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OXFORD SPECIALIST HANDBOOK OF
Forensic Psychiatry
OXFORD SPECIALIST
HANDBOOK OF

Forensic Psychiatry
SECOND EDITION

Nigel Eastman
Emeritus Professor of Law and Ethics in Psychiatry
St George’s, University of London
Honorary Consultant Forensic Psychiatrist
South West London & St George’s Mental Health NHS Trust

Gwen Adshead
Consultant Forensic Psychiatrist and Psychotherapist
Broadmoor Hospital

Simone Fox
Consultant Clinical and Forensic Psychologist
South London and Maudsley NHS Foundation Trust

Richard Latham
Consultant Forensic Psychiatrist
East London NHS Foundation Trust

Seán Whyte
Consultant Forensic Psychiatrist and Clinical Director
South-West London & St George’s Mental Health NHS Trust
Visiting Senior Lecturer, Institute of Psychiatry, Psychology &
Neuroscience, King’s College London

Hannah Kate Williams

Specialty Registrar in Forensic Psychiatry & Medical Psychotherapy
South-​West London & St George’s Mental Health NHS Trust
Great Clarendon Street, Oxford, OX2 6DP,
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Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
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contained in any third party website referenced in this work.
 Professor Nigel Eastman died unexpectedly in February 2022, while this work
was still in press. Prof. Eastman was a passionate and dedicated educator, and
his publications are a testimony to that passion, and the culmination of a life-
time of study, clinical practice and research. This book would not exist without
him and it is with both sadness and respect that we, his co-​authors and editors,
dedicate this book to him, as a posthumous thank you for the enthusiasm,
intellect and generosity that made it possible.

As for the first edition, this book is dedicated to the late Dr James
MacKeith, a compassionate forensic psychiatrist who dedicated his wisdom
and integrity to both the care of his patients and properly informing legal
process
 vii

Preface
The preface to the first edition of the handbook offered justification for ad-
dressing its ‘psychiatry and law interface’, alongside clinical forensic psych-
iatry, based upon the fact that UK practice of forensic psychiatry had, by
2012, substantially moved on from its largely clinical service roots. So that
‘forensic psychiatry’ had become, and now firmly is, concerned with both
the clinical discipline of assessing and treating mentally disordered offenders
and the meeting of law and all psychiatry, within the academic discipline
of ‘psycho-​legal studies’. Hence, now a significant proportion of higher
trainee forensic psychiatrists not only train in their clinical speciality but also
undertake some form of legal training, most commonly an LLM in Mental
Health Law; based upon recognition that clinical forensic psychiatry cannot
be practised effectively, or ethically, without a real understanding of how
psychiatry and law relate to one to the other (and often ‘don’t’). Whilst
some higher training schemes have developed ‘psycho-​legal workshops’,
which aim to offer ‘quasi experience’ at the interface between clinical psych-
iatry and law. And, most notably, the GMC New Curriculum for Forensic
Psychiatry includes the express requirement for forensic trainees (surely
also seniors) of gaining both ‘knowledge’ of a wide range of relevant law
and also ‘capabilities’ that are not only clinical but also ‘clinico-​legal’.
This second edition of the handbook is published alongside its companion
volume, the Oxford Casebook of Forensic Psychiatry. This offers a wide range
of ‘case problems’ across both ‘clinical forensic psychiatry’ and ‘law and
psychiatry’, as well as some related separate advisory text on ‘decision-​
making techniques’ and ‘critiquing paradigms for decisions taken’; with cross
referencing into this new edition of the handbook to enable the reader to
find information relevant to each case. It is also presented in a fashion that
allows for psychiatrists from other Commonwealth common law jurisdic-
tions to import their own particular law into the cases.
The necessity of understanding ‘law and psychiatry’ is not limited to
those who practice the designated speciality of forensic psychiatry. It ap-
plies to all psychiatrists who are regulated by, operate within, or make use
of law. And this is emphasised by the advancing scope and complexity of
mental health and mental capacity legislation, and their interface; making
increasingly ‘technical’ satisfying the duty of all psychiatrists not only to treat
their patients well clinically but also to pay proper regard to their civil rights.
The three domestic jurisdictions, plus the RoI, reflect each nation’s different
emphasis on individual freedom, paternalism, legalism, and public protec-
tion. So that, whilst their various mental health laws remain true to many of
the principles of the first very early Mental Health Acts, particularly medical
dominance within the legal process, the details have diverged in the four
jurisdictions. So that we lay out a detailed comparison of each of the four
jurisdiction’s law in regard to treatment of both mental and physical condi-
tions; including for Northern Ireland the new ‘fusion’ legislation expressed
by the MCA(NI) Act 2016, due soon to come into force. Notably, the UK
viii Preface

government has very recently published, post the Wessely Review, a White
Paper for its intended new Mental Health Act for England and Wales.
It is also not possible for criminal lawyers effectively to represent or pros-
ecute someone with a mental disorder, or for any civil lawyer to deal prop-
erly with a litigant in any legal context involving psychiatric evidence, without
a real understanding of both the nature of psychiatry and of its interface
with law. Hence, this handbook remains distinct from others in the OUP
series in addressing not one discipline but two, and the relationship between
them. As such it is intended therefore not only for trainees and senior prac-
titioners in forensic psychiatry, indeed all psychiatry, but also for all lawyers
who need to understand psychiatric concepts and thinking, and how they
relate to law and legal process.
The justification for a second edition of the handbook lies not only in its
‘companion’ relationship with the Oxford Casebook but also in the substan-
tial legal, research, clinical, and service developments that have occurred
since publication of the first edition.
The first edition was published very soon after the partial defences to
murder had been reformed in England and Wales, based upon the recom-
mendation of Law Commission that particularly ‘diminished responsibility’
should be made much more congruent with psychiatry. With the implica-
tion also that there should be less room for jury decision-​making not prop-
erly underpinned by expert evidence. However, in a number of important
cases the Court of Appeal has been highly resistant to this change, and
effectively has dragged the law back towards its perhaps natural, and more
comfortable, incongruence with medicine, expressed in reiteration of the
traditional ‘primacy’, even ‘exclusivity’, of the jury, so as to render the prac-
tical impact of the reform minimal. We also further describe developments
in the law of insanity, automatism, and intoxication, as well as in regard to
‘joint enterprise’; with an update also on the law of self-​defence in Irish law.
And there is new law in England and Wales on both ‘coercive control’ and
‘slavery’. We have also updated our treatment of safeguarding in light of its
new statutory basis. In regard to civil rights, there is new law on ‘deprivation
of liberty safeguards’, and the boundary between applying the MHA and
MCA, and on Article 2 of the ECHR, plus further developed extradition
case law. We also now give law relating to the regulation of medical prac-
tice, including expert witness practice, enhanced space.
The Sentencing Council helpfully published in 2020 Sentencing Offenders
with Mental Disorders, Developmental Disorders, or Neurological Impairments.
Although this emphasises ‘culpability’ over ‘safety’, including perhaps
privileging ‘hybrid orders’ over ‘hospital orders’. The Guidance not only re-
quires expert witnesses to offer reports written in its terms, but also pre-
sents ethical challenges to such experts. It also has potential implications
for services.
In line with our intention to render both the handbook and the case-
book further applicable to non-​ UK common law jurisdictions in the
Commonwealth, this edition also deals with the death-​penalty and related
capital jurisdiction practice.
Relevant epidemiological knowledge has advanced a good deal since the
first edition was published, particularly expressed through a number of
 Preface ix

well-​designed systematic reviews which allow us to be better able to quan-

tify the magnitude by which various mental disorders affect the risk of vio-
lence, and, perhaps more importantly, to examine hypotheses about how
much other factors such as socioeconomic status, family environment, and
substance misuse do (or do not) explain away increased risks of violence
for some mental disorders. For this reason, the clinical pages have changed
substantially, with updated epidemiological data and with many questions
posed in the first edition now answered, on occasion leading to new under-
standing that contradicts what was common understanding at the time of
publication of the first edition. We have also included reference to recent
research about the effectiveness of various treatment programmes dis-
cussed in the first edition, for example sex offender programmes, whilst
highlighting some gaps upon which the next generation of researchers might
focus their efforts. Forensic psychotherapy was inadequately dealt with in
the first edition, and we hope that we have now rectified this.
Clinically we have enhanced our treatment, in relation to offending, of
developmental disorders, including autism, ADHD, and intellectual dis-
ability; neuroscience; dementia; traumatic brain injury; genetic disorders;
and sexsomnias. We have also included more about marginalised groups,
with new pages on ethnicity, transgender issues, and old age psychiatry
within forensic psychiatry. Of particular importance, we have now given
more space to physical health in secure forensic settings, given the vexed
problem of weighing risk management against causing iatrogenic disease.
Whilst we have brought together and updated topics previously scattered
throughout the first edition. We also have added new topics, including ‘rad-
icalisation’ and its relationship with mental disorder (if any), given expansion
of the government’s Prevent and Channel anti-​radicalisation programmes
into health and social services; plus new drugs of misuse, including ‘legal
highs’; and ‘gangs’.
The issue of ‘integrated’ versus ‘parallel’ service provision has now
largely been settled in favour of extending specialist service provision into
the community (perhaps logically so, in that assessing and managing risk is
the more difficult in that context). Alongside some geographically prox-
imate comprehensive forensic mental health services seeking efficiencies
and economies of scale by forming ‘service partnerships’. Whilst, in regard
to the issue of ‘prison versus hospital’ service provision for offenders with
severe personality disorder, DSPD within hospital has been abandoned, in
favour of an OPD pathway favouring prison, with some medium secure
and very limited high secure provision. We have also now included infor-
mation about new assessment tools, both in regard to appropriate secure
placement of patients and in regard to sexual offenders with intellectual
disability.
As regards diagnostic aids, DSM-​IV has become -​5, and ICD has become
11, and we of have course taken account of this. Although, to economise
on space, this edition now refers the reader to those volumes, or to the
Handbook of General Psychiatry, for detailed description of categories, ra-
ther than reproducing them within the handbook. Both DSM-5 and ICD11
are referred to in the book, but with a focus primarily on DSM-5.
x Preface

We hope that this new edition of the handbook will make a further con-
tribution to enhanced understanding and enjoyment of the ethical practice
of forensic psychiatry, and to the practice of lawyers who have to deal with
mentally disordered individuals subject to criminal or civil law.
NE
GA
SF
RL
SW
HKW
London
August 2021
 xi

Acknowledgements
In compiling and writing this handbook we have benefited from the hard
work and good advice of a considerable number of our colleagues and
friends, and from the support of our families and employers. We would like
to thank in particular the following psychiatrists, psychologists, barristers,
solicitors, judges, academics, and other colleagues for their support and for
giving of their time so freely to comment upon drafts of parts of the hand-
book, and to suggest corrections and improvements:
Dr Ali Ajaz
Ms Jo Bownas
Dr Bee Brockman
Mr Michael Botham
Mr Chris Butterfield
Dr Bernard Chin
Ms Emma Chandra
Prof John Crichton
Dr Hannah Crisford
Dr Rachel Daly
Prof Kimberlie Dean
Dr Mayura Deshpande
Dr Claire Dimond
Dr Bridget Dolan QC
Ms Lorna Downing
Dr Simon Duff
Ms Mhairi Fleming
Dr Alasdair Forrest
Dr Rachel Gibbons
Dr Emily Glorney
Dr Adrian Grounds
Prof Gisli Gudjonsson
Dr Az Hakeem
Dr Nick Hallett
Ms Stephanie Harrison QC
Mr Anthony Haycroft
Dr Eleanor Hind
Dr Nick Hindley
Ms Julia Houston
Prof Harry Kennedy
Prof Michael Kopelman
Dr Sanya Krijes
Ms Julia Krish
Dr Tina Irani
Dr Sarah Mackenzie Ross
Ms Heldi McCaskill
Prof Amina Memon
Prof Gill Mezey
xii acknowledgements

