CH 10: Mental Disorder in the Criminal Justice System

What is the primary tool used in North America to diagnose mental disorders?

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA).

What international tool is used outside North America to classify mental disorders?

The International Statistical Classification of Diseases (ICD), published by the World Health Organization (WHO).

When was the DSM first published, and for what purpose?

In 1952, to facilitate diagnosis and collect statistical information about mental disorders.

Define a mental disorder according to the DSM-5.

A syndrome with clinically significant disturbance in cognition, emotion regulation, or behavior reflecting dysfunction in psychological, biological, or developmental processes, usually causing distress or impairment.

What does the DSM say about culturally expected responses or socially deviant behaviour?

These are not considered mental disorders unless due to individual dysfunction.

What was the multi-axial system, and when was it used?

From DSM-III (1980) to DSM-IV-TR (2001), disorders were classified along 5 axes, separating clinical and personality disorders.

What change did DSM-5 make to the multi-axial system?

It abandoned it in favor of a holistic approach, integrating all relevant information within one system.

What replaced the Global Assessment of Functioning (GAF) scale in DSM-5?

The World Health Organization Disability Assessment Schedule (WHODAS).

Which group of disorders is most often diverted to the forensic mental health system rather than corrections?

Serious or major mental illnesses (SMI/MMI), often involving disconnection from reality.

Why are personality disorders (PD) common in correctional settings?

Because they impair interpersonal functioning but usually don’t affect appreciation of wrongfulness, so individuals remain criminally responsible.

Why is a diagnostic system like DSM important?

It provides standardized language, guides treatment recommendations, supports insurance claims, and acts as clinical shorthand.

What are some criticisms of the DSM system?

• Lack of construct validity and reliability

• Overemphasis on symptoms → diagnostic inflation

• Inclusion of disorders based on consensus, not evidence

• Lack of dimensional measures of impairment

By how much did the number of disorders increase between DSM-I and DSM-IV-TR?

Approximately 280%.

What caution does DSM-5 give about forensic use?

Psychiatric information may be misunderstood; DSM diagnoses are not designed for legal decision-making.

By how much did the number of disorders increase between DSM-I and DSM-IV-TR?

Approximately 280%.

What caution does DSM-5 give about forensic use?

Psychiatric information may be misunderstood; DSM diagnoses are not designed for legal decision-making.

At what two stages does mental impairment matter in the criminal process?

1. At the time of the alleged crime → Criminal responsibility

2. At the time of court proceedings → Fitness to stand trial

What are possible initial actions when police suspect mental illness?

• Direct to psychiatric emergency department

• Civil commitment order

• Arrest → jail/court → forensic assessment

What does it mean to be unfit to stand trial (UFST)?

The accused, due to mental disorder, cannot conduct a defense or instruct counsel because they can’t:

• Understand the nature/object of proceedings

• Understand possible consequences

• Communicate with counsel

What happens if someone is found UFST?

They are diverted to the mental health system for treatment to restore fitness before trial resumes.

What section of the Canadian Criminal Code defines Not Criminally Responsible on Account of Mental Disorder (NCRMD)?

Section 16.

What are the four conditions for criminal responsibility?

1. Mens rea (guilty mind)

2. Actus reus (guilty act)

3. Causation

4. Absence of viable defence

What does NCRMD mean in legal terms?

The person, due to mental disorder, was incapable of appreciating the nature and quality of their act or knowing it was wrong.

Who bears the burden of proving NCRMD?

The party that raises it, on a balance of probabilities.

What happens when someone is found NCRMD?

They are hospitalized indefinitely until their mental health improves and risk is manageable.

What are the three types of Review Board decisions for NCRMD individuals?

1. Continued detention

2. Conditional discharge

3. Absolute discharge

How common is the insanity (NCRMD) defence in Canada?

Fewer than 1 in 1,000 court cases (2005–2012).

What did the National Trajectory Project (NTP) find about the NCRMD population?

• 84% male, avg. age 36.6

• Most single

• Common offences: threats (27.4%), assault (26.5%)

• Main diagnoses: psychotic disorders (71%), substance use (31%), mood disorders (23%)

• 44% detained, 37% conditionally discharged, few absolute discharges.

What is deinstitutionalization?

The large-scale closure of psychiatric hospital beds (1960–1980), reducing from 4 to <1 bed per 1,000 Canadians.

