Care of the Mentally Disordered Offender in the Community

In the past decade, the full force of the British government has come down solidly on the side of protecting the public from people who are mentally ill. Treatment has taken second place. One result of this policy shift is a heightened sense of professional vulnerability on the part of British psychiatry; another is this book, whose authors were clearly driven by concerns about what these policies augur for mental health providers and their clients.

Today in Great Britain, every patient must be assigned to one of three levels of care according to the risk presented. Risky persons must be identified and placed on a supervision registry. When a patient commits a homicide, the responsible medical officer is subjected to a searching formal inquiry. A 1999 government initiative proposed indefinite detention of persons with diagnoses of "dangerous severe personality disorders," whether or not they have been convicted of a criminal act.

The first chapters of Care for the Mentally Disordered Offender in the Community, as well as the final chapter, raise familiar issues with a new urgency: What is the relationship of the psychiatrist to the state? To whom does the individual clinician owe primary allegiance? When does criminal behavior become a mental disorder? How do we define "untreatable"? Who should be deprived of liberty, on what grounds, and who decides?

Although the primary focus is on policy developments in Great Britain, a chapter by Marvin S. Swartz and Jeffrey W. Swanson on outpatient commitment in the United States touches on many of the same issues. The chapter provides an excellent summary of the research and pays careful attention to views on both sides. However, this issue, which provokes such passion in the United States, seems to pale in light of the policy changes that have swept Great Britain.

The authors also deal with more practical matters: the organization of services for mentally disordered offenders, treatment models, risk management, and medication compliance. Although most of the material is presented in the context of the highly complex British system, practitioners from other countries should have no trouble relating to the major themes.

With the exception of the chapter by Jennifer L. Skeem and Edward P. Mulvey on risk assessment and the chapter by Frank Holloway on the use of the community mental health team, the material tends to be academic—long on presentation of research findings and short on hands-on information for those in the field. Surprisingly, there is little commentary on the integration of substance abuse treatment into the service mix. For the rare provider who has the resources and the desire to offer individual therapy, the chapter by Kingsley Norton and Jonathan Vince explores in detail the clinical issues involved in psychotherapy with this population.

Care of the Mentally Disordered Offender in the Community offers the experienced practitioner a comprehensive summary of the research on the mentally ill offender but little in the way of practical strategies for community care. For the novice, it provides an introduction to the ongoing issues in caring for the mentally disordered offender. Finally, without a doubt, the book is a must read for those who are contemplating a mental health career with the British National Health Service.

Dr. Scott is assistant commissioner for forensic services in the Massachusetts Department of Mental Health in Boston.