Is This Logical? Applying Therapeutic Logic in Mental Health Law Proceedings

By David S. Prescott, LICSW, Kieran McCartan, Ph.D., and Kasia Uzieblo, Ph.D.

A new study in the International Journal of Forensic Mental Health deserves our field’s attention. Sven Pedersen, Thomas Nilsson, and Lena Eriksson examined the experiences of people who are patients in forensic psychiatric services and recurring mental health law proceedings. Readers are likely already aware that all work at the intersection of mental health and the law can become challenging on even the best days. As challenging as it might be for professionals, however, it is apparently even more frustrating for the patients themselves.

The themes that emerged from the interviews were:

1.  A manifest hierarchy with the patient at the bottom

2. Patient contributions as irrational and unwelcome

3. The patient as evidence, not a person

4. The devaluating effect of not being heard or being treated as something bad

5. Lack of useful allies willing to challenge the status quo

6. The need for compliance and loyalty

In analyzing the themes within the patients’ narratives, the authors stated that “Taken together, these themes illustrate a process whereby the patient is kept from influence through a manifest hierarchy based on authority more than on evidence or argumentation; through the objectification and devaluation of the patient; through the lack of potent professional support; and through the need to abstain from challenging the authorities in order not to disrupt their benevolence. The six themes are structured linearly, in accordance with the process described above.” (P. 4)

It may be that the best news in these findings is the fact that anyone tried to seek out the experiences of these people and that there was a structure in place to do so. It is doubtful whether either would have occurred a century ago except in an informal or haphazard fashion. The bad news is that these circumstances send contradictory messages to the very people who need open and straightforward dialog the most: people with diagnoses of major mental disorder.

These contradictions include: On the one hand, you should have input into your treatment and legal proceedings. On the other hand, we will not value what you say about your experience. On the one hand, we want you to talk with us about that which is meaningful to you, and on the other hand, we may dismiss what you say outright. On the one hand, we want you to have a better life and on the other hand, we continue to view you as dangerous, irrational, and a probable liar, and not more than the sum of your diagnoses and your offenses. While it is no surprise that these clients wouldn’t find the experience to be helpful, the paradoxical nature of these contradictory messages brings forth the possibility of making matters worse in treatment and the legal proceedings.

Sadly, our field does not lack information on how to work with these individuals. Jaakko Seikkula and his group in Finland have demonstrated that early intervention using an open dialog approach can address each of the concerns expressed above. Motivational Interviewing can also be helpful. Ultimately, what these findings show is the importance not only of the structures of interventions but the spirit in which these interventions is offered. This (again) reinforces the need to hear, and recognize, the voices of our service users in the treatments and interventions that we deliver with them.

The fields of health, medicine, psychology, and psychiatry have attended to the service user’s voice for a long time at an abstract level. Yet in our work with people who have caused harm to others, these ideas and findings rarely appear to be applied at the individual level. We question whether this doesn’t leave treatment clients with a two-tiered client-engagement program based on their offense and not criminogenic needs. Our clients’ aspirations are not so different from ours. For example, they also strive for a feeling of connectedness and a sense of self (Clarke, Lumbard, Sambrook, & Kerr, 2015).

Perhaps the biggest take-home message from Pedersen et al.’s work is that even with the most challenging population, in the more challenging arena, there is a need for proactive engagement between professionals and their clients to better understand the impact of the criminal justice process on those who experience it. This is starting to happen with the consideration and implementation of trauma-based approaches at a policy and practice level. Therefore, we in the sexual abuse field need to ask ourselves how can we further develop this work in our own practice?

Finally, researchers also have a responsibility within this regard; we have already gathered uncountable data on the characteristics of forensic patients and on their offenses, but we tend to overlook that these participants are individuals who may actually themselves suffer from the offenses they have committed, who may have been traumatized by the judicial process they went through, or who feel more like a guinea pig that has to be studied because of his/her criminal behavior rather than for who he/she really is.