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33. Forensic Aspects of Schizophrenia Care
Keywords
Violence risk assessmentViolence preventionAssisted outpatient treatment (AOT)Involuntary treatmentEthics of coercionCapacity evaluationPaternalismEssential Concepts
Physicians have moral obligations not only toward the welfare of their patients but also toward the commonwealth of the citizens in their community. Protecting the public from harm from psychotic patients is such a professional duty for which society has given us great powers. We owe it to our patients and society to use them judiciously.
A violence risk assessment is part of every psychiatric evaluation as some patients with schizophrenia are potentially violent when untreated.
The standard of care is the so-called structured clinical judgment, a systematic assessment of risk factors to estimate risk, followed by clinical management that matches the estimated risk.
Prevention of violence due to psychiatric illness is a crucial treatment goal as patients may not only harm other people but ultimately themselves. Providing effective treatment with antipsychotics is the best clinical tool to reduce violence in those patients.
Involuntary hospitalization and treatment may be necessary and in most countries are allowed for patients with psychosis who are dangerous to others and to themselves or who are incapacitated to the point that they can no longer take care of themselves.
Assisted outpatient treatment (AOT) is but one tool along a spectrum of tools for assisted treatment (coerced care).
The ethical use of power in the service of treatment (coercion) is a key concern for psychiatry. Our profession’s history is a stark reminder that each of us has the moral obligation to working on reducing the amount of coercion used in psychiatry and speaking up when there is misuse of power.
Evaluations for capacity to consent to or refuse medical treatment follow the same principles for patients with schizophrenia as for any other patient. You need to assess a patient’s ability to choose a course of action, to retain facts about the possible treatment options, to appreciate the likely consequences for each option (including foregoing treatment), and to reach a reasoned conclusion consistent with professed values.
The four-quadrant approach offers a framework for ethical decision-making that assures a broad inquiry into all facets of a case: the medical facts, the patient’s values and wishes, the patient’s quality of life, and other stakeholders’ concerns.
Lack of appropriate paternalism in healthcare can result in patient abandonment.
“… nor shall any state deprive any person of life, liberty, or property, without due process of law; …”
– Fourteenth Amendment to the United States Constitution
A fundamental right in our society is that citizens have the “right to be let alone,” in Supreme Court Louis Brandeis’s words [1]. In the medical arena, this means that (competent) patients can refuse even lifesaving treatments. However, the public also has the right to be protected, and physicians have obligations toward the welfare of the general public as well. In diseases that potentially affect a community, the personal perspective on liberty is important but not sufficient to ignore community interests. Just as patients might not have the right to go untreated and spread tuberculosis, they might not have the right to endanger other people while psychotic. Forensic psychiatry sits uncomfortably between systems of care (the medical system) and systems of punishment (the criminal justice system) [2]. Patients caught up in both systems bring to the forefront your own views about moral responsibility, the limits of an open society, and how to balance conflicting dual roles as a physician and as an agent of the state.
In this chapter, I examine forensic issues that all psychiatrists deal with on a daily basis: violence and its relationship to psychiatric illness, including the task to assess violence and prevent violence; involuntary treatment; and capacity assessments. Narrow forensic issues such as an assessment for competency to stand trial are outside the scope of this chapter. Correctional psychiatry that emphasizes the setting of care is dealt with in the last chapter (Chap. 34).
Tip
Be a good clinician, not a bad lawyer: provide good clinical care not only based on respect of patient autonomy but also based on the values of nonmaleficence (doing no harm) and beneficence (doing good). Do not give bad legal advice, but consult a lawyer for legal questions. Obviously, know and follow the laws of the land as they pertain to your practice. Above all, know your Weltanschauung with regard to your own responsibilities toward society.
Violence
The link between psychosis and violence has been much debated and at times even discounted, probably because of efforts to decrease stigma [3]. I think it defies common sense that psychosis would not in certain instances and in certain people increase the risk for violence: it certainly does, unless you have never worked in a psychiatric hospital or emergency room. Hospitals, particular psychiatric settings, are a high-risk workplace, and violence against healthcare workers should not be ignored but openly discussed [4]. While the risk for violence is difficult to predict and impossible to avoid completely, we can nevertheless manage it. A systematic risk assessment combined with clinical interventions flowing from the identified risk factors to estimate risk (structured professional judgment model) is our tool as clinicians to play our part in preventing violence and its pernicious consequences for the victims.
