Psych 2032 april 1 - Lecture notes 7 PDF

Preview

Summary

lecture 7 lecture notes...

Description

Lecture 9 Monday, April 1, 2019

6:52 PM

Assessing Fitness & the Not Criminally Responsible Designation Jonathan Ross • Pic taken in 2013 • Jeannine on right • Looks like idealist life ○ Teaching at Catholic school at Richmond Hill • He has long-standing history with mental illness ○ When he was in college, 22 years old, he was hospitalized with brief psychotic episode ○ He came home from states and went on medication ○ Recovered nicely and completed studies • In weeks of 2013, his father described him as having increased levels of paranoia ○ Increased anxiety about stock market ○ Converted life-savings into literal gold and silver ○ Friends said he was paranoid ○ He began to fear he was being watched be secret police/ then pursued by robots ○ Increasingly alarmed, his family intervened • His sister flew from thunder bay to Toronto feb 1st Jeannine Ross-Armstrong • He had been sent home from work that day from having incident in principle's office ○ "panic attack" • His sister landed and took cab to his place; arrive at 5pm • They went to McDonalds ○ He grew agitated and suspicious • He eventually refused to speak with her ○ Said they should only communicate by notes

• • •

• •

She called her parents and said he should move back home At 1:30 AM, neighbours called security ○ Saying they heard thumping/slapping/screaming from the apartment Security Guard knocked on the door but no answer ○ Called police ○ They knocked on door and still no response ○ They eventually got in Found Jeanine dead & very mutilated/disfigured ○ Done with crystal + shell + knife + sword that had been gifted from dad Jonathan appears indifferent to situation and said "I had to disrupt circuitry"

Jonathan Ross NCR in Sister's Death • Hospitalized and assessed and 6 months later declared NCR • But he's a guy who has history of responding to medication ○ He has to come to realization he killed his sister Schizophrenia • Predominant source of violence that leads to NCR ○ Actus reus but NOT mens rea ○ This is diagnosis in question • "split personality" ○ NOT. ○ Not the same thing • A disease of psychosis, with a variety of perceptual, cognitive, and social abnormalities ○ 5 Diagnostic criteria ○ Affects ~1% of population ○ Marginalized from inappropriate use of language Schizophrenia = Abnormalities in 5 Domains • (1) Delusions: erroneous beliefs that involve misinterpretations of experiences or perceptions ○ Common delusions § Persecution (i.e. individual is being conspired against, followed, threatened) □ Paranoid § Referential (i.e. gestures aimed at individuals) □ Messages on radio/TV are meant specifically for you

Loss of bodily control (i.e. manipulation of actions) □ Believe external factors are controlling their movements/hearing/vision § Loss of mind control (i.e. thought implantation) □ Some influential individual is inserting thoughts § NOTE: bizarre vs. nonbizarre delusion □ Nonbizarre could be conceivably be true but no way to prove it □ Bizarre is impossible things that couldn't actually be possible Positive symptom (influx of something) §

○ •

(2) Hallucinations: distortion of perception in any sensory modality (although auditory is most common) ---"perception-like experiences without an external stimulus" ○ Can be in any sensory modality; typically auditory ○ Usually experienced as voices distinct from one's own thoughts ○ Conversations or a voice maintaining a running commentary on an individual's actions is particularly characteristics § If this exists alone, you can receive diagnosis of schizophrenia: □ 2 voices in head that converse with each other OR voice that carries on in your head continuous commentary of what are you doing ○ Can experience paralysis --- protective measure --- during sleep we have this so we don't act out our dreams ○ Positive symptom (influx of something)

•

(3) Disorganized Thinking (Speech) ○ Loose associations/derailment - speech changes from topic to topic with no clear connection § Conversation tends to derail ○ Tangentiality - answering a question in an unrelated way § Ask the person a question about their living situation & then they go on long conversation about god ○ Incoherence - speech that is completely incomprehensible ('word salad') ○ Positive symptom (influx of something)

