Advancing community safety through forensic mental health research

Together, the countries of Europe make a substantial contribution to understanding the nature and extent of relationships between mental disorder on the one hand and acting unlawfully and/or dangerously on the other. This builds towards a wide scientific base, from which experts can assist the courts, develop effective clinical services to treat disorders and repair any harm already caused as well as develop and advise on prevention of new harms at every level. This themed issue of Revista Española de Medicina Legal ranges widely in adding to this knowledge.

In Europe, as in most countries, worldwide, mental health professionals may be asked to give expert evidence in court. Unlike most witnesses, who may give evidence only on facts, experts may also offer opinion. This is allowed whenever there is pertinent, usually scientific information which is likely to be outside the knowledge and experience of the judge (e.g. Kennedy v Cordia [2016] UKSC 6). For forensic psychiatry and psychology, designation as an expert is, in essence, in recognition of the scientific method and knowledge behind our work, and we must live up to that expectation.

Clinicians may not, however, be very knowledgeable about just how much lay people – for these purposes including lawyers – know about mental disorder and its effects. Their evidence might be more clearly given and more relevant if they did. In common law countries, where alleged offenders may be tried before a jury of ‘their peers’, it is particularly important to understand the extent of relevant knowledge among the general public. Fresán et al. survey of young people's perceptions of the concept of ‘not guilty by reason of insanity’ reported in this issue suggests that schools could play a substantial role in improving understanding of relationships between common illnesses and offending¹. People with enduring and serious mental disorders are often disadvantaged in their communities. Thus, although they might never have offended in the absence of their mental disorder, any link between mental disorder and crime may be moderated or mediated by many other factors. Across the world, people with mental disorder are disproportionately vulnerable to violent attack or exploitation ^2–4. Thus, in some instances, they may be truly be defending themselves if they hit out. They might not have had to do so if they had not appeared unwell, but this is not how we usually think of the relationship between mental disorder and violence. We are more familiar with the idea that, sometimes, schizophrenia, say, so alters cognitions and judgement that the individual does not know what he or she is doing and/or that it is wrong. The students surveyed for this article showed interest in participating in the topic; they showed skill in recognising that not all mentally people offend in a way that is directly driven by their illness, but also that when cognitions are sufficiently distorted to qualify for an insanity defence, then such illness would probably be diagnosed. This article might encourage clinicians to reach out to schools to help teach about mental illness, the needs it creates and treatments and other solutions. We might then have many more allies in delivering the best services and making everyone safer.

Suicide is one of the most common dangers posed by untreated mental disorder. Accurate treatment for the disorders associated with particularly high rates of suicide, including depression, the psychoses and personality disorders, prevents harm here too, but it is not the only important preventive measure. Public health has had and will have a substantial role to play. The UK National Confidential Inquiry into Suicide and Homicide (NCISH) reports annually on correlates of suicide, and has evidenced important and simple life saving recommendations for enhancing safety⁵. A substantial contribution to reducing fatal self-harm in UK institutions, for example, followed its evidence on how aspects of hospital architecture and furniture could become ligature points. Environmental adjustment – for example by ensuring that curtain or clothing rails simply collapse under more than a small weight – has subsequently saved lives. Evidence from this national enquiry has led to a suicide prevention toolkit⁶, which emphasises the importance of timing and professional and social networks. Need for early follow-up after discharge from hospital and 24-hour crisis team availability, familiarity with staff (low staff turnover) and proximity of staff, with outreach services, family involvement, guidance on illness, especially depression, attention to comorbid substance use as well as personalised risk management have all been cited. Vera-Varela et al. show in this issue of REML that important contributions may come from forensic scientists too⁷.

