PSY C10

Chapter 10: Mental Disorder in the Criminal Justice System

Mental Disorder and Crime

PSY 230. 3 (04)

Overview

Myths, misconceptions, and media
The case of Johnnie Baxstrom
Violence and crime among the disordered
Mental disorder among the violent/criminally active
Risk factors and assessment of MDOs
Treatment for MDOs
General conclusions

Backgrounder on Mental Illness

Schizophrenia and other psychotic illnesses
Hallucinations
Delusions - These 3 are positive symptoms
Disorganized behavior/thinking

Negative symptoms:

Behavioral deficits
Lack of social contact
Lack of withdrawal
Bipolar Disorder
Alternating episodes of mania and depression
Unipolar Mood Disorders
Major depressive episodes, persistent depressive disorder

Myths, Misconceptions, and the Media

The mentally ill have long been stigmatized as prone to violent behavior as seen in literature, the media, folklore, and common sense.
Shakespeare, Taming of the Shrew, Henry the Sixth

17% of American prime-time dramas contained a character who was mentally ill (Gerbner et al., 1981).
73% of mentally ill characters are portrayed as violent (vs. 40% of “normals”).
23% of mentally ill characters were shown to be homicidal (vs. 10% of “normals”).

The Case of Johnnie Baxstrom

In 1966, Johnnie Baxstrom challenged a ruling to civilly commit him on the grounds that he posed a risk for future violence since he had a mental disorder.

The case of Baxstrom set a precedent which sparked the release of 976 institutionalized mentally ill patients.

Over a 2-year follow-up, 20% of the “Baxstrom patients” were rearrested, 11% were reconvicted, and only 2% committed a violent offense

Relationship between Crime and Mental Disorder

Monahan (1993): two paradigms for investigating the relationship between violence and mental disorder (can also be applied to general criminality):

Crime among the disordered
Disorder among the criminally active

Violence and Crime Among the Disordered

Several studies have examined the base rates of violence and general criminality in psychiatric populations compared to non-psychiatric controls.

Hodgins (1993): Swedish Metropolitan Project
Examined base rates of violence and general crime in a sample of 15,117 persons born in Stockholm, 1953.
Residents followed up for 30 years.
Hodgins et al. (1996)
Similar methodology as above, only with Danish sample
358,180 persons born b/w 1944 and 1947

Base Rates of Violence and Crime:
Swedish and Danish Census Data

Violence and Crime Among the Disordered

Epidemiological Catchment Area (ECA) Study (Swanson et al., 1990; Swanson, 1994)

Sample of 10,059 respondents from geographically diverse locations.
DSM-III-R diagnoses made using Diagnostic Interview Schedule (DIS).
Violent incidents in the current and previous year recorded.
55.5% of violent respondents met criteria for a DSM disorder.
19.6% of non-violent respondents had a DSM disorder.

Estimated Probabilities of Violence for Different Psychiatric Diagnoses

Mental Disorder Among the Violent or Criminally Active

Alternative paradigm
Examining base rates of mental disorder in violent or incarcerated populations (i.e., prison inmates)

Mental Illness in Canadian Corrections

Mental Disorder, Recidivism, and Crime

Rezansoff, Moniruzzaman, Gress, and Somers (2013)

BC Corrections
31,014 provincial offenders followed up 3 years post release
39% no diagnosis
21% nonsubstance related mental disorder (NSMD)
10% substance use disorder (SUD)
23% dual diagnosis
SUD + mental disorder
7% Unknown

Mental Disorder, Recidivism, and Crime

Several studies have found certain diagnoses to be associated with a greater number of criminogenic needs = higher risk (Skeem et al., 2014; Kingston et al., 2015, 2016)
PD, SUD, and DD largest number of positive associations with criminogenic need
These studies have also found particularly high prevalence of PD and SUD
Any PD: ≈ 50-75%
ASPD: > 50%
SUD: ≈ 50-75%

Conclusions on Association between Mental Disorder and Crime/Violence

Base rates of crime/violence are consistently higher among mentally disordered populations.
Base rates of crime/violence are particularly high amongst substance abusers.
Males are consistently higher risk (i.e., have higher base rates of crime/violence).
Major mental disorder has higher prevalence among offender samples than the general public.
PDs (especially ASPD) and SUDs are particularly common in offender populations.

