Forensic Psychiatry Steps into the Social Media Age

Regular followers of this blog know that every year about this time I put up a series of posts entitled "What I Learned." The purpose of the posts is to give people a peek inside the annual conference of the American Academy of Psychiatry and the Law as well as some exposure to the kind of topics forensic psychiatrists are interested in. General psychiatry residents may find it helpful, particularly if they are considering a career in forensic psychiatry and if they can't afford to travel to the conference. Our organization, AAPL, is an international group with members from Canada, the UK, Australia, and South America. Our international members deserve to see what's going on, as well.

This year, we will boost our international presence by livestreaming a select number of presentations through the Meerkat mobile app. Here is a schedule of the presentations we will stream. Directions on how to use Meerkat are below. In addition, select AAPL members have volunteered to moderate questions on each presention through Twitter. Hashtags will be announced through Meerkat, Twitter, and slides at the actual presentation. We've never tried this before, and we are all volunteers rather than professional videographers, so there may be a few snags or hitches but overall we're hopeful people will find it educational and fun. The conference begins on Thursday, Oct 22nd and continues through Sunday.

Here's the schedule:

Thursday 8:00-10:00	Graham Glancy  Witness Protection Program: A Matter of Training
Thursday 10:15-12:00	Ken Appelbaum The New APA Guidelines on Correctional Psychiatry
Thursday 2:15-4:00	Ryan Wagoner The Psychiatrist in Peril: Current Topics in Malpractice
Friday 8:00-10:00	Tobias Wasser  Novel Approach to Teaching Residents About Violence & Safety
Friday 8:00-10:00	Drew Kingston PhD  The Relationship Between Mental Illness and Violence
Friday 10:15-12:00	Caitlin Costello  Adolescents and Social Medica: Privacy, Brain Development and Law
Friday 10:15-12:00	Robert Forrest  Treatment of Transgender Inmates
Friday 4:15-6:15	Rosa Negron Munoz  Educational Factors Contributing to Juvenile Delinquency
Saturday 10:00-12:00	Madelon Baranoski  Role of Forensic Psychiatry in Veteran Evaluations
Saturday 2:15-4:00	Anna Glezer  Myths and Realities of Women in Prison
Saturday 2:15-4:00	Jennifer Piel  What Gets Judges in Trouble?
Saturday 4:15-6:15	Keith Stowell  Forensic Issues in Emergency Psychiatry
Sunday 8:00-10:00	Hal Wortzel  TBI Update: International Collaboration on mTBI and DSM-5
Sunday 8:00-10:00	Stephen Simring  Forensic Psychiatry and the Death Penalty
Sunday 10:15-12:15	Lynn Maskel  Rock and a Hard Place: Debating Sexual Sadism Diagnosis

Here’s how you use Meerkat:

1. First, go to the app store, search for “Meerkat app,” and download it.
2. Meerkat will ask you to type in your phone number for verification. Then, they’ll send you a four-digit confirmation code.
3. Next, connect the app with your Twitter account. (If you prefer, you can skip this step and check the app out in stealth mode.)
4. If you don’t want to add friends, don’t connect your accounts. Simply scroll down and you’ll see anyone who’s live streaming right away. Keep scrolling for more.
5. Search for and follow @AAPL2015. We will have a schedule of streams posted each day. For simultaneous sessions, AAPL members may use their own Twitter accounts which we will announce. You can search for them on Meerkat as well.

This is all a tremendous experiment so I want to thank my colleagues, AAPL, and our viewers in advance for participating. I'm looking forward to your questions, comments, and discussion.

--ClinkShrink AKA @ClinkShrink AKA Annette Hanson, MD Program Co-Chair

The Hired Gun

I know I'm going to get nudged to talk about this article so I'll beat Dinah to the punch. Today's New York Times has a story entitled "Witness for the Prosecution" about a neuropsychologist who frequently is retained to testify on behalf of the state in criminal trials. The expert witness gets criticized for slanting his opinion in favor of the prosecution by ignoring previous history or making certain presumptions about the defendant's previous education or experience. You can read the article yourself, I won't repeat it here.

The article quotes questions from the doctor's cross-examination about the assumptions he based his opinion on: how do you know the defendant took a psychology class? Why are you ignoring or not considering his mental health history? Why are you disregarding DSM diagnostic criteria?

All of this sounds pretty horrible, but the fact of the matter all the questions asked by the cross-examining attorney at the beginning of this article are routine questions that will get asked of any testifying expert. As I mentioned at our recent talk at the Johns Hopkins Odyssey lecture, these questions are designed to make the expert look incompetent or foolish. They are an attempt to undermine the credibility of the expert in the eyes of the judge or jury and to get him flustered and confused.

