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The psychotherapy of a murderer adjudged not guilty by reason of insanity is presented through dated excerpts from twenty-six months of process material. The patient was treated in a maximum security facility. The murder is interpreted psychodynamically as an identification with the aggressor, the patient's mother. It is also understood as a pathetic appeal for help.
As long as psychiatrists are human, there will be episodes of unethical psychiatric practice and ineffective, sometimes damaging psychiatric treatment. The author argues that these incidents do not detract from the overall integrity of the profession, the reality of mental illness, or the increasing sophistication of psychiatric treatment and knowledge. Rather than being oppressive, as a minority of former patients have charged, the policies of the American Psychiatric Association related to patient care are broadly worded ethical principles intended to foster the patient's good. The author defends the need for involuntary treatment and suggests that controversies surrounding involuntary treatment, the insanity defense, and the homeless mentally ill are essentially social, legal, and legislative issues in which psychiatry has found itself in the middle.
The role of the psychiatrist in the determination of fitness to plead is reviewed by reference to 77 pre-trial psychiatric reports prepared on 31 Special Hospital patients detained under the provision of Section 5(1)(c) (Unfit to Plead) of the Criminal Procedure (Insanity) Act 1964. Each psychiatric report was analysed using a standardized checklist which addressed the legal criteria used to determine fitness to plead, the nature of the alleged offence and the clinical diagnosis. The results showed that almost 40% of the reports made no mention of fitness to plead at all and that only one-third of the reports made a statement about fitness to plead which was supported by reference to standard legal criteria. The results of this study support earlier work which has suggested that psychiatrists have a poor understanding of the issues surrounding fitness to plead and criminal responsibility. These findings are discussed in relation to recommendations made by the Report of the Committee on Mentally Abnormal Offenders, 1975 (Butler Report) and legislative changes introduced by the Mental Health Act 1983.
This paper examines three categories of mentally abnormal offenders who are held under Lieutenant Governor's Warrants. It explores the psychiatric-legal issues in cases of pre-trial (not fit to stand trial) and post-trial (not guilty by reason of insanity) L.G.W.'s. An attempt is made to provide a structure for such psychiatric-legal evaluations. Clinical guidelines are offered about the objectives, the assumptions and the criteria which form the basis of such evaluations. Suggestions are made for collection of relevant data which should inform psychiatric and legal judgement-making in this area. The role of the psychotropic medication in N.G.I. cases is discussed. It is recommended that whenever medically feasible, a controlled drug-free trial should be carried out in N.G.I. cases prior to their final release, in order to unambiguously establish their need for medication.
The authors compiled demographic, psychiatric, and criminological information on persons who were held on warrants of the Lieutenant Governor in Ontario. These warrants were vacated between the period 1969-1982. Of the entire population of 296 such persons, 46% were held as being Unfit to Stand Trial, 51% were Not Guilty by Reason of Insanity, and the remainder were Mentally Ill prisoners. Separate analyses were conducted with the Unfit sample. The average length of confinement on a warrant was 7 years.
The current Canadian legislation regarding dangerous offenders is reviewed, with specific emphasis on the role of the required psychiatric testimony. It is suggested that, although this legislation as it is currently formulated could be viewed as an attempt to broaden the insanity defence, and permit the diversion of mentally ill offenders from a punitive to a therapeutic milieu, it enables the preventive detention of recidivist offenders. Some fundamental ethical issues which follow from this are identified, together with the issues which have dominated expert testimony in hearings held in British Columbia during the past 13 years.
Bill C-30, implemented in February 1992, made a number of significant changes to the Criminal Code provisions concerning the assessment, treatment and disposition of mentally disordered persons charged with a crime, including persons considered to be unfit to stand trial or pleading insanity. The changes deal mainly with procedural law and the civil rights of persons being assessed or held in custody, and put limits on where, how long and for what purpose persons may be detained. The new law abolishes the automatic, indeterminate detention of persons found unfit to stand trial or not criminally responsible on account of mental disorder. The changes may mean that the forensic psychiatric route is now a more "attractive option" for defendants. The new law may create administrative problems for clinicians by leading to increased requests for psychiatric assessments while at the same time constraining the assessment process.
