Finding the evidence in forensic rehabilitation

Cure & Adams (2000) suggest that we managed to overlook 22 000 potential references including 2000 which apparently contain data relevant to our inquiries. Contrary to our belief, they also claim that the randomised trial is the preferred research methodology in forensic psychiatric rehabilitation.

These criticisms are, in our view, based on a poor understanding of the process of rehabilitating mentally disordered offenders, and reveal a blinkered approach to novel research strategies which may be of value in such atypical settings.

Cure & Adams cited three examples of the many quality studies they allege we overlooked in our review. All were published after the final submission of our paper, but are presumably presented as examples of the treatment and rehabilitation of mentally disordered offenders. Two of the cited reviews examine antipsychotic treatment (in people with learning disabilities and with acute schizophrenia) and the other is a review of sex offender treatment. These studies are, without doubt, most relevant to clinical forensic psychiatric practice. They do not, however, target the process of rehabilitation in a more general sense, as outlined in our paper. There is more to forensic work than drugs and specific programmes for certain offender groups.

Apparently, Cure & Adams fail to appreciate the difference between psychiatric work among forensic and non-forensic populations. That difference is the rationale for our remark that a randomised trial is not the method of choice in evaluating the outcome of forensic psychiatric rehabilitation. The crucial point is that allocation to forensic psychiatric treatment is not controlled by medical professionals but by legal authorities, refractory to the systematic and premeditated manipulation that some research requires. Although mentally disordered offenders, delivered by the courts to the hospitals, can be diverted into different treatment schemes, it is not feasible to maintain a predetermined course of rehabilitation. Important factors such as the length of incarceration, number and duration of leaves as well as external support by non-forensic caregivers, are not possible to randomise and control.

Randomised trials do not provide the only source of data on treatment efficacy, although where these trials are possible, valid and important data may be presented. Our paper did not pretend to review all articles related to the field of forensic psychiatric practice. Such magnificent and ambitious endeavours can only be embarked upon by the privileged few who are provided with considerable support from national funding institutions. Their reports may prove invaluable in guiding clinicians, assuming that the issues are correctly presented — a considerable responsibility. One obvious risk of the rapid growth of evidence-based medicine is its inhibiting effect on the advancement of the theory of clinical practice and its potentially discouraging effects on active contributors and reviewers of articles to medical journals.