Dr Anna Motz
Dr Catherine Penny
Prof Derek Perkins
Dr Danny Riordan
Mr Mark Simpson
Dr Andrew Smith
Dr Huw Stone
Dr Derek Tracey
Prof Birgit Völlm
Ms Connie Wernham
Mrs Lisa Whyte
Mr Brian Williams
Dr David Alun Williams
Prof Huw Williams
We would also like to thank trainees from the South London Higher Training
Scheme in Forensic Psychiatry who read some parts of the handbook
alongside ‘test-using’ cases in the companion Oxford Casebook of Forensic
Psychiatry; also Rachel Goldsworthy, Lauren Tiley, and Pete Stevenson at
OUP for their advice, support, patience, and hospitality.
 xiii

Contents

Abbreviations xv

Part I Introduction to the handbook

1 Introduction to the handbook 3

Part II Clinical forensic psychiatry

2 Clinical and social aspects of crime 19
3 Mental disorders in forensic psychiatry 71
4 Assessment in forensic psychiatry 121
5 Risk assessment 163
6 Treatment 181
7 Risk management 237
8 Forensic psychiatric services 255

Part III The ethics of forensic psychiatry

9 Ethical decision-​making 281
10 Professional duties and personal integrity 293
11 Conflicting ethical values 311
12 Clinical matters raising ethical issues 327

Part IV Law relevant to psychiatry

13 The interface between psychiatry and law 351
14 Legal systems 361
15 Criminal law 397
16 Mental health and mental capacity law 461
17 Civil law 547
 xiv Contents

Part V Psychiatry within the legal system0

565 18 The criminal justice system
601 19 Legal tests relevant to psychiatry
651 20 The psychiatrist in court
661 21 Applied ethics and testimony
677 22 Providing reports
711 23 Giving evidence

Part VI Appendices
731 Appendices

Index 789
 xv

Abbreviations
5HT 5-​Hydroxy Tryptamine (also BPD Borderline Personality
known as serotonin) Disorder
AA Alcoholics Anonymous BPSD Behavioural and Psychological
ABC Antecedents, Behaviours, Symptoms of Dementia
Consequences CAF Common Assessment
ABH Actual Bodily Harm Framework
ABI Acquired Brain Injury CAMHS Child & Adolescent Mental
Health Services
AC Approved Clinician (E&W)
CARATS Counselling, Assessment,
ACCT Assessment, Care in Custody, Referral, Advice, and
and Teamwork Throughcare Services
ACE Adverse Childhood CAT Cognitive Analytic Therapy
Experiences
CBT Cognitive-​Behavioural Therapy
ACS Abel Cognitions Scale
CCE Child Criminal Exploitation
ADHD Attention Deficit Hyperactivity
Disorder CCG Clinical Commissioning Group
(England)
ADMCA Assisted Decision-​Making
(Capacity) Act 2015 (RoI) CCRC Criminal Cases Review
Commission (UK)
AMCP Approved Mental Capacity
Professional (E&W) CD Clinical Director/​Conditional
Discharge/​Conduct Disorder
AMHP Approved Mental Health
Professional (E&W) CE of the Common Era
(equivalent to AD, Anno
AMP Approved Medical Practitioner Domini)
(Scotland)
CFT Community Forensic Team
AOT Assertive Outreach Team
CHAT Comprehensive Health
AP Approved Premises Assessment Tool
APA American Psychiatric CID Criminal Investigation
Association Department
ART Aggression Replacement CJD Creutzfeld-​Jacob Disease
Training
CJS Criminal Justice System
ASBO Antisocial Behaviour Order
CLIA Criminal Law (Insanity) Act
ASD Autistic Spectrum Disorder 2006 (RoI)
ASPD Antisocial Personality Disorder CMHT Community Mental
ASR Annual Statutory Report Health Team
ASSET Assessment Tool (used CoP Court of Protection (E&W)
by YOTs) Coru ‘Fair’, the Health & Care
ASW Approved Social Worker (NI) Professional Regulator (RoI)
AWIA Adults With Incapacity CPA Care Programme Approach
(Scotland) Act 2000 (E&W), Continuing Power of
BAME Black, Asian, and Attorney (Scotland)
Minority Ethnic CPD Continuing Professional
BCE Before the Common Era Development
(equivalent to BC, Before CPN Community Psychiatric Nurse
Christ) CPS Crown Prosecution
BCS British Crime Survey Service (E&W)
BMI body mass index CPSA Criminal Procedure (Scotland)
Act 1995
xvi Abbreviations

CQC Care Quality Commission EPSE Extra-​pyramidal Side Effects

(England) EQUIP Equipping Peers to Help One
CRPD UN Convention on the Rights Another
of Persons with Disabilities ERASOR Estimate of Risk of Adolescent
CSA Child Sexual Abuse Sexual Offence Recidivism
CSE Child Sexual Exploitation ETS Enhanced Thinking Skills
CSO Community Support Officer EU European Union
CT Computed Tomography EUPD emotionally unstable
CTO Community (E&W)/​ personality disorder
Compulsory Treatment Order E&W England & Wales
(Scotland) EWO Education Welfare Officer
CU Callous-​Unemotional FASD Foetal Alcohol Spectrum
DA Dopamine, or Dopaminergic Disorder
DBS Deep Brain Stimulation FBI Federal Bureau of
DBT Dialectical Behaviour Therapy Investigation (US)
DHSC Department of Health & Social FCAMHS Forensic CAMHS
Care (E&W) FFT Functional Family Therapy
DoJ Department of Justice (RoI) FIPP Firesetting Intervention
DoL deprivation of liberty Programme for Prisoners
DoLS Deprivation of Liberty FME Forensic Medical Examiner
Safeguards (E&W) (formerly known as police
surgeon)
DMP Designated Medical
Practitioner (Scotland) FMHU Forensic Mental Health Unit
DPP Director of Public fMRI Functional Magnetic
Prosecutions Resonance Imaging
DSM-​5 APA Diagnostic and Statistical FRQ Forensic Restrictiveness
Manual, 5th Edition Questionnaire
DSPD Dangerous & Severely FSH Follicle-​Stimulating Hormone
Personality Disordered FTTMH First Tier Tribunal (Mental
DTO Detention and Training Health) (E&W)
Order (E&W) GAD Generalised Anxiety Disorder
DVLA Driver and Vehicle Licensing GBH Grievous Bodily Harm
Agency (UK) GCS Glasgow Coma Scale
DVPO Domestic Violence Prevention GMC General Medical Council (UK)
Order (UK)
GnRH gonadotrophin releasing
ECG Electrocardiogram hormone
ECHR European Convention on GP General Practitioner
Human Rights & Fundamental
Freedoms GRC Gender Recognition
Certificate
ECtHR European Court of
Human Rights HCA Health Care Assistants
ECT Electroconvulsive Therapy HCP Health Care Professional
EDR Expected Date of Release HCPC Health & Care Professions
Council (UK)
EEG Electroencephalogram
HCPTS Health & Care Professions
EGVE Ending Gang Violence and Tribunal Service (UK)
Exploitation
HCR20 Historical, Clinical & Risk
EIS/​T Early Intervention (in Management 20-​Item Scale
psychosis) Service/​Team
HIW Healthcare Inspectorate Wales
EMDR Eye Movement Desensitisation
Reprogramming HLA human leukocyte antigen
EPA Enduring Power of HMP Her Majesty’s Prison
Attorney (RoI) HMPPS Her Majesty’s Prison and
Probation Services
 Abbreviations xvii

HMRC Her Majesty’s Revenue and LPS Liberty Protection

Customs Safeguards (E&W)
HoNOS Health of the Nation LREC Local Research Ethics
Outcome Scale Committee (UK)
HR Human Resources LSU Low Secure Unit
HSE Health Service Executive MACI Millon Adolescent Clinical
(Ireland) Inventory
IAPT Improving Access to MAO Monoamine Oxidase (MAOA,
Psychological Therapies type A; MAOB, type B)
ID Intellectual Disability MAPPA Multi-​Agency Public Protection
ICD11 WHO International Arrangements (E&W,
Classification of Diseases, 11th Scotland)
Edition MAPPP Multi-​Agency Public
ICJ International Court of Justice, Protection Panel
The Hague MARAC Multi-​Agency Risk Assessment
ICS Integrated Care System (UK)/​ Conferences
Indefinite Custodial Sentence MASH Multi-​Agency
(NI), Indeterminate Custodial Safeguarding Hub
Sentences MBT Mentalisation-​Based Therapy
IM Impression Management MC Medical Council (RoI)
IMCA Independent Mental Capacity MCA Mental Capacity Act
Advocate (E&W) 2005 (E&W)
IMHA Independent Mental Health MCANI Mental Capacity Act
Advocate (E&W) (Northern Ireland) 2016
IMR Inmate Medical Record (in MDO Mentally Disordered Offender
prison)
MDT multidisciplinary team
IPP Indeterminate sentence of
imprisonment for Public MHA Mental Health Act (E&W
Protection 1983; RoI 2001)
IPS Individual Placement and MHC Mental Health Commission
Support (NI, RoI)
IPT Interpersonal Therapy MHCTA Mental Health (Care and
Treatment) (Scotland)
IPV Intimate Partner Violence Act 2003
IQ Intelligence Quotient MHNIO Mental Health (Northern
IRA Irish Republican Army Ireland) Order 1986
IRMS Integrated Risk Management MHO Mental Health Officer
Services (Scotland; a social worker)
IRRMS Intensive Risk and MHRT Mental Health Review Tribunal
Rehabilitation Managements (NI, RoI)
Services MHT Mental Health Tribunal
ISSP Intensive Supervision and (Scotland)
Surveillance Programme MHU Mental Health Unit (of the
IT Information Technology Ministry of Justice, E&W)
JP Justice of the Peace MI Motivational Interviewing (or
LA Local Authority Mental Illness)
LALY Liberty-​Adjusted Life Year MoCA Model of Creative Ability
LD Learning Disability MoHO Model of Human Occupation
LED Licence Expiry Date MoJ Ministry of Justice
LH Luteinising Hormone MPCS MacArthur Perceived
Coercion Scale
LHB Local Health Board (Wales)
MPTS Medical Practitioners Tribunal
LPA Lasting Power of Service (UK)
Attorney (E&W)
xviii Abbreviations

MREC Multi-​centre Research Ethics PCSO Police Community Support

Committee (UK) Officer
MRI (Structural) Magnetic PD Personality Disorder
Resonance Imaging PDS Paulhus Deception Scale
MST Multi-​Systemic Therapy PED Parole Eligibility Date
MSU Medium Secure Unit PET Positron Emission Tomography
MWC Mental Welfare Commission PICU Psychiatric Intensive Care Unit
(Scotland)
PIPE Psychologically Informed
NA Narcotics Anonymous (or Prison Environment
Noradrenaline)
PPANI Public Protection
NAPO National Association of Arrangements for Northern
Probation Officers (E&W) Ireland (cf. MAPPA)
NCA National Crime Agency PPD Paranoid Personality Disorder
NCISS National Council of PPG Penile Plethysmograph
Investigation and Security
Services (US) PREM Patient-​Related Experience
Measure
NDD neurodevelopmental disorder
PRN Pro Re Nata (as required)
NFA No Fixed Abode/​No
Further Action PROM Patient-​Related Outcome
Measure
NHS National Health Service (UK)
PSA Professional Standards
NI Northern Ireland Authority
NICE National Institute of Health PSR Presentence Report
and Clinical Excellence (UK)
PTSD Posttraumatic Stress Disorder
NIMHE National Institute for Mental
Health (England) QALY Quality-​Adjusted Life Year
NMBI Nursing & Midwifery Board of QTc Q-​T interval (corrected for
Ireland (RoI) heart rate)
NMC Nursing & Midwifery RA Responsible Authority
Council (UK) RC Responsible Clinician (E&W)
NPD Non-​Parole Date RCPsych Royal College of
NPS National Probation Psychiatrists (UK)
Service (E&W) RDS Research Development and
OASys Offender Assessment System Statistics
OCD Obsessive-​Compulsive REBT Rational emotive behavior
Disorder therapy
ODD Oppositional Defiant Disorder REC Research Ethics Committee
OLR Order for Lifelong Restriction RoI Republic of Ireland
ONS Office for National RMA Risk Management Authority
Statistics (UK) (Scotland)
ONSET An Assessment Tool Used RMO Responsible Medical Officer
by YOTs (Scotland, NI)
OPD Offender with Personality RMP Registered Medical
Disorder Practitioner
OT Occupational Therapy R&R Reasoning & Rehabilitation
programme
PACE Police and Criminal Evidence
Act 1984 (E&W) /​Order RSA Road Safety Authority
1989 (NI) (RoI)
PCC Police & Crime Commissioner RSU Regional Secure Unit (may
comprise both MSU and LSU)
PCL-​R /​ -​YV Psychopathy Checklist
(Revised /​Youth Version) RSVP Risk of Sexual Violence
Protocol
PCN Primary Care Network
(England)
 Abbreviations xix

SAMM Support After Murder and TC Therapeutic Community

Manslaughter TCO Threat Control Override
SAVRY Structured Assessment of TD Tardive Dyskinesia (Persistent
Violence Risk in Youth Oro-​facial Dyskinesia)
SCPO Serious Crime Prevention TDCS Transcranial Direct Current
Order (UK) Stimulation
SDE Self-​Deceptive Enhancement TOMM Test of Memory Malingering
SED Sentence Expiry Date TPIM Terrorism Prevention and
SFT Schema-​Focused Therapy Investigation Measure (UK)
SHPO Sexual Harm Prevention TWOC Taking (a Vehicle) Without
Order (UK) Consent
SIFA Screening Interview for UK United Kingdom
Adolescents UN United Nations
SMI Severe (and enduring) Mental US United States (of America)
Illness
VAF Vulnerability Assessment
SNASA Salford Needs Assessment Framework
Schedule for Adolescents
VBP Values-​Based Practice
SOAD Second Opinion
Appointed Doctor VOO Violent Offender Order (UK)
SOAP Sex Offender Assessment Pack VRAG violence risk appraisal guide
SOTP Sex Offender Treatment WEMSS Women’s Enhanced Medium
Programme Secure Service (E&W)
SPECT Single Photon Emission WHO World Health Organisation
Computed Tomography WMA World Medical Association
SPR Scope of Parental WPA Welfare Power of Attorney
Responsibility (Scotland)/​World Psychiatric
SQIFA Screening Questionnaire Association
Interview for Adolescents YISP Youth Inclusion and
STC Secure Training Centre Support Panel
STEPPS Systems Training for Emotional YJA/​B Youth Justice Agency (NI) /​
Predictability and Problem Board (E&W)
Solving YJS Youth Justice System (cf. CJS)
SVP sexually violent predator YOI Young Offender Institution
TBI Traumatic Brain Injury YOT Youth Offending Team
TBS Terbeschikkingsteling (Dutch YRO Youth Rehabilitation Order
system similar to DSPD)
 Part I

Introduction
to the
handbook

1 Introduction to the handbook 3

 3
Chapter 1

Introduction
to the handbook
Welcome 4
Using this handbook 6
Clinical forensic psychiatry and legal psychiatry 8
Forensic services and teams 10
Who became the forensic psychiatrists? 12
History & future of forensic psychiatry 14
4 Chapter 1 Introduction to the handbook

Welcome
We hope you enjoy this second edition of the Oxford Specialist Handbook
of Forensic Psychiatry; we have enjoyed writing it. Whether you are an es-
tablished psychiatrist brushing up on the Pritchard criteria (p.602) before
entering the witness box, a trainee psychiatrist drafting your first risk as-
sessment (p.164) or a lawyer looking for guidance on the likely quality of a
psychiatric expert witness (pp.654–659), we hope you will find it a useful
and reassuring pocket guide.
The model of the handbook is unchanged. However, it is now accom-
panied by a companion volume, the Oxford Casebook of Forensic Psychiatry,
intended to give practical decision making guidance on the use of the infor-
mation set out in the handbook.
Forensic psychiatry, which expresses a domain of medical jurisprudence,
comprises offending behaviour in mental disorder (clinical forensic psych-
iatry), plus law in relation to all psychiatry (legal psychiatry): it is an ‘inter-
face’ discipline. The handbook and casebook aim to be equally useful to
clinicians, lawyers, and judges operating on either side of that interface.
No page covers a topic comprehensively, as this would lead to vast dupli-
cation, with the same points being raised on many different pages to which
they are relevant. Instead, we have cross-​referenced between pages.
We have used the following conventions throughout the handbook:
• Abbreviations are used wherever you would encounter them in clinical
or legal practice. You can find a list of abbreviations on p.viii.
• We indicate cross-​referenced topics by underlining, followed by the
page number in brackets (e.g. functional psychosis, p.72).
• Diagnostic terms are those of the DSM-​5 (p.144) except where
otherwise specified.
We have relied heavily on the work of a large number of other authors in
the compilation of this handbook, without space for detailed referencing.
We thank them all, and acknowledge their copyright in their work. That
said, any errors or omissions are our responsibility alone. If you would like
to give us feedback, correct a mistake, or make a suggestion, you can do so
at www.oup.com/uk/academic/ohfeedback.
A note on jurisdictions
Law and aspects of legal systems relevant to the forensic psychiatrist differ
from one country to another. Our primary focus is on the three UK jurisdic-
tions (England & Wales, Scotland, and Northern Ireland), plus the Republic
of Ireland (RoI). However, the companion casebook is, by its design, cap-
able, we hope, of use across a wide range of Commonwealth and other
common law (p.368) jurisdictions.
Welcome 5
6 Chapter 1 Introduction to the handbook

Using this handbook

Our philosophy
This book is for everyone who is interested in, or encounters practitioners
of, forensic psychiatry and related disciplines. It focuses on the relationship
between psychiatry and law, and the clinical practices that underpin it.
We aim to enable readers to find out some of the key facts and issues
within a given topic simply, rapidly, and in an easily digestible form. The
handbook therefore promotes brevity and ease of reference, at the ex-
pense of detail, and with some over-​simplification. For example, the preva-
lence figures for the mental disorders listed on pages 72 to 119 are derived
from a variety of studies that use different definitions of the disorders in
question, occasionally use different prevalence periods (although it is usually
one year), and cover different populations.
Organisation of the handbook
The handbook is divided into four main parts (II to V), which are intended
to be complementary in presenting both clinical forensic psychiatry and legal
psychiatry. We have used detailed cross-​referencing of topics.
A clinician dealing with a man exhibiting personality disorder (PD) might
begin by looking at pages within Part II dealing with the clinical assessment
and treatment of PD and its behavioural manifestations from a specific fo-
rensic perspective, then be cross-​referred to pages in Part IV for informa-
tion about a criminal charge and process faced by their patient, and then
refer to Part V for information about legal tests to which PD might be rele-
vant. They might later wish to seek guidance in Part III on how they might
ethically decide whether to recommend treatment in hospital, in the know-
ledge that the risk assessment could be used by the court instead as a basis
for the imposition of indeterminate penal sentencing.
A lawyer dealing with the same man, as a defendant, might look for guid-
ance in understanding the clinical concepts in the psychiatrist’s court report,
or the risk assessment offered to the court, within Part II, and then be re-
ferred to pages in Part V, concerning the court report and how it might be
probed in cross-​examination.
Our approach to the law
Although we have written extensively about many areas of law in the hand-
book, we have self-​consciously not tried to write a legal textbook. The aim
of the handbook is to summarise and describe areas of law of relevance
to the interface between law and psychiatry (p.351). This necessarily im-
plies that we do not always write in the technically precise manner of legal
texts. However, by sometimes adopting a different approach we hope that
the handbook will be of use to both medical and legal experts, from their
different sides of the frontier. Where we refer to a legal case its citation ap-
pears either immediately within the text or, if the case is either particularly
important or the relationship between its clinical psychiatric aspects and
legal issues is of particular interest, then both the citation and a summary of
its facts and legal analysis appear within the appendix, Legal Cases.
 Using this handbook 7

One of the difficulties of writing a handbook of psychiatry and law is that

fact and opinion in both fields is changing rapidly, particularly in the UK and
Ireland, in the early years of the twenty-​first century. We have tried to en-
sure that we have reflected accurately the position in the four jurisdictions
of the UK and Ireland as of mid-​2020, and have referred to impending
changes where appropriate.
8 Chapter 1 Introduction to the handbook

Clinical forensic psychiatry and

legal psychiatry
Clinical forensic psychiatry is concerned with the assessment and treatment
of mental disorder where it appears to be associated with offending be-
haviour. A clear understanding of law is therefore necessary in order to
practise clinically. For example, it is not possible to transfer your patient out
of the criminal justice system into hospital, or to write a report to aid your
client in compensation proceedings, without knowledge of the relevant law.
Legal psychiatry comprises all law relating to mental disorder and its
treatment and care. The relationship between psychiatry and the law is bi-
lateral, including the giving of psychiatric evidence in a wide variety of civil
and criminal legal contexts, and the use of law for clinical purposes and for
the regulation of clinical practice.
Why all psychiatry is forensic psychiatry
All psychiatrists must be acquainted with those areas of law that bear dir-
ectly on treating and managing their patients. These include mental health
and mental capacity law (pp.462–545), the law and procedures relating to
public protection (p.592, p.252, pp.296–301) and report-​writing (pp.678–710)
for courts and mental health tribunals. Psychiatrists do not need to become
‘quasi-​lawyers’, but they do need to be ‘frontier’ professionals capable of
recognising and understanding legal questions, knowing how to prepare evi-
dence relevant to those questions, and being capable of understanding how
lawyers and courts reason and make decisions.
Tensions between law and psychiatry
The purposes of a discipline and the interests of its practitioners determine
the constructs it uses. Constructs in psychiatry are determined by its pursuit
of human welfare, including through understanding disorder in order to re-
verse or manage it, or its effects. By contrast, law pursues abstract justice,
though it may sometimes involve balancing the welfare of different parties
against one another, or against societal welfare.1
Even within one discipline, different branches often give rise to different
approaches to determining constructs. For example, since criminal law is
concerned with culpability (p.354), its definitions of mental disorder are
characteristically tight, and address justice, not human welfare. By contrast,
the constructs utilised in sentencing, often focused upon determining the
degree of culpability, or relating to public protection, are more loosely de-
fined. In turn, these differ from the constructs of aetiology and treatment
used in Medicine and Psychology.
The balance struck between patient welfare and public protection is
bound to differ between mental health professionals and legal agencies.
Psychiatry and law address related concerns with potentially different values
(pp.281–291). Negotiating the interface (p.358) between the two is both
difficult and crucially important.

1 Justice from the perspective of the individual (i.e. proportionality, p.355, or ‘just deserts’). There
are other meanings to justice—​see the discussion on p.352 and elsewhere.
Clinical forensic psychiatry and legal psychiatry 9
10 Chapter 1 Introduction to the handbook

Forensic services and teams

Criminal justice and court services
Almost any professional group can offer forensic testimony. There are fo-
rensic entomologists and forensic accountants, as well as forensic patho-
logists. Psychologists and psychiatrists who give expert testimony act as
‘forensic’ professionals, regardless of their clinical practice.
Clinical mental health services for offenders may be offered by general
psychiatrists, rehabilitation psychiatrists, substance misuse services or any
psychiatrist working in a secure setting or court diversion service (p.268).
Mental health services in prison
British and Irish prisons receive mental health inreach services (p.270), pro-
vided in the UK by the NHS, and usually comprising community psychiatric
nurses and visiting psychiatrists, often with a dedicated healthcare centre.
Prisons may also ask for opinions from the catchment area psychiatrist (typ-
ically a general psychiatrist working in psychiatric intensive care, or a fo-
rensic psychiatrist if secure hospital treatment is thought necessary).
In addition to the psychiatric services into prisons, many prisons also re-
tain their own psychology service staffed by forensic psychologists.
Secure psychiatric services
The professionals who work in secure mental health services (p.258) include
the same disciplines expected in any mental health service, although often
in greater abundance. Some secure services will also employ forensic psych-
ologists because of their expertise in offender management programmes.
Generally, however, the distinguishing feature of any ‘forensic’ mental health
professional is that they have experience of working with severely mentally
disordered men and women, usually with long and/​or significant histories
of violence, and often in long-​stay residential care.
Specific staff groups found in forensic
multidisciplinary teams
Most clinical forensic MDTs consist of psychiatrists, psychologists, nurses,
occupational therapists, social workers, and sometimes a creative/​forensic
psychotherapist (e.g. music/​drama and/​or arts therapist).
Forensic psychiatrists are psychiatrists with further higher training in the
subspecialty of forensic psychiatry. Typically, though not always, they chair
or lead MDTs. They often hold legal responsibility for the patient as re-
sponsible clinician or responsible medical officer (RMO, p.468). They will be
supported by a specialist pharmacist.
Clinical psychologists working in forensic settings have undertaken general
training in Clinical Psychology to doctorate level. Within forensic services
they usually have expertise in risk assessment, and the use of specialist
psychological tools and treatment programmes that involve psychological
techniques such as cognitive and behavioural therapies (p.206). Psychology
services also include assistant psychologists who are professionals, who typ-
ically have an undergraduate degree but have not yet gained a place on
a clinical training course, and/​or trainee psychologists, who are currently
completing the doctoral course.
 Forensic services and teams 11

Forensic psychologists are, by training, quite distinct from clinical psych-

ologists, typically having a master’s degree in their subject. They usually
address offending behaviour, often not in the context of mental disorder.
Hence, they often carry out risk assessments and oversee the psychological
treatment programme for offenders (p.220), particularly in prisons. They
may or may not have general mental health experience.
The nurses (p.224) in forensic mental health services have different
roles depending on the service setting. Qualified nurses have a specialist
mental health nursing qualification and manage the more junior nursing
staff. Health care assistants may be unqualified; associate practi-
tioners may have an undergraduate degree (such as in Psychology) and
basic nursing training. Community teams include nurses whose role is to
make good therapeutic relationships with patients, and act in liaison be-
tween the patient, the patient’s carers and the rest of the MDT. In secure
residential settings, nurses also take the lead responsibility for relational se-
curity (p.224), together with specialist security staff who manage physical
and procedural security (p.190). They may have the best understanding of
patients’ mental state and thought patterns; they are also subject to the
greatest stress and anxiety in the MDT because of their prolonged close
patient contact.
The occupational therapist (p.228) is trained to understand the ef-
fects of mental disorder on work and creative function, and to offer inter-
ventions that promote recovery. They typically work closely with both
psychologists and nursing staff, especially in inpatient settings.
The social worker (p.226) in a forensic MDT may or may not have spe-
cialist forensic experience. They typically have a degree in social work; then
acquire mental health experience.
Forensic psychotherapists are trained psychotherapists (p.204) who
have specialised in working with mentally disordered offenders. They may
or may not be medically qualified. They may work in specialist services or
provide consultation and supervision for forensic multidisciplinary teams.
They may deliver individual or group interventions. There are few such
posts in the UK; emphasising the need for forensic psychiatrists to develop
some psychotherapeutic skills.
Probation officers (p.584) may be involved in supervision of mentally
disordered offenders in the community, usually in collaboration with mental
health professionals. Interventions may include measures aimed at risk re-
duction and rehabilitation. They also take on particular roles with sex of-
fenders, and commonly co-​ordinate sex offender interventions, sometimes
with mental health service involvement. They may work jointly with forensic
psychiatrists in the production of presentence reports.
Criminologists study crime and criminals, and do not, in the UK or
RoI, have direct involvement in the care of mentally disordered offenders.
The impact of criminological research is, however, widespread and seen
throughout this handbook, since many mentally disordered offenders are
driven to offend not only in the context of their mental disorder but also
by criminogenic factors.
12 Chapter 1 Introduction to the handbook

Who became the forensic psychiatrists?

The modern forensic psychiatrist combines up to three historical roles: the
physician tending the mentally unwell, the superintendent of the asylum,
and the expert witness to the court. Each of the three has its own origins.
Physicians
Physicians—​appliers of specialised knowledge in order to treat the sick,
distinct from a religious role of ministering to the sick—​can be recognised
as long ago as Egypt in the twenty-​seventh century BCE. A theme common
to early medicine across many cultures, including Europe, India, China, and
the Islamic world, is that physicians dealt only with physical health: mental
ill-​health was not seen as a ‘medical’ problem at all, but rather as a personal,
family one, mostly dealt with informally by extended family networks (ex-
cept for people who were rich or of high social status, who could afford
personal physicians to treat their mental illnesses). Only with the beginning
of the industrial era in the West from the eighteenth century onwards, and
the associated dislocation of families and disruption of kinship networks,
did mental illness become a social problem requiring the intervention of
specialised social actors and social institutions.
Asylum superintendents
People with mental illness who were poor or of low social status were
committed to lunatic asylums, which were originally nonmedical institutions.
Over time these went from being progressive institutions that aimed to
offer a human sanctuary to the distressed, to overcrowded ‘bins’ whose
chief aim was the removal of the obviously mentally ill from the streets.
Treatment was rarely available. Each asylum was presided over by a super-
intendent, who might or might not be medically qualified, but even if so, did
not treat inmates personally, but merely oversaw the unqualified ‘lunatic at-
tendants’. Nineteenth-​century asylums in the UK included those developed
specifically to deal with the ‘criminally insane’, first at the Bethlem Hospital
and then Broadmoor Hospital, built for the purpose.
Psychiatrists
With the dissemination in the early twentieth century of new scientific
(or sometimes pseudo-​ scientific) developments—​ such as Kraepelin’s
identification and classification of psychotic disorders, Charcot’s research
on hypnosis and hysteria and Freud’s establishment of psychoanalysis—​
practitioners of psychiatry, who now had an institutional home in the asy-
lums, were recognised as a single profession with a specialised body of
knowledge. Psychiatrists, now so called, edged out office-​based neurolo-
gists from the treatment of mental illness.
Psychiatry consolidated its professional position during the twentieth cen-
tury, with armies turning to it after the First and Second World Wars to
treat their ‘shell-​shocked’ soldiers (which led to the development of group
therapy, p.214), and with the discovery of antipsychotics (p.200)—​which
presaged the ascendancy of biological psychiatry and the side-​lining of psy-
choanalysis. During the latter half of the century, psychiatric subspecialties
developed alongside the biological/​psychoanalytic division, such as child
psychiatry, liaison psychiatry (providing advice and psychiatric care to pa-
tients of other medical specialties), and community psychiatry.
 Who became the forensic psychiatrists? 13

Forensic psychiatrists
The forensic subspecialty was a relatively late arrival, separating from main-
stream general psychiatry largely because of two developments, one in-
stitutional and one ethical. In the UK, although there had been an isolated
body of (with hindsight) recognisably ‘forensic’ practitioners in prisons and
the special hospitals (p.258), the development of the regional secure units
(RSUs, p.258) from the 1980s onwards led to the establishment of a group
of psychiatrists with a distinctively different role (i.e. caring for patients de-
tained in a secure hospital environment, or in prison), who were numerous
enough to develop their own subprofessional identity and their own Faculty
of the Royal College of Psychiatrists. In a very different vein, and partly
to sidestep any perceived compromise of their ethical position as doctors
(p.298), many psychiatrists in the USA who had traditionally concentrated
on assessment of defendants or litigants for the courts, rather than treating
patients, redesignated themselves as ‘forensicists’ and sought separate rec-
ognition in the American Academy of Psychiatry and Law. Thus, somewhat
divergent ethical and clinical traditions of forensic psychiatry were estab-
lished in the USA and Europe, according to whether the doctor’s primary
duty was seen as being to the patient or to the State via aiding the adminis-
tration of justice or public protection.
Expert witnesses
The role of the expert witness (p.652) can be traced back to the Roman
Empire, with courts accepting evidence from physicians, amongst others.
However, as dealing with mental illness was not yet seen as part of medi-
cine, judges and juries regarded themselves as competent to decide ques-
tions of insanity. Only in the nineteenth century, as asylums spread and
those administering them came to be seen as experts, did courts begin to
defer to psychiatric expert witnesses.
14 Chapter 1 Introduction to the handbook

History & future of forensic psychiatry

The origins of what are now called forensic psychiatric services are found
first in the provision of secure residential care for people with mental
illnesses who committed serious offences and second in concerns about
the mental health of prisoners.
Madness has been seen to be associated with unpredictable violence
since Roman times. However, until the nineteenth century, families were
largely responsible for the care of their dangerous relatives. Long before
the emergence of forensic psychiatrists (p.13), special facilities were created
to manage mentally disordered offenders. Chiefly because of the effects of
the Criminal Lunatics Act 1800 (p.462), two new wings of Bethlem Hospital
were opened in 1816 to accommodate high-​risk patients who needed long-​
term supervision in a secure setting. In 1853, Broadmoor Hospital (p.258)
was built to accommodate overcrowding in the Bethlem units, three years
after the Central Mental Hospital in Ireland, which took offenders as well
as other patients.
People with mental illness who offend
In Victorian times, mental health care focused on ‘asylum’, indefinite resi-
dential detention safe from the rest of society. It was envisaged that patients
would live in the hospitals for the rest of their lives, meaning many of the
early residents of Broadmoor Hospital would not now be seen as needing
high secure care. The concept of different levels of security need arose
in the wake of the closure of the county asylums, and increasing under-
standing of mental disorders as being treatable.
After the opening of two further high secure hospitals in England in the
twentieth century, plus the State Hospital in Scotland, there was, much
later, the development of RSUs (p.258) in the UK, as recommended by the
Butler inquiry (p.780) in 1974; it and other contemporaneous reports also
recommended increased provision for prisoners with mental health needs,
women patients, offender patients from different ethnic backgrounds and
offenders with PD, plus court diversion (p.268).
Mentally disordered men and women in hospitals who posed a risk
to others were managed exclusively by general psychiatrists until the
subspecialty of forensic psychiatry emerged in the 1970s. Thereafter, fo-
rensic psychiatrists took over the management of higher-​risk patients, whilst
leaving general psychiatrists to care for a large number of patients who still
posed a significant risk of harm to others.
Prisoners with mental health needs
Professional concerns about the risk posed by the mentally disordered pro-
ceeded in parallel with public health concerns about the mental wellbeing
of prisoners. Prisoners who became mentally ill in prison (or were ill on
arrival) needed to be transferred to psychiatric services secure enough to
prevent most escapes. In part, the development of secure mental health
services was driven by the results of epidemiological studies that showed
very high levels of mental illness and PD in prisons, most notably the ONS
studies (p.781).
 History & future of forensic psychiatry 15

Serendipity and disaster

The development of services for people who commit crimes whilst men-
tally disordered has often occurred in response to high-​profile ‘disasters’,
and associated public anxiety about the risk of violence that those with
mental disorders may pose—​rather than rational needs assessment (p.276).
However, most people with mental disorder do not commit violent crimes
(see p.44), and most prisoners who need mental health services are serving
sentences for nonviolent offences.
A good example of how service development can be driven by publi-
city rather than evidence-​based policy was the development of the former
DSPD services (p.781) in E&W. Over £140 million was spent developing
services for the needs of 2,000 men who were thought to be at espe-
cially high risk of violence. However, the programme was inefficient, and
much less effective in risk reduction than community substance misuse
and rehabilitation programmes. The hospital DSPD programme has been
scrapped, in favour of the offender personality disorder pathway, which
includes some hospital, but predominantly prison, provision.
The future of forensic psychiatry
The debate at the time of the Butler report about making prisons thera-
peutic institutions was rapidly won by those in favour of creating separate
secure hospitals instead. The debate then shifted to the extent to which the
secure hospitals and forensic psychiatrists should be separate from general
psychiatric hospitals and psychiatrists. Initially, there was almost complete
separation in the UK, and forensic institutions grew to consume almost 15%
of all NHS funding for mental health, despite treating fewer than 0.1% of
the patients receiving mental health care from the NHS.
This situation was clearly unsustainable both financially and ethically (as
it led to a sense that all the ‘bad objects’ were somewhere else), and there
has been gradual reintegration of forensic services, and forensic patients,
into mainstream psychiatry. This has had the beneficial effect of spreading
some forensic expertise into general psychiatry, with risk assessment and
legal knowledge being particular examples. However, complete integra-
tion would likely be unsustainable: medical services overall tend to become
more rather than less specialised because research consistently shows that
the best outcomes of complex interventions are obtained by practitioners
who practise it frequently rather than only occasionally.
 Part II

Clinical forensic
psychiatry

2 Clinical and social aspects of crime 19

3 Mental disorders in forensic psychiatry 71
4 Assessment in forensic psychiatry 121
5 Risk assessment 163
6 Treatment 181
7 Risk management 237
8 Forensic psychiatric services 255
 19
Chapter 2

Clinical and social aspects

of crime
Crime to the forensic psychiatrist 20
Prevalence and measurement of crime 22
Psychology & philosophy of volition 24
What is violence? 26
Social factors in crime and violence 28
Neurobiology of violence 30
Adverse childhood experiences 32
Unconscious factors in violence 34
Crime and violence from a developmental perspective 36
Gang crime 38
Ethnicity, crime, and psychiatry 40
Extremism, terrorism, & radicalisation 42
Do mental disorders cause violence? 44
Homicide 46
Nonfatal assaults 48
Fire-​setting behaviours 50
Stalking behaviours 52
Sexual offending and its social context 54
Sexual offending against adults 56
Sexual offending against children 58
Other types of sexual offending 60
Motivations for sexual offending 62
Other types of offending 66
Why divide violent & sexual offending? 68
20 Chapter 2 Clinical and social aspects of crime

Crime to the forensic psychiatrist

Forensic psychiatry and crime
Forensic psychiatrists are generally referred a subgroup of criminal of-
fenders, for either of two reasons:
Concerns that the offender is mentally disordered
• Where an alleged or convicted offender has a history of mental illness.
• Before trial (p.566), where mental disorder may be a ground for
diversion (p.268) on bail or while on remand.
• At sentencing (pp.442–444), when a treatment order (pp.500–502) is
considered.
• While an offender is serving a sentence, especially in prison (p.270).
• After an offender has been released and is under supervision.
Concerns that the offence is unusual and odd
• Crimes involving great or unusual cruelty to the victim.
• Crimes committed by someone unusual, such as a child or elderly
person.
• When a defence team hopes that a psychological explanation may
appeal to a jury or judge, and affect the likelihood of conviction (p.407)
or be taken in mitigation (p.638) of the offence.
• When the prosecution think that psychological or psychiatric testimony
may properly lead to an extended (pp.442, 448) or indeterminate
sentence (p.449) on risk grounds.
General psychiatric colleagues may also seek advice where a patient’s
mental disorder poses a risk of harm to others, and treatment may reduce
their risk of offending.
Conflicts and confusions
Forensic psychiatrists may disagree on their role in the criminal justice
system (pp.8 298):
• Some argue that their predominant role is to diagnose and treat
mental disorders, and only address risk of offending if it is
functionally linked to mental disorder.
• Others argue that their role is to assist in the psychological
explanation of serious crimes, and if possible to reduce the risk of
reoffending by whatever means, including nontherapeutic means.
Each position raises its own problems for the profession and for the indi-
vidual practitioner because the association between mental disorder and
violence (p.44) is not straightforward nor, usually, can the violence be man-
aged (p.240) solely by addressing the mental disorder; because British (or
at least English) society in particular expects forensic psychiatrists to con-
tribute to public protection (p.592) and because there are unavoidable eth-
ical role conflicts (pp.298, 314, 318) between being a doctor and working
with the criminal justice system. Each strand of opinion resolves these con-
flicts in its own way.
 Crime to the forensic psychiatrist 21

Violence, crime, and mental disorder

Crime statistics (p.22) provide a picture of criminal rule-​breaking behaviour.
The commonest type of criminal rule-​breaking is theft and other types of
acquisitive offences. Only 20% of recorded crime involves physical violence,
and only a minority of those offences will cause serious physical harm.
Debate continues as to whether violence is uncommon but normal be-
haviour (given its occurrence in all human societies) or whether it is an
abnormal behaviour arising from at least an unusual mental state (given its
comparative rarity as a form of social rule-​breaking). Whichever view is
taken, there is good quality evidence that some mental disorders can be
a risk factor for violence (pp.166, 180), usually in combination with other
risk factors.
22 Chapter 2 Clinical and social aspects of crime

Prevalence and measurement of crime

There are several difficulties in establishing how rates of crime differ, ei-
ther between different regions or in one place over time. Court records
and rates of conviction and imprisonment are of some use, but the most
reliable and commonly cited measures are national and international police
records of crime (e.g. the European Sourcebook) and household surveys of
victimisation (e.g. the British Crime Survey (BCS)). See Box 2.1

Box 2.1 Sources of comparative crime statistics

British Crime Survey
US National Crime Survey
European Sourcebook of Crime & Criminal Justice Statistics
Home Office Research Development & Statistics publications
UN International Crime Victims Survey
US Department of Justice World Factbook of Criminal Justice Systems

These measures give an indication of the frequency of specific crimes

and, if the crimes are repeated, the measures can be used to estimate
trends over time.
For example, the 2019-​20 BCS shows that the proportion of people who
were a victim of violent crimes was 1.6% in E&W, compared to 3% in 2007-​8.
More generally, it shows that total crime in all the UK nations, which rose in-
exorably throughout the twentieth century, has fallen steadily from 1996 to
the present. In RoI, by contrast, rates of violent crime have risen between
2010 and 2020, when over 2% of adults were victims of violence.
Comparative prevalence figures for different countries can be found on
pages for individual crimes (e.g. homicide, p.46; stalking, p.52; and sexual
assault, p.56). Some broad international patterns, all expressed as rates per
100,000 citizens per year, include:
• The clear gap in crime rates between continental European countries
and the ‘Anglosphere’ (USA, UK, Canada, Australia, and New Zealand)
that existed ten years ago has vanished: the former range from 21.6
(Switzerland) to 47.3 (France); the latter from 40.6 (Canada) to
47.7 (USA).
• The UK rate on the same survey is 44.5; RoI’s 45.7, and Sweden’s
surprisingly 47.4.
• The USA, Russia, and many Eastern European countries have higher
rates of murder (5.0–​8.2) than Australia, New Zealand, the UK, and
other Western European countries (0.7–​1.2).
• El Salvador has the world’s highest murder rate (52.0); all of the top-​ten
countries are in Central and South America, with the exception of South
Africa (36.4).
• Property offences such as burglary show a very different pattern from
violent offences, with for example the rate in otherwise peaceful New
Zealand (1353.6) being vastly higher than that in Eastern Europe and
Slovakia (83.0).
• In general, Middle Eastern and other Islamic countries report lower
rates of most crimes than Western or former Eastern Bloc countries.
 Prevalence and measurement of crime 23

• Finland arrests or cautions more of its population (8233.9) than

Anglosphere countries (USA 3152.3, New Zealand 2045.5, and Canada
2751.1); other European countries tend to have even lower rates.
The data from which such interpretations are made are not perfect.
Problems with official figures include:
• Misleading and internationally inconsistent definitions of crimes (e.g.
rape, p.56, includes consensual sex with a minor in the USA, whereas in
E&W this is a different crime: see p.58).
• Reported crime statistics can be inflated by multiple charges arising from
the same instance of crime, especially in property offences.
• Crimes may not be reported to the police. In 2017–18, only 11% of
violent crimes in E&W led to criminal charges. Under-​reporting may be
influenced by local culture and expectations (e.g. a man may not report
domestic violence by his wife, fearing stigma, or if reported, it may not
be recognised as ‘domestic violence’ but categorised differently).
• Changes in the reporting and recording of crimes may lead to a
misleading impression of increasing crime. For example, from 2015
to 2017 in the UK, the rate of police-recorded sexual offences and
violent crimes more than doubled. However, this trend was not seen in
the BCS.
• The statistics are typically collected for political reasons (e.g. to assess
the performance of the police service), not to describe social reality in a
neutral fashion.
• They are not a complete record of criminal offences known to the
authorities. For example, in E&W some include ‘Notifiable offences’
(those tried in a Crown Court, p.384) but not ‘Summary offences’
(those dealt with by lower courts).
• There are changes over time in what is counted for the purposes of
inclusion into the official records.
Victimisation surveys attempt to overcome these difficulties: typically sur-
veys of a randomly selected representative group conducted by a neutral
organisation. Their own limitations include:
• Omission of crimes without identifiable victims (e.g. fare evasion, drug
possession) or where victims cannot be surveyed (e.g. children).
• Recall and response biases determined by surveyed victims (e.g.
greater chances of remembering more traumatic crimes, or middle-​
class respondents might classify some acts as crimes that working class
respondents might regard as noncriminal behaviour).
Both sets of figures, some sociologists aver, cannot ever be reliable because
whatever their source they rely on someone interpreting and classifying a
series of events, and this process of the construction of meaning is inevit-
ably determined as much by social structures, ideologies, and values as by
anything intrinsic to the events themselves.
24 Chapter 2 Clinical and social aspects of crime

Psychology & philosophy of volition

Philosophy of volition
In Nicomachean Ethics, Aristotle argued that people are not responsible for
actions they have not freely chosen. This argument has continued to be the
basis for attributing criminal responsibility: essentially, you are only respon-
sible for actions that are under your volition (from the Latin, Volo, meaning
‘I want’, i.e. that you have freely chosen with knowledge of the meaning and
possible consequences).
Philosophical debates often address the extent to which people feel com-
pelled to do actions they do not really intend or whether you can be re-
sponsible for actions with unintended and unforeseen consequences. You
may be less to blame if you can show that you did not intend the outcome
of your choices or you intended some positive outcome (e.g. in palliative
care when giving high-​dose opiate medication that may relieve pain but also
hasten death).
Another philosophical debate involves the question of whether humans
are free to make choices. Some philosophers argue that all events (including
mental events) are caused by what preceded them, and, therefore, free will
does not exist or is an illusion. There are strong counter-​arguments against
this position: philosophers and lawyers have argued that free will, respon-
sibility, and determinism are metaphysical concepts that cannot be proved
through science. The law exists independent of scientific data to regulate re-
lationships between individuals, and the assumption of freely made choices
is crucial to social contracts and civic trust.
Neuropsychology of volition
Neuroscientists have attempted to study free will, using neuroimaging
to identify parts of the brain activated when people make choices. The
orbitofrontal cortex is differentially activated depending on whether the
choice-​maker feels that they are making a free choice, and neuronal activity
takes place before the choice-​maker is aware of making a choice. Whether
this means that the choice was truly ‘free’ depends upon whether the sub-
conscious parts of the mind involved are regarded as part of the ‘self ’ that
is making the choice.
It is often assumed that people choose actions rationally so as to maxi-
mise the probability of achieving their ‘best possible goals’. However,
studies suggest that humans use differing systems for analysing choices1 and
are influenced by many factors that are not always conscious or based on
unbiased appraisal of evidence.
It has been hypothesised by Damasio and others that, whereas long-​term
goals are selected consciously and through intellectual processes, emotional
processing is essential to volition, and that it is this discrepancy that explains
the common experience of repeatedly choosing something that conflicts
with one’s goals (e.g. overeating when trying to lose weight, smoking cig-
arettes when trying to quit or shopping for luxuries despite wishing to pay
off a large overdraft).

1 Collectively known as ‘system one’ in the work by Kahnemann and others, drawn on elsewhere in
the handbook, as opposed to the conscious, rational but slow ‘system two’.
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"No fear of that, sir," replied Trulock grimly.

Mr. Cloudesley found that the aged cab which was maintained at the
little hospital in High Fairford was fortunately at home, and so without
loss of time the two Garlands were carried off to Lady Mabel's Rest. The
crowd seemed rather disappointed when the children appeared at the
door, apparently uninjured; but the truth was now be coming generally
known, and there was great excitement in the town. One woman was
heard by Mr. Cloudesley to say with great solemnity,—

"And I bought a loaf from her only a week ago—think of that now, and
there she lies dead now!"

Mr. Cloudesley failed to see how the purchase of that particular loaf
affected the matter one way or the other, but he was very glad that he
had not allowed his pretty May to enter the house.

CHAPTER IX.
RALPH'S LETTER.

BY the time the cab reached Lady Mabel's Rest, Ruth Garland had quite
regained both her senses and her self-command. She was even ready
to lift Ollie out of the cab, but this Mr. Cloudesley would not allow her to
do.

"Why, Ruth," he said, "the boy is nearly as big as yourself; but you're an
ambitious little party, and think you can do everything. I'll whisk him into
the house before he can say Jack Robinson."

"But why should I say Jack Robinson?" inquired Ollie, laughing.

"Little boy," said Mr. Cloudesley, setting him gently on his feet in the hall,
"your education has been dreadfully neglected! You are seven years old,
and you never heard of Jack Robinson!"

"No, sir; is he in English history, or in Roman? No, he can't be in Roman

history; I suppose I have not come to him yet."

"Let me know what you think of him when you do," said Mr. Cloudesley.
"Now I must take the old cab back to the hospital; so good-bye, all of
you. Mr. Trulock, don't let Ruth sit up late to-night. Indeed, I am not sure
that I would not send her to bed, as well as Master Curlypate here."

Ollie was soon disposed of, Ruth contriving a comfortable bed for him by
the help of sundry pillows and a big chair cushion. Then the question
arose, where was a bed for poor Ruth herself?

However, Ralph bethought himself of kind Miss Jones, and never

remembered, in his anxiety to make Ruth comfortable, that he was
actually asking a favour of his neighbour! Miss Jones was delighted to
be appealed to, and lent everything that was wanted. She begged Ralph
to allow her to provide a nice meal for the two children that afternoon,
that he might have nothing to do but to take care of Ruth. Ollie was soon
fast asleep, and then it was that Ruth told her story. Ralph was rather
unwilling to let her speak of it at all, but she declared she should feel
better when she had told him.

"Poor Mrs. Cricklade!" she said; "you don't know what a kind-hearted
woman she was. When we first came to Fairford, she took so much
trouble about us, and let us live there rent-free. But when she found that
you were helping us, she began to drink again; she had never quite left
it off, but she only drank on Sunday, or quite late at night for some time;
now she began to drink much more. She made me pay rent, and yet
more than once she gave me back the shilling, and said, 'It's not me,
Ruthie, it's the devil that has possession of me that makes me take your
hard-earned shilling.' That was after she found out that you didn't pay
the rent for me."

"But I never knew that you paid rent, Ruth."

"No," she said, colouring. "You did too much for us already. But though
she gave me back the shilling, she generally came for it again at night,
and was so noisy and angry that she frightened me very much. Then
Ollie got ill, you know; and I pawned poor father's clothes to keep us
until I could get work again."

"But, Ruth, you had money laid by, dear," interrupted Ralph anxiously.

Ruth grew crimson, and tried to answer carelessly. "Very little of it was
left: the rent came out of it, and—other things."

"That wine for me," groaned Ralph, "and I never paid you. Oh, Ruth, you
ought to have told me."

"How could I, sir? you had been ill, you are nearly as poor as I am, and
you had given us so much help. I knew you had not the money, and that
you would pay me when you had it."

"I had plenty, dear child. Oh, I have been a fool! Never mind, Ruth, finish
your story now, and I can explain some other time."

"Well, you know the man could only give me a very little for father's
clothes, because of the risk of infection. I got five shillings the first day;
then I got three for other things. But after that, Ollie was so poorly that I
did not like to leave him, and I asked Mrs. Cricklade to go for me; and,
poor thing, she never would have done this if she had been quite
herself, but she came home quite tipsy, and told me she had lost all the
money except one shilling. And I had no coal left! I was so vexed that I
said, Oh, Mrs. Cricklade, you will not keep it from me! Do give me my
money, please.' But she was terribly angry, and she struck me and drove
me upstairs before her. I had to bolt our door to keep her out; and she
stood on the landing-place for ever so long, calling to me that I had
accused her of stealing. And after all, perhaps I was mistaken, and she
had really lost it. That was yesterday."

"Yes, and you had no fire, and it was a bitter night."

"I had no fire and no food, for I was afraid to go down again. But Ollie
was beginning to get well, you know; and this morning he said he was
hungry. I knew he ought to get food, so I ventured down. I had no water
left besides, and I thought she would be in bed, because it was very
early, quite dark still. I found the place all shut-up, and though I looked
about I could see no food of any kind (I knew she would not mind if I
borrowed from her for Ollie); so I went up again and coaxed Ollie to wait
until it was light. I thought that if I found the poor thing was not yet quite
recovered, I should not be so much afraid if it were light and people
were moving about, because I could call from the window."

"I think we both fell asleep, and when we awoke it was quite light, and I
ventured down again. I went to her door and knocked again and again,
but there was no answer. Then I went in, and she was asleep, I thought.
I spoke to her, shouted to her, but she never stirred; so I was frightened,
and was going away, when it struck me that she was very, very still. I
went back and took her hand. Oh, Mr. Trulock, it was so cold! I ran
upstairs to Ollie then; I was so frightened I did not know what I was
doing. And the next thing I knew was that you were giving me water.
How did you come there?"

"I should have come to see you before, my dear, only I had another
sharpish turn,—not so bad as the first, but I was afraid to be out, and I
little knew how things were with you. When I did get so far, I found the
place all shut-up. We had to get help to open it; and it was well that I
was able to go that morning, for—there's a knock. No, dear, don't you
stir. It is Miss Jones, I'm sure, and I'll let her in."

Ralph was so sure that the person who knocked was Miss Jones, that
he opened his door wide, standing aside to let her pass in with the
expected tray; and the visitor did pass in, but there was no tray, and, to
his horror, it was Mrs. Short! Taking advantage of his mistake, she
waddled up the little hall as fast as her rapidly increasing size would
permit, and was actually in the little parlour before Ralph had recovered
his senses. He rushed after her, and found her embracing Ruth with
every appearance of affection.

"You poor, unfortunate, ill-used child!" she panted out. "To think that to-
day, of all the days in the year, I should have gone to Derby to buy a
warm shawl; for as to choice of colours, there's no such thing at Price's,
but dum-ducketty-mud colour and greys, that looks like poorhouse folk.
My 'art bleeds for you, Ruth Golong. I'm that good-natured, I never could
bear malice. I know you behaved rude-like when you turned me out, as
one may say, when Mr. Trulock was so bad. But truly he was over the
worst of it by that time, and so it did him no harm getting a
unexperienced nuss instead of me. But there, I forgive and forget, Ruth,
my dear. I'm full of sympathy with you. And now tell me all about it. I'm
told the wicked old creetur beat you and half killed Ollie, and then killed
herself a-purpose; is that true, child? Is it true, Ruth Golong? Can't you
speak, child?"

"Ruth," said Ralph, "I think this noise may waken Ollie; you'd better go
and have a look at him."

"Mrs. Short," continued Ralph, "there will be an inquest to-morrow, and

Ruth will be the principal witness. So she must not be talked to about
the matter now. And Ollie has the measles, ma'am; did you ever have
them?"

"Oh yes, when I was a little gel."

"I've known several people have them a second time," remarked Ralph
thoughtfully; "and they go hard with people of a full habit, and not so
young as they have been."

Mrs. Short grew red with fear and anger mixed. "Good evening," said
she, "and I only hope you won't take 'em yourself, Mr. Trulock; for full
habit or no full habit, you're little or no better than a walking skelington,
and can't have it in you to throw out a rash handsome."

With this cutting remark she tossed her head and left the house, Ralph
laughing to himself as she disappeared. Before he could call Ruth down
again, Miss Jones and her tray made their appearance, and Ruth was
kissed and fed and put to bed, with the utmost tenderness, to a running
accompaniment of scolding that was wonderful to listen to.

The inquest took place next day. Ralph took Ruth to the house, and
Miss Jones sat with Ollie during their absence. Ruth's evidence was
given with such modest self-possession, and was so clear and plain,
that it did not matter that no one else could give any evidence at all,
except to the fact that the woman was dead. The verdict was "Died of
alcoholic poisoning;" and then the inquest was over, and nothing
remained but for the parish authorities to bury the poor remains of one
who had once been a kind-hearted, honest, hard-working woman. Ruth
had spoken so gratefully of her kindness, that the memory of a time
when Mrs. Cricklade was a pleasant neighbour was revived among the
listeners, and one woman said, as they all watched the funeral going up
the hill next morning,—

"Poor soul! She was a good creetur, for sure,—a kind body; no fault but
the drink."

"Ah, Mrs. Jeffars," said Miss Jones, who had been collecting Ruth's few
possessions, and was now at the door, "there's the misfortune. That one
fault swallows up all the good qualities one may happen to have. She
was a kind woman, as you say, and yet she took rent from that poor
child, and struck and abused her more than once. And she was an
honest woman too, and yet you see she took the child's money that she
was trusted with, to get drink. Whatever a person may have been, never
reckon on them, once they take to drinking; for the one thing that's
certain about a drunkard is, that he'll do anything to get the means of
drinking."

Miss Jones walked off down the hill, followed by a man carrying Ruth's
big trunk.

Mrs. Jeffars looked thoughtfully after her.

"She couldn't have known that I take it sometimes," she thought; "but I'll
never touch it again. I might go on and on, by degrees, until I ended like
that, and disgraced my Paul that's at sea. I'll go this very evening, God
helping me, and take the pledge—and I'll take the bottle, and leave it
with Mrs. Francis for the use of the hospital."

And she kept her word, and kept the pledge too; so Miss Jones had said
a word in season for once, at all events.

Ruth was far from well for some days, and Ralph felt very miserable.
The girl had been so badly fed, and so thoroughly chilled, that the shock
found her weak and nervous, and therefore had more effect upon her
than it would have had some weeks before. She could not sleep, and
every noise made her start violently, and turn quite sick and faint. The
doctor said, however, that there was nothing seriously wrong, and that
with care and quiet she would soon be quite herself again. And after
about a fortnight she was much better; and as to Ollie, he was as well as
ever again.

