in the community reinte-gration of NCRMD patients who have been detained in state hospitals fordurations of 2 to 20 years (Maier, Morrow, & Miller, 1989). This serviceprovides community living skills programs, release planning groups, pa-tient buddy systems, meetings with community leaders, and a 3-monthperiod of hospital to community orientation involving numerous commu-nity outings. Although follow-up data has not been reported to date on thesubsequent success of NCRMD patients that have participated in thisprogram, it was reported that no community excursions (including unsu-pervised outings) had resulted in criminal charges against patients during7 years of operation (Maier et al., 1989).

Developments in Canadian law have reflected the increased need to dealappropriately with mentally ill individuals. The verdict of NCRMD, andsubsequent use of this defense, was established in Canadian law (Bill C-30)on February 4, 1992, and legally changed the provisions made concerningaccused individuals who were mentally ill (Roesch et al., 1997;Verdun-Jones, 1994). Under this legislation, the impetus for communitymanagement of individuals deemed to be NCRMD was further empha-sized. In Canada, provincial forensic psychiatric services are responsiblefor maintaining public safety and providing treatment to clients who havebeen found by the courts to be Not Criminally Responsible Due to a MentalDisorder (NCRMD; section 16 of the Canadian Criminal Code). An indi-vidual is determined to be NCRMD if he/she is suffering from a mentaldisorder of a nature that has rendered them incapable of appreciating the

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nature of the act they were charged with, or knowing that their actions werewrong. Potential dispositions for NCRMD individuals include absolutedischarge (if the patient does not pose a “significant threat” to the public),conditional discharge, or an unspecified period of detention in a forensicpsychiatric facility/hospital (Ogloff, Eaves, & Roesch, 2000). The ratio-nale behind the indefinite detention of NCRMD patients is that intensivetreatment is necessary to treat and/or stabilize the individual’s mental ill-ness, and that both the public and the patient must be protected from anypossible future violent or harmful behaviour that the individual may engagein. Further, detention and subsequent discharge dispositions rely on an as-sessment of the reintegration needs of NCRMD individuals (Whittemore,Ogloff, & Roesch, 1997). In order to accomplish these goals, Canadian pro-vincial psychiatric services provide inpatient programs of varied securitylevels, as well as an increasing number of outpatient programs to aid incommunity support and mental health services. For example, approxi-mately one-quarter of the NCRMD cases that were brought before thecourts in the year following the implementation of the NCRMD legislationwere granted immediate conditional discharges into the community (Da-vis, 1996).

The authors of the present paper were contacted by the professionalsinvolved with the Forensic Community Program (FCP) established atthe Nova Scotia Hospital in Dartmouth, Nova Scotia, Canada. This par-ticular FCP commenced in May 1997 out of concerns regarding the lackof comprehensive aftercare for mentally disordered patients followingdischarge into the community. These NCRMD outpatients primarilyconsisted of men, all were diagnosed with an Axis I mental disorder,and offence histories ranged from public mischief and nuisance crimesto murder. The professionals involved with this program were inter-ested in having the authors of the current paper examine the effective-ness of their FCP and (among other things) to make recommendationsthat would potentially improve the overall functioning of the program.The current article will discuss the eight main considerations and rec-ommendations that were provided by the authors after an extensive re-view of the literature as well as the current structure of the Nova ScotiaFCP. The specific goal of these recommendations was to increase theoverall effectiveness (in terms of client management and treatment, andrisk reduction) of the Nova Scotia Hospital’s FCP. However, the moregeneral goal was that these recommendations could translate to virtu-ally any community treatment program that is available for NCRMD in-dividuals.



RECOMMENDATIONS

1. Necessity of community treatment programs for NCRMD individ-uals. Based on recidivism rates alone it is somewhat difficult to deter-mine the level of need for outpatient community programs. Forexample, the actual rearrest and/or rehospitilization rates for NCRMDindividuals is hard to determine and estimates have varied widely inprevious studies. Heilbrun and Griffin (1998) examined the rate ofrehospitilization for conditional release patients and found reportedrehospitilization rates that ranged between 11 and 40%. Further, a re-cent major review of the literature by Edens and Otto (2001) found thatthe rates for rearrest for conditionally released NCRMD patients rangedbetween 30 and 60% over an average two- to five-year follow-up pe-riod. It should also briefly be noted that the accuracy of violence predic-tion for individuals with a mental disorder has proved to be particularlydifficult due to low base rates of violent recidivism, and the question-able relationship between violence and mental disorder (Borum, 1996).

