Looking from the outside: No substitute for rigorous evaluation

Looking in from the outside, what would the ordinary person expect of forensic mental health services? I suggest that there are three questions he or she would ask: (a) Are there public health measures that can be introduced to prevent those with mental disorder going on to commit crimes? (b) Can we identify in advance the individual who is likely to go on and commit a violent act because of his or her mental health difficulties, and prevent that or limit damage? (c) If a seriously harmful act has already been committed, what interventions might prevent a repetition? All of these questions are about prevention of an untoward event in the future and anticipate knowledge. How secure can we be that current forensic mental health practitioners can make adequately evidenced responses? I fear that examination of current literature would indicate that they and their academic colleagues would fall short of these expectations. Reasons for this are undoubtedly numerous. The issues are complex, with the interplay of many variables from the vagaries of human nature through varying presentations of disorders, still often classified rather than diagnosed, to widely differing environments which, further, may suddenly change in a critical way. The impact of a serious offence can be so catastrophic that officialdom often decides that "something must be done." Yet, without a good evidence base, such decision-making is often ineffective and wasteful of resources. The limited evidence base has not been helped by the virtual extinction of an academic forensic psychiatry infrastructure and funding within British universities and the National Health Service. This does not bode well for the future.