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Correspondence |
Macarthur Mental Health, Campbeltown, NSW 2560, Australia.
Correspondence: E-mail: sameiaman{at}yahoo.co.uk
Hodgins & Müller-Isberner (2004) in their clinical implications assert that schizophrenia patients with antisocial behaviour ‘require cognitive–behavioural interventions aimed at changing antisocial behaviours...’, yet the paper itself can only quote evidence of effectiveness of these techniques in offenders who are not mentally ill (McGuire, 1995). It therefore seems unclear why they then suggest that these techniques will be effective in reducing antisocial behaviours in people with schizophrenia and should be regarded as ‘required’. Unfounded assumptions like these may be quoted by others referencing this paper and lead people to assume, mistakenly, an evidence base for this assertion. Providing cognitive–behavioural therapy to this client group may therefore provide no benefit but divert resources that may have benefited others. While I agree that reducing antisocial behaviour in this client group is desirable, we should not hasten to assume, in the absence of evidence, that cognitive–behavioural therapy will provide a panacea.
REFERENCES
Hodgins, S. & Müller-Isberner, R.
(2004) Preventing crime by people with schizophrenic
disorders: the role of psychiatric services. British Journal of
Psychiatry, 185, 245
–250.
McGuire, J. (1995) What Works: Reducing Reoffending. Guidelines from Research and Practice.Chichester: John Wiley & Sons.
Department of Forensic Mental Health Science, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.
Haina Forensic Psychiatric Hospital, Haina, Germany
Correspondence: E-mail: s.hodgins{at}iop.kcl.ac.uk
Thank you for your interest in our work. It is important to note that we proposed that cognitive–behavioural interventions that have been shown to reduce offending could be adapted to treat a sub-group of offenders with schizophrenia. This sub-group shares with the offenders who have benefited from these interventions a history of antisocial behaviour since childhood, and antisocial attitudes and ways of thinking.
Dr Huda makes the presumption that interventions proven to reduce offending would not have a similar effect among offenders with schizophrenia. In our view, this presumption is unfounded. For example, treatments for medical conditions proven to be effective in people without schizophrenia are used with equal success with those with schizophrenia. We also disagree with Dr Huda’s presumption because, generally, effective treatments target specific problems, not a disorder. This is true in the case of schizophrenia where different treatments have been shown to have a positive impact on positive and negative symptoms, substance misuse, life skills, social skills and employment skills (Bloom et al, 2000).
As we noted, compliance with medication is a prerequisite to participating in interventions aimed at reducing offending. Furthermore, these interventions need to be adapted for use with people with schizophrenia and their effectiveness evaluated. This has been done recently, for example, with interventions that targeted substance misuse. Programmes that were adapted to patients with schizophrenia and integrated with their other treatments are reported to be effective (Mueser et al, 2003).
We agree with Dr Huda that evidence for the effectiveness of cognitive–behavioural programmes in reducing offending among persons with schizophrenia is still sparse. It is presently limited to naturalistic follow-up studies with non-random assignment of participants (T. Fahy, personal communication, 2004; Kunz et al, 2004). In our view, however, the available evidence is encouraging and sufficient to undertake randomised controlled trials of these interventions with the sub-group of offenders with schizophrenia who display a stable pattern of antisocial behaviour from an early age. Given the potential of these interventions to prevent criminal activity, improve the individual patient’s life, and reduce costs to both the health and criminal justice system, such trials are urgently needed.
REFERENCES
Bloom, J. D., Mueser, K. T. & Müller-Isberner, R. (2000) Treatment implications of the antecedents of criminality and violence in schizophrenia and major affective disorder. In Violence among the Mentally Ill: Effective Treatments and Management Strategies (ed. S. Hodgins), pp. 145 –169. Dordrecht: Kluwer Academic.
Kunz, M., Yates, K. F., Czobor, P., et al
(2004) Course of patients with histories of aggression and
crime after discharge from a cognitive–behavioral program.
Psychiatric Services,
55, 654
–659.
Mueser, K. T., Noordsy, D. L., Drake, R. F., et al (2003) Research on integrated dual-disorder treatment. In Integrated Treatment for Dual Disorders: A Guide to Effective Practice (ed. D. H. Barlow), pp. 301 –321.
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