Managing offenders with psychiatric disorders in general psychiatric services
James R. P. Ogloff
It has been shown that the prevalence of mental illness among those in the criminal justice system is significantly greater than that found in the general community.(1,2) As presented in Chapter 11.4, for example, the per capita rate of psychotic illness in prisons is approximately 10 times greater than that found in the general community. Tragically, relatively few services exist that provide continuity of mental health care between gaols and the community.(3) This produces a situation where individuals whose mental illness may have been identified and treated in gaol find themselves without services in the community. Typically, only when in crisis do they find their way into general psychiatric services either in community settings or in hospital. This situation has produced considerable stress on already taxed mental health services.(4)
Given the prevalence of offence histories among psychiatric patients, it is important for mental health professionals to be aware of the unique issues—and myths—that accompany patients with offence histories. At the outset it is important to emphasize that the duty of mental health services is to address mental health issues. That ought to be the focus of mental health services. As this chapter makes clear, though, for some patients, there is a relationship between the mental illness and offending and by addressing the mental illness, the risk of re-offending might well be reduced. Moreover, many of the ancillary issues that lead to relapse and destability in psychiatric patients also may lead to offending. Addressing these issues will both help provide long-term stability for patients and will help reduce their risk of offending. As a result, there is a need for general mental health services to acquire expertize to identify and manage patients with offending histories.(5)
This chapter will provide information about the relative risk of offending among psychiatric patients and the relationship (or lack thereof) of inpatient aggression and community-based violence and offending. A framework will be provided for assessing and treating patients with offending histories and issues using a typology of mentally ill offenders. The role of forensic mental health services in bolstering general psychiatric services, and in sometimes providing primary care for mentally ill offenders, will also be discussed.
How many patients have criminal histories?
Surprisingly little research exists that investigates the number of patients entering general psychiatric services who have an offence history. For reasons having to do with privacy, lack of perceived relevance, and professional reluctance, general mental health services do not consistently obtain reliable information regarding patients’ offence histories. This is often the case even when the patient has a current community-based corrections order. The two following studies can help shed light on the question of how many general psychiatric patients have histories of criminal offending.
In a study that was conducted to investigate the post-discharge violence of psychiatric patients and the predictive validity of risk assessment measures among almost 193 involuntarily committed psychiatric patients in British Columbia, Canada who were discharged to the community, Douglas, Ogloff, Nicholls, and Grant(6) obtained official criminal histories for all patients who had ever been arrested or convicted of any criminal offence. The vast majority of patients had prior psychiatric hospitalizations (n=184, 95 per cent). Informally, members of the hospital staff were asked what percent of patients they believed had a prior criminal history. Staff, including psychiatrists, estimated that a very small percent of patients would have been arrested or convicted of offences—less than 20 per cent. The review of criminal histories, however, showed that 64 per cent (n=123) of patients had previous arrests or convictions for any type of criminal offence, including 40 per cent (n=78) who had been arrested or convicted of violent offences.
In an Australian study based upon Victorian samples of cohorts of patients with schizophrenia, Wallace and colleagues have found that almost 22 per cent of patients with schizophrenia have a history of offending at some point in their lives.(7) Moreover, eight percent of patients with schizophrenia had a criminal conviction for a violent offence. These percentages increased three-and-four fold when the patients with schizophrenia also had a known substance abuse problem. In a recent study, Hodgins and Muller-Isberner(5) found that one quarter of patients discharged from a general mental health service had a criminal record.
While it is difficult to know exactly how many psychiatric patients across different services have committed offences, the point that may be drawn from the above research suggests that many patients have offence histories—likely more than mental health professionals would expect. The starting point of the chapter, therefore, is that while most psychiatric patients will not have violent criminal histories, many will have offence histories, including the commission of violent offences. Moreover, many more patients will have exhibited violent behaviour that did not lead to arrest or conviction. Therefore, even if they do not realize it, all psychiatrists and other mental health professionals have experience working with patients who have offence histories.
What leads mentally ill people to offend?
Although the reasons that anyone—including psychiatric patients— offends are myriad and complex, a typology of mentally ill offenders is helpful for understanding the reasons they offend.1 There are three general categories of people with mental illness who offend; understanding the general mentally disordered offender type will enable clinicians in general psychiatric services to provide appropriate treatment. The first, and smallest group, includes those psychiatric patients for whom a necessary and sufficient cause of their offending is the presence of their mental illness and the symptoms the illnesses produce. The second group includes patients who do not offend because of their mental illnesses, per se, but due to the concomitant social difficulties that all too often accompany mental illness. The final general group of offenders with mental illness include those patients whose offending occurs irrespective of their mental illness. Each of these groups will be described below.