Accurate assessment informed management of risk of harm in the wide variety of ways it may creep into everyday life is a cardinal skill of forensic mental health practitioners. This issue of REML takes on a topical range – from the truly intimate, through the people who feel so alienated that they apparently bond only with extremists, to the world of cyberspace, where loners can use and abuse false intimacy. We can see potential links between REML's articles too – for example, from cyberbullying to suicide. The National Confidential Inquiry into Suicide in England (2016) found that nearly a quarter of young people had used suicide-related websites before their fatal act. Although cyberbullying occurred with almost the same frequency, face-to-face bullying was a stronger correlate, and social isolation a serious contributor. Maybe the next survey project for young people might be about themselves and mutual support and protection? Gassó et al. focus on ‘sexting’ and online grooming in this issue of REML as well as on bullying⁸ – a welcome new example of how Spanish researchers are adding to other European research on the understanding of cyberbullies⁹.

Domestic violence - in this issue intimate partner violence is the focus – has been a problem for societies throughout their history. With the possible exception of homicide, however, in Europe and the USA, intimate partner violence has only become a matter for systematic criminal justice involvement as recently as the latter part of the 20^th century¹⁰. Subsequent literature has usually been about such violence against women, and Pujol et al. contribution is no exception¹¹. This is hardly surprising given the nature of the worldwide prevalence of the problem¹², but it is important to remember that women may sometimes be the perpetrators and/or men the victims¹³. Police themselves are now seeking models of best practice¹⁴, so may be helped by reliable and valid protocols. The big question when focussing on recidivism risk, however, is whether recidivism after risk informed management is lower than after well defined ‘standard practice’. López-Ossorio et al. article is a potentially useful first step in answering this¹⁵.

Risk of radicalisation and resultant terrorism is a prominent 21^st century fear. People who are or who feel isolated from mainstream society, are consciously or unconsciously unhappy with their position and/or who feel powerless in society may find a coping strategy in religious fundamentalism¹⁶. This may be benign, but it may be a step on the path to terrorism. Mental health has been shown to be relevant, for example Bhui et al. reported that even mild depressive symptoms are associated with sympathies for violent protest and terrorism¹⁷. Fernández García-Andrade et al. acknowledge that clinicians are now increasingly asked to assess and advise, perhaps as expert witnesses, after a terrorist event¹⁸. Their focus is on mental health clinicians as risk assessors and risk reducers, and evaluate a method of helping them. They offer a research validated a tool, with the horrible acronym ‘TRAP-18’. As such radicalised individuals are still rather rare, despite the feeling engendered by media interest, the study had to be completed with a small sample. The tool will need further evaluation, but still may prove invaluable if closely coupled with interventions informed by it. It could complement the public health model proposed by Bughra et al¹⁹.

Gómez-Durán et al. focus on a supremely important area of work that we too often avoid – practical strategies for primary prevention of child sexual abuse²⁰. Paedophilia is almost unique as a designated mental disorder for which it is rare to be able to get treatment unless a related criminal offence is committed – and so opportunities for primary prevention are missed. Gómez-Durán and her colleagues highlight projects, becoming available throughout Europe, which could achieve this. Vital for protecting children, evidence is growing for the value of extending the reach of the German Dunkenfeld project which they cite and the similar UK Circles of Support and Accountability project²¹. The key principle of valuing the person of the perpetrator while condemning the offence may also save lives when the criminal justice system becomes involved. Phillips et al. highlighted the exceptionally high suicide rate among people arrested for downloading indecent images of children [IIOC]; people under investigation for IIOC offences accounted for 17 (28%) deaths among the 60 recorded suicides following law enforcement or criminal justice contact in 2015/16²². Key et al. suggest a safeguarding strategy bringing law enforcement and health services together²³.

It is good to see that research continues to develop in the field of forensic mental health. It is essential that we build on this ever more strongly. Patients and clients in our field have generally made others suffer; they also suffer greatly themselves and are often survivors of violence. Thus, treating to reduce harm covers a wide range or tasks, all needing an evidence base for their individual effectiveness and their effectiveness as part of wider management strategies. Tasks must include prevention of suicide and other self-harming behaviours as well as prevention of harm to others. No one clinical discipline or agency can do this in isolation. Sharing knowledge and joining up research across all relevant clinical groups and with police, probation, the legal profession and the public is clearly the best way forward and this issue of Revista Española de Medicina Legal gives a glimpse of how to achieve that.