Violence Risk Assessment
“Violence” is clearly etiologically heterogeneous [5], and in only a small subgroup of people is violence directly linked to psychosis. A host of static and dynamic risk factors have been identified. Alcohol and drug use are particularly important triggering factors of violence across all disorders [6]. A second path toward violence is paved by criminogenic risk factors [7]. The “Big Four risk factors” are a history of antisocial behavior, antisocial personality patterns, antisocial cognitions, and having antisocial associates or peers. Premorbid delinquency manifesting in childhood is an ominous sign that contributes to violence independent from psychosis [8]. The most dangerous patients I have encountered come from a small subgroup of persons with schizophrenia: young, substance-using male patient who are antisocial and suffer from paranoid schizophrenia. When decompensated, these patients are extremely volatile and paranoid, with no impulse control or moral barriers, which makes them dangerous. Traumatic brain injury can compound the problem of poor impulse control [9].
Unfortunately, several cultural scripts (e.g., school shooting, mass shooting) are available that give psychotic patients who are alienated from society a form of recognition by means of hitherto unthinkable acts of violence against members of their community. Not all school shootings or other mass shootings are perpetrated by psychotic individuals [10]; a correct diagnosis that also takes into account psychological motivations (anger, revenge fantasies, degree of alienation) is critical if we want to intervene effectively, including not expediently and simplistically blaming all mass shootings on untreated serious mental illness [11]. Identifying psychotic patients in order to treat them and prevent violence is a critical public health task. While early and consistent treatment for psychotic patients who are prone to violence will not address all (or even a large part of) violence in our society, it will address those acts of violence attributable to psychosis. An offender typology brings some conceptual order to violence: is violence the result of psychosis, of being disadvantaged, reactive, and instrumental, or gang/drug related [12]?
Tip
The most useful predictors of violence are any past history of violence and substance use. Therefore, get a good legal history, previous arrests, prison time, probations, and exact legal charges. Go back to middle school, and look for conduct disorder as a sign of beginning sociopathy and early substance use [13]. Look for bullying as a sign of alienation from peers and harboring grudges and resentments against society. Manic symptoms are another clinical indicator of potential violence as patients are disinhibited.
The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) evaluated the propensity for violence in a sample of almost 1500 patients. The 6-month prevalence for any act of violence was close to 20% [14]. You should note, however, that serious violence (in this study defined as assault resulting in injury, lethal weapon threat or use, or sexual assault) was much less common, 3.6%. Serious violence was associated with positive symptoms, whereas other forms of violence were better predicted by environmental variables. Not surprisingly, negative symptoms had a protective effect. In a different analysis of serious, injurious violence (i.e., actually inflicting physical injury) in the CATIE sample, baseline injurious violence, recent violent victimization, and poor medication adherence were the best predictors of harming somebody physically during the 18 month trial, occurring in 5% of patients [15]. This risk may be an underestimate as the assessments were based on self-report.
Tip
It is not psychosis per se that determines the risk of violence but the nature of the delusions (particularly thoughts of persecution) and hallucinations (i.e., command type) [16]. Find out exactly what patients are thinking and planning, and engage them in a discussion of violence, for example, how likely they think it is that they will take preventive or retaliatory action. Is your patient embittered [17]?
You must know your legal responsibilities with regard to warning identified victims and protecting them and the public (the so-called duty to warn and protect). To safeguard the public, all states have provisions for committing a patient with schizophrenia who is violent.
When you work with psychotic patients, remain alert to the possibility of harm from your patient. There is no glory in being stoic and accepting being assaulted as part of your job. Always trust your limbic warning system if it signals “danger.”
Just like you assess the potential for suicide in all patients, you must estimate the risk for immediate violence and the potential for violence in the future. You do this by combining an actuarial approach (past history) with your cross-sectional data on exam (Table 33.1).
Simply ask a patient about his self-perception of future violence. It correlates with other methods of risk assessment and is an easy way to augment your assessment [18]. A positive response in insightful patients is more helpful than in patients who not only deny any possibility of future violence but who (inaccurately) deny any history of past violence [19].
Record any history of violence during acute psychosis in your lifetime problem list, so the information does not get lost.
Have a plan in place in your treatment setting how to respond to violence. Debriefing after an incident of violence and an administrative review are important steps to prevent future acts of violence and support affected staff member [20].