Few studies have extensively studied the aggressive behaviours of mentally disordered offenders. This investigation compared 14 schizophrenics found not guilty of homicide by reason of insanity (NGRI) with 12 schizophrenics convicted of homicide. A comparison group of 15 homicide offenders with no major mental disorder was used. Drug and alcohol consumption, previous history of aggression against others as well as mental health were assessed using standardized, reliable, valid instruments. Significantly more of the inmates with no major mental disorder were diagnosed as having a history of drug or alcohol abuse or dependency (60%) than the NGRI schizophrenics (35.7%). In addition, both groups of convicted homicide offenders were more likely to have committed homicide under the influence of drugs or alcohol than the NGRI group. No significant difference distinguished the groups for the mean number of aggressive incidents. The subjects found NGRI assaulted more often during an acute phase of mental illness than the convicted schizophrenics. Although both groups appeared to have a similar number of hospitalizations, most of the hospitalizations of the convicted schizophrenics occurred after the crime.
The Council for Secular Humanism identifies Secular Humanism as a "way of thinking and living" committed to rejecting authoritarian beliefs and embracing "individual freedom and responsibility ... and cooperation." The paradigmatic practices of psychiatry are civil commitment and insanity defense, that is, depriving innocent persons of liberty and excusing guilty persons of their crimes: the consequences of both are confinement in institutions ostensibly devoted to the treatment of mental diseases. Black's Law Dictionary states: "Every confinement of the person is an 'imprisonment,' whether it be in a common prison, or in private house, or in the stocks, or even by forcibly detaining one in the public streets." Accordingly, I maintain that Secular Humanism is incompatible with the principles and practices of psychiatry.
OBJECTIVE: The purpose of this article is to discuss the interface between judicial discipline and behavioral science in the context of substance-related disorders. METHOD: We review the epidemiology of psychoactive drug use and crime and discuss the courts' decisions on relevant landmark cases, particularly as they influence the practice of psychiatry. RESULTS: (1) The phenomenology of addiction and crime is of great epidemiological import. (2) Our legal system inclines toward the view that the use of alcohol or other substances involves an element of choice and therefore would not amount to a legal insanity defense if the substance abuser commits a crime while intoxicated. (3) A state can confine an addict or alcoholic for compulsory treatment if that individual presents a danger to self or others. (4) The law has found that alcoholism and drug abuse are both "willful misconduct" and a disabling condition; the former definition contains the end in view of punitive action. The latter is aimed toward treatment and rehabilitation. (5) The law gives the right to the employer to test a suspected employee for drug abuse. The addicted or alcoholic employee has the choice to either go for treatment or face job termination. (6) Our judicial system gives serious consideration to the welfare of a child whose parents are alcoholic or drug addicted. CONCLUSION: The two disciplines of psychiatry and law follow their own modes in resolving issues in alcoholism and other substance abuse. We need research and new approaches to build a bridge between the two.
Psychiatry and criminal justice have been closely related for a long time. Traces of such ties can already be found during the 19th century through the establishment of the contemporary systems of social control. Various questions that will mark the development of policies in this domain were important objects of discussion and analysis: Is mental illness a cause of criminality? Should the "insane" be held responsible for their crimes? What are the appropriate measures to heal, reform, control? In other words, should we consider the individual as sick or as criminal? If these questions are formulated differently nowadays they haven't lost any of their relevance. In this article, we will briefly present the forms of intervention available to the criminal justice system when dealing with persons suffering from mental health problems. This presentation is based on recent studies conducted in Montreal, elsewhere in Canada, as well as in the United States. The main stages of the criminal justice process will be examined, taking into account the recent modifications to the Canadian Criminal Code and its impact on the relations between the courts and psychiatric facilities. This type of situation is not without impact on community mental health for two main reasons. First, with the diminishing public funding of various health services there seems to be a growing practice of criminalization of persons suffering from mental health problems, especially the most vulnerable segments of this population. Secondly, there is a growing trend, in the criminal justice system, of requiring support from community groups or facilities to deal with these criminalized individuals. In the coming years criminalization will constitute an increasing and complex challenge for community mental health.
Since their adoption in 1892, the insanity laws in the Criminal Code of Canada have utilized a modified M'Naughton rule. The Department of Justice began work in the 1970s to update these laws. In 1983, soon after the Canadian Charter of Rights and Freedoms was proclaimed, the case of Regina v. Swain provided the impetus for this change. In 1990 the Supreme Court of Canada struck down the old law, giving parliament a specific time to pass new legislation. Bill C-30 modernized the language of the Criminal Code and introduced a number of procedural safeguards to protect the rights of the accused.
