Victims as a concern for forensic psychiatrists Ghent group working group 20th September 2012

What prompted you to join the discussion on victims? Work with victims has been an aspect of my work, but there is little if any teaching about it and little discussion/opportunity for reflective practice in this area *** How to deal with victims as the ‘third party’ – what to do when approached by my patient’s victim(s) Becoming a recidivist victim? Victim history as a static factor/as a dynamic factor

Our interests - 2 The job is 100% with offenders, but they turn out to be victims too * in childhood * in adult life * of the system * of what they did *** Justice too often shifts from the victim to the perpetrator

Our interests - 3 Victim centred research offers a more accurate picture of crime rates, and some other aspects of crime, than offender centred measures *** How should victim services be funded and supported? What are victim aid work is forensic psychiatry specific? What training might we need for this?

What is a victim? A person who has suffered some form of substantial trauma – (illness or developmental disorder or physical or psychological harm from an external agent) and perceives him/herself to be a victim of such trauma and/or is perceived by others to be a victim of such trauma and is seriously impaired emotionally and/or functionally as a result

Our three chosen areas for detailed discussion The tension between the poles: My patient’s needs My patient’s victim’s needs Right because ethically correct Right because evidence based Victim experience is a static Risk factor Victim experience is a dynamic risk factor

A vignette Married man with pathological jealousy killed the man he suspected of having an affair with his wife about 10 years ago He is in hospital You are the ‘responsible clinician’ He remains unwell and discharge is unlikely He is due for a routine review of his detention Under new law, his victim’s wife is entitled to know about the review date When she finds out, she wants to speak to the man’s psychiatrist ; she thinks he should never be discharged and is prepared to go to the press

What if - He were better and ready for discharge? She suggests she has friends who would beat him up/kill him if he is discharged? She has never received any professional help or attention for her plight and has no-one to turn to for help? It sounds as though she is seriously depressed? She says she would love to make contact with him because she thinks she could help him to resettle? .......?

The key to appropriate management? A clinically sensitive way to separate physician roles for the patient and for the victim(s) This requires recognition of the multiple needs A system which is well enough resourced and flexible enough to provide for skilled input for the victim as well as the offender-patient Good enough resources and network outside the immediate system to allow for victim referral if necessary And which allows for clear and appropriate communication between the clinicians and other interested parties

But what is the evidence base for this? Accurate acquisition of individual case information Outcome data on interventions? Are we sure anyway what outcome we want? And how does this relate to what the victim wants? To what extent is relevant outcome data achievable in such circumstances? Does it matter and why?

What about more general outcome data about helping victims of crime? Inferences from other victim intervention studies? Do we have good enough models of what we want to achieve? * Prevention of PTSD/distress? * Relief of symptoms? * Accommodation to symptoms? * Safeguarding our own position?

Victim status It happened, nothing can change that It happened within a personal or social context which leaves the victim disproportionately vulnerable to * repeated victim experiences * psychopathology * becoming a victimiser * all of these things Impact on the clinician may limit appropriate responsiveness