Some limited research has suggested that outpatient psychiatric carefor NCRMD patients is generally not successful. For example, a studyby Gandhi et al. (2001) reported that significantly more participantswho had a personality disorder and who had received community-ori-ented care had contact with police compared to patients that receivedhospital-oriented care. Further, Kravitz and Kelly (1999) examined theneed for rehospitalization and criminal recidivism in 43 NCRMD pa-tients (aged 26-63) who were mandated to receive treatment in 1996 in aforensic psychiatric outpatient program in Chicago. Data were col-lected on socio-demographic, psychiatric, and criminal characteristicspredating the index offense, rehospitalizations and new crimes/rearrestsafter the offense, as well as clinical and psychosocial functional out-comes after enrollment in the outpatient program. At the end of 1996,Kravitz and Kelly (1999) reviewed the outcomes for all 43 NCRMD pa-tients. Since program enrollment, 20 subjects had been rehospitalized atleast once, nine were in full remission, and 26 showed at least one indi-cator of difficulty reintegrating into the community. Further, seven (16percent) had been rearrested for a new crime. The researchers con-cluded that even after treatment in a specialized forensic outpatient pro-gram, many of the subjects remained symptomatically and functionallyimpaired. Finally, Boyer, McAlpine, Pottick, and Olfson (2000) foundthat 149/229 inpatients with a primary psychiatric diagnosis failed toeven attend scheduled or rescheduled initial outpatient mental healthappointments after hospital discharge.

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However the majority of research has shown that an efficient com-munity outpatient program does have the potential to provide beneficialservices to the mentally disordered population. For example, studieshave reported that there is a significant decrease in the recidivism rate ofmentally-disordered offenders when additional case management ser-vices are implemented to serve their needs once they are released fromprison (e.g., Dale & Storey, 2001; Ventura, Cassel, Jacoby et al., 1998).Additionally, the implementation of FCPs allow for ongoing monitor-ing of psychological changes that are indicative of an increased risk ofharm in NCRMD clients. For example, a study by Grisso et al. (2000)indicated that reporting violent thoughts while hospitalized for a mentaldisorder was significantly related to engaging in violent behaviourwithin 20 weeks of discharge. The presence of an outpatient programmay assist professionals in both identifying potential risk situations andmore effectively monitoring their symptoms, prior to (and hopefullypreventing) recidivism. Sometimes the increased supervision of a com-munity program may lead to a period of rehospitalization, that may benecessary to effectively maintain a low level of risk for that individualin the community. Indeed, a recent paper by Kravitz and Kelly (1999)stressed that although the avoidance of rehospitalization was the mostdesirable outcome for an outpatient program, this scenario was cer-tainly preferable to rearrest. Previous studies have shown that rearrestrates rise substantially once community-based forensic programs are nolonger available for an individual who is suffering from a mental disor-der. For example, Heilbrun and Griffin (1998) reviewed the outcomesof a number of conditional release community-based forensic programsfor offenders suffering from a mental disorder and found rearrest ratesof 2 to 16 % during conditional release. However, when they examinedstudies that had included a long-term follow up after the offender’s con-ditional sentence had ended, rearrest rates were as high as 42 to 56%.

Further, psychiatric resources provided within a community programenables NCRMD clients to gain easier access to necessary treatment re-sources. Studies have revealed that there are frequently a large numberof inmates who are suffering from a mental disorder within prison andnot receiving sufficient treatment for their illness. For example,Hodgins and Cote (1990) found that only 36% of 112 offenders withmajor mental disorders even discussed their serious symptoms withprofessionals in the prison. Further, they reported that only 21% of theoffenders with psychological problems were transferred to psychiatriccare while in the penitentiary. A community program may be one of thebest resources available to an NCRMD client (and potentially inmates



with some type of conditional sentence) to help reduce his/her likeli-hood of recidivism and still helping to manage his/her mental disorder.

Currently most correctional programs are evaluated on the basis oftheir effect on recidivism; however, a broader scope needs to be appliedin evaluating the effects of treatment for an individual suffering from amental disorder. Other measures are needed to validate the efficacy ofmental health interventions, many of which are best employed within acommunity setting. For example, measurements of independent behav-ioural functioning, as well as an analyses of the actual level of use ofvarious mental health services are important considerations when con-sidering treatment success.