Death row prisoners may elect to forgo appeals, thus hastening execution. There are many reasons for such a decision, including depression, psychosis, incompetence, conditions in prison, and others. Due to the gravity of the sentence, and the states' duty to ensure fairness, some jurisdictions impose restrictions on the waiver. An inmate who lacks trial competence may be subject to a habeas corpus hearing and the appointment of a "next friend," often a family member. Moreover, the Constitution forbids execution of the "insane." The decision, then, may be taken out of the inmate's hands. The author outlines the various tests for competence to waive appeals. The Pennsylvania case of Gary Heidnik (In re Heidnik, 112 F.3d 105 (3rd Cir. 1997); and In re Heidnik, 720 A.2d 1016 (Pa. 1998)) illustrates the issues surrounding waiver of appeals that concern psychiatrists, attorneys, and judges. Following a discussion of Heidnik and related cases, the author offers a proposal for a classification of types of inmates requesting waiver.
The purpose of this article is to review the law and literature involving the guilty but mentally ill (GBMI) verdict to provide a clear conceptual examination of the actual intent and impact of the verdict. Such an examination may help to clarify continuing debates and confusion about the nature of GBMI and its success in addressing perceived problems with insanity acquittals. This review suggests that the actual intentions of the GBMI verdict are associated with minimal and largely unsuccessful results. In addition, the typical absence of treatment for defendants found GBMI appears unsurprising given that the provision of treatment for mentally ill offenders is not a legal intention of the GBMI verdict. Finally, the introduction of the GBMI verdict has had unintended negative consequences that include increased confusion among jurors and the legal profession and possible increased occurrence of inappropriate verdicts. In conclusion, significant problems can be noted with regard to both the intent and impact of the GBMI verdict.
Major mental illnesses, such as major affective disorders and schizophrenias, form a relatively small diagnostic group among mentally disordered offenders. The major affective disorders are less common when compared with schizophrenics among such offenders. Yet, some of the most violent crimes, such as murder, attempted murder, and serious assaults, especially intrafamilial violence, are committed by major affective disorder patients. The offenses by this group of patients are committed while suffering from active symptoms of the illness. As such, a substantial majority is not considered fully criminally responsible for the offense. Many such offenders are found not guilty by reason of insanity and are sent to psychiatric hospitals.
A nationwide (U.S.) survey of major public mental hospitals treating patients who are incompetent for trial, not guilty by reason of insanity, mentally disordered sex offenders, or mentally ill inmates was conducted. Responses were received from 71 percent of the 115 facilities surveyed. Respondents were the directors of psychiatry from the respective facilities. The pattern of treatments delivered generally appeared clinically appropriate. However, behavioral and cognitive-behavioral treatments were reported infrequently, even in areas in which they would be particularly useful.
This study describes the five-year outcomes of an assertive community treatment (ACT) program that monitored 83 acquittees found not guilty by reason of insanity (NGRI) placed on conditional release (CR) into the community. Data were collected by retrospective review of court reports and a state computer database. Five arrests and 60 hospitalizations occurred during the study period; overall, the NGRI acquittees were in the community for 83 percent of the time they were eligible for conditional release. Multivariate logistic regression analysis showed that the duration of conditional release was a positive predictor, and paranoid schizophrenia was a negative predictor of hospitalization or arrest. The estimated annual rate (EAR) of hospitalization was 14.0 percent, and the arrest EAR was 1.4 percent. The ACT model for NGRI acquittees on CR yielded a low arrest rate, a moderate hospitalization rate, and good community tenure.
We begin with a brief overview of the Not Guilty by Reason of Insanity (NGRI) and Guilty but Mentally Ill (GBMI) verdicts in the United States and then report on a study of qualified jurors (n=96) in which we examined jurors' understanding and attitudes about mental illness verdicts and the disposition of mentally ill defendants. Results indicate that although the jury pool was highly educated, only 4.2 percent of jurors could correctly identify both the definitions and dispositions of defendants found NGRI and GBMI. Jurors with lower educational levels were less likely to identify the dispositional outcome of a GBMI verdict (p<.05). Eighty-four percent of respondents believed that juries should be informed of dispositional outcome before deciding a verdict. Also, 68.4 percent of jurors erroneously believed that a defendant found GBMI could not receive the death penalty. Among jurors who correctly identified the definition of GBMI, those with lower educational levels were more punitive in their attitudes toward disposition of the GBMI defendants, believing they should eventually be sent to prison (p<.05).