Integrated Forensic Health Services:
A 21st Century Model
Thomas W Miller1* and Robert F Kraus2
1Professor Emeritus & Senior Research Scientist, Department of Psychiatry, University of Kentucky, USA
2Professor Emeritus and Retired Chair, Department of Psychiatry, University of Kentucky, USA
Submission: November 14, 2017; Published: November 30, 2017
*Corresponding author: Thomas W. Miller MS, Ph.D. ABPP, Professor Emeritus & Senior Research Scientistm Department of Psychiatry, College Medicine, University of Kentucky, US; Email: email@example.com
How to cite this article: Thomas W M, Robert F K. Integrated Forensic Health Services: A 21st Century Model. J Forensic Sci & Criminal Invest. 2017; 6(3): 555691. DOI: 10.19080/JFSCI.2017.06.555692
Addressed is the practice of forensic psychology and what it brings to the multidisciplinary integrated treatment team in a public state psychiatric unit. Offered is acursory historical review of the psychiatric model specializing in of forensic services with specific attention to the value of clinical psychological contributions in the diagnosis and treatment of individuals who are provided interdisciplinary services within a designated forensic unit. Psychological protocols are provided with current measures found beneficial for the psychological evaluation of forensic cases referred and mandated on the forensic unit. Issues and import for further discussion is explored.
The history of forensic mental health care, until recently, has been marked and marred by limited success in treatment and rehabilitation of psychiatrically referred criminals. The judicial system and forensic providers continue to seek clinical measures that are beneficial in accurately diagnosing this criminal population. Community-based and rehabilitative services are often rudimentary and limited in their scope. This is despite the reality that nearly all patients for whom forensic mental health services assume care will eventually return to the community, and for most the vast majority of their care, or lack of it, will occur in the community. New models of forensic inpatient care are emerging with an emphasis on integrated and multidisciplinary assessment and intervention for patients who are adjudicated to the care and treatment of psychiatric forensic unit. An effort to examine new models of forensic care highlights the need for integrated care. Integrated care requires a new look at what each professional and discipline brings to the forensic unit. For any level of success to occur on such a unit, requires that accurate and detailed measurement and assessment of psychopathology occur before any intervention is offered. Among the professionals that provide essential diagnostic services to such units is that of the clinical forensic psychologist. Clinical psychology offers a critical role in the functioning of a forensic unit in a psychiatric hospital setting Benjamin & Baker  have summarized the specialties in psychology and among them in the 21st century is forensic psychology.
According to the American Board of Forensic Psychology, forensic psychology is the application of the science and profession of psychology to questions and issues relating to law and the legal system Tartakovsky . The word "forensic" comes from the Latin word "forensic," meaning "of the forum," where lawyers of the day discussed the issues of justice in ancient Rome. Today the concept of forensic has adopted an evidence based reference in the application of scientific principles and practices for the adversarial process in our justice system. Forensic psychology has been instrumental in providing the expertise in advancing evidence based clinical measurement in forensic mental health care. Forensic mental health is defined as an area of specialization that involves the assessment and treatment of those individuals who carry a diagnosis of the psychiatric Diagnostic and Statistical Manual of the American Psychiatric Association [3,4]. These populations thinking and behavioral functioning is outside the range of the norms of the society in which they live. Within the civil sphere, forensic psychology has a more complex significance which is reflected in how we come to understand the psychopathology the offender brings to the integrated clinical treatment unit. Forensic psychology has emerged with new directions in both the assessment and the treatment of forensic patient populations. This specialty of forensic psychology dates back to the earliest days in psychological science when one considers the role of psychology in the study of criminal behavior.
