The Myths of Mental Illness

Chapter 4

What is Abnormal? Judgments between normal and abnormal differ

depending on time and culture…….a social construction

“Medicalization of deviance” Judgments of abnormality based on 3 Ds

Distressing to self or others Dysfunctional for person or society Deviant: violate social norms

Mental illness as a form of deviance and mental health as a form of conformity are difficult to define

Andrea Yates Case

Four Categories of Mental Disorders

Most likely associated with violent, serious criminal or antisocial behaviourSchizophrenic disordersPersonality disorders (PDs)

Mood disordersParanoid disorders

WHAT Is A Psychopath?

Defined as a personality disorder with a cluster of interpersonal, affective, & behavioural characteristicsDominant, selfish, manipulative individuals

who engage in impulsive and antisocial acts Feel no remorse or shame for behaviour that

often has a negative impact on others

BEHAVIOURAL DESCRIPTIONS of a PSYCHOPATH

Research by Cleckley & Hare Outgoing, Charming, & Verbally fluent Psychological testing – score higher on IQ tests Not mentally disordered by traditional standards Flat emotional reactions, inability to give affection,

superficial emotions, impulsive, disregard for truth Cardinal trait: lack of remorse or guilt; semantic

aphasia

Not always criminals

The Criminal Psychopath

Demonstrate wide range of serious repetitive crimes with violence

Motives:Primarily instrumental (planned, motivated by

external goal, revenge or retribution)

Psychological Measures of Psychopathy

See generally www.hare.org (good articles ) Psychopathy Checklist (PCL)

http://www.minddisorders.com/Flu-Inv/Hare-Psychopathy-Checklist.html

Assesses: two behavioural dimensions; interpersonal and emotional components & socially deviant lifestyle

Score of 30 or above qualifies a person as a primary psychopath

See Focus 4.1 in text

Mental Disorders Among Offenders

High rates among prisoners More visible; more likely caught & plead guilty;

revolving door Prevalence Rates of Psychiatric Disorders in a Sample

of Defendants (Bland et al., 1990) Type of Mental Disorder Rate

Substance abuse 87%

Antisocial personality disorder 57%

Affective disorder 23%

Anxiety/ somatoform disorders 16%

Schizophrenia 2%

Mental Disorders Among Offenders

Most no more dangerous (exceptions may be subset of population – male, history of violence & current illness; schizophrenia (paranoid); substance abuse plus schizophrenia problematic)

Frontline: The New Asylums www.pbs.org/wgbh/pages/frontline/shows/asylums

Re-Offending and Risk Assessment

Two components of primary concern: Future criminal activity or violent acts (prediction

component); danger to self or others Development of strategies to manage or reduce risk

level (management component)

Need for information that enable legal judgments, parole

Errors and biases in making predictions Implications of errors varies – stakes may be high for

individual or for society

Dangerousness and the Assessment of Risk

Canada at forefront Actuarial instruments v. structured professional judgment Violence Risk Assessment Guide (VRAG) Historical/Clinical/Risk Management scaled (HCR-20) MacArthur Network research Specific types of violence: spousal, sexual, workplace Measured primarily actuarial in nature

Dangerousness and the Assessment of Risk

Charles Joseph Whitman http://www.youtube.com/watch?

v=n22pRAK9N2Q&feature=related James Huberty http://www.youtube.com/watch?v=PjpL8HfWiiY

Risk factors unique for each individual

Profile of People Who are a Risk to OthersVariables Higher risk Lower risk

Age Younger Older

Sex Male female

Living arrangements Unstable Stable

Intelligence Low Average +

Education attainment

Low High

Mental health Disordered Other diagnosis

Substance abuse Alcoholism; drugs None

History of criminal behaviour

Past violence across diverse situations

No history or occasionally in some

situations

Risk Factors Associated with Violence Committed by People with Mental Disorders

History of violence Personality factors Active symptoms &

clinical diagnosis Failure to keep

appts/take meds Drugs and alcohol Homelessness Situational factors

Specific situations? Previous victimization?

High levels of anger & poor impulse control?

Hallucinations & delusions? Deterioration Social network, sense of

belonging, easy access? Substance use, lack of

supports –increases risk Specific to individual (past

violence; crowding)

Mental Disorder and Criminal Behaviour

Schizophrenia Complex and poorly understood Behavioural manifestations varied: severe breakdown

in thought patterns Delusions (false beliefs about the world) Hallucinations (auditory most common)

Aggression & violence serious problems Characteristic positive & negative symptoms

Crime as a response to positive symptoms?

