Tuesday, 17 April 2007

Mental Illness and the Criminal Justice System

Mental Illness and the Criminal Justice System
by Susan Henderson
Mental Health Co-ordinating Council
May 2003


Relationship Between Mental Disorder and Crime
The prevalence of mental illness in the prison population is the focus of much of the current literature (Davis, 1992, p532; Anonymous, 1999, p1243; Walker, 2002; Steadman et al, 1995; Schizophrenia Fellowship, 2001; Ditton, 1999) and, as reflected by the diversity of findings, it is also difficult to determine. Henderson cites a study in which 31% of prison inmates were classified as having a mental illness (1988, p123). More recent literature from Britain and the United States cites prevalence of severe mental disorder at between 5?14%, and 6?15% of prison populations respectively (Greenberg and Nielsen, 2002, p158). A study by the Schizophrenia Fellowship of NSW identified 60% of admissions to prison as having an active mental illness (Schizophrenia Fellowship, 2001, p1). The NSW Corrections Health Service Inmate Survey (1997) was more specific in its findings. In this study 50% of women and 33% of men reported they had undergone some form of psychiatric treatment or assessment for an emotional or mental problem at some point in their lives. Of these people, more than a third reported that they had been previously admitted at least once to hospital as a psychiatric in-patient. Twenty six per cent of women and 12% of men reported pre-imprisonment psychiatric diagnoses, including depression (women 16%; men 7%), schizophrenia (women 2%; men 3%), severe manic depression (women 4%; men 1%), and anxiety disorder (women 5%; men 1%).

The discrepant findings of these various studies may reflect methodological inconsistencies between them. It is pertinent to pose the following questions in assessment of any study in this area.

Does the study rely on self-report? In any study, this presents an opportunity for bias – of recall, or selective reporting, or yay or nay-saying. Reporting may inflate prevalence or reduce it, depending on the context and what participants understand to be the purpose of the study and its effect on them. While in general populations, participants may be more likely to under-report mental symptoms, in this population it is similarly possible that motivation exists for over-reporting illness behaviour or 'faking bad'. Too, self-administered reports raise issues of literacy and comprehension, especially pertinent in light of the educational disadvantage experienced by many inmates. An ideal is to supplement any assessment of the individual with collateral information from a close relative.

What specific diagnostic tools were used? Did they focus on symptom presence or severity? Apart from symptoms, was disablement in daily life assessed? What range of disorders did they cover, and were the tools of established reliability and validity?

Such scrutiny is not intended to cast doubt on claims about excess morbidity. It is however an indictment of the non-specific approach to people with mental illness in the criminal justice system. Uniting a diverse range of disorders and symptoms under the one general categorisation emphasises the role of mental illness in contributing to incarceration. Ignored are specific disorders, their symptoms and, more significantly, their correlates with social and other health outcomes.

However, a further query may be raised in regard to such statistics and that is, like arrest rates, what do they really tell us? While to forensic psychiatrists, the criminal justice system is an obvious focus, to developers of policy and programs for mental health within the community it is much less so.

Henderson (1988, p122) succinctly illustrates that the relationship between mental disorder and crime is a fundamental one to be explored, to identify cause and effect and to develop appropriate policies and services accordingly. In order to answer the question 'What is the relationship between mental illness and crime?' It is presumptuous to identify the proportion of prison inmates with a mental illness; the question to be asked first is 'What proportion of people with a mental illness commit a crime?'. Gunn cites a lifetime crime prevalence of 4% out of 500 psychiatric patients, which is unlikely to be higher than the general population (Henderson, 1988, p123). The importance of this observation in highlighting areas for redress must not be under-estimated. It states, simply, that there is no inherent link between mental illness and crime, but indeed a strong causal link between mental illness and incarceration. As that author notes, 'the epidemiological approach which asks, "what is the true denominator out of which this group is derived?"' opens up a new perspective on some of the fundamental issues in forensic psychiatry (Henderson, 1988, p123).