In addition to the reasons discussed above, there is a decreasing num-ber of long-term beds in the Canadian mental health system and in-creased pressure on community programs to provide comprehensivemental health care (Goering et al., 2000). Indeed, one of the leading Ca-nadian researchers in the field recently stressed the importance of pro-viding effective post- release follow up and treatment for mentallydisordered offenders (Ogloff, 1998). Further, Salekin and Rogers(2001) argued that monitoring the adjustment of a NCRMD patient inthe community should be considered one of the four crucial goals of anytreatment program (the other three goals were diagnosis, reduction ofrisk, and preparation for the community).

2. Community awareness of FCPs. Considering that patients involvedwith the FCP are being released into the community, one directive of thecommunity program should be to increase public awareness and percep-tion of NCRMD individuals. The actual characteristics of NCRMD indi-viduals (e.g., generally commit non-violent crimes, and have a longhistory of serious mental illness) often do not fit with the public’s incor-rect and misguided belief that many NCRMD individuals are “brutal kill-ers” (e.g., Ogloff & Whittemore, 2001). Indeed, despite the fact thathigher rates of incarceration have been reported for mentally disorderedindividuals, mentally disordered offenders are often incarcerated for lessserious or summary convictions (e.g., Greenberg, Shah, & Seide, 1993).Another misperception is that the NCRMD defense is used much morefrequently than is the case, and that it often serves as a loophole for aguilty individual to escape punishment (please refer to Perlin, 1996, for amore thorough review of this point). Forensic community programsmight endeavor to work more closely with organizations and individualswithin the community to raise awareness and understanding regardingNCRMD acquittees and mental illness in general.

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3. Level of monitoring. The importance of close and regular contactwith NCRMD individuals who are assigned to the community programseems critical. For example, in a substantial number of cases, theNCRMD individual may tend to reside with family or friends in a set-ting where he/she feels comfortable. However, recent research hasshown that frequent contact with family members and friends may notalways be beneficial for individuals with a mental illness (e.g.,Steadman et al., 1998; Swanson et al., 1998). For example, Steadman etal. (1998) reported that individuals with a mental illness were morelikely to engage in violence in their home, as opposed to non-disorderedindividuals who were more likely to engage in violence in a public set-ting. Therefore, it would appear particularly important that individualsinvolved in the community treatment program be closely monitored ona regular basis within their home environment.

Symptom monitoring also becomes relevant after an NCRMD clientis released into the community where he/she often will be exposed tosituations/stimuli that could exacerbate symptoms. Symptom-inducingsituations encountered in the community should also be monitored notonly for the management of mental illness, but due to the reported pre-dictive link between increased symptomatology (e.g., violent thoughts)and perpetrated violence in the community (Grisso et al., 2000). In addi-tion, factors that influence the individual’s ability to function sociallyand economically on an everyday basis are a necessary consideration ofany outpatient maintenance program. In fact, some studies have sug-gested that both clinical assessment and actuarial instruments may notbe as predictive of future violence as a handful of sociodemographicvariables such as employment status (e.g., Menzies & Webster, 1995).Therefore, any change in the “sociodemographic” elements of an indi-vidual participating in the community program (e.g., loss of employ-ment or a change in social relationships) should be closely monitored.Roskes and Feldman (1999) ascertained the major strength of FCPs asbeing a collaboration between treatment and monitoring agencies withthe common goal of maintaining the offender in the community.

Necessary monitoring of the various sociodemographic variablesmust also be accompanied by up-to-date and accurate recording of in-formation pertaining to NCRMD individuals. To help maintain accu-rate records regarding the potential of an individual for recidivism oncehe/she is admitted into the community program, it seems important tostay connected with as many institutions and individuals that are in-volved with the outpatient’s life as possible. It is recommended thatFCPs maintain regular and close outpatient care over as long of a time



interval as resources will permit, while still stressing the importance ofgetting the patient to attend appropriate self-help groups in the commu-nity for potential problem areas, such as substance abuse.

Finally, relevant clinical interventions and monitoring before an in-dividual is accepted into the FCP program are also essential to ensure agreater level of program success. For example, Boyer, McAlpine,Pottick, and Olfson (2000) indicated that some clinical interventionsdid substantially increase the likelihood of maintaining successful out-patient care. One major factor was communication regarding the pa-tients’ discharge plans between inpatient and outpatient clinicians. Asecond factor was whether the patient had started aspects of the outpa-tient program before final discharge, and a third factor was that therehad been a higher level of family support and involvement during thepatients’ hospital stay. Accurate and well-maintained records, as wellas a comprehensive case management team consisting of communitymental health professionals, should be established to appropriately ad-dress the needs of NCRMD individuals.