Inducing the Symptoms

Symptoms can be provoked in “normal” peopleSleep deprivationSensory deprivationBereavementTraumaSolitary confinement

Think of a person with drug-related psychosis. Would you consider them to be either:

Dangerous to others

Unpredictable Hard to talk to Have only themselves to

blame Would improve if given

treatment Feel the way we all do at

times Will eventually recover

fully Could pull themselves

together if they wanted to

Not dangerous to others Predictable Easy to talk to Are not to blame for their

condition Would not improve if

given treatment Feel different from the

way we all do at times Will never recover fully

Can’t do anything to improve how they feel

The real story about schizophrenia

www.youtube.com/watch?v=f4R6jln_eZg

The History of Mental Illness within the Law

1800’s – idea of insanity – Criminal Lunatics Act - insane person not blamed because the person was not acting as themselves but overcome by uncontrollable urges or delusions

successful use of defence (not guilty by reason of insanity) resulted in acquittal and custody into an asylum

The History of Mental Illness within the Law

Flash-forward: Criminal Code in Canada Basic idea behind defence did not change,

changes made to terminology used, restrictions on time and some of the legal processes Change ‘insanity’ to ‘mental disorder’ and provide

more fair treatment (fitness hearing) Change ‘NGRI’ to ‘Not Criminally Responsible’ Review boards created; dispositions with time line

Mental Disorder and the Law

Elements that must be present for criminal guilt:

Actus Reus = physical act of committing a crime

Mens Rea = mental intent to commit a crime

Controversy with mentally ill is they are incapable of having mens rea in some instances

Fitness to Stand Trial and Criminal Responsibility

Both fitness and CR are concerned with mental status

CR is concerned with mental status at the time of the crime

Fitness is concerned with the mental status at the time of the trial

Fitness assessment must precede judgment of criminal responsibility

Fitness to Stand Trial

“Is unable on account of mental disorder to conduct a defence at any stage of the proceeding before a verdict is rendered or to instruct counsel to do so, and in particular, unable on account of mental disorder to a) understand the nature or object of the proceedings b) understand the possible consequences of the proceedings, or c) communicate with counsel.”

(Canadian Criminal Code)

The Insanity Defense

Insanity is not being of sound mind, and being mentally deranged and irrational at the time the offence was committed

Legally, insanity removes the responsibility of performing an act because of uncontrollable impulses or delusions e.g., hearing voices

The Insanity Defense

M’Naghten Rule: Excuses a defendant who, by virtue of a

defect of reason or disease of the mind, does not know the nature and quality of the act, or, if he does, does not know that the act is wrong.

Emphasis on cognitive elements

Influential Cases of the Insanity Standard

The Durham Rule Assumed person cannot be held responsible for criminal

act if suffering a mental illness Excuses a defendant whose conduct is the product of

mental disease or defect. Brawner & Ali Rule (incorporates cognitive & volition elements)

Excuses a defendant who, because of a mental disease or defect, lacks substantial capacity to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to the requirements of law. Excludes repeated criminal or antisocial behaviour (psychopaths & APDs )

So Where Does That Leave Us?

As a group, no more likely than general population to commit crimes

More visible presence within community Appear frequently in criminal justice

system Co-occurring problems make them

vulnerable

Mental Disorders as Defences

Dissociative Identity DisorderFormerly multiple personality disorderPresence of at least 2 distinct identities or

personality statesHillside Strangler (Kenneth Bianchi)

Amnesia

Refers to complete or partial loss of an event or series of events

Temporary Faking memory loss?

PTSD

Post-traumatic stress disorderCharacteristic symptoms following exposure

to extreme traumatic stressor (identifiable cause for psychic damage)

Variants such as battered-woman syndrome

Personality Disorders (PDs)

Occur when:personality traits become inflexible and

maladaptive and cause significant functional impairment or subjective distress.

Very important to note:virtually all individuals exhibit some behaviors

associated with the various personality disorders from time to time.

Diagnosing Disorders

DSM-IV-TR (APA, 2000) Contains detailed lists of observable

behaviours that must be present in order for a diagnosis to be made

Checklist of symptoms Some 400 mental disorders; revised

periodically http://allpsych.com/disorders/dsm.html