"Les incurables": How to approach treatment in forensic population?

Working with clients in forensic mental health is oftentimes more challenging than those in clinical care, especially when they can't be trusted or show little insight into their (offending) behaviour and/or related mental health issues. Hence, when discussing these types of clients in forensic mental health care, the often-posed question is whether they are treatable? Specifically, should we be hopeful about their improvement or are we treating "les incurables" and should we only focus on managing risk of recidivism? This chapter will reflect on such questions. First of all, we will discuss the overlap and differences between clinical and forensic mental health care, focusing on some challenges. Then, a current state of affairs of Forensic Mental Health Care (FMHC) is given, mainly focusing on systematic reviews and meta-analyses representing the most robust level of scientific evidence currently available. Within FMHC, a distinction can be made between programmes focusing on fixing the problem, reducing risk to recidivate, or treatment programmes that combine the two, with its focus being placed on more positive psychological aspects in rehabilitation. Overall, there are clear indications that FHMC can be effective in the context of primary outcomes like risk management, symptom reduction, but also well-being. Yet, the neglect of scientific research hampers its evolution. We will close this chapter with some cautionary notes regarding further development of FHMC, and with a realistic but also a hopeful conclusion.