Management of the Mentally Disordered Offender in Prisons 9780773566071

Table of contents :
Contents
Acknowledgments
1 Introduction
PART ONE: MANAGEMENT TOWARDS RELEASE
2 Assessment
3 Secure Stabilization
4 Preparation for Release
5 Community Supervision
PART TWO: SPECIAL ISSUES IN PRISON PSYCHIATRIC CARE
6 Ethical Considerations
7 Predatory Sexual Behaviour in Prisons
8 Self-Mutilation in Prisons
9 Suicide in Prisons
10 The "Inadequate" Offender
11 The Predictably Dangerous Mentally Disordered Offender
12 Conclusion
Appendix A: Release of Confidential Information
Appendix B: A Multidisciplinary Correctional Assessment of a Convicted Serial Murderer
Notes
References
Index
A
B
C
D
E
F
G
H
I
J
K
M
N
O
P
R
S
T
V
W

Citation preview

Management of the Mentally Disordered Offender in Prisons

Possibly no area of human endeavour poses a greater ethical challenge to a free society than the safe control of mentally disordered persons who represent a significant social danger. Managing mentally disordered offenders (MDOS) is a major challenge for the clinician because they have multiple problems and diagnoses and the cost of a "mistake" can be very high. Despite these complexities, until now there have been few guidelines for dealing with MDOS. Drawing on extensive case studies and his experience as director of psychiatric services at the Regional Treatment Centre in Ontario, Neil Conacher traces the MDO management process from initial assessment, through secure stabilization, to preparation for release and subsequent community supervision. He outlines the difficulties of managing a population of serious offenders and highlights elements of treatment that are essential if the MDO is to be reintegrated into the community. Conacher also considers dangerousness, issues of treatment, and forensic aspects of mental disorder, as well as psychiatric concerns that are particular to the prison context, such as ethical issues, predatory sexual behaviour, self-mutilation, suicide, the "inadequate offender," and the predictably dangerous mentally disordered offender. The Management of the Mentally Disordered Offender in Prisons makes an important addition to existing psychiatric literature by bringing to the fore a neglected area of tremendous social concern. G E O F F R E Y N E I L C O N A C H E R is associate professor of psychiatry, Queen's University.

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Management of the Mentally Disordered Offender in Prisons GEOFFREY NEIL CONACHER

McGill-Queen's University Press Montreal & Kingston • London • Buffalo

McGill-Que en's University Press 1996 I S B N 0-7735-1419-8 Legal deposit third quarter 1996 Bibliotheque nationale du Quebec Printed in Canada on acid-free paper Publication of this book was made possible by a grant from the Research Committee, Ontario Region, Correctional Service Canada. McGill-Queen's University Press is grateful to the Canada Council for support of its publishing program.

Canadian Cataloguing in Publication Program Conacher, Geoffrey Neil, 1950Management of the mentally disordered offender in prisons Includes bibliographical references and index. ISBN 0-7735-1419-8 1. Prisoners - Mental health services. I. Title. RC451.4.p68c65 1996 365'.66 C96-900198-3

Typeset in Sabon 10/12. by Caractera inc., Quebec City

Contents

Acknowledgments vii 1 Introduction PART ONE:

2 Assessment

3 MANAGEMENT TOWARDS RELEASE

13

3 Secure Stabilization

22

4 Preparation for Release

32

5 Community Supervision

41

P A R T TWO:

SPECIAL ISSUES IN PRISON

P S Y C H I A T R I C CARE

6 Ethical Considerations 49 7 Predatory Sexual Behaviour in Prisons 8 Self-Mutilation in Prisons 9 Suicide in Prisons

55

60

70

10 The "Inadequate" Offender

81

11 The Predictably Dangerous Mentally Disordered Offender 85 12 Conclusion

92

vi

Contents

Appendix A: Release of Confidential Information

95

Appendix B: A Multidisciplinary Correctional Assessment of a Convicted Serial Murderer 98 Notes

113

References Index

135

123

Acknowledgments

I presented an outline of the substance of this book to the Queen's University Department of Psychiatry Grand Rounds in September 1992. I am indebted to Dr Stephen Hucker, then director of the Forensic Division of Toronto's Clarke Institute of Psychiatry, for the suggestion that it could benefit from inclusion of case material, and it was the complexity and diversity of the cases available that resulted in its subsequent expansion into book form. Without doubt, the encounter with such rich clinical material is the chief reward of working in this difficult area. A production such as this can never arise simply from the labours of one person. Many people have contributed to its formation - too many to acknowledge individually, but principally the employees and inmates of Correctional Services Canada, Ontario Region. Thanks are due to members of staff at the Regional Treatment Centre (Ontario) in Kingston Penitentiary; their dedication and professionalism are seldom given the credit they deserve. I wish to extend particular thanks to people on my own staff, whose careful attention to their duties has freed me for extended periods of research and writing: Diane Anthony, Barb Clark, Dan Crockett, Louise Kennedy, Pat Onysko, and Yvonne Stoddard. Thanks also to my colleagues Neil Oliver, who lifted from my shoulders what had come to seem an exhausting burden of clinical responsibilities, and Bob McCaldon, whose resilience at the front line continues to amaze me; to Mike McCabe, for computer and graphics assistance; and to Glenys Elliott, who read the manuscript and offered percipient criticism along with the observation that a habit of brevity

viii

Acknowledgments

acquired composing clinical notes and reports is not necessarily appropriate to the writing of a book. The staff at McGill-Queen's has been most helpful and encouraging, and the book has been greatly improved by the professional editing of John Parry. Grateful acknowledgment is extended to the editors of the British Journal of Psychiatry, the Canadian Journal of Psychiatry, the Canadian Medical Association Journal, Forum on Corrections Research, the Journal of Clinical Forensic Medicine, and the Journal of Forensic Psychiatry and to the minister of Supply and Services Canada (Canada's Mental Health) for permission to adapt and use case studies or material originally published as articles in their journals. Material used in this way is cited in the text. Last, but most, thank you to my wife and family for your patience and support and for the long hours you allowed me to lie undisturbed in the bath. G.N.C. Kingston, Ontario.

Management of the Mentally Disordered Offender in Prisons

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I Introduction

The mentally disordered offender is not an attractive subject; the double problems of dealing with him are not readily understood ... Although some disordered offenders may deserve censure or punishment, all of them alike deserve understanding, support and an opportunity to put themselves back in tune with the social order. Lord Justice Mustill1 THE PROBLEM

There is quite possibly no single area of human endeavour that poses a greater ethical challenge to a free society than safe control of mentally disordered persons whose behaviour represents a significant social danger.2 Jurisdictions everywhere struggle with this issue, the economic costs involved are enormous, and the shortcomings of existing systems are generally recognized.3 The problem of providing a comprehensive, modern psychiatric service for the mentally disordered offender (MDO) has yet to be systematically addressed. Should such services be an integrated part of mental health systems? Should there be a separate but parallel forensic system?4 And should prison systems be providing their own psychiatric services for inmates, or should they rely on those of community mental health services? Within prison systems these questions are compounded by continuing confusion about the role of psychiatric units. Good clinical practice can all too often become obscured in issues of "political decision making, legal sentencing procedures, medico-legal ethics, [and] prison

4

The Mentally Disordered Offender in Prisons

management."s But whether a service for the incarcerated MDO is to be provided by mental health, correctional, or independent administrations, it will necessarily be subject to certain common and general constraints if the goal of safe return to the community is to be achieved. Constraints related to sentencing and conditional release impose on the service a process of management that applies to each MDO, and the constraints of incarceration itself give rise to specific concerns that can affect the mental health of prisoners. It is the purpose of this monograph to examine the essential elements of a complete service for the MDO that can provide for eventual and safe release of the offender to the community. To illustrate the particular clinical problems that can be encountered by such a service, I refer below to the work of Kingston Penitentiary's Regional Treatment Centre (Ontario), or RTC(O), in providing psychiatric services to the inmates of the Ontario Region of the Correctional Services of Canada (esc). Because of the complexity of the topic, I have chosen to present a descriptive study, illustrated by case material drawn from the patients of RTC(O). Reliance on individual case material may easily descend to the level of anecdote, and, in alleged contrast to a scientific, statistical method, it is subject to the various biases of individual experience. Without wishing to take sides in the debate between a number-oriented "scientism" and a subjective attempt at understanding another's individual experience - sometimes described as the nomothetic and idiographic approaches, respectively - I would agree with Halasz6 that "[wjhile a psychiatric service informed by science is necessary, it is not sufficient for the highest standards of clinical care." I have no intention of minimizing the value of a scientific, statistically based psychology and its application to offending behaviour. As I hope to make clear in the course of the monograph, there have been significant advances in recent research, particularly in the areas of statistical prediction of future offending behaviour and analysis of the outcomes of treatment. In contrast to earlier findings, which were often confused and contradictory, these results support an active treatment and management approach both towards the "ordinary" offender and towards some categories of MDO. In other words, it can now be asserted on the basis of scientific findings that the final interests of public safety are best served by allocation of resources towards active treatment and management both during incarceration and during a supervised release process. These findings offer the only rational foundation for any discussion of the problems posed by the MDO. But for those working with offenders it is often the vivid nature of their individual character and histories that is most striking.

5

Introduction

Forensic psychiatry has been contrasted with other social sciences as still bound to the study of the individual and to use of case studies rather than large samples, which can end "in the formulation of weak generalisations masquerading as natural laws of human behaviour."7 Some great psychiatrists, including Maudsley and Pinel, have stressed the importance of the case study. Carl Jung observed: "A scientifically oriented psychology is bound to proceed abstractly; that is, it removes itself just sufficiently far from its object not to lose sight of it altogether. That is why the findings of laboratory psychology are, for all practical purposes, often so remarkably unenlightening and devoid of interest. The more the individual object dominates the field of vision, the more practical, detailed and alive will be the knowledge gained from it."8 I have deliberately altered details within case histories so as to protect the anonymity of the subjects. I make reference to relevant literature but have not attempted a comprehensive literature review, which would of necessity encompass a wide range of topics. For those who wish to probe deeper into specific subjects, the references provided should serve at least as a convenient starting point for a comprehensive literature search. The alert reader, particularly from a discipline other than psychiatry, will note that the majority of references are to the psychiatric and medical literature. This fact simply reflects the reading of a time-bound clinician; other disciplines, of course, make equally important contributions to the care and treatment of incarcerated MDOS. It is not my purpose here to address the ethics of social control or to consider the complex issues of guilt (in a criminal sense) in relation to mental illness. The patients with whom RTC(O) works have all been tried in a court of law, found guilty, and committed to the custody of the esc for a sentence of at least two years. Borzecki and Wormith, reviewing the literature in 1985,9 found little evidence to confirm an increase in the number of mentally ill people in Canadian prisons that would be consistent with hypotheses of deinstitutionalization and "criminalization,"10 but a recent, major survey of federal correctional institutions11 confirms that significant numbers of the mentally ill are confined in Canadian prisons.I2 Nor is it my intention to answer questions about whether prison psychiatric services should be independent of the prison administration, though I refer in chapter 12 to the desirability of offering a service specializing in the particular psychiatric problems of prison inmates. The esc has been providing prisoners with a medical service independent of the provincial health services which has included since 1973 a full range of psychiatric care. Under the provisions of the Chalke Report*3 three regional psychiatric centres were established in Canada

6 The Mentally Disordered Offender in Prisons

to provide in-patient and out-patient services to csc inmates,14 and a fourth centre has now been established in the Atlantic region. Each of these centres has evolved along differing lines in terms of provision of services and relations with provincial ministries. The work of one has been described in a brief, anecdotal report,15 but RTC(O) is the oldest and serves the largest population - approximately 3,700 inmates in the Ontario region - while offering tertiary services to the Atlantic region. STRUCTURE

OF THE SERVICE16

RTC(O) lies within the walls of the maximum-security Kingston Penitentiary, a protective-custody17 institution built as Canada's first penitentiary in 1835. Kingston Penitentiary18 has held a prominent place in the history of secure mental-health care in Canada,19 but the treatment centre was officially designated so only in 1982. The centre has avoided stigmatization as a protective-custody institution because it was set up in a cell-block separate from the main prison. It has been administered as a separate institution, and, as a hospital facility, it has a role acceptable to inmates who have not acquired protective-custody status. Recent major renovations, including provision of an elevator, have raised the standard of the accommodations to a level approximating that of a modern psychiatric hospital. Lying within a federal-government "reserve," the centre is not technically bound by provincial legislation, but since 1989 it has been a recognized schedule-1 facility under the Ontario Mental Health Act (OMHA). 20 In order to establish conformity with prevailing community standards of care, particularly in relation to treatment without consent, the RTC(O) uses the procedures mandated under the OMHA, ZI even though they can result in significant delays.22 Within the centre, two of the three units are devoted to provision of acute and chronic psychiatric care; the third provides for assessment and treatment of sex offenders. Each unit consists of two ranges of 17 single-bedded cells. Ten cells on the mental-health unit (for acute and sub-acute cases) are equipped with cameras for Z4~hour monitoring of disturbed or suicidal inmates. The low number of beds relative to the catchment population dictates an active treatment policy, with early discharge to the parent institution, even in the psychosocial rehabilitation unit. Despite this, on both the mental-health and psychosocial rehabilitation units, a certain proportion of patients are unable to adapt to any other prison environment and require in-patient care for extended periods of their

7

Introduction

Figure 1 RTC(O) mental-health units, discharges, 1990/91-199x793

incarceration. The problem of "blocked beds," familiar to any hospital, has been mitigated to some extent by establishment of a specialneeds unit at Kingston Penitentiary. This is essentially no more than a dedicated prison block providing some shelter, but little treatment, for such "inadequate" inmates (see chap. 10, below) as those suffering from chronic psychosis, mental retardation, or brain damage or for those lacking in the social skills or physical strength to survive without exploitation even in a protective-custody population. Figure 1 outlines the principal diagnoses on discharge from RTC(O)'S mental-health units for the years 1990-93. The treatment centre provides "out-patient" services to each of the six major Ontario penitentiaries and their satellite, minimum-security institutions by contracting with psychiatrists from the local community in Kingston to provide two or three sessions a week to each institution. Unlike the situation in csc's other regions, all the current mediumand maximum-security federal penitentiaries of the Ontario region are, for historical reasons, near to each other, with Kingston being described, as a result, as "the prison capital of Canada." The "institutional psychiatrists" based at RTC(O) provide consultation on referral from penitentiary psychologists or institutional physicians. Inmates view psychiatrists with some ambivalence, regarding

8

The Mentally Disordered Offender in Prisons

them as friends and confidant(e)s when their requests are acceded to and as representatives of the establishment when they are denied. Consultations include requests for minor tranquillizers, particularly benzodiazepines, but it has become the policy of this region to supply such medication only in the most exceptional circumstances. One reason for this restriction is that prisoners can use benzodiazepines as currency (for example, five "Vs," or 5-mg tablets of diazepam have paid for a man, admittedly unpopular, to be "piped" or beaten about the head with a baseball bat). Other reasons include unpredictable reactions in crowded conditions23 and a suspicion that use is associated with a higher incidence of self-mutilation and violence.24 Suggested alternatives to benzodiazepines (such as anti-depressants for help with insomnia and major tranquillizers to treat agitation) are often contemptuously refused as "bug-juice," deriving from reference to the mentally ill as "bugs" and RTC(O) as the "bug-house." Other common referrals are for evaluation of suicide risk or for an opinion on behaviour considered suggestive of mental illness, extreme forms of which can be encountered. In the fiscal year 1991-92,, institutional psychiatrists provided a total of 1,949 consultations. Of these, 68 per cent were for the purpose of evaluation, 16 per cent were requests for medication, 8 per cent were for psychotherapy, and 7 per cent were for advice on the disposition of an inmate. Psychiatrists saw an average of 3-6 patients per 2-3-hour session. Admissions to RTC(O) and follow-up of discharged patients are coordinated by a team of three psychiatric nurses reporting to the director of psychiatric services. Implementation of this "ambulatory service" has resulted in significant improvements in follow-up and maintenance care and substantial reduction in readmission rates to the centre. The centre keeps its own, independent file bank on patients, with special procedures to protect confidentiality. TWO

C A T E G O R I E S OF M D O

In the following discussion, the great majority of serious MDOS fall into two distinct, but overlapping groups - the psychotic and the personality disordered. Within these two groups, and treated as paradigmatic for their group, are paranoid schizophrenia and psychopathy, respectively. As I examine management of the MDO for each of four stages - assessment, stabilization, preparation for release, and community supervision - I compare and contrast the approach to these two groups. Paranoid schizophrenia as a mental disorder fits well within a "medical model" of illness. Treatment is directed initially towards

9

Introduction

stabilization on medication, and if there is a good response, maintenance on medication can result in the patient's entering treatment programs, which may lead to improved control of criminal aspects of behaviour. Forensic aspects of paranoid schizophrenia are reviewed in greater detail below in chapter 2, in the section "Forensic Aspects." While the medical model provides the framework for a flexible approach to the psychotic patient in prison, the personality disordered and those suffering from possibly related conditions such as some paraphilias require a quite different management approach 25 Included in this group might be sadists, but our understanding of the ramifications of this condition is so rudimentary that few generalizations are possible. Our understanding of psychopaths, however, while still limited, is perhaps sufficient to allow some conclusions to be drawn regarding their overall management. Psychopaths are variously defined, and it has become conventional for some forensic psychiatrists to deny that people so labelled are mentally ill. The work of Robert Hare26 and his colleagues has increased the confidence with which this condition is identified and stimulated a growing and exciting research effort. Conclusions are still tentative, but the diagnosis carries implications of higher recidivism,27 a poor or even negative response to treatment efforts,28 and perhaps better success with release programs that include intensive supervision. About 60 per cent of federal-penitentiary inmates in Canada might qualify for a diagnosis of anti-social personality disorder (ASPD), 29 but psychopathy as defined by Hare is a more restrictive diagnosis than DSM-IIIR ASPD and constitutes perhaps 20-30 per cent of the population of federal offenders.30 Indeed there is a feeling that psychopaths represent a quite separate group. The majority of the ASPDS in prisons bear a remarkable similarity to each other - caricature males, with their tattoo-covered muscles, postures, and heroic attitudes, they are clones of a counter-culture but by their very likeness betray a degree of acculturation. In contrast, each psychopath seems unique - isolated, and elusive, and completely lacking in acculturation, despite a veneer of social skill. Psychopathy is discussed more extensively below in chapter 2, in the section "Psychopathy." Multiple diagnoses are common within prison populations,31 and a subset of MDOS with paranoid schizophrenia would also qualify for a diagnosis of coexistent ASPD. Some recent evidence suggests that coexisting psychosis32 may ameliorate the tendency to recidivism of the psychopath,33 but the group of mixed psychotic and ASPD offenders that is made up of the most difficult inmates in any prison population 34 is poorly researched and understood.

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PART ONE

Management towards Release

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2 Assessment

Early identification and assessment of mentally ill offenders as they enter the correctional system are an important part of their management, but they have yet to be satisfactorily achieved within the Ontario region of esc. During renovation of RTC(O) in 1991-92, an experimental, satellite mental-health unit was in operation at the maximumsecurity reception facility at Millhaven, and this temporary unit has so sufficiently revealed the utility of early psychiatric assessment as part of the reception process that resources for creation of a permanent unit were allocated from the fiscal year 1993-94. Inmates frequently arrive to begin their sentences with little psychiatric information available to the psychiatric services, and the most reliable way of obtaining psychiatric reports that might be part of the public record as a result of the trial process is still to ask the inmate if he or she has been assessed previously and to apply to the authors of the report with his or her consent. Obtaining previous reports is a valuable part of the initial assessment, since failure to do so can undermine the credibility of later recommendations to such bodies as the National Parole Board. The purposes of the initial assessment include formulating diagnostic and treatment issues. Ideally a management plan should be set up that considers security placement (maximum, medium, or minimum) during the sentence, risk presented to the community on release, and ways in which that risk can be treated or minimized during and after incarceration. Examples of the kinds of multidisciplinary reports generated by an actual, if rather unusual, case during an assessment are given below, in Appendix B.