Clinical assessment of aggressiona
Excitement | Is the patient motorically accelerated and pressured in his or her speech (this looks hypomanic)? |
Tension | Is the patient showing overt signs of anxiety or fear? Is he tense and sweating? |
Hostility | Is the patient angry and irritable? Sarcastic? Resentful? Making threats? |
Uncooperativeness | Does the patient refuse to comply with tasks asked of him or her? |
Poor impulse control | How well is the patient able to tolerate frustration? Does the patient fly off the handle regardless of consequences? |
The currently best model to estimate risk and devise a risk management plan that matches the risk estimate is called “structured professional judgment model.” In this approach, risk factors are systematically evaluated, including past behaviors but also current clinical markers and factors impacting risk management. Thus the obtained actuarial information is then used to inform clinical judgment. Clinical judgment alone tends to overestimate risk. The most commonly used instrument to assess and manage violence risk is the Historical Clinical Risk Management-20, Version 3 [22].
Violence Risk Reduction
Preventing violence is important not just to protect yourself and society but also to combat stigma. Allowing a small subset of violent persons with schizophrenia to go untreated is a disservice to all patients with schizophrenia who are trying to live peaceful lives. In addition to healthcare workers and innocent bystanders, there are two other groups who suffer if psychotic violence is not prevented. The most common targets of violence are family members since patients often live with them. Discuss the possibility of violence with the family who (just like clinicians) may have a tendency to minimize this aspect of the illness. Last, patients themselves become victims if they commit a crime while psychotic, a potentially preventable socio-toxic consequence from being psychotic. In one chart review study, clozapine was found to reduce recidivism in patients with criminal histories [23]. Preventing the “criminalization” of being psychiatrically ill is a legitimate treatment goal. Unfortunately, the reduction in psychiatric treatment beds since the 1950s had two unintended consequences: (1) it has shifted treatment into jails and prisons or to no treatment in the streets, and (2) I suspect it effectively prevents treatment prior to an act of violence has occurred, when patients are less ill, as psychiatric beds are now reserved for the most ill.
Nonadherence – Consider long-acting antipsychotics. Refer to ACT teams (Table 33.2), if available. Consider outpatient commitments, if available. While there are efficacy differences between antipsychotics with regard to reducing hostility [24], those pale in comparison to receiving no treatment.
Drug use – In some jurisdictions, probation and court-mandated treatment (e.g., random urine drug testing) instead of prison time can provide motivation. In some programs, entitlement benefits can be contingent on drug-free status.
Residual psychosis – Use the most effective antipsychotics, including clozapine; clozapine also has anti-aggressive properties independent of its antipsychotic properties [25].
Gun access – Ask about gun possession and take necessary steps to remove guns. In some jurisdictions, extreme risk protection orders (ERPOs) or red flag laws allow weapons to be removed preemptively from households if there is risk of violence [26].
Involuntary Treatment
Involuntary or coercive measures are most visible when somebody gets involuntarily committed to a hospital. Prior to the 1960s, involuntary civil commitments were largely left to the discretion of psychiatrists if there seemed to be a “need for treatment.” With the rise of the civil liberties movement, this prerogative has been severely curtailed, and patients today are mostly committed for “danger to self or others” and no longer for need for treatment. Many believe the pendulum has swung too far and rightly point to the difficulties in getting psychotic but non-dangerous patients appropriately treated if they refuse treatment. A purely individual rights-based approach that includes the right to refuse treatment negates the clinical reality of an anosognosia-like inability to see oneself as ill and in need of treatment (see Chap. 31 on insight).
Key Point
Currently, the threshold for involuntary intervention is high, usually dangerousness to self or others or clear inability to care for oneself. The dangerousness or inability to care for oneself must stem from a mental illness. Psychiatric (civil) commitment is usually a two-step process: the initial involuntary hospitalization, which can be initiated by a physician, for an emergency evaluation, followed by a petition to the court for psychiatric commitment, which may or may not be granted. Technically, it is not psychiatrists but judges who “commit” patients, a point often overlooked. State laws and local culture vary considerably on the details and outcomes of the process.
Psychotic patients who are potentially violent, to acutely reduce risk to specific people or the community at large. This is the typical case of commitment for “danger to others” and refers to state-based and modifiable dangerousness due to symptoms of a psychiatric illness. You act as an agent of the state to protect the community, but you also act as the patient’s advocate to protect the patient from legal charges and criminalization or injury.
Psychotic patients at acute risk for a suicide attempt. This is the case of commitment for “danger to self.”
Patients who are unable to care for themselves while psychotic. This is the remnant of the in-need-for-treatment approach. Depending on the exact interpretation and wording of the respective statute, this can be very difficult to apply, and judges might have a threshold very different from yours or the patient’s family. Are you unable to care for yourself if you can line up in a shelter line and find the local soup kitchen?
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