Transcript Mental health

The Myths of Mental
Illness
Chapter 4
What is Abnormal?
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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
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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
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Most likely associated with violent, serious
criminal or antisocial behaviour
 Schizophrenic
disorders
 Personality disorders (PDs)
 Mood
disorders
 Paranoid disorders
WHAT Is A Psychopath?
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Defined as a personality disorder with a
cluster of interpersonal, affective, &
behavioural characteristics
 Dominant,
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
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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
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Not always criminals
The Criminal Psychopath
Demonstrate wide range of serious
repetitive crimes with violence
 Motives:
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 Primarily
instrumental (planned, motivated by
external goal, revenge or retribution)
Psychological Measures of Psychopathy
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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
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High rates among prisoners
 More
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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
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Most no more dangerous (exceptions may be
subset of population – male, history of violence
& current illness; schizophrenia (paranoid);
substance abuse plus schizophrenia
problematic)
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Frontline: The New Asylums
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www.pbs.org/wgbh/pages/frontline/shows/asylums
Re-Offending and Risk Assessment
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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)
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Need for information that enable legal
judgments, parole
Errors and biases in making predictions
of errors varies – stakes may be high for
individual or for society
 Implications
Dangerousness and the
Assessment of Risk
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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=n22pRAK9
N2Q&feature=related
 James Huberty
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http://www.youtube.com/watch?v=PjpL8HfWiiY
 Risk
factors unique for each individual
Profile of People Who are a Risk to Others
Variables
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
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History of violence
Personality factors
Active symptoms &
clinical diagnosis
Failure to keep
appts/take meds
Drugs and alcohol
Homelessness
Situational factors
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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
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Schizophrenia
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Complex and poorly understood
Behavioural manifestations varied: severe breakdown
in thought patterns
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Delusions (false beliefs about the world)
Hallucinations (auditory most common)
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Aggression & violence serious problems
 Characteristic positive & negative symptoms
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Crime as a response to positive symptoms?
Inducing the Symptoms
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Symptoms can be provoked in “normal”
people
 Sleep
deprivation
 Sensory deprivation
 Bereavement
 Trauma
 Solitary confinement
Think of a person with drug-related psychosis.
Would you consider them to be either:
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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
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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
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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
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The History of Mental Illness within the Law
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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
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Elements that must be present for criminal
guilt:
Actus Reus = physical act of committing a crime
Mens Rea = mental intent to commit a crime
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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
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Fitness to Stand Trial
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“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.”
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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
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 e.g.,
hearing voices
The Insanity Defense
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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
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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.
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Brawner & Ali Rule (incorporates cognitive & volition elements)
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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
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Mental Disorders as Defences
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Dissociative Identity Disorder
 Formerly
multiple personality disorder
 Presence of at least 2 distinct identities or
personality states
 Hillside Strangler (Kenneth Bianchi)
Amnesia
Refers to complete or partial loss of an
event or series of events
 Temporary
 Faking memory loss?
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PTSD
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Post-traumatic stress disorder
 Characteristic
symptoms following exposure
to extreme traumatic stressor (identifiable
cause for psychic damage)
 Variants such as battered-woman syndrome
Personality Disorders (PDs)
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Occur when:
 personality
traits become inflexible and
maladaptive and cause significant functional
impairment or subjective distress.
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Very important to note:
 virtually
all individuals exhibit some behaviors
associated with the various personality
disorders from time to time.
Diagnosing Disorders
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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