14

Management towards Release

FORENSIC ASPECTS

OF

PARANOID

SCHIZOPHRENIA

The relationship between mental illness and criminal behaviour has been a matter of long-standing controversy. Lionel Penrose in 1939 reported an apparent inverse relationship between figures for violent crime and the number of mental-health beds in different European countries.1 The finding has been widely but uncritically quoted for its implied support for a mental-health-oriented rather than punitive social policy. In an authoritative review, Gunn in 1977 noted a lack of interpretable results and much confusion surrounding the subject. He concluded: "All in all, it is probably better to concentrate upon specific behavioural problems caused by specific disorders and to avoid too many generalisations."1 Since then, much of the debate on the relationship between mental illness and criminal behaviour has centred around the "criminalization" of the mentally ill arising out of the deinstitutionalization of the chronic psychiatric population in mental hospitals.3 It is now recognized that this movement has resulted in an overall deterioration of services for the chronically mentally ill and put pressure on other agencies, such as correctional services, to accommodate some of this group.4 Support for the hypothesis that the mentally ill have been diverted into the criminal justice system5 has been found by a number of workers in different settings,6 though no clear evidence for this phenomenon7 has been established in Canada.8 A study of schizophrenics on remand concluded that they were "treated in legally and medically appropriate ways," at least in Alberta.9 In the public perception the mental patient is seen as dangerous and unpredictable,10 and there has been some empirical support for this view,11 but the prevailing professional assertion has been that this is not true.11 Even as a general statement the assertion that the mentally ill are not more violent than other people is now being questioned,13 and community studies appear to support an association between mental illness and violence that is significantly increased when substance abuse is also present.14 As Gunn has stressed,15 it is crucial to know which group has been examined in which context before drawing general conclusions from any particular study, and this caveat would apply to the study of criminal behaviour among schizophrenics. Schizophrenics are responsible for most criminal acts by psychotic patients,16 but the expert view has been that they are less prone to committing violent crimes than the general population and more likely to be victims than victimizers. This theory is supported in at least one study of hospitalized schizophrenic patients.17 However, dangerous

15

Assessment

behaviour in substantial subgroups of psychotic patients is increasingly reported.18 Particular groups at risk might be those acting on delusions of misidentification,19 or on paranoid delusions involving particular individuals, or those experiencing command hallucinations.10 In studies of the incarcerated population, a violent subgroup of paranoid schizophrenic patients emerges more clearly.21 Some evidence suggests that there are two groups of psychotic offenders in prisons those whose criminal behaviour precedes the onset of psychosis and is similar to that of healthy criminals, and those whose offending behaviour followed the onset of a psychotic illness that may have helped to precipitate the offence.22 This second group of offenders does not have a previous history of offences, early anti-social behaviour, or alcohol abuse.23 Many in this group "seem to have been imprisoned rather than hospitalised because of the serious nature of their crimes"24 (see case study no. 3.3, below, for example). An extended twin study of psychosis and criminality found that in 34 of 59 offenders psychiatric contact preceded first conviction; for 2.0 the reverse was true.25 The study found that schizophrenics were significantly more often convicted and imprisoned than the affectively disordered. To these two groups of offending schizophrenics we might add a third: those disabled, chronically psychotic patients who have been deinstitutionalized and who, now homeless and without support, commit "survival crimes"26 only to secure shelter and sustenance (see case studies nos. 5.2. and 9.1). In terms of a tendency to recidivism, schizophrenic offenders released from a maximum-security mental hospital have been found to be less likely to commit an offence than a control group of imprisoned nonpsychotic offenders matched for age, offence type, and criminal history.27 Criminal-history variables still remain the best predictors of future recidivism. This finding is consistent with our own experience.28 The great opportunity afforded by early assessment in the prison population is to identify, using such factors as lack of criminal behaviour or alcohol abuse before the onset of illness as described above, that group of mentally ill whose criminal behaviour has arisen through poor control of their illness. These people might be safely and speedily returned to the community on parole once their illness has been stabilized. Community psychiatric services could then have the chance to exploit an extended period of parole supervision to try and achieve effective integration into the community. Members of that group who commit survival crimes have often been resistant to community psychiatric services, or rejected by them, but even they can show extended periods of stable behaviour when conditions of parole require them to cooperate with community

16

Management towards Release

mental-health staff and when supervision by the parole services is adequate. Discussions with the National Parole Board arising from concerns that the mentally ill may be spending more time in prison than their mentally healthy peers29 have resulted in a number of successful releases. Many more could safely benefit from rapid release to community supervision but lack the initiative or assistance to set up a viable parole plan. Even those who started criminal behaviour before the onset of illness can benefit from community management that combines parole supervision and cooperation with psychiatric services enforced by conditions of parole. Case Study No. 2.1 In 1986, a 43-year-old Caucasian male was admitted to RTC(O) for medical and psychiatric stabilization after he had wandered away from a minimum-security correctional facility (farm camp) in the winter and suffered substantial frostbite to both feet. A known chronic schizophrenic, he had a number of previous admissions to the treatment centre for stabilization of his psychosis. This relapse and "escape" appear to have been precipitated by the refusal of the parole board to consider an application for parole. The board had been advised by a psychiatrist that the prisoner could not be relied on to keep taking his medication. Twenty years earlier, during an armed robbery, he had shot two men, one of whom died. It was not clear from current records whether he was suffering from mental illness at the time of the crime, but he was convicted of second-degree murder and given a life sentence, with a minimum of seven years to be served before he could be considered for parole. Because of concerns about his apparent lack of insight into his mental illness, occasional relapses associated with failure to use medication properly, and his failure to formulate realistic release plans, he had never been seriously considered for parole and had served 19 years, whereas someone without mental illness and serving a similar sentence could realistically hope for parole shortly after the minimum time stated. On admission he was neglected in appearance and dress, with a vacant expression on his face and mild, tardive dyskinesia. He was vague and apathetic in answering questions but reported suicidal ideas, based on realization that he might never be released. Following stabilization, RTC(O) staff began protracted negotiations with the psychiatric hospital serving his home town. Two years later, and supported by independent psychiatric opinion, the

i7 Assessment

parole board agreed to release him on parole to that facility, with a condition of parole being that he cooperate with treatment. The terms of his parole have since been loosened because of his continued cooperation; he is independently employed, living in a group home; and he has regained contact with his family. At a time when prison populations are rising, there are significant social and economic advantages to the early release on parole of stabilized schizophrenic offenders. An extended period of parole with conditions to cooperate with treatment allows community psychiatric services the opportunity to establish a good therapeutic relationship, and parole-service supervision can separate coercive aspects of management of the offender from the therapeutic component. PSYCHOPATHY

"History has demonstrated that the sheer range of psychopathology exhibited by psychopaths and its unusual complexity have always posed major challenges to classification."3°As a diagnostic category, psychopathy has had a chequered history. In his authoritative review of the subject in 1974, Aubrey Lewis found the diagnosis lacking in "sharp and definite limits," and in this respect he felt it could be regarded as the most vague of all current psychiatric diagnoses.31 Numerous reviewers have contributed to a vast and confusing literature, which embraces the full spectrum of possible aetiologies, conflicting views on whether the "medical model" properly applies, and explanatory paradigms ranging from demon possession31 to a failure by society to provide strong moral leadership.33 A more recent, conventional review of the topic concluded that, in terms of drawing attention to a poorly defined area that requires further empirical research, it might be better to use a generic term of "psychopathic disorders."34 Case Study No. 2.2 A z 5-year-old Caucasian male was admitted for an assessment of his treatability following repeated and importunate demands for prolonged intensive psychotherapy, about which he none the less expressed some ambivalence. "Even if I say no, I want you to take me over there, in spite of my fear." His fear was of possible sexual abuse, of which he was then able to catalogue an extraordinary amount throughout his life, including experiences at another secure treatment facility. These accounts had attracted concerned sympathy from the institutional psychiatrist, who felt that he showed "much

18

Management towards Release

insight and good intentions." On arrival he was wearing a pair of deeply tinted spectacles obtained on medical grounds of having sensitive eyes. After only minutes he became frustrated with admission procedures and insisted on being returned to the maximum-security penitentiary. He had been adopted within hours of birth into a well-to-do, middle-class family. He knew nothing of his biological parents and expressed no interest in knowing. From the age of eight he had shown behavioural problems of concern to authorities, and from the age of nine he was experimenting with LSD and alcohol. He was expelled from school at 15. His adult criminal record began at the age of 16, and before the current sentence he had accumulated four previous provincial incarcerations (i.e., sentences of less than two years) and two federal sentences (i.e., of two years or more) for a wide range of criminal offences. He had spent a total of only six months out of prison since he was 16. His performance on conditional releases35 was noteworthy. Two days after release on parole from a provincial institution he had committed the robbery for which he received his first federal sentence. Released 18 months later, he was rearrested within a day for break and enter vis-a-vis his parents' home. Released again a year later, within two days he had set fires in five locations on the lower floors of a large multi-storey hotel, moved to a different town, and begun a spree of robberies. Throughout his file notes from professionals record evidence of remorse36 and his determination "to turn himself around," though few observers seemed convinced of his sincerity. "Although he often spoke in positive terms concerning his problems and the need for treatment, I have been strongly suspicious throughout that he was only here to avoid spending time in jail (age 21, during a hospitalisation for slashing)." "He was articulate and quite intelligent ... pleasant and cooperative. Although he accepts, albeit superficially, culpability for his crimes, he shows no consideration for the rights and sensitivities of other people ... (age 2.2.)." "His attempts to understand his own behaviour are as heroic as they are hopeless ... (age 24)." "I have decided to undergo a 100% sincere effort to seek help to understand and deal with my problems ... (extract from a letter, one of many on file, age 24)." "[He] has gained much insight into his life and attitude of late ... (age 2,5)." "I have just started to deal with my impatience and the largest step was to accept the fact that my impatience was largely due to the fact that if I didn't get what I wanted when I wanted then I'd become impatient ... (letter age 27)."

19 Assessment

The view that the diagnosis of psychopathy represents an unacceptable intrusion of psychiatric classification into areas more properly covered by moral and legal concepts, and should therefore be abandoned, is still supported by some professionals in the field.37 It is indeed "difficult to be thoroughly wicked without achieving a psychiatric diagnosis,"38 but this does not invalidate the concept of psychopathy. It could equally be observed that other conditions that today have an accepted place in our diagnostic systems have in the past also been dismissed as merely reflecting weakness of character or an evil disposition. In this case study, and elsewhere, particularly in written productions, there is evidence of a subtle failure of logical thinking in psychopaths. In the course of a direct interaction this is difficult to observe, and the usual impression created is of a normal and rather interesting personality. On later reflection, however, it is difficult not to think that there must be a disorder of high-level thinking, that psychopathy in its extreme manifestations is a form of mental illness. If a valid case can be made that the concept of psychopathy can help isolate a discrete diagnostic entity or "taxon,"39 then the assertion that psychopathy is no more than a pejorative label is weakened. Evidence that psychopathy is a taxon is based on a taxometric analysis of data derived from Hare's Psychopathy Checklist - Revised (PCL-R). 4 ° The PCL-R was developed from the observations of Hervey Cleckley, author of a now deservedly classic clinical study, The Mask of Sanity.41 Using Cleckley's descriptive material and case studies, Hare derived a list originally of 2.2. items or features said to be associated with psychopathy. The revised, 2,o-item checklist is scored from a semistructured interview and review of file material, with each item being assigned a value between o and 2..42 The final score is the sum of scores for each item, with the recommended cut-off score for a positive diagnosis being 30 out of a possible 40 points.43 There is debate about the optimal cut-off score for different populations. Table i lists the 2,0 attributes identified from Cleckley's work. For clinical purposes in a correctional setting, the person applying the PCL-R should be a qualified professional, psychologist, or psychiatrist, experienced in the forensic field, who has received standard training and inter-rater reliability testing.44 The person should not have been closely involved in treatment with the subject (see case study no. 4.1, for example). An excellent, non-technical review is to be found in Hare's recent book, Without Conscience: The Disturbing World of the Psychopaths among Us. Debate about this controversial diagnosis is likely to continue. A number of different classifications of psychopathic personality have

20

Management towards Release

Table i Items derived from Hervey Cleckley's The Mask of Sanity, and used in Hare's Psychopathy Checklist - Revised (PCL-R) Grandiose sense of self-worth Glibness and superficial charm Need for stimulation/proneness to boredom Pathological lying Shallow affect Cunning/manipulative Lack of remorse or guilt Callousness and lack of empathy Early behavioural problems Poor behaviour controls

Impulsiveness Irresponsibility Parasitic life-style Promiscuous sexual behaviour Many short-term marital relationships Lack of realistic long-term goals Failure to accept responsibility for own actions Juvenile delinquency Criminal versatility Revocations of conditional release

been proposed on the basis of clinical experience or empirical data,45 and it has been suggested that the PCL-R tends to identify a heterogeneous group possessing only anti-social behaviour in common.46 None the less "there is a growing body of research, particularly in Canada, that highlights the importance of identifying psychopaths in our criminal populations."47 In particular, the findings of a strong association between PCL-R score and prediction of failure on conditional release48 or violent recidivism49 have been very robust. Violent psychopaths show a different pattern of violence than violent non-psychopaths, with greater likelihood of using "instrumental" aggression, threats, and weapons.50 The assumption that psychopaths might "burn out" and reduce their criminal behaviour after the age of 40 is not supported in relation to violent crimes by at least one study,51 and this observation is consistent with experience in a population of serious offenders. Treatment of psychopathy is considered in "Treatment," in chapter 3. Prevailing professional pessimism is amply confirmed by experience. Despite the common feeling of the involved therapist that the patient is making significant gains in insight, treating psychopaths is like writing on water. Accurate diagnosis is important, however; this group can be at least managed, if not treated. Management of psychopathy during incarceration is most often a matter of resisting unnecessary expenditure of treatment resources. (This principle might also apply within the community. One patient, a released sex offender, revealed that he was seeing four independent therapists separately on a weekly basis at the expense of various agencies, with none knowing about the others.) Acute behavioural decompensations can be extreme (see case studies nos. 3.z and 7.1), particularly in the early stages of

21

Assessment

a sentence, but these can usually be treated with a brief crisis admission and early return to the parent institution. Members of this group have remarkable facility for functioning well in a structured, secure, institutional environment without extensive psychiatric intervention. In prisons they are able to sustain a relatively high quality of life with access to educational, employment, and leisure programs within a culture whose contingencies are suited to their comprehension. Many show more stability than they have been able to sustain "on the street" and, as "model inmates," pose a dilemma when they apply for parole. In contrast, in a less-structured hospital environment they can generate tension, undermine the treatment milieu, and compete for staff attention with other patients, echoing the malign and destructive competition for parental attention that so many have shown towards their siblings as children. The observation that psychopaths appear more stable and less socially disruptive in prison than in the hospital environment could, if confirmed, have important implications for judicial policy towards their placement after sentencing. Without prejudging the still-undecided issue of whether psychopathy constitutes a mental illness, we should note that containment in prison is likely to remain the most economical management option by far for members of that serious group, who not only are able to cause untold suffering to literally hundreds of victims but also represent a huge economic burden when at large in the community.

3 Secure Stabilization

The mentally ill are vulnerable to stigmatization and exploitation at the hands of fellow inmates,1 and conditions in prison for this group are probably less humane than those in a modern psychiatric hospital, but the correctional environment offers some opportunities in terms of stabilizing an MDO whose behaviour is unreliable or unpredictable - most important, the continuity of care available. Over some years, depending on the offender's sentence, treatment staff can get to know a patient who in other settings would seldom stay for long, and a longterm perspective encourages them to adopt a tolerant and creative response to disturbed behaviour. As well, the correctional environment has available levels and instruments of force that might not be available even in a forensic psychiatric hospital. USE OF FORCE, AND

CHEMICAL AGENTS,

RESTRAINT2

Recent mental-health legislation in many developed countries has laid down procedures that govern the circumstances under which a psychiatrist may override the rights of a patient to refuse treatment. A stress upon respect for patients' autonomy and recourse to judicial rather than medical, paternalistic processes is common to much of this legislation. In Sweden, this shift in emphasis has been shown to be out of step with public attitudes, and lack of public confidence in the legal system's involvement in decisions about compulsory psychiatric care has been reported at the same time as legislation increasing judicial

23

Secure Stabilization

involvement was being enacted.3 Elsewhere, attention has been drawn to the enormous costs incurred in a judicial approach to preservation of patients' rights.4 Implicit or explicit in legal approaches defining the restricted circumstances under which treatment can be administered without consent is agreement that once legal procedures are exhausted, and some form of treatment order has been granted, then treatment is given against the patient's will and, if necessary, against his or her active resistance. Such circumscribed legislation generally leaves in place a more or less well-defined general obligation on the part of physicians to intercede when they believe that a patient's behaviour is threatening the life or health of the patient themself, or of others. Under both types of circumstances, physicians may find themselves party to use of force against their patients. In prisons, where the patient quite possibly has a proven capacity for extreme forms of violent response, the ethical problems surrounding such use of force can be complex. Case Study No. 3. i A 32-year-old patient is serving a life sentence for second-degree murder for beating to death a gang member. He suffers from a psychotic illness, well established from previous admissions, and had refused his last maintenance depot neuroleptic. After being unmedicated for four weeks he was reported to be isolated in his cell, threatening violence if disturbed, refusing food, and fearing that the water had been poisoned. Consistent with past admissions, he appeared to be entering a catatonic phase but was suspected of remaining capable of a violent response to intervention. A decision to transfer him to RTC(O) was made. To secure cell entry and apply physical restraint an emergency-response team of six specially trained and equipped prison officers was activated. Once physical control was effected, a long-acting depot neuroleptic was administered on site, cuffs and leg irons were applied, and he was transferred to a camera (i.e., observational) cell in the mental-health unit. Within five days he was lucid, non-aggressive, and cooperative with further treatments. This case represents a situation where ethical and legal arguments to justify use of force are at their most clear. Refusal to take fluids over an indeterminate number of days makes clear the existence of a lifethreatening emergency, attempts to persuade him to consent to treatment

24

Management towards Release

"voluntarily" are ignored or responded to violently, the diagnosis has been worked out previously, and the patient's reaction to his medication, in regard to both side effects and good therapeutic response, is known. None the less, counter-arguments to certain aspects of the process of effecting control can be entertained. Use of a long-acting neuroleptic as a means of chemical restraint blurs any distinction between emergency intervention and long-term treatment, for which either voluntary, informed consent or a protracted legal procedure is required. Injection of a medication of any kind may be seen in some jurisdictions as use of a greater degree of force than is required for physical control, even if it has to be repeated. Legislation, where it exists, usually requires that the minimum possible or least intrusive form of force be used. "Chemical restraint" is sometimes used as a pejorative term applying to general use of neuroleptic medication5 but refers here to forcible injection of neuroleptic medication, usually by an intramuscular route, to an uncooperative patient to prevent serious self-injury or, more rarely, serious harm to others. Tardiff, in a number of thoughtful publications, has reviewed the general indications and contraindications for use of force, seclusion, and restraint.6 In this context "Restraint or seclusion of a patient as a purely punitive response is contraindicated,"7 though the distinction between punishment and establishment of control over a disturbed patient is not always clear, as illustrated below, in case study no. 3.2.. In a review of the literature on restraint and seclusion Fisher concluded that it is nearly impossible to run a unit for the anti-social personality disordered (ASPDS) without some form of seclusion or physical or mechanical restraint but warned that their use can have significant adverse effects for both patient and staff.8 Where the occupant of a cell may be armed and is showing readiness to resist, chemical agents may be considered. MACE is a respiratory irritant supplied in a hand-held, compressed canister from which a stream, effective to about two metres, may be squirted in the direction of the subject's face, usually producing immediate immobility. Such agents, by our own experience and that of others,9 can reduce the risk of injury, but they are not without serious side effects,10 and the realization that MACE may be used against the mentally ill can be disturbing to some people. In the Forensic Psychiatry Section of New Jersey State Hospital in Trenton, over a two-year period, 44 patients were exposed to MACE; all but seven "responded satisfactorily,"11 and a substantial reduction in injuries to attendants was recorded, without any harmful after-effects to patients.

25

Secure Stabilization

In RTC(O) a decision to use MACE is taken by senior security personnel in consultation with nursing and medical staff after all other efforts to secure the patient's cooperation have failed.12 Where possible, consistent with the sense of urgency in the situation, formal warning is then given to the patient that security staff may use the chemical if the patient remains uncooperative. Following exposure to MACE, the patient's eyes and exposed areas of skin are flushed with cold water. In the period from March 1986 to November 1987, MACE was used five times at RTC(O). Three of the patients were psychotic, and two ASPDS. In one instance the patient was out of his cell, threatening and hostile; in the others patients were in their cell and "smashing up" or flooding the cell by blocking the toilet and sink, or setting fires, and requiring to be moved to a seclusion cell. In the same period, mechanical restraints were applied 14 times on four occasions to one particularly disturbed psychotic patient. Restraints were applied following use of MACE - three times in similar situations of a disturbance within the cell, four times to prevent selfinjury, once following an attack on another inmate, and once to control an uncooperative inmate during a move. Use of a mechanical restraint such as handcuffs or shackles requires a medical order that must be renewed every Z4 hours, 15-minute observation and documentation by nursing staff, and 15-minute checks to ensure that the patient's circulation is not impaired and that restraint is still required. The tactical realities of entering a cell through a narrow doorway against someone prepared to resist have been described elsewhere.13 Repeated procedures against possibly armed resistance are fraught with risk of serious injury both to staff and to patient. Cases have now been reported of possible transmission of HIV virus14 in the course of violence.15 It is to reduce these risks that tear-gas may be used and long-acting medication may be chosen over short-acting for chemical restraint in selected cases. When the risk of injury or death is directed by the patient at other inmates or staff, the need for such intervention is less clear. This risk can be controlled, at least in the short term, by solitary confinement - indeed, some patients request it, and some certainly benefit from the reduction in stimulation - which may render more forceful procedures unnecessary. However, solitary confinement for the mentally ill should not be continued indefinitely. Sensory deprivation in secure settings harms mental processes16 and carries significant psychiatric risks.17 Prolonged periods of solitary confinement may be construed as inhuman and degrading treatment.18 ASPDS, particularly of the

26 Management towards Release

"borderline" type, are vulnerable to psychotic breakdown in conditions of isolation and effective sensory deprivation, and in psychotic patients isolation can induce hallucinations and delusions even when the confinement is not total and the patient is allowed out under secure conditions for showering and exercise. In their review of the psychiatric effects of solitary confinement and sensory deprivation, Grassian and Freedman conclude that legal safeguards in use of solitary confinement are essential but, rather than imposing restricted options on clinical practice, should ensure independent clinical observation and assessment, and intervention if necessary.19 Case Study No. 3.2 A 28-year-old man starting a two-year sentence for armed robbery had been admitted to the mental-health unit for assessment of a possible psychotic illness. During admission, his ideation was strange, but his behaviour was controlled, he could express reasoned arguments against treatment, and it was judged that an application for a treatment order was unlikely to be successful. He was discharged with a diagnosis of factitious disorder, but within days he had flooded the segregation unit of one penitentiary, shorting out the electrical system for a complete wing. He was throwing faeces and urine and spitting on staff, keeping other inmates awake all night with his shouting. When he was transferred to a different penitentiary, his behaviour remained uncontrolled and aggressive. In the solitary-confinement unit, naked and deprived of mattress or gown, he had contrived to pull ceramic tiles off the floor. With these he was able to obtain the metal edging of a grille three metres above the floor and by grinding the edge on the cement shelf of his bed using faeces as a lubricant was able to fashion overnight a sharp and effective blade. He had a previous history of superficial self-mutilation for manipulative purposes. He had a significant previous psychiatric history, but no consistent diagnosis had been reached and he had rarely stayed long enough for any effective attempt at stabilization. Staff in the segregation unit were understandably disturbed at his behaviour, and alarmist views about the risk of contracting disease from body fluids were being expressed. Administrative pressures for psychiatric intervention were intense. A decision to transfer him to RTC(O) "for further assessment" was made, and in order to effect this the emergency-response team, in full riot-control paraphernalia, made an entry into the cell. The inmate threw the blade at the staff.