This is predictable, and to a certain extent it's a choreographed dance. When you express an opinion you will be asked the basis for that opinion---what information did you consider, did you have all the information, why do you rely more heavily on one source of information than another, did you consider the credibility of the information?

The next step is to alter all the details slightly in an attempt to get your opinion to waver or even change: what if this piece of information weren't true, or you found out a certain fact was different from what you assumed? How would this affect your opinion? This step of the process could go on for hours. It can be painfully boring for a jury, so when the NYT article talks about the importance of "presentation" and communication for a good expert witness, that's why. You have to hold a jury's attention for hours in spite of excruciatingly detailed questions, a court room that is either too hot or too cold, and chairs that you can't quite get comfortable in no matter how you twist.

Once all of this is exhausted the last stage is to attack you, personally. If you don't have the guts for this, if you have an issue in your professional past you'd rather not have public, this is the stage that will weed you out of the expert witness field. I note that the NYT article mentioned the expert's appearance on his Facebook profile, and also mentioned he had a Twitter feed. I plan to send this article to my students to remind them that anything they write, anywhere, could theoretically end up on the New York Times web site. I certainly keep this in mind when I blog and tweet. This is the chance you take when you do forensic work, whether or not you are forensically trained.

The last point I'm going to make using this article is the fact that this particular expert is retained as a prosecution expert. There are both advantages and disadvantages to being retained by one side or another, as opposed to working as a neutral court evaluator as I do. A defense expert has the advantage of being able to get in to see the defendant as soon as possible after the offense. This is good because you're more likely to get an accurate picture of the defendant's mental state at the time of the crime. A state or court's expert sees the defendant weeks or even months later, after bail review and arraignment and after the defense expert has had a chance to advise counsel on the likelihood of a viable insanity defense. Experts acting in a neutral court-appointed role have to work harder to gather the data to put together a retrospective picture of that mental state.


I could go on and keep rambling about this but that's enough for now. The NYT's point about the expert being a hired gun as an old one I've talked about before. Ironically, the NYT just made my point about this---if you are a hired gun everyone will know it, it will undermine your credibility and make you less useful as an expert. Being a hired gun is bad for business so most experts know you just can't get away with it over the long term. And that's one of the standard cross-examination techniques as well---trying to paint you as a hired gun.

Enough.

The Wicked Witch of the West, Behind the Scene

One week from now our legislative session will be over and we'll be left to sort through the wreckage of the new laws that hit us. Every year I do this I wish we had some way to limit the number of bills that could be introduced, to give the public a fighting chance to figure out what their representatives are trying to do to them.

The Shrink Rappers have been pretty busy with this particular session and I've written a short column about it over on Clinical Psychiatry News. Feel free to hop over there and read my piece "A Glimpse Under the Hood." The site doesn't require you to register anymore although there is one small annoying popup ad you have to click past first.

This afternoon is the big day. The House version of our governor's gun bill is going to a vote in a joint committee. If it passes, which everyone expects it will, that will be the final step before it joins the other version already passed by the Senate to become law. We've managed to keep psychiatry out of the decision to take guns away from people and to at least provide some education to the legislators about the limitations and dangers of policies based on categorical mental illness.

It looks like insanity acquittees, criminal defendants who are incompetent to stand trial and people under guardianship will be barred from purchasing weapons, as will be anyone under an active protective order. This addition is required by the Federal government to be compliant with their gun laws. People can petition to have their gun rights restored although the administrative logistics for this have yet to be hammered out, and legislators (in spite of their professed intent to get guns out of the hands of dangerous people) have shown a striking reluctance to enforce seizure of weapons from anyone who falls into one of these categories. And yes, they carved out certain assault weapons out of the list of proposed banned weapons.

The final piece is the Maryland version of the New York SAFE Act. The original bill has been dropped, but it bounced back in the form of an amendment to today's bill which will be voted on this afternoon. The last three days have been pretty intense with discussions about how to protect our patients from getting reported to police. Dinah has already written extensively about this in USA Today and in Clinical Psychiatry News, and I outlined the New York requirements here. We're hopeful Maryland is not going to skip down that yellow brick road. That yellow isn't gold.

Which brings me back to the Wicked Witch of the West. When crafting law, her advice "These things must be done carefully" is a good thing to remember. I thought of this often when looking at bills proposed to modify all of our involuntary treatment laws. Regardless of which way you fall on the issue, the worst outcome is to create confusion. I don't know if any of the changes will actually make it out of committee next week so I won't speculate here, but like most states following all these high profile shootings there was a rush to cobble together a lot of changes while the time was ripe. And it showed in the legislation.

