Court-Mandated BY ROBERT
Treatment:
LISS,
PH.D.,
iD.,
AND
Dilemmas ALLEN
FRANCES,
for Hospital M.D.
The authors present clinical material to illustrate the special treatment and management problems posed by different types ofmentally ill offenders; they suggest that court-mandated hospital treatment is often destructive and unrelated to the needs ofthe patient. the community. and the mental institution. Thefailure to create new kinds ofinstitutions, combining modalities derived from the hospital and correctional systems, is traced to poor communication among the disciplines involved. The “mentally
systems victimizer.
illoffender”
and
is caught
is consequentlt’
in the interplay
both
their
victim
,
of these
and
THE MENTALLY ILL OFFENDER often becomes a nomad caught between the jurisdictions of law and psychiatry, neither of which knows quite how to deal with him. In this paper we will discuss the special treatment problems posed by such individuals in conjunction with their legal status. We hope to illustrate that the current “solutions” are absurd for many mentally ill offenders. Despite research and experience indicating that hospital treatment is often ineffective, inappropriate, and destructive, it continues to be mandated by the courts. We will attempt to define a population of mentally ill offenders who should not be judicially remanded to the hospital and for whom other sorts of rehabilitative institutions need to be developed.
AND
THE
LAW:
FUN
l)AMENTAI.
DIFFERENCES
Dynamic psychiatry and opposed sets of assumptions. the law that men act freely for their actions. From this penal methods for dealing psychiatry has as one of its chic determination, i.e., each determined by unconscious and one’s choices are very structure whose formation
the law operate on radically It is a necessary premise of and may be held responsible assumption flow the various with lawbreakers. Dynamic basic tenets the notion of psyact of an individual is multias well as conscious forces, much limited by a character and functioning is often
Dr. Liss is Staff Psychologist and Ward Attending at the Manhattan Veterans Administration Hospital. Dr. Frances is Director of Undergraduate Medical Education, Bronx Psychiatric Center, and is on the faculty of the Albert Einstein College of Medicine, Bronx, N.Y. Address reprint requests to Dr. Liss at 215 W. 90th St., Apt. 15-E, New York, N.Y. 10024
924
beyond one’s willed control. Undesirable behavior is to be understood and treated rather than punished. In the face ofthe legal prescription of psychiatric treatment (court commitment), it is the law, not psychiatry, that defines the “mentally ill offender,” i.e., those offenders who will be remanded to a hospital for treatment instead of going to prison. This decision is not generally informed in regard to the existence or lack of an effective treatment for the defined “mental illness” ( I 2).
THE
PSYCHIATRY
Am
J Psychiatry
132:9, September
/975
Psychiatry
SITUATION
IN
NEW
YORK
The problems caused by the legal prescription of psychiatric treatment in New York State most often follow actions under Section 730.50 of the New York Criminal Procedure Law (CPL). This section applies to indicted felons who are incompetent to stand trial and empowers the court to issue renewable one- or two-year orders of retention, placing the incompetent defendant in the custody of the commissioner of mental hygiene until he has served two-thirds of the maximum sentence he could have received iftried and convicted. In May 1974 Section 730.50 was amended to delete all references to “dangerousness.” Before this change, a finding of dangerousness allowed the commissioner to send an incompetent defendant to Matteawan, a Department of Corrections institution, instead of to a civil psychiatric hospital. This legislative action was apparently a response to a New York Court of Appeals decision in 1973 in the case of Kesselhrenner v. Anon t’mous (3), in which the court held that a civil patient, dangerous or not, could not be sent to Matteawan. As a result of the change in the New York CPL, only convicted and sentenced mentally ill offenders can be sent to Matteawan. In effect, these changes eliminate the possibility of separate facilities for mentally ill offenders.
CATEGORIZATION MENTAI.E.Y
ANt) ILl.