27

Secure Stabilization

A short-acting, intramuscular injection was given against his resistance, mechanical restraints were applied, and he was transferred. (He subsequently became more cooperative, accepted anti-psychotic medication, and over a period of months demonstrated a dramatic improvement in all areas of social functioning. In view of this change his diagnosis was revised to an atypical psychotic disorder.) Here the role of psychiatry as an agent of social control was troublesome. The patient's disturbed behaviour was not considered at the time to arise from a psychiatric disorder, and the psychiatrist was concerned because mental-health resources were being employed in a disciplinary function to re-establish the "good order" of the institution. Staff members were expressing strongly hostile views about the patient, and some gained satisfaction from the punitive nature of the intervention. The difficulties of securing treatment for a psychotic and dangerous, non-consenting offender have been described in a recent paper20 which stresses the inadequacies of the Ontario Mental Health Act21 in this context. In common with much other recent mental-health legislation," concern to protect the civil rights of the mentally ill has imposed lengthy and costly legal procedures before treatment without consent can be initiated in Ontario.23 Recent evidence suggests that prolonged delays in providing neuroleptic treatment may seriously harm the subsequent prognosis,24 and in the correctional context, when offender/ patients with a proven potential for violence are being dealt with, such delays can expose staff to prolonged risk of assault. Case Study No. j.j25 A Z9-year-old Caucasian man, six feet tall and heavily built, is serving eight years for manslaughter. From an immigrant background and socially isolated, he had come to believe that a group of local youths was involved in a scheme to tempt him into becoming a homosexual. Resolved to protect his "morality," he decided to kill the supposed ringleader, but in the very act of drawing aim with a rifle he realized that it was not that person there was masterminding the plot, but a 15-year-old male standing some distance away. He switched aim and shot the youth through the head. He was a "loner" in prison and asked to be locked up in segregation. He began writing letters about a stiletto he had invented, which would be a mandatory side-arm for all citizens to protect them from homosexual attack. He seemed to believe that "the Axis" was in a conspiracy with the Toronto police, his parents, and prison officials.

z8

Management towards Release

He began expressing fears of being manipulated into a homosexual relationship by other inmates or guards. Upon transfer to the RTC(O), he confirmed the above ideation but denied that he was ill and refused treatment. He was found incompetent by the review board but appealed the decision to the district court. The official guardian's office would not indicate whether or not a treatment order would be given until the judge had ruled on his incompetence. The legal-aid lawyer had to wait to see if legal aid would grant funding for the appeal and so required an extension by the court. On the last possible day, arguments for and against the inmate's appeal (formulated by his lawyer and the Correctional Service of Canada's [csc's], respectively) were submitted in writing to the district court. While all this legal wrangling was going on, we were aware of the Gallagher decision - Fleming v. Gallagher (Ontario Court of Appeal) - which allowed in desperate circumstances for treatment to proceed. The csc's lawyer felt that desperate circumstances might be difficult to establish in this case. Meanwhile the patient began throwing food, urine, and faeces and spitting through his bars at passersby. Patients and staff were incorporated into his delusional system and threatened with murder. Emergency chemical restraint was used, and for some weeks the patient settled well enough to be let out of his cell under close supervision. Blood work revealed a folic-acid deficiency, and supplementation was begun. He still refused neuroleptics and began drifting into a paranoid psychosis again, but this time with less vehemence and aggression. Eventually, six months after we began the proceedings, his appeal failed, and we obtained a treatment order from the official guardian. Treatment with a long-acting, injectable neuroleptic was commenced. In contrast to many forensic mental-health facilities, RTC(O) may discharge patients who are uncooperative or aggressive. This factor may reduce the number of violent incidents, for patients are made well aware that violence of any kind may precipitate immediate discharge, to the dissociation unit of Kingston Penitentiary if necessary. While the reasons are probably complex, violence towards staff or other patients is rare at RTC. But when violent incidents occur, they can be serious. The period since 1986 has seen one prolonged hostage taking (see case study no. 8.3), two attempted hostage takings, and five suicides. A review of all incidents reported from i January to i July 1991 (chosen as the six-month period prior to major disruptions in operations caused by renovations) shows a total of eight: two attempted suicides by hanging, one slashing of a wrist, two incidences of "inmate

29

Secure Stabilization

causes disturbance," one possession of "brew" (alcohol) and a still, one finding of a small amount of cannabis, and one use of physical force to administer medication. No assaults took place in that time. It is well recognized that prisons offer an environment where ethical conflicts and abuses of power can occur.16 Indeed, this possibility is so well recognized that the scrutiny of professional practice within prisons by independent agencies and individuals from outside the system can be more intense than any encountered in ordinary mental-health practice. It is regrettable, if understandable, that such scrutiny occurs most often after a tragic or unfortunate incident, but close public examination of service provision within such closed institutions as prisons is always to be welcomed. Though undergoing a rigorous and informed critical investigation in the full glare of media coverage can be quite devastating, to survive such examination without being found at fault can fairly be regarded as an affirmation of good standards of practice. It is difficult for abuses to flourish in a climate of openness to independent inquiry. Professional organizations occasionally offer ethical guidelines to members involved in prison practice,27 though such guidelines are not always suited to the everyday contingencies of this special environment.28 Prison staff members know well the adverse light in which their decisions can be cast after the event and as a consequence may become more cautious and uncertain in their management of dangerous patients, which scrupulousness may itself lead to increased risk of injury to patient or staff. A more complete discussion of ethical concerns surrounding use of force, and other areas of potential ethical conflict, is to be found in chapter 6, below. The possibility of transmission of the HIV virus during a violent incident adds a whole new dimension of risk to the already complex problem of managing the dangerous patient. Members of staff cannot be expected to work therapeutically with a patient if they feel that their safety is compromised and greater priority has to be given to safe control of patients who may act violently and unpredictably.29 In the interests of reducing the chances of injury to all involved, if force is to be used then it should be overwhelming. Staff involved should be properly equipped with protective clothing, and the potential for chemical agents to reduce injury to all parties involved should be taken into consideration. TREATMENT

The structure and environmental characteristics of a treatment program for patients requiring secure care have been described by

30 Management towards Release MacCulloch and Bailey.30 Treatment institutions for this population must have a secure perimeter, with a design to manage "both disturbed and devious behaviours" and facilities for very-long-term care.31 Prevailing pessimism about the effectiveness of treatment addressed to reducing recidivism in the ordinary offender population has been mitigated by a recent meta-analysis which found evidence for positive effects.32 In the view of the authors, successful programs reflected "three psychological principles: (i) delivery of services to higher risk cases, (2.) targeting of criminogenic needs, and (3) use of styles and modes of treatment (e.g., cognitive and behavioral) that are matched with client need and learning styles." A standardized battery of "core" treatment programs has been developed by esc for eventual administration to every offender. These programs, based on a cognitive-skills and relapse-prevention model, may be beyond the ability of the particularly disadvantaged MDO. Consistent with the principle of "responsivity" (namely, that treatment should be matched with the client's learning style), RTC(O) has sometimes had to adapt such programs to its own population. As a multidisciplinary mental-health facility, RTC(O) provides a range of assessment and treatment to its patients in addition to the standard "core" programs offered to all inmates of the esc. Occupational therapists and teachers offer modified versions of these standard programs responsive to the patient's cognitive style and apply a range of "modularized" illness-self-management tools.33 Application differs little from that encountered in mental-health facilities in the community and is not considered in detail here. "Sex offenders" are not a homogeneous group, but at least in the public eye they constitute a special group requiring special treatment before they can be considered fit for release. A well-systematized process of assessment and treatment is in place in the Ontario region of esc, and parole is almost always contingent upon successful completion of treatment. A range of programs is provided for different levels of security; the model of treatment is cognitive-behavioural, with growing emphasis on relapse prevention. Provison of these programs is the responsibility of institutional and contracted psychologists, and their content and application are outside the range of this monograph. Demand for treatment of psychopaths is boundless, and they are frequently received into the system with accompanying recommendations for treatment (or recommendations not to be released until they have been treated) from judges and other interested parties. However, no consensus exists34 on what treatment might be effective for the antisocial personality,35 and the most intense treatments appear almost uniformly ineffectual.36

31

Secure Stabilization

Poor response to treatment is even more clear for the psychopaths as a subgroup; indeed, Rice, Harris, and Cormier, in a retrospective study of one intense and, at the time, innovative, therapeutic community-treatment program, found treated psychopaths somewhat more likely to recidivate than an untreated comparison group of incarcerated offenders. 37 They found that the program appeared to benefit a non-psychopathic (as measured by a file-review PCL-R with a cut-off score of 25) group and a schizophrenic group, which both showed less recidivism than the comparison group. In addition to the apparent negative effect of treatment, the authors also found that high psychopathy scorers were more often chosen in the program for leadership positions, privileges, and release, even though their behaviour on objective measures obtained from the files was worse than that of the low scorers. This worsening of criminal behaviour following treatment might partly explain poor treatment results for the ASPDS overall, if the groups studied contain a high proportion of unrecognized psychopaths. I have observed consistently that psychopaths will attempt to monopolize any treatment programs offered in prisons, and they will subtly undermine the efforts of others to change at the same time as they convince the therapists, in the face of all evidence to the contrary, that they themselves are improving dramatically. It can always be argued that not all possible treatments have been tried and that much research in this area is methodologically flawed. Modern treatment emphasizes cognitive-behavioural approaches that are arguably better suited to the egocentric-exploitative style of psychopaths. The esc is considering a pilot effort based on a cognitivetherapeutic approach.38 If a successful treatment for psychopathy were to be developed, it would probably be very cost-effective,39 as psychopaths are prominent in that small group of "habitual" offenders who commit such a high proportion of all crimes, and even a moderate treatment effect could translate into significant reduction in offences. In the meantime, management of ASPD, and perhaps of psychopaths in particular, has been aptly summarized: "Basically it is symptomatic relief, clear guide-lines about expected behaviour, treatment of any major psychotic illnesses, realistically accepting them as they are and trying extremely hard not to be too frightened of them."40

4 Preparation for Release

In preparing for release of a sentenced MDO, two quite different processes are dictated by the type of sentence the MDO has received. Those who are serving a fixed sentence must be released by the time their warrant of committal expires - the warrant-expiry date (WED). Beyond this date, the offender, having served his or her sentence, can be subject to no more constraints than the ordinary citizen. A special condition was required by the Ontario Ministry of Health in granting schedule-1 status to RTc(o) 1 - that the Ontario Mental Health Act (OMHA) should under no circumstances be used to prolong the incarceration of an inmate. Management during the fixed-term sentence is governed by the consideration that the individual be settled safely, and with as much stability as possible, in the community, before his WED. Those who are serving an indefinite or life sentence are subject to different constraints, and considerations of public safety, rather than time, assume priority. In either case, progress towards freedom is predicated on approval by the National Parole Board, which has been given wide powers to impose special conditions after release. Conditions to be observed on pain of revocation of parole can include quite specific directions regarding medication, but more useful is a general injunction to cooperate in treatment with a mental-health service. Good communication between Parole Services and clinical staff is essential if such conditions are to work, but they can be of great assistance to community psychiatrists in encouraging a patient to cooperate with psychiatric care after release.

33

Preparation for Release

For the group of psychotic offenders, the main priority is to establish effective contact with community psychiatric services, where they exist. This in itself can be a major challenge in the face of what John Gunn has aptly described as the "banishment pressure"1 on MDOS. Psychiatric facilities are frequently reluctant to take on the care of such patients,3 believing, in some ways accurately, that in doing so they will be seen as accepting responsibility for the future actions of their charges. Pressure on urban mental-health services can mean that the released inmate does not obtain the consistent care essential for this population. Establishing links with community services is also contingent on the consent of the offender being released, and these patients are not always cooperative. The psychopathic offender requires a release process that lays greater emphasis on supervision. The greatest difficulties are encountered with this group, and management strategies are inadequate at present. A specially resourced team supervision unit has been established by the Toronto Parole Services, and it has been effective in supervising release of a number of difficult MDOS. Both within prison and during the release process, stability of the psychopathic patient can be enhanced in some cases by his development of a close relationship with a powerful other person, staff, inmate, or member of the public. Observations suggest that with such a relationship extremely disruptive psychopathic patients can be maintained for lengthy periods without behavioural deterioration. The other person involved must be considered to have lost his or her objectivity in the case, no matter how great his or her experience. This loss of objectivity can cause tensions within a multidisciplinary team, and it is not uncommon for normally prudent professionals to send outraged memoranda on behalf of their clients to independent colleagues who might have expressed the view that their therapeutic optimism is misplaced. Indeed such memoranda can be considered a good sign of the influence of a psychopath (see case study 4.1, for example). The powerful hold that a psychopath can exert on those in close contact is frequently underestimated or overlooked altogether. Countertransference and enmeshment can be similar to those encountered with borderline patients.4 Clues to over-involvement can be found in remarks such as "I ordinarily don't do this ..." or "While I don't usually do this with my patients ..." These statements suggest boundary problems and a "narcissistic isolation of the dyad" 5 and are as useful indicators of loss of objectivity with psychopaths as they are with borderline patients. Idealization of the therapist by the patient is

34

Management towards Release

more likely to be a consciously manipulative ploy on the part of the psychopath than an unconscious mechanism, as postulated for the borderline patient. Because close contact with a psychopath often leads to loss of objectivity, it is therefore important that the parole board be provided with objective, independent assessments when it seeks a psychiatric opinion about release. The esc has been fortunate to contract for the services of the Forensic Divisions of the Clarke Institute of Psychiatry in Toronto and Queen's University in Kingston, to provide some 250300 independent psychiatric assessments a year for the board. Referral for assessment is made by institutional psychologists, and reports, which are supplemental to a standardized assessment using statistical predictors,6 can significantly affect release planning. Useful suggestions regarding conditions of release and indicators of relapse can create greater confidence in a difficult release decision. Interdisciplinary tensions can be encountered in almost any work environment. These can be, and often are, exploited by a psychopath to provoke confusion and discord within a multidisciplinary team. The point of the following case study is not that psychiatrists and psychologists can disagree - that is well known - but that independent assessors are a necessary part of a release process and that this factor can disturb the treatment team. Case Study No. 4.1 A 3O-year-old man had served four years of a seven-year sentence for sexual assault, arising out of an incident where he had stalked a female pedestrian, grabbed her from behind in a choke hold, and tried to get her onto the ground. Hearing her screams, a passing man came to her aid. The assailant ran off with her handbag to his parked car and, in escaping, attempted to run down the rescuer with the car, slightly injuring his knee. The assailant was on probation for a previous sex offence at the time. He had a history of anti-social behaviour from the age of nine, with expulsions from school for fighting, lying, and stealing, sexual involvement at the age of 13 with a boy and girl of ages seven and six, respectively, and early experimentation with alcohol and drugs. He quit school at the age of 16 because of boredom and began an almost-continuous adult criminal record. He blamed an authoritarian and physically abusive father for many of his problems, but his several other siblings have pursued careers, married, and had families without experiencing problems with the law.

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Preparation for Release

While he was in the maximum-security institution, the offender's favourable response was recorded to preparatory treatment for serious sex offenders, but further treatment was recommended. He had been given "wall clearance" and had gained the support of his institutional psychologist, who recommended transfer to a minimumsecurity institution, which offered treatment for those considered unlikely to reoffend. An independent psychiatric opinion was requested at this time. The independent psychiatrist, very experienced with offender populations, recommended against this plan: "I think [he] is a classic psychopath with all the typical features of superficial charm and good intelligence, manipulativeness, lack of true remorse, untruthfulness and insincerity." Based on this report, the case-management team began to process the inmate for a detention review, in which he would be considered for placement in maximum security until expiry of his sentence, instead of progressing towards minimum security. The inmate grieved this unexpected result, attaching to his grievance form a five-page, detailed rebuttal of the report. This rebuttal, neatly written in a rather immature hand, consisted largely of restatements of clauses in the report accompanied by exclamation marks. Some alleged inaccuracies were challenged. Referring to his thoughts leading up to the crime: "I didn't say, 'You're going to try and score with her.' In fact, I said, 'This looks like a score,' meaning I knew I was going back out at that moment, and 'was going to raise hell,' and said as much too." A second psychiatric opinion was obtained, and it supported the first. The offender's statement quoted above was felt to be very revealing of his thought processes: the wording he denied reflected consciousness of the personhood of the victim, whereas the wording he insisted was his true thought portrayed her only as an object and an opportunity - a "score." A pattern of concentrating on appearance and semantics rather than on the substance of issues was evident throughout the rebuttal. Commenting on the way the patient blamed his family for many of his problems, the original report had noted that none of his siblings had serious psychiatric or criminal histories. The rebuttal stated: "X [a sibling] was in counselling for years! - is that serious?" On his apparent lack of remorse, at his second interview he shouted forcefully, "Remorse? I've shown remorse! I've shown remorse, the reports say so, but I have to put it behind me and get on with my life!" Remorse for this man was something you show and then leave behind.

36 Management towards Release

The institutional psychologist at this stage performed his own Hare psychopathy-checklist rating, finding the inmate "only about average for this population," and submitted a report challenging the "labelling" of the inmate by the two psychiatrists. He continued to support direct transfer to minimum security. The second psychiatrist, required to comment, questioned the objectivity of the psychologist, who then wrote a memorandum protesting what he saw as an attack on his professional conduct that was "offensive and unjustified." The case-management team suspended moves towards lesser security until the results of a full treatment program within maximum security were available. That treatment had to be discontinued when the patient was caught using cannabis. DANGEROUSNESS

Dangerousness is by no means an easy concept to define. It is not necessarily the same as recidivism, and some definitions include a quality of unpredictability: "Dangerousness ... is an unpredictable or untreatable tendency to inflict or risk serious, irreversible injury or destruction, or to induce others to do so."7 It has been suggested that the problem of appearing to claim that clinicians can predict the future can be avoided by describing evaluations of dangerousness as risk assessments rather than as predictions of violence.8 The inadequacy of psychiatry and other disciplines in predicting future behaviour is widely asserted,9 though the empirical evidence on which this conclusion was reached was limited, and, in the words of John Monahan, "Rarely has research been so uncritically accepted and so facilely generalized."10 Assessment of dangerousness remains an area where empirical evidence is scarce. It could still be argued that "Clinical impressions and reviews predominate in the literature on dangerousness; facts and figures are few."11 Even if it is considered to have been established that professionals have overpredicted violence in populations where the base rate of violent acts is low, there may still exist a subpopulation with a high base rate of violence for whom predictions of dangerousness can be made with more confidence.12 In calling for more sophisticated prediction studies, Monahan particularly mentioned use of actuarial techniques.13 Prospective studies using a variety of predictors are now being reported. In one study of a sample of 685 MDOS released from the maximum-security Oakridge mental-health facility at Penetanguishene,14 an actuarial instrument correctly predicted 75 per cent of those 618 who were released to be (or not to be) violent or sexual recidivists. Development of this instrument

37

Preparation for Release

and its further refinement and application have been described in a recent book.15 The discriminating power of different instruments16 to predict recidivism17 is improving.18 These instruments are currently most useful in identifying that large group likely not to reoffend, but risk assessments can have meaning only in the context of post-release supervision that can manage risk and prevent relapse.19 The most cogent ethical criticisms of estimates of "dangerousness" concern their use in simple release decisions with no after-care, and I argue that risk assessments should not be conducted in isolation from considerations of risk management. "We cannot at present hope, by taking infinitely careful aim, to direct our dangerous patient to safety like an arrow to its target; rather, through effective supervision, we must accompany him, being prepared to adapt to his varying needs, whether encouraging independence, moderating activity or recalling him to start again from the beginning. "zo The best of actuarial instruments will remain statistical generalizations, and forensic clinicians, despite their own reservations about whether or not they can actually improve on actuarial techniques, will continue to be called on to provide "more subjective assessments and judgements based inevitably upon clinical wisdom and experience."2'1 Case Study No. 4.2 A 31-year-old man was referred by the parole board for a psychiatric assessment of his suitability for release on day-parole (at completion of one-sixth of his sentence). He was serving five years for a robbery in which he was the driver of the car. The car was followed, and when being arrested the offender was flourishing a knife. During a fight shortly after beginning his sentence, while in a maximumsecurity penitentiary, he was beaten about the head and stabbed in the neck and in his face. Subsequent loss of sight in one eye and impaired vision in the other were attributed to optic-nerve damage. He claimed to have been high on tranquillizers and unable to identify his assailants. Six months later, from a medium-security institution where he had been sheltered in the hospital, his case-management team recommended him for day parole so that he could attend a residential instructional institution for the blind. A psychological report supporting the recommendation asserted that his risk to reoffend had been "drastically reduced by non-psychological factors" and that his

38

Management towards Release

"previous history is almost immaterial in helping to predict his future behaviour." His early history was chaotic. His father had himself served time in federal penitentiaries and was murdered. His mother had a history of committing abuse, and he was taken into the care of the Children's Aid Society at the age of two. He was fostered to and then adopted by a family that he characterized as abusive, though he admitted that the physical abuse was usually in response to his bad behaviour at school. An altar boy, he began stealing the sacramental wine at age eight, by 14 he was using cannabis, and he had a wide and varied history of drug abuse, which he had supported during his last release by acting as a debt collector for cocaine dealers. He had never had regular work. His adult criminal record began from the age of 17, and included in a continuous criminal record were property-related offences, weapons charges for both guns and knives, assault with a weapon, and at least four violations of probation or parole. He had a number of short-lived relationships, the latest, of two years duration, with a woman who was also a cocaine user who had herself been charged with bank robbery. He claimed wide knowledge of the "magic arts" after the style of Aleister Crowley and described, for example, as an interesting but emotionally neutral act the ritual killing of his girlfriend's cat two years before, "to get the life-force." His girlfriend was persuaded to cooperate in this act by the threat that he would otherwise kill her the same way. His other hobbies were weightlifting and artwork. He was a tall but muscular man, tattooed about the face and arms. Without any apparent difficulty he was able to lead the way to the interview room, negotiating at least one change in floor level. He helped himself to an ashtray, easily interpreted a nod as meaning yes to smoke, and chose a seat facing away from the light. At the end of the interview he glanced at the wall clock to confirm the time. His manner was familiar and outgoing, he made good eye contact, but he spoke without empathy for his victims, he placed blame for the consequences of his actions on others, and he was adept at finding reasons to be righteously angry. His basic attitudes were anti-social, and he appeared unrealistically confident that he could control his longstanding drug problems. In his report, the psychiatrist stressed the wide repertoire of criminal behaviour and questioned the assertion that previous history was not relevant to the assessment of the inmate's risk of reoffending. The diagnosis was of anti-social personality disorder. The degree of functional ability shown at the interview was felt to be inconsistent

39

Preparation for Release

with definitions of blindness, and it was recommended that if he were to be placed in a residential training centre for the blind then staff there should be alerted about his diagnosis and the possibility that he might intimidate or exploit more disabled residents. As a result of the report his application for day parole was turned down. Clinicians involved in assessment of dangerousness have continuing concerns about possible conflict with an ethical and legal duty to protect the confidentiality of information gained from someone who may be said to have gained the status and ethical rights of a patient. But even within the doctor-patient relationship the primacy of confidentiality as an ethical principle has been undermined. In at least one jurisdiction it has been judged that confidentiality can be overridden where there is sufficient evidence to suggest that a third party may be seriously harmed by the patient. The implications of the Tarasoff decision in California are still being discussed and defined,22 but a trend for public safety to be given greater priority than confidentiality appears to be emerging in many jurisdictions. This issue is discussed in greater detail below, in chapter 6. DESISTANCE

If the concept of dangerousness and its prediction may be said to be approaching a degree of maturity after a troubled adolescence, the study of those factors that promote stable, non-criminal behaviour after release is only in its infancy. Sometimes referred to in the area of juvenile delinquency as "desistance,"23 the concept has parallels with that of "resilience" in the face of adversity which promotes resistance to psychiatric disorder.24 Methodological problems confound study of this topic, especially that of establishing contact with enough individuals who have left prison and managed to refrain from further criminal activity. In a study of young offenders with moderate or serious criminal involvement as adolescents who had later gone "straight," subjects were invited to volunteer through newspaper articles and by a letter passed on through various agencies having contact with young offenders.25 The 2,0 male participants were asked to rate those factors that they felt were important influences on their desistance. Personal maturation was given the most importance, followed by the support of parents, wives, or girlfriends. Interventions by social workers or corrections staff and the effects of incarceration were given low ratings. In a longitudinal study, the presence of an intact family unit in childhood and adolescence was found to be a major protective factor

40

Management towards Release

in the lives of those delinquent youths who did not go on to adult criminal careers.z6 Desisting subjects also had a lower divorce rate by age 30 than did those who developed an adult criminal record. Investigation of this interesting area is still in the early stages, but such results at least lend indirect support to efforts to maintain and promote family and marital contacts during incarceration and the process of release. The existence of protective factors that may not necessarily be simple opposites of those factors predicting recidivism prompts the speculation that desistance may be seen as a separate dimension from recidivism, which may in turn further refine prediction instruments and offer more fruitful areas for intervention.

