Tuesday, June 7, 2011

Dangerous behaviour of mentally disordered individuals in the Community.

Introduction

Richard Harvey from the Royal College of Psychiatrists asked a group of psychiatrists on-line among other things, about community treatment of dangerous offenders. My response prompted Ben Green, Editor of Psychiatry On-Line, to suggest an article on the subject. I am happy to comply. The discussion will focus on the Province of Saskatchewan, Canada because that is where I practise and with which I am most familiar.

Saskatchewan was a world leader in implementing the effective discharge of patients from large asylums. Its move began in 1964 with the establishment of community mental health centres throughout the Province and regulations for the use of approved homes, community psychiatric nurses and facilities for re-integrating the mentally disordered into the community. The Province in 1994 had a new convulsion in Health Services with the establishment of Health Districts each of which is theoretically autonomous for Mental Health. In practice the established Mental Health Centres, associated as they are with general hospital inpatient facilities and larger urban groupings, are still used and their services purchased for needy patients from smaller Districts.

Again, accompanying this move to Districts there have been some changes to the Mental Health Services Act that have given some cause for concern. The current rule is that for a person to be detained involuntarily (certified) in a Mental Health Facility [Psychiatry ward] the following conditions must be met:

The person must be mentally ill
The person must require treatment that will probably improve the illness
The person must refuse that treatment.
The illness must be such that it results in danger to the person or to others or if it continues will result in continuing deterioration in the person's health.

A certificate written by an admitting physician who must practise in the facility, is valid for three days during which a second certificate can be written by a psychiatrist to detain the person for a maximum of three weeks. Many appeal processes are built in as are prohibitions against using any experimental or neurosurgical techniques on a certified patient. For continuing treatment there are several mechanisms now being used:

1. A repeat of the original detention certificate by two doctors one of whom must be a psychiatrist and both of whom must practise in the facility.
2. A Certificate of Incompetency, which allows others to take over limited areas of the patient's life (especially financial).
3. A Community Treatment Order requiring the person to take specific treatment at home or be readmitted involuntarily introduced in 1995.
4. A Dependent Adults' Certificate which can allow up to year at a time of detention introduced in 1994

The last three certificates require appearance before a judge and a judicial ruling.

Saskatchewan has, in addition to its Mental Health Services, a forensic system consisting of a range of services from private psychiatric practitioners to a Regional Psychiatric Centre operated by the Federal Government. There is continual pressure to reduce the length of stay or not admit mentally disordered persons unless their plight is extreme. Long stay and particularly long stay for cognitive impairment is sharply discouraged as is the admission of children to mental health facilities [there are none.]

The dilemma is always where to place an individual who may be dangerous to the community. Should such a person be in hospital ( for treatment of an underlying condition increasing the danger ?) Should they be in prison to provide security for the community and receive whatever "treatment" is needed in a prison centre ? Should they be managed in the community to limit costs and hospital overcrowding? Can this type of behaviour also be seen as a manipulation leading to the protected comfort of hospital or even prison as opposed to the demands and stress of the community ? These questions are the areas discussed in this article.

Despite the repeated urging of researchers, the use of pilot projects and management research is woefully underused. Decisions regarding the whole system are made by industrial managers and based on political expediency instead of by health care professionals and based on patient and family need. We have few test labs for experiments to study the impact of one policy over another. Perhaps it is time for these to be conducted. However, this is for the future. Let us consider the present.

Dangerousness and Mental Disorder

Not all mental disorder is associated with, nor induces dangerous behaviour. Equally, not all dangerous behaviour has a mental disorder at its root (at least as currently defined.) There are perhaps precedents in which suicide has been committed "while the balance of the mind is disturbed" and for while virtually all suicide was seen in this light.
We now recognise altruistic suicide and rational suicide as subtypes where the mind is not disordered. Indeed there are societies that advocate the use of suicide and the "right" to suicide in certain circumstances. In the United States there is a very active debate on whether a person should be charged for assisting someone who wishes to commit suicide but despite laws enacted, juries refuse to convict.

We do not universally recognise altruistic murder nor active euthanasia but do recognise "rational" murder in executions, war and in removing the life support systems in people who are terminally ill. So there are many pitfalls in the legal and ethical definitions of what constitutes the most extreme forms of dangerous behaviour. We have therefore to come to some agreed-upon conclusions about which forms of dangerous behaviour we wish to limit or eliminate in the community. We have to balance safety for the dangerous one and the putative victim with optimal treatment of any underlying mental disorder. And it is certainly true that certain mental disorders associated with fixed and obsessive thinking, impulsivity, hormonal imbalances, substance abuse, fear, depression and suspiciousness or with a constitutional lack of moral development are more likely than average to produce dangerous behaviours. These behaviours are likely by their nature, to be unpredictable.

Dangerous behaviours

The community tends to be scared of certain forms of behaviour more than others. They are worried about personal safety and about behaviours like 'stalking', 'assaultiveness', ' sexual predation', 'kidnapping', 'murderous predation' and 'terrorism' or group threats of assault andmurder. These aggressive invasions of personal space often have mental processes underlying them. They may be perceived by the aggressor as sensible, logical, justified and "right". To the victim they are never any of these things. To the observer they may one or the other depending on circumstances.

Underlying thoughts may be divided into ideas of omnipotence or grandiosity, a false assessment of "justice", suspicion of others planning or plotting against one, or obsessions such as those of erotomania, guilt, revenge, and so on. These thoughts may be accompanied by more dramatic effects such as hallucinations, delusions, illusions, or ideas of being controlled. These are familiar signs of mental disorder as we pass from errant thoughts to rooted obsessions and from internal experience to external actions to try to correct these. As psychiatrists say, there is movement from egosyntonicity to egodystonicity. Ordinarily we exert considerable control over our thoughts and test them against reality constantly. When this facility is compromised or absent, problems arise with more intelligent people more likely to have difficulty because of the range and variety of their thoughts. So should we "lock up"all intelligent people because of the possibility that they might be dangerous at some time ? Of course not.

Beneath the dangerous thoughts lies a layer of hurt or angry feelings. These feelings are seen as the engines of the thoughts, making them persist in the face of rationality. Fears lie beneath suspicions, anger beneath vengeance, misery beneath hopelessness, pain beneath all, loneliness beneath guilt and self blame and hunger beneath the various desires. These desires - sexual satisfaction, food, fluids, air, substances (for the addicted), company and love, religious ecstasy, domination are strong motivators although they must be expressed via feelings and thoughts and be subjected to rational filters before being implemented. And above them all, does the offender WANT to be dangerous or perhaps NEED to be dangerous. This is a question we should perhaps try to answer before passing judgment or sentence.

Managing dangerousness & chronic mental disorder

Currently we try to deal with aggressive individuals by preventing the acceptance of hostile aggressiveness in Society through early education by parents and school teachers. Modern examples of this approach are the attempts to reduce bullying and sibling fighting and the re-training of males to respect and discuss issues with females. These methods are slow but could prove to be effective in the long run. In those places where effective programs are in place it will be years before the results can be measured and even then intervening variables may cause confusion. So again, we are left with a dilemma - should we implement such programs everywhere or to wait for the pilot results, even interim ones ?

Potentially dangerous people may be recognised through their childhood behaviours but the remedies are less obvious. Many more children exhibit the potential than eventually become dangerous but the seeds are sown early in those whose moral development is stunted or absent. This in turn may be biological like attention deficit disorder or learning disability. Some of these early problems Bowlby attributed to maternal deprivation but that has been demonstrated to be reversible by proper foster care. Some are related to attention deficit hyperactivity disorder where again we have treatment assistance available. Some however, of these conduct-disordered children do go on to become conduct-disordered adults with disastrous consequences for the community . Should we have screening programs in place to identify all children with aggressive tendencies and require parents / teachers / therapists to deal effectively with this problem when found?

Applying corrective techniques -usually some form of positive parenting as soon as possible - has been shown to produce good results. This is the form of discipline now favoured, although in Sweden confrontation and angry word exchanges are preferred over the old corporal punishment techniques. But, do we have long term studies that show these methodologies are successful in the long term? Has the dropping of corporal punishment in Sweden resulted in a lessening of dangerousness in the community ? We need to know the answers from these social experiments.

The interesting point is that as aggression increases, the rejection by others increases and the sense of rejection increases, leading to more need for revenge and the cycle continues. Social skills training on a steady and regular basis is called for, with children being involved in as many combinations and permutations as possible of cooperative activity as they learn to work with and for others, reducing the need for aggressiveness from loneliness or frustration.

