Forensic psychology: Part 4: Chapter 10: Assessing offender populations

by TimothyA. Leis, Ph.D., C. Psych.^{Footnote 1}
Terty Nicholaichuk, Ph.D., C. Psych.^{Footnote 2}
and Robin Menzies, M.B., B. S., FRCP (C)^{Footnote 3}

Objectives

• To focus primarily on severe and incapacitating mental disorders and to assist in the assessment of this population.
• To comment on appropriate referrals for assessment.
• To identify key theoretical and practical issues for psychological assessments of offenders with major mental disorders.^{Footnote 4}
• To offer guidelines for clinical practice.

Referral questions
The present paper addresses assessment issues relating to offenders with Axis I diagnoses of a major mental disorder. It is not intended to deal with Axis II disorders.

Subsequent to the identification of severe and debilitating symptoms of mental disorder or a prolonged history of psychiatric institutionalization, case management may request direction with regard to diagnosis, management and treatment, as well as implications for future management of the offender's risk.

In this context, likely referral questions will include

• What is the diagnosis?
• What are the functional implications of the disorder? (e.g. social, vocational, interpersonal, adjustment in the institution, capacity for self harm etc.)
• What are your recommendations for the short-term management of this individual's crisis?
• What are the most suitable interventions/ treatments?
• Does the disorder contribute to the risk the offender presents?
• Under what conditions is risk exacerbated or mitigated?
• What treatment is required, under what conditions and in which facilities is treatment available?
• What are the implications of the disorder for the management of the offender in the institution and upon release to the community?
• What elements have to be in place to manage the offender?
• What are the likely long term outcomes?

The focus given to the referral and the related assessment activity will vary as a function of the situation and the point in the offender's sentence.

In general terms, screening for mental disorders will identify individuals who require further assessment to determine their risk for self-harm or suicide, or to determine whether they require special services or placement. Such screening may be undertaken by correctional, case management or health care staff.

Upon admission, and during the sentence, offenders may develop mental health problems or crises which require assessment and intervention. Here again, correctional staff are important in problem identification and referral.

The central nervous system, human experience and mental disorder
The first section of this paper provides a very brief overview of a current perspective of mental disorder, along with several references which practitioners may find useful. While the facts and concepts will be familiar to psychologists from their training, experience and reading of the current literature, the intent here is to draw these together in their application to clinical work within corrections.

i) Watching the brain at work
The nervous system controls thought, emotion and behaviour. This can be illustrated through the use of technology which allows researchers to monitor brain activity.

For example, if a person extends their left hand in order to pick up an object, we would generally observe, using a PET scan of brain activity, an activation of a part of the brain in the right frontal area together with normal background activity elsewhere.

If we asked the person to pick up the object upon hearing a verbal order to do so, we would see that the portion of the brain involved in hearing would be also be activated. But, if we asked the person to decide for themselves when they would pick up the object, we would find that reaching for the object would be preceded by a more general activation of the entire brain beginning in the subject's frontal lobes.

This little scenario illustrates how the brain controls thought, emotion and behaviour from second to second. It constitutes a starting point for our understanding of mental disorder and its management.

ii) Complex behaviour, nature and nurture
In thinking about our own experience we know that human behaviour is extraordinarily complex. In considering the development of a child, we realize that this complexity of human behaviour requires time to develop. In addition, the process of development is affected by the genetic inheritance of the individual as well as his or her learning experiences.

Stated otherwise, a person's nervous system and musculature require a tremendous amount of training in order to acquire and execute the complex range of skills required of the professional athlete. Similarly, if you think of all the decisions, conversations, and interactions you must engage in during the day, you will realize that even ordinary human behaviour requires a tremendous number of acquired skills as well as a high degree of sophistication and flexibility in their use. For example, we are required to do things such as solve life's practical problems and understand others. In such tasks, we require sensitivity and balance to the point where relatively small departures from normal social expectations can hold significant consequences. For example, whether or not you say hello to your boss in the hall may appear an insignificant issue at face value. It does nevertheless reflect a basic life skill in most peoples' view.

We can readily understand the idea that social skills and social judgment are often impaired to some degree in mental disorders. However, many of these skills can be learned or relearned in relatively brief and focused interventions. At the same time, in dealing with severe mental disorder, we must be cautious lest we underestimate the severity of the impairment as well as the time and effort which will be required in order to effect significant improvement. Finally, in many cases, the individual will never be symptom free. While these distinctions represent an appropriate topic for clinical supervision provided to the psychology intern or the recently appointed psychologist, the temptation to underestimate pathology is particularly pronounced for clinicians working with the severely disordered on a regular basis. In such circumstances, clinicians may become unduly habituated to the functional implications of severe disorders. As a result, where consistent with operational requirements, it is useful for psychologists to have exposure to different client groups.

iii) Mental disorders as impairments
In light of our introductory comments regarding the brain and the development of complex behaviour, let's take a closer look at the mentally disordered offender.

Mental disorders are disorders which manifest themselves in abnormal thought, emotion, behaviour, or biological dysfunction. In effect, this means that the normal range and flexibility of human behaviour is disrupted or impaired in one or more areas, some of which are quite insignificant, others of which are not. For example, a person's emotions may be limited to sadness, and he or she may be unable to experience the normal range of feeling. Or, perhaps a person shows little sensitivity to the needs of others, and often dwells on thoughts and plans to hurt them. Although some variation in mood or behaviour is quite normal, if sufficiently pronounced, such phenomena may reflect that this person's functioning has deviated from the wide range we recognize as practical, functional or socially acceptable and become abnormal.

