Assessing the probability of patients reoffending after discharge from low to medium secure forensic mental health services: An inductive prevention paradox

Abstract

Citizens of developed societies are troubled by those who commit 'irrational' crimes against the person. Reoffending after release from secure mental health services triggers particularly intense angst when amplified by media and political scrutiny. However, forensic mental health service providers making discharge decisions are required to predict the probability of patients reoffending after discharge by observing behaviour in secure institutional settings designed specifically to prevent such transgressions from occurring. This paper will explore this 'inductive prevention paradox' by drawing on data drawn from qualitative studies undertaken in two medium to low secure UK institutions, one providing forensic mental health and the other forensic learning disability services. The views of 56 staff members and 21 patients about risk management in forensic services were explored, and an additional 25 staff interviews were undertaken for case studies of these patients. Data analysis focussed on patient and staff responses to the inductive prevention paradox with respect to a highly sensitive issue. The wider applicability of this framework will be considered in the Discussion. It will be argued that the prognostic limitations arising from the inductive prevention paradox have been underestimated by policy-makers and in official inquiries; and that the prevailing personal risk assessment framework needs to be complemented by greater attention to the environments which patients will be discharged into.2

Playing the game: service users’ management of risk status in a UK medium secure forensic mental health service

“…We give examples of service providers' responses to service users' attempts to actively manage their risk status, including the active encouragement of the silencing of indicators. Thus beyond the existence of an inadvertent inductive prevention paradox in which risk management interventions block the flow evidence needed for risk assessment (Heyman et al 2013), we found evidence of an active damping down of the communication of risk indicators by service users. Such damping down makes it unclear whether reduced risk indicators are evidence of a sustained change in the service users' risk status or, in a manner reminiscent of Goffman's work on asylums (1961), this is a deliberate subversion of the process of risk assessment upon which the forensic heath care system is based.…”

“…Thus the organisation must judge when, despite their forensic label, a user's risk status has been reduced sufficiently to be considered acceptable within a community setting. However, it is not always possible to know with any confidence whether an individual will reoffend seriously or not (Heyman et al 2013). The best that can be done is probabilistic prediction of recidivism, the assessment of which is problematic.…”

‘Signs of Safety’ Practice at the Health and Children’s Social Care Interface

“…An understanding of risk based an objective phenomena grounded in a search for confirming evidence is a common approach in health and social care. Used in this way, risk can be reified into an objective reality and this makes it difficult for those subject to such assessment to challenge definitions of being 'at risk' or posing a risk (see Heyman's discussion of risk classification in forensic mental health -Heyman et al 2013). This is exacerbated at the borders of health and social care (Colyer 2012) in referral communications.…”

Practice Needs to Be Braver: The Role of Entry to Care Panels

“…Any need to render risk into more certain measurable and objective facts is problematic for child protection practice. The understandings of risk as an objective phenomenon is grounded in a search for confirmation evidence and as risk gets reified as an objective reality this makes it difficult for families and young people to challenge (see Heyman's discussion of risk classification in forensic mental health Heyman et al, 2013).…”