And now for something completely different:

Well, not completely. I listened to a presentation yesterday by Dr. Jeff Swanson, a sociologist and epidemiologist who studies the impact of certain public policy decisions and programs. He was part of a summit meeting on gun policy recently at Johns Hopkins. I listened to 90 minutes of impressive outcome data on gun violence and mental illness. His research provides strong support for the futility of reducing gun-related violence by singling out people by diagnosis. Unfortunately, as we've already seen with the sex offender registries, futility and costly ineffective public policies are not mutually exclusive.

So that's where I've been disappeared to lately. I hope to come up for air soon.

What This Shrink Rapper Would Tell Congress

Recently one of our readers posted this comment:

“If any Shrink Rapper ever has the time and inclination it would be interesting to read about what you would do to fix the mental health system, particularly the issue of involuntary hospitalization, if you had unlimited funds and political resources. You've been in the trenches, it would be great to hear your thoughts.”

Simultaneously, over on Peter Earley’s blog I see that he is planning to testify next week before a U.S. house subcommittee regarding issues related to violence and severe mental illness. He is asking for people to contribute responses to six specific questions he expects to be asked. Please go over there and contribute your ideas---this is your chance to make a difference.

Meanwhile, I have my own thoughts about this which may or may not be directly relevant to the six questions, but I want to bring this to the attention of the subcommittee if Mr. Earley would be kind enough to include it. For those of you who want the "bottom line," I've underlined my main ideas.

First, a bit about why I think my experience and ideas are relevant.

As a forensic psychiatrist, I evaluate and treat severely mentally ill people who are or have been violent. I see the rare exceptions, the people who as a result of their disease commit acts that seriously injure or kill others. As a correctional psychiatrist I have also evaluated and treated thousands of prisoners, many of whom also have serious psychiatric disorders.

I will emphasize, as you've already heard from others, that violent offenses due to psychosis are the exception to the rule. Almost all crimes of violence are not committed by people with schizophrenia or other psychotic disorders. Drug and alcohol abuse is the culprit in most violent crimes and we must vigorously address this and do more to provide treatment to people with substance abuse problems at the time that they are willing to accept treatment.

From evaluating insanity acquittees, people who are found not criminally responsible for  their crimes due to mental illness, I’ve learned that one significant systemic problem is the lack of public awareness about psychosis and how to recognize prodromal symptoms. Often the early symptoms get written off as attributable to some other life stressor: the breakup of a relationship, the stress of a young adult's transition to college or some other understandable life event. Sadness, withdrawal from family, loss of interest in hobbies or friendships can be explained in this context. However, as the illness gets worse and the patient's personality changes, there is more recognition that something serious is going on. Friends, neighbors and teachers recognize psychosis only when there is increasing disorganization, inability to complete tasks, or eventual bizarre behavior and unusual statements.

Therefore, my first suggestion to address violence due to mental illness would be to provide better public education to recognize emerging psychosis.

Once the psychotic episode is recognized for what it is, the challenge for families then becomes figuring out what to do. Finding a psychiatrist and getting prompt evaluation and treatment is a tremendous challenge particularly in rural or underserved areas. In southwestern Minnesota where I was raised, there is only one fulltime psychiatrist serving a seven county area of 70,000 people. Our local Baltimore City Detention Center has a higher per capita number of psychiatrists than my hometown. That has to change.

My second recommendation is this: the government needs to provide increased funding for medical education, particularly the training of psychiatrists. There should be additional incentives, beyond Federal public health service commitments, to work in underserved regions or state facilities.

All of my patients are institutionalized but most will return to the community eventually. Insanity acquittees typically are hospitalized for substantially longer than they would have been incarcerated if convicted. The majority of my mentally ill offenders are convicted of misdemeanor property offenses that are drug or alcohol-related, and return to the community within months to a few years. Regardless of the length of confinement, we need better programs to transition patients from a public institution to the community. Insanity acquittees and mentally ill offenders need housing, transportation, educational and vocational programs in addition to addressing their medical and mental health needs. Lack of adequate community services and transition plans are a key factor in unnecessarily prolonged hospitalizations.

Many recent high profile crimes have lead the public to demand looser civil commitment standards and easing of laws for involuntary treatment. In my opinion, this creates an adversarial atmosphere and unnecessarily sets families in opposition to their mentally ill loved ones. People with psychiatric illnesses have legitimate reasons to oppose confinement, and we should examine these reasons thoroughly and address them.

