Distinctions within distinctions: The challenges of heterogeneity and causality in the formulation and treatment of violence

Abstract

In this chapter, I address three broad approaches to understanding and formulating (and hence subsequently treating) violent behaviour in forensic settings. In particular, there is a focus on the issue of heterogeneity of the patient or offender population. My (or any other) perspective is inevitably shaped by the particular context within which the clinical work is conducted, by the specific characteristics of the offender population receiving attention and by the philosophy, assumptions and policy objectives of the organization within which the clinical work occurs. The particular context that most informs the discussion in this chapter is that of the 'Dangerous and Severe Personality Disorder' initiative in England, which is described in more detail below. A brief clarification of appropriate terminology is required at the outset. Individuals whose serious violent behaviour has brought them into conflict with the law may subsequently be dealt with, assessed and treated (or rehabilitated) either within the criminal justice system or within forensic mental health services. Although there are areas of common purpose and practice within these two systems, for example, risk reduction, there remain substantive differences in underlying philosophies, assumptions, cultures and ways of conceptualizing problems of violence. The distinction between 'normal' and 'mentally disordered' offenders, with possible underlying assumptions that the two categories of person have fundamentally different causal antecedents for their violent acts, and hence different therapeutic needs, has been questioned and provides another example of the heterogeneity to be discussed in detail below. In this case 'offenders' and 'patients' may be less different than traditional thinking might lead us to expect. For now, the point to be emphasized is that many violent individuals may be characterized as 'offenders' or 'patients' or both. For purposes of brevity and convenience, I use the term 'offenders' throughout the discussion to follow, rather than 'patients' or 'offender-patients'. The use of terms such as a 'clinical approach' or reference to 'clinicians' or 'treatment' does not imply a medical model, nor should it be taken to imply that professional work is exclusively the province of mental health professionals, rather than criminal justice professionals such as forensic psychologists, criminologists or probation and prison staff. (PsycINFO Database Record (c) 2016 APA, all rights reserved)