As a result of the diversity of normal and abnormal behaviour, when interviewing an offender, it is useful to maintain a practical approach in attempting to understand the individual's disorder. What exactly is the specific problem? How does it impact on everyday life? How does it impact on the person's relationships with others? Which relationships seem to be most fragile and difficult to establish, and which are the most supportive and helpful?

Bear in mind that the mentally disordered do not normally become offenders. In other words, to suffer a mental disorder is not in itself sufficient to result in contact with the criminal justice system. Rather, it is best to view the mentally disordered as being subject to many of the same influences and problems as "nondisordered" offenders. Accordingly, the mental disorder represents one aspect of an individual's behaviour and we should make a conscious effort to understand other of their individual aspects as we would with any non-disordered offender.

At times, a criminal act may be the direct result of a mental disorder which prevents a person from recognizing right from wrong. In such cases, the law allows for people to be designated as "not criminally responsible." These cases are relatively rare and will not be the focus of our present discussion. Most of the mentally disordered offenders we see have been found criminally responsible for their acts and are serving sentences in excess of two years in the federal prison system.

iv) The relationships between causes of mental disorders
Although sometimes it is difficult to provide details, it is important to understand that mental disorders can arise for a wide range of reasons. For example, it is widely accepted that although an individual may carry a physically based predisposition for a variety of illnesses, including mental illness, the onset of the illness may be triggered by a number of factors. These include lifestyle, life events or stress, and the availability of supportive relationships.

For the sake of simplicity, let's consider mental disorders in terms of two sets of factors, central nervous system functioning and the individual's social environment. Keep in mind as we go through these types of causes that they can overlap. In other words, factors which can produce illness are not mutually exclusive and can interact.

First, we note that the central nervous system controls the body's functioning. We also understand that physical illnesses, biological and genetic abnormalities, nutritional deficiencies, as well as environmental toxins can impact on the central nervous system. For example, major psychiatric disorders such as schizophrenia are found in above chance levels within families, suggesting that genetics do influence the appearance of the disorder, at least to some degree.

Second, aside from the interactions between the brain and the body's internal systems, the operations of the central nervous system support memory processes such as learning from experience. As a result, interpersonal and life events leave traces in the nervous system, and impact on the functioning of the brain on an ongoing basis.

To continue, let us also note that not only are interpersonal events "remembered," they have emotions associated with to them. Researchers now suggest that it is this emotional component which may change the way the brain functions as a result of an experience such as a trauma. As a result, traumatic experiences may disrupt normal processing of information as well as the normal process of development mentioned earlier. An example of this process is the response of some individuals to severe and traumatic events such as being the victim of violent or sexual assault. In such instances, the traumatic event may be re-experienced as flashbacks, they may produce heightened levels of anxiety, sleep disorders, intense feelings of guilt and anger, inappropriate affect and a wide range of interpersonal difficulties.

As an example of how a given disorder can be a product, as well as an effect, of both the biological and interpersonal/experiential levels of the nervous system, consider schizophrenia for a moment. Although a biochemical abnormality may be clearly indicated in schizophrenia, the patient's disordered thought processes, the content of his or her thinking, is largely learned and depends upon the patient's social context. Such learning may heavily influence the expression of the disorder. As was previously mentioned, not all mentally disordered patients develop criminal lifestyles or express their disorder in a violent antisocial manner. Presumably, this is because of differences in social systems and learning histories.

It is important to note that the interpersonal environment of the patient, including the amount of stress or support it provides, may influence the course of the illness. The mechanisms through which this occurs are not entirely clear. However, bear in mind that stress does result in biological changes in the body's functioning (e.g. changes in hormone levels) which impact on the functioning of the central nervous system. These changes may render the organism more vulnerable to deterioration, whether physical, mental or both. On the other hand, there is reason to believe that the presence of supportive social contacts serve to protect individuals from stressful and disruptive events and lessen the impact of illness.

v) Treatment of mental disorders
At the level of the study of the brain itself, it is clear that patterns of brain function can be altered by chemical means as well as through environmental events, either acute or sustained.

Psychopharmacology involves treatment of mental disorders with medication. Therapeutic drugs fall into three major groups with one notable leftover that doesn't fall neatly into any of the basic categories. The three major groupings are: 1) antianxiety drugs; 2) antipsychotic drugs; and 3) antidepressant drugs. The leftover is lithium, which is used in the treatment of bipolar mood disorders.

Antianxiety drugs serve to provide relief from tension, apprehension and nervousness. Antipsychotic drugs are used to gradually reduce psychotic symptoms, such as hyperactivity, mental confusion, hallucinations and delusions. Antidepression medication serves to elevate mood and reduce depression.

Psychotherapy is the second major approach to treating mental disorder. During psychotherapy and counselling, the therapist's aim is to establish a relationship with the patient and to: 1) remove or modify symptoms; 2) change disturbed patterns of behaviour; and/or 3) promote positive changes in personality.