CURRENT
TREATMENT
OF
THE
OFFENDER
We divide mentally ill offenders who are sent to psychiatric hospitals into three categories, each of which presents different problems for treatment and management. I. The psychotic offender who is too severely impaired to be held responsible for his crime or to cooperate in his defense. If he could stand trial, this individual would probably be acquitted on an insanity defense. 2. The person who was not impaired at the time of the
ROBERT
criminal act but later becomes so acutely psychotic or depressed in prison that he needs psychiatric hospitalization. These individuals very often have an impulse personality disorder. The close structure and confinement of prison, with its homosexual threats and temptations and separation from familiar people and surroundings, sometimes triggers an acute prison psychosis or depressive suicide attempt in people who would ordinarily have other channels for impulsive behavior. Removal from prison alleviates these psychotic or depressive symptoms, sometimes causing an observer to conclude (mistakenly) that they were feigned. 3, The manipulator who is in the hospital because it suits him better than prison does. We find that the present solutions are too unrelated to the needs of each type of mentally ill offender and that there is a haphazard “dumping” of patients from the courts of law and correctional facilities into psychiatric facilities. There is also a “conceptual dumping” -a lack of clarity as to whether the offender should be regarded from the point of view of law or of psychiatry. The courts are too ready to recommend treatment where only custodial care exists (I), thus inappropriately applying psych iatric concepts. In order to rectify this situation, psychiatrists must be willing to testify in court to document their field’s limitations, perplexity, and frustration in treating manipulative psychopaths and individuals with impulse disorders. Psychiatrists who do not take this initiative are complying in the dumping process (4, 5) and are accepting “patients” for whom there is no treatment. We will present case material to illustrate two different categories of mentally ill offenders committed under Section 730.50 of the New York CPL and the impact of these patients on the hospital staff and functioning. The major points we will make about the manipulative patient are applicable with some modifications also to the patient with an impulse disorder.
CASE
REPORTS
The
Case
I. Mr.
years
for
shooting
fense
Psychopath
A, a 42-year-old
at
Matteawan.
in
which
manipulative
expression, system him
at
to
730.50. Ward When sisting
of
that
often
and
Mr.
by of
of
someone,”
awe
began
A became
ward
them
before last
becoming arrest, he
involved began en-
by
his
was
mental
slashing
surround
president
his
arms,
treatment
discover hospital.
return
and test Although
was
able
aged
to
an
from
to evaluate
to flexible limits of a psychiatric to leave the hospital grounds, he
doctor
impotence,” that
to
Mr.
A
stand
open
ward
who in
competency
trial.
Mr.
almost
was
at
treating
although
engaged
his
FRANCES
was
the
outside
ALLEN
him
the relatively not allowed
to depart visit
cation-induced dicated
plan
quickly
AND
very
sexual
began
will.
He
him
for
credible
activity
and.
A
man“medi-
rumors with
in-
both
staff
and patients and was also involved in a profitable drug trade. He was well known throughout the hospital and displayed in virtuoso fashion the psychopath’s ability to divide a ward staff internally (6, 7). It was finally decided that Mr. A was competent and should be returned to stand trial. On the appointed day, when the two detectives
soon
appeared,
emerged
district
Mr.
A casually
with his wrist
attorney
and
the
went
bleeding.
to
the
bathroom
The detectives
presidingjudge,
who
and
called
ordered
that
the Mr.
A not appear in court, presumably on the basis that no man who had slashed his wrist could be competent. This decision was made despite psychiatric determinations of competency by the team that had interacted with the patient for 7 months. This case illustrates the frequent confusion of competency with “sanity” or “nondangerousness” and the degree to which the law can be evaded by an individual’s use of manipulative self-destructive gestures. The
P.st’chotic Offender
Case ry of
2. Ms. B, a 31-year-old
psychiatric
volvement.
single
hospitalizations She
was
first
that
woman,
hospitalized
so)
on
her
felony
indictment
any
(civilly)
symptoms of paranoia and homosexual a woman who had been a long-standing and hatred. She was found incompetent ately
had a long histo-
preceded
and
at
criminal age
in-
20
with
panic. She later stabbed object ofher fears, love, to stand trial (appropriwas
instead
remanded
for
a prolonged enforced hospitalization under Section 730.50. Ms. B had clearly been “incompetent” for years and years and gave no indication that she would ever become competent. Her delusional
thinking
Her court was permitted torney. This
became
prevalent
whenever
she
was
anxious.
commitment under Section 730.50 meant that she no passes without the approval of the district atcrippled her incentive to “improve.” The district
chose
not
to
permit
passes
because
she
was
a “dan-
gerous person,” and he explicitly demanded that the stafl take all “due precautions to prevent her from escaping.” As there were no other patients on the ward in similar circumstances, she was a perpetual outsider, quite alone in her lack of even potential
freedom,
singled
out
from
and
by other
patients,
and
unable
to participate in any meaningful way in the ward’s treatment program. Ms. B completed two-thirds of her maximum sentence and was then converted to civil status.
Mr. A was clearly without resigned
serious and
the
a voice
to
the
under with
cus-
Section suspicion.
occasionally
atmosphere him.
conlistless
correctional that rendered
committed hygiene patients
about a special
to
of-
had a long
his
He
this
A
court-referred to
“kill
assault; Mr.
gestures
trial.
view
with
15 years.
a psychiatrist in a psychotic depression
stand
A “bragged” he
of
self-mutilation along with
commissioner
staffs Mr.
curiosity,
month,
to
the
charged
a grid. Although
dramatic gestures,
incompetent
tody
suicide
were taken indicative
be
was activities After
to resemble
these
man, came to the hospital after been arrested 3 years earlier
sentence
and drug system.
had come
accomplished sequences,
had
and
a maximum
history of criminal with the psychiatric gaging
He
a detective
carries
The
if possible,
attorney
Manipulative
2’
tivities.
LISS
During
and helped
in-
of
dread, his
organize
first
ac-
In a more recent case like that of Ms. B, the United States Supreme Court decision in the case of Jackson v. Indiana (8) would apply. This 1972 decision held that a person could be considered incompetent to stand trial as a result of a criminal charge only long enough to determine if there was a substantial probability of his achieving competency in the foreseeable future. If there was such a possibility, the state would have to show some progress toward competency within a “reasonable period of time.” In practice, this seems to mean about a year for a serious offense. The decision puts the burden of proof
AmJ
Psychiatry
132:9, September
/975
925
COURT-MANDATED
TREATMENT
on the state to show may be effective.
IMPACT
ON
TIlE
that
treatment
is being
given
and
HOSPITAl.
The manipulator differs from the impulse disorder patient by having much greater ego control over his actions. His flare-ups of violence and/or self-destructiveness are less frequent, less chaotic, and more designed to achieve a specific end. These types of individuals, however, have similar impacts on a hospital ward. They are quickly recognized by others and themselves as different from the “regular patients.” They have the apparent strengths and resources to be the effective “missing link” between the staff and patients. The patient rises to the top immediately and assumes control of therapeutic community meetings. He often has the drive, charisma, and ruthIessness to dramatically improve the organization of the ward. The manipulator and impulse disorder patient soon give up helpful participation in the therapeutic community and develop instead a rapacious subculture, preying on the relative helplessness of other patients and on the psychiatric staff’s tendency to “treat” people rather than “punish” them. These individuals learn to treasure the heady freedom from responsibility conferred upon them by virtue of their status as mental patients. The usual ward restrictions provide woefully inadequate external structures for the manipulator or the impulse disorder patient, and this often results in a progressive deterioration of his behavior (9). He may have been labeled neurotic or psychotic within the close structures of a prison, but he becomes a relatively unconflicted “personality disorder” by virtue of the unintended invitation to act out in the more permissive hospital structure. The need to have a hospital setting for the psychotic offender is clearer, since he is more likely to be similar to the other patients on the ward, fits into the existing treatment system, and has psychopathology the hospital is generally equipped to treat. However, problems arise here too by virtue of the patient’s court commitment. The district attorney and the courts are the overseers of the patient’s treatment. This makes sense in terms of their responsibility to protect society and is fully appropriate in cases wherein treatment will be short term and the patient returns quickly into the legal system. It presents what may be insurmountable obstacles to treatment if the patient remains in the hospital for long-term or indefinite treatment. He becomes an isolate in the therapeutic community, unable to participate fully in programs, unable to gradually readjust to the outside world, and lacking in the usual incentives to increase self-control and socially appropriate behavior (i.e., passes and privileges). In addition, it must be clearly recognized that the “incompetent” patient protects himself from prosecution by remaining incompetent. The Jackson v. Indiana decision (8) represents a beginning step to combat these dilemmas. 926
Am
J Psychiatry
/32.9. September
/975
DISC
USS
ION
There is no comprehensive system in New York State for dealing with mentally ill offenders. Many such patients drift back and forth from prison to the hospital to the community. Society is neither affording itself protection from this potentially harmful group nor confronting the difficult and unpleasant rehabilitation issues such people dramatize. Psychiatry, the law, and the political system have unwittingly allowed the creation of a system
that
makes
no
sense.