Working through the family is an attractive option. Mediation, coercion, assistance and support are increasingly available as an extremely expensive option. Canada has also brought in two recent laws to try to curb some of the aggression and predation: - anti-stalking laws are now available to assist women in their need to escape spousal abuse and threats of death or harm should they try to get away. Gun-control legislation is being introduced to try to prevent the large number of domestic aggression incidents and danger from the inappropriate use of guns.

Work continues too on the dangers of exposing of the public and segments of the public in particular to erotically stimulating literature where there is no outlet for the discharge for such heightened desires. Control of imported pornography, especially that using underage children and that demeaning women is increasing and film and video classification allows parents to be selective in their own as well as their childrens' viewing pleasures.

Canada has laws permitting a man to be excluded from the family home if he is abusive and indeed while under suspicion of being abusive. This avoids the need for the woman to leave although even with a restraining order the man may return and cause harm. The restraining orders need to be more effective and be combined with some sort of neighbourhood watch to assist the family settle down without the offender. Public and political solutions continue to be applied. The politicians may in their zeal to correct one problem over-regulate or arbitrarily deny other segments of the population their legitimate rights.

Although an option in Canada for the judges under the Young Offenders Act, parents are rarely held accountable for their children's actions. As a consequence there is a feeling that others are supposed somehow to accept the child's misbehaviour just as the parent has had to do. Is more accountability for parents with support from the community in parent training, discipline techniques and encouragement needed ?

For the aggressive dangerous person attempts are often made before going to Court. Bonds, undertakings to be of good behaviour, promises and contracts and warnings are used in schools and in Society by employers or family members. These mostly seem to be ineffective and rarely prevent the inevitable Court or Emergency Room appearance.

All these methods try to change the person's attitude - to encourage responsibility, increase self-worth, value others, follow the "Golden Rule," "to do unto others as you wish that they would do unto you." The attempts follow a set pattern of demonstration, explanation, recapitulation, examination, practice and progress. These methods often fall short in the first and third areas, especially demonstration, where people are urged to do as I say but NOT as I do. Successful dangerous behaviour is sometimes smiled upon by Society where unsuccessful dangerous behaviour is punished.

To move to the next phase of physically stopping the dangerous person we employ various restraints. We use physical restraint with greater violence offered to combat violence, chains and handcuffs, wounding with weapons, hunting, trapping and caging the dangerous person. We then try to force change by talking AT the person, using drugs to subdue or alter thinking, offering worse threats if the problem continues or using behavioural manipulation to change the person in the desired direction and ultimately removing the threat altogether by judicial execution (not in Canada.) An alternative technique is to change the person by fatigue, malnutrition or drugs until they are in a weakened psychological state and then offering a "way out" through some form of conversion - religious, political or other. These solutions are political mainly and not really for those mentally ill who "cannot help" the way they behave. Are there really any such ?

Thinking these days especially among mental health nurses, social workers and psychologists and physicians questions the role of the unconscious in motivation. The expectation on those who work in mental illness facilities is that the patients (clients) will control themselves and not harm the staff or they will be charged with offences. Substance abuse is met with discharge; violence against staff with discharge and a criminal charge. So these dangerous people are placed back on the street. Those who "slash" themselves to produce a counter pain to their depression and misery inside are not readmitted because the behaviour is reinforced by admission. Meanwhilethe police, seeing a tide of potentially dangerous persons being released onto the streets are calling for more punishment, more jails, They cannot accept bizarre behaviours, the baseless threats and the uncontrolled expressions of emotion. They call for more physical restraint but not necessarily more medication nor chemical restraint.

In the community, recovering alcoholics call for a ban on all psychoactive medication. They extol the virtues of the Twelve Steps even in inappropriate circumstances. They tend to deny the reality of comorbid disorder although there are some ex-addicts who seem to changing their minds at the moment. Another factor in current difficulties is the assertive expectation, supported from a feminist position, that all male physical aggression must be stopped. This limits the placement of an aggressive male back in his community. It also heightens the expectation that someone ( the hospital ?) must be held responsible for aggressive incidents. The expectation that aggression can and should be curbed is as common as the injunction that people should not smoke and probably for the same reasons - that others are affected.

Methods that have been tried where results are uncertain

The Community Treatment Order, law in Saskatchewan now since late 1995, permits a patient to be treated in the community and brought back into hospital if he or she fails to accept the treatment prescribed. It is regretted by most physicians who want a voluntary agreement with their patients for treatment; opposed by many patients who do not want to be "forced" to take medication and looked at askance by medical insurance companies who see legal wrangles ahead in which the prescribing physician will be held accountable for medication errors caused by a patient's self-administration of toxic compounds. In hospital these errors would be detected by nurses and stopped before damage was done. In the community with a non-consenting patient the scene is very different and the physician could be liable for damages.