In recent years, many comprehensive reviews of psychotherapy outcome studies in community populations have appeared and the results indicate that, on average, people who receive psychotherapy for a wide variety of disorders do better than about 80 percent of those who receive no treatment (Lambert et al., 1986). Studies on treatment outcome have indicated that the effectiveness of psychotherapy and medications (where appropriate) are additive and roughly comparable (Smith & Glass, 1980). More recently, outcome evaluation studies have focused upon what works best and for whom, an approach which is demonstrating wider practical value both in mental health and corrections.

vi) The broader context of mental health
The current definition of mental health used by Health and Welfare Canada (1990) emphasizes the importance of the fit of the individual with their environment and of the quality of their social interactions with others. The type of practical and multifaceted impairment that we have been describing in the mentally disordered is captured in this definition.

Among other things, this definition emphasizes the importance of interpersonal and environmental conditions in the support of wellness. In our review of the causes of mental disorders, we have noted that personal experience and the quality of the environment is important in the determination of mental status and may have a relationship to neurobiological functioning.

Accordingly, with reference to recommendations regarding special conditions for parole, and the importance of a particular type of supervision or social support system, it is quite appropriate to bear in mind that while medical or psychological intervention is often required, general life conditions may have an impact on the successful reintegration of the mentally disordered offender.

Prior to examining risk factors and risk management strategies, we need to review background information regarding classification systems of mental disorders. In particular, we will be attempting to assist National Parole Board Members in understanding the actual value of such information since it figures prominently in some psychiatric and psychological reports.

i) Purposes of classification systems
Classification refers to the process of grouping things or events according to their similarities. First, this gives us a way of naming phenomena that appear similar and of talking about them. In this case we are talking about a nomenclature of mental disorder. Second, using a classification system allows professionals to accumulate clinical knowledge over time about identifiable patient groups. In other words, classification systems are important in collecting research information. Third, classification systems represent the results of meticulous observation and research and therefore assist mental health professionals in describing important differences and similarities between patients. Fourth, these systems assist clinicians in the prediction of the outcome depending upon of the observed clinical symptoms and signs. In other words, to some extent, distinct disorders can be expected to evolve in known patterns. In addition, there is increasing interest in the most effective treatment and management strategies for specific types of disorders. This approach has served to increase consensus about how patients should be treated and managed. Fifth, the classification systems and knowledge generated through research based on them serve as reference points for theories of mental disorder, or theories of psychopathology (Phares, 1992).

Finally, classification systems are used for administrative purposes ranging from public and private insurance payments to the planning of clinical service delivery and research. The organization and planning of service delivery can be greatly facilitated when we are able to determine how many individuals suffer from a given disorder within a given population.

ii) Concerns and issues related to classification systems
While classification systems do have useful purposes, they also have liabilities and disadvantages. In particular, a number of serious concerns and issues have been identified (Phares, 1992).

First, we should not confuse categorization with explanation or understanding. For example, if we say that a person is psychotic because he is suffering from schizophrenia, we have made a circular statement without much explanatory value. By assigning a name to a condition, we do nothing to explain its cause.

Second, using a diagnostic term may serve to reduce our awareness of an individual's unique personal traits as well as the situational determinants of behaviour. Rather, we may tend to assume that disorders are more chronic and resistant to change than they actually are. We therefore need to remember that real people rarely conform to textbook presentations.

Third, diagnostic systems can serve to reduce awareness of the social values which underlie them. For example, for many years homosexuality was included in psychiatric classification systems. However, as social norms have changed, the gay life has become increasingly visible and homosexuality is now considered an alternative lifestyle rather than a mental disorder.

Fourth, diagnostic systems for the classification of the mentally disordered are subject to ongoing scrutiny regarding the degree to which they provide reliable and valid categories to describe patients. In other words, all diagnostic categories are not equally easy to use in a consistent manner. They do not always clearly distinguish between phenomena which are truly separate. In addition, diagnostic criteria are not often always of great practical significance. They do not tell a great deal about how well a person will be able to function in everyday life, in an institution, or after release.

Finally, we should be wary of any satisfaction related to the process of diagnosis itself. Diagnosis should be viewed as a tool to be used for the patient's benefit as it relates to the process of treatment or symptom management. The act of diagnosis does nothing in and of itself to enhance patient welfare. Naming a condition does not mean a therapeutic intervention has been accomplished.

Against the background of the above limitations, it is suggested that diagnostic information be used sparingly in reports. It may be most useful in the development of treatment strategies. As we will note, select diagnoses may have relevance to risk prediction and risk management, however, this should not be assumed to generally be the case. Overall, given the potential for harm, the act of diagnosis must always be undertaken with caution and diligence and is subject to prevailing mental health legislation.

iii) The Diagnostic and Statistical Manual-1V (DSM-1V)
DSM-IV was published in 1994 as a result of the work of a group organized by the American Psychiatric Association (see Appendix A). To a great extent, DSM-IV was developed using behavioural criteria and other objective measures. The goal was to develop a reliable and valid classification system because of criticisms directed at previous systems. The developers of the DSM-IV also acknowledged that the causes of many disorders, or their etiology, was not known in sufficient detail to determine diagnosis. For example, the term neurosis was discarded due to its close association with psychoanalytic etiology. This emphasis on the importance of objectivity has paid off to a substantial degree in higher rates of reliability, the degree to which a diagnosis can be made consistently by different clinicians.