5 Community Supervision

General psychiatric services frequently disclaim facilities for offender patients thus often condemning them ... to a disorganized, unsupported and untreated life in the community.1 Community support represents the least-well-developed of the services provided to the MDO. All too often a damaging and costly routine of relapse and reconviction is precipitated by a chain of circumstances that includes failure of mental-health care. Many failures arise from poor communication2 between supervisory and clinical personnel, and remedial efforts have been directed at establishing effective liaison between parole and mental-health services. Better contact has been hampered by lack of resources, but enough progress has been made to make it clear that good liaison can help prevent relapses. Case Study No. 5.1 A 3O-year-old man was admitted for stabilization six months prior to his release at the expiry of his sentence of two years for robbery with threats of violence. He had been detained for the full term of his sentence because of his persistent pattern of violence, failure to control his impulses, and threats against staff. The youngest of five children, he was the only one with a criminal or psychiatric history. From an early age he was described as "unruly, self-willed and given to extravagant behaviour to get his own way." The majority of his life from the age of n had been spent in institu-

42

Management towards Release

tions, both correctional and psychiatric. His adult criminal record preceded his psychiatric problems and included convictions for arson, robbery, and assault. Psychiatric problems first revolved around selfmutilatory or suicidal attempts precipitated by adverse circumstances, and diagnoses were of anti-social personality disorder and drug abuse, but at the age of 24 acute, supposedly drug-induced psychoses were first diagnosed, and by the age of 28 diagnoses included paranoid schizophrenia. With his consent, in-patient admission to a psychiatric hospital was arranged on expiry of his sentence. He cooperated with the admission, complied with medication requirements, and was discharged on a disability pension to a group home. He was subsequently non-compliant with out-patient attendance and stopped taking his medication. Two years later, after a prolonged period without medication, he committed another robbery and was given a sentence of four years. This time round, the psychiatric hospital, somewhat reluctantly because of his previous performance, agreed to repeat the process of admission, stabilization, and discharge to a group home while he was on parole and under a condition of having to undergo psychiatric treatment. The patient, grateful for his first-ever chance to be released on parole prior to any mandatory release, was enthusiastically cooperative with the plan and two years later, still under conditions of parole, reported himself settled in an apartment with a female companion and taking his medication and insisting that he was entirely convinced of the benefits of cooperating with his community psychiatric services. He has continued stable and in chemical remission within the community for a further three years, maintaining intermittent contact with treatment centre staff. Close supervision of a released MDO can reveal signs of an impending relapse, but parole services have few resources and officers carry caseloads too large to allow the individual attention that an MDO often needs. In recognition that a proportion of releases could benefit from more intense supervision, the esc has established a team-supervision unit in Toronto that allows active community supervision of parolees considered likely to reoffend dangerously. Two or more parole officers may be assigned to one individual, and officers have the opportunity to visit their charges at their lodgings or work places for spot checks, day or night. Case Study No. 5.2 A 62-year-old man was serving a four-year sentence for the latest offence in a criminal history of more than 30 years. His previous

43

Community Supervision

offences included property and alcohol-related crimes, breaches of trust, and at least one assault, but over the years his modus operandi has become stereotyped to the handing across of a threatening note to a bank teller in a particular bank in Toronto. His crimes have shown a clear relation to his social circumstances, occurring only when he is destitute and in need of shelter. Passing sentence, the judge agreed that he was a "classic example of a burned-out institutionalized old lag ... There's no hope for him, but ... four years," and recommended that he spend it in minimum-security institutions. The patient's psychiatric history is as long as his criminal record, and he is well known to the psychiatric services of detention facilities in Toronto for a chronic psychotic illness, with thought disorder, paranoia, anger, and a capacity for physical aggression when unmedicated. During this sentence his clinical picture had become modified following a stroke that exacerbated the negative (passive) symptoms of his schizophrenia, and he developed a mildly euphoric mood. As the date for his mandatory release approached, concern was expressed that he would recidivate unless a structured support system was in place, with financial assistance and accommodation. He was placed in a private group home specializing in MDOS, with psychiatric follow-up at a weekly clinic at the parole service offices and run by the team-supervision unit. Significant bureaucratic delays were encountered in trying to obtain a disability pension. Relying solely on welfare payments, he was unable to afford both tobacco and food, and he chose the former when possible. He severely neglected personal hygiene. Accordingly, and with his complete agreement, a temporaryaccommodation provision in new legislation was invoked, and he was returned to RTC(O) while still under full parole, only three months after his release. On arrival he was found to be infested with lice and cachectic. While integration of the released MDO into community mental-health services might represent the ideal both in terms of reducing stigma and in terms of the costs of providing separate services, general psychiatrists are often reluctant to take on these cases. The alternative, of providing an independent, specialist, forensic community service, as has been described for one community,3 might appear to be more practical, at least where sufficient numbers of clients can justify the resources. Simply doing nothing "would mean awaiting scandals and political concern and subsequent committees of enquiry."4 All too often, unfortunately, such is the way that changes are brought about in this area.

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Management towards Release

It is the capacity to impose and, where necessary, act on conditions of parole that makes possible management of patients who might not otherwise accept psychiatric treatment in the community. Conditions of parole for the psychopathic population should be strictly enforced. Cleckley observed that psychopaths may have an idiosyncratic response to alcohol and disinhibiting drugs,5 with rapid onset of disinhibition at small doses, followed by little subsequent evidence of intoxication even with a large intake. This observation, and its importance for supervision and strict enforcement of abstinence, have not received the attention they deserve. Careful monitoring of the psychopathic releasee's reliability in complying with a condition of avoiding drugs or alcohol is essential. Without strict monitoring the psychopath will ignore any restraints. If caught he will often plead that his was only a minor infraction - "just a couple of beers" - of the sort that any ordinary person would commit, and it should be overlooked. The present unreliability of any treatment for this group must be stressed again. The difficulties of managing in the community patients "with histories of psychotically based dangerousness, poor compliance and recidivism"6 have been recognized in a number of jurisdictions. Little is known about the factors that might predict a successful outcome, but adjustment to the community in the form of achieving employment, establishing a network of social supports, and complying with treatment appear to be the most favourable predictors. Improvements in the measures of such qualities on average occur in the first year, suggesting that after that time "concerns such as community safety should take precedence over goals of improved social functioning."7 There has been a bit of research into the effectiveness of compulsory treatment in the community.8 Experience with community-treatment orders in the Australian state of Victoria has been described,9 and one conclusion drawn is that such orders are unlikely to work unless there is in place an effective means of preventive detention that can be invoked in the event of non-compliance.10 A report of three cases in Massachusetts supports the possible effectiveness of coerced community treatment,11 but the legal and ethical problems involved in undertaking such treatment are stressed. Dunn has reviewed these and other studies from a British perspective,12 also exploring alternatives to community-treatment orders. These studies again draw attention to the question of what sanctions are to be imposed in the event of noncompliance. If effective and safe post-release care is to be provided in the community, certain difficult social decisions will have to be made. To force an injection on someone living in the community or to require

45

Community Supervision

readmission is regarded as a serious infringement on that person's civil rights. "The traditional task of balancing protection of society with the civil liberty interests" in the case of insanity acquittees, but equally of MDOS in general, "remains a continuing challenge."13 When the mandatory-release date, or the warrant-expiry date, of an offender falls on a weekend, administrative directions require that the offender be released on the preceding Friday. The utility and fairness of this approach are obvious, but from the point of view of good relations with community mental hospitals to whom a patient might be released, it is unfortunate that so many releases occur on a day when hospital staff are predisposed to resist an admission. The following case illustrates the ease with which considerations of public safety can be forgotten in the reluctance of some community facilities to accept offender patients. Case Study No. 5.3 A 26-year-old man was serving an aggregate sentence of four-and-ahalf years for multiple offences, including break and entry, causing bodily harm by criminal negligence, possessing a weapon while prohibited, and revocation of mandatory supervision. His criminal record extended over ten years and included armed robbery, for which he had completed his sentence just six days before committing his current crimes. For the armed robbery he used a drilled starter's pistol loaded with live ammunition. Forensic tests later confirmed that the gun was capable of firing. The criminal negligence conviction resulted from a high-speed car chase in which two police officers received minor injuries. The charge for possession of a weapon arose from one of the break and enters, when he and an accomplice were caught emerging from a gun store carrying stolen semi-automatic rifles. He had first begun showing the symptoms of paranoid psychosis while incarcerated for armed robbery. He was experiencing auditory hallucinations, or "voices," giving confirmation of his divine origin and talking of a special mission on Earth. On one of his previous admissions the treatment team had obtained a treatment order under the Ontario Mental Health Act (OMHA), which was upheld on appeal to a district court. On this admission, the patient unsuccessfully challenged the finding of his incompetence. His symptoms remained partially responsive to medication, and he continued to deny his illness and to protest having to take his medication. Though his criminal history presented some alarming features, he had not yet caused serious injury to anybody and was not eligible for

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Management towards Release

detention to the expiry of his sentence. With his mandatory-release date fast approaching and no adequate control of his illness established, it was decided that he should be transferred under civil commitment procedures of the OMHA to the mental hospital serving the community to which he was being released. A covering letter was sent some weeks in advance of the release with a package of file information, but no reply was received. Telephone contacts were not returned until, literally in the last hours of the day before release, a chief of service at the receiving hospital attempted to have the patient diverted to the mental hospital serving the community in which the prison was sited; this was refused on the grounds that federal legislation required his release to the other community and overrode the provincial mental-health legislation, which required admission to the nearest hospital. The release went ahead as planned. The hospital accepted the admission but did not uphold the committal and discharged the patient on expiry of the committal form signed by the penitentiary psychiatrist - a Sunday. In the middle of a long weekend, a man with serious criminal convictions and vulnerable to paranoid delusions was discharged into the community with nowhere to go. The money he had brought with him from the penitentiary was still locked in the hospital safe. He was carrying $1.50 in his pocket. In this case the community was fortunate that the hospital had been given a contact number, and a parole officer was available to provide assistance in securing commercial accommodation.

P A R T TWO

Special Issues in Prison Psychiatric Care

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6 Ethical Considerations

Soldiers and prisoners need medical care, with the full rights of patienthood attached, but to provide it we often settle for a compromise with authority. Meta-ethics will not bail us out here, only a recognition of the basic anarchism of medicine. In this the doctor who cleaves to Hippocrates must be arrogant. What tempers his arrogance is the knowledge that repudiation of authority involves a fine-tuned acceptance of responsibility.1 "Can prison medicine be ethical?" asks one authority, z and he answers in the affirmative, provided that certain conditions are met. The conditions he would require are independence from the prison administration, freedom of decision making, equivalence with community health-care standards, freedom of access to medical services, and respect of basic principles of medical ethics, including informed consent to treatment and confidentiality. He observes that these conditions are seldom met. "Can prison medicine be ethical?" he concludes, casually impugning the integrity of hundreds, if not thousands of his colleagues. "It could be but isn't." It might be argued that the conditions he requires are unrealistic. Independence from the prison administration does not ensure ethical medical treatment of inmates - quite the contrary, if services are used that do not accept special responsibility for inmate care. Without such special responsibility, preconceptions and prejudices against offenders will probably confuse proper management, and unethical treatment of prisoners is as likely in the emergency rooms or wards of a general medical teaching hospital as in a prison. More important than independence

50 Issues in Psychiatric Care

of the service is provision of adequate resources. A harassed, overworked, and isolated prison doctor cannot be held to the supposed ethical standards of a well-resourced teaching hospital, whoever is underpaying him or her. Decision making in this environment cannot be free, for it must take account of the contingencies of security. Health care for this special population can be quite different to that required in the community at large, where, for example, the motives of the patient are not normally subject to prudent suspicion. Equivalence of services presupposes that the same measures of service would apply - a supposition that does not withstand close scrutiny. The prison doctor often finds himself or herself restricting access to medical services by certain patients who have an appetite for expensive investigations and amusing trips to the outside hospital. A simple example, common in prisons, is the problem of issuing special shoes for medical reasons. Such shoes are desirable items, inmates are prepared to go to great lengths to cajole or intimidate the doctor into signing the form to get them, and the doctor is forced to spend significant amounts of time on the issue. A worthy ethical aim, of providing for the medical needs of inmates, results in the doctor's becoming enmeshed in a thankless, wearisome task that can steadily erode his or her commitment to medical practice of the kind practised outside prisons. Underlying the critique made by those who appear to feel that prison medicine is inherently unethical is the assumption that ethical behaviour requires adherence to absolute principles that should be independent of the setting. But principles that appear reasonable in one setting can compete in another setting and contradict each other in a third. The assumption of an absolute ethical behaviour is untenable, and in a different article the same author asserts that pragmatism is the cardinal ethical principle in psychiatry.3 In our complex society, "ethical choices that enable one to preserve one's personal moral accountability and empathy have become increasingly difficult to make."4 Respect for the basic principles of medical ethics does not of itself resolve potential conflicts among basic principles, and many such conflicts can be found in prison practice. Perhaps the best current example is the clash between a requirement of medical confidentiality and responsibility to consider the needs of public safety, but other examples are legion. Ethical concerns can include those that arise from use of prediction instruments,5 particularly if they include clinical information; whether forensic psychiatrists engaged in risk-management assessment actually incur a doctor-patient relationship, with all its traditional ethical obligations;6 the questions of consent and coercion in relation to accepting treatment in a restrictive

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Ethical Considerations

setting;7 frequent use of therapists and clinicians untrained in prison work (though this becomes an ethical issue only if one presupposes that ethical behaviour is determined by the setting); and use of information gained during treatment about previously unprosecuted crimes. CONFIDENTIALITY AND PUBLIC SAFETY8

Despite firm statements to the contrary,9 it is not immediately evident in practice that confidentiality must be preserved under all circumstances. A duty to warn a known potential victim of a patient's violence has already been held to override a duty to confidentiality in a number of jurisdictions.10 But the expectation by some that therapeutic professionals working with offenders should act where possible to prevent future crime goes beyond a simple duty to warn a potential victim. Given advances in our capacity to predict, it is now possible for clinicians to identify offenders who are highly likely to reoffend violently, but not to identify a particular future victim. Is it reasonable to expect those people required to make decisions about release, such as parole boards, to do so without being fully informed about the clinical aspects of such cases? Psychiatrists who are exposed to a public inquiry will be left in no doubt that the public and its elected and judicial representatives in fact expect them to place higher priority on public safety than on maintaining the confidentiality of their relations with a convicted felon. Forensic psychiatrists have largely been left "to decide for themselves the balance of duties to the offender, potential victims, and society at large."11 Though much new mental-health legislation has been passed, there has been very little case law established in any country. It is likely that prison psychiatrists will have the uncomfortable role of pioneers in this uncharted territory, as grist for the mill that will grind out legal precedent, but the psychiatrist who refuses to reveal information of possible relevance to issues of dangerousness or violent recidivism will encounter little public understanding or sympathy. While awaiting case law to clarify areas of uncertainty, we can make certain observations. First, problems with obtaining consent to release information are rare in ordinary prison practice. Most inmates will consent to release of information to appropriate bodies on request, if only because refusal might delay consideration of their release. The voluntariness of such consent might be questioned. When a professional tells a client that his release may be delayed if he refuses to release information, is the professional using coercion or simply informing the patient of the consequences of his decisions? Those few inmates who are prepared to embark on extended litigation to protect

52. Issues in Psychiatric Care

the privacy of psychiatric information are often those in whom considerations of risk to the public are very clear. The interim policy at RTC(O) on release of confidential information without the patient's consent (see Appendix A) holds that matters of public safety can override a duty to confidentiality only where information in the file is relevant to dangerousness and public safety. Files are reviewed by a psychiatrist before information can be released, and information will be released only to wardens of institutions, directors of parole districts, or representatives of the National Parole Board who are involved in release decisions. The policy has yet to be tested in law.

"WHISTLE-BLOWING" Prison clinicians will probably encounter circumstances where their role as physician or other mental-health professional places them at odds with the prison administration. Under such circumstances they may come to believe that they have a duty to make the situation known to a wider group. Righteous indignation is not conducive to calm, rational thought, and this is a situation where clinicians should take pains to be both modest and cautious. Most organizations contain what they themselves consider to be appropriate channels of communication for complaint. "Whistleblowing" by definition implies that the person disseminating the information is doing so outside those channels, and before doing that the professional has an obligation to explore official channels as far as possible. A report from the Special Committee on Unethical Psychiatric Practices of Britain's Royal College of Psychiatrists suggests that once these channels are exhausted, and if his or her concerns remain, the psychiatrist is "entitled" to take the concerns to a professional organization and to the professional or ordinary press. IZ Whether he or she does so will depend on his or her own sense of the urgency of the situation and the heinousness of the ethical transgression. It is questionable, for example, whether much can be gained from publicly protesting inadequate allocation of resources. Resource deficiencies for psychiatric care within prisons are endemic. They are embedded in a context of competition for scarce funds allocated by administrations preoccupied with security issues that are not always compatible with mental-health concerns. Correction of these deficiencies can take years, even with a sympathetic administration, and the most the whistle-blower can hope to achieve is to place his or her views on record. In doing so, of course, the clinician can undermine his or her capacity to work constructively with the administration. In such cases, as with cases where the clinician disagrees with policy decisions, placing a dissenting view on record, whether by internal

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Ethical Considerations

memorandum or by a letter to a professional journal, can give comfort to a troubled conscience. However, it is remarkable how easy it is for an administrator to overlook an irate memorandum, and how difficult it is to retrieve memoranda consigned to official archives; the whistleblower, if he or she chooses this method, should send copies of memoranda to others within the organization and keep copies in a place outside the office. It somehow seems more creditable if the professional-as-whistle-blower does not attempt to conceal his or her own identity. USE OF FORCE13

It is a feature of many violent incidents that they do not allow much time for reflection, and the interaction with dangerous patients can be such that total concentration is needed, again leaving little time for reflection until after the event. The fear that something done during these interactions may be seen by others as ethically unjustifiable or even legally culpable can inhibit subsequent analysis and discussion with colleagues. Any examination of personal moral principles can "reveal parts of us that we often hide from ourselves, let alone from friends or colleagues."14 Nowhere is this more true than in the decision to use force. The general medical and psychiatric literature rarely offers any discussion of application of ethical principles to use of force. That force is used in a wide range of health-care settings is undeniable, but little studied. In one recent report of four different institutions (an acutecare hospital, a chronic-care hospital, a home for the aged, and a psychiatric hospital) all used restraints "excessively, especially with older patients," and all lacked detailed documentation on those restrained.15 Even in these settings, the perception that use of force is morally incompatible with ethical professional behaviour only serves to limit recognition of its reality. Clinician-teachers often display a certain impatience with academic ethics,16 and the clinician in prison practice may well agree that "the constant recycling of high-sounding ethical principles is of little help - mainly because as rules or guidelines they tend either to contradict each other or to be mere platitudes."17 It is simple-minded to cling to a single principle as a guide to action,18 but the attempt to list and weigh against each other the competing values involved in any one case can lead to paralysis and indecision, to the further detriment of good patient care. Philosophical approaches to clinical ethics too easily become "a conversation in the Tower of Babel with no common language for ethical analysis."19 Recognizing that the ultimate purpose of striving

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to be ethical can get lost in such discussions, Devettere suggests that the personal happiness of the clinician, rightly understood, is a legitimate and important goal. "Personal happiness rightly understood is living justly, temperately, courageously and lovingly."zo It may seem complacent or insensitive to include a criterion of personal happiness, even defined in such a way, in consideration of the ethics of deciding to use force against another person, but experience quickly teaches that the hardest task in making these decisions can be that of being able afterwards to live in peace with one's conscience. Force will be used in prisons, for that is in their nature. The clinician can hope that his or her presence will moderate the use of force, that force will be used only as a last resort, and that its purpose will not be punitive but to minimize the risk of serious injury to all involved. Every case must be assessed on its own merits and in the full knowledge that it may be subject to detailed public examination after the event. Under that scrutiny it will be necessary for the clinician to show that he or she has given professional consideration to the practical and ethical issues involved. It will probably not be sufficient to demonstrate adherence to a pre-established set of guidelines or policies or to cite sanction for use of force given by a higher administrative authority. The clinician called to account for a decision to use force will stand alone. Here the quotation that opened this chapter21 becomes relevant. What Comfort describes as "the basic anarchism of medicine" is another way of saying that there is no appeal to higher authority. By participating in the decision to use force the clinician accepts personal responsibility that cannot be passed on. In accepting responsibility the clinician recognizes that his or her own conscience must be the deciding factor, and his or her personal happiness, as defined above - his or her capacity to live with the decision - assumes an importance that overrides ordinary pragmatism. It is with such a perspective that the prison clinician who cannot simply look away might reconcile very difficult professional and ethical conflicts with the need to maintain some sense of dignity and self-respect.