There are several problem areas that must be considered, and an attempt should be made to develop better structures for solving them. First, people who commit crimes because of a personality disorder are sent to hospitals for treatment that often simply does not exist ( I ). As Lowenkopf and Yessne documented ( 10), these patients often tear the hospital apart, both by overt acts of violence and by nonparticipation in and subversion of treatment programs designed for schizophrenic and depressed patients. They often elope, return to the community, and commit repeated offenses, only to be readmitted to a hospital setting that has failed to help them previously. Second, patients with prison psychoses are in a revolving door situation. They become psychotic or depressed within the tight structure of the prison. which restricts their usual forms of acting out. This psychopathology often disappears rapidly when they enter the relatively looser hospital structure, but returns when they go back to prison--a cycle that sometimes becomes endless. Third, the chronic psychotic offender who will be spending a long period and perhaps a lifetime in an institution is not best served by being mixed with patients who are admitted for short-term treatment, who are allowed passes and privileges. and whose treatment is focused on a return to the community. An action under Jackson v. Indiana (8), if brought promptly. may be the solution here. There are no easy solutions to the very difficult problems we have outlined. We are suggesting that current solutions are the result of haphazard and poorly planned interactions among law, psychiatry, and the political system. This issue is being discussed increasingly in the press and community forums, particularly in New York State. The facilities that now receive patients formerly sent to Matteawan have been offered no additional stall and, more importantly, no additional program planning for their management or treatment. It seems clear that impulse disorder and manipulative court patients should not be assigned to psychiatric hospitals that are dealing primarily with schizophrenic and depressed civil patients. Offenders with impulse problems who have acute prison psychoses and are awaiting sentencing are probably better managed in hospital units attached to the prisons and specializing in this problem. This follows the military principle of not allowing secondary gain of illness and regards the episode in context, i.e., as a traumatic prison neurosis or psychosis. This would be a short-term treatment to allow the mdi-
ROBERT
vidual to quickly return and fense. For those impulse disorder sentenced or otherwise have long-term disposition is often tional solutions, both legal failures. The most successful problems may well be within model. There is resistance to the institutions for the mentally stitutions have traditionally It has been difficult to merge edge derived from psychiatric the expertise and limits of a stitution. Our present system serves study and change. We law should devote themselves establishing institutions that of each approach. This would
participate
in his
legal
de-
offenders who have been been found incompetent, a necessary. Current instituand psychiatric, are dismal rehabilitation of impulse the therapeutic community establishment of specialized ill offender because such inbeen scandalously managed. the experiences and knowltreatment institutions with correctional confinement inis clearly chaotic and defeel that psychiatry and the to greater collaboration in would reflect the advantages replace the current empha-
sis of legal-psychiatric ters around the issue
interaction, of competency.
LISS
AND
which
ALLEN
FRANCES
fruitlessly
cen-
REFERENCES I. Tweski AD: Treating the untreatable: a critique of the proposed right to treatment law. Hosp Community Psychiatry 22:17 21. 1971 2. Robitscher J: Courts, state hospitals, and the right to treatment. AmJ Psychiatry 129:298-304. 1972 3. Kesselbrenner v Anonymous, 347 NYS 2d 369 (1973) 4. Robey A. Bogard WH: The compleat forensic psychiatrist. Am J Psychiatry 126:519525, 1969 5. Suarez JM: Psychiatry and the criminal law system. Am J Psychiatry 129:293 297. 1972 6. Main TF:The ailment. BrJ Med Psychol 30:129-145, 1957 7. Cleckle H: The Mask of Sanity. St Louis, CV Mosby. 1964 8. Jackson v Indiana, 406 US 715 (1972) 9. Kalogerakis MG: The assaulfive psychiatric patient. Psychiatr Q 45:372 381, 1971 10. Lowenkopf EL, Yessne D: The mentally ill offender in a civil hospital. Journal of Bronx State Hospital 1:16 21. 1973
Am
J Psychiatry
132:9, September
1975
927
Treatment:
LISS,
PH.D.,
iD.,
AND
Dilemmas ALLEN
FRANCES,
for Hospital M.D.