It is expected that in the event that diagnostic information is requested and obtained, a full accounting of the diagnosis is normally appropriate. Accordingly, the use of all axes of DSM-IV are generally indicated in order to capture the behavioral complexity mentioned earlier, along with environmental, interpersonal and medical factors.

i) Personality disorders
For our discussion, we will distinguish between Personality Disorders and other types of mental disorders such as schizophrenia. Individuals with personality disorders show "acting out" types of behaviors rather than experiencing intrapsychic disturbances. That is, the individual behaves in ways that are contrary to the prevailing social attitudes or expectations of others rather than stifling such behaviour and experiencing inner anxiety. Often these patterns of behaviour are recognizable by adolescence and continue into adult life.

The category of personality disorders is a broad one, with behaviour problems that differ greatly in form and severity. On the mildest end of the spectrum we find individuals who generally function adequately but would be described by their friends or relatives as eccentric or troublesome. They have characteristic ways of approaching situations and other people that make them difficult to get along with, yet can be quite capable of getting along in their careers. At the other end of the spectrum are individuals whose more extreme and often unethical "acting out" against society makes them less able to function in a normal setting. Many are incarcerated in prisons or maximum security hospitals, but the ability of some to manipulate others may keep them from getting caught.

ii) Clinical features of personality disorders

• A pattern of disrupted personal relationships marked by difficulties they have caused others.
• Their problems are long standing and marked by behaviour that is considered troublesome to others. There is a persistent pattern of recurring problems.
• Personality disorder is often associated with other negative life outcomes such as addictive behaviours, divorce, and criminal or illegal behaviour.
• Whatever the particular trait behaviour they have developed (stubbornness, hostility, or suspiciousness for example), it colours each new situation they meet and leads to a repetition of the same maladaptive pattern of behaviour.
• Patterns of behaviour reflected in personality disorders are highly resistant to change. These individuals typically neither seek to change nor to accommodate to the demands other people require of their behaviour. They rarely seek treatment on their own and are often not motivated to profit from it.

iii) Mental disorders
For our discussion, we will address two severe forms of mental disorder, Schizophrenia and Bipolar Affective Disorder (manic-depressive Psychosis). In the latter case, we will focus upon the manic phase.

Schizophrenia

A. Characteristic symptoms. Two (or more) of the following, each present for a significant portion of time during a one-month period (or less if successfully treated):

1. delusions;
2. hallucinations;
3. disorganized speech (e.g., frequent derailment or incoherence);
4. grossly disorganized or catatonic behaviour; and
5. negative symptoms, i.e., affective flattening, alogia, or avolition.

Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behaviour or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration. Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion. Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either: 1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or 2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and re periods.

E. Substance/general medical condition exclusion. The disturbance due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or successfully treated).

Manic Episode
Next, we have the case of the Manic phase of Bipolar Affective Disorder. The person who experiences a manic episode has a markedly elevated, euphoric and expansive mood, often interrupted by occasional outbursts of irritability or even violence, particularly when others refuse to go along with the manic person's schemes. 'There is an increase in physical and mental activity. Inflated self esteem is also present which at severe levels can become frankly delusional so that the person has feelings of enormous grandeur and power.

The following are the symptoms of the Manic phase taken from the DSM-IV:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1. inflated self-esteem or grandiosity;
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep);
3. more talkative than usual or pressure to keep talking;
4. flight of ideas or subjective experience that thoughts are racing;
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli);
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation; and
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The symptoms do not meet criteria for a Mixed Episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

The prevalence of mental disorders among federal offenders in Canada
Until the early 1960s, it was rare for correctional systems in North America to view the mentally disordered as a significant operational problem or a major focus of activity and responsibility. However, in the early 1970s, a series of parallel changes began to occur within the mental health, legal and criminal justice systems. Of most significance was the progressive deinstitutionalization of the mentally disordered, and the commencement of their gradual entry into the criminal justice system in increasing numbers. For example, the patient census in Saskatchewan Hospital has gone from 2200 to 200 over the last few decades.

In a survey of studies investigating prevalence rates of mental disorders, Steadman, McCarty and Morrissey (1989) noted that: "the true prevalence rate of severe mental disorders (i.e. psychoses) in local jails ranges from 3% to 11% and that the rate of less severe forms of mental illness (i.e. nonpsychotic and personality disorders) varies greatly, ranging up to 15%-20%."

In view of such data, it has been increasingly noted over the past two decades, both in the U.S. and Canada, that the mentally disordered represent a significant proportion of inmate populations. In addition, it has been noted in some samples that the vast majority of the severely mentally disordered are more likely to have two or three disorders as opposed to a single mental disorder (Abram & Teplin, 1991). Of particular note are the number of mentally disordered who also suffer from various substance abuse disorders. These individuals have come to be known as "dual diagnosis offenders." As we will note, this multiple problem offender profile may be of equal importance for risk prediction as the diagnosis of a major mental disorder.

In 1988, the Correctional Service of Canada undertook a major study of the prevalence of mental disorders among federal offenders (Motiuk & Porporino, 1992). Using estimates obtained fi-om the study, the following percentages were adopted for planning purposes:

• 4% acute psychotic disorders;
• 2% transitional states (onset — conclusion of disorder);
• 3% significant chronic impairment; and
• 9% other disorders (e.g. depression, anxiety).