7 Predatory Sexual Behaviour in Prisons

Personality-disordered offenders present a number of challenges to mental-health services within a correctional system. Psychopaths who, for whatever reason, place few constraints on the exercise of their most casual impulses towards self-gratification will behave in an exploitative and threatening way towards their weaker peers, and such behaviour can be very difficult for administrations to control. Adjustment disorders often take the form of brief regressive deterioration, accompanied by aggressive or self-mutilatory behaviour. Prison populations are recognized to be at high risk for suicide. The following chapters address some of these aspects of psychiatric practice that are pertinent in the prison context. Though well recognized as an aspect of prison cultures, predatory homosexual behaviour has received little attention from researchers. Sagarin1 considers three groups of incarcerates - most of them previously heterosexual in orientation - that might become involved in homosexual relations. In a brief report of experience with a maximumsecurity population11 note two general types of facultative homosexual behaviour apart from mutually supportive coupling - exploitation for sexual favours of a low-status inmate, who may or may not be effeminate, by a number of others, and predation on younger, "attractive" inmates by older men serving long sentences. Homosexual predators are frequently psychopathic, and they distribute themselves within a prison in a similar fashion to biological predators in a prey population.3

56 Issues in Psychiatric Care Case Study No. y.14 "X" is a 55-year-old Caucasian male under a life sentence for second-degree murder and has served n years. Periodically, he will get into conflict either with his peers or with staff and will claim suicidal ideation or mutilate himself to escape the situation. He stresses that he does this not from fear but from a wish to stay out of trouble. On the occasion of this admission he had become involved in a fight and, while in solitary confinement, had gnawed a hole about 5 cm by 2, cm into the flesh of his inside left elbow. He had done so more out of anger than out of any genuine suicidal urge, even though he was trying to bite into a blood vessel. Emphasizing his sincerity, he pleaded for treatment aimed at his poor anger control, and this was agreed to on the condition that all areas of his behaviour, including his sexual activities, be open to examination. X has no memory of his mother, who placed him in an orphanage at a young age. He was eight when his father, a non-commissioned officer in the armed forces, took him from the orphanage. He describes his father as a bitter, punitive man, alcoholic and unpredictably violent. There is an older sister with whom he has maintained no contact. His childhood was unhappy. Hating his father, he felt himself rejected by his peers and did not do well at school. He was twice sexually fondled by a male friend of his father's. At the age of 12. he was committed to a reform school following an assault on his teacher, which he justified as retaliation for beatings. He was already experienced with street drugs, alcohol, and solvents. From the age of 17, his criminal record has been nearly continuous, including property-related crimes, frauds, numerous assaults - some with weapons - and an attempted murder. He has never been employed but has drifted across the country. He was married twice to prostitutes. He recently wed a prison visitor. He has spent by far the greatest portion of his life since the age of 14 in penal institutions. His institutional behaviour is characterized by frequent fights with other inmates, threats against officers, and possession of contraband and weapons. Psychiatric assessments, in the context of forensic issues or reactive states, often including a selfmutilatory episode, consistently note his long history of criminal activity, his lying, and his extreme hostility and aggression; diagnoses have been of psychopathic personality disorder and its equivalents. Within hours of admission he became assertive and demanding of special treatment. A squat but muscular and still handsome man, he

57 Predatory Sexual Behaviour in Prisons

showed contempt for his fellow psychiatric patients, or "bugs." Mental-state examination revealed nothing apart from his complete failure to accept responsibility for any of his actions and lack of empathy for others. He could unhesitatingly be described as callous and remorseless. Over the weekend he was denied access to his shaving equipment for a short period. He threatened the nursing staff and ordered his fiancee over the telephone to complain to her member of Parliament, which she did. When his handling of this situation was questioned at interview, he became angry with the psychiatrist, accused him of being threatening, and insisted on being discharged. But during his short admission and while he was cooperating with staff he was able to complete interviews about his sexual behaviour in prison. X does not consider himself to be "gay" - rather, he regards himself as a "normal" male, perhaps with stronger sexual urges than most. By his account, he first became involved in "so-called" homosexual activity about the age of 30 during a long prison sentence. Reports on file state that he had begun hanging around gay bars in his early teens and has continued to do so in the short periods he has been free. The reason he gave for turning to homosexual activity was that a man of his appetites needs an outlet, but he added that an emotional component frequently enters into a relationship, with much the same feelings of jealousy and pride of possession that he regards as normal to a heterosexual relationship. He describes a seductive approach by him involving the offer of drugs in his cell, but such is his reputation that youths approached in this way might often panic and sign themselves into segregation or demand transfer. He has trouble understanding this, except that they might be using a manipulative ploy to secure transfers, because he does not see himself as violent or threatening. In his view, the kids that he approaches are already feminine, "sluts" who lead him on, sheltering behind his readiness to fight, even provoking conflicts. "They're not stupid, they know what they're getting into." In conformity with his masculine self-image, he denies being any but the active partner, and he prefers penetrative anal intercourse. He is believed to have caused significant rectal damage to some victims. Anecdotal accounts from victims suggest that dominant masculinity may in some cases be a facade and that it may in fact be the "wolf" who, after insisting on secrecy, "goes down." "Fisting," or insertion of a hand completely into the rectum, is something that X denies having done. This is a practice with different connotations from those perceived by experienced homosexuals with an already enlarged anal sphincter, who may do it for pleasure. In prisons it

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is conjectured to be a form of punishment and to render the victim undesirable to other predators. X evaded questions about numbers of victims involved. Idealized relationships might last "years," but, in practice, the young offenders are often serving shorter sentences and do not spend a lot of time in maximum security. Conservative estimates might be two or three a year. While he is frequently in trouble with authorities over other matters, they are curiously cooperative with this aspect of his behaviour, agreeing to "double-bunking" a young man into his cell and arranging a quiet transfer if the relationship breaks down. Regarding the question of AIDS, he does not believe that he has ever caught any diseases from this activity and has trouble incorporating use of a condom into his masculine self-image, but - and this could be a crucial issue in terms of prophylaxis - he might be willing to use one if his partner insisted. The need to maintain at least the appearance of a mutual relationship with elements of affection might allow him to humour the other's wishes. The penitentiary where X was placed at the time of this study is not typical, being a protective-custody institution with a high proportion of sex offenders. According to X, who has wide experience, there is more predatory homosexual activity there than in other penitentiaries, but the behaviour is very similar to that described elsewhere.5 In a population of about four hundred, we estimated that there are at least five active predators, one of whom employs force and does not attempt, like X and most others, to establish relatively more enduring relationships. Prison rape has been emphasized as a possible factor in high prison suicide rates.6 The immediate and long-term consequences of sexual assault on men are very similar to those of female rape victims.7 Sagarin describes changes in choice of sex object associated with postrelease confusion of sexual identity in many victims of prison sexual practices,8 but his subjects were identified retrospectively in the community through homosexual social channels. The aggressors he examined showed coarsening of their post-release sexual behaviour but lived "normal" or exclusively heterosexual lives. To our knowledge, some victims have gone on to become predators, and a similar brutalization of sexual practices may well affect more victims. In contrast to Sagarin's findings, prison nurses report that affectionate and supportive homosexual coupling in prisons is not uncommon. The csc's recent decision to allow distribution of condoms within federal penitentiaries9 is overdue, if only for this group. But without systematic educational efforts, preferably at induction, "involuntary

59 Predatory Sexual Behaviour in Prisons

recruits" for homosexual acts10 may be unaware of opportunities to control or reduce high-risk activities. Many do not realize the particular risk of passive anal penetration and the relatively lower risks involved in fellatio. The facultative homosexual predator is unlikely to use condoms unless pressed by his partner, but such pressure may be successful in some cases. Single cells may help in controlling prison homosexual behaviour.11 Proper attention to use of needles11 in prison13 will also reduce the risk of HIV transmission. Though administrative resistance to needle exchanges in prisons can be predicted to be extreme, education and provision of bleach for cleaning needles may have some impact. But questions have been raised about the effectiveness of household bleach in controlling transmission of HIV through contaminated needles/4 Apparently, low numbers of HIV carriers entering some correctional systems suggest a "window of opportunity" for prevention strategies,15 most appropriately through voluntary programs emphasizing education and counselling.16 These approaches have an urgency that grows as we come to understand more about the AIDS epidemic and the role of infected, promiscuous, heterosexual males in determining rate of spread of this disease in the population at large.

8 Self-Mutilation in Prisons

Prison inmates are at high risk for self-mutilation,1 particularly the personality disordered and habitually violent.2 Extreme forms of selfmutilation are encountered and possibly show a different epidemiology from those reported from the wider community.3 I S O L A T E D BUT S E R I O U S ACTS SELF-MUTILATION

OF

Case Study No. 8.i4 A 44-year-old Caucasian male and first offender is serving a life sentence, with a minimum of 15 years, for a double homicide. He was admitted to RTC(O) for psychiatric assessment following reattachment at a local general hospital of an almost totally severed penis. By his own account, after serving four years, he had transferred to his present institution from a different region of the country two years ago, to be near relatives. He had been turned down for regular counselling with the prison psychologists. Frustrated by what he saw as lack of awareness of the seriousness of his needs, with "no one careing to give me a light to briten the hallway of the future" (quotation from a written autobiography prepared during initial assessment) and facing long-term imprisonment, he formed the intention of killing himself. He was aware that many intending suicides slash their wrists to no avail but had recently read of someone bleeding to death after his

61 Self-Mutilation in Prisons

genitals had been severed. After careful planning over some days, in the early hours of one morning he sawed deeply into the base of his penis with a razor blade; his "intention was to total cut penis and scrontom [sic] away then bleed to death." Thinking that he had cut through his penis, he fainted. The next morning he stayed in bed, claiming "flu." By the evening, bleeding had stopped, and he reported his condition to the staff. Because of the time elapsed, initial surgical treatment in hospital was directed towards cleaning the clotted blood and tissue, repairing the urethra, and healing by secondary intention under cover of a mixed antibiotic regime. In the days following, the patient showed interest in the wound, assisted nurses with dressings, and performed the hydrogen-peroxide cleaning. After three weeks, the wound was closed and healing well, with good urinary function. He was transferred to RTC(O). The second oldest of a family of seven children, he describes his childhood as unhappy and himself as shy and lonely. His father was a drinker, violent with his wife and a strict and unpredictable disciplinarian. In his autobiography, the patient describes with vivid feeling the memory of his father tricking him into inhaling a cigarette at about the age of three or four, and though "he realy didn't mean to heart me did he? To this day I feel some how he was pervers in his action." His mother too was strict, but a source of stability. His parents separated when he was an adult. He characterizes his older brother as a bully, whom he also has trouble forgiving for incidents in his early childhood, but he loved his younger siblings, especially his sisters: "In a special way girls were then soft beautiful things of caring." He suffered from nightmares and recalls another incident when, at the age of eight, his father forced him to put on a diaper in front of his siblings; "needless to say I never wet the bed again." He was as a child fondled sexually by older men but never reported these incidents. At 14 he was caught in his sisters' bedroom. "I'd go in at night late and lift the covers and try to pull her P.J. down." His father beat him with a broomstick before calling the police, but he maintains adamantly that he was only looking. "Tell the truth I wish some how that I was her." After running away from home, he was sentenced to a year at training school. He went on to complete grade ten at school and described himself as an average student, better at technical than at academic subjects. At that stage, when he was 17, his father threw him out of the home because he had begun to take instruction to change his religious affiliation, under the influence of his girlfriend of two years. This was the girl he was to marry at age zo when she

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became pregnant. He had qualified as a plumber, and he worked as such, changing employers six times or so over the next 15 years. His account of the marriage has not been independently confirmed and seems at times self-serving and self-exculpatory. There were separations and doubts even before the wedding. According to his account, his wife came to believe that he had robbed her of her youth, and she became sexually promiscuous, despite their own satisfying sex-life. In particular, she allegedly developed an affair with a youth living in the neighbourhood, considerably younger than she. The patient and his wife separated on a number of occasions. He experimented with recreational drugs, including hallucinogens, PCP, and cocaine, but preferring cannabis. His first experience of amphetamines was so good that he never repeated it, for fear of addiction. He described himself as a moderate social drinker. At the time of the crime, charges that he had sexually abused his daughters had just been dropped, for lack of evidence. The family, quarrelling and ambivalent, embarked on a four-week holiday at a seaside cottage. The night before the family was due to return home, he saw his 15-year-old son standing at the bedroom door. Allegedly confusing him for the youth he believed to be his wife's lover, he went "on a rampage of death I guess as he was naked in the doorway to our bedroom." He claims no clear memory of subsequent events but does not dispute that he shot both his wife and his son, and he was arrested taking his daughters back to his mother's home. On admission to RTC(O) he was a wiry, balding, bespectacled man of low-average height, looking older than his years. He gave wandering and over-detailed replies in questions but showed good eye contact. At times, talking of his family, he fought against tears. He reported a good appetite, no recent weight loss, no change in his normal sleep pattern, and no diurnal variation in mood. Mental-state examination showed nothing remarkable. He settled on the ward without apparent distress, cooperating with staff but remaining socially distanced from other patients. Psychological assessment of the man was undertaken within the framework of hypotheses generated by literature on genital selfmutilation. Results of three MMPIS on file suggested that he was an individual who tends towards obsessive thinking but who is evasive and defensively oriented during discussions of psychological difficulties, particularly if these carry potentially negative connotations. No psychometric evidence of latent or manifest psychosis was seen. These findings were confirmed at interview, where the patient's replies were somewhat evasive but not supportive of serious mental disorder.

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The patient discussed his wish that he had been born a woman. He referred to dressing up in female clothing as a boy, a practice he abandoned but one that adds to the picture of long-standing confusion about sexual identity. He admitted that he has occasional homosexual urges but stated that he never acts on them and considers himself to be primarily heterosexual. Religious and biblical allusions emerged, particularly in reference to sex roles. In later interviews it became clear that he firmly believes that he attempted suicide over remorse at the killing of his wife and his son. He attached particular significance to the fact that he had survived this attempt, concluding that he was not meant to die "by his own hand," and he appeared to reduce his tension somewhat by this interpretation. He was positively oriented towards the future and expressed a desire to return to his parent institution, where he could meet educational and career goals and prepare himself for the possibility of parole when he becomes eligible. He was discharged to routine psychiatric follow-up 14 weeks after the suicide attempt. Follow-up after one year showed continuing stable adjustment to incarceration. Final diagnoses were of genital self-mutilation, adjustment disorder with depressed mood, and personality disorder of a mixed type. Isolated but serious acts of self-mutilation do not, in our experience, conform to the pattern suggested in the literature of being strongly associated with psychosis and youth but, in the penitentiary population at least, appear to occur more in the third and fourth decades and in association with personality disorder or gender dysphoria.5 Genital self-mutilation has often been reported in the context of single, noteworthy case studies,6 which, as the following series accumulated over ten years suggests, may not be typical of cases encountered in the correctional environment, since only one was diagnosed as psychotic. Case Study No. 8.2 (Series)7

(i) A z3-year-old inmate was incarcerated for life for the seconddegree murder of his mother, which occurred during an argument about his transsexual behaviour. He inserted foreign bodies into his scrotum as an attempt to force surgical castration. During reparative surgery his physique caught the attention of the urologist, and subsequent tests confirmed an XYY karyotype. Three years later he lacerated his scrotum, intending castration, as part of a suicide attempt in protest at prison authorities' refusal to finance sexreassignment

64 Issues in Psychiatric Care

surgery. Final psychiatric diagnoses were of transsexualism and schizoid personality disorder. (2,) A 5O-year-old immigrant, also serving life for murder, cut his scrotum, removed his testicles, flushed them down the toilet, and then swallowed the razor blade. He revealed that he did so to preempt a Mafia-inspired scheme for other inmates to crush his testicles in punishment. Final diagnosis was of paranoid schizophrenia. (3) A 38-year-old inmate, serving two years for theft, and with earlier convictions for prostitution, lacerated his scrotum, removed the right testicle, and by stuffing the cavity with cigarette ends forced surgical removal of the other testicle, too. Diagnoses were of transsexualism and antisocial personality disorder. (4) A 41-year-old man lacerated his scrotum as part of a suicide attempt after revocation of his parole. He had served ten years of a composite Z4~year sentence for a series of rapes. While out on parole and because of impotence he had refused continued provera treatment, which in turn lead to the revocation. Diagnoses were of adjustment disorder with depressive features and anti-social personality disorder. (5) A 4O-year-old transsexual, who had castrated himself a year earlier, slashed at his penis in protest at being placed in a male, rather than female institution after his conviction for a series of armed robberies. He repeated the act three years later. Diagnoses were of gender dysphoria and personality disorder, unspecified. (6) A 34-year-old serving ten years for six counts of robbery almost completely severed his genitalia and slashed his wrists, intending suicide. He did it, he said, to punish himself. His sexual orientation was normal; diagnoses were of substance abuse and borderline personality disorder. (7) A 2,7-year-old transsexual was serving a 15-year composite sentence for assault and attempted murder. While under the influence of "brew" and illicit drugs, he attempted self-castration to force sexreassignment surgery. Diagnoses were of transsexualism, substance abuse, and personality disorder, unspecified. Experience at RTC(O) so far does appear to confirm a good prognosis for immediate restorative surgery, where possible, and psychiatric

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treatment.8 Repeated compulsive acts of self-mutilation are much more difficult to treat. CHRONIC

SELF-MUTILATION

Case Study No. #.3 A z5-year-old Caucasian male was admitted to RTC(O) on transfer from a different region. He is serving a life sentence with a minimum of 15 years for the brutal murder, at the age of 2,2, of a homosexual man who had invited him to his apartment and whom he intended to rob. He had a disrupted childhood, with no consistent parent figure apart from his paternal grandmother, and he developed into a disturbed and isolated adolescent with an interest in Satanic rituals. He became involved with alcohol and drugs, and it was to finance these habits that he started out on his crime by allowing himself to be picked up at a gay bar. He had a prior history of suicide attempts and self-mutilation by slashing, with admissions to a number of psychiatric hospitals. While on remand, and during the process of his trial, he had coped with his anxieties by thrusting a sharpened pencil into the skin of his torso and upper arms in a methodical manner that left his upper body covered in carefully spaced triangular scars, sparing only areas covered by two large, inverted pentacles tattooed on his deltoid and chest. In prison, and in addition to a number of wrist-slashing attempts precipitated by minor setbacks and frustrations, he had in one period of solitary confinement neatly branded the back of his hand and his forehead with the number "666," using a bent paper-clip. During the admission assessment, the patient remained withdrawn and socially isolated; after transfer to a long-stay, sheltered range, where he was relatively less disabled than his fellow patients, he became ward cleaner. He was pleasant and, in one violent incident involving another patient, protective towards staff, but several months later he and another inmate, presumed to be the instigator, forced a female nurse into a cell and were able to hold her hostage behind an improvised barricade for over 48 hours. The hostagetaking was abruptly terminated by an emergency-response team as the other hostage-taker was in the act of hanging himself, and the nurse was rescued physically unharmed. At the subsequent trial the patient broke into fits of giggles when the judge ordered that he should have no access to firearms for five years. Both inmates were transferred to a special handling unit for the seriously violent.

66 Issues in Psychiatric Care The patient was seen for psychiatric follow-up at a maximumsecurity institution 18 months later. By this stage, he had developed the habit, almost a weekly ritual, of selecting an area of his torso or arms of about 5 sq cm and covering it with a neat lattice of superficial lacerations. These areas would then be carefully disinfected and dressed with sterile materials stolen from the prison hospital by a friend. The ritual complete, he would experience relief of tension and sleep peacefully. On examination, which he reluctantly allowed, none of the sites was infected. He had chosen several areas to disrupt the lines of the inverted-pentacle tattoos, on the argument that this might help "break the hold of evil" over him. He would periodically become suicidal at failures to contact his increasingly demented grandmother. As of the last interview, he had once again secured the position of cleaner on a sheltered range for the mentally disabled and took justifiable pride in its gleaming cleanliness. He denied any further episodes of self-mutilation, having, as he put it, discovered the healing value of prayer. His diary, illustrated with carefully drawn and coloured drops of blood, which he allowed the psychiatrist to read as a gesture of trust, contradicted this claim: I'm shutting myself off to people. Too many mind games. I don't need their fuckin friendships or headgames. If they want my blood, then that's exactly what they will fuckin get. Fuck them all. It seems that the only time I'm in charge of myself, is when I'm drawing blood from my arms. Total control of my reality is when it comes down to a choice, do I just scratch the skin with the razor, go deep, or go for the vein and jump in bed and bleed to death. Truly the feelings that come can only be described as relief, and calmness. A truly wonderful experience. Watching the blood drip from my arm and hit the side of the toilet bowl. Crimson colour invading the surreal white pureness of the enamel. The drip, the hit, the explosion of genetic upheaval, as the drop of blood explodes on contact with the bowl. During his years of incarceration, doctors had tried numerous major tranquillizers and anti-depressants, including clomipramine, without apparent effect on his mental state or his tendency to self-mutilation. A three-week trial of fluoxetine was, perhaps coincidentally, associated with rapid onset of homicidal ideas and severe onset of selfmutilatory behaviour. His management over the following year was complicated by his preoccupation with the act of suicide and occasional letters to his psychologist or psychiatrist referring to "headgames" and the sense that he was a player in a complex game against the system and those in authority.

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Early one September afternoon, without any prior evidence to suggest his intentions, he hanged himself in his cell. WRIST-S LASHING

"Slashing" at the wrists has usually been identified with female patients, and efforts have been made to establish a particular syndrome of wrist-cutting.9 The extent of male wrist-slashing has probably been underestimated because it often occurs in an institutional setting,10 where superficial or minor slashings are handled by nursing or medical staff and not routinely referred for a psychiatric opinion unless they are accompanied by unusual or bizarre symptoms. In prisons, slashing represents the most common method of attempted suicide,11 in contrast to completed suicides, in which hanging is by far the most common (see chapter 9). Motives for slashing may be mixed, there is very often a clear situational component, and the inmate may be seen as trying to coerce the administration perhaps to let him escape from a threatening environment.12 The offenders themselves will frequently offer an explanation of manipulative intent, but this should not always be accepted at face value.13 "Manipulative" attempts should also not be dismissed as lacking in seriousness; in one study of completed prison suicides 43 per cent had shown previous self-injurious behaviour,14 and in another, 59 per cent "had either demonstrated manipulative attention seeking behaviour or presented problems of control."15 Among personality-disordered patients, self-mutilators are distinguished from a non-self-mutilating comparison group by their more severe character pathology and the presence of aggression, impulsiveness, and anger.16 MANIPULATION

The problem and management of the manipulative patient within psychotherapy have been well discussed,17 and, while the term may be seen as pejorative18 or nebulous in definition,19 recognition of such behaviour is important in the correctional environment. A letter to a psychiatrist at RTC(O) reads: Dr. Z, On tuesday evening I was interviewed by a psychiatrist who also thinks I should be re-admitted to RTC. As a matter of fact he has referred me to RTC for assessment and programmes.

68 Issues in Psychiatric Care But according to Nurse W (who seems to think she knows more than a psychiatrist) "I will have to slash up before I am even remotely considered for another start at RTC". So, as you very well know, the minute I run out of tobacco, she will get her wish, so to speak. (And, even before you get to read this, probably, I will be smoking my last smoke). (For, I have but half a pack left). (So, by the time they get this memo to your attention, I could be "expediting" matters in my usual fashion). They always tend to wait till I show them I mean business before acting on either my requests or Doctor's referrals. Well, they wont have to wait very long this time. And, the psychiatrist who saw me agrees that my case should be given top priority and speedy consideration. He even increased my PRN medication. As you know, where there's a will - there's a way. So, come hell or high water, I will be a candidate for "sutures" very soon after I smoke my last cigarette. Only two acts can avoid all that paper work and "sowing": A: Re-admittance to RTC and/or B: A supply of tobacco and writing material before I run out of my current supply. We dont have much time. So, unless you dont give a fuck, I would strongly suggest that you do not call my bluff. For, in the past, I've always kept my promise, Sincerely, Here the psychiatrist can be of assistance not just to the patient, in terms of setting appropriate limits to acceptable behaviour, as described in Murphy and Guze's paper,xo but also in terms of enabling the frontline correctional staff to cope with the extreme threats that such patients can make and carry through. The presence of a manipulative motive does not mean that the attempt will be mild or non-lethal,21 and without professional support front-line staff will remain vulnerable to manipulative threats. Great care should be taken in "calling a bluff," or appearing to challenge a patient to carry through on his threat to slash or otherwise harm himself. In doing so, the clinician may be seen as accepting responsibility for the patient's behaviour and inviting a potentially lethal action. A more effective method, when one is sure of manipulative intent, is to write, and make known to the patient and institutional health-care staff, a report to the effect that the patient has been examined by a psychiatrist and has been found, as far as can be determined, to be sane and rational. The report should stress that only the patient, and no one else, can be held responsible for his

69 Self-Mutilation in Prisons actions. He can then be returned to the care of the prison administration. Rather than being a "cry for help," many self-destructive acts by an anti-social personality, up to and including suicide or even murder, in prisons as outside them, seem to be saying something along the lines of "now look what you have made me do."

9 Suicide in Prisons1

Relative to the psychiatric centres of other regions of esc, 2 RTC(O) has proportionately fewer psychiatric beds to service its catchment population - 67 beds for some 3,700 inmates. As a consequence, in-patient care must always hold as a priority early return of the patient to his parent institution. An Ambulatory Services Programme was established in 1987, with one - now three - full-time psychiatric nurses, who visit all the major institutions to monitor the discharged patient at the parent institution, organize follow-up psychiatric care, and consult with the institution on the patient's management. The program has been successful in terms of reducing readmission rates and reinforcing the confidence of institutions in their capacity to support the mentally ill within general prison populations. We believe that there is a reduction in suicide rates in the region, but, as Figure z demonstrates, numbers have fluctuated widely, no doubt for many reasons. "It is important to remember that suicides, whether they take place in or outside prison, are rare events, and that it is difficult to prevent such an event ... The suicidal prisoner presents with few characteristics which would assist the process of identification."3 RESEARCH ON THE P R E D I C T I O N OF SUICIDE

Specific research on prison suicides has been limited, and published studies have tended to follow a stereotyped format. The relatively high risk of suicide in prison systems is stressed. Incidence may be said to

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Suicide in Prisons

Figure 2, Suicides in penitentiaries served by ambulatory services, Ontario region, 1981-91

be rising,4 but figures are subject to challenge,5 and, indeed, high rates relative to the community are not a consistent finding.6 Calculation of incidence in custodial establishments can be complicated7 and does not always take into account such factors as the high rate of population movement. The initial phase of imprisonment is identified as the most vulnerable time (but "some suicides occurred many years after reception into prison"8). Prisoners on remand9 are the highest-risk group,10 there is an excess of violent and sex offenders and those serving life sentences,11 and a history of psychiatric problems is common. The most common method of suicide by far is hanging, followed by slashing and drug overdose. Much of this research is of little help in Canadian federal penitentiaries because there are few young, first-time offenders who have not already spent a significant amount of time in other prisons before entering this particular system. Green and colleagues," examining 133

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suicides of Canadian federal offenders during the period 1977-88, find that suicide is not more common in certain age ranges and no significant relation to type of offence or length of sentence. One of the 133 suicides was a first-time offender. Most suicides were unmarried, separated, or divorced, and most had earlier attempts. Previous psychiatric problems were common, and the majority of suicides had a history of problems with alcohol and/or drugs. The time of the act of suicide was spread evenly throughout the 24-hour period. P R E V E N T I O N OF

PRISON SUICIDE

"A number of authors have suggested methods to prevent jail suicide, although few have been evaluated rigorously, and their appropriateness in long-term prison populations has not been determined."13 The frankness of Salive and colleagues in acknowledging the lack of useful research on prevention does not stop them, like virtually every other author, from making assertions on how correctional services should go about preventing suicides. On the same page as the quote above, they affirm that "security staff should be aware of the importance of inmate suicide as a preventable problem so that they can be involved in prevention programs." It is customary for authors making recommendations in this area to distinguish between secondary prevention, aimed at the particular individual already identified as at risk, and primary prevention, which addresses factors in the environment that might reduce overall suicide rates. Basic principles in secondary prevention are laid down in an article by Rakis and Monroe, "Monitoring and Managing the Suicidal Prisoner." They call for special facilities to house the suicidal, with the opportunity available for special observation, including 24-hour, oneon-one surveillance if necessary; measures to recruit family and friends to help authorities identify potential suicides; and use of "inmate observation aides" as part of a "comprehensive program." However, little consideration is given to the ever-present problem of ensuring that resources for such an expensive approach are available to those truly suicidal and are not overwhelmed with inmates merely seeking "relief from the obligations of the imprisoned."14 There is little evidence that such programs can be effective; indeed, "[cjonvincing arguments can ... be made against the effectiveness of prevention strategies aimed at identifying the at-risk individual and attempting to prevent his suicide."15 Individual risk factors are not of themselves informative; for example, attempted suicide is a recognized risk factor for later suicide, but in one British study in 1986 only 21 out of 8,500 inmates with a history of previous attempted suicide

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committed suicide.16 Even the most exhaustive of checklists of such factors would produce many false positives. As a consequence of the prison culture itself, with ethics of "doing your own time" and freedom to choose to die, cooperation of other inmates in identifying those at risk may be limited. Recommendations for primary prevention generally require politicians and administrations to plan and implement measures in advance. They require the judiciary to change policy on remand and sentencing and demand consideration of prison design before prisons are built. They require higher staffing levels, and implementation may have little to do with front-line members of staff, who are nevertheless often asked to communicate better with inmates. Primary prevention can be very expensive, and those who recommend it seldom examine the costs. "When considering the prevention of suicide in prison it may be more appropriate to emphasise general measures designed to reduce stress and promote coping mechanisms, rather than concentrate on the recognition of the suicidal prisoner."17 "Opportunities for the primary prevention of suicide lie in the use of alternatives to imprisonment, in hospitalisation and treatment when appropriate and in policies that are designed to reduce the stress of imprisonment by improvements in prison conditions and the provision of adequate support services for prisoners."18 Such statements can appear naive in the context of rising prison populations and economic constraints. "Common sense might suggest that people who kill themselves in prison do so because they are in prison,"19 and most administrations are likely to agree with her majesty's chief inspector of prisons that "general penal reforms were not justifiable on the basis of a single issue such as suicide."20 "[I]t is hard to imagine any humane system of custodial management which does not allow the prisoner some privacy and time alone."ZI But so long as that principle is accepted, opportunities for primary prevention of suicides in prison remain limited. Though they always admit that predicting suicide in prison is very nearly, if not definitely, impossible, and they sometimes concede that preventive efforts are speculative or impractical, researchers generally conclude with a recommendation that further research could change this pessimistic assessment. But will it? For over forty years attempted suicide in developed countries has been recognized as a major public-health problem. In that time, the social and personal costs of treating drug overdoses and other selfinjurious behaviour have been incalculable. A huge, multinational research effort has been mounted to discover the reasons why people

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attempt suicide and to try and reduce the damage caused, and an enormous number of articles and books have been published. And yet, in reviewing one of the pioneering books on the subject, an authoritative professor of psychiatry commented: "Ironically, having come to realise the full complexity of its aetiology, effective intervention in terms of both primary and secondary prevention of attempted suicide still eludes us"2'2' If such massive research into a much more common event can fail to produce a practical approach to prevention, then it might seem unrealistic to suppose that further research into prison suicides is going to make much difference. THE PROBLEM IN PRACTICE

It is everywhere recognized that the people who only attempt suicide are different in significant ways from those who succeed, though the two groups overlap and a history of suicide attempts is accepted as an important risk factor for suicide.23 In prisons, overdose with drugs or medications is rare, and the usual way to attempt suicide is by "slashing" - inflicting wounds on wrists and/or forearms, usually with a razor blade24 - or by hanging. The great majority of completed suicides are by hanging, but slashing attempts should not be dismissed as nonserious or manipulative.25 In practice, attempted suicide is the most common way in which potential suicides are identified. The other way is somebody's expression of suicidal intent. It is rare for potential suicides to be identified from other behaviour unless the risk is part of an apparent mental illness. The group of mentally ill inmates in fact consistently represents a considerable proportion of prison suicides,26 which are among the easiest to prevent. Timely and effective treatment of the illness can reduce risk, and it is this group that psychiatric services can most help by conventional psychiatric methods. Schizophrenia27 and depression28 carry an increased risk of suicide, and, as the following case demonstrates, even with the best of management the determined or noncommunicative patient can succeed in killing himself or herself. "It is fortunate that such unambivalent suicidality is the exception to the rule."29 Case Study No. 9.1 A 43-year-old Caucasian male was admitted to the RTC(O) for stabilization of a known, chronic schizophrenic illness. He was starting a

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three-year sentence for a bank robbery in which he had passed over a note to the teller and waited to be caught. He had a 2,5-year criminal history, with three previous federal terms, with convictions mostly for robbery and thefts but including four for assault. In his childhood he was abused by his father, a chef and alcoholic, who died aspirating vomit. His mother died of a heart attack three years before his admission. He had no contact with any of his five half-siblings or one full sister. He reached grade nine at school but quit at age 15 and had had only unskilled employment since. He had extensively abused alcohol from his teens, reporting occasional blackouts, and had used amphetamines intravenously. In his day he was known as Toronto's best street-fighter - "I've been fighting all my life" - but he denied earning money that way. He had numerous psychiatric admissions, both within and outside prison, with diagnoses of paranoid schizophrenia. He reported one previous suicide attempt, by hanging, during an earlier federal sentence but stated "I can't hang myself because the computer, er, I was too tall, the computer put me on my feet." Asked if the computer talked to him, he paused, "It's saying, 'No, I'm not talking to you right now, Bobby.'" He was tall and slim, with a battered and scarred face and missing teeth and an expression of slight bewilderment, but he moved with an athlete's coordination. He had a fixed delusional system, believing that the government was out to get him because "you might find this hard to believe, I saved the world from starvation, by fighting, I'm the Son of God" and had cured inflation. Now that he had saved the world, he said that he had nothing left to live for. Diagnoses were of chronic paranoid schizophrenia, with probable brain damage secondary to repeated injury, and possible low initial intelligence. He was identified as a potential suicide risk. On the ward over the following weeks he remained largely quiet and socially isolated. He would box at shadows, and the other patients were a little afraid of him. He refused to attend groups but did accept a neuroleptic depot medication which had little impact on his delusions. Electroencephalograms were reported normal. The patient complained consistently of being unable to sleep, but nursing observations suggested otherwise. Because of the risk he posed to the other patients he was not transferred to the chronic range but was retained on the sub-acute ward as a long-stay patient. At 11:30 one night, eight months after admission, he was found hanging in his cell with a bedsheet round his neck. Efforts at resuscitation were unsuccessful. He was declared dead on arrival at hospital. The verdict of the inquest was suicide.

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Figure 3 Institutional response to identified suicide risk

Every penitentiary in the Ontario region maintains an active system for identification of those at risk for suicide (see Figure 3). A mentalhealth-care team meets regularly to discuss intervention and management of those identified. Possible interventions in prison are limited, and, as is well known, in crisis the usual option is to isolate the sufferer and deny him or her access to the more common tools of suicide attempts - a razor blade or a noose. But razor blades are easily concealed in a body cavity, and nooses are readily improvised. The offender considered at immediate risk of suicide is dressed in canvas or paper gowns, housed in a bare cell, if possible with 24-hour camera observation and visual checks at defined but irregular intervals. (Offenders serious about suicide might make their attempt immediately after a routine check.) Physical restraints are rarely necessary. This kind of intervention saves lives, but it can result in loss of trust on the part of the sufferer, and it cannot be pursued indefinitely. Isolation in this way should probably be regarded as an emergency response where there exist no alternatives, such as placement in a hospital cell. Medical authorization is mandatory, as is early examination by a mental-health professional; otherwise, concerns about abuse and inhumane treatment will continue.30 Use of prescribed drugs, effective for the mentally ill but unpredictable for the mentally well, is decided on an individual basis and, except perhaps in life-threatening emergency, must always be administered

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with the consent of the patient. Since sedation might actually increase the risk of someone carrying out a suicide, and since hoarded antidepressants can be an effective means of taking one's own life, it is more common, in practice, to refuse drugs to someone who is requesting them, and this too poses ethical problems for the prison physician. In an isolation room or area, the sense of crisis may diminish. This may not be true of all prisons. In institutions such as Kingston Penitentiary and the Federal Prison for Women in Kingston, because the isolation areas can contain a number of disturbed inmates, an atmosphere of crisis may be sustained for long periods. Only after the crisis feeling has been resolved can any realistic attempt be made to assess the "actual" suicide risk. Clinicians working in this area have accumulated a great deal of experience at making complex, life-and-death judgments in difficult conditions and under time pressures. At this stage, in assessing suicide risk, every clinician may have a number of "rules of thumb," of which he or she may be more or less aware. In my own practice, after searching for evidence of mental illness, I make strong efforts to identify the social situation that may have precipitated the crisis (though offenders are frequently reticent about this), and I place great reliance on the patients' own statements about their future intentions. If they are prepared to give their word that they no longer intend to harm themselves I am usually prepared to accept the risk of reducing surveillance. I am helped in this decision if the person is willing to accept ongoing counselling of some kind. However, the benefits of different kinds of counselling are questionable. There is no good evidence that it works, and it can be expensive and time consuming. It is accepted by many in the field of drug abuse that forming relationships with concerned peers (people from the same background, themselves struggling with similar problems), can be as effective as, if not more so than, professional interventions. The same principle possibly applies to the problem of intended suicide in those not suffering from mental illness. Encouraging formation of peer groups in prisons or establishing a system of peer counsellors carries its own dangers. In particular - and many inmates will stress this - formal peer groups supported by the prison administration can be taken over by powerful psychopaths and become an instrument to exploit the weak and disadvantaged. "The management of the aftermath of suicidal behaviour is also crucial to its future prevention. Staff are likely to feel guilty ... and so if suicides are solely attributable to staff negligence, the way is paved for increased staff vulnerability to, and inmate use of, manipulative threats of suicide."31

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REACTIONS OF STAFF

Little attention has been given to the effect that a suicide can have on a staff member who has been closely involved with the inmate. Some kind of emotional reaction is inevitable. One review of the sparse literature available outlines three phases that individual clinicians pass through after their patient has committed suicide: stunned disbelief, lasting perhaps a week; turmoil, lasting perhaps two months; and resolution, over six months, which offers an opportunity for growth or for prolonged disability.32 A study of 43 train drivers in the London Underground who had experienced someone jumping in front of their train found that one month later 2.1 were experiencing recurrent and intrusive, distressing recollections of the event; 13 showed difficulty in staying or falling asleep; and 17 displayed irritability or outbursts of anger. Sixteen per cent of the drivers could be diagnosed as suffering post-traumatic stress disorder, and a further 39.5 per cent qualified for other psychiatric diagnoses, such as depression or phobic states.33 In another study, nearly half the psychiatrists who had a patient commit suicide reported stress levels comparable to those found in people seeking help after the death of a parent.34 Some staff members may react with an apparent hardening of attitude against inmates. This stance can be seen as protection against an underlying sense of guilt, which is generally present, even though frontline staffers know that they are often helpless to prevent these events. In others - and this may seem the more healthy response - there will be a bereavement reaction that may include questioning of themselves and their purpose in life, depression, and tears. If organizational and management practices are sensitive to the issues involved, exposure to distressing and traumatic experiences need not necessarily lead to long-term disability. In one study of stress among police officers retrieving and identifying human remains after a major disaster, few showed any increase in anxiety levels at three-year followup, and a number appeared to gain greater confidence from their experience.35 Those involved felt that good organization, with preparation, emphasis on personal relationships, and "debriefing," made a significant contribution to the lack of long-term impairment. SUICIDE IN SPECIAL GROUPS OR CLUSTERS

If little is known about the general problem of suicide in prisons, then much less is known about outbreaks or clusters of suicides in particular

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groups within prison,36 except that they occur.37 Contagious patterns of behaviour, where whole groups can become "infected" by the actions of one, usually dominant, person, are well recognized in "mass hysteria." Epidemic self-mutilation has been described in a treatment program for disturbed adolescents.38 A rise in suicide rates has been observed in communities in Britain and the United States following media depictions of suicide, known as the "Werther effect" from the widespread impact of Goethe's novel, in which the fictional hero shoots himself.39 One cluster of prison suicides has been blamed on restriction of access to psychiatric services.40 In trying to understand epidemic suicide, sociological perspectives are likely to be more useful than medical or psychological concepts. Each individual might have his or her own reasons for deciding to die, but in an epidemic these are influenced by wider social factors. To prevent epidemics of suicide it becomes necessary to identify and correct these factors. In some cases, the growing concern expressed about the situation with each new suicide can itself be seen as feeding into, maybe even encouraging, the next suicide. Until the fundamental faults are addressed, or until such suicides receive no further publicity, the epidemic will probably continue. Prison administrations might prefer to restrict media attention to prison suicide; indeed, one of the more than fifty recommendations of a esc investigation into a cluster of seven suicides in the Atlantic region in 1983 was that esc "undertake a program which would lead to the media in the area down-playing suicide by an inmate."41 However, restricting media coverage might equally increase despair and helplessness, thus making an epidemic worse. The decision to correct the underlying causes, even if accurately identified, does not rest with front-line correctional service staff. Common factors in the suicides of First Nations female offenders in the Federal Prison for Women in Kingston were given explicit recognition by the decision to hold a joint inquest on three deaths in 199091. There would seem to be the same risk that growing public concern might itself fuel an epidemic unless effective political solutions are achieved. Death for the sake of one's nation can become more meaningful to the individual than a life of incarceration, and society should seek a way to make it more meaningful for such people to live than to die. CONCLUSION

The first thing that the new clinician recognizes in working with prison suicide is that the literature is of scant help. Research so far has shown

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only how little we know. Prediction and prevention of suicides are extraordinarily difficult in this high-risk environment, and staff working with inmates may be easily demoralized by the apparently critical evaluations of a formal public inquiry. Resources for mental-health care within prisons are often inadequate for their difficult population, but this is the result of political and administrative decisions, and economic considerations do not affect only health services. Increasing resources for mental-health services may have little real impact on the number of prison suicides, and much more needs to be known about what really is effective before major costs are incurred, particularly when such expenses will result in deficiencies elsewhere. Suicides in prison come in clusters, not all of which may be possible to explain. Bearing this in mind, we should hesitate before accepting the explanation for a suicide outbreak from possibly interested parties42 and consider cautious scepticism when an effective preventive response is claimed at the termination of an outbreak.

1o The "Inadequate" Offender

Chronically psychotic offenders, the brain-damaged, the mentally retarded, or just the socially or physically inadequate pose a problem to prison services in terms of their vulnerability to exploitation, their failure to conform to established norms of inmate social behaviour, and the particular difficulty they represent for release planning. These people, whose common characteristic appears to be "their inability to cope unaided with the ordinary problems of everyday life,"1 are widely recognized. Case Study No. 10.1 A 39-year-old man was admitted from the reception unit (at entry into the correctional system), with reports of bizarre and withdrawn behaviour. He was starting a three-year sentence for sexual assault on a nine-year-old boy, because he had twice during a brief car journey tried to touch his genitals, though he desisted when the boy pushed his hand away, and for assault, because he ran after a young man in a car who had called him a "fag" and scratched the rear of the car with a jack-knife blade, shouting "I'll kill you." He had, as advised by his lawyer, pleaded guilty to the charges. He did not have a previous criminal record. Few details of his background were available. He was one of three mentally retarded children, and his mother was an invalid with a history of cerebrovascular accidents. His IQ had been measured variously between 45 and 70. Until his arrest and conviction he had

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stayed with his mother and worked as a dish washer at a nearby restaurant in the small community. He was also reported to be a steady and reliable agricultural labourer. He had a previous admission to a mental hospital eight years before with a diagnosis of mental retardation with psychosis. It was noted that he was a conscientious worker at simple tasks in the industrial therapy shop. It was alleged that he had made previous advances towards young boys, and the police report concluded: "If he were to be granted parole before he displayed a change in his sexual behaviour, the area people would be very upset." On admission, he was mute and unresponsive, with an angry expression on his face, but he was very interested in the toilet bowl, to which he appeared to be listening. It was suspected that he was responding to auditory hallucinations. He was started on antipsychotic medication and made significant improvements in socialization. He showed intermittent outbursts of angry and confused behaviour and tried to act tough with the other patients, but he held his arms in a funny way and his scowl was laughable. He was, in any case, only five feet tall. From early in his admission, attempts were made to secure an institutional placement in the community. "It must be said that to have this little man in a penitentiary represents a grotesque travesty of the judicial process," but, just as in his previous admission to a mental hospital, he was refused for chronic placement by mental hospitals on grounds of his mental retardation and refused by mental-retardation institutions on grounds of his psychosis and aggressive behaviour. He served his time on the long-stay ward at the treatment centre, without problems, apart from occasional outbursts of frustration related to failures to obtain placement in the community, and on mandatory release he was directed to his community mental hospital under a committal form of the Mental Health Act. For historical reasons, inadequate offenders within the Ontario region have tended to become concentrated within the protective-custody population of the maximum-security Kingston Penitentiary. A specialneeds unit (SNU) of 3z cells there provides some degree of protected accommodation but is overwhelmed by demand and provides limited specialist programming. To address the needs of inadequate offenders, a psychiatric day-care centre at Kingston Penitentiary has been accepted as part of the regional strategy for mental-health care, and resources were allocated for the financial years 1994-95 and 199 5-96.