•

(4) Grossly Disorganized or Abnormal Motor Behaviour (Including Catatonia) ○ "childlike silliness to unpredictable agitation"

○ ○ ○

○ ○ •

Untriggered agitation (i.e. sudden swearing) Inappropriate sexual behaviour (i.e. public masturbation) Catatonia § Purposeless motor activity ('catatonic excitement') § Active resistance to instructions to be moved ('negativism') □ If you try to bring them in one direction, you can feel them pulling back against you § The assumptions of bizarre or inappropriate positions ('waxy flexibility') □ They'll stay like this for period of time Poor personal hygiene § Role of psychologist is to help with ADL (i.e. grocery shopping) Positive symptom

(5) Negative Symptoms: represent diminution of loss of normal functioning ○ Diminished emotional expression: immobile and unresponsive facediminished emotional expressions- Intonation of speech ('prosody') ○ Avolition: inability to initiate and sustain goal-directed activities ○ Alogia: poverty of speech-- brief, laconic and empty replies to questions § Flat voice § Short replies ○ Anhedonia: decreased ability to experience pleasure ○ Asociality: apparent lack of interest in social interactions

People with Schizophrenia Often Get Into Trouble • Often not b/c of real violent behaviour • They are disorganized, agitated, do dumb things ○ i.e. tickle a cop Borderline Personality Disorder (BPD) • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: ○ Meet new people idealize them, & then that person fails to live up to their expectations AND this person lashes out ○ They lash out in vicious ways (harassment, stalking, trespassing) • They don't qualify for NCR designation ○ They know what they're doing is wrong

They are justifying what they're doing in their head b/c they were wronged When interrogated at length they know what they did was wrong ○

•

Out of Mind Out Of Sight: Inside the Brockville Psych • Brockville Mental Health Centre-- forensic psychiatry unit • Schizophrenia patients DOES NOT mean you have violence tendencies • People here though have had criminal offences i.e. murder • Michael Stewart ○ Sensitive in social situations ○ He has a feeling that people knows what he did ○ Unit 4 (most secure) ○ Second degree murder of his mother ○ Schizophrenia + major depression ○ Not actively psychotic, but he still talks very slow/has negative symptoms ○ Not good at emotional processing • Carole Seguin ○ Hears her sister's voice ○ Estranged from her family ○ Minor assaults ○ Needs to be 5-point restrained ○ Actively psychotic • Justine ○ Challenging patient ○ Self-harm attempts • Command hallucinations ○ "jump off this bridge" Ontario's Protecting First Responder's Act • Paramedics, firefights, police offices immediately qualify for WIB, without any delay ○ Workplace insurance board • These people have taken on jobs that have distinct societal importance & have imminent threat of physical and psychological History NCRMD Aristotle • Sub-division of society that engage in behaviour we may find

• • •

unappealing/violation of norms If they violate or trespass against others, we need to consider their free will ○ Free will is fundamental aspect of assessing blame-worthiness Animals, children and the insane were incapable of having free will We shouldn't punish the insane when they violate social norms, but find alternative ways to deal with them

•

(1) The first application of this reasoning in a judicial system is in Britain in 1724. ○ 1st formal definition: “Wild Beast Test” ○ Lord Onslow shot by Edward Arnold, who believed Onslow had “bewitched” him. ○ Judge instructed jury that Arnold didn't know what he was doing … “any more than an infant, brute, or wild beast.” ○ Intervention of Onslow, who he shot, that his sentence was changed to just life in prison (not death)

•

(2) Next landmark again in England, in 1834. Daniel McNaughton found NOT guilty of assassination attempt on British PM Robert Peel by reason of insanity This case established the so-called “McNaughton Rules.” Contains three elements: 1. Defendant suffering “a defect of reason, from a disease of the mind.” 2. As a result, the defendant did not “know” the “nature and quality of the act he was doing.” 3. An inquiry has been conducted to determine whether the defendant “knew what he was doing was wrong.”

