Transcript Document

FORENSIC PSYCHIATRY AT THE INTERFACE
BETWEEN PSYCHIATRY AND THE LAW
John Monahan, Ph.D.
 Forensic Psychiatry and Psychology in the U.S.
 Legal context
 Economic context
 Expert Psychiatric and Psychological
Testimony
 Amicus Briefs by the American Psychiatric and
Psychological Associations
 Psychiatric and Psychological Research for
Evidence-Based Law Making
Forensic Psychiatry and Psychology in the U.S.
Legal Context
Psychological Evaluations for the Courts:
A Handbook for Mental Health Professionals
and Lawyers (Melton et al, 2007)
• Free will v. determinism
Clinical Handbook of Psychiatry and the Law
Appelbaum & Gutheil, 4th ed (2007)
Clinicians, accustomed to speaking their own private language, are
forced to speak in legal terms. They are asked whether individuals
have acted with appreciation of the nature of their acts or with the
free will to avoid violations of the law if they so choose. They are
sometimes asked to evaluate the effect of a complex disease process
on a remote act that they did not witness and that the alleged
perpetrator may maintain has never occurred…
During the process, they must keep in mind that the system for
which they are working (i.e., judicial) denies a fundamental
theoretical premise of much of psychiatry (i.e., that all behavior is
influenced by unconscious forces beyond the control of the actor
and is thus, to some extent, involuntary and predetermined).
DSM-IV Cautionary Statement
It is to be understood that inclusion [in DSM-IV], for clinical
and research purposes, of a diagnostic category such as
Pathological Gambling or Pedophilia does not imply that
the condition meets legal or other non-medical criteria for
what constitutes mental disease, mental disorder, or
mental disability.
The clinical and scientific considerations involved in
categorization of these conditions as mental disorders may
not be wholly relevant to legal judgments, for example,
that take into account such issues as individual
responsibility, disability determination, and competency.
Psychological Evaluations for the Courts: A
Handbook for Mental Health Professionals
and Lawyers (Melton et al, 2007)
• Free will v. determinism
• The adversary system: “Battle of the experts”
The Adversary System
Forensic Psychiatry and Psychology in the U.S.
Economic Context
Texas Mental Health Budget Could Be Cut
By as Much as 40% (KHOU-TV, 2011)
“Mental health services could see drastic cuts, if
a version of the draft budget passes the Texas
Legislature.
Texas ranks 49th in the country in per capita
spending on mental health programs. The
proposed budget would cut spending by 40%.”
California Dept of Mental Health (DMH)
DMH budget has been cut 29% in the past 2 years.
“The administration stated its intent to eventually
eliminate the DMH. Responsibility for the programs
administered by DMH would be transferred to other
departments. The administration indicates that as
part of its 2012–13 budget proposal, it will submit a
detailed plan to eliminate this department.”
Patients in Public Psychiatric
Facilities in California
Expert Psychiatric and Psychological
Testimony
Most Frequent Types of Expert Testimony
in U.S. State Courts
Domitrovich, Merlino, & Richardson (2010)
Type
Psychiatry/Psychology
Medical/Health
Chemistry
Toxicology
Economic
%
29
20
13
10
9
Type
Sociology
Pharmacology
Statistics
Engineering/Physics
Epidemiology
%
8
4
4
3
1
Mental States, Motivations, and Behaviors
During Past Events
Adapted from Heilbrun, Grisso, & Goldstein (2009)
• Capacity to waive rights
• Criminal responsibility
• Abuse and neglect
• Testamentary capacity
• Eyewitness identification
Deficits in Abilities Relevant to Current Functioning
Adapted from Heilbrun, Grisso, & Goldstein (2009)
• Competence to consent to treatment
• Guardianship
• Competence in criminal proceedings
• Termination of parental rights
• Civil commitment (current mental illness)
Likelihood of Future Behaviors
Adapted from Heilbrun, Grisso, & Goldstein (2009)
• For denying bail
• For sentencing (e.g., probation or prison, or death)
• Civil commitment of “sexually violent predators”
• Civil commitment of people with SMI who are
likely to be violent to self or others
• Child custody
Amicus Briefs by the American Psychiatric
and Psychological Associations
“Amicus curiae (friend of the court) briefs are
approved by the Board of Trustees and present to the
court the views of the American Psychiatric
Association on matters of mental illness, patient care,
psychiatric practice, and other forensic issues.”
Graham v. Florida, 2010
Issue: Can a juvenile offender be sentenced to
life in prison without the possibility of parole for
a nonhomicide crime?