These issues are further highlighted by the long-held evidence that people with severe mental illness are more likely to be convicted of misdemeanours than their mentally healthy counterparts, and tend to be incarcerated for longer periods (Lamberti et al, 2001, p64).

The observation that there is no correlation between mental illness and crime, in the face of such demonstrative statistics, obviously implies the existence of another variable or variables that may have an association with both mental illness and imprisonment.

Relationship Between Mental Disorder And Violence
Similar scrutiny must also be applied to the theory that people with a mental illness are more violent than the general population.

Violence and violent crime are commonly regarded by the public as the domain of the mentally ill (Australian Institute of Criminology, 1990). Public misconception about the true nature of mental illness, as distinct from personality disorder or behavioural disorder, frequently links extreme violence with mental illness. This misconception is enhanced by media depictions of the involvement of the 'schizophrenic' or 'psycho' in violent crime. The Victorian Government's health information website, BetterHealth Channel, gives the following content analysis:

'A one-year analysis of television drama programs (for example, soap operas, plays and films) in the USA found that 73 per cent of people with a mental illness were depicted as violent, while 23 per cent of people were portrayed as homicidal maniacs. When the same study analysed media reports about mental illness on television and in newspapers, it found that nearly 90 per cent of stories depicted people with mental illness as violent and usually homicidal.' (BetterHealth Channel, 2002)

The evidence base has long displayed greater scepticism. Monahan's 1983 study observed no relationship between mental illness and general crime, when controlled for age, race, socio-economic status and previous hospitalisation or imprisonment. Monahan's more recent work has demonstrated an association between mental disorder and violent behaviour (1992, p519), although, like Steadman (2000) he is careful to note this relationship may be mediated by a range of factors, including gender, socio-economic status, age, and substance abuse. This latter item is one now favoured by many researchers as a powerful co-morbid factor. Several studies have identified a weak association between mental illness and violence, limited to people with mental illness whom:

  • Are not receiving treatment
  • Have a history of violence
  • Abuse alcohol or drugs (BetterHealth Channel, 2002; Swartz et al, 1998; Steadman et al, 1998; Munetz et al, 2001)
Monahan's survey of studies also noted that increased risk was evident only in the immediate presence of psychotic symptoms, thus removing the vast majority of people with mental disorder. With regard to policy and programs, such vague prescriptions are rendered practically useless. The inability of professionals to predict violent behaviour with any precision is well-recognised (Mullen, 1984; Australian Institute of Criminology, 1990).

A further important consideration is the broader context in which violence in our community takes place. An Institute of Criminology literature review observes that even where a relationship between illness and violence can be demonstrated statistically, it is merely a link in a more complex causal chain and in any case is rare (1990, p76). People with a mental illness are more likely to cause themselves harm ? or to be harmed ? than they are to harm others (Jablensky et al, 1999). For example, a person with schizophrenia is 2,000 times more likely to suicide than they are to harm someone else (BetterHealth Channel, 2002).

Of far greater threat are people without a mental illness who abuse drugs and alcohol, and young men aged 15-25 (Lamberg, 1998, p407; BetterHealth Channel, 2002). For scale, Monahan offers the following figures for violence within society:

  • two times as prevalent among men than women
  • three times as prevalent among people of the lowest socio-economic status as compared to those of the highest socio-economic status
  • five times more prevalent among people with a diagnosis of mental illness
  • seven times more prevalent among young people
  • twelve times more prevalent among alcohol-dependent people
  • sixteen times more prevalent in people abusing other substances.
As Monahan concludes: 'Clearly, mental health status makes at best a trivial contribution to the overall level of violence in society' (1992).
Kali :

Kali is jnana´shakti, the energy of Wisdom, the intuitive illumination within, as compared with the intellectual contemplation of the external. Knowledge is conceived, Wisdom is intuited. When Kali takes away the darkness of the outside world, She grants illumination of the inner world. Such is Her Grace.

Kali Puja (Introduction) - by Swami Satyananda Saraswati

No comments: