Contents
This post contains information from the book.
Watch The New Asylums (PBS/Frontline)
1. Mental Disorders and the DSM-IV
Mentally Disordered Offenders (MDOs): these are people who have come into contact with the criminal justice system and also have a mental disorder; this includes those found unfit to stand trial (UST), not criminally responsible on account of mental disorder (NCRMD) and mentally disordered or seriously mentally ill.
DSM-IV: organizes diagnoses into five axes relating to different aspects of disorders.
- The first two axes represent the major mental disorder axes:
- Axis I – Clinical disorders, such as major depression, substance dependence and schizophrenia; the impact is on affective and reality.
- Axis II – Personality disorders and mental retardation.
- Axis III – General medical conditions.
- Axis IV – Psychosocial and environment problems.
- Axis V – Global functioning.
- Criticisms: construct validity; reliability of the diagnostic categories and symptoms (Why are certain disorders included? How were the symptoms for each disorder selected?); lacks a strong empirical basis; and too much emphasis placed on the existence of symptoms (which is why when you read it, YOU THINK YOU’RE CRAZY).
Problems with Diagnosing Mental Disorders: mental disorders were developed primarily by the field of psychiatry (DSM) so it may not reflect psychological research, it’s unrelated to causation, there are different classification systems (DSM versus IDC-10), prevalence varies by the model used and Canada and the UK are using severe personality disorder as a criterion for indeterminate sentencing.
1.1 Prevalence Rates
| Adult Population | Criminal Population | |
|---|---|---|
| APD | 1-3% | 74.9% |
| Paranoid | 0.5-2.5% | 10-30% |
| Borderline | 2% | 10-20% |
| Major Depressive Disorder Point Prevalence Men and Women | 2-9% | 15-40% |
| Psychosis | No data | 10.4% |
| Bipolar (at least once) | 0.4-1.6% | 7-12% |
| Schizophrenia | 0.2-2% | 4.6-7% |
Prevalence of Mental Disorders:
- 80% of a prison population (compared to 31% of a community sample) had a mental illness.
- Prisoners are 10 times more likely to have a mental illness.
- Major mental illnesses (Axis I) account for 6.5 to 10% of the population
- Moderate mental illnesses – 15 to 40%
- Diagnosable mental disorders (SA, APD) – over 80%
Prevalence of Personality Disorders: personality disorders are grouped into three clusters: Cluster A – personality disorders involving odd or bizarre behaviour (ex: paranoid); Cluster B – involve dramatic or erratic behaviour (ex: antisocial and borderline); and Cluster C – involve anxious or inhibited behaviour (ex: dependent, OCD).
- Most common types of personality disorders are antisocial, paranoid and borderline (for females and males).
Comorbidity of multiple mental disorders:
- Schizophrenia and bipolar are most likely to be occur with more than 2 other diagnoses.
- Depression, APD, alcohol abuse and drug abuse are most likely to occur with 1-2 other diagnoses.
Comorbidity of mental disorders and crimes:
2. Role of Mental Illness in the Courts
2.1 Unfit to Stand Trial
Unfit to Stand Trial – Section 2 of Criminal Code: where a person is not fit because they...
- Don’t understand the nature of the proceedings...
- Don’t understand the consequences of the proceedings...
- Can’t communicate with counsel...
- Because of a current mental disorder.
The Ontario Review Board must consider:
- The protection of the public
- The accused’s mental state
- The reintegration of the accused into society; and
- The accused’s other needs.
2.2 Criminal Responsibility
Historical Overview:
- N’Naghten Standard (Cognitive): (USA) at the time of the crime, you must suffer from a defect of reason and you must not know the nature of the act or understand that it was wrong.
- NCRMD (Not criminally responsible on account of mental disorder) (R v. Swain):
- (Canada) not legally responsible while suffering a disorder that renders you incapable of appreciating the nature of the act or incapable of knowing that the act was wrong (similar to M’Naghten Standard)
- A defendant should only be found NCRMD if they pose a criminal threat to the public; otherwise, they should be granted an absolute discharge.
3. Link between Mental Illness and Crime and Violence
3.1 Risk Factors
Here are some of the major risk factors:
- Active psychosis (currently) but not lifetime diagnosis (such as schizophrenia);
- Prior crimes and violence are a better predictor;
- Substance abuse and APD (antisocial personality disorder) are important comorbid predictors.
- Even though MDOs are at a higher risk of re-offending compared to the general population, compared to the criminal population, they are at a lower risk (it’s all relative!)
- Schizophrenics: co-occurring substance abuse and acute psychotic symptoms are associated with minor violence; acute positive psychotic symptoms, depressive symptoms, victimization and childhood conduct problems are associated with serious violence; and negative psychotic symptoms are associated with lower risk.
- Majority of people with mental disorders don’t engage in violent behaviour but there is a close parallel between predictors for MDOs and non-MDOs, in terms of demographics, criminal history, deviant lifestyle and clinical diagnosis.
- People with serious mental disorders are more likely to be victims of violence (compared to people with no mental disorder).
- TCOs – Threat/Control Override Symptoms: psychotic symptoms that cause a person to feel threatened or involve the intrusion of thoughts that can override self-controls. (Delusions)
- Research suggests that patients who endorse these symptoms were more likely to be violent. Other research suggests that hostility, not TCOs, predict violence. Other research also suggests that treat delusions in men were related to violence (not in women and control delusions weren’t related to violence in men or women)
- Hallucinations:
- Type: Non-violent and self-harm command hallucinations are more likely to be obeyed.
- Belief: If the person believes the command is justified, they’re more likely to obey.
- Voice Perception: benevolent (as opposed to malevolent) voices are more likely to be obeyed.
- Consequences: if the person believes something bad would happen to them or someone else, they’re less likely to obey.
Why should we screen for mental disorders?
- There are high rates of mental disorders in correctional populations.
- Early identification improves treatment response.
- Reduces victimization (of offenders).
- Consistent with the law – we need to provide community standards of care.
- Admission to jail is when the risk for suicide is greatest:
- Precipitating Events: recent transfer, pressure from offenders, in segregation, and other negative decisions.
3.2 Assessment Methods
- Interview Based (in order of complexity)
- Structured Clinical Interview for DSM
- Diagnostic Interview Schedule (ICD)
- Brief Psychiatric Rating Scale
- Referral Decision Scale: sample items...
- Schizophrenia (4.6%), major depression (39.3%), manic depressive illness, bipolar (12.7%)
- Questionnaires
- Beck Scales
- Computerized Lifestyle Assessment Inventory
3.3 Treatment
Five components of community treatment programs associated with success:
- Multifaceted, intense and highly structured.
- Treating clinician accepts the dual role of treating the mental disorder and preventing violence.
- Treating clinician takes responsibility for ensuring that the patient follows the treatment programs.
- Treating clinic should re-hospitalize the patient if it’s needed to stabilize acute symptoms or if there’s an elevated risk for violence.
- Obtain court orders, if necessary, to ensure patients comply with their treatment.
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