Implementing the risk paradigm in forensic mental health: Evidence and values

An emphasis on the notion of 'risk' in sociopolitical discourse has been a dominant trend throughout the developed world in recent decades (Breakwell 2007), influencing both public expectations and professional responsibilities in all spheres of public life. It is both unsurprising and appropriate that health care has not been immune to this trend: expectations around risk regulation or 'governance' have escalated in the wake of various high profile scandals (Department of Health 2002; Eastley 2013). In mental health specifically, increasing expectations around risk management have had a number of drivers: the move towards community- based care in the late twentieth century; high profile enquiries into homicides committed by patients under mental health services in the UK (Sheppard 1995); and contemporary empirical evidence that, contrary to earlier assertions, severe mental illness is indeed a statistically significant risk factor for the commission of serious violence (Mullen 1997; Douglas et al. 2009; Fazel et al. 2009). This trend, and the consequent expectations placed on mental health services, has generated understandable concerns about both unrealistic expectations being placed on psychiatrists (Holmes 2013) and the insidious erosion of traditional medical ethics that rioritise care of the individual patient over possible protection of society (Adshead 2014). Not surprisingly, expectations around risk management for forensic mental health services are especially high: such services provide treatment to 'mentally disordered offenders' - persons suffering with severe mental illness (and, in some jurisdictions, severe personality disorder) with a history of serious (generally violent and/or sexual) offending - with the eventual aim of facilitating their safe reintegration into 'mainstream' society. The key question that clinicians working in such services are faced with is starkly summarised in the title of a monograph from the 1990s by the sociologist Herschel Prins: 'Will they do it again?' (1999). This chapter will focus on the dilemmas posed by this challenge for forensic mental health services, particularly the dilemmas posed by the implementation of graduated 'community leave' programmes from high- secure institutions. The emphasis will be on hospital- based secure services, although many of the issues also pertain to community- and prison- based mental health services delivered to mentally disordered offenders