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by Peter Matthews MB, BS., FRCPC. MRCPsych.
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.
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.
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.
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.
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 ?
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 ?
Peter Matthews
MB BS FRCPC MRCPsych
Dept of Psychiatry
University of Saskatchewan
Saskatoon, Canada.
e-mail matthwsp@duke.usask.ca
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