The authors present clinical material to illustrate the special treatment and management problems posed by different types ofmentally ill offenders; they suggest that court-mandated hospital treatment is often destructive and unrelated to the needs ofthe patient. the community. and the mental institution. Thefailure to create new kinds ofinstitutions, combining modalities derived from the hospital and correctional systems, is traced to poor communication among the disciplines involved. The “mentally
systems victimizer.
illoffender”
and
is caught
is consequentlt’
in the interplay
both
their
victim
,
of these
and
THE MENTALLY ILL OFFENDER often becomes a nomad caught between the jurisdictions of law and psychiatry, neither of which knows quite how to deal with him. In this paper we will discuss the special treatment problems posed by such individuals in conjunction with their legal status. We hope to illustrate that the current “solutions” are absurd for many mentally ill offenders. Despite research and experience indicating that hospital treatment is often ineffective, inappropriate, and destructive, it continues to be mandated by the courts. We will attempt to define a population of mentally ill offenders who should not be judicially remanded to the hospital and for whom other sorts of rehabilitative institutions need to be developed.
AND
THE
LAW:
FUN
l)AMENTAI.
DIFFERENCES
Dynamic psychiatry and opposed sets of assumptions. the law that men act freely for their actions. From this penal methods for dealing psychiatry has as one of its chic determination, i.e., each determined by unconscious and one’s choices are very structure whose formation
the law operate on radically It is a necessary premise of and may be held responsible assumption flow the various with lawbreakers. Dynamic basic tenets the notion of psyact of an individual is multias well as conscious forces, much limited by a character and functioning is often
Dr. Liss is Staff Psychologist and Ward Attending at the Manhattan Veterans Administration Hospital. Dr. Frances is Director of Undergraduate Medical Education, Bronx Psychiatric Center, and is on the faculty of the Albert Einstein College of Medicine, Bronx, N.Y. Address reprint requests to Dr. Liss at 215 W. 90th St., Apt. 15-E, New York, N.Y. 10024
924
beyond one’s willed control. Undesirable behavior is to be understood and treated rather than punished. In the face ofthe legal prescription of psychiatric treatment (court commitment), it is the law, not psychiatry, that defines the “mentally ill offender,” i.e., those offenders who will be remanded to a hospital for treatment instead of going to prison. This decision is not generally informed in regard to the existence or lack of an effective treatment for the defined “mental illness” ( I 2).
THE
PSYCHIATRY
Am
J Psychiatry
132:9, September
/975
Psychiatry
SITUATION
IN
NEW
YORK
The problems caused by the legal prescription of psychiatric treatment in New York State most often follow actions under Section 730.50 of the New York Criminal Procedure Law (CPL). This section applies to indicted felons who are incompetent to stand trial and empowers the court to issue renewable one- or two-year orders of retention, placing the incompetent defendant in the custody of the commissioner of mental hygiene until he has served two-thirds of the maximum sentence he could have received iftried and convicted. In May 1974 Section 730.50 was amended to delete all references to “dangerousness.” Before this change, a finding of dangerousness allowed the commissioner to send an incompetent defendant to Matteawan, a Department of Corrections institution, instead of to a civil psychiatric hospital. This legislative action was apparently a response to a New York Court of Appeals decision in 1973 in the case of Kesselhrenner v. Anon t’mous (3), in which the court held that a civil patient, dangerous or not, could not be sent to Matteawan. As a result of the change in the New York CPL, only convicted and sentenced mentally ill offenders can be sent to Matteawan. In effect, these changes eliminate the possibility of separate facilities for mentally ill offenders.
CATEGORIZATION MENTAI.E.Y
ANt) ILl.