Some public psychiatric hospitals, of the few that remain, are antiquated and dilapidated. We need to improve environmental conditions of these facilities and address the poor ventilation, bad plumbing and faulty infrastructure. The inpatient unit should emphasize treatment plans that respect a patient's educational level, skills and interests rather than focussing solely on disability. Inpatient safety and security are increasing concerns, leading some patients to be strip-searched arbitrarily. We must improve hospital security to protect both patients and staff from physical assault. As a recent story in our local newspaper indicates, concern about violence is not limited to free society and must be addressed within facilities as well.

Finally, we need to reinvigorate collaborative treatment planning through the use of psychiatric advance directives. Make them meaningful and useful. Currently patients don't trust them because they know doctors can override them. Ironically, doctors don't trust advance directives for exactly the same reason---because they can be revoked by patients. We need to update psychiatric advance directive laws to make them binding, effective and safe, then make sure treatment providers are educated about their use.

Thank you for reading this far. We can’t make the system perfect, but I’m sure we can make it better.

Pick Your Insanity Test

Here's my followup to the post I started yesterday.


If the insanity defense were reformed (again), you'd have to decide which new legal test you'd use. A legal "test" is a written definition or standard. In general, there are two insanity tests in common use: the ALI test and various derivations of the McNaughton test. The McNaughton test states that a defendant is insane if he is unable to understand the nature or quality of the act, or---if he did understand the nature of his actions---that he didn't understand that they were wrong. In 1955 the American Law Institute (A.L.I.) wrote the Model Penal Code in an effort to make criminal laws uniform across the country. The Model Penal Code's insanity test, also called the ALI test, states that a defendant is insane if he "lacks substantial capacity to appreciate the criminality of one's conduct or to conform one's conduct to the requirements of the law". It has two parts, a cognitive standard and a volitional or behavioral standard.

Here is a link I posted last year to a state-by-state break down of insanity standards. It's a little out of date; Kansas is listed as using the McNaughton test but they have since abolished the insanity defense.


Frontline did a nice series a while ago about the insanity defense and they have a summary of the historical tests here.

Reforming the Insanity Defense

Over on Peter Earley's blog there is a post entitled "How Fair Is The Insanity Defense" that you should all go over and read. I thought about writing a comment there but quickly released this would require a post of its own, so here it is.


He starts out with a case description of a man with an undoubtedly severe mental illness who either shot or assaulted many people while delusional. In 1992, after a failed attempt at civil commitment, he shot and killed two people. At trial state psychiatrists testified that he knew killing was wrong, even though motivated by delusion---in other words, a legally sane crime by the McNaughten test of insanity (which Mr. Earley describes well, I won't be repetitive here). He was sentenced to death and eventually executed in spite of a recommendation for commutation by the Texas Board of Pardon and Paroles.

Mr. Earley is critical of the McNaughten test and feels that we should rethink the legal definition of insanity. He also advocates to end the use of private forensic experts, a point I'll return to later.

First, I think the public should understand there is a certain logic to when and how a defense attorney decides to file an insanity plea. Mr. Earley is appropriately critical of attorneys who file the plea "when their client is obviously guilty and they don't have any other rational explanation to fall back on." It's true that there is sometimes a hidden agenda for requesting a sanity evaluation: there may be a chance that an evaluation could turn up mitigating information that could be used at sentencing, or as leverage in a plea bargain.

Setting aside the hidden agenda, the fact of the matter is that insanity pleas are filed rarely compared to the overall number of offenses that happen every year. This is particularly true of misdemeanors. That's because an insanity plea, if successful, could lead to the defendant ending up under court or health and mental hygiene supervision for years. A simple guilty plea could get a client out of jail, with or without supervision, in months. The attorney is obligated to act in the stated wishes of his client, and that wish is obviously going to be to get out as soon as possible. Thus, we usually only see insanity pleas filed in very serious, felony cases.

So how rare is it? In Maryland, an insanity plea is filed in fewer than one-half of one percent of all crimes commited in a year, both in Circuit and District Court. Out of all crimes committed in Maryland, only 0.032% end in a successful insanity verdict. This certainly doesn't suggest that the defense is being abused.

Regarding the proposal to use court appointed experts (please see also my previous post on private evaluations):

We're already doing that. Most jurisdictions have individual psychiatrists or psychologists working on behalf of the court, either in a court-affiliated medical clinic or under contract with the state's department of health. As the system usually works, this independent court-appointed evaluator completes an assessment and sends a report with an opinion about sanity back to the judge who ordered the evaluation, with a copy sent to the defense attorney who filed the plea and to the prosecution. (Exact details of who gets the report, when they get it and how it can be used may vary between states. I'm speaking in very general terms here.)