4. Assessment of psychopathy. The assessment of psychopathy, us-ing the Psychopathy Checklist-Revised (PCL-R; Hare, 1991), has beenwidely adopted in prison and forensic psychiatric populations. In fact,in the Canadian correctional system, risk assessments routinely includean evaluation of psychopathy by forensic psychologists. However forthose individuals who have been found NCRMD, a PsychopathyChecklist-Revised (Hare, 1991; PCL-R) assessment is still not as com-monly conducted. Psychopathy is a serious mental disorder that nega-tively affects an individual across a variety of interpersonal andbehavioural domains (e.g., Hart & Hare, 1997). A defining characteris-tic of this personality disorder is a profound affective deficit that is typi-cally accompanied by a lack of respect for the rights of others andsocietal rules (e.g., Cleckley, 1976; Hare, 1998). A psychopathic indi-vidual can be described as a manipulative, calculating, callous and irre-sponsible individual who is likely to engage in a variety of antisocialbehaviours (e.g., Hare, 1991; Hart & Hare, 1997). Further, recent re-search by Woodworth and Porter (2002) has suggested that in at leastsome circumstances psychopaths may be more likely to engage in in-strumental and premeditated violence. The PCL-R, which assesses bothpersonality traits and antisocial behaviours, is considered the most validand reliable assessment tool within the field (e.g., Hart & Hare, 1997).In fact, the reliability and validity of the PCL-R have been extensivelyresearched and it is well established with both male adult offenders andforensic patients (see Hare, Clark, Grann, & Thorton, 2000; Lilienfeld,

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1998, for reviews). Although the PCL-R assessment is usually based ona review of file information and an interview with the offender, severalstudies (e.g., Grann, Langstrom, Tengstrom, Stalenheim, 1998) haveshown that assessments based only on the offender’s file informationare highly valid (see Hare, 1991).

With a prevalence of 15 to 25% in federal offender populations, psy-chopathy is an important risk factor for violent and criminal behaviour(e.g., Hemphill, Hare, & Wong, 1998). Psychopathy is strongly predic-tive of both criminal behaviour and violent recidivism (e.g., Cunningham &Reidy, 1998). Indeed, studies have shown that recidivism rates are higherfor psychopathic offenders than for non-psychopathic offenders (e.g.,Porter et al., 2001; Hart & Hare, 1997). Results of a meta-analysis byHemphill, Hare, and Wong (1998) indicated that the correlation betweenpsychopathy and criminal recidivism was even stronger than the correla-tion between personality disorders and criminal recidivism. In addition,they found that determining the presence of psychopathy was as effectiveas actuarial risk instruments that were specifically designed to determinean offender’s risk of general criminal recidivism. In fact, measures ofpsychopathy were actually more effective than actuarial risk instrumentsat predicting violent recidivism. Porter et al. (2001) investigated the com-plete criminal career and community release profiles of 317 Canadianfederal offenders. They found that psychopathic offenders failed duringcommunity release significantly faster than non-psychopathic individu-als. Although the mentally disordered individuals (inpatient and outpa-tients) in the current study generally had relatively low PCL-R scores incomparison to the general offender population, this does not imply thatthey are at little or no risk to reoffend. A lower PCL-R score should onlybe interpreted as implying that the individual is at a lower risk to reoffend.Further, a low PCL-R score is one useful indicator (taken in conjunctionwith other assessment tools and clinical judgment) that an individual whois being considered for the community program, may be at a lower riskfor recidivism. However, it is strongly recommended that a PCL-R as-sessment be conducted on each patient by a well-trained evaluator beforeany final decision is made regarding possible admittance into the com-munity program. In fact, Ogloff and Whittemore (2001) recently notedthat “psychopathy eclipses all other known risk factors as a predictor offuture violence” (p. 337).

5. Actuarial risk assessment tools. In addition to the PCL-R, manyother objective risk assessment tools are available including the Dan-gerous Behavior Rating Scale, (Menzies et al., 1985), the Violence RiskAppraisal Guide (VRAG; Harris, Rice, & Quinsey, 1993), the Sex Of-