CURRENT
TREATMENT
OF
THE
OFFENDER
We divide mentally ill offenders who are sent to psychiatric hospitals into three categories, each of which presents different problems for treatment and management. I. The psychotic offender who is too severely impaired to be held responsible for his crime or to cooperate in his defense. If he could stand trial, this individual would probably be acquitted on an insanity defense. 2. The person who was not impaired at the time of the
ROBERT
criminal act but later becomes so acutely psychotic or depressed in prison that he needs psychiatric hospitalization. These individuals very often have an impulse personality disorder. The close structure and confinement of prison, with its homosexual threats and temptations and separation from familiar people and surroundings, sometimes triggers an acute prison psychosis or depressive suicide attempt in people who would ordinarily have other channels for impulsive behavior. Removal from prison alleviates these psychotic or depressive symptoms, sometimes causing an observer to conclude (mistakenly) that they were feigned. 3, The manipulator who is in the hospital because it suits him better than prison does. We find that the present solutions are too unrelated to the needs of each type of mentally ill offender and that there is a haphazard “dumping” of patients from the courts of law and correctional facilities into psychiatric facilities. There is also a “conceptual dumping” -a lack of clarity as to whether the offender should be regarded from the point of view of law or of psychiatry. The courts are too ready to recommend treatment where only custodial care exists (I), thus inappropriately applying psych iatric concepts. In order to rectify this situation, psychiatrists must be willing to testify in court to document their field’s limitations, perplexity, and frustration in treating manipulative psychopaths and individuals with impulse disorders. Psychiatrists who do not take this initiative are complying in the dumping process (4, 5) and are accepting “patients” for whom there is no treatment. We will present case material to illustrate two different categories of mentally ill offenders committed under Section 730.50 of the New York CPL and the impact of these patients on the hospital staff and functioning. The major points we will make about the manipulative patient are applicable with some modifications also to the patient with an impulse disorder.
CASE
REPORTS
The
Case
I. Mr.
years
for
shooting
fense
Psychopath
A, a 42-year-old
at
Matteawan.
in
which
manipulative
expression, system him
at
to
730.50. Ward When sisting
of
that
often
and
Mr.
by of
of
someone,”
awe
began
A became
ward
them
before last
becoming arrest, he
involved began en-
by
his
was
mental
slashing
surround
president
his
arms,
treatment
discover hospital.
return
and test Although
was
able
aged
to
an
from
to evaluate
to flexible limits of a psychiatric to leave the hospital grounds, he
doctor
impotence,” that
to
Mr.
A
stand
open
ward
who in
competency
trial.
Mr.
almost
was
at
treating
although
engaged
his
FRANCES
was
the
outside
ALLEN
him
the relatively not allowed
to depart visit
cation-induced dicated
plan
quickly
AND
very
sexual
began
will.
He
him
for
credible
activity
and.
A
man“medi-
rumors with
in-
both
staff
and patients and was also involved in a profitable drug trade. He was well known throughout the hospital and displayed in virtuoso fashion the psychopath’s ability to divide a ward staff internally (6, 7). It was finally decided that Mr. A was competent and should be returned to stand trial. On the appointed day, when the two detectives
soon
appeared,
emerged
district
Mr.
A casually
with his wrist
attorney
and
the
went
bleeding.
to
the
bathroom
The detectives
presidingjudge,
who
and
called
ordered
that
the Mr.
A not appear in court, presumably on the basis that no man who had slashed his wrist could be competent. This decision was made despite psychiatric determinations of competency by the team that had interacted with the patient for 7 months. This case illustrates the frequent confusion of competency with “sanity” or “nondangerousness” and the degree to which the law can be evaded by an individual’s use of manipulative self-destructive gestures. The
P.st’chotic Offender
Case ry of
2. Ms. B, a 31-year-old
psychiatric
volvement.
single
hospitalizations She
was
first
that
woman,
hospitalized
so)
on
her
felony
indictment
any
(civilly)
symptoms of paranoia and homosexual a woman who had been a long-standing and hatred. She was found incompetent ately
had a long histo-
preceded
and
at
criminal age
in-
20
with
panic. She later stabbed object ofher fears, love, to stand trial (appropriwas
instead
remanded
for
a prolonged enforced hospitalization under Section 730.50. Ms. B had clearly been “incompetent” for years and years and gave no indication that she would ever become competent. Her delusional
thinking
Her court was permitted torney. This
became
prevalent
whenever
she
was
anxious.
commitment under Section 730.50 meant that she no passes without the approval of the district atcrippled her incentive to “improve.” The district
chose
not
to
permit
passes
because
she
was
a “dan-
gerous person,” and he explicitly demanded that the stafl take all “due precautions to prevent her from escaping.” As there were no other patients on the ward in similar circumstances, she was a perpetual outsider, quite alone in her lack of even potential
freedom,
singled
out
from
and
by other
patients,
and
unable
to participate in any meaningful way in the ward’s treatment program. Ms. B completed two-thirds of her maximum sentence and was then converted to civil status.
