Forensic case formulation
Integrating forensic data into a case formulation can prove challenging, but there is some guidance in the literature [2–5,10–12]. In particular, the research literature supports the utility of structured risk assessment, etiology, and diachronicity as helpful components of a forensic case formulation [2,13,14].
For patients, such as those found “not guilty by reason of insanity” or classified as a “mentally disordered offender,” whose sole discharge criterion is often simply the ability to be safely treated in the community, utilization of a structured clinical risk assessment that delineates risk factors into historical, clinical, and risk management domains can provide a useful framework . An examination of past violence to determine the etiology (psychotic, impulsive, predatory) [13,14] allows for further refinement of the formulation. Recent guidelines for treatment based on etiology have been developed . A critical component of a forensic case formulation, identified by Hart et al., is the concept of diachronicity . This means that the forensic case formulation includes information from the patient’s past and present, which generate predictions about the potential future clinical outcomes. The amount of historical information available to forensic clinicians in the form of documentation and evaluations completed during previous hospitalizations varies greatly from case to case, but a case formulation is incomplete and perhaps inaccurate without adequate historical information, especially related to past violence and criminal history. The reliability of information coming from patient self-report should be verified by collateral information whenever possible.
Patients who have been sent for competency restoration have met discharge criteria when they have sufficient present ability to consult with their lawyers with a reasonable degree of rational understanding and have a rational as well as factual understanding of the proceedings against them . Therefore, there is utility in organizing case formulations for these patients into those categories identified by UC Davis, because it provides a focus for treatment on the primary barrier to competency (e.g., psychopharmacology intervention for a psychotic barrier to competency). For example, while issues related to substance use or a history of violence may be present, they do not represent a barrier to being discharged as competent, and ironically, incorporating multiple foci of treatment can prolong lengths of stay and ultimately impede upon constitutional rights . The value of a forensic case formulation in these cases is to help clinicians determine what the barriers to regaining competency are and which treatments will be most effective in helping to quickly eliminate those barriers (see Figure 25.2). Doing so will prioritize forensic outcomes such as restoration of trial competence or mitigation of violence risk as the first steps in a continuum of care that eventually leads to the patient’s ability to resolve forensic issues and return to the community for recovery-oriented care.
Forensically driven discharge criteria
The term “discharge criteria” is somewhat of a misnomer, given that a forensic mental health system is only the first step along a continuum of care. Typically, discharge criteria are generated from the case formulation and directly influence the development of interdisciplinary plans of care. However, in the forensic setting, discharge criteria flow from the statutory language under which the patient is admitted. The case formulation should provide, primarily, an analysis of an individual’s mental condition as it relates to that legal status. So the discharge criteria need to reflect resolution of the mental health/criminogenic dimensions that have bearing on the patient’s legal status. Many stakeholders are involved in developing discharge criteria; however, unlike civil settings, it is ultimately the committing court that makes a decision regarding discharge. It is therefore suggested to design discharge criteria that speak directly to the statutory language (see Table 25.2) and are organized following the structure in the forensic case formulation.
|1. Patient will demonstrate adequate knowledge in the court proceedings.|
|2. Patient will demonstrate an ability to assist his or her attorney.|
Forensic interdisciplinary plans of care
The principles of good treatment planning apply to forensic plans. Kennedy  identifies several mechanics that are essential to treatment planning. Focus statements, objectives, and treatment interventions, developed by a multidisciplinary team of clinicians, should come together to form interdisciplinary plans of care, which serve as the functional components of a forensic-focused treatment plan. In treatment plans, focus statements should clearly articulate the problem. Whether it is medication noncompliance in a patient with psychotic aggression or a need to develop prosocial thinking, a succinct focus statement is crucial to gaining understanding among all readers. Objectives that are behavioral, observable, and/or measurable ensure that forensic clinicians can appropriately track the patient’s progress toward meeting desired outcomes. Attaching reasonable target dates to objectives provides a mechanism by which to establish the continued review of progress. Group, individual, and milieu treatment interventions are also important in establishing exactly what therapeutic modalities and strategies staff will provide in order to assist the patient in meeting their goals  (see Table 25.3).