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"Partial hospitalization," or use of day hospitals in psychiatry, has been evolving for over fifty years.2 It has therapeutic advantages over out-patient treatment for certain categories of people and economic advantages over in-patient care. It has been defined as "an ambulatory treatment programme that includes the major diagnostic, medical, psychiatric, psychosocial, and prevocational treatment modalities designed for patients with serious mental disorders and who require a coordinated, intensive, comprehensive, and multidisciplinary treatment not provided for in an outpatient clinic setting. It allows for a more flexible and less restrictive treatment programme by offering an alternative to inpatient treatment."3 The term "day-care centre" (DCC) refers here to a program that includes training, rehabilitation, and maintenance4 of chronic psychiatric patients. In the outside community, such patients must be able to maintain themselves at a basic level in a place of residence, without threat of harm to themselves or others. In Kingston Penitentiary, sheltered residential accommodation is available in the SNU, but one of the treatment goals of the DCC will be to assist transfer of patients from the SNU to other ranges, when possible, and in this way to resist the tendency to segregate such problem inmates. Satisfactory day care requires "a well staffed unit that is prepared to accept a wide range of patients and include several treatment programmes that can be run simultaneously."5 Staff numbers are given in a study comparing seven centres in an inner-city area.6 In two, five to six staff members provide care for 40 places per day. The mix of disciplines is not described, but a multidisciplinary approach is a necessary part of the day-care concept. In the model proposed for Kingston Penitentiary, the core staff will consist of three psychiatric nurses, one in a supervisory position and with responsibility for program direction. Part-time input for teaching programs will be provided by Kingston Penitentiary; psychology by Kingston Penitentiary or perhaps RTC(O); and psychiatry, occupational therapy, and possibly social work by RTC(O). Close liaison will be expected with referring agencies. The DCC will be offering "a highly structured environment suitable for patients severely handicapped by negative symptoms, or within which programmes of behaviour modification could be carried out."7 Problem areas in medication compliance and social and cognitive skills are readily identified. It will be an important function of the DCC "to develop systematic plans of management and to review these plans regularly."8 Attendance at the DCC will be considered part of the inmate's sentence-management plan and should qualify the inadequate

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offender for the higher levels of pay available to those undertaking educational and employment programs. Various outcome criteria have been used to evaluate day care centres.9 Readmission rates can be measured in a number of ways and produce conflicting results, but a report of experience at Kingston Psychiatric Hospital10 suggests that DCC services help to ensure that in-patient readmissions occur only in the event of a significant relapse of psychosis. A large number of readmissions to RTC(O) from Kingston Penitentiary appear to be related to situational difficulties or adjustment disorders, and the DCC should be able to produce evidence of cost savings by the measure of readmission. A diagnosis of anti-social personality disorder (ASPD) has been one factor in predicting poor outcome in day patients,11 and, while some success with some types of ASPDS has been reported,12 it is recommended that ASPDS of the psychopathic type be excluded as far as possible. Members of this group have not been shown to respond favourably to the types of treatment available, they tend to monopolize treatment resources, and the more disadvantaged inmates are seen to be at serious risk of exploitation. Implementation of this kind of centre within a prison will not solve all the problems of inadequate inmates, but it is hoped that provision of resources in this way will give them the opportunity to live in greater conformity to the norm within their community, to gain access to higher levels of pay which are often denied to them because of their inability to maintain employment or education, and to obtain a measure of protection and support against victimization. The problem of growing numbers of prisoners segregated into protective-custody areas is well recognized.13 Inadequate inmates are already concentrated within that population, and to further segregate them into "PC within pc"14 sub-populations is only likely to aggravate their difficulties. A DCC represents the opportunity to resist this pressure and provide assistance in gaining early release for a disadvantaged but relatively harmless group.15

II The Predictably Dangerous Mentally Disordered Offender

The right of the vulnerable members of the public to enjoy society's protection should be considered before the expectations of persons reliably considered dangerous eventually to be free.1 Despite proven flaws in any attempts at prediction, there exists a small population for which seriously violent recidivism seems certain.2 The assessment reports in Appendix B are an example. Recent completion of an extended, prospective study of recidivism in patients released from the maximum-security Oakridge mental-health facility at Penetanguishene confirms the existence of a small group of offenders that can be predicted with confidence to recidivate dangerously.3 If a mentally disordered offender (MDO) is serving an indefinite or a life sentence and is considered predictably dangerous - reliably or demonstrably likely to commit another seriously violent offence - it is important for those involved in risk management to ensure that the National Parole Board is aware that an opinion of dangerousness exists when parole is being considered. Procedures should require regular, independent psychiatric review. A recent and excellent paper by Nigel Walker touches on some of the implications of recognizing and acknowledging the existence of a group of offenders who may never be considered safe to release.4 PREVENTIVE DETENTION

Where a dangerous MDO is serving a fixed sentence after which he will be released, the possibility of preventive detention must be

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considered. Preventive detention, as practised in the Ontario region, takes two forms. The National Parole Board is able, on application from a case-management officer and with strict procedural safeguards, to "detain" certain defined categories of inmates for the time between their "mandatory" release, on completing two-thirds of their sentence, and the warrant-expiry date (WED). National Parole Board statistics reveal that in the five years previous to 1993, 92,z such referrals were made in Canada. Half of the inmates involved were sex offenders, and about three-quarters were detained.5 A number of dangerous MDOS have been detained in this way. The dilemma of such cases is that release at WED is still obligatory, and the opportunity for conditional release under parole supervision has been lost. The sole management option available within Ontario at this time is use of civil-commitment procedures for the mentally ill. Criteria for involuntary detention as a result of mental illness differ in various countries, but many require that there be a potential for dangerousness,6 and this is the case in Ontario. For about four years an arrangement has been in existence between RTC(O) and the secure mental-health centre at Penetanguishene, whereby a patient considered dangerous may be transferred there three months prior to WED, for consideration of preventive detention under the civil-commitment procedures of the Ontario Mental Health Act (OMHA). In our own review of seven patients treated in this manner, two were returned to esc for release and five were detained beyond their WED, of whom three have been cascaded through the provincial mental-health system to medium-security and open units.7 Case Study No. n.i (Series)8 (i) A zy-year-old man, over six feet in height, and with an athletic build, had served a four-year sentence for three counts of bank robbery and a consecutive eight months for an assault on a penitentiary officer. He had no previous convictions. He had been a very angry individual throughout his sentence, threatening inmates and staff, frequently on the basis of delusional ideation. Psychiatric assessments reached diagnoses of paranoid schizophrenia, only partial responsiveness to medication, and, variously, impulse-control disorder, immature personality, and borderline intelligence. There was a strong family history of schizophrenia. The patient showed no insight into his illness and was irregular in taking medication, often refusing it. At a hearing before the mental-health review board prior to expiry of his sentence, it was decided that the criteria for committal were satisfied. He has been detained in the secure mental hospital for the past four years.

87 The Predictably Dangerous Mentally Disordered Offender

(z) A 39-year-old man had served an eight-year sentence for his second rape offence with violence. His criminal history from the age of 16 included sex offences, assault, prison breach, and propertyrelated crimes. He also had an extensive record of juvenile crimes and admitted to committing several unreported violent and sexrelated offences including child molestation. His childhood history included being severely sexually abused, institutionalization, and extensive and varied drug abuse. Psychiatric diagnoses were of psychopathic personality disorder, or its equivalents. Throughout his sentence he was a disciplinary problem, having particular difficulty with female guards and expressing extreme hostility towards women. He admitted to having violent fantasies, including murder, and warned that he would probably murder if released. Prior to his WED a mental-health review board determined that he could not be detained under the OMHA, he was returned to RTC(O) and was released. He evaded police surveillance but was arrested some months later and charged with the brutal sexual murder of a 12-year-old girl, to which he pleaded guilty and for which he is now serving a life sentence. (3) A 3 2,-year-old man served two years for assault, robbery, and threats against his family. He had been sexually abused by his alcoholic father, an itinerant musician. He lived on the street from the age of 15, abusing both drugs and alcohol. His adult criminal record began at the age of 17, with numerous property-related offences, assault convictions, and an escape. During his sentence his father died. He developed delusions that remaining family members were poisoning him with faeces and that the police were plotting to assassinate him. His paranoid symptoms responded to medication, but he made threats that on his release he intended to murder single women in underground carparks. Diagnoses were of paranoid schizophrenia and anti-social personality disorder. He took his medication regularly after transfer to Penetanguishene and was found to be uncertifiable under the OMHA. He was released from there. Within two years he was reconvicted for arson and sentenced to five years after he set fire to a rooming-house as part of a failed suicide attempt. (4) A 31-year-old man had served a seven-year sentence for a number of crimes, including armed robbery and aggravated assault. His adult criminal record dated from the age of 16 and included numerous property-related offences and an assault. During this sentence he had to be transferred to a number of different institutions because of his assaultive behaviour. Included in an

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extensive list of major institutional offences were physical assault on a teacher and the unprovoked stabbing of a fellow inmate. He was transferred to a secure psychiatric institution, but he held a patient hostage with a knife to force a return to the penitentiary system. He slashed his forearm with glass and developed the delusion that he was possessed by demons and witches. Diagnoses were of paranoid schizophrenia in an ASPD. His delusions did not respond to medication, and he committed at least one sudden assault while well medicated. On transfer to the secure hospital before his sentence expired his committal was upheld, and he has been detained in hospital for 18 months. (5) A 44-year-old man had served 15 years for the rape of a 13-yearold female. He had previous convictions for rape and assaults and for property-related offences, many committed while he was under the influence of alcohol. During his sentence he had assaulted another inmate with a knife, assaulted one staff member, and attempted the sexual assault of another. He developed the fixed delusion that he had been spoken to by God and given custodial care of the world. Diagnoses were of paranoid schizophrenia and ASPD. He had little insight into his illness. When medicated he could conceal the delusional aspects of his disorder and appear relatively normal to superficial examination. Three years prior to WED an attempted release on parole was revoked as he began drinking within days. Medication was discontinued at the secure hospital. When appearing before the review board, he showed no signs of active psychosis, but the board determined that he could be detained on the basis of his psychopathic disorder and dangerousness. His psychosis relapsed, but after restabilization he was transferred to a lower-security mental-health facility, where he sexually assaulted a fellow patient and was sentenced to three years' imprisonment. Back at RTC(O) a year later, he hanged himself. (6) A 37-year-old man with scoliosis and internal strabismus served an aggregate sentence of five years and six months for a number of counts of threatening death. He has a continuous previous criminal record from the age of 18, consisting of property-related offences, including fraud, a series of convictions for threatening, one conviction for carrying a concealed weapon, and one conviction for abduction of a child under 14. During his incarceration, he compiled extensive files of the addresses of school boards and of children appearing in the media.

89 The Predictably Dangerous Mentally Disordered Offender

Testing of sexual preference established a diagnosis of homosexual paedophilia. The patient none the less developed an erotomanic fixation on a female staff member, to whom he sent a large number of indecent and threatening letters, including threats directed towards her children. Diagnoses were of erotomania, borderline mental retardation, ASPD, and homosexual paedophilia. In this case the decision of the review board, based on the fact that physical dangerousness had not adequately been established from his record, determined that he could not be detained. He was returned to the penitentiary for release. New charges arising out of further threats to staff were prosecuted successfully, and he is currently serving a six-month provincial sentence. The female staff member has taken medical leave. (7) A 39-year-old man with a muscular build served a five-year sentence for stabbing his friend in the chest with a large kitchen knife. He believed that the friend had stolen his winning lottery ticket. His belief was almost certainly delusional. He has a previous criminal record from the age of zz, with convictions for drug trafficking, possession of a weapon, aggravated assault, and three "breaches of trust." He had, in addition, terrorized his family, which had experienced a number of unreported assaults. During a previous sentence he was treated for a paranoid psychosis after he assaulted a relative in the visiting room, accusing her of being responsible for the shrinking of his penis. During this sentence he was irregularly compliant with medication routines, frequently relapsing into an angry state, during which he threatened the lives of former psychiatrists and his family, made spitting and stabbing motions as he rehearsed in fantasy his revenge for the stolen ticket, and became enraged about an alleged homosexual rape committed on him in childhood. Diagnosis was of chronic paranoid schizophrenia, partially responsive to medication. The determination of the review board was that he could be detained. He cooperated with treatment and was transferred to a less secure mental-health facility, whence he was subsequently released. Within two years he had been charged with the second-degree murder of a 69-year-old man, of whom he later said: "He just pissed me off ... I di'n't wanna kill him. If I did, I'd a used a bigger knife. I only stabbed him once ... I di'n't even twist the knife in him." He is now serving a life sentence with a minimum of ten years before becoming eligible for parole. It can be seen that of the five people who were released or cascaded to lower-security mental-health facilities, one has since been convicted

90

Issues in Psychiatric Care

of the first-degree murder of a child, one of the second-degree murder of a 72,-year-old man, and one of sexual assault on a fellow psychiatric patient; one is now serving a five-year sentence for an attempt to set fire to a rooming-house. The fifth is unlawfully at large in the community, wanted for uttering threats of death after having already served a provincial sentence for the same. These results, admittedly only very small in number, support the need for some form of effective response to that very small group of MDOS "whose offences are so serious and their actuarial risk scores so high that they are proper candidates for incapacitation (through indefinite incarceration)."9 Serious and valid concerns have been expressed about psychiatrists becoming involved as agents of preventive detention,10 and it can be argued that mental hospitals are not appropriate institutions for detention of subjects who are defined solely in terms of the danger they represent to society, rather than in terms of any treatment that may be offered.11 The increasing sophistication of prediction instruments, and the recognition of the existence of a small group with an extremely high probability of reoffending, however, mean that the pressure for some form of preventive detention will only increase. "It might be better for society as a whole for the question to be debated openly, and, if provisions for some form of preventive detention are desired, for them to be implemented independently of the mental health system."12 The dilemma then becomes one of determining what degree of risk should be demonstrated to invoke preventive detention and how such an independent system might resist the "banishment pressure"13 on MDOS showing any degree of capacity for violence. Discussion of the issues surrounding the debate on preventive detention is to be found in Nigel Walker's paper "Dangerous Mistakes," referred to above. The paper exposes some fallacies in the argument that there are no reliable predictors of dangerousness. It offers a graduated typology of dangerousness,14 of four groups: those who harm others only if "sheer bad luck" brings them into a situation of provocation; those who get into such situations by following inclinations, such as the paedophile who chooses to work with children; those who are consciously on the look-out for opportunities; and those who deliberately make opportunities, who must be regarded as unconditionally dangerous. Walker argues that, while those citizens who have never harmed another person are entitled to what may be termed "the presumption of harmlessness,"15 this presumption can no longer apply to those who have been proved to have inflicted serious harm on another. Society is entitled to make such offenders the subject of precautions. Ideally, these

91 The Predictably Dangerous Mentally Disordered Offender precautions would consist of more than simply use of preventive detention. For safe management of the dangerous MDO there should be a range of clearly defined options, from prolonged parole with enhanced supervision, or residential placement in the community, to secure, life-long containment.

I2 Conclusion

Despite periodic efforts to divert the mentally ill from justice systems, high levels of psychiatric morbidity in prisons will probably continue. For the foreseeable future, the combination of a population predisposed by character and circumstance to be vulnerable to mental disorder, and a restrictive milieu that imposes great stresses on that population, will generate a need for psychiatric services of some kind. These services will encounter the full spectrum of mental illness, often complicated by coexistent personality disorder and multiple diagnoses, and will have to cope with extremes of disturbed behaviour. Prison psychiatric services, whether administered by the prison system itself, and thus tainted with the possibility of collusion with a repressive bureaucracy, or administered independently, and plagued with the problems of interacting effectively with an organization of alien aims and philosophies, will face very much the same clinical problems. Some of these dilemmas are particular to the prison environment and culture but often show a remarkable similarity across different prison systems; some are the consequences of the particular personality types that are predisposed to criminal behaviour and incarceration. The special psychiatric problems encountered by incarcerated offenders, as demonstrated in the case studies throughout this monograph and examined specifically in part II, constitute a powerful argument for the presence of full-time psychiatrists able to offer a "continuity of skilled care and constant availability to assess referrals from any of the prison staff."1 The difficulties of working within custodial institutions in "a situation of permanent contradictions and tensions" are very real, but that

93

Conclusion

very custodial environment is nevertheless "also a situation of profound clinical interest. "z It is probably only in a prison system that the psychiatrist trained in developed countries can catch a glimpse of the clinical problems encountered in Third World psychiatry. In addition to having full-time psychiatrists, a complete prison psychiatric service should be able to provide rapid access to secure psychiatric hospital facilities.3 Where these are provided by separate administrations, access to in-patient services is often delayed. Some general hospital staff may display attitudes against convicted offenders that can undermine the quality of care they might receive. Prison psychiatry is often regarded as "a backwater, the preserve of the young, the ill trained or the unfit," 4 but a multidisciplinary, dedicated facility may be able to provide "a centre of excellence with experienced staff, sound facilities, [and] good liaison with outside agencies "5 Advances in the use of actuarial techniques to quantify the risk presented by each offender offer the opportunity for a systematic approach to risk management, and one that is defensible in scientific terms. At the same time, greater understanding of the benefits of treatment for different kinds of MDO provides the basis for modifying risk factors to minimize the risk of reoffence. It then becomes possible to view management of the MDO in terms of a process whose endpoint is safe release into the community. Just as there are psychiatric problems common to prison systems but not often encountered outside custodial institutions, so also differing processes of securing safe release have common elements, irrespective of the structural organization of the service or judicial system and independent of the content of particular treatment programs. These elements are considered above in part I and are • comprehensive assessment of the MDO as soon after identification as possible; • the opportunity for stabilization in a secure environment that allows staff and patient to interact with minimal fear for personal safety; • an independent process for consideration of the patient's readiness for safe release into the community that can impose conditions of mandatory cooperation with treatment and supervision; • effective after-care and supervision within the community following release. But in order to achieve the desired end result, in order to combine the concerns of public safety with good clinical management of the MDO, it is necessary to look at mandatory community treatment and preventive detention. There is growing recognition that without some

94

The Mentally Disordered Offender in Prisons

form of coercion to comply with treatment many psychotic MDOS will relapse and become dangerous again.6 Coerced community treatment is controversial7 and, to be successful, would need to be reinforced by an effective means of preventive commitment8 that is absent in many jurisdictions. It has been said that it seems illogical to insist that committed persons should have the right to refuse the very treatment that might allow their freedom to be restored,9 and while it is understandable that the difficult ethical issues might cause reluctance to address the problems, it is equally clear that failure to face them has a significant cost in terms of public safety. In some respects, the criminal justice system, with a wellestablished program of conditional release on parole, has advantages over mental-health systems bound by recent rights-oriented mentalhealth legislation. It remains as true in Ontario as in most jurisdictions that, "amidst all the ministries, courts, hospital authorities, probation services, local government dependencies, social services, housing departments and prisons, there is not one with the task either of planning and executing general measures capable of reconciling the needs of disordered offenders and of society, or of taking an individual offender in charge from the very outset and steering him towards the best available means of disposal."10 RTC(O) - a federal-government facility with province-wide responsibility for psychiatric care of federal offenders - is in the unusual position of attempting to carry out that general mandate for a special population. By examining the work of that institution, we can offer general observations on how the mandate of safely releasing MDOS might be accomplished. These observations are the main substance of this monograph. Finally, there exists a group of offenders who may never be considered safe to release. There is now sufficient expertise to identify that group with confidence. In the event that preventive detention is considered feasible, predictably dangerous MDOS present judicial, political, mental-health, and correctional systems with the problem of their disposition. Providing a legislative framework for their detention in suitably humane and safe surroundings has become an urgent task.

APPENDIX A

Release of Confidential Information

REGIONAL TREATMENT MEDICAL

CENTRE

POLICIES AND

(ONTARIO)

PROCEDURES

Release of Confidential Information without the Consent of the Patient Preamble: At present it is unclear under the law what circumstances might allow a psychiatrist or other therapist professional to override an ethical and legal obligation to hold confidential information obtained from his patient. Relevant parts of the Privacy Act, the Ontario Mental Health Act (OMHA), and such other legislation or CD'S [Commissioners' Directions] as might apply do not yet have an established body of case law to assist interpretation. Legal opinion has often been conflicting. The following, provisional, policy will be in effect pending legal clarification. Policy: i.Under normal circumstances, release of patient information will require the consent of the patient, and information will be released upon application with the original copy of a form #14, OMHA, or equivalent. z. Where consent has been sought and refused, confidential information may be released upon request, without the consent of the patient, a. to a provincial mental health institution, whether or not in Ontario, under procedures outlined in Section 29, OMHA. b. to the National Parole Board (NPB) or a Warden of a esc institution or District Director of the Parole Service, where the information is required to assist in a decision likely to affect public safety, and where it has been determined from a review of the file by a psychiatrist that information

96

Appendix A

possibly relevant to the issues of dangerousness and public safety is contained in the file. 3 . Response to a request for information without the consent of the patient from other parties. a. No information will be released to parties outside the esc, except under the terms of s 29, OMHA. b.In reply to enquiries from within esc (Case Management Officers, etc.), after review of the file by a psychiatrist, and determination as to whether the file contains information possibly relevant to the issues of dangerousness and public safety, the Director, Psychiatric Services will send one of two standard letters (Appendix A and B). [from] Director, Psychiatric Services. (as amended by the Medical Management Committee, 93.02.01.)

Negative Response Regional Treatment Centre (Ontario), Kingston Penitentiary, P.O. Box zz, KINGSTON, Ont.,

K/L 4\J.

To Whom it May Concern re: (Patient name) In response to your request for the release of information without the patient's consent, the Treatment Centre file has been reviewed by a qualified psychiatrist and in the opinion of the person reviewing the file, no information relevant to issues of dangerousness or public safety is contained within that file. Accordingly, information from that file will not be released, Yours sincerely,

Director, Psychiatric Services.

97

Release of Confidential Information

Positive Response Regional Treatment Centre (Ontario), Kingston Penitentiary, P.O. Box 2.2., KINGSTON, Ont., KyL 4Vy. To Whom it May Concern re. (Patient name) In response to your request for the release of information without the patient's consent, the Treatment Centre file has been reviewed by a qualified psychiatrist and in the opinion of the person reviewing the file, information is contained on that file that may be relevant to issues of dangerousness or public safety. In the event that it is required to assist in a decision involving issues of dangerousness or public safety, information on that file may be released on application to the undersigned by a Warden of a esc institution, a District Director of the Parole Service, or an official of the National Parole Board, Yours sincerely,

Director, Psychiatric Services.