Amicus Brief of the American Psychiatric Assn and the
American Psychological Assn in Graham v. Florida (2010)
Research in developmental psychology and neuroscience… confirms
and strengthens the conclusion that juveniles, as a group, differ from
adults in salient ways… Juveniles—including older adolescents—are
less able to restrain their impulses and exercise self-control; less
capable than adults of considering alternative courses of action and
maturely weighing risks and rewards; and less oriented to the future,
and thus less capable of apprehending the consequences of their
often-impulsive actions.
For all those reasons, even once their general cognitive abilities
approximate those of adults, juveniles are less capable than adults of
mature judgment, and more likely to engage in risky, even criminal,
behavior as a result of that immaturity.
Graham v. Florida, 2010 (Vote: 6-3)
MAJORITY: As petitioner's amici point out, developments in psychology
and brain science continue to show fundamental differences between
juvenile and adult minds. For example, parts of the brain involved in
behavior control continue to mature through late adolescence.
Juveniles are more capable of change than are adults, and their actions
are less likely to be evidence of “irretrievably depraved character” than
are the actions of adults. It remains true that “[f]rom a moral
standpoint it would be misguided to equate the failings of a minor with
those of an adult, for a greater possibility exists that a minor's
character deficiencies will be reformed…”
This Court now holds that for a juvenile offender who did not
commit homicide the Eighth Amendment [banning “cruel and
unusual punishment”] forbids the sentence of life without parole…
Because “[t]he age of 18 is the point where society draws the line
for many purposes between childhood and adulthood,” those who
were below that age when the offense was committed may not be
sentenced to life without parole for a nonhomicide crime.
DISSENT: The Court cites “developments in psychology and brain
science” indicating that juvenile minds “continue to mature through
late adolescence.”… But even if such generalizations from social
science were relevant to constitutional rulemaking, the Court
misstates the data on which it relies. See Moffitt, AdolescenceLimited and Life-Course-Persistent Antisocial Behavior: A
Developmental Taxonomy, 100 Psychological Rev. 674, 678 (1993)
(cited in APA Brief ) (“The well-documented resistance of antisocial
personality disorder to treatments of all kinds seems to suggest that
the life-course-persistent style is fixed sometime before age 18”)...
In sum, even if it were relevant, none of this psychological or
sociological data is sufficient to support the Court's “ ‘moral’ ”
conclusion that youth defeats culpability in every case.
Schwarzenegger/Brown v. Planta
Issue: Can a court order a limit to a state’s
prison population, if necessary to remedy the
violation of prisoners’ constitutional rights to
adequate mental health and medical care?
Amicus Curiae Brief of the American Psychiatric Assn
and the American Psychological Assn in
Schwarzenegger/Brown v. Planta
The [trial] court… found that overcrowding in CA’s prisons was the
primary cause of the State’s failure to deliver constitutionally
adequate mental health care to its prison inmates and that no relief
other than a reduction in overcrowding would address the
constitutional violations. Those findings…are consistent with the
clinical experience of professionals with expertise in correctional
mental health care and the scientific literature…
More than 34,000 of the approximately 160,000 inmates in CA’s
prisons suffer from serious mental illness requiring intervention..
Clinical experience supports the conclusion that crowding may
create pervasive and intractable problems for the provision of
minimally adequate mental health care.
Brown v. Planta, May 2011 (Vote: 5-4)
MAJORITY: For [21] years the medical and mental health care provided
by CA’s prisons has fallen short of minimum constitutional requirements
and has failed to meet prisoners’ basic health needs. Needless suffering
and death have been the well documented result…
Because of a shortage of treatment beds, suicidal inmates may be held
for prolonged periods in telephone-booth sized cages without toilets. A
psychiatric expert reported observing an inmate who had been held in
such a cage for nearly 24 hours, standing in a pool of his own urine,
unresponsive and nearly catatonic…
Brown v. Planta, May 2011 (Vote: 5-4)
MAJORITY: For [21] years the medical and mental health care provided
by CA’s prisons has fallen short of minimum constitutional requirements
and has failed to meet prisoners’ basic health needs. Needless suffering
and death have been the well documented result…
Prisoners in CA with serious mental illness do not receive minimal,
adequate care. Because of a shortage of treatment beds, suicidal
inmates may be held for prolonged periods in telephone-booth sized
cages without toilets. A psychiatric expert reported observing an inmate
who had been held in such a cage for nearly 24 hours, standing in a pool
of his own urine, unresponsive and nearly catatonic…
Wait times for mental health care range as high as 12 months.