Then and only then will a private expert get involved, mainly because one side or the other won't be happy with the independent expert's opinion. In my experience, this usually takes place when the independent expert thinks a defendant is sane and the defense wants to challenge the report. In Maryland, if the court's expert finds someone insane that opinion is almost never challenged by the prosecution because both sides recognize, and agree, that this person is very very sick. (I think the number is somewhere near 90% agreement on insanity but I don't have the study in front of me.)

In short, the insanity defense is hardly ever used and private forensic expert involvement is even less common than that. Out of a few hundred evaluations done every year in our forensic hospital, only a handful will involve a private opposing expert.

Whether or not the legal test of insanity should be changed is an issue that arises regularly throughout history, most recently in 1984 following the assassination attempt on Ronald Reagan. Then, Congress passed the Insanity Defense Reform Act which changed the test on a Federal level. It excluded any category of mental illness from serving as the basis of an insanity plea unless the diagnosis was a "serious" mental illness. Many states, including Maryland, revised their insanity statutes following the Hinckley verdict. Four states have completely abolished the insanity defense.

And I guess that's the trick when it comes to opening the bag of worms of insanity reform: there's always the chance, particularly given the outrage following the Connecticut shooting, that the defense could be thrown out altogether. And then where would my seriously mentally ill forensic patients be? The Supreme Court recently had the opportunity to hear a case that would have challenged the constitutionality of a state statute barring the defense, but they turned the case down.

OK, that's wraps up my response. I just wanted to provide a little more background and factual information to the topic since it is going to be discussed a lot in the news as certain high profile cases come to trial.

What I Learned Part 1

Those of you who have been reading the blog for a while know that every year I blog and live-tweet from the American Academy of Psychiatry and Law conference. This year we are hosted in Montreal, the land of fine dining and the most beautiful language in the world. Thus, the foodie picture. When I fly back I will be carrying extra baggage and I don't mean my luggage.

The poster session this morning was quite crowded and I wasn't able to get near most of them, but I did see a lot about legal and clinical implications of synthetic marijuana. Forty-one states have laws criminalizing sale and use of these new chemicals which go by a variety of street names. Effects on mental state can be extreme, including disorganized and violent behavior and hallucinations. So far there are no known longterm clinical effects associated with its use, however. Intoxication has been used in criminal defenses to mitigate culpability (although not generally successful as the basis for an insanity defense) and in states where the substances are still legal courts are struggling to figure out how it should play into a mental state defense.

Dr. Charles Scott gave an outstanding presidential address entitled "Believing Doesn't Make It So: Forensic Education and the Search for Truth." He discussed the evolving---and higher---expectations for forensic evidence, including psychiatric testimony, and how this should inform forensic training and practice.

The next session was a very nice (if I do say so myself) panel presentation about civil commitment of mentally ill offenders following release from prison. California has a mandatory civil commitment law which requires transfer of certain violent offenders with serious mental disorders to a psychiatric hospital at the end of incarceration. Legal challenges to this law were discussed and compared to the New Jersey system, which uses a non-mandatory administrative procedure instead. Finally, these procedures were compared to the state of Maryland where there is no established transfer policy but a wide degree of consultation and collaboration between the correctional and mental health systems, which in many cases obviates a need for hospital transfer.

[At this point in the day I stepped out for lunch and came back four courses later. Oh my, the food was amazing.]

The afternoon session was a very practical panel presentation about who should get access to forensic reports and the implications of HIPAA on evaluee access to protected health information in the report. Historically forensic reports were considered legal work products rather than medical documents, and as such an evaluee did not necessarily have a right to get a copy of or read the report. Under HIPAA some types of reports---such as a disability evaluation or fitness for duty evaluation---might be considered to be protected health information which an evaluee has a right to access. This is an evolving area, however. And under HIPAA, evaluees do not have a right to reports generated for civil, criminal or administrative hearings. This isn't a settled issue and there was good audience discussion.

The evening session was a mock trial which presented the new DSM 5 proposed criteria for hebephilia. The limitations and implications of the new criteria were discussed, which appeared to rely heavily upon an assessment of the victim's Tanner stage. The issue was presented in the context of a fictional sex offender civil commitment hearing, with three mock experts: one for the state, one for the defense, and one independent court-appointed expert. A strong case was made against inclusion when the defense expert testified that the new criteria could result in an 80 percent increase in false positive diagnoses.

So that was the first day. More to come so stay tuned. Live-tweets can be followed at: www.twitter.com/clinkshrink. [For those concerned about speakers' informed consent for social media coverage, all presenters are advised at abstract submission that sessions are recorded and they know that sessions may be covered by the media.]