fender Risk Appraisal Guide (SORAG; Quinsey, Harris, Rice, &Cormier, 1998) and the Historical/Clinical/Risk Management 20-itemscale (HCR-20; Webster et al., 1997). In terms of risk assessment formentally disordered populations, there are two primary actuarial vio-lence prediction tools that should be considered essential by any FCP(e.g., Heilbrun & Kramer, 2001). First, the VRAG was derived and vali-dated from data on Canadian mentally disordered offenders (Harris,Rice & Quinsey, 1993). Based on two cross validation studies, Rice(1997) concluded that the adoption of the VRAG as an assessment toolwith NCRMD patients would lead to a reduction in new crimes and newvictims. Rice also concluded that the VRAG performed particularlywell at predicting violent criminal behaviour among those NCRMD pa-tients who had previously committed a violent crime. Second, theHCR-20 was designed to assess risk of future violence, and considersboth clinical and historical factors, as well community conditions fol-lowing hospitalization or incarceration. These “risk management” fac-tors such as potential for exposure to destabilizers, and lack of personalsupport, are particularly pertinent for consideration by communitytreatment program providers. A recent article by Mossman (2000), sug-gests that the HCR-20 represents many of the current important anduseful advances that have been made in terms of accurately predictingfuture violence. The HCR-20 can be reliably scored and has been shownto have some predictive power and validity when compared to other riskassessment instruments (Douglas & Webster, 1999). In fact, it is gener-ally agreed upon that both the VRAG and the HCR-20 are useful “actu-arial” methods in assessing risk that can be a beneficial addition toclinical judgement (e.g., Salekin & Rogers, 2001).

6. Combining clinical and actuarial tools. Professionals should notattempt to solely rely on actuarial assessments or clinical judgment, andensure that they incorporate a combination of these tools. Current re-search has shown that decisions regarding the disposition of offendersare frequently more reliant on clinical judgment than actuarial tools(Hilton & Simmons, 2001). However, there are some compelling rea-sons why clinical assessments should be augmented with various objec-tive risk assessment tools. For example, clinical assessments ofoffenders can predict risk of recidivism but often show a high level ofheterogeneity. On the other hand, objective risk assessments, which usestructured and standardized instruments, are frequently better predic-tors of violence and recidivism than clinical judgments of risk, and en-hance the accuracy of clinical prediction for violent outcomes (Bonta etal., 1998). However, treatment providers should also be wary of relying

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too heavily on the results of actuarial assessment tools. For example,Litwack (2001) has suggested that actuarial tools have not been satis-factorily demonstrated as superior to clinical assessments, cannot bemeaningfully compared to clinical tools due to differing primary objec-tives, and have not been adequately validated for use in disposition de-cisions. Further, Litwack cautions against the sole reliance on actuarialassessment tools to predict risk of future violence or recidivism.

Professionals involved with FCPs should ensure that standard riskassessment tools are always employed in addition to clinical judge-ment. This can serve to both validate and support the clinical judgmentof the mental health professional. Ideally (and in what is more fre-quently the case), good ‘clinical’ assessment will take into consider-ation various actuarial predictors and actuarial instruments will beinformed by good clinical input, to a degree where the distinction be-tween the two assessment styles becomes somewhat unnecessary (e.g.,Litwack & Schlesinger, 1999).

7. Effective communication and understanding of risk. In recentyears, there has been a shift in focus for both offenders and NCRMD cli-ents who are being considered for release into the community. Mentalhealth professionals are now trying to determine the level and magnitudeof danger that an individual poses, rather than trying to specifically deter-mine if an individual will or will not commit a violent or anti-social act(Monahan & Steadman, 1994). Mental health professionals involvedwith forensic community programs need to be confident that they haveestimated the level of harm that a potential candidate for their programrepresents as accurately as possible, and that they have sufficiently com-municated this information to decision makers such as criminal code andparole review boards. Echoing this sentiment, one of the leading re-searchers within the field of risk assessment suggested that adequate “riskcommunication” is one of the most essential parts of violence prediction(Monahan, 1996). In addition, mental health professionals involved inFCPs should endeavor to conduct regular literature reviews of all newand pertinent information regarding NCRMD patients and other mentallydisordered individuals. The science of risk assessment is still being de-veloped and refined, therefore clinicians need to be able to clearly dem-onstrate the rationale and theoretical/empirical background regardingtheir decisions on violence risk (Dolan & Doyle, 2000).

