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Ask the Mental Health Expert Archives 2001-2004

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Forensic Therapeutic Environment

Q. I was wondering if you could identify what makes a good forensic therapeutic environment with regards to patient risk assessment?

A. I'm not sure I fully understand your question, but I'll give it a whirl. First, I think you are raising two separate (though related) issues in forensic psychiatry: risk assessment, on the one hand, and therapy, on the other. Very often, forensic risk assessment goes on in a semi-hostile environment, in which clinicians are really being directed (by a court or judge) to perform an evaluation on a potentially dangerous, involuntarily committed patient. In such cases--in which the clinician must file a report with the court, and in which the usual rules of confidentiality do not apply--it's often very difficult to gain the patient's trust or even cooperation. After all, the clinician is acting, in part, as a kind of agent of the state, even though he or she may genuinely wish to help the patient.

It is critical to level with the patient from the beginning as to your restrictions and responsibilities. This is all quite different from a situation in which, say, one is working with a potentially violent or self-injurious patient on an outpatient basis, in which there is no court-mandated evaluation or treatment at issue.

Without a better understanding of your question, all I can do is refer you to the excellent book, Psychiatry and Law for Clinicians, by Robert Simon, MD; and to several articles that might bear on your question: Steadman HJ. From dangerousness to risk assessment of community violence: taking stock at the turn of the century. J Am Acad Psychiatry Law. 2000;28(3):282-9; and Wack RC. The ongoing risk assessment in the treatment of forensic patients on conditional release status. Psychiatr Q. 1993(Fall);64(3):275-93.

I hope this is helpful.

December 2001

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