• •

-

Beginning of actual formal assessment of can this person satisfy requirements of mens rea

Rule Evolution in the U.S. • John Hinklee shot Ronald Regan ○ He was schizophrenic ○ He should have been assessed and determined to be NCR ○ Forensic psychiatric hospital for treatment instead of long hours of incarceration (should have) ○ Released in 2016 after 35 years • "Guilty but Mentally Ill" Ad i i il bl i 13

○ ○

A decision available in 13 states Defendant remanded to secure psychiatric institute until sane; then transferred to a prison ton serve out the remainder of a term that would have been sentenced to if not mentally ill

Presumptions in Canada's Legal System • Elements that must be present for criminal guilt: 1. Actus reus = a wrongful deed 2. Mens rea = criminal intent • Must be found beyond a reasonable doubt for a guilty verdict to be reached ○ Beyond reality testing & does not know what they did was wrong, at the time they did it • Not Criminally Responsibly due to a Mental Disorder (NCRMD) ○ Typically schizophrenia ○ BUT also: § Bipolar disorder (irrational when manic) § Delusional disorder (some people become so delusional they don't know what they're doing is wrong) -

Effort to create scales to get sense of to what extent do people understand NCR defense Effort to assist jury-selection, so they are able to make rational decision Lawyers, judges can make irrational decisions

Myths & Misconceptions 1. The insanity defense is overused ○ Reality: the actual plea rate is 0.9% & only 26% of insanity defendants are successful § 1/400 will eventually get NCR designation 2. Defendants who plead guilty are usually faking ○ Reality: a significant number of insanity defendants are diagnosed with a major mental disorder at the time of psychiatric evaluations, and most have prior histories of mental hospitalizations § History of previous mental illness 3. Pleading insanity is a strategy used by defense attorneys to get their clients acquitted ○ Reality: there is a 93% concordance rate b/w the opinions of mental health examiners and final court decisions § Most cases in NCR both defense and prosecution approach judge

Most cases in NCR, both defense and prosecution approach judge and say the person was not lucid when crime was committed The insanity defense is sued almost exclusively in cases that involve violent crimes ○ Reality: non-violent offenses accounted for 31.6% of defendants indicted on felony charges There is no risk to the defendant who pleads insanity ○ Reality: in order to plead insanity, the defendant must admit to committing the crime in question, which negates a not guilty verdict. This can be particularly risky when the other evidence against the defendant is weak or circumstantial § Mental health court predicated on helping people become healthy again Insanity acquittees spend much less time in custody than do defendants convicted of the same offense ○ Reality: insanity acquittees spend nearly twice the amount of time in detention. For those who have committed nonviolent offenses, they spend up to nine times as long as offenders convicted of similar crimes ○ In Quebec, health care professional has to say they would risk their entire professional career and say they are confident this person will not reoffend again... Insanity acquittees are quickly released from custody ○ Realty: following an NGRI verdict, between 84 and 95% of NGRI acquittees are hospitalized and only 4% are conditionally released Trials involving an insanity defense almost always feature "battle of the experts" ○ Reality: mental health examiners agree on a primary diagnosis in 81% of the cases they examine §

4.

5.

6.

7.

8.

London Asylum • Still stands somewhere • Throughout most of Canada's former years, those who demonstrated disorganized behaviour were left o wander aimlessly • Perceived to endanger people or property, then put in jails or poor houses • In 1870, the London Asylum opened with 500 bed capacity ○ Filled up quickly ○ Police had place to deposit homeless people/mentally ill/sick people London Asylum, redux

• • •

Patients warehoused in large wards with many beds No privacy or confidentiality Quickly outgrown

The Ontario Hospital • 1930, construction began • Designed to have 1800 beds • Situated north of St. Thomas The War Years • During WWII, the 1800 beds were empty and used as training grounds for Canadian armed forced • Patients dumped back into the streets • •