Mr. A was clearly without resigned
serious and
the
a voice
to
the
under with
cus-
Section suspicion.
occasionally
atmosphere him.
conlistless
correctional that rendered
committed hygiene patients
about a special
to
of-
had a long
his
He
this
A
court-referred to
“kill
assault; Mr.
gestures
trial.
view
with
15 years.
a psychiatrist in a psychotic depression
stand
A “bragged” he
of
self-mutilation along with
commissioner
staffs Mr.
curiosity,
month,
to
the
charged
a grid. Although
dramatic gestures,
incompetent
tody
suicide
were taken indicative
be
was activities After
to resemble
these
man, came to the hospital after been arrested 3 years earlier
sentence
and drug system.
had come
accomplished sequences,
had
and
a maximum
history of criminal with the psychiatric gaging
He
a detective
carries
The
if possible,
attorney
Manipulative
2’
tivities.
LISS
During
and helped
in-
of
dread, his
organize
first
ac-
In a more recent case like that of Ms. B, the United States Supreme Court decision in the case of Jackson v. Indiana (8) would apply. This 1972 decision held that a person could be considered incompetent to stand trial as a result of a criminal charge only long enough to determine if there was a substantial probability of his achieving competency in the foreseeable future. If there was such a possibility, the state would have to show some progress toward competency within a “reasonable period of time.” In practice, this seems to mean about a year for a serious offense. The decision puts the burden of proof
AmJ
Psychiatry
132:9, September
/975
925
COURT-MANDATED
TREATMENT
on the state to show may be effective.
IMPACT
ON
TIlE
that
treatment
is being
given
and
HOSPITAl.
The manipulator differs from the impulse disorder patient by having much greater ego control over his actions. His flare-ups of violence and/or self-destructiveness are less frequent, less chaotic, and more designed to achieve a specific end. These types of individuals, however, have similar impacts on a hospital ward. They are quickly recognized by others and themselves as different from the “regular patients.” They have the apparent strengths and resources to be the effective “missing link” between the staff and patients. The patient rises to the top immediately and assumes control of therapeutic community meetings. He often has the drive, charisma, and ruthIessness to dramatically improve the organization of the ward. The manipulator and impulse disorder patient soon give up helpful participation in the therapeutic community and develop instead a rapacious subculture, preying on the relative helplessness of other patients and on the psychiatric staff’s tendency to “treat” people rather than “punish” them. These individuals learn to treasure the heady freedom from responsibility conferred upon them by virtue of their status as mental patients. The usual ward restrictions provide woefully inadequate external structures for the manipulator or the impulse disorder patient, and this often results in a progressive deterioration of his behavior (9). He may have been labeled neurotic or psychotic within the close structures of a prison, but he becomes a relatively unconflicted “personality disorder” by virtue of the unintended invitation to act out in the more permissive hospital structure. The need to have a hospital setting for the psychotic offender is clearer, since he is more likely to be similar to the other patients on the ward, fits into the existing treatment system, and has psychopathology the hospital is generally equipped to treat. However, problems arise here too by virtue of the patient’s court commitment. The district attorney and the courts are the overseers of the patient’s treatment. This makes sense in terms of their responsibility to protect society and is fully appropriate in cases wherein treatment will be short term and the patient returns quickly into the legal system. It presents what may be insurmountable obstacles to treatment if the patient remains in the hospital for long-term or indefinite treatment. He becomes an isolate in the therapeutic community, unable to participate fully in programs, unable to gradually readjust to the outside world, and lacking in the usual incentives to increase self-control and socially appropriate behavior (i.e., passes and privileges). In addition, it must be clearly recognized that the “incompetent” patient protects himself from prosecution by remaining incompetent. The Jackson v. Indiana decision (8) represents a beginning step to combat these dilemmas. 926
Am
J Psychiatry
/32.9. September
/975
DISC
USS
ION
There is no comprehensive system in New York State for dealing with mentally ill offenders. Many such patients drift back and forth from prison to the hospital to the community. Society is neither affording itself protection from this potentially harmful group nor confronting the difficult and unpleasant rehabilitation issues such people dramatize. Psychiatry, the law, and the political system have unwittingly allowed the creation of a system
that
makes
no
sense.