Patients who offend because of their mental illness
This group is likely the smallest of the three groups. This group includes people who may not be criminally responsible because, as a result of their mental illnesses, they do not know what they are doing, or do not appreciate that what they are doing is wrong. Their offences occur as a direct result of the mental illness. But for the mental illness and the presence of symptoms which led to the patient’s offending behaviour, the crime would not have occurred. Their mental illness is both a necessary and sufficient explanation for their offence. They only offend when they are acutely unwell and the offence behaviour is a product of their mental illness (e.g. acting on delusions or hallucinations). Depending upon the jurisdiction in which they reside, they may be found not guilty by reason of insanity or mental illness. They most likely will be housed in secure hospitals rather than prisons following legal adjudication. Typically the illnesses that are present in people who fall into this category are psychosis or serious affective disorders accompanied by psychosis. Many jurisdictions that retain some form of insanity defence specifically exclude the use of the defence by those with antisocial or dissocial personality disorder.
Patients who offend as a result of the sequelae of mental illness
The second general group of psychiatric patients who offend comprises hose whose mental illnesses are a necessary but not sufficient explanation for their offending. It is by far the largest group of psychiatric patients who offend. As is typical for many patients with serious mental illnesses, these patients begin to spiral downward socially as a result of their mental illnesses. They can become estranged from family and pro-social support networks. Their lives become unstable; housing, basic needs, and their need for non-judgmental personal support may go unmet. They may end up being accepted by groups of people who are themselves unstable. They often resort to engaging in illicit drug abuse. These social factors contribute to their resultant offending. While their mental illness may be a catalyst in the course of events that lead to the offending, the mental illness itself is not the direct cause of the offending. Had they not had a mental illness, they likely would not have begun offending. However, by the time they develop offending behaviour, their lives have become so disorganized and their maladaptive coping and survival strategies have become so entrenched as to make the reversal of these processes difficult over the long-term. Psychiatric treatment, while a necessary starting point, will not be sufficient alone to eliminate the offending behaviour.
Patients who offend despite their mental illness
The final group of patients are those who would offend irrespective of the fact that they have a mental illness. Although not as large a group as the one above, many more patients who offend fall into this category than into the first. The fact that they have a mental illness is neither a necessary or sufficient explanation for their offending. Patients in this group are typically characterized by early onset antisocial and illegal behaviour. They differ from other mentally ill offenders by having a pervasive and stable pattern of offending regardless of their mental state.(5) This behaviour almost always precedes the onset of mental illness. While people with a psychopathic or dissocial personality disorder will be included in this group, most of the people in the group will not be so disordered. It is important to acknowledge, though, that the broad range of people that may fall into this group, including the psychopaths, may well develop psychiatric illnesses. We must avoid the tendency to deny this group proper services or to acknowledge their mental illnesses. These patients’ mental illnesses may well exacerbate their offending or lead to unusual offending; however, even when they are asymptomatic they may continue to offend.
Aren’t psychiatric patients with offence histories unusually burdensome or too dangerous for mental health services?
The perception all too often still exists that patients with offence histories are unusually burdensome or even too dangerous to be seen by general mental health services. While there are doubtless patients, largely those drawn from the third group above, who are burdensome and even dangerous, in the main patients with offence histories are nether unduly burdensome nor dangerous. For example, in a recent prospective study of violence among discharged general and forensic psychiatric patients, Doyle and Dolan(8) found no
significant differences in post-discharge violence rates (both official and unofficial) between patient groups in the UK. Ogloff and colleagues have obtained similar results from separate studies of post-discharge violence among samples of general and forensic psychiatric patients.(6)
significant differences in post-discharge violence rates (both official and unofficial) between patient groups in the UK. Ogloff and colleagues have obtained similar results from separate studies of post-discharge violence among samples of general and forensic psychiatric patients.(6)
One of the concerns expressed in general psychiatric services about patients with offence histories is the risk for aggression and violence they might present during hospitalization. It is often assumed that if a patient has an offence history, particularly one marked by aggression, that the patient will be more likely to be aggressive in hospital. Research suggests, however, that this may not be the case. It is true that over the entire period of hospitalization patients who have more psychopathic traits might have higher rates of aggressive incidents.(9) Research shows that in fact there is no significant relationship, at least for forensic psychiatric patients, between aggression in hospital, aggressive behaviour preceding admission, or violent recidivism.(10)
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