Linda E. Weinberger

Mentally Ill Persons in the Criminal Justice System: Some Perspectives

There is an increasing number of severely mentally ill persons in the criminal justice system. This article first discusses the criminalization of persons with severe mental illness and its causes, the role of the police and mental health, and the treatment of mentally ill offenders and its difficulties. The authors then offer recommendations to reduce criminalization by increased coordination between police and mental health professionals, to increase mental health training for police officers, to enhance mental health services after arrest, and to develop more and better community treatment of mentally ill offenders. The necessary components of such treatment are having a treatment philosophy of both theory and practice; having clear goals of treatment; establishing a close liaison between treatment staff and the justice system; understanding the need for structure; having a focus on managing violence; and appreciating the crucial role of case management, appropriate living arrangements, and the role of family members.

Child and Adolescent Suicide in a Large, Urban Area: Psychological, Demographic, and Situational Factors

We examined all completed suicides by children and adolescents in Los Angeles County who died during 1996 and 1997. There were 46 subjects, aged 11 through 16. The majority of the decedents were males and over age 14. The predominant racial group was Hispanic. There was an almost even split between firearms and hanging as the means of death. Females had a statistically significantly higher rate of prior suicide attempts than males. Over one-third left a suicide note, almost one-half were noted to be depressed, and 22% tested positive for alcohol or illicit drugs. Less than one-quarter were in mental health treatment. Eighty-seven percent had difficulty transitioning to or during adolescence; e.g., problems at home, legal and school difficulties, and relationship losses. These findings are discussed in terms of Eriksonian developmental theory. We offer recommendations for intervention and prevention of suicide.

Psychological Factors in the Determination of Suicide in Self-Inflicted Gunshot Head Wounds

Self-inflicted contact gunshot wounds to the head have usually been considered presumptive of suicide. This study evaluates whether sufficient psychological data are gathered in such cases to support a manner of death determination of suicide. We suggest that law enforcement agencies and coroners departments do not fully explore the decedents state of mind at the time of death. We studied the first 50 consecutive deaths in 1993 in a major metropolitan county due to self-inflicted gunshot wounds to the head. The sample consists primarily of unmarried, white males, with a median age of 35 years, who displayed psychiatric disturbance, primarily depression, before their death. Younger individuals were often under the influence of alcohol and/or drugs at the time of death. Stressors, such as the loss of a loved one, are common among young and middle-aged persons, while serious health problems are found among the majority of middle-aged and elderly individuals. Many of the findings of this study are consistent with the literature regarding individuals who commit suicide. Although data on many important psychological risk factors are missing in most cases, sufficient psychological material is gathered about the decedents mental condition at the time of death to support a suicide determination.

Mental health courts as a way to provide treatment to violent persons with severe mental illness.

WHILE THE GREAT MAJORITY OF PERSONS WITH severe mental illness (eg, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and other psychotic disorders) are not violent, there is a small minority who may become aggressive when stressed. For instance, in a US national study of persons with schizophrenia and violent behavior, the prevalence of serious violent behavior in the past 6 months was 3.6%. Many persons with severe mental illness and a history of violence reside in jails and prisons. As an example, a recent study in a large US metropolitan jail found that 72% of persons with severe mental illness had a history of arrests for a violent offense. In this Commentary we discuss how mental health courts could divert violent persons with severe mental illness from the criminal justice system to the mental health system and ensure that they receive needed treatment. Why does this minority of persons with severe mental illness become violent when under stress or pressure? Individuals with severe mental illness who are psychotic are more likely to become violent if they do not adhere to their treatment regimens. Substance abuse also has been shown to increase the risk of violent behavior in persons with severe mental illness. Moreover, some individuals with mental illness have anosognosia, a biologically based inability to recognize that one has a mental illness. In recent decades, there has been a growing literature on anosognosia in which researchers have identified various parts of the brain (such as the ventricles, frontal and temporal lobe subregions, medial temporal and inferior parietal regions, and subcortical structures) in which pathology is associated with anosognosia. This biologically based lack of insight of having a severe mental illness may be one of the predictors of violence in persons with schizophrenia; thus, demonstrating a relationship between poor insight and violent behavior. Criminalization and Mental Health Courts Since the latter part of the 20th century, there has been an increase in the number of persons with severe mental illness who have been placed in US jails and prisons. As of December 2006, using estimated percentages from the US National Commission on Correctional Health Care, at least 341 000 severely mentally ill persons were incarcerated representing a substantial proportion of the total jail and prison population of 2.3 million. These include many who have a history of violence. Despite this, there is a shortage of mental health treatment resources in jails and prisons. The large-scale criminalizationofpersonswithseveremental illness has stimulated a variety of modalities to reduce the risk of violence for individuals with severe mental illness. One approach is to divert these persons from jails and prisons into treatment inthementalhealthsystem.Ameansforaccomplishing this is through special courts called mental health courts. At first, these courts were established to hear cases of persons with mental illness who were typically charged with misdemeanors. In recent years, these courts extended their purview to serve persons with mental illness charged with nonviolent felonies. Some courts now consider cases of mentally ill persons who are charged with violent felonies. Ideally, in mental health courts all courtroom personnel (ie, judge, prosecutor, defense counsel, and other relevant professionals) have experience and training in mental health issues and available community resources. These courts are characterized by hearing specialized cases involving defendantswith mental illness, using a nonadversarial team of professionals (eg, judge, attorneys, mental health clinician), and using some way to monitor adherence that may involve sanctions by the court. In addition, mental health courts have links to the mental health system that can provide treatment as well as needed services and support after discharge from jail to help enable the persons to successfully reenter their communities. By diverting persons with serious mental illnesses charged with

Evolution of the psychological autopsy: fifty years of experience at the Los Angeles County Chief Medical Examiner-Coroner's Office.