The CTO requires supervision. This might be by the approved home manager or by a psychiatric home care nurse. One question that arises is how quickly should one return a non-compliant patient to the hospital. In some cases a person with schizophrenia and well established on medication could be left for three or four months before symptom recurrence. A lithium taker for bipolar disorder might go years without another episode. When exactly should a person be returned to hospital and would the order expire before a need demonstrated itself ?

As noted above some dangerous characters are required to live away from the targets of their special interest. In Canada we have one famous case in which a man persists in bothering singing star, Ann Murray. This is erotomania and nothing so far seems to have changed his fixation on her. Prison sentences have been carried out but he resumes his pestering immediately on discharge from jail.,

Canada has developed an anti-stalking law to try to make police action easier in these cases where even with a restraining order the stalker does not stop his behaviour. Of the cases involving stalking of course, the erotomanic is an irritating but less dangerous example than the man who being abandoned by a wife or mate who cannot tolerate his continuing jealousy and violence toward her, threatens to kill her and follows her everywhere. These individuals who threaten are not necessarily physically dangerous but are frightening. Should they be restrained like a serial assaultive male?

For these serial assaulters - people stuck in the mould of having their way, be it never so simple - forms of jail sentence and prolonging the sentence have been used. This process is extremely costly to Society and one would wish another solution. In Canada one possible solution proposed in the Province of Ontario (or course) where the administrators and politicians seem to have had little understanding of mental disorder, is to transfer offenders, identified as "dangerous" to mental health facilities for "treatment." This ignores the fact that they would not be in jail if they could have been treated in the first place and that hospitals are for treatment, not for detention and are much more expensive on the public purse than even prisons.

There is often no absolute requirement that a predatory offender be treated either voluntarily (best) or involuntarily if necessary to stop the behaviour. Lawyers prefer to send a person to jail where they can "do their time" and "pay the price" rather than to hospital for an indeterminate period of treatment. Thus a number of these predators are held in jail with no real attempt to change them. Opportunities are afforded them to practise their art of intimidation on other inmates.

Suppose these individuals were transferred to "hospitals." They are in prison now for at least 15 years before they can even think of parole. They have little to lose and will try manipulation on essentially defenceless mentally disordered persons and the nursing staff. Hospital security personnel who are not trained prison guards with appropriate back-up, will be supposed to control any incidents. At least in Saskatchewan currently we can ensure that a violent person is first detained in a corrections facility and treated there before transfer to a regular hospital for the next phase and prior to discharge there is always the option of returning the prisoner at any time to jail.

Increased security frightens and angers paranoid persons. It decreases the sense of trust that staff try to give to all patients and it turns the hospital into a jail instead of a place of safety, caring and healing. These dangerous people are mostly predators and given a victim population will surely seek their prey close at hand.

Isolation methods can be tried. Interestingly Saskatchewan has tried this too although the results are not to hand. A Healing Circle of First Nations people sentenced a male sexual predator to isolation for two years on a small island away from other people. He accepted the sentence and had served 9 months before a higher Court at the behest of the Crown said that this sentence was too light for his offence and sent him to jail. The Court felt that the sentence was not appropriate for the magnitude of the crime of spousal abuse and the victim agreed.

Part of the problem of dealing with dangerous person is fear for oneself. This type of person has already demonstrated a rejection of the rules by harming others and by treating him or her too lightly one condones and rewards the offence but if one treats the person harshly one confirms the negative opinion they have of Society and the whole situation may well worsen. This is a dilemma from the beginning and right to the end. Religious conversion has been known to succeed where all the coercion and "treatment" has failed. Love may well conquer but who has enough and is willing to risk everything including life for this damaged individual ?

Summary

This has been a discussion of some of the issues involved in the management of dangerous persons in the community from a Canadian and especially Saskatchewan perspective. The problems are fairly universal and solutions, if such there be, may come from anywhere in the world. It is important to retain an open mind and compassion for victims, dangerous offenders and fearful others and to seek to assist all in their pain and anxiety.

Can psychology, the law, social engineering, pharmacology or even love find a way ? What do you think ?

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