They returned, beds filled up quickly 1970s, the building had fallen into state of disrepair

Forensic Psychiatry - St. Thomas • Still stands • Areas fenced off b/c broken windows and poor insulation • Stopped being hospital in 2013 Southwest Centre for Forensic Mental Health • Replacement • Like Brockville hospital, it tends to have a triple-down process of treating the ill • Beautiful facility with lots of windows ○ Ambient light ○ Opportunities for outdoor activities ○ Bright colours • In patient room ○ Each have their own room ○ Bed, wardrobe, desk ○ Humane environment with focus on treatment + rehabilitation Good & Bad • “Treat people like they are people and they will act that way. Treat them like animals and you will get animal behaviour in return.” ○ Ewen Cameron, 1953

• • • • • •

President of Canadian psychiatry association People shocked by this statement In Montreal, every patient had their own mirror, bed, etc. He felt strongly about treating patients humanely Underlying philosophy of southwest center (good) Bad: ○ After certain about of time we realized patients were self-sabotaging ○ As they got better, they began to question if they wanted to be released

ODSP • Ontario disability support program • People who are sufficiently mentally ill can't really work • Once released they end up in "flop houses" ○ Rent a room & bathrooms and kitchens are communal Automatism • Specific type of defense in the Criminal Code that can lead to a finding of NCRMD – Automatism. • Contrary to other forms of NCRMD, this refers to perpetration of crimes that is involuntary. Two kinds: ○ Sane ○ Insane •

•

B i

Non-Insane Automatism: Refers to an involuntary action that is not caused by a mental disorder and will lead to a verdict of complete acquittal ○ R. v. Parks (1992). [Killed his in-laws while sleep-walking. Acquitted; upheld by Ontario Appeal Court; Supreme Court] § Guy who, one night, spontaneously murders his in-laws § No motive, no rationale, no financial benefit § Long history of sleep-walking Insane Automatism: Used if an involuntary action was cased by a “disease of the mind” ○ Failure: R. v. Lomax (2002) § Defended himself for robbery saying he temporarily lost his mind, with no absence of mental illness § Found guilty ○ Absence of previous mental health history F

d NCRMD

Being Found NCRMD • Defendants found to be not criminally responsible are usually committed to a psychiatric hospital ○ Brockville ○ Southwest Centre ○ Wentworth (houses the most serious, violent offenders in Ontario) • But what kind of mental hospital varies according to the nature of the index offense & geographic location ○ If severe crime, or history of severe crimes/treatment nonresponsive, these folks go to Wentworth Ontario Review Board Decides if you're getting out • Annual Review (or more often) ○ Open to public ○ Stressful experience for the patient ○ Assess risk to public ○ Impose least onerous restrictions • Composition ○ Chair – usually retired judge ○ Crown (represents interest of society) ○ 1 member of the public ○ 2 mental health professionals (at least one psychiatrist) •

•

•

•

Mental health practitioner gives evidence ○ Written report from the team; team members can be called; usually warned of this intention in advance ○ This is stressful Disposition report outlining restrictions provided in writing within 2 weeks ○ AKA decision ○ Must be provided within two weeks Reason for disposition within month after ○ Rationale ○ And full report ○ This can be very long How long can someone be under a disposition? ○ Have to check in for the rest of their lives

•

Capping'?

Competency to Stand Trial • A different type of assessment that are often requested is the "competency" (also called a 'fitness') assessment ○ 2 doctors ○ 1 psychiatry and 1 random doctor • Pretty common about 5000 per year in Canada • In Canada, a person is fit to stand trial if he or she is able to: 1. Understand the nature or object of the proceeding 2. Understand the possible consequences of the proceedings 3. Communicate with counsel • We don't do these Assessing Defendant Competency • The MacCAT-CA • Has to do with intellectual functionality...