Relationship between Crime and Mental Disorder

Violence and Psychosis

Psychosis as a possible cause of violence
Psychosis serves a focusing role by providing a clear motivation for violence (Link & Stueve, 1994)
Threat Control Override
Principle of “rationality within irrationality”
Psychosis destabilizes decisions and behavior
Leads to disorganized/impulsive violence and crime
Psychosis serves a disinhibiting role in violence
Negative symptoms block inhibitions to act violently

Violence and Psychosis

Douglas, Guy, and Hart (2009)

Meta analysis of 204 studies examining association between psychosis and violence
Psychosis associated with a 49% to 68% increase in the odds of violence
Finding held up across gender and country
Several moderators (i.e., lots of variability) among studies
Effects were largest in:
Community settings (350% increase or 3.5X odds of violence)
MUCH smaller effect in correctional settings (27% increase)
Patients with schizophrenia diagnoses
Positive symptoms
Psychotic patients were compared to non-mentally disordered, non-offenders
No significant effect when compared against other antisocial individuals

Relationship between Crime and Mental Disorder

Risk factors for recidivism among mental health correctional populations

Psychopathological Theory:
Mental disorder symptomatology would constitute the strongest predictors of recidivism (e.g., depression, anxiety, delusions).

General Personality Cognitive Social Learning (GPCSL)
General criminogenic needs and other variables transcend different correctional populations, and tend to be the strongest predictors of recidivism (e.g., criminal attitudes, peers)

Predictors of Recidivism in mental health correctional populations

Bonta, Blais, and Wilson (2014)
Meta analysis of predictors of violent and general criminal recidivism among mental health correctional samples specifically
(Update on Bonta, Law, & Hanson, 1998)
126 studies on 96 unique samples and 23,900 offenders
Douglas et al. (2009) examined studies of mentally ill patients across a range of samples and settings; not just offenders
In correctional settings, psychosis associated with a 27% increase in the odds of violence, much smaller than civil psychiatric (69% increase) or community settings (350% increase)

Predictors of Recidivism in mental health correctional populations

The Central Eight predict recidivism in mental health correctional samples
NSMD, and psychosis specifically, are weaker predictors in offender samples
PD, ASPD, and psychopathy are predictive
They embody collections of criminogenic needs or directly represent criminogenic needs (e.g., antisocial personality pattern)
Severe mental disorder
Likely has modest criminogenic relevance
May interact with other criminogenic predictors
Is an important responsivity consideration

Relationship between Crime and Mental Disorder

Treatment of Mental Health Correctional Populations

Absence of controlled treatment studies specifically targeting mental health correctional populations
Most programs are no different than those provided for non-offending psychiatric patients
Medication
Inpatient treatment

Two Promising Developments:

Recognition that treatment of mental health correctional pops should attend to the general offender rehabilitation literature
Importance of providing treatment/support post hospitalization/release is being given more attention

E.g., Bow Unit, RPC

Treatment of Mental Health Correctional Populations

Mental Illness as a Need and Responsivity Issue:

As a need issue
Certain mental illnesses and mental illness symptoms are criminogenic
Treated through medication, therapy, and community supports (e.g., employment, housing, family psychoeducation)
As a responsivity issue (adapt to the characteristics of your patient)
Mental health symptoms can undermine engagement in treatment if left untreated
E.g., cognitive and attentional deficits of active psychotic symptoms, interpersonal problems with staff and patients

Treatment of Mental Health Correctional Populations

So, the RNR principles should apply at least in theory
…Remarkably little research has examined this
Morgan, Flora, Kroner, Mills, Varghese, & Steffan 2012
Most programs targeted persons with severe mental illness (schizophrenia)

Treatment of Mental Health Correctional Populations

General Conclusions

A modest, yet consistent and significant relationship exists between crime/violence and mental illness.
Prevalence rates of crime/violence appear to be highest in the most severe mental disorders.
The risk for crime/violence is greatest when mental disorders are comorbid with substance abuse.