"Mr. Trulock," said Ruth, "don't you think I may go to Price's for work
again now? Ollie is quite well, and I think he may begin to go to school.
And—I wonder where I could find a lodging?" she asked slowly.

"Ollie had better not go back to school until after the Christmas holidays,
I think," said Ralph; "and as to the other matters, I will talk to you to-
morrow, Ruth."

And taking his hat, Ralph opened the hall door and was passing out,
when Ruth ran after him.

"Won't you put on your great-coat, sir, and your comforter? You don't
take a bit of care of yourself, Mr. Trulock!"

"I have a good caretaker in you," said he, coming back to her.

Ruth helped him to put on the coat, mounting on a chair for that
purpose, and wrapped the comforter round his neck, tucking in the ends
snugly.

"Now you may go," said she; "but don't stay out very late, please."

"Bless the child's sweet face!" muttered Ralph. "She certainly grows
more like my Annie every day, or else I fancy it as I grow fonder of her.
Well, the time has come for me to decide. I can't let things drift any
longer, for she won't, the little creature. I must do either one thing or the
other, and I'll make up my mind before I eat another meal. I'll go into the
Forest—it will be quiet there—and think."

He walked along the forest road until he reached the place where he
had found the children on that bright sunny Sunday when he first
brought them to his home. This was a still, grey day, very unlike that
other, but it was not very cold, here among the trees. Ralph clambered
up the bank, found the fallen tree, and seated himself upon it. There he
remained deep in thought for some time: then he rose and paced to and
fro, then sat down again. At last, he covered his face with his hands and
groaned aloud, "I can't! I can't do it!" But even as he said the words he
knew and felt that he could do it.

Ralph had been reading his Bible to better purpose lately than when he
only searched for texts wherewith to confound Mrs. Cloudesley. He had
learned many lessons during the last few months. To distrust himself; to
fear that he might be mistaken, and May Cloudesley right; to wish
earnestly to do what God would have him do, and to ask for help to do it;
—all this and more had Ralph Trulock learned, partly from May, partly
from Ruth, but still more from his Bible, which had begun to take such
new meanings lately. And now he asked for guidance, and felt that he
had it—that he knew what he ought to do; now he asked for strength to
do it, and even while he said aloud, "I cannot," he felt that he could. And
when at last, he walked home, very tired and worn with the conflict, he
went up to his own room and, without waiting to take off his great-coat,
wrote the following letter:

"Lady
Mabel's Rest,"
"
Fairford."

"MY DEAR ARNOTT,—"

"I never wrote to thank you, and those who joined you,
in writing to Mr. Barton on my behalf; but I hope you will
forgive me, and let me explain why I did not write, and
thank you all now."

"When I first came here, I had no intention of accepting

your kindness except for a time. My health was broken,
and I was unfit for work; but I had made up my mind to
save every penny I could until I had paid off the small sum
still remaining due to all of you with whom I used to have
dealings; and then, if my strength would permit, leave this
place, and look out for some small situation as clerk or
caretaker, which would support me. With these plans
 before me, I did not write. I felt sore and angry at needing
even temporary help, and soothed my pride by continually
telling myself that in the end you, and not I, should be the
gainer."

"But God in His mercy has led me, by means into which
I cannot enter (as it would take up so much of your time)
to see that such a state of feeling is not right in His eyes. I
am old and feeble now, and you all meant to secure
peace and comfort for one whom you had known long,
and who had been unfortunate. It was nothing but pride
that made me resist this kind feeling, as I acknowledge I
once did, and determine not to profit by it. I see this now."

"So I write to thank you, and through you, if you will

allow me, my other creditors, for your kind consideration,
which I thankfully accept; and the benefits which you
have secured to me I hope henceforth to share with
others even more helpless than I am myself."

"I remain,"
"Very faithfully
yours,"
"RALPH
TRULOCK."

Ralph put his letter into a cover and addressed it, but did not close it.
Next day he went to the garden and asked if he might keep Ollie,—Ruth
he had a right to keep, as his housekeeper, or "gel," as Mrs. Short put it.
The warden said he was sure there would be no difficulty about it, and
promised to arrange it all, for him. Then Ralph toiled up the hill to High
Fairford, and went to see Mrs. Cloudesley.

"Madam," said he, "as long ago as last Christmas you said a few words
to me, to which I would scarcely listen at the time, but which I could not
forget, though I surely did my best. You spoke to me of my pride, of
which up to that time I had been very proud; you spoke to me of love
and kindness—things I had hardly thought of for years. You advised me
to help some one, and that I should find my heart growing softer—and
you were right, madam. I began to search the Bible for something to
justify my own opinion, and I could not find what I wanted; but I found a
great deal about love and humility. And Ruth Garland, madam, has
taught me much. If you will kindly look over this letter, you will see that I
am in earnest."

May, with tears in her eyes, took the letter and read it. Then she looked
up at him with a smile upon her pleasant face, though the tears were
there still.

"Now that is what I like in you so much!" she said heartily. "I always
knew that you would do what was right the moment you saw it. You don't
know how happy you have made me by telling me all this. In trying to
help people, one fails so often—and the worst failure of all is, when they
acknowledge that they are in the wrong, but won't make any change.
One gets sadly disheartened then. It's quite delightful to know a person
who no sooner sees what is right, but he goes and does it."

"You must not think that of me," Ralph said sadly. "I think I saw it some
time ago, but I would not acknowledge it: and how nearly I lost my
children by that delay!"

"Well, it was not a very long delay," said May kindly. "I like your little
Ruth so much. I'm sure you will never repent having befriended her: and
as to the boy, he is a darling."

"Yes, madam, a fine boy. I will ask you to tell Mr. Cloudesley that Ollie
will not attend the Greatrex School any more. I shall send him to Mr.
Hawthorne as a day boy, and, when he is older, get him into the
Commercial school in Foxton. I think I could do that."

After a little more conversation, Ralph went home, to have a talk with
Ruth.
 CHAPTER X.

RALPH'S CHRISTMAS ROSES BLOOM AT LAST.

A BRIGHT little fire burned that evening in Ralph Trulock's parlour, and
at one side of it sat Ralph, in the easiest chair the house contained (and,
with the help of pillows, Ruth had made him very snug, though the chair
was by nature angular and uncompromising). Opposite him, in a low
wooden chair, sat Ruth, her small fingers plying her knitting-needles with
great zeal, while her eyes rested fondly on Ollie, who was stretched at
lazy length upon the little rug between the other two, reading a book lent
him by Miss Jones. Ollie lay face downward, his round chin propped up
on his two hands, and the firelight playing upon his dark hair and bright
face, made him "quite a picture," as Ruth privately told herself. Oh, if
Ollie could always have such a fire as that to bask before! For the child
loved warmth like a little cat.

"Ruth, do you remember what you said to me yesterday about getting

work?" said Ralph.

Ruth started and blushed, half afraid that he had discovered what was in
her thoughts at the moment.

"Oh yes," she said hurriedly; "do you think people would be afraid of the
measles now?"

"No, I don't suppose they would. But, Ruth, I don't want you to work for
Price's any more. I want you and Ollie to stay here with me."

"Always?" exclaimed Ollie, turning over on his back suddenly, and

gazing up at the speaker. "Oh, Mr. Trulock! Never go back to Mrs.
Cricklade again! That would be so lovely!"

Ollie did not know, even yet, that Mrs. Cricklade was dead. He had not
been told at the time because he was still weak, and Ruth had shrunk
from the subject afterwards.
"Mr. Trulock," said Ruth, "you are good—too good. You would only have
to pinch yourself for us: it could not be. Ollie, don't say any more, dear."

"Listen to me, Ruth," said Ralph earnestly. "You think I am very poor,
and I don't wonder at that, because I have given you good reason to
think so. But I am not really poor. I have as much to live on as any one
else in the Rest: as much as Mrs. Short, or Mrs. Archer, and you know
she has six children."

Ollie gave a quick look round the room, mentally contrasting it with Miss
Jones's and Mrs. Short's parlour; but Ruth shook her head and
answered,—

"You told me once, you know, that there was a claim upon your money. I
remember it, because it was what father used to say when people told
him he ought to send me to a better school."

"Yes, I told you so, and I thought so at the time. But I was wrong, Ruth. I
was too proud to accept a kindness, but I have made up my mind to
accept it, and to spend my money in making us all happy and
comfortable. You shall keep house for me, my dear, and I can teach you
in the evenings,—I'm a fair scholar in a plain way. And Ollie shall go to a
good school, and get a good education."

"Oh! Oh, Mr. Trulock! if I were only sure that you would not be making
yourself poor for us."

"I shall be richer, Ruthie, than I ever thought to be, for I shall have a
daughter and a—"

He stopped short. He could not say the word "son." Poor lost Fred!

"You mean me," said Ollie. "But, Mr. Trulock, we ought to be called your
grandchildren," he added after a little reflection. "We're too little to be
your children, don't you think? Ruthie, what makes you cry? I think it is
too good to be true. You know how cold it is at Mrs. Cricklade's, and she
is very often cross too! She hit you often, I know she did. Oh, Ruthie, do
say you will stay here. It can't be wrong—is it, Mr. Trulock?"

"It would be wrong and unkind to leave me," replied Ralph quickly.
"Oh, I am only too glad to stay—you know that," Ruth cried, springing up
and running to his side. "I only feared—"

"Have no fears, my dear child. We shall be very comfortable, and I hope

very happy too. I thank God for my two dear children."

So the question was settled, and the little Garlands stayed with Ralph.
Ollie had a holiday, as we know, but he was not allowed to be idle, for
Ruth found employment for him. She set to work, with a charwoman to
assist, to clean the house from top to bottom, and Ollie was as busy as
any one. What a polishing and brightening that house got, to be sure!
Ralph bought a little additional furniture too; and altogether his abode
quite lost the poverty-stricken air which had so distressed May
Cloudesley.

Christmas Eve came round again, and Mr. and Mrs. Cloudesley betook
themselves to Lady Mabel's Rest, to pay a short visit to each house.
May had persuaded her mother to send her a great hamper of apples,
nuts, pears, gingerbread, and jam tarts, that she might have little
presents for the children, for she knew them all now, and loved nothing
better than giving them pleasure. She had some small gift for every one,
mostly made by her own hands, and that intended for Mrs. Short was a
pretty woollen mat to ornament her table. Mrs. Short liked the mat better
than the flowers of last year, but she was intensely curious to know what
Mrs. Cloudesley was taking next door, to Mr. Trulock and the Garlands,
and May was quite determined that she should not find out. Mrs. Short
had a long list of grievances to mourn over, and was not nearly so alert
and lively as she had been on that day last year. A whole year of eating
more than enough for two had told upon her.

"Mr. Trulock never was much of a neighbour," she said, "as you know,
Mrs. Cloudesley; but when he was tramping the country from morning till
night, and never had a bit or sup in his house that a proper-minded
person would care to eat, it did not matter so much. But now, ma'am,
things is very different, and they set down to as good meals in a plainish
way as any one could desire, and Ruth is learning cooking from Miss
Jones, and she's learned her to make coffee, and cakes, and things
tossed up in the frying-pan—and I must say the smell is most tempting
—and it's all one gets of them. And if I want anything off the common, I
may just turn to and cook it, which gets to tire one, somehow; but never
once, ma'am, has they said, 'Mrs. Short, will you step in to tea?' and I
that nussed Trulock when every one else forsook him!"

"You should have a servant, Mrs. Short," said May, for want of
something to say. "She would be company for you."

"Gels eat so much," said Mrs. Short pensively. "I've a good appetite,
ma'am: I re'lly don't see how I could afford a gel. When I say a good
appetite, I don't mean a appetite as can eat anything, but if I gets what I
like I can pick a good little bit; but anything in the way, say of a
sweetbread, now, or mutton kidneys, or a Yorkshire 'Am, or a veal pie or
the like,—which I re'lly require such food, ma'am,—they cost a deal, and
no common gel can be expected to cook 'em. I can't afford a gel, and
that's the truth."