Against this background, we consider the clinical assessment of the mentally disordered for risk assessment purposes.

i) Introductory remarks
The possibility that mentally disordered offenders are at greater risk to be violent has always been a concern for National Parole Board Members and correctional staff, but there is a degree of uncertainty in this area. As a result, we should be aware that the empirical question of the relationship between mental disorder and violent behaviour has only begun to be addressed. Nevertheless, we will devote ourselves to the presentation of some of the more important and relevant findings and concepts.

In general, recent research suggests that the presence of a major mental disorder is to be considered a significant but modest risk factor for the occurrence of violent behaviour (Monahan, 1992). More specifically, it appears that active psychotic symptoms are among the most important predictors of violent behaviour. Personality disorders and substance abuse disorders can also be highly relevant in the prediction of violent recidivism.

ii) Mental disorder and violence: Two approaches to the study of the relationship
There are two methods to study the relationship between mental disorder and violent behaviour (Monahan, 1992).

The first method is to study the prevalence of violent behaviour among persons with mental disorder versus non disordered individuals:

• among identified mental patients;
• among identified incarcerated populations; and
• among random community samples.

The second method consists of the study of the prevalence of mental disorder among persons committing violent behaviour:

• among identified mental patients;
• among identified criminal offenders;
• among random community samples.

Both of these types of studies are valuable. At the same time, both also have limitations in the study of the relationship between mental disorder and violence.

iii) Violence among the disordered
Community samples
In 1990, Swanson, Holzer, Ganju and Jono published a study on "Violence and psychiatric disorder in the community: Evidence for the Epidemiologic Catchment Area Surveys." Using the National Institute of Mental Health's Epidemiological data, representative weighted samples of adult household residents of Baltimore, Durham and Los Angeles were pooled to form a data base of approximately 10,000 people. The DIS was used to establish mental disorder according to DSM III.

Five items on the DIS were used to indicate violent behaviour:

• Did you ever hit or throw things at your wife/ husband/partner?
• Have you ever spanked or hit a child (yours or anyone else's) hard enough so that he or she had bruises or had to stay in bed or see a doctor?
• Since age 18, have you been in more than one fight that came to swapping blows, other than fights with your husband/wife/partner?
• Have you ever used a weapon like a stick, knife, or gun in a fight since you were 18? Have you ever gotten into physical fights while drinking?

Respondents were counted positive for violence if they endorsed one of the items and reported that the act occurred during the year prior to interview. There was no differentiation between frequency and severity of violence in this study.

The study found that violence was seven times as prevalent among the young as among the elderly, twice as prevalent among men in comparison to women and three times as prevalent within the lowest social class as within the highest social class. In computing the clinical data, individuals who met the criteria for more than one diagnosis were included under each category.

Remember that these findings refer to a community sample of non disordered individuals. Three findings emerge clearly: a) violence is more than five times more prevalent among people who met DSM III Axis I diagnosis than among people who were not diagnosed; b) violence among persons who meet the criteria for a diagnosis of schizophrenia, major depression or bipolar disorder is comparable in prevalence; and c) violence among persons who met criteria for a diagnosis of alcoholism was more than 12 times more prevalent than that of persons who were not diagnosed. Other drug abusers were found to commit violence at 16 times the rate of those who received no diagnosis.

In addition, consider the work of B. Link, F. Cullen and H. Andrews in a 1992 article entitled "Violent and illegal behaviour of current and former mental patients compared to community controls." The study was based on a comparison of 400 adults from the Washington Heights area of New York City with several samples of former mental patients from that same area.

Of most interest in this study was the authors work on "current symptomatology". This was undertaken using the False Beliefs and Perceptions scale of the Psychiatric Epidemiology Research Interview (PERI). This scale measures core psychotic symptoms using questions such as:

• How often have you felt that thoughts were put into your head that were not your own?
• How often have you thought you were possessed by a spirit or devil?
• How often have you felt that your mind was dominated by forces beyond your control?

It is noteworthy that measures of current psychotic symptoms were significantly correlated to most indices of recent violent behaviour. In other words, when mental patients were actively experiencing psychotic symptoms like delusions and hallucinations, their risk of violence was significantly elevated, compared with that of nonpatients. When patients were not actively experiencing psychotic symptoms, their risk of violence was not appreciably higher than demographically similar non-treated members of their home community. Taken together with the Swanson et. al. (1990) study, the data suggest that while the mentally disordered were more violent than non-diagnosed individuals, their episodes of violent behaviour were largely confined to periods when their symptoms were poorly controlled.

Incarcerated samples

Porporino and Motiuk (1993) recently reported that the mentally disordered in the Correctional Service of Canada were more likely to have their supervised releases revoked (without committing a new offense) and to be afforded fewer opportunities for early release than non-disordered offenders. However, they note that mental disorder alone did not predict recidivism for their sample. Only "number of previous convictions" and "total number of convictions" were significantly related to readmission. In comparison to non-disordered offenders, mentally disordered offenders were at reduced risk to commit further serious crimes while posing a relatively greater risk to commit minor "nuisance" offenses. Apparently, non-disordered offenders were at greater risk to commit a violent offense while under supervision than their mentally disordered counterparts.

These findings suggest caution in assuming that the mentally disordered are at higher risk to reoffend and may be quite compatible with the previously reported research.