In the absence of a criminal history and other criminogenic markers, mental disorders are likely poor predictors of violence and other types of crime.

Risk factors derived from a general personality cognitive social learning model are the strongest predictors of violence and general criminality.

Dearth of controlled treatment studies

Textbook Notes:

Criminal Justice System: the aggregate system for processing and managing individuals who come into conflict with the law, which includes the law courts, police, and corrections.

Corrections: A system for criminally sentence individuals who are incarcerated or serving sentences in the community that provides housing, supervision, stabilization, and reintegration services in an effort to balance punishment with the prevention of future crime and violence for individual and Public Safety

Forensic Mental Health: The term pertaining to mental health issues and professional practice (ex. Assessment and treatment) in legal contexts; also pertains to the sector of the health system that manages individuals with mental illness who have committed crimes but do not fall under Correctional jurisdiction (ex. Due to legal designations such as criminally responsible)

1.1

In North America, the primary tool used to diagnose mental disorders is the:

Diagnostic and Statistical Manual of Mental Disorders (DSM): manual published by the American Psychiatric Association that lists mental and personality disorders

The DSM was first published by the American Psychiatric Association (APA) in 1952 to facilitate the diagnosis of mental disorders and to collect statistical information about the prevalence of different types of mental disorders.
Mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. mental disorders are usually associated with significant distress and social, occupational, or other important activities.
A diagnostic system such as DSM is of considerable importance. For one, treatment recommendations, and payment by healthcare providers, are often dependent on DSM classifications.

Within a correctional environment, the focus tends to be more on symptoms rather than a diagnosis, except perhaps when pretrial psychiatric evidence is presented. Diagnosis are also reported at Specialized treatment facilities that are combined prisons and accredited hospitals, often known as:

Regional Treatment Centres (RTC): Institutional facilities within the correctional service of Canada that are designed hospitals with a prison like setting that provide treatment and stabilization services for federally sentence men and women's criminogenic and mental health needs

The Intersection of Mental Illness with the Criminal Justice System:

This impairment is considered at two key times during the criminal justice process- at the time of the alleged crime and at the time of court proceeding. The former is a criminal responsibility assessment and the latter is a fitness assessment.

If the assessment finds the person:

Unfit to stand trial (UFST): A person who, due to mental disorder, is unable to understand trial proceedings, interpret the consequences of a crime, or communicate with their counsel.

Not criminally responsible on account of a mental disorder (NCRMD): Describes a person who do to a mental disorder at the time of an offense is incapable of appreciating the nature and quality of the act or knowing what is wrong

They are transferred to a psychiatric hospital for treatment and stabilization and they remain in the health system until discharge.
If there are ongoing mental health concerns but the individual is found fit to stand trial as well as criminally responsible, they proceed through the correction system either probation or present depending on the court ruling
For mentally disordered persons with the correction system, releases granted by the parole board or at expiration of sentence. For those in the mental health system, the release authority is generally the Criminal Code Review Board.

Unfit to Stand Trial (UFST)

In Canada, if an accused is not able to participate in their defense on account of a mental disorder including cognitive impairment it is deemed unfair to try this person. According to section 2 of the Canadian criminal code, and accused as unfit to stand trial if they are:

Understand the nature or object of proceedings
Understand the possible consequences of the proceedings
Communicate with counsel

In such cases, the accused would be diverted to the mental health system prior to sentencing, and they would not enter the criminal justice system

Not Criminally Responsible on Account of Mental Disorder: (NCRMD):

In order to find a person guilty of a crime, they need to have criminal responsibility.
4 conditions exist for criminal responsibility:

Mens Rea: (guilty mind): legal term for criminal intent.

Must be established. If there is no criminal intent then there is no crime. It is presumed that if you know what you are doing and subsequently choose to do it you are culpable.