The End of the Stories: Patient A

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. I thought it was interesting that people with different professional backgrounds and levels of experience pretty much agreed on what to do, who to keep and who to send out.

Since people seemed to enjoy speculating on the back stories, I thought I'd supply the endings.

Patient A was kept in the jail and admitted to the infirmary. After a few days of medication he quickly got better and was able to tell you what happened since his last release. His mother tried to get him an appointment at the local mental health clinic shortly after he got home, but she was told there was a three month wait until the first available appointment and that she should call the police or take him to an emergency room if it was an emergency. After he ran out of his thirty day supply of release medication he went to the emergency room to get it renewed, but when he ran out of meds a second time he was told he could no longer get his meds renewed through the emergency room. It didn't really matter though since his benefits were cut off while he was in jail and he couldn't afford them anymore anyway.

His mental state went downhill quickly after that. His mother, the much-beloved Cookie Lady (as she was known in the neighborhood), didn't stand much of a chance. I'll spare you the details. As a well-trained forensic psychiatrist you know that ethical standards for correctional work forbid you from collecting forensic evidence in jail as a treating clinician, so you are circumspect about your documentation as it regards the current offense. Eventually, an outside forensic evaluation is done and Patient A becomes an insanity acquittee. He is transferred to a forensic hospital.

Immediately after the verdict, there is public uproar. The local newspaper publishes an opinion piece calling for reform of the public mental health system and looser standards for civil commitment and involuntary treatment. A state delegate proposes legislation for outpatient civil commitment. The governor organizes a task force to study the issue and the entire police force is required to undergo crisis intervention and mental health training. Mental health advocates decry Patient A's incarceration, loudly insist that jail couldn't help anybody, and accuse the jail (not you in particular, but the jail) of giving lousy, horrible, inadequate or nonexistent care. (Meanwhile, the somatic jail doc has diagnosed Patient A's new-onset diabetes and Patient A is getting a diagnostic workup for the lump that was discovered on his admission physical---it turned out to be benign. Because of patient confidentiality, none of this can be revealed to the public but you know it.) Meanwhile, on the newspaper internet discussion board some people express outrage that "that dangerous nut case" should have been sent to prison forever, given the electric chair, or made to undergo the same horrible acts he did to his mother. Patient A reads all about this in the newspaper delivered to his ward, and hears about it on the ward television news reports.

Years later, many years later, Patient A is quietly granted conditional release by a sympathetic judge, with the support of the local state's attorney. He goes to live back in his old neighborhood---now gentrified beyond recognition, where he spends a few minutes every morning sipping coffee at the corner Starbucks. His neighbors---a young attorney fresh out of law school, a music student at the local conservatory, and a young couple who work for the local newspaper, see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person. They enjoy having him as a neighbor.

More Forensic Stuff

I'm going to apologize to regular readers for missing your usual Shrink Rap fare. This blog isn't usually this heavy into forensic topics but since Dinah is on hiatus, I'm commandeering the blog to talk about my own interests.

I wanted to address some ideas Sunny brought up in my last post. Her comment was: "...I can't figure out why it is that when a psychotic person commits a crime, that "they" send the person to jail to take psych drugs so that they can become "normal" to stand trial. Weren't they mentally impaired at the time of the incident? Why would we, as a society, not consider the state that person was in at the time of the crime? I wonder how those people feel, when they "wake up" from a psychosis to find that they killed people. It must be awful."

There's a lot to talk about here. The first issue is why people have to become 'normal' to stand trial. This is something that is required by the American constitution. The Sixth Amendment gives every defendant the right to call and confront accusers. While defendants can voluntarily give up their right to be present at trial, they can't otherwise be tried in absentia. If someone is too mentally ill to understand what's going on in the courtroom, that's considered an absence (physically present, but mentally 'in absentia'.) This is the origin of the requirement for competency to stand trial.

The state---or more properly, the defense---does consider the mental state of the person at the time of the offense. This is done through a category of defenses known as 'mens rea' defenses---criminal defenses based upon some aberration of mental functioning. There are a lot of them: extreme emotional disturbance, heat of passion, intoxication and insanity. Mens rea defenses don't generally lead to an acquittal---the person doesn't 'walk'---it just reduces the level of guilt. So, for example, instead of being guilty of first degree murder a defendant may only be guilty of involuntary manslaughter. Exactly what you have to prove to make your case about the mental state will be determined by the law. Each state will have statutory or case law that defines insanity or other various mens rea situations.

The states takes mental state into account at sentencing, too. The defense can introduce all kinds of mitigating information for the judge (or jury, in a death penalty case) to consider.

