Assessing the probability of patients reoffending after discharge from low to medium secure forensic mental health services: An inductive prevention paradox

Citizens of developed societies are troubled by those who commit ‘irrational' crimes against the person. Reoffending by ex-patients following their release from secure mental health services triggers particularly intense angst when amplified by media and political scrutiny. Forensic mental health service providers are expected to minimise the occurrence of such transgressions by releasing only those patients who are judged acceptably unlikely to reoffend. However, reoffending probabilities can only be estimated by observing behaviour in secure institutional settings designed specifically to prevent patients from transgressing. The article explores this ‘inductive prevention paradox' which arises when the implementation of measures designed to avoid an adverse event obscures direct observation of what might have happened if prophylaxis had not been attempted. The analysis presented draws on data obtained in 1999–2003 from two qualitative studies in medium to low secure UK institutions, one providing forensic mental health services and the other forensic learning disability services. We explored the views of 56 staff members and 21 patients about risk management in forensic services and undertook additional 25 staff interviews for case studies of the 21 patients. The wider applicability of the inductive prevention paradox will be considered in the Discussion. We argue that the prognostic limitations arising from prevention have been underestimated by policy makers and in official inquiries; and that the prevailing personal risk assessment framework needs to be complemented by greater attention to the environments which patients will be discharged into.