Actus Reus: (“guilty act”): the crime itself.

If you did not perform the behaviors constituting the criminal act, you also cannot be held currently culpable.

Causation: Meaning that one's actions caused the offense to occur (ex. reckless driving caused the death of a pedestrian); again without one's actions having caused the offense to occur, one cannot be held criminally responsible.

Absence of a viable defence: Which means that there are no my dating circumstances that could reduce culpability for committing the criminal act example self-defense. it is the final prong that is material to NCRMD, which has historically been referred to as the:

Insanity defence: A defense used to argue a lack of criminal responsibility owing to a mental disorder or substantive impairment at the time of the crime, which if successful, results an acquittal on the grounds not criminally responsible on account of mental disorder (NCRMD)

When people are found NCRMD, they are committed to an indeterminate of hospitalization where they remain until their mental health has improved and the risk to the public can be managed in the community
the provincial and territorial criminal code review board, made up of a group of mental health and legal professionals, as well as citizens from the community to determines who is released of which they are generally three options:

continued detention
conditional discharge
absolute discharge

The primary diagnosis for most people found NCRMD was psychotic disorder (schizophrenia) at 70.9% followed by substance use disorder at 30.8%, mood disorder 23.2%, or personality disorder 10.6%. Crocker et al. 2015b

The effects of deinstitutionalization on the Prison Population:

People with antisocial personality engage in criminal behavior. prisoners have high rates of antisocial personality. Therefore, mental disorders are related to crime. this is referred to as the “criminalization of the mentally ill” Brink et al, 2001

Mental Disorder and Stigma:

Stigma: Combination of stereotypes ( cognitive labels used to describe a person), prejudices ( negative emotions toward individuals), and discrimination (curtailing the rights and opportunities of an individual) toward a specific group

A primary problem of behaviors resulting in the unfair and inadequate treatment of people with a mental illness and their family members, likely due to misconceptions and misunderstandings about mental illness.

The Mental Health Commission of Canada (2013) Noted media portrayals of individuals with mental illness are problematic. For instance, they found that 40% of Canadian newspaper articles negatively associate crime, violence, and danger with mental illness.

Only 17% of Articles include the voice of someone living with a mental illness; only 25% include the voice of an expert; only 19% of Articles discuss treatment; and only 18% discussed recovery and Rehabilitation
Self stigma occurs when people with mental illness accept and agree with negative cultural stereotypes. they feel ashamed, blameworthy, and try to conceal their illnesses from others. public stigma and Compasses the projectile attitudes and discriminatory behaviors expressed toward people with mental illness by members of the public.
This relates to changes such individuals face when attempting to re-entry into the community after being in prison. agency level or structural stigma occurs at the levels of institutions, policies, and laws. it creates situations in which people with mental illness are treated inadequately and unfairly, such as placement and segregation
Police officers are becoming the front line contact for many of these people, who are both victims of crime and perpetrators. As a result, some researchers have labeled the police as “Street Corner Psychiatrists”

Theories and Pathways:

Prevalent Studies have also indicated that prevalence rates for jails are not demonstrably higher than for prisons, although the overlap among risk factors and comorbidity of major mental illness and criminogenic.

Substance misuse: A problematic pattern of substance consumption linked to the negative social, occupational, legal, medical, and or other personal consequences; some experts only use the term in regards to misuse of prescription medication

Diagnoses prompted Bonta, Blais and Wilson (2014) to argue for the application of a general Personality Cognitive Social Learning (GPCSL) approach to intervention strategies.

