Words of Caution: Recommendations to Consider when Interviewing Patients with a History of Aggression or Violence

Andrew Day, Indigenous Education and Research Centre, James Cook University, Queensland, Australia Michael Daffern, Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia; Victorian Institute of Forensic Mental Health (Forensicare), Melbourne, Australia Ashley Dunne, Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia; Victorian Institute of Forensic Mental Health (Forensicare), Melbourne, Australia Nina Papalia, Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia; Victorian Institute of Forensic Mental Health (Forensicare), Melbourne, Australia Kylie Thomson, Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia

This article discusses issues arising when interviewing men and women in forensic mental health services, noting that many patients in these settings have significant histories of aggression or violence. The differences between interviews conducted for assessment purposes and those that are conducted as part of treatment are noted. We identify some important considerations for interviewers. These relate to characteristics of the client, characteristics of the interviewer, and features of the mental health setting that might impact on the interview. Some practical recommendations are offered to assist forensic mental health practitioners who conduct both types of interview.

Violent; offender, interview, therapeutic alliance

“Patients of forensic mental health services are those who have both been diagnosed with a mental disorder and broken the law…it has long been known that many forensic patients are admitted with a history of aggressive and/or violent behavior…and rates of in-patient violence towards staff and patients can be high…The aim of this article is to consider the range of factors that potentially influence the way in which the mental health professional might approach the task of interviewing patients who have a high risk of doing so in the future. Our focus is on interviewing in-patients, although similar considerations will inevitably arise when interviewing forensic patients in the community” (p.12).

“…It is important to note that assessment interviews with mentally disordered patients can differ in important ways from general counseling encounters. For example, the forensic patient’s response style may be characterized by positive impression management motivated by strong external incentives, such as efforts to avoid court proceedings or imprisonment, or to secure a discharge from hospital…Given the disincentives that sometimes exist to open disclosure in the forensic setting, the development of trust is considered particularly important, with feelings of safety also widely considered to be key to therapeutic change in most psychotherapeutic approaches…” (p. 13-14).

“Forensic patients also typically present with a range of co-morbid problems, including substance abuse…and family dysfunction that may distract them from the focus of any interview. It is, however, personality and interpersonal difficulties that are perhaps most commonly identified as challenges to the effective interviewing of violent patients and, in particular, traits of antisocial personality disorder…They are more likely to perceive threat and hostile intent from the interviewer, which may then impact upon their level of engagement, willingness to disclose, and ability to build rapport…In short, the interviewer qualities that are thought to enhance effectiveness include those that lead the patient to view the interviewer as interested, authoritative (not authoritarian), warm and empathic, and tolerant of the patient’s challenges…” (p. 14-15).

“…Relatedly, there is a particular need to acknowledge that experiences of trauma will often act as a key driver of aggressive and violent behavior. This might involve, for example, the interviewer paying particular attention to how negative life experiences…and associated traumatic experiences might be relevant to the purpose of the interview…Of particular relevance for the interviewer is using the developing understanding of a person’s history to inform judgments about how the patient is experiencing the mental health service and the interview itself…It is already clear that various factors will impact on the quality of the forensic interview. It is possible to group these factors into two key domains that apply to both assessment and treatment interviews; those that related to the patient and those that are relevant to the interviewer…” (p. 14).

“…There can, of course, be an advantage in commencing the initial assessment interview soon after the patient has been admitted to the service…as this may help the mental health professional to better appreciate the nature of the person’s mental health problems, and their relationship with aggression. However, there are also benefits in delaying the initial assessment interview until the more florid symptoms have resolved and the patient’s capacity for reflection and concentration is improved. Ethically, it is also important to wait until the patient has the capacity to consent to the assessment interview” (p.14).

“It is also important to remember that many forensic patients will arrive with traumatic histories and they are, therefore, likely to experience a range of factors that will heighten their sense of threat…and influence their interpersonal engagements…Considering the meaning of these presentations will, therefore, be a key tasks in an effective interview, whether it is for assessment or treatment purposes. Finally, patients will often be very anxious about meeting new staff and it is the interviewer’s responsibility to seek to reduce this anxiety. This may involve considering both strengths and weaknesses, rather than focusing solely on problem behavior, the elucidation of risk factors and/or antisocial personality traits.” (p. 15).

“What follows are four suggestions for how a professional might approach the task of interviewing a forensic patient…A helpful starting point in any interview, after outlining the purpose of the interview and addressing issues of consent, is to summarize what the clinician already knows about the patient and then ask the patient for feedback (points of agreement and disagreement)…Acknowledging information that the clinician already knows also demonstrates openness” (p.16).

“Barber (1991) has proposed a six-step model of what he terms ‘negotiated casework,’ which we suggest provides useful direction to any interviewer who is assessing a forensic patient. Barber starts with the suggestion that the first step is to talk directly about the order or conditions that led to the interview…Then, it is important to identify those aspects of the interview that are non-negotiable and those that can be negotiated…The next step is to make decisions about the way forward, identifying goals and responsibilities, before seeking agreement on criteria for progress and what will happen if the patient fails to comply with aspects of the interview. This approach can help to clarify the boundaries of the interview, as well as the purposes for which information will be used and address concerns about confidentiality” (p.16-17).

“We suggest that interviewers should adopt an affiliatory interpersonal style…This may be particularly difficult to achieve when working with patients who…may evoke both pessimism and rejection. Techniques for engagement that have been reported to be helpful include offering choice, information-giving, preparing people for therapy, goal agreement, treatment contracting, building self-confidence and self-esteem, and feeding back treatment progress, particularly for those with diagnoses of personality disorder….More broadly, violent offenders with high levels of entitlement, grandiosity, and superiority may, on occasion, display behavior that is aggressive…in order to establish or reestablish a sense of self-worth or interpersonal control…The important task for the interviewer here, however, is not to react – but, once again, to use this type of reaction as information that can help conceptualize the patient’s presenting problem and level of risk. Often this will require the support and advice of another professional…” (p.17).

“Given the potential volatility of patients who have a history of violence, it is imperative that interviewers familiarize themselves with the safety procedures of the location in which the interview is taking place. Some important considerations may include carrying a duress alarm, ensuring that the door of the interview room remains unlocked at all times, ensuring other staff are aware of their interview and any potential risks…Careful planning and seeking the advice of other staff who know the patient well and who are familiar with the patient’s present state is prudent. Notwithstanding measures to protect physical safety, it is also important to acknowledge the psychological impact of being in a forensic service where autonomy is limited and the patient is exposed to experiences that may be personally distressing or frustrating” (p.17).

“The interpersonal style of the mental health professional may impact alliance and may also impact on the outcome of any interview or therapeutic encounter. [Previous researchers], for example, have reported that sex offenders evaluate their treatment more positively when therapists are perceived as ‘affiliative,’ and weaker when they are previewed as ‘controlling.’ At the same time, there have also ben suggestions that interviewers have to be flexible in their interpersonal approach; adapting their style in line with the interpersonal skills and attachment styles of the patient” (p.14).

“Ross et al. (2008) have also highlighted he possible influence of therapists’ expectations on offender treatment outcomes in correctional settings. They suggest that it might be harmful for clinicians to have too high or low expectations of patients, as they may feel a sense of frustration if their expectations are not met, or be less likely to create opportunities for change if they believe that the likelihood of success is low…preexisting knowledge of certain individual characteristics, such as violence risk level, previous treatment noncompliance or failures, therapy interfering behaviors, and records of negative client labels…can generate negative expectations and judgments, and thus adversely impact the quality of the therapeutic relationship…” (p.15-16).