Balancing risk and recovery

¹ McMaster University, Department of Psychiatry and Behavioural Neurosciences, Hamilton, Canada

² St. Joseph’s Healthcare Hamilton, Forensic Psychiatry Program, Hamilton, Canada

Gary Chaimowitz is a Professor of Psychiatry at McMaster University and the Head of the Forensic Psychiatry Program at St. Joseph’s Healthcare Hamilton. Among many roles, Professor Chaimowitz has been granted Forensic Psychiatry Founder Status. He is one of the creators the Hamilton Anatomical Risk Management (HARM) and the Aggressive Incident Scale (AIS). Professor Chaimowitz is the Editor in Chief of the International Journal of Risk and Recovery.

It is into a crowded world of journals that the first issue of the International Journal of Risk and Recovery arrives. Although there are forensic psychiatry journals that talk to a variety of issues, this journal will not only address key forensic psychiatry issues but we will strive to make the articles pertinent and applicable to forensic psychiatry clinicians. In doing so, we are acutely aware that an important aspect of forensic psychiatry that needs to be thoughtfully addressed with discussion, debate and research is the area of risk. However it is finding the fine balance between risk management and recovery promotion that is both delicate and critical to our work. Hence, finding and maintaining the balance between risk and recovery should be one of our key goals in forensic psychiatry [1].

Viewed from an international perspective, the area of forensic mental health can encompass a multitude of clinical, academic, and service delivery do-mains. One such domain is that of risk assessment, prediction, and management. It is thus an expectation that forensic mental health clinicians have the ability to assess, predict, manage, and mitigate risk [2]. In fact, this has been a fertile area for research over the last several decades as its application in the clinical space is both immediate and practical, and the consequence of faulty risk management can have severe repercussions.

Correspondingly, an area that has bedeviled researchers has been getting forensic mental health clinicians to actually incorporate the scientifically validated risk tools into their practice. However, from a forensic mental health clinician’s perspective, too often risk tools appear too impractical to be implemented at the bedside. The divide between researchers whose tools have evidence to support their usage, and clinicians who do not have the time or inclination to use them, still remains unacceptably wide. A large area of research dealing with implementation has sprung up to try to understand how to bridge the gap between what academia produces and what the service delivery sector actually uses [3].

Notwithstanding that, several significant advances have been made over the past decades to bridge these gaps. Increasingly evidence-based practice has become the norm in the clinical sector, with structured professional judgment tools now essentially integrated into clinical practice. However, as risk assessment, prediction, management, and mitigation have become standard practice in forensic mental health, and slowly so in the civil mental health services, something else appears to have been lost.

As the title of this journal suggests, forensic mental health practice requires finding a fine balance between risk management and fostering recovery [1]. All too often, risk management can become the dominant view and the clinical setting begins to approximate a correctional environment. Consequently, patients’ needs and their rehabilitation can be lost when risk management is the only lens applied. Fortunately, in many jurisdictions, the designated forensic facility is mandated by law to provide opportunities for rehabilitation of forensic patients. This is important as finely written vision and mission statements may obscure what happens on the frontline, specifically with the obligation to care for and assist the consumers of healthcare services in their recovery. This plays out specifically where stigma looms large, namely in mental health, and even more so in the forensic mental health domain, where the patients may be doubly or even triply stigmatized. This may seem unintentional, but there has been a perception over the years of a loss of understanding or even an acceptance of forensic mental health patients as people, rather than offenders or perpetrators.

The social contract that has created forensic mental health systems demands not only the detention and risk management of our patients, but also the rehabilitation of those self-same patients. The question then becomes how do we promote recovery in the forensic mental health system. On the face of it, recovery in its purest form may seem incompatible with a forensic system, where choice is subservient to risk management, and coercion implicit in the law, statutes, and regulations that govern patients.

If we are truly going to make a difference, fostering an environment of positive change can ultimately impact patients’ mental health, reduce recidivism, protect the public, and make for a healthier and safer society.

Although much effort is put into prescribing the correct medication for the patient, ensuring medication adherence, monitoring for substance abuse, and arranging for substance abuse programs should be standard operating procedures in any mental health service. In fact, in all services that deliver mental health care, completing accurate mental state examinations of patients, ensuring safe environments, and engaging in structured professional judgment processes should be a basic expectation.

However it is the ability to understand the forensic mental health patient as a person that appears still to be lacking. Of course, no organization or clinician would freely admit to this but many thoughtful clinicians can speak to this issue. Although increasingly more staff are now able to talk with some confidence about what would be considered evidence-based risk factors for violence, few of the staff actually get to know the patients as people [4]. Understanding our patients’ strivings, goals, life experiences, and what would make for a healthier and meaningful life, gets lost in the multitude of mental status examinations, checklists, tools, protocols, and programs. Determining what our patients’ goals are and so as to assist them in moving forward to living a meaningful life remains still one of our biggest challenges. Something that seems superfluous when compared to risk management is in fact probably the core factor that will provide access to assisting patients in changing, changing the very things that have driven them to enter the forensic psychiatry system [5]. This is then true risk mitigation.

Incorporating recovery principles into forensic mental health practices at the clinical, research, and educational levels must be our next initiative [6]. Some would argue that we already have sufficient structured professional judgment tools to manage risk of violence. In fact, with the use of analytics, those tools are probably close to where we want them to be. Fortunately, proponents of recovery and rehabilitation in the forensic mental health area are speaking out, research is growing, and various models such as the Good Lives Model are being examined for incorporation into a forensic psychiatry domain [7].

This journal intends to provide a forum for healthy discussion, debate, and innovation in the area of forensic mental health services by focusing on the delicate balance of risk management and recovery promotion. Its articles and commentaries will be accessible to both the academic world and to the clinical sector. We want to close the divide. We invite further discussion of this important topic and other related topics as we look at the balance between risk and recovery in forensic mental health services.