Symptoms of Mental Disorder that Increase Risk of Crime and Violence:

Douglas et al. 2009: Suggest three mechanisms by which psychosis can potentially serve as direct cause of violence

psychosis serves as a focusing role by providing a clearer motivation and violent Behavior

**Threat Control Override: (TCO)

psychosis destabilizes decisions and behavior, leading to disorganized and impulsive acts of violence and crime;
psychosis serves disinhibiting role in violence, in which case negative symptoms such as affective flattening, lack of goal Directed behavior, motoric slowness block normal inhibitors to act violently

Individuals with schizophrenia who experience:

TCO Delusions: Entrenched delusion beliefs of perceived threat and loss of perceived personal control, linked to violence in persons with acute mental illness

Command Hallucinations: Auditory hallucinations directing an individual to perform an act that may be criminal or non-criminal in nature

As noted above, they are at an elevated risk. The other factor that increases the risk of violence in those with schizophrenia, Is the combination of psychotic symptoms and substance abuse/dependence.
according to the DSM-5

Delusions: erroneous beliefs that usually involve a misinterpretation of perceptions or experiences

Are fixed beliefs that are not amenable to change in light of conflicting evidence (APA, 2013)
TCO symptoms and violence (Skeem et al, 2006), Finding that hostility, not TCO symptoms, predicted violence in a community of samples of patients. One potential explanation for the discrepant findings has been progressed
These authors found that men and women respond to TCO symptoms differently. Although the rates of threat delusions and control override delusion were similar in men and women, it was only in men that threat delusions were related to violence.

In summary, Increase risk of violence and Justice involved persons with mental illness is likely when the following are present:

active psychotic symptoms with a substance abuse disorder and a History of Violence or current attitudes supportive of violence
the presence of a delusional belief
command hallucinations to commit violence

GPCSL Perspective:

GPCSL Theory would acknowledge the criminogenic prevalence of certain mental health symptoms as noted above but would assert that:

mental illness in of itself is automatically criminogenic
the factors associated with crime and violence is non mentally ill populations are all so associated with crime and violence (criminogenic) for persons with major mental illness; the central 8 along with other relevant domains of risk and need

Assessment:

First, substance use diagnosis are inherently criminogenic; they point to a need area linked to recidivism, and unfortunately, Correctional clients with mental health concerns who use substances often do so while not adhering to their psychotropic medication
this results in an exacerbation of Mental Health symptoms (bizarre behavior, agitation, impulsive unpredictable acts) and elevated propensity for crime and violence

Dual Diagnosis: the co-occurrence of a substance use disorder with another mental health condition

Protective Factors:

An important area that warrants increased attention relates to the management or reduction of risk through the presence of protective factors.

Assessment Indicators:

Many Correctional agencies utilize a mental health screening approach or triage, whereby is specific items are identified during an interview with Correctional officer, a referral is made to a mental health specialist

The Referral Decision Scale:

Is another popular measure and it has 14 items reflecting schizophrenia, major depression, and bipolar disorder symptoms. However, concerns regarding its validity and utility and jail samples have limited its application
Since 2009, CSC has been using a computerized mental health intake screening system which includes self-report measures of mental health symptoms: brief symptom inventory and depression, hopelessness, and suicide screening form.

Assessment for suicide:

In jail and prisons, when an offender's assessed as having high risk for self-harm or suicide, they're typically placed on a watch in an isolation cell. monitoring can be done one-on-one or via camera. a mental health assessment is required before an individual can be taken off suicide watch.
suicide is the leading cause of unnatural death among federal inmates, accounting for about 20% of all deaths in custody in any given year
typically a suicide risk assessment includes items that assess to what extent the individual:

has made a previous suicide attempt
has undergone recent psychological/psychiatric intervention
has experienced recent loss of relative / spouse
Is presently experiencing major problems
is currently under the influence of alcohol drugs
show signs of depression
has expressed suicidal ideation
Has a suicide plan

There are some general and violence specific measures developed with mental health populations in mind, but these tend to also be employed with General Correctional samples and their item content and organization is similar to other established actuarial and structured professional judgment SPJ tools.

