These laws serve to alleviate public anxiety by asserting that we are able to “do something” about the problem, yet there is no evidence that this “something” is actually effective. Moreover, incarceration is enormously expensive. Estimates of bed need continuously rise because we cannot really define the end point of the mental abnormality that occasioned the confinements in the first place. Our best actuarial instruments for sexual offense risk assessment cannot take adequate account of response to interventions in reducing risk.
In 10 years, we will be more fully confronted with the dilemma of exhausted public resources for expanding confinement, and the use of this methodology will have crested. We will be forced to do what we should have done all along—which is to invest more extensively in research and the development of expertise in care and management of problem sexual behavior and to think more clearly and dispassionately about appropriate public policy.
Risk of violence
Similar problems will continue to plague us in the next decade regarding the issue of violent behavior by persons with mental illness. In the past 20 years, we have made substantial progress in our understanding of the relationships between mental health factors and violent behavior. We have seen growth in the accuracy of risk assessment using actuarial and structured clinical judgment instruments. But what we know does not truly assist us in our common clinical decisions because we are not able to make meaningful clinical distinctions among the populations of high-risk people that we serve on a daily basis.28
Improvements in our ability to make these distinctions are likely to be limited.29 We do not have adequate empirical investigation of dynamic risk or of the relationship of intraindividual changes with risk of violence.20 But we are coming to the realization that all the people we serve deserve the best treatment we have available, not just those we identify at highest risk for violence.28,30
Thus, in 10 years, scientific investigations are likely to be devoted extensively to dynamic risk research. The data will demonstrate the continued significant impact of active substance abuse and anger/irritability as important dynamic variables. To the extent that we can operationalize the measurement of dynamic functioning, certain functional deficits will be identified that correlate with violence. We will be more circumspect about applying group statistics to individual cases, and will be more conversant with intraindividual change as a better way to address the latter.
Mental health diagnoses or even particular symptoms will not emerge further as highly predictive of violence. This will encourage libertarian advocates for persons with mental illness who wish to restrict further the use of involuntary commitment for psychiatric care. There will be confusing and ill-conceived legal decisions about such matters, which will unfortunately—and wrongly—portray psychiatrists and patients as enemies. The adversarial uses of risk assessment research will provide heat, but not much light, in resolving these tensions.
We have not, and probably will not soon heed the advice of such scholars as Mullen31 and Lindqvist and Skipworth32 about the requirements for the ethical use of risk assessment in clinical practice. Their advice includes the notion that appropriate risk assessments must be linked to risk management strategies that ameliorate the risk and must always have the benefit of the patient in mind.
If we continue to talk so prominently in our literature about risk, we will fail to combat the stigma and fear produced by tragedies like Virginia Tech. Instead, we must take seriously the notion of function—which serves all persons who struggle with the effects of illness—without embracing models of fear and extrusion/confinement.33 We must ask what the rehabilitative task is for every individual who faces limitations and disability, and we must provide services equally to all who need them, without reference to risk.32
A decade from now, we will be further along this road because containment of people labeled as risks will be too costly and because further advances in dynamic risk research will not identify discrete groups of risky people (other than people who are actively using substances). Such advances will inform our clinical assessments of dangerous impairments in functional capacity and our interventions for functional improvement. With such knowledge, recovery ideology will finally have its practical evocation at the clinical level.