That mentally disordered offenders tend not to be released as soon as non-disordered offenders, and when given conditional release tend to be suspended more readily, may suggest a number of processes in operation. Perhaps supervising authorities are more sensitive to deviations in the behaviour of the mentally disordered offender by virtue of the preexisting diagnosis. Alternately, the supervision potentially in place through community based mental health services may provide a level of supervision post-release which is uncharacteristic in the case of the non-disordered offender. It is also possible that the behaviour of mentally disordered offenders is less well regulated than others. This suggests that when they experience difficulty coping, they tend to "telegraph" more clearly their indications of relapse. Also, it may be that because of their behavioral instability at time of active symptomology, they are less capable of the sort of organized behaviour which premeditated violent crime requires. This interpretation of the data is supported by the fact that in the Porporino and Motiuk study neither antisocial personality disorder or substance abuse was predictive of higher recidivism within the mentally disordered group whereas both factors significantly increased the risk for reoffense within the nondisordered group. Quite clearly, it is desirable to closely scrutinize the risk factors documented by research in the examination of any specific case.

iv) Disorder among the violent
The second approach to the examination of the relationship between violent behaviour and mental disorder focuses upon the prevalence of mental disorder among people who commit violent crimes. We can study people who are within institutions under treatment for violence or we can investigate those in the community who have not been institutionalized.

We have previously commented on the rates of mental disorder in prison populations and as a result we will not repeat them here. Suffice it to say that the relatively high prevalence of mental disorders among jail and prison inmates cannot be used to address the relationship between violence and mental disorder. The methodological problem is that of bias in selection. It may well be that the mentally disordered are more or less likely to be arrested and incarcerated than non-disordered offenders for reasons other than their criminality.

Rather, data on the prevalence of mental disorder among randomly selected samples of people in the community who commit violent acts is desirable. Here the previously reported data by Swanson et al. (1990) is again useful.

In that study, schizophrenia was approximately four times more prevalent among respondents who endorsed at least one of the five questions indicating violent behaviour in the past year when compared to respondents who did not report violence. Similarly, affective disorders were three times higher in prevalence and substance abuse eight times higher. When all DIS diagnoses were taken into account, the prevalence of mental disorder was three times higher among respondents who endorsed questions indicating violent behaviour when compared to respondents who did not report violent behaviour.

v) Risk factors and risk assessment
Overall, while there is a relationship between mental disorder and violent recidivism, it is clear that the magnitude of risk contributed by other factors such as young age, male gender, and socioeconomic status is more substantial than that contributed by mental illness.

Several attempts have been made to more accurately assess the risk contributed by mental disorder and to assist with risk assessment in the mentally disordered population. For example, Harris, Rice, & Quinsey, (in press) have prepared an actuarially based risk assessment instrument for use with severely mentally disordered offenders. While their assessment procedure was based upon the population of patients at Penetanguishene Mental Health Centre, their findings may generalize to some degree to the mentally disordered found within federal institutions.

The following 12 factors were found to be predictive of violent recidivism:

1. High score on the Psychopathy Checklist - Revised.
2. Separation from parents under age 16.
3. Victim was injured in the commission of the index offense. *
4. A DSM - III diagnosis of Schizophrenia. *
5. Never married.
6. Elementary school maladjustment.
7. Index offense involved a female victim. *
8. Failure on prior conditional release.
9. Property offense history.
10. Relatively young age at index offense. *
11. Alcohol abuse history.
12. DSM — III personality disorder.

* = Negatively correlated with outcome

As the detailed information described above would not always be available, a short list of routinely available information was selected from the original pool of items. The resulting list was highly similar to systems employed to assess risk in non-disordered populations (e.g. Andrews and Bonta). This list predicted violent recidivism less accurately, but still significantly.

The revised list of predictors follows:

1. Victim was injured in the commission of the index offense.
2. Never married.
3. Index offense involved a female victim.*
4. Failure on prior conditional release.
5. Property offense history.
6. Relatively young age at index offense.*
7. Alcohol abuse history.

* = Negatively correlated with outcome

In another attempt to evaluate the factors considered by experts in making recommendations for conditional release, Brown and O'Brian (1990) reported a number of variables which predicted successful adjustment among paroled mentally disordered offenders. They reported two classes of variables which were favourable indicators of successful conditional release.

Demographic factors

1. Has less than two thirds of sentence left until date for release on mandatory supervision.
2. Has experienced significant consequences for criminal behaviour (e.g. divorce, job loss, sentence exceeds minimum sentence for the offense by one year).
3. Has less than four past criminal acts or sprees (not necessarily convictions) for which Federal imprisonment was possible or likely.

Clinical factors

1. Accepts responsibility for behaviour.
2. Appreciates significance of criminal behaviour.
3. Does not cast self as victim of the crime, of society or of the criminal justice system.
4. Has experienced productive and unpleasant consequences of behaviour (not including time served).
5. Shows flexibility and tolerance regarding the legal and institutional process (not including institutional behaviour).
6. Is not unusually self-centred..
7. Has gained some understanding of what personal characteristics led to criminal behaviour.
8. Has realistic or achievable post-release plans, given abilities and resources.
9. Has the understanding, ability and interest to make positive changes to lifestyle (what he or she was doing wasn't working).
10. Will not benefit further from treatment or counselling, or the treatment or counselling required is available and appropriate on an outpatient basis.
11. Will not benefit from further incarceration (will be unproductive or counterproductive).
12. Has provided sufficient information so that the clinician understands why (for what clinical reasons) the parole applicant committed current and past offenses.