8. Incorporating elements of other community programs. Althoughmore research is needed to examine the effectiveness of treatment forNCRMD clients within institutions and following release into the com-munity (Ogloff & Whittemore, 2001), there are a few defining charac-



teristics of effective community treatment programs for mentallydisordered offenders within North America. Most community treatmentmodels focus on case management services for mentally disordered of-fenders. Case management involves collaborating with the client to for-mulate treatment and rehabilitation plans, advocacy, service brokering,monitoring treatment compliance, providing on-going support, and pro-viding assistance with vocational goals (Johnson & Rubin, 1983;Soloman & Draine, 1995). In the United Kingdom, key areas associatedwith mentally disordered offenders in community programs are risk as-sessment and management, crisis intervention, prevention of relapseand recidivism, structured follow-up, compliance, comprehensive care,adequate supervision, and a multidisciplinary/multiagency approach(Dale & Storey, 2001). In Canada, case management programs are ei-ther intensive and attempt to provide directly a comprehensive continu-ous treatment and rehabilitation program, or are generic; being lessintensive, less specialized and less comprehensive (Goering, Wasylenki, &Durbin, 2000). Goering et al. (2000) estimate that 25% of individualswith severe and persistent mental illnesses who are in treatment requirean intensive approach. Key components of community treatment havebeen shown to be: the continuity of care for mentally disordered offend-ers, collaboration between systems (i.e., mental health, criminal justice,and corrections), transition of mentally disordered offenders from jailsto the community, and housing initiatives (Solomon & Draine, 1995).For example, law enforcement agencies are frequently in contact withmentally ill offenders, yet lack the appropriate knowledge and resourcesto divert them to mental health professionals (Husted, Charter, & Perrou,1995). Barriers to successful community integration include lack of so-cial support, comorbidity of psychological disorders, and community ad-justment issues (Roskes, Feldman, Arrington, & Leisher, 1999).

Due to the lack of research that has been conducted specifically onNCRMD client community treatment programs, procedures and goalsthat are used by other types of mental health community programs toenhance community safety should be reviewed by FCP health provid-ers. For example, the Relapse Prevention Treatment and Supervisorymode supports the maintenance of change (within the community) oftreated sex offenders and has three overall goals:

1. To increase the clients’ awareness and range of choices concern-ing their behavior

2. To develop specific coping skills and self-control capacities3. To create a general sense of mastery or control over their lives.

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To attain these goals, Relapse Prevention includes intervention pro-cedures that are designed to help clients anticipate and cope with the oc-currence of lapses and to modify the early antecedents of lapses. Theinterventions to be used with a particular client are determined by as-sessing high-risk situations and coping skills (Pithers & Cumming,1995). Although designed for sex offenders, the relapse prevention planprovides criteria that would be relevant and potentially useful for FCPtargeted at NCRMD individuals as well.

Interestingly, many of the general suggestions of Harris and Rice (1997)for community treatment programs could also be beneficial for the commu-nity case management of NCRMD patients. For example, they suggest that asuccessful community program cannot merely be “custodial communitycare or traditional casework.” Further, they suggest that the program must(a) be assertive and seek out their clients in their clients’ environment; (b) en-sure that there is a high quality relationship between the community casemanager and the outpatient; (c) attempt to minimize rather than emphasizetheir professional status; and (d) maintain long-term contact with clients (al-though it can be challenging from a logistical and financial standpoint).

CONCLUDING COMMENTS

Community programs like the FCP have been designed to provideNCRMD patients with an increased potential to function in the communityoutside of a hospital setting, while still monitoring their symptomatologyand their level of risk.

We would suggest that community programs develop a report or as-sessment template that includes:

a. A current psychological assessment (based on a PCL-R interviewguidelines and file review).

b. Actuarial assessment tools including the PCL-R, HCR-20, and theVRAG.

c. A document outlining the clinical judgment of the client’s level ofrisk written by the main professionals who have been involved inthe care of the patient

d. A list of reasons (based on the above 3 suggestions) why the of-fender should be accepted into the program.

We believe that this is an essential part of any program, as an increas-ing number of studies are finding that guided judgments based on a



structured assessment protocol are more accurate in predicting futurerisk of mentally disordered offenders than those based on general clini-cal assessment alone (Borum & Otto, 2000).

In closing, the majority of research has demonstrated that a FCP maybe one of the best resources available to NCRMD patients to help reducetheir likelihood of recidivism while still managing their mental disorderand providing them with a structured opportunity to function successfullyin the community. We believe an understanding and adherence to theabove 8 recommendations/considerations will help to increase the gen-eral effectiveness of the community treatment program, ensuring greatercommunity safety as well as a higher level of patient success.

NOTE

1. For the purposes of this paper, these mentally ill offenders (or NGRI) will hereaf-ter be referred to as NCRMD patients in accordance with the legal definition in theCriminal Code of Canada. The terminology of NGRI and NCRMD are frequently usedinterchangeably, and refer to the same legal disposition of offenders.

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