Regarding how insanity acquittees feel when they 'wake up' and realize what they've done: oh yeah, awful---really awful. Particularly since many insanity acquittees commit offenses against their own families. (See the New York Times article I linked to in my last comment on yesterday's post.) Sometimes you wonder which is worse for them: the symptoms of active psychosis or an awful reality.

Lessons from Guiteau

Over the last few days I've been reading online discussions and blog posts about the Norwegian spree killer and also reading a book on Google about Charles Guiteau, President Garfield's assassin. I thought it was a bit eerie how similarly the arguments sounded for and against insanity, and how little has changed regarding attitudes toward politically-motivated violence in the last 130 years. I put up a post about the topic over on Clinical Psychiatry News. For more, see Political Violence: A Challenge for Forensic Psychiatrists.

Voices From Within

Tonight CNN will be airing a documentary shot inside the old St. Elizabeth's Hospital, made by patients, about insanity acquittees. This is a very rare opportunity to see the realities of daily life for those found insane and learn more about the insanity defense. For more see the CNN story here.

Budgets, Crime and What Happened to Stephanie

From the New York Times today we have a story entitled, "A Schizophrenic, A Slain Worker, Troubling Questions," a horrible story about a mentally ill man who killed a social worker in his group home. The story highlights the defendant's longstanding history of violence with several assaults in his past. He once fractured his stepfather's skull and his first criminal offense involved slashing and robbing a homeless man. (On another post on this blog Rob wondered why the charges were dismissed in that case; from experience I can tell you it's probably because the victim and only witness was homeless and couldn't be located several months later when the defendant came to trial.) The defendant, Deshawn Chappell, also used drugs while suffering from schizophrenia. Before the murder he reportedly stopped taking his depot neuroleptic and was symptomatic. The news story also suggested that he knew he was committing a crime: he got rid of the body, disposed of the car and changed out of his bloody clothes. Nevertheless, he was sufficiently symptomatic to be found incompetent to stand trial and was committed to a forensic hospital for treatment and restoration. At his competency hearing the victim's family thought that the defendant was malingering his symptoms, while the victim's fiance was distraught enough that he tried to attack Chappell in the courtroom. The point of the Times article appears to be an effort to link the crime to cuts in the Massachusetts mental health budget.

So what do I think about this story? (As Dinah would say, this is a 'Clink' thing.)

About the crime itself I have little to say. There's nothing that out-of-the-ordinary or unusual about this as a forensic case. I have no opinion about his legal sanity since I know nothing other than what's presented in the media (and I've had enough of my own cases covered in the media myself to take what I read with a large grain of salt!). Frankly, these kind of cases happen every day as you could tell by following the Psychiatry and the Law twitter feed.

Why does this story, of all the potential psychotic killer stories, showing up in the New York Times, and why is it showing up now?

Because New York is trying to "beef up" their assisted outpatient treatment law, of course. And the Times has come out in favor of it. They've had other articles in the paper promoting assisted outpatient treatment.

Now, I'm all in favor of advocating for improved mental health services as well as adequate training and reimbursement for well-qualified mental health staff. I just wish they wouldn't feed into the fear and public stereotyping of seriously mentally ill people to do it. That's my first reaction to this piece.

My second reaction is in response to this quote:

"The first time Mr. Chappell secured a state hospital bed — and the treatment that comes with it — was when he ended up behind bars."

And the observation by Chappell's mother:

"In 2007, Mr. Chappell, sentenced to a year in jail but required to serve only three months, ended up at the prison psychiatric hospital. When his mother visited him there, she said, she was heartened to see the effects of an enforced medication regimen. “This was the son I raised,” she said. “He talked about going back to school and getting a college degree.”

I'm going to link back to those quotes the next time I hear somebody comment that "locking people up doesn't do any good." There are some people---fortunately relatively few---who can only be treated in a secure environment because they are just too repetitively assaultive to be treated anywhere else. That's what forensic hospitals and prisons are for.

Podcast Number 55: What Happens to Shooters with Mental Illnesses?

There has been a lot in the media recently about mental illness and it's relationship to violence.
In this episode we have ClinkShrink walk us through what happens to a mentally ill defendant in a violent crime. First, there is the question of Competence: is the defendant able to meaningfully participate in his/her trial, this is the present mental capacity. If the defendant never becomes competent, he generally remains in a forensic facility indefinitely. At some point (10 years in our state for a capital crime), the law requires a final disposition, and the defendant who is not likely to ever attain competence will be civilly committed and will remain in a forensic facility.