Through our work with sex offenders at the RPC (Prairies), Clearwater, several additional factors have been identified which may be useful with regard to risk prediction in the mentally disordered sex offender population.

Program evaluation data indicate that offenders with prior convictions for sex offenses and heterosexual and homosexual paedophiles are at greatest risk to recidivate. In addition, individuals who do not complete the program reoffend at approximately twice the rate of program graduates (24% as opposed to 13%).

Offenders who have assaulted adults and children recidivate rather like our sample of rapists (i.e. at lower rates), and incest offenders display the lowest rates of recidivism.

Given the parallels between risk factors for nondisordered and disordered offenders noted elsewhere, our observations with regard to our released sex offenders may well apply to mentally disordered sex offenders. When there is evidence of extensive criminal behaviour and violence and/or compulsive sexual behaviour, risk is increased in the mentally disordered population as well as the non-disordered population.

In concluding this workshop on the mentally disordered we will review two cases of patients with histories of psychotic illness. These cases illustrate how active psychotic symptoms may represent an imminent risk to reoffend, how these symptoms are entwined with additional risk factors, and finally, they provide illustrations of appropriate risk management strategies.

Case studies
In approaching a particular case it may be helpful to divide mental disorders into the following broad categories:

Axis I disorders:

• Psychotic disorders (functional or organic), e.g. schizophrenia, bipolar affective (manic depression), dementia, brain damage etc.
• Non psychotic disorders e.g. anxiety, phobias, mild depression etc.
• Substance abuse/dependence e.g. alcohol, drugs.

Axis II disorders:

• Personality disorders, e.g. antisocial, paranoid, borderline etc.

As mentioned, these disorders may exist separately or coexist in the same individual. Substance abuse/ dependence frequently occurs in individuals with antisocial personality disorders. Individuals with a major disorder like schizophrenia may also suffer from other disorders like personality disturbances such as antisocial personality disorder. These individuals will meet the criteria for both disorders.

The relationship between mental disorder and antisocial or criminal behaviour is complex and depends on a number of factors. Clearly, individuals with a personality disorder and/or a history of substance abuse often engage in antisocial behaviour for self-evident reasons.

In psychotic conditions the relationship is often less obvious. However, certain psychotic symptoms, e.g. delusions of persecution (paranoia), delusions of infidelity (usually involving a spouse), command hallucinations and extreme forms of mania, are more likely to result in antisocial, and sometimes dangerous, behaviour than other symptoms. Individuals with psychotic symptoms may hold the view that they need to defend themself against dangerous forces, right a terrible wrong, seek vengeance on an unfaithful spouse or follow an urgent command in the form of auditory hallucinations to punish or destroy.

Such psychotic thinking may be boldly expressed in interview or on the other hand it may be secretly held or "latent." For example, psychotaranoid patients may withhold delusional material from their interviewers and the material is only revealed through sustained interviewing or projective testing.

Sometimes, symptoms of a psychotic disorder are directly related to antisocial behaviour. Usually these cases are diverted to the mental health system after a finding of "not criminally responsible." However this is not always so, as illustrated by case #1 below.

When a psychotic condition like schizoaffective disorder — a condition combining features of both schizophrenia and bipolar affective disorder (manic depression) — coexists with an antisocial personality disorder, the resultant criminal behaviour may be dependent on which condition is primarily responsible. An example is given in case #2 below.

Of course it is quite possible for someone with a serious illness like schizophrenia to behave criminally in a manner which is unrelated to any psychotic symptoms, e.g. shoplifting, sexual assault etc.

One rare delusional disorder has gained some notoriety because of the extreme risk it is thought to pose to others. Erotomania is a psychotic disorder characterized by a delusion that another person (object) is in love with the person with erotomania. This condition illustrates the interplay of factors, aside from the delusions, which seem to be important in the development of dangerous behaviour. Many authorities, including the RCMP, believe that the presence of the delusion alone heralds dangerous behaviour. This is directed at either the delusional object or anyone perceived as a "rival" or an "interfere." Consequently all those who suffer from this disorder are seen as equally dangerous. A recent study (Menzies et al, 1994), examined 29 cases of male erotomania and found that only a proportion (44%) had engaged in serious antisocial behaviour (violence) which was related to the delusional beliefs. Even so, actual physical harm to others occurred in only 22% of all the cases and did not involve any fatalities. The two factors significantly associated with dangerous behaviour were the presence of more than one delusional object and a history of significant antisocial behaviour, unrelated to the erotomanic delusions. Using these two factors, it was possible to correctly predict all the cases which had exhibited dangerous behaviour. No false negatives were identified, i.e. dangerous cases misidentified as benign or non dangerous.

Overall, while men and women with erotomania can be included in the category of stalkers, any risk they may pose might be less than the risk posed by the majority of stalkers (estranged spouses and lovers) who do not suffer from a psychotic illness.

i) Case study #1
Mr. A., a 35 year-old truck driver, pleaded guilty to the second degree murder of his wife and was sentenced to life imprisonment. The couple had been married for four years but the relationship had become strained because Mr. A entertained serious doubts about his wife's fidelity. His suspicions were without foundation but he felt compelled to put an end to his misery by killing her and then himself. "I wanted to make sure she would never fool around again."

Following an argument she went to bed and while she was asleep he went out and bought some shells for his shotgun. He returned home and shot her three times as she lay asleep in bed. He contemplated killing himself but after several hours gave himself up to the police.

