Wednesday, August 17, 2016

Forensic Mental Health - Part 2: If You Weren't Crazy When You got Here...

Welcome to day 2 of Forensic Mental Health!  Let's jump right in with...
Not Guilty by reason of Insanity:  First, the defendant has to already have been diagnosed with a mental illness.  So, the NGI defense is an admission that the defendant did the crime of which they are being accused.  However, due to the symptoms of the mental illness, the person was unable to understand the nature of the criminal act, or that what they were doing was wrong.  Also, the severity of the symptoms must also have been the cause of the criminal act.  This part I think a lot of people have trouble grasping when they hear that someone was found NGI.  It’s almost impossible to understand the mindset of someone experiencing the symptoms of mental illness.  I worked with people with Major Depression for years before experiencing my first episode.  I am good at the work I’ve done.  I enjoy the therapeutic process.  I have seen profound changes in my clients.  All of this is to say that even working every day in this field and hearing the same experience come from different clients time and time again, I couldn’t possibly have understood how a person’s thought process completely changes when mental illness takes hold.  This is why we have the NGI defense.  A person is truly unable to understand the true nature and outcome of their actions.  In a criminal trial, the burden of proof is on the prosecution to make the case the the defendant is guilty.  For an NGI, the burden of proof is on the defense to make the case for insanity.
Once a person has been found Not Guilty by reason of Insanity, they will be committed to the State Hospital.  This is the part that people don’t seem to understand.  The person is not just set free.  Once they are committed to the State Hospital on an NGI, it is extremely difficult to be released.  People will often be committed to a State Hospital far longer than they would have served in prison.  What is often reported, which is technically true, is that the minimum a person can be hospitalized for NGI is 6 months.  This is the part public defenders tell their clients: “You could be out in 6 months!” IT NEVER HAPPENS.  EVER.  I can think of one person, in the whole time I worked there, who was out in less than a year.  It was an extraordinary case.  
When a person is released after an NGI, they are released to their county’s Mental Health department.  For the time that they are hospitalized, a member of the treatment team, usually the patient’s psychiatrist, will write a letter to the court detailing the person’s progress in treatment.  In order to even be considered for release, the patient will have to demonstrate a significant period of time without the symptoms of their mental illness interfering with their ability to function.  They will also have to write an accurate and detailed account of the crime, including how their mental health symptoms led to the event.  They must take responsibility for their part. They must be able to state, from memory, what medications they take, how much, how often, and for what symptom.  If the medications changed the day before the interview, they are still responsible for this knowledge.  They must have a detailed Wellness and Recovery Plan.  They have to know their triggers, warning signs, decomposition signs, and what to do every step of the way.  They will also be required to complete anger management, symptom management, and substance recovery groups.  All factors which lead to the committing offense must be resolved to the satisfaction of every party who has a say in the decision to release the person.  This is in addition to managing day to day life on a psychiatric ward.  Once a person has achieved all of these things to the satisfaction of the treatment team, the county is notified.  They will then come to see the patient.  They will review every word in that patient’s chart.  They may decide that even though the patient has done well for the last year, they were not able to discuss their specific triggers for substance abuse during the interview, and are therefore not ready for release.  Now let’s say that during the next 6 month period, the patient has a bad day, and yells at their roommate, who has been singing all night for the past 3 nights.  The yelling goes in the chart.  When they are reevaluated at the end of the 6 months, it is decided that they need to attend anger management because of the incident.  A person without a mental illness would be discouraged and feel stress.  Mental illness, however, is opportunistic.  So guess who’s starting to have symptoms again?  I have had clients who would have served 3 years in prison for their offense who had been hospitalized for 10, 15, or 20 years with no end in sight.
I am not attempting to garner sympathy for these patients.  Many of them are right where they should be.  Ideally, they would be getting all of their treatment needs met, and on their way in a reasonable amount of time.  Budgets and staff ratios make this nearly impossible.  I believe we can have compassion for people without making excuses for them.  But the next time you hear that someone has been found Not Guilty by reason of Insanity I hope you will have a better understanding of what that’s going to mean for them.  Try to imagine knowing that, in an altered state of consciousness, you had committed a felony.  Maybe you even harmed the person you love the most. Now you’re not only going away for it, but indefinitely.  Possibly for life.  Now tell me it’s a Get Out of Jail Free card.  All right, this one was heavy, but important.  I’ll try to post something lighter next.

Be well.


  1. I've enjoyed the two posts on forensics. You've clarified several terms and issues. Thank you.

  2. I've enjoyed the two posts on forensics. You've clarified several terms and issues. Thank you.