What were some consequences of deinstitutionalization?

• Reduced access to care and supports

• More mentally ill individuals entering the justice system

• “Criminalization of the mentally ill” phenomenon

What does “criminalization of the mentally ill” mean?

Minor offences or disturbed behaviour lead to arrest due to lack of mental health supports.

What did the WHO call the biggest barrier to mental illness treatment in 2001?

Stigma.

What are the three types of stigma?

1. Self-stigma – internalized shame

2. Public stigma – negative attitudes/discrimination

3. Structural stigma – institutional policies/treatment inequities

How does the media contribute to stigma?

Over 40% of articles link mental illness to crime; only 18–25% mention recovery, treatment, or expert voices.

Why are police called “street corner psychiatrists”?

They often manage crises involving mentally ill persons in the community.

What percentage of people with mental illness have been arrested in their lifetime?

About 2 in 5.

What proportion of police encounters involve people with mental health problems?

Around 1 in 20.

What key principles were emphasized at the 2014 Mental Health Commission of Canada conference on policing and mental illness?

• Include lived experience voices

• Collaboration & info-sharing

• Procedural justice

• Police mental health

• Anti-stigma initiatives

• Full continuum of supports

What did Beaudette & Stewart (2016) find about lifetime prevalence of DSM disorders among inmates?

• 80% had a lifetime DSM disorder

• ~75% had a current disorder

• 44% had ASPD

• ~16% had borderline PD

• 25–66% had substance or alcohol use disorder

How do correctional mental disorder rates compare to the community?

3–10× higher across major categories (psychosis, mood, anxiety, substance use).

What did Wilton & Stewart (2017) find about crime type and mental disorder?

No specialization—each crime category had representation across mental disorders.

What did international data (e.g., Hodgins et al., 1996, Denmark study) reveal?

Nationwide data confirm higher criminality among those with mental disorders, reinforcing sample-level findings.

What early theory explained the criminalization of persons with mental illness?

The deinstitutionalization theory (Teplin, 1990), which proposed that people with mental illness ended up incarcerated due to a lack of community mental health resources and a law enforcement rather than social work response.

What evidence challenged the deinstitutionalization explanation?

Research (Brink et al., 2011) found that police contacts and satisfaction with police interactions do not support the idea that deinstitutionalization alone caused criminalization.

What did Bonta, Blais, and Wilson (2014) argue about addressing crime in persons with mental illness?

They recommended using the General Personality Cognitive Social Learning (GPCSL) model, suggesting that criminogenic needs (like antisocial traits and substance abuse) drive offending, not mental illness itself.

How does GPCSL theory view mental illness in the context of crime?

Mental illness is seen as a responsivity issue, not inherently criminogenic. Only certain symptoms overlap with criminogenic needs (e.g., ASPD, substance misuse).

What is the psychopathological perspective?

It links specific mental health symptoms (like delusions or hallucinations) to criminal behavior because these symptoms can have criminogenic potential (Bonta et al., 2014).

What did Douglas, Guy, and Hart (2009) find about psychosis and violence?

Psychosis increased the odds of violence by 49–68%, with higher effects in community samples (350% increase) than in correctional settings (27%).

Which psychotic symptoms are most associated with violence?

Positive symptoms (hallucinations, delusions), especially when accompanied by substance abuse or violent attitudes.

What are the three mechanisms by which psychosis may cause violence (Douglas et al., 2009)?

1. Focusing role – provides motivation (e.g., TCO delusions).

2. Destabilizing role – impairs decision-making, causing impulsive acts.

3. Disinhibiting role – removes normal restraints, especially via negative symptoms.

How do different types of violence relate to symptoms in schizophrenia (Swanson et al., 2006)?

• Minor violence: substance abuse + acute psychotic symptoms.

• Serious violence: acute positive psychosis, depression, childhood conduct problems, victimization.

• Negative symptoms: associated with lower risk.

What are TCO (Threat Control Override) symptoms?

Psychotic symptoms where individuals feel threatened or that their thoughts are being controlled or overridden, reducing self-control (Link & Stueve, 1994).

What did Link and colleagues find about TCO symptoms and violence?

TCO symptoms are strongly related to violence, doubling the risk (Swanson et al., 1997).

What explains inconsistent findings about TCO and violence?

Gender differences—threat delusions were linked to violence in men, but not in women (Teasdale, Silver, & Monahan, 2006).

What are command hallucinations, and how do they relate to violence?

Auditory hallucinations that instruct a person to act. 30–50% of inpatients experience them; 29% involve violent content, and 15% comply with violent commands (Lee et al., 2004).

What three factors together indicate high violence risk in mentally ill offenders?

1. Active psychotic symptoms + substance use + violent history/attitudes.

2. Delusional beliefs (especially TCO).

3. Command hallucinations to commit violence.

What are GPCSL’s two main points about mental illness and crime?

1. Mental illness alone is not criminogenic.

2. The Central Eight criminogenic factors apply equally to persons with or without major mental illness.

What percentage of those with major mental illness (but no substance disorder) have a history of criminal violence?

Fewer than 10%.

What did Bonta et al. (1998, 2014) find about predictors of recidivism in mentally ill vs. non-mentally ill populations?

Predictors are largely the same—criminogenic factors (like antisocial traits) predict reoffending better than clinical symptoms.

Which static factors predict recidivism in mental health populations?

• Younger age, single status.

• Early/dense criminal history.

• Prior violent offences predict future violence.

• Longer hospitalizations reduce recidivism.

Which dynamic (criminogenic) factors predict recidivism?

• Antisocial personality disorder (ASPD).

• Substance use.

• Antisocial attitudes.

• Low intellectual ability (for general recidivism).

What is a dual diagnosis, and why is it important?

The co-occurrence of a substance use disorder (SUD) and a mental health disorder—linked to the highest recidivism rates (Rezansoff et al., 2013).

What did Rezansoff et al. (2013) find about recidivism by diagnosis group?

• SUD: 55.7% reoffended.

• Dual diagnosis (DD): 55.5%.

• Mental illness only (NSMD): 31.6%.

• No disorder: 33.9%.

• Mental illness only increases recidivism when paired with substance use.

What are two major protective factor tools for violence risk?

• SAPROF (Structured Assessment of Protective Factors).

• START (Short-Term Assessment of Risk and Treatability).

Examples of protective factors for offenders with mental illness?

• Medication compliance.

• Employment.

• Positive social relationships.

• Stable housing.

What key question remains about protective factors?

Whether they reduce risk directly, act as buffers, or are independent of risk factors.

What is the Brief Jail Mental Health Screen (BJMHS)?

A short, 2.5-minute tool used by non-specialists to screen for mental health issues and suicide risk in jails (Osher et al., 2006).

How accurate is the BJMHS?

About 74% accurate, but misses about ⅓ of symptomatic women.

What is the Jail Screening Assessment Tool (JSAT)?

A structured professional judgment interview covering legal history, violence, mental health, suicide risk, substance use, and social background (Nicholls et al., 2005).

What is CoMHISS and what does it assess?

CSC’s Computerized Mental Health Intake Screening System, using Brief Symptom Inventory (BSI) and Depression, Hopelessness, and Suicide (DHS) forms.

CSC’s Computerized Mental Health Intake Screening System, using Brief Symptom Inventory (BSI) and Depression, Hopelessness, and Suicide (DHS) forms.

• 46% of women: high distress.

• 50% of men: follow-up needed; 12% had a major disorder.

• Indigenous women: higher suicidal ideation (58% vs. 30%).

• 70% of women with high distress also had substance issues.

How common is suicide in Canadian federal prisons?

It accounts for ~20% of all deaths in custody, with a rate of 95.9 per 100,000 (vs. 14.2 in the general population).

What are key suicide risk factors assessed in prisons?

• Prior attempts.

• Recent losses or legal problems.

• Depression and suicidal ideation.

• Having a plan.

• Substance use.

What are common risk tools for persons with mental illness?

• HCR-20 V3 (Historical Clinical Risk).

• VRAG-R (Violence Risk Appraisal Guide–Revised).

• VRS (Violence Risk Scale).

• LS/CMI (Level of Service/Case Management Inventory).

• START (Short-Term Assessment of Risk and Treatability).

• PCL-R (Psychopathy Checklist-Revised).

What makes the START unique?

It assesses both strengths and vulnerabilities across 20 items, showing good predictive validity for short-term inpatient violence.

What is the main practical benefit of dynamic risk tools (like START or LS/CMI)?

They can track changes in risk over time and inform treatment intensity and case management.