He underwent a thorough psychiatric assessment before his trial and was diagnosed as suffering from morbid jealousy (delusions of jealousy). He told the psychiatrist that he knew his wife was having affairs with a number of men including her uncle. Although he had made repeated attempts to catch her in flagrante delicto, by returning early from work etc., he had been unsuccessful. Nevertheless, he "knew" his suspicions were true because of the "expression on her face" when he arrived home unannounced. He had also found "evidence of other people's sperm on her underwear" and saw "her boyfriends' cars driving around the house." He knew she let other men into the house at night for sex, because he found "their sperm" on his mustache when he woke up in the morning. He did not believe that his ideas were bizarre or a product of mental illness. The psychiatrist was prepared to give evidence that Mr. A. was not criminally responsible on account of mental disorder. Mr. A considered himself to be mentally normal, and against his lawyer's advice, chose to plead guilty to murder.

Mr. A had been a law-abiding citizen, prior to the homicide, and had been gainfully employed most of his adult life. He had some personality problems but not to the degree that he could be diagnosed as personality disordered. 'There was no history of psychiatric problems but he did suffer from a moderate degree of depression after the offense.

When this man is released on parole, he will pose an extreme risk to any other woman with whom he becomes emotionally involved. This risk will be significantly modified if he undergoes successful treatment with antipsychotic medication, but at this stage he is not prepared to accept any treatment because he has no insight. A further complication is that this condition is notoriously resistant to treatment in any event. In addition to psychiatric follow up, it will be extremely important for any future emotional relationships to be monitored very closely. The partner should be aware of the circumstances of the offense and particularly the role of jealousy. If any similar behaviour should occur in a new relationship (and there is a high probability it will), the problem should be addressed immediately by the parole officer and others involved in the case. Conditions of any parole should include compliance with psychopharmacological treatment and participation in counselling focusing on anger management and spousal abuse.

ii) Case study #2
Mr. B, a 39 year-old unemployed single man, was sentenced to four years for assault causing bodily harm. At a party, where he consumed prodigious amounts of alcohol and drugs, he attacked a man he believed had designs on his girlfriend.

He underwent a psychiatric examination after his arrest and was diagnosed as manic. His behaviour was overactive and aggressive and his mood was elated and irritable. He spoke non stop about irrelevant matters, thought he had special powers and believed he was related to royalty. He explained the assault as justified because the victim had "looked with a lascivious eye at my woman." During his remand he was treated involuntarily with antipsychotic and mood stabilizer medication and within four weeks was judged to be free from any disturbance. He chose not to continue with medication because he did not feel he needed it.

He was the product of a broken home and there was a family history of mental illness on his mother's side. He posed behavioural problems at school and was in trouble as a juvenile for property-related offenses. He began abusing drugs and alcohol at an early age and had a sporadic employment history. His first psychiatric admission, at 24, was precipitated by an assault on his mother. He was diagnosed as suffering from a schizoaffective disorder and treated involuntarily. His compliance with treatment as an outpatient was poor and he had further admissions over the next five years. Typically he was brought to hospital by the police for threatening harm or fighting. During his early 30's, he developed some insight into his illness and took medication on a more or less regular basis. His mental state became stable, but criminal activities continued and he served several provincial terms for property-related offenses. Following a marital breakup, he became depressed and stopped taking medication. A manic episode followed some months later and led to his current conviction.

Mr. B has an antisocial personality disorder in addition to a schizoaffective disorder. While the latter usually responds fairly well to medication, his personality disorder has been more resistant to therapeutic endeavors to date. It is clear that his criminal and non violent life style is the result of his abnormal personality while his violent behaviour is directly linked to episodes of mental illness. An important aspect of reducing his propensity for violence would be to maintain him on appropriate medication, however this will probably be complicated by his generally irresponsible approach to life.

This case illustrates a number of risk factors which need to be addressed. His mental illness will require long term psychiatric treatment and supervision, and a lack of community support will necessitate placement in an approved mental health boarding home. This will also provide added supervision. He will need counselling focusing on anger management and continued rehabilitation for his substance abuse. His personality problem and behavioral difficulties may respond to regular contacts with parole officers, inter alia, cognitive behavioral intervention, as well as consistent guidelines and parole conditions.

Since assessment of mental disorders constitutes a major focus in graduate training and supervision, it will not be reviewed here. Rather, the bibliography includes several references which the practitioner may find useful (e.g. Gregory, 1992).

In summary

1. Major mental disorder is a factor in the prediction of risk but its role is secondary to other factors such as environment and criminal history.
2. Where violence among the mentally disordered is evident, it appears to be largely restricted to periods when symptoms are most active.
3. The role of the environment is as important for the disordered offender as it is for the nondisordered offender.
4. There are a number of static predictors of risk which should be employed along with clinical judgments in making statements about risk.

Chapter 10 Appendix

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Bednar, R. L, Bednar, S. C., Lambert, M. J., Waite, D. R. (1991). Psychotherapy with High-Risk Clients: Legal and Professional Standards. Pacific Grove, California: Brooks/Cole Publishing Company.

Brown, R. J. (Sx. O'Brian, K.P. (1990). "Expert clinical opinion in parole decisions: The Canadian experience," American Journal of Forensic Psychology, 8 (3), 47-60.

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