The origin of the psychological autopsy was in the late 1950s and the result of a collaboration between the Los Angeles County Chief Medical Examiner‐Coroners Office and the Los Angeles Suicide Prevention Center. It was conceptualized as a thorough retrospective analysis of the decedents state of mind and intention at the time of death. It was used initially in “equivocal” deaths where the manner of death was possibly either suicide or accident. Later, it was used in cases where a party (primarily family members) protested the Medical Examiner‐Coroners suicide determination. Over the past 25 years, the University of Southern California Institute of Psychiatry, Law, and Behavioral Science has served as the psychiatric/psychological consultants to the Coroners Department. Research findings, the use of this approach in high‐profile cases, and the most recent manner in which the psychological autopsy is conducted are discussed.

Four-Facet PCL–R Structure and Cognitive Functioning Among High Violent Criminal Offenders

High violent inmates (N = 126) were administered the Psychopathy Checklist–Revised (PCL–R; Hare, Clark, Grann, & Thornton, 2000; Hare et al., 1990) and neuropsychological measures. No significant correlations were present between the overall PCL–R score and 14 cognitive measures. A violence score, computed as the total number of violent acts across all situations and types, was significantly correlated with the PCL–R total score and Facet 2 but not with the other three facets. Our data suggest that Facet 2 elevations may prove relevant to violence risk assessment; this link, however, needs further exploration with larger samples.

A Proposed Exception to the AIDS Confidentiality Laws for Psychiatric Patients

The authors offer psychotherapists a proposed exception to strict acquired immune deficiency syndrome (AIDS)-related confidentiality laws. The proposal is based on previously established exceptions to the psychotherapist-patient privilege. The recommended breach of confidentiality applies only to cases that meet all of the following criteria: (1) A patient knows that he or she has a human immunodeficiency virus (HIV) positive blood test and has been informed of AIDS-related safety precautions, (2) the HIV-positive patient has a mental disorder, and (3) it is reasonable to believe that the mental disorder has significantly impaired or may significantly impair the patients ability and behavior to follow AIDS-related safety precautions.

Understanding and Treating Offenders with Serious Mental Illness in Public Sector Mental Health

This article begins with the history of the rise and fall of the state hospitals and subsequent criminalization of persons with serious mental illness (SMI). Currently, there is a belief among many that incarceration has not been as successful as hoped in reducing crime and drug use, both for those with and those without SMI. Moreover, overcrowding in correctional facilities has become a serious problem necessitating a solution. Consequently, persons with SMI in the criminal justice system are now being released in large numbers to the community and hopefully treated by public sector mental health. The issues to consider when releasing incarcerated persons with SMI into the community are as follows: diversion and mental health courts; the expectation that the mental health system will assume responsibility; providing asylum and sanctuary; the capabilities, limitations, and realistic treatment goals of community outpatient psychiatric treatment for offenders with SMI; the need for structure; the use of involuntary commitments, including assisted outpatient treatment, conservatorship and guardianship; liaison between treatment and criminal justice personnel; appropriately structured, monitored, and supportive housing; management of violence; and 24-hour structured in-patient care. Copyright

Surgical Castration and Sexual Recidivism Risk

A review of the literature related to castrated sex offenders is provided as a backdrop to the relevance of bilateral orchiectomy in risk assessment among sexually violent predatory offenders. Data from difficult-to-obtain reports and older studies are summarized as well as their methodological limitations. More recent studies related to bilateral orchiectomy and sexual function drawn from testicular/prostate cancer research demonstrate that while sexual desire is reduced, the capacity to develop an erection to sexually stimulating material is not eliminated. Moreover, the effects of castration on sexual desire and erectile functioning can be reversed by exogenous testosterone. Consequently, while orchiectomy may have a role in risk assessments, other variables should be considered.

Psychological Autopsy: Consultative Tool for Suicide Determination

Abstract The psychological autopsy has become an essential part of the evaluation of manner of death in difficult forensic cases. Through careful assessment of scene investigation, autopsy findings, the decedent’s psychological background, presence or absence of risk factors for suicide, and other information, mental health professionals can provide significant insight into the decedent’s state of mind at the time of death. In a “contested” case, the medical examiner has determined that the manner of death is suicide and the psychological autopsy determines whether there is enough evidence to overcome this presumption. In an “equivocal” or “undetermined” case, the medical examiner does not have enough information to determine the manner of death. The purpose of the psychological autopsy in this situation is to look for information that either supports or contradicts a mental condition consistent with suicide.