The second question is one of sanity at the time of the crime. ClinkShrink talks about the complexities of insanity evaluations and the rarity of having a Not Criminally Responsible plea. We discuss the idea that incidental mental illness is not enough to be found not guilty by reason of insanity, that the mental illness must have influenced the criminal behavior or obscured the defendant's ability to appreciate the criminality of his behavior. Finally, Clink talks about what happens after an insanity acquittee is released and what type of aftercare planning gets put into place.

The photo is Billy Bob Thornton in Slingblade--he's our example of an insanity acquittee.

Once again, thank you for listening and please do write a review on iTunes.

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What I Want From ClinkShrink, by Dinah

Dear ClinkShrink,

Thank you for writing your post yesterday in response to requests for your input on the tragedy in Arizona. I liked reading about The Killers I've Known (or rather the killers you've known) and certainly I enjoyed revisiting your article on Shooter Psychology. And it does seem to be true that we all pester you every time there is a mass shooting.

I know you can't really comment on the motives of a mass murderer whom you've never examined.

Here is what I think it would be interesting for you to write about, if you want to. Or maybe if our readers bother you because they seem to have more influence than I do.

I'd like to read about the process of what will happen to the man who committed this heinous act. The descriptions in the news paint a picture of a man who may have been mentally ill or under the influence of drugs, or both. So what happens from here? Does he go to jail or to a psychiatric facility? How is it determined if he was mentally ill? What sorts of documents are examined and what sorts of people (if any) are interviewed? If he's found to be unable to stand trial, how does that work? Will he be treated with medicines? If he's very psychotic, might the medicines make him much better, and how would play out? Could he then stand trial? I'm going to assume that there's no chance (I hope) that he will be released back into free society, at least not now. What factors influence whether he is found not guilty by reason of insanity (does that designation even exist anymore?) And where does he go if he's found to be a) mentally ill and unable to understand the consequences of his actions, b) mentally ill but able to understand that what he did was wrong, c) that drugs were part of the picture or d) not mentally ill and fully able to understand what he did. How much difference does it make as to which state someone lives in who does something like this in terms of where he might end up? And in death penalty cases, does his mental state matter at the time of the crime? At the time of the trial? At the time of execution?

So perhaps I want you to give us a full forensic fellowship in a blog post. You are a good sport. It seems we're going to hear a lot about gun control and tea party's and political agendas and obstacles to treatment of the mentally ill and what obligation society has to prevent such atrocities. You have something different and important to add.

Cheers,
Dinah

The Killers I've Known

Some blog readers have been asking for a post about the Arizona shooting incident. The issue of spree killing has come up on the blog before, after the Amish killings in Pennsylvania, after Virginia Tech and the Fort Hood incidents. This will officially be my third poster about shooter psychology and it's getting hard to find something new to say.

First of all, most murderers don't have multiple victims. According to the Uniform Crime Reports, the number of multiple-victim killings has remained pretty stable over the last five or so years, at about 350 per year. Almost all multiple victim killings are committed using guns, although in 1987 there was an anomaly in which 24 people were killed by poison. More about that later.

In most cases, the killer knows the victim and that's true both for single and multiple victim offenses. The nature of the relationship varies with the setting and type of killing: spree shooters most often kill co-workers or other students, while single victim killers murder their partners or drug acquaintances. Psychotic killers will usually murder a caretaker, a mother or wife, but only if the killer is a young male. Female psychotic killers tend to kill their children. It's rare for a psychotic killer to murder multiple strangers. Locally I can recall only one case like this over the last twenty years. In this case the killer suffered from a grandiose delusion, and the victims were killed in a car crash. Psychotic people can stalk or threaten political or other high profile figures, but this usually doesn't result in violence. Typically what motivates psychotic political stalkers is a delusion of some type, for example the belief that a political (or other stranger victim) is threatening them in some way. For example, one political stalker I examined believed that a U.S. Senator was a devil worshiper, and that he was destined to kill all devil worshippers. Another psychotic letter writer had a delusion about the president, although he was so thought disordered it was a little hard to sort out the "logic" behind the delusional motivation.

Multiple victim killers could be spree killers or serial killers. That 1987 anomaly with the poison deaths was partly due to Donald Harvey, a serial killer in Ohio who poisoned patients at the hospital where he worked.

Non-psychotic spree killers have the same motivations as "regular" single victim murderers: frustration over the loss of a job, the loss of a relationship, loss of a living situation, lack of money or friends, alienation from family and substance abuse. Killing is an act of desperation whether you're killing one person or many. Political motivations may come into play, but without the "nothing left to lose" factor political motivation isn't enough.

So why did the Tucson shooter act? Ya got me, I haven't examined him so we can only speculate based on what's in the news. All I can tell you about is the usual characteristics of the killers I've known.