Prisoners suffering from physical illness also receive severely
deficient care…Prisons were unable to retain sufficient numbers of
competent medical staff, and would “hire any doctor who had ‘a
license, a pulse and a pair of shoes.’”… Prisons have backlogs of up
to 700 prisoners waiting to see a doctor…
The medical and mental health care provided by California’s prisons
falls below the standard of decency that inheres in the Eighth
Amendment. This extensive and ongoing constitutional violation
requires a remedy, and a remedy will not be achieved without a
reduction in overcrowding.
It is so ordered.
DISSENT: “The [trial] court ordered the premature release of
approximately 46,000 criminals—the equivalent of three
Army divisions...
The prisoner release ordered in this case is unprecedented,
improvident, and contrary to the [law]. The majority is
gambling with the safety of the people of California. Before
putting public safety at risk, every reasonable precaution
should be taken… I fear that today’s decision… will lead to a
grim roster of victims. I hope that I am wrong.
In a few years, we will see.
California Static Risk Assessment (CSRA)
22 Items to Predict Recidivism
• 2 demographic items
– Age
– Gender
• 20 items on prior criminal sentences
– Number of felony sentences
– Felony sentences for murder, manslaughter, sex, violence,
weapons, property, drug and, escape offenses
– Misdemeanor sentences for assault, sex, weapons,
property, drug, alcohol, and escape offenses
– Revocations of probation or parole supervision
Validity of the CSRA
% of Prisoners Arrested within 3 Years for a
New Felony
90
80
70
60
50
40
30
20
10
0
Low
Moderate
High
Psychiatric and Psychological Research for
Evidence-Based Law Making
Outpatient Commitment in New York
•
•
•
•
•
Increased medication adherence
Reduced inpatient hospital admission
Reduced inpatient hospital days
Reduced arrest rate
No differences with the comparison group in
perceived coercion, working alliance, or
treatment satisfaction
• Statute renewed for 5 years.
Interventions Used by Colleges to Respond
to Student Mental Health Crises
Monahan, Bonnie, Davis, & Flynn, Psychiatric Services, in press.
State population:
8,100,000
Student population
Public 4-yr colleges (15 colleges):
206,338
Private 4-yr colleges (24 colleges):
76,752
2-yr community colleges (24 colleges): 177,121
Total student population (63 colleges):
460,211
Seung-Hui Cho (Virginia Tech, April 2007)
In the spring of 2010, the Joint Commission on Health Care of the
Virginia General Assembly, conducted a survey to gather—for the
first time—comprehensive empirical information from each public
and private college in the Commonwealth regarding the adequacy of
students’ access to mental health services and the ways in which
colleges respond to students’ mental health crises.
Findings from this survey will be reported to the Joint Commission
and may inform recommendations for legislative or other policy
changes to improve both student access to mental health services
and institutional responses to mental health crises.
Students Accessing Care at the
Counseling Center (CC)
Total N
Students
Accessing Care
Mean %
Student Body
Accessing Care
Public
11,117
6
Private
2,800
11
0
0
Community
Care Accessed at the CC: Suicidal Ideation
and Ideation of Violence to Others
Public
Private
Mean % at CC w
Suicidal Ideation
Mean % at CC w Ideation
of Violence to Others
15
12
4
1
Involuntary Medical Withdrawal
“[The College] reserves the right to require a
medical withdrawal if the student:
 Presents an ongoing, clear and present danger to
self and/or others; [or]
 Shows potential for presenting a clear and present
danger, and refuses to cooperate with treatment
recommendations.”
 91% of private colleges—but only 47% of public
colleges— have involuntary medical withdrawal.
Psychiatrist/Psychologist Recommendation
for Reenrollment at the University of Virginia
 “DSM-IV diagnosis; # of times patient was seen by you
since withdrawal; prescribed medications and dosages
 Issues addressed in treatment
 Functional difficulties which need to be addressed in
continued treatment or which may pose difficulties in
relation to student’s reenrollment [including homicidal or
suicidal ideation/intent]
 Your recommendation: patient is/is not ready to return
 Recommended treatment plan if patient returns:
continued treatment is/is not necessary.”
August 24, 2010
A new [computer] prompt each fall will ask that students
disclose relevant criminal arrests or convictions [i.e., all
arrests/convictions except minor traffic violations] and will
also remind them of their continuing duty to do so within
72 hours of any future such incident.
For more serious infractions, there may be a meeting [with
the Dean] to discuss what the student is doing to prevent a
repeat offense and also an offer of information regarding
counseling, alcohol or substance abuse resources.
Questions from the Survey for the Virginia
Joint Commission on Health Care
 Should community colleges have counseling centers?
 Should colleges be required to have procedures for
involuntary medical withdrawal for MH reasons?
 Does the psychiatric/psychological “clearance” for reenrollment violate student confidentiality?
 Should all student arrests be reported to the Dean and
potentially result in a referral for treatment?
[email protected]