There are several problem areas that must be considered, and an attempt should be made to develop better structures for solving them. First, people who commit crimes because of a personality disorder are sent to hospitals for treatment that often simply does not exist ( I ). As Lowenkopf and Yessne documented ( 10), these patients often tear the hospital apart, both by overt acts of violence and by nonparticipation in and subversion of treatment programs designed for schizophrenic and depressed patients. They often elope, return to the community, and commit repeated offenses, only to be readmitted to a hospital setting that has failed to help them previously. Second, patients with prison psychoses are in a revolving door situation. They become psychotic or depressed within the tight structure of the prison. which restricts their usual forms of acting out. This psychopathology often disappears rapidly when they enter the relatively looser hospital structure, but returns when they go back to prison--a cycle that sometimes becomes endless. Third, the chronic psychotic offender who will be spending a long period and perhaps a lifetime in an institution is not best served by being mixed with patients who are admitted for short-term treatment, who are allowed passes and privileges. and whose treatment is focused on a return to the community. An action under Jackson v. Indiana (8), if brought promptly. may be the solution here. There are no easy solutions to the very difficult problems we have outlined. We are suggesting that current solutions are the result of haphazard and poorly planned interactions among law, psychiatry, and the political system. This issue is being discussed increasingly in the press and community forums, particularly in New York State. The facilities that now receive patients formerly sent to Matteawan have been offered no additional stall and, more importantly, no additional program planning for their management or treatment. It seems clear that impulse disorder and manipulative court patients should not be assigned to psychiatric hospitals that are dealing primarily with schizophrenic and depressed civil patients. Offenders with impulse problems who have acute prison psychoses and are awaiting sentencing are probably better managed in hospital units attached to the prisons and specializing in this problem. This follows the military principle of not allowing secondary gain of illness and regards the episode in context, i.e., as a traumatic prison neurosis or psychosis. This would be a short-term treatment to allow the mdi-
ROBERT
vidual to quickly return and fense. For those impulse disorder sentenced or otherwise have long-term disposition is often tional solutions, both legal failures. The most successful problems may well be within model. There is resistance to the institutions for the mentally stitutions have traditionally It has been difficult to merge edge derived from psychiatric the expertise and limits of a stitution. Our present system serves study and change. We law should devote themselves establishing institutions that of each approach. This would
participate
in his
legal
de-
offenders who have been been found incompetent, a necessary. Current instituand psychiatric, are dismal rehabilitation of impulse the therapeutic community establishment of specialized ill offender because such inbeen scandalously managed. the experiences and knowltreatment institutions with correctional confinement inis clearly chaotic and defeel that psychiatry and the to greater collaboration in would reflect the advantages replace the current empha-
sis of legal-psychiatric ters around the issue
interaction, of competency.
LISS
AND
which
ALLEN
FRANCES
fruitlessly
cen-
REFERENCES I. Tweski AD: Treating the untreatable: a critique of the proposed right to treatment law. Hosp Community Psychiatry 22:17 21. 1971 2. Robitscher J: Courts, state hospitals, and the right to treatment. AmJ Psychiatry 129:298-304. 1972 3. Kesselbrenner v Anonymous, 347 NYS 2d 369 (1973) 4. Robey A. Bogard WH: The compleat forensic psychiatrist. Am J Psychiatry 126:519525, 1969 5. Suarez JM: Psychiatry and the criminal law system. Am J Psychiatry 129:293 297. 1972 6. Main TF:The ailment. BrJ Med Psychol 30:129-145, 1957 7. Cleckle H: The Mask of Sanity. St Louis, CV Mosby. 1964 8. Jackson v Indiana, 406 US 715 (1972) 9. Kalogerakis MG: The assaulfive psychiatric patient. Psychiatr Q 45:372 381, 1971 10. Lowenkopf EL, Yessne D: The mentally ill offender in a civil hospital. Journal of Bronx State Hospital 1:16 21. 1973
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J Psychiatry
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1975
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