The role of observation and measurement in the practice of forensic psychology is attributed to the early efforts of Wilhelm Wundt in the late eighteen hundreds when he began to standardize measurement if behavior. His initial efforts inspired James Cattell  to conduct some of the earliest research on the psychological of testimony utilizing such standardized measure of observing behavior. In his research Cattel found a surprising degree of inaccuracy, inspiring other psychologists to conduct their own experiments in eyewitness testimony. With even eyewitnesses being unsure of them, this raised serious issues about the validity of their usefulness in court testimony. Cattell's research led Alfred Binet to carefully examine Cattell's research and develop standardized intelligence testing and its application as it relates to in understanding psychopathology as it relates to forensic populations. Psychologist William Stern studied witnesses' ability to recall information. Stern discovered errors were common among witnesses and concluded that a person's emotions could affect how accurately he remembered things. The misrepresentation of accuracy of information provided resulted in the use of the polygraph testing results was first realized by psychologist William Marston  who found that systolic blood pressure had a strong correlation to a person who is found to be lying in court testimony.
The role of forensic psychology as an expert witness gained judicial value in the case of Frye  United States. This case is significant because it established the precedent for the use of expert witnesses in courts. In the case of People v. Hawthorne, the court ruled that the standard for expert witnesses depended on how much the witness knew about a subject based on measurable information gained about a In the case of Brown v. Board of Education, where several psychologists testified for the plaintiffs and the defendants. Later, the courts gave support to psychologists serving as mental illness experts in the case of Jenkins v. United States. As we embrace the new horizons for forensic mental health care including assessment and treatment, the clinical and legal domains must come to value the significance of psychological measures and assessment if we are to realize significant change in the forensic population we are asked to provide treatment. The expanded role of forensic mental health professionals that has accompanied the increasing prominence of risk assessment and risk management in our society has not been confined to traditional mental health areas. Psychologists and psychiatrists are being asked to assist a wide range of community organizations and the very levels of the judiciary in both assessing their exposure to risks from mentally disturbed individuals and in effectively minimizing the perceived threats.
The demands of today's criminal activities in our society, the influence of cyber-crime and new technologies and the shifts we are facing require important shifts in assessment of individuals referred to inpatient forensic facilities. We are witness to escalating rates of referral to forensic services with increasing stressors about the potential for violent behavior by patients engaging in criminal activity. The shift to mental health services that are community based and rely on general hospital units for in-patient facilities has tended, understandably, to decrease further the confidence that the general mental health services have in their facilities, or even skills, to manage the more challenging and potentially frightening patient. What is compounding these influences are changes in our society that tend to decrease the tolerance for difficult and intrusive behavior and to increase the demand that professionals, rather than friends and family, control such deviance. With this in mind, the structure and function of forensic inpatient diagnosis and treatment care must have both the structure and the clinical staff to assess and accurately diagnose this criminal population. Staffing a Forensic Unit should include the following staff members and their role and their responsibilities.
Chief of Service provides the leadership for the forensic unit and is responsible for the overall administration of the unit. In doing so this individual provides an environment and insures that patients are receiving the highest level of clinical care possible which includes ensuring an adequate number of trained staff and budget to meet the program goals and maintain a safe and therapeutic environment. Program Administrator is responsible for their program and the assigned staff. The program administrator is the direct line supervisor. Specialized training and experience in criminal justice system is essential. Psychiatrist with forensic training and experience, who provides medical oversight pertaining to diagnosis and treatment. The psychiatrist is responsible for orchestrating the treatment planning process, ordering medications, evaluating the patient's response to treatment, and discharge planning. Internal Medicine Physician is responsible for the physical health care during incarceration on the Forensic unit. The psychiatrist and the internist work closely together to deal with all medical concerns.
Nurse Manager supervise the activities of the care team responsible for ensuring that quality care is coordinated and delivered to patients, through careful management of the nursing staff and other resources.
Social Worker with clinical expertise in helping your family member deal with psychiatric problems as well as casework issues related to the criminally mental illness. Social workers on this unit have, and casework management and direction with respect to discharge planning for a population with psychopathology. Clinical Psychologist provides a forensic training and experience in utilizing specialized psychological measures designed to assess criminal psychopathology. Evidence based treatment interventions designed in the areas of psychotherapy, family, individual and group psycho education through individual and group therapy modalities designed for the criminally mentally ill. Dentist provides with both routine and emergency dental care. Should specialized dental care be needed, the staff dentist makes the referral to the appropriate dental specialist. Other allied health care staff is team members as appropriate.
Understanding the change in the roles of forensic mental health professionals in the provision of forensic services has been the focus of Fletcheret al. . Fletcher notes is making available mental health expertise to relieve perceived social problems should not conflict with traditional medical practice if its aim is, through identifying and relieving disorder, to benefit primarily patients and, through their more adequate care and management, to benefit those they potentially threaten. Forensic psychology is proficient in dissecting details and identifying and interpreting the psychological clues. But their background in human behavior often extends their work beyond the yellow police tape. In fact, they offer their expertise on many legal matters, including the mental state of criminal defendants. They may be called in to examine and determine whether a defendant should be declared incompetent to stand trial or receive a reduced sentence due to temporary insanity. The spectrum of roles that the Forensic psychologist brings to the table involves valid and reliable measures of psychopathology, clinical treatment planning bases on psychological testing, advice on jury selection, child custody and family law, violence risk prediction, mediation and dispute resolution, discrimination, civil damages, social science research, and civil commitment, where individuals with symptoms of severe mental illness are ordered by a court into treatment . There are some forensic psychologists work in the area of threat assessment, an emerging science predicting who may be at risk of committing a violent acts of behavior as in acting out against self or others.
The specialty skills of Clinical forensic psychologists contribute can be to the benefit pf populations in prisons, rehabilitation centers, police departments, courthouses, law firms, schools, government agencies or private practices. They are needed to determine whether a suspected criminal has a mental illness, for example, and are called upon to treat incarcerated individuals with substance abuse and addiction issues. Legal activities that involve minors involving a wide range of abuse, neglect and sexual exploitation are the domain of the forensically trained psychologist [10-12]. They help children in suspected abuse cases to process and communicate their experiences truthfully and accurately, and may prepare them to testify in court or child custody disputes. It is the forensic trained clinical psychologist who studies criminal behavior to determine common traits among types of perpetrators. This includes interviewing criminals, along with their loved ones and even victims. They focus on the study crime scenes and evaluate evidence left behind to develop a profile of a particular criminal and narrow a list of suspects. Forensic psychologists also take the stand in court to explain possible motives behind a crime or whether they feel a defendant is guilty based on what they know about his or her behavioral history. As a result, they may influence a criminal's sentencing. Research is a key component of a career in forensic psychology and it comes in several forms.
The dominant model continues to be one in which an individual earns a doctoral degree in clinical psychology, and subsequently pursues a postdoctoral specialization in forensics. However, more graduate schools are adopting forensic tracks. Forensic psychology is a recognized specialty in professional psychology.
The American Psychological Association embodies the specialty of forensics psychology through Divisions 18 Public Service and Division 41 Psychology & the Law. Both these Divisions are inter-disciplinary organization devoted to scholarship, practice and public service in psychology and This professional organization notes that forensic psychology is a specialty in professional psychology characterized by activities primarily intended to provide professional psychological expertise within the judicial and legal systems.
The model forensic unit in which this author served as a senior clinical psychologist providing a spectrum of psychological services ranging from clinical diagnostic interview, clinical assessment, and treatment based on best practices for the acute mentally ill patients [13-16] who had been admitted to a forensic unit through court order because of criminal behavior. These are regionally based that serve the needs of various county jails in the region. In addition such a unit provides services for patients classified as chronically mentally ill individuals who are remanded to the facility by State Courts due to competency related issues. Finally, patients who are classified as harm to self or others or are considered dangerous legal standards are remanded to such facilities. As with any medical and health care facility, there is a mission and vision statement that serves as a guide to the services and direction of the unit. Such a facility provides integrated and multi-disciplinary evaluation, treatment, and rehabilitation services for those individuals who have committed some form of criminal behavior with serious mental illness. The goal is working toward recovery. The primary mission of a forensic unit is to provide evidence based inpatient psychiatric assessment, treatment and other relevant services for mentally ill individuals who are currently involved or were involved with the Criminal Justice System.
Contemporary clinical psychologists with the specialty of forensic science are a professional that studies the thinking and behavior of criminals [17-22]. Such a career has received considerable note in recent years because of a number of popular television programs that depict forensic psychologists, such as Criminal Minds, the Crime Scene Investigation series and just this year with a focus on jury selection and behaviors viewed on Bull. Considerable research attention has focused on serial killers and understanding the thinking and behavioral processes of this category of criminal activity [17,22]
The forensic clinical psychologist provides a standardized initial interview that includes but is not limited to a detailed review of previous and present medical records, history of criminal records, history court ordered evaluations and testimony. The primary components include but are not limited to his childhood, adolescence and adulthood thought processes and behavior In addition particular attention is given to any history of cruelty to animals and cruelty to children and peers. Special attention is paid to aggressive thoughts and lasting and recurring fantasies. The use and abuse of alcohol and substances of abuse, along with previous arrest record, authority issues and problems at home, in school and during employment are examined. The psychological evaluation is tailored made to include relevant valid and reliable psychological measures for assessment. These can include but are not limited to the following primary measures available today are the following psychological measures. (Table 1) summarizes the clinical and psychological assessment tests. Found to be especially beneficial in screening for forensic purposes are three of the following measures.
A. Symptom Checklist-90-Revised: It is a 90-item measures psychological symptoms and related distress along nine primary symptom dimensions (i.e., somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism). Additionally, the SCL90-R contains three summary, or global, scores (i.e., global severity index [GSI], positive symptom distress index [PSDI], and positive symptom total [PST]). The GSI represents a respondent's average score across the 90 items and is an indicator of overall level of functioning. The PSDI is a measure of intensity that is calculated by averaging all responses above zero. The PST is the total number of symptoms endorsed by the respondent. The SCL90-R has been used extensively in forensic and correctional settings to assess general psychological functioning [23,24].
B.Psychological Inventory of Criminal Thinking Styles: It is an 80-item self-report questionnaire that measures eight thinking patterns (i.e., mollification, cutoff, entitlement, power orientation, sentimentality, optimism, cognitive indolence, and discontinuity) that are believed to be instrumental in maintaining a criminal lifestyle . In addition to calculating eight scales representing the thinking types proposed by Walters, the PICTS also generates a global measure of the presence or absence of criminal thinking (general criminal thinking), four content scales (proactive, reactive, current, and historical criminal thinking), and five factor and special scales (problem avoidance, interpersonal hostility, self-assertion, denial of harm, and the fear of change). Proactive criminal thinking is a measure of goal- directed, deliberate, and organized forms of aggression or criminal behavior, whereas reactive criminal thinking is a measure of spontaneous, impulsive, and reactionary forms of aggression or criminal behavior.
C.The Measure of Criminogenic Thinking Styles: It is a 70-item self-report inventory that was developed based on common theories of criminal thinking errors, thought patterns) and irrational beliefs and cognitive styles. It is designed to assess a broader range of dysfunctional thought processes prevalent in offender populations that may be
As an excellent protocol and guide for the forensic clinical psychologist is the Serial Murder Personality Protocol . This is a structured Interview Checklist of Symptoms and Behavioral Experiences that must be addressed in a thorough evaluation before psychological testing is conducted. This structured clinical interview covers the following topics:
The forensic clinical integrated team may also benefit from the results obtained on the Keaton: Conceptualization of Personality Disorders [25,28-32]. This measure includes an assessment of multiple symptom and behaviors associated with criminal activities found during various phases of life usually classified by childhood, adolescence, and the adult life span. Special attention is paid to activities that include drug use and abuse, incidence of reported eating problems, enuresis, feared by others, feelings of helplessness, isolation, and for some feelings of omnipotence . Also examined is the presence of delusions and/or hallucinations, any trauma to the brain or history of head [presence and pattern of headaches, symptoms related to head injury, homicidal thoughts and Impulsivity [34,35].