Historical Clinical Risk-20: A structured professional judgment violent risk assessment tool comprising 20 items organized into three domains: historical, clinical, and risk management

Violence Risk Appraisal Guide- Revised: Here 12 items static actuarial violence risk assessment measure

Violence Risk Scale: A 20 item violence risk assessment and treatment planning tool designed to assess violence risk, identify targets for treatment, and to assess changes and risk from treatment and other change agents

Short-term assessment of risk and treatability START, were developed to assess risk for inpatient violence, as well as improvements and risk and release potential in mental health populations. The START is an SPJ tool that incorporates 20 items that can be scored as either risk or a strength factor. items include areas to reflect social situation and relationships, mental state, substance use, impulse control, medication adherence, treatability, supports, insight, coping, and current plans.
Measures such as START are also intended to assess more acute and intimate risk, such as potential for inpatient Hospital Ward violence.
Dynamic tools can be readministered to evaluate possible changes and risk to inform follow-up treatment and discharge decisions, either by provincial or territorial review board for hospitalized patients, or the parole board of Canada for federal incarcerated persons with mental illness

Practical Considerations:

Two issues with mental health samples:

Evidence for predictive validity, including the evaluation of change, referred to as

Discrimination

The applicability of recidivism norms referred to as

- calibration

Discrimination: Relative risk- the extent to which scores can differentiate higher risk from lower risk persons

Calibration: Absolute risk- the rate of recidivism associated with risk scores, or how well a risk measure recidivism rates from a reference group apply to those of another sample

Treatment Approaches:

Mental health diversion programs are becoming popular, whereby people coming in contact with the criminal justice system with mental illness are diverted pre-charged so they can be assessed and receive treatment. one example that has proliferated in recent years is:

Mental Health Courts: Diversionary Court intended to provide support and legal oversight for individuals with mental illness who come into conflict with the Justice system, typically for non-violent crimes

The researchers found a small, significant effect for their association between MHC participation and reduced recidivism
compared to traditional criminal justice processing routes (receiving a probation or jail time)
A benefit of the MHC diversion model is that it is cost-effective: court cost are reduced because there are fewer hearings involving judges, prosecutors, and lawyers; police costs are lower because more people are assessed and supported before they get into crisis; and hospitalization costs are reduced because intervention typically occurs in outpatient settings.
A major goal will be to allocate resources based on risk and diagnostic profile to improve intervention and post-release outcomes for persons with mental illness. the overlap among risk factors and co- morbidity of psychiatric major mental disorder in criminogenic APD and substance abuse diagnose prompted by Bonta et al 2014
Within the RNR framework, mental illness would serve as both a need issue and a responsibility issue. as a need issue, certain mental illnesses and mental health symptoms are criminogenic, such as substance misuse, antisocial personality features, and certain active symptoms of psychosis
mental health symptoms that are criminogenic in nature would thus be treated through medication, psychological therapy, and community support to Aid reintegration.

Changing Lives Changing Outcomes (CLCO): A comprehensive treatment program designed to treat the criminogenic and mental needs of Justice involved persons with acute mental illness.

CLCO is an RNR-based Treatment program for Correctional clients with major mental illness. The program targets both mental illness to improve adaptive functioning and criminogenic needs to reduce the risk of recidivism. it is a comprehensive structure cognitive behavioral treatment program organized into nine modules across 77 sessions:

preparing for change
mental illness and criminal awareness
thoughts and attitudes
medication adherence
coping with mental illness and criminalness
emotions management
Associates
skill development
substance use

Treatment Effectiveness:

Morgan et al. 2012: Conducted a meta-analysis of 26 Correctional treatment outcomes studies for persons with mental illness. most of the programs targeted persons with severe mental illness schizophrenia was the most common diagnosis and the average program length was 25 weeks

improvements with treatments were evident for most domains including large effects for improvements in mental health symptoms and a medium effect for improved institutional functioning
However, a very small non-significant effect was observed for decreases in recidivism, which was examined in only three studies
Morgan et al 2012 concluded that there was ample evidence for effectiveness of Correctional mental health treatment programs and improving a number of outcomes although the effect of recidivism was inconclusive
Morgan et al 2012 meta-analysis there have been multiple evaluations of the CLCO program described above. in a sample of 47 incarcerated men with mental illness who had attended the CLCO program, about 2/3 completed the program, and there was significant pre /post improvements in mental health symptomatology, interpersonal functioning, and reactive criminal thinking