"Oh, Mrs. Short, you are no worse off than your neighbours, you know."

"Well, I don't know how they manage," said Mrs. Short thoughtfully.

"I think," said silent Mr. Cloudesley suddenly, "that by thinking a little of
other people, and not spending every penny they have upon themselves
alone, they seem to get more comfort out of this life even, to say nothing
of a life beyond this. Come, May, it is getting late."

Mrs. Short was offended, and showed them to the door in silence. Her
"Good-afternoon, ma'am," was the stiffest thing imaginable.

"That poor woman! She always depresses me, Gilbert. Why did you not
say more to her? It is so very sad."

"There was no use in saying more, my dear. One can't say more than
one sharp thing, and anything less sharp would not get through the poor
thing's coating of fat. Now, perhaps that small harpoon may stick."

The door of Ralph's house was opened by Ollie whose cheeks were
crimson with excitement.

"Please come into the parlour, ma'am, and I'll tell them. We're all in the
kitchen mixing the pudding."
"Ah, Ollie! Let me go into the kitchen and see the fun," said May. "Ruth
won't mind."

"Indeed she won't mind," said Ollie. "Come along. Will you come, sir?
You've no idea, ma'am, how many things have to go in a pudding, a real
English plum-pudding. We never saw one in France. Ruth wrote the list
and went to the shops, but when she came home, she had forgotten
both the suet and the nutmeg, and I had to run for them. Ruthie, here's
Mrs. Cloudesley, she wants to see the fun,—I suppose she means the
pudding; and Mr. Cloudesley came too."

May stood to look at the scene before her, with all the pleasure and
sympathy she so truly felt, looking out of her sweet eyes. Standing
before the fire with a cookery book in his hand, was Ralph Trulock; at
the table, mixing the various ingredients in a basin, was Ruth, her hand
in no state to be shaken. Her face was very grave. It was a great
undertaking. Ralph, on the contrary, looked amused and happy. What a
contrast to the man May had seen for the first time that day last year!

May helped to finish the mixing, and then to tie the pudding in a cloth;
and it was well she was there, as otherwise the due flouring of the cloth
would have been forgotten, and Ruth's pudding would not have
presented the handsome appearance it did present the next day. May
had brought Ollie some apples and Ruth a little book; but for Ralph she
produced a bunch of Christmas Roses, saying:

"I hardly think you want these now, Mr. Trulock?"

"Truly, madam, they grow by my own fireside now; and for great part my
thanks are due to you. You first told me how to grow them."

"I expect that's a parable," said Ollie, gravely. "Isn't it, Mr. Trulock?"

"It is, Ollie."

"And we are the flowers?" said the boy with a nod of his curly head.

"You! You are a weed, Master Ollie!" cried May laughing; "And an ill
weed too. Don't you know the old saying that 'Ill weeds grow apace'?"
Mr. Cloudesley's sharp harpoon stuck fast, but the effect was not exactly
what he wished!

A day or two after Christmas, Ruth was running home from Miss Jones's
house, where she had been having a lesson in clear starching from that
notable lady, when she was surprised to hear Mrs. Short calling to her,
in very dulcet and amiable tones.

"Where are you, ma'am?" inquired Ruth, after looking round in vain.

"In my own kitching, Ruth, and the 'all door is open. You just step here, I
want a word with you."

"Oh dear!" thought Ruth, "And I can't venture to talk French to her, like
that saucy Ollie. What can she want?"

She found Mrs. Short sitting in a well-padded beehive chair before the
kitchen range. A basket at her feet contained various brushes, saucers,
and bits of rag, and her face beamed with complacency and self-
satisfaction.

"Good-day, Ruth Golong," said she. "I've been thinking how kind Miss
Jones is, teaching you so much and having you there so constant; and I
feel I ought to help both you and her a bit."

"Yes, ma'am," said Ruth doubtfully.

"Yes, indeed, Ruth; which I am a very notable woman, my dear, and can
teach you even better than Miss Jones can, though the gentry do think
such a heap of her. My Matthew, that's dead and gone, poor fellow, used
to say that for cleanly ways and housekeeping generally, there was not
a woman to equal his wife in England; and if not in England, where? For
it's not to be thought that amongst poor benighted furriners and sich,—
black, some of 'em, I'm told, and copper-coloured others,—would be as
nice in them respects as a English woman. So I've made up my mind as
it's selfish in me to keep all that knowledge locked up in my own
buzzom, and take it, as one may say, out of the world with me when the
time comes as I must leave all my little comforts and go to a better
place, and therefore I'm going to teach you, Ruth Golong. And as it's
best to begin at the beginning, we'll begin by learning to black up the
kitching range. I've everything ready; so now, my dear, you begin. Here's
a rag, rub the rust off first with ile—this bottle's the ile."

"But, ma'am," said Ruth, "I have learned to do all this, and my dinner is
in the oven, and no one is there to look to it; for Mr. Trulock and Ollie are
gone for a walk."

"Well, you know, Ruth, there's the comfort of a oven, your dinner is a-
cooking all the same and will never miss you. Here, child, take the rag."

Ruth, unwillingly enough, took the proffered rag and removed the rust as
directed. She was rather vexed, but being shy could think of no way of
escape.

"Now here's the blacklead, child, and this is the brush. Rub it on well,
dear—oh, that won't do at all—rub hard—harder—quick now, up and
down the bar. That's more like it. Good, my dear!"

In this manner did the good creature keep her pupil to the task until the
grate was polished to her liking, and Ruth in a glow with heat and
vexation.

"Now," said she, "that's not bad, my dear, for a beginning. A few more
lessons, and you'll black a grate with any one living, you will indeed.
Now there's a great art in lighting of a oven. Some folks will take an hour
or more to do it. Very disconvenient these here little ovens are, as have
a fire all to themselves. You take a shovel full of lighted coal, my dear,"
etc., etc.

Again poor Ruth found herself unable to escape, the fire was lighted
under Mrs. Short's directions.

"That's enough for one day, my dear," said the old woman. "I'll call you in
again whenever I can make time to give you another lesson. Good-day,
Ruth Golong; you're a handy gel, and will do us credit yet."

Ruth escaped as fast as she could, and ran home, half angry, but more
than half amused. Mrs. Short rose from her chair and got her neatly
made veal pie from her cupboard.

"Sich a comfort," she murmured, "to get the grate done. Mrs.
Cloudesley's sure to hear of it. It will be nearly as good as having a gel,
and it's no more than good-natured to teach that poor orphian to get a
living, as that crusty old feller may turn her out to do for herself any day."

Mrs. Cloudesley did hear of it, and so did Mr. Cloudesley; and what a
laugh May had at her husband about his "harpoon!"

For some time after this Ruth's life was rendered a burden to her by the
exactions of her "good-natered" neighbour; but at last she was obliged
to rebel, and told Mrs. Short that she had not time to do the work of two
houses. Mrs. Short characterized this as an act of the basest ingratitude,
and was never tired of telling any one who would listen, how she tried to
befriend that set-up-thing, Ruth Golong, and how the gel turned upon
her with langwich which was too violent to be repeated!

In consequence of Ruth's vile ingratitude, it became plain to Mrs. Short

that she must do one of three things, none of which she entirely liked.
She might return to doing the work herself, which her rapidly increasing
size rendered both difficult and distasteful to her. Or she might leave the
work undone—cease to keep her place so beautifully clean, and attend
merely to her cooking; to do her justice, this idea only suggested itself to
be rejected. Or again, she might get a "gel." This she would do, she
decided, after much deliberation.

The next point was, to get a "gel" for as little wages as possible—for
none, if it could be managed. She therefore wrote to her son, offering in
the handsomest manner to take "his Mary Kate" off his hands, educating
her to be a notable woman like herself, and leaving to her such sums as
she should have saved before her death. But Mat Short was very fond of
his children, and they were not fond of their grandmother! Moreover Mat
did not believe in the savings, for as he said to his wife, "Mother'd eat
five hundred a year if she had it!" This obliging offer was declined. Mary
Kate howled from the moment she heard her grandmother's letter read
until the reply was safely posted. Then, and not till then, did Mrs. Short
bethink herself of her long-lost daughter.
Now, though she always spoke of Jane as lost, Jane might more
properly be said to be merely mislaid. Mrs. Short did not know where
she was, simply because she had never inquired! Jane had offended
her mother while very young, by going out as a servant, owing to what
Mrs. Short called "competition of temper" at home. Then she had
married, and Mrs. Short, then a widow, had cast her off: people were
unkind enough to say that she feared lest Jane might expect a little help
occasionally. Now, however, the case was different, and Mrs. Short
caused a little quiet inquiry to be made about Jane, and discovered that
she was a widow, with one son, who was at sea. Mrs. Short piously
declared that it was "quite a Prominence," and forthwith wrote to Jane
whose name, by way of a joke, was Mrs. Long,—to invite her to be a
comfort to her mother's declining years.

Mrs. Long, who was again in service, thought she might as well try, in
spite of the "competition" I have mentioned; or perhaps she knew that
her temper had improved since the last competition, and wished to try
again. At all events, she came, and great was Ollie's amusement at the
queer contrast presented by Mrs. Long and Mrs. Short when he first saw
them, on their way to church together, on the first Sunday after Mrs.
Long's arrival. Mrs. Short, broader than she was long, waddling up the
hill in her handsome tartan shawl, the tartan of some clan which was
addicted to colour, and did not mind being seen a good way off. Mrs.
Long, a very tall, thin woman, with an expression of meek obstinacy in
her face, stalking beside her mother in a shabby, rusty black cloak, and
a bonnet which looked as if she had accidentally sat down upon it.

But before long (I don't mean that for a pun) Mrs. Short found that she
had made a great mistake, and, what was worse, one that could not be
un-made. Jane's temper had quite the best of the competition now! She
did not scold or storm, she seldom even answered again; but she smiled
sourly when her affectionate mother tried to feed her upon bacon and
cabbage, while she herself dined upon various costly delicacies. After a
brief struggle, Jane had her own way, and her full share of such good
things as were going. But these were not as plenty as of old.

Mrs. Long remarked that it was her mother's plain duty to save a certain
sum weekly, to form a little fortune for her when she should be again left
homeless by the old woman's death. She not only pointed out this duty,
but she saw that it was done. She made the old woman fairly
comfortable, however, and nursed her carefully when she required it; but
she ruled her completely, and altogether things were not to Mrs. Short's
mind, and she sometimes mournfully wished that she had "got a gel."

"But there," she said, "that's me all over; I couldn't get Jane out of my
head, thinking she might be actially in want, and I in comfort; I'm too
good-natured, that's the truth, and Jane don't take after me!"

"That's the Long and the Short of it!" As saucy Ollie Garland remarked
when he heard this lament.

CHAPTER XI.
MONSIEUR OLIVER.

A YEAR passed very quietly and happily in Ralph Trulock's house. Ollie
was going to school now, and Ruth was a busy and a happy little
woman, and had grown much stronger and less nervous than she had
been when she first came to Lady Mabel's Rest. Ralph gave her lessons
every evening, when the day's work was over, and was making a good
scholar of her in a plain, old-fashioned way. Mrs. Cloudesley taught her
various kinds of fancy-work, and Miss Jones made her a first-rate cook
and a capital housekeeper in every way. So Ruth bade fair to be an
accomplished woman, according to my notions. If a woman can do with
her own hands, and do well, everything that is needed for the comfort of
her household; can read and enjoy books on a variety of subjects in two
languages; can keep accounts well, and write a good hand, and has,
moreover, an employment for her leisure hours which she likes and
excels in,—I call her an accomplished woman, though she may never
have learned to torture my ears with "a tune" on the piano, or to paint