APPENDIX B

A Multidisciplinary Correctional Assessment of a Convicted Serial Murderer

THE CLINICAL PSYCHIATRIST

Y was admitted for evaluation of suitability for assessment and treatment. Of specific concern were his needs for tests for sexual preferences, and for treatment in A . Y said that he wanted to go to A for several reasons. By his account no parents of his victims are in A , and he is so well known that he would not need to be in Protective Custody there. He states that a [staff member] has assured him that they do have a program for his special needs in A , and that he would be acceptable to them, and he understands that there is no other program in Canada which would be of value to him. As well he noted that he could not be seen as a sex offender, as he has never been convicted of a sexual offence only 9 murders. Although he had sexual relations with all his victims, he states that only one was not sexually experienced. By his account, all were willing to engage in the act while conscious, although he had sex with them, as well, when they were unconscious. Y was unwilling to give any elaboration on his upbringing or development other than that which he has written in his autobiography. In brief, he was born and raised in V . His parents worked in an apartment complex where his father was the head of maintenance. His mother was a housewife, but also helped with this. Both parents have since passed away. He described his mother as kind and understanding and his father, an alcoholic who "could handle it," in similar terms although he was closer to

99

A Multidisciplinary Correctional Assessment

the mother. The father may have been involved in a fraud related offense, but Y was ambiguous about this criminal history. There were four siblings, he says, three brothers and a sister who were without problems, according to Y, in part because he never involved them in his antisocial pursuits. He sees his sister as wonderful and his brothers in similar terms. Y denies any sexual feelings at any time to the sibs. Y says that he was a normal baby and child. He did not know dates of developmental milestones. By his account he excelled at sports and won "everything" at boxing. He remembers himself as an "all letter man" who is still able to run the mile in less than five minutes. Academically he was less proficient. He failed grade seven and achieved only grade eight, and remembers being average, although he feels that he is now functioning at the university level, having done several college courses at which he "excelled." Indeed he tells me that others have described his writings of his insight as a "brilliant piece of work," and representative of either a "genius or idiot." Socially he always stuck up for the underdog, and claims that he has never lost a fight in his life. He described himself as taking out girls that no one else would. His sexual relationships began at about 16, apparently (initially) all normal and without any paraphilic thoughts or impulses until a decade later. After quitting school he worked at a race track from 15-16 years of age, walking horses. He had returned to school several times for short periods of time, always to withdraw. He was apparently not religious through upbringing, but now states that he is, and that having repented for his sins, the sins are gone, "never to be recalled." His criminal history dates back to 16 years of age when he stole a truck and received probation. Following this were break and enters, thefts, armed robberies, bad cheques, and in the incarcerations which followed, seven escapes. This variety of criminal skills is well documented in his files. The extent of his involvement in paraphilic behaviours is unclear, as he says that he may be extradited to the States should he admit to other incidents, and that the issues of extradition for these offenses is unclear. This is a reference to the suggestion he has made that he may have been involved in, or knowledgeable about the S killings. He claims to have an option of partial immunity for other incidents, likely similar to the 9 in A . If we may reflect, at least hypothetically, on what was implied, rather than explicitly stated, he may have been involved in paraphilia and killing from about 2,4 years of age. At this time there may have been some sexual activity with a teenager who was killed because of the probability that she would have told her mother. If so this would have been the prototypical and desensitizing situation for all subsequent killings, including the 9 of which he has been convicted. Should his history be valid, there were no further immediate incidents as he was then incarcerated on a B&E and armed robbery. He was released from

1oo Appendix B penitentiary, committed an armed robbery and received six years concurrent, and one year consecutive, escaped, then was incarcerated for five years, after which he was out for one year, and during which time, he tells me, there were a couple of murders in the States. Following this he was reincarcerated for three years. He was out for one year during which time he notes that there were the S killings, and implying that he may have knowledge of them. He was reincarcerated for two years for theft, B&CE and forgery, and released for the period during which he states that the 9 killings for which he was convicted, were carried out. The specific details of the offenses are well known, and will not be repeated. Y was graphic in his description, and in his writings about the offenses. He said that he used memories of the sexual components of the killings as masturbatory fantasies for years following the killings, but that he has now overcome them since becoming a Christian. In brief, each killing involved Y seeking out or happening on an attractive ("cute, petite, youthful, dressed to their body shape, gullible and vulnerable") victim. He offered them employment, and when in his car, had sex, which he sees as mutually consenting, then gave them alcohol and sedatives, and when they were unconscious had sex with them again. He killed those whom he thought would turn him in. Y claimed that all (and more) were willing to become sexually involved with him, and all had previous sexual experience excepting the youngest victim. He feels most remorseful about this person's killing. Y had some satisfaction that most of the deaths were "clean kills," that is the victims did not know that they were to die. He says that he became "addicted to killing" after the third death. Also common to the situations was his intoxication, which he feels disinhibited him sexually. The pattern began, he feels with a killing associated with rage at his wife, who was absent from the house when Y did not know where or why. In a kind of revenge he picked up the first victim, parenthetically he notes on her way to her father's birthday. His attitude to the killings is difficult to understand at times. He claims remorse, but seems to feel this is mitigated by what he feels was the previous sexual experience of victims, their consent to sex, and their anticipated betrayal of him which in some way justified their deaths. Y remembers the aftermath of one killing with some humour. The implication of being a serial killer [is] also not without some emotional rewards: Y feels that his writings have been seen as "... brilliant ... ," has relived the killings through the writings in part, at least for years after the incidents, as masturbatory fantasies, sees the S killer as "... the greatest ..." and vicariously shares some of this acclaim, and has the attention of important people in police forces, and "the top psychiatrists all over the

101

A Multidisciplinary Correctional Assessment

world." He displays humour at the ways in which his lawsuits have caused problems for the system which he blames for the 9 killings because of the way incarceration following his testifying against a paedophilic rape-murderer who would otherwise have got away without being convicted. On examination he presented as a short, stocky man, well groomed, and cooperative to the interview. Affect was euthymic, and positive, although some emotional lability to anger was noted especially if challenged. He admitted to episodes of anxiety-tinged anger at the system, leading him to make plans to "get out" or "hurt someone," although he claimed to try to cope through schooling and other distractions. There were no tics, habits nor disorders of speech or articulation. Speech revealed a preoccupation with the killings and the public response. He tended to revert to the documents he had prepared, rather than express himself spontaneously, and he read with considerable difficulty, misreading and mispronouncing words with which he seemed only marginally familiar. Y was most forthcoming about the acclaim, as above, which he felt he had received from noted authority figures in the community. He denied, at any time, illusions, hallucinations or delusions, and he showed no thought disorder. He was oriented in three spheres, and memory seemed intact. Although protesting an IQ of 12,0, his vocabulary, abstracting ability, and conceptual skills would suggest a lesser ability or compromised learning. Insight was clouded by an inflated interpretation of his perception of his significance, even if supported by the attention he has sought and received. Impressions: Y is a 55 year old man, convicted of 9 murders who presents for assessment regarding programs and transfers within the system. Although the psychiatric and medical records were available, most of the information was provided by Y in about three hours of interviews, and the conclusions are limited by the validity of this information. I did not judge him to be a reliable historian. By history he sees himself as a normal child developmentally, the eldest of five sibs raised by what he remembers as warm parents. There is a family history of alcoholism on the father's side, but the mother and sibs were apparently without problems. School history suggests some learning problems, and failure, but compensation through excellence in sports, perhaps especially individual rather than team. He enhanced his esteem early by standing up for the underdog, taking out girls no one else would, and working walking horses after failures in school. Antisocial behaviours began at about 16, dissimilar to his sibs who remained out of trouble. The criminal behaviour persisted after that, recurring each time

IO2

Appendix B

he was returned to the community from jail, and culminating in the killings for which he is serving this sentence. Dynamically one would postulate a multiproblem lad with family history of alcohol and antisocial traits and learning problems raised in an environment without a strong prosocial male figure, and clearly different from his younger and more successful sibs. He styled himself as a protector of the underdog, allowing himself also to feel judgemental and superior to the more successful and attractive. Alienated, he sought gratification through work and increasing criminal activities. He found, by accident should his story be valid, that he could enjoy narcissistic and sexual gratification from attractive youngsters. These victims would be interpreted as representing the peer group socially and sexually unavailable to him as an adolescent, his sibs, more successful and acceptable than he, and himself the opposite, as he sees himself, of the vulnerable, attractive and desirable features he saw in them. Disinhibited by alcohol, impressing them with money and claimed status, he was able to sexually assault then kill them, thus mitigating the risks of his identification to the police, and expressing the depth of his rage and need for control and revenge over what they and their parents represented. Additional rationalisations included their alleged previous sexual experiences, and the role of prison authorities in causing his anger. Indeed a focus of his rage is their not releasing him after he testified against a paedophilic murderer who otherwise would have gone free again. Treatment is problematic. He has evidence, clinically of both Narcissistic and Antisocial Personality Disorders, and Homosexual and Heterosexual Paedophilia with sexual sadism, and is almost certainly Psychopathic. Y feels that he now has complete insight into his problems and is therefore safe to society and forgiven by God so the motivation for treatment seems less to change himself, and more to help others and to secure release. It is my opinion that he remains stimulated by the memories of the sexual and killing components of the murders, and that he has not shown the evidence of "burnout" seen in some Personality Disorders in later life. He entertains fantasies of revenge to esc, including harming others or eloping, so that his impulses remain - suggesting modest insight, and continuing danger in treatment settings. I would suggest, on the other hand, that removing all hope from this man may be counterproductive, in that it would feed what I feel are the primarily revenge/overcompensation motives which fuel his actions. It seems not inappropriate to offer management/treatment on a 1:1 basis to evaluate his ability to respond, with transfer to the group treatment setting noted as wanting him if true - conditional on compliance, and a lengthy, if arbitrary period of problem-free institutional behaviour. A trial of antiandrogens would be of interest should he be compliant, and while being behaviourally and sexually evaluated.

103

A Multidisciplinary Correctional Assessment

Diagnosis: i) Antisocial and narcissistic personality disorders z) Homosexual and heterosexual paedophilia and sexual sadism 3) History of alcoholism Prognosis: Poor with or without treatment THE CLINICAL PSYCHOLOGIST

Referral was from Dr. , Program Director, Unit I, RTC(O). A complete psychological assessment was requested. Method I spent about 2. hours of direct interview time with Y, and about z i/z hours administering psychometric testing. I had him complete three psychometric tests in his cell. I reviewed case management, psychology, psychiatric, and treatment centre files. Background Y is a 55 year old federal recidivist who has served about iz years of a life/ Z5 sentence for 9 murders. His adult criminal history begins at age 16. His record prior to the current offenses is extensive and varied, consisting of numerous B&E, theft, and fraud related charges, as well as a number of escapes, attempted escapes, and breaches of parole and mandatory supervision. Personal/Family/Educational History Y is the eldest of five children, with three brothers and one sister. He lived with both parents until the age of 17, and left school before completing grade 10. He reports that none of his siblings have experienced trouble with the law. His parents are now deceased. He claims that his father was once imprisoned for a fraud involving "millions," but his mother was never in trouble with the law. He could not recall any psychiatric illness or hospitalization in the nuclear family. It is difficult to establish at this point the onset of behavioural problems. There is little evidence that marked problems were present prior to iz years. There are reports, however, from persons who knew Y as a child, that "as a

104

Appendix B

teenager," he would do things like steal money from a blind man who sold apples door to door in the pretext of assisting him, and would in fact "steal anything." At age 16, Y received probation for what he describes as "joy-riding." At age 17, a short time after leaving school, he was incarcerated for the first time, for property offences. Y's crime sheet, as well as comments by penitentiary staff made during his numerous incarcerations, clearly suggest a commitment by him to support himself solely through crime. Except for a few brief periods, in fact, his personal history is synonymous with his criminal history. He married one L— of M— at age 25, and she bore a son by him. They are divorced and he has no contact with either his ex-wife or his son. Current

Offences

Between — and —, Y killed 9 persons of both sexes. He would typically lure them into his car, drive to a secluded area, and give them alcohol and pills. He would then sexually assault and murder them, often in brutal, sadistic ways. He was eventually arrested on two Break & Enter charges, and objects belonging to one of the victims were discovered in his accommodation. He was charged with and pled guilty to the 9 murders. He was sentenced to life/ 25 with the above parole eligibility date. Current Assessment Intellectual Functioning: Two IQ estimates were seen on the psychology file for Y. Both were close to 20 years old, and were derived from a "quick" IQ test. I administered the Wechsler Adult Intelligence Scale - Revised. The Verbal, Performance, and Full Scale IQ estimates all fall in the Average range of intellectual functioning. These scores fall in the same range, but are somewhat lower numerically, than previous estimates on file. I could not find any testing on file which supported Y's claim that his measured IQ is 120. Neuropsychological Screening: The Wisconsin Card Sorting Test was administered to screen for neuropsychological impairment. Three calculations, the results of which are sensitive to brain damage were performed upon WAIS-R subtest scores, as a further screening mechanism. All results were within normal limits. Personality Testing: Y completed the Minnesota Multiphasic Personality Inventory - n (MMPI-II), the Millon Clinical Multiaxial Iventory - n (MCMI-II) and the Balanced Inventory of Desirable Responding. The MMPI-II profile shows some evidence of a defensive response set, but is nonetheless a valid result. A significant elevation is seen on a scale which

105

A Multidisciplinary Correctional Assessment

reflects antisocial attitudes and behavioural patterns. A moderate elevation is seen on a scale which reflects a tendency to complaintiveness, which may be focused upon real or imagined physical complaints, or upon other life conditions. Such elevations tend to be observed in persons who may have specific organic disorder but present as complaining, irritable, whining, and immature with an over-concern with personal health, dieting, weight, and bodily functioning. The MCMI-II shows elevations on, in order of magnitude, Antisocial, Histrionic, and Narcissistic basic personality scales. This is indicative of characterological problems in self-image, affect, cognition, and behaviour. In combination, these elevations are indicative of: i an unrealistic, grossly inflated self image, unsupported by actual achievements; z shallow, superficial, and fleeting emotional responses, and immature attention and stimulus seeking behaviour; 3 difficulty in integrating experiences to exert control over behaviour on the basis of its probable consequences; 4 interpersonal vindictiveness and suspiciousness, and egocentric disregard for the rights of others. Diagnostic Issues Y meets DSM-III-R (the diagnostic manual of the American Psychiatric Association) criteria for Narcissistic Personality Disorder, as well as Antisocial Personality Disorder, as might be expected from his history and the above psychometric results. Criminal Psychopathy The above observations clearly indicate a need to address the issue of criminal psychopathy. This term is used here within the restricted context of scores on the Hare Psychopathy Checklist - Revised. It should not be confused with a psychiatric diagnosis, because the diagnosis of psychopathy per se is not currently employed in established diagnostic schemes. Conceptually, PCL-R scores are related to DSM-III-R Antisocial and Narcissistic personality disorders, but they have been shown empirically to have greater utility in terms of the prediction of behaviour. Based upon extensive file review and my interview and psychometric testing contacts with Y, I assigned him a score of 3 5 on this instrument, relative to a maximum possible score of 40. (I have placed on the psychology file, a detailed review, with behavioural examples and quotations from file material, of my scoring of this checklist. I

10 6 Appendix B wish to make it clear that I consider this material to be raw psychometric data. As such it should not be shared, uninterpreted, with the inmate. If such information were to be shared, it would also compromise the validity of future testing of this nature.) The obtained score of 35 is extremely high, and as such, has a number of implications. Firstly, high PCL-R scores are seen as a very significant risk factor vis a vis the probability of general, violent, and sexual reoffending in persons released from prisons or maximum security psychiatric settings, depending upon the individual's personal and criminal history. The second implication, of more relevance at present, involves the issue of treatability. Conceptually, criminal psychopathy as assessed by the PCL-R is a personality disorder. As such, it is an ingrained, characteristic pattern of thinking, feeling, and behaving which permeates the individual's existence. Personality disorders are generally recognised as being extremely difficult, if not impossible to successfully treat. There is in fact evidence that some types of treatment can actually increase the probability that persons scoring high on the PCL-R will recidivate violently if released. This latter observation comes from a retrospective study of the results of an intensive and at the time innovative therapeutic community type program conducted in the 6os and yos at Penetanguishene Mental Health Centre, Penetanguishene Ontario. Participants who had spent at least 2, years in the program and were subsequently released, had their files coded some years later, with one of the assessed variables being scores on the PCL, the immediate forerunner of the PCL-R. Analyses by psychologists of the Penetanguishene Research Department (Rice, Harris, and Cormier, "Evaluation") indicated, however, that the program actually increased the violent recidivism rate among PCL psychopaths, relative to a control group of PCL psychopaths who were imprisoned rather than committed to maximum security psychiatric hospitalization. Thus in this case at least, not to have treated would have apparently been more beneficial, from the standpoint of reducing risk, than treatment. Notably absent from the treatment philosophy in the therapeutic community, however (see, again, Rice, Harris, and Cormier, "Evaluation"), was a direct attack upon antisocial attitudes. It remains to be seen whether such.an approach can ever be useful with criminal psychopaths. There is little optimism in this regard, to the best of my knowledge and experience. Returning to Y, one can easily discern a complex of antisocial/narcissistic/ psychopathic attitudes and behavioural patterns which have persisted unabated from his teenage years to the present. Depending upon one's level of optimism, these could be viewed as targets for treatment or total barriers to treatment. The first issue is his total unwillingness to make and keep commitments unless he perceives them as serving his own personal agenda, which are not in any way therapeutic.

107

A Multidisciplinary Correctional Assessment

The second issue relates to the degree to which Y continues to accrue gratification and an increasingly inflated sense of self worth and entitlement from the fact that he murdered and sexually assaulted a number of people. A third issue is the degree to which he may be capable of integrating any material presented in therapeutic sessions. His overall intelligence and his verbal abstraction abilities are average, but he demonstrates a singular inability to apply these abstractions to his own behaviour. He professes idealized beliefs concerning sex and love, but apparently sees no inconsistency between these abstractions and the fact that he constantly seeks out new audiences to whom he can describe his brutal sex murders. A final issue, which is related to all of the above, is Y's inability or unwillingness to truly accept the fact that he is responsible for the murders, that he made a conscious choice to commit them; that he was not in fact an individual deprived of his free will, driven by forces beyond his control. In sum, I feel that Y is not treatable, due to the above factors. While persons with personality disorders or with high PCL scores may receive treatment via various modalities, within the correctional system, Y is exceptional even among this group in terms of his seemingly limitless capacity for self delusion. While I am not optimistic that any of the above factors will change, I would suggest that the initial indications of a positive change in his "treatability status" can only come from Y, and that he need not be in a treatment setting to make these initial changes. In essence, this would require that his psychological representation of the murders become more than simply an intellectual exercise and a source of ego gratification. It would require that he cease using the deaths of other victims to gain new, high profile audiences, such as media reporters and public officials, that he cease his endless quest for attention based solely upon the fact that he is a murderer. I cannot, nor would I wish to, address the issue of Y's rights to interact with the media, or to tell his version of his story to new audiences. I am simply suggesting that as long as his story remains replete with rationalizations and self-serving distortions of the truth, its telling, and the ego gratification that accompanies it, run counter to the most fundamental potential goals of any treatment with this man. Until such time as he is willing to make these first concessions to the treatment process, it is my opinion that successful treatment will be impossible. SEX OFFENDER TREATMENT PROGRAM

Reason for Referral. Y was referred for an assessment of sexual behaviour by Dr. N, Psychiatrist, R.T.C.(O). This assessment was requested to determine Y's need and suitability for treatment in the sex offender program. Y began an

1o8

Appendix B

assessment of sexual behaviour eight years ago but withdrew his consent prior to completion of the procedures. His reasons are well documented. Y was interviewed on a number of occasions and file information was reviewed. I am aware of the report by Mr. D , Psychologist, R.T.C.(O) and will not duplicate his efforts with regard to Y's history. Phallometric Testing. Y was administered evaluations of the age/gender preference profile and the female sexual violence profile. Overall, Y's level of responding was low but within interpretable limits. The results of the sexual violence profile indicate two valid responses. One of these responses was to a scene describing sexual violence while the other was to a neutral scene. As well, Y responded to two of the non-sexual violence scenes immediately after they were terminated. This type of response is often taken as an indication of voluntarily suppressed responding to preferred stimuli. The results of the age/gender preference profile also had a few valid responses. These responses were associated with the presentation of prepubescent female slide and a neutral slide. Y also had four substantial responses following the termination of all the pubescent female slides and one of the prepubescent female slides. Again these types of responses often indicate voluntary control. Psychometric Testing. Y was administered the following self report inventories: The Marlow-Crowne Social Desirability Scale; The Balanced Inventory of Desirable Responding; The Hostility Towards Women Scale; The Inmate Sex Knowledge Test; and The Clarke Sex History Questionnaire. Y did not appear to have any difficulties reading or understanding these tests. The results of the social desirability inventories indicate that Y did not attempt to present himself in an overly favourable light. He reports on the Clark Sex History Questionnaire that he has had numerous sexual interactions with males and females of all age classifications (adult, pubescent, and prepubescent). The sexual activities in which he has been involved include those considered as "normal" as well as forced sexual involvement best described as sadistic. The results of the Inmate Sex Knowledge Test were within normal limits. Risk to Re-offend. The Hare Psychopathy Checklist (PCL-R) was administered based on file information and a semi-structured interview. The result indicates that Y presents a very high risk for violent re-offence. Interview Observations. Y seemed to understand the procedures involved in the assessment. He was pleasant and cooperative throughout the assessment procedures and complied with all the instructions. During interviews he

109

A Multidisciplinary Correctional Assessment

volunteered information that in the past he had denied. For example, without prompting y admitted that the 9 murders for which he was convicted were sexually motivated. In fact he took great delight in describing some aspects of the murders. Indeed while commenting on the slides of children in the age/ gender assessment he offered, "why don't you show their asses." Recommendations. Clearly, the results of the Clarke Sex History Questionnaire indicate that Y's past sexual behaviour has been extremely deviant both in terms of activity (sexual sadism) and partners. In addition, the results of the phallometric testing suggest that his preferred sexual behaviour and partners continue to be inappropriate. The real issue however, is treatability. On a number of occasions Y has referred to himself as not treatable, and I agree. Y is an extremely proud individual. He is proud of the brutality of the acts he has committed and he is proud of the notoriety that he has acquired as a result of these acts. While some may express shame or embarrassment at a past such as Y's he expresses pride at being considered among the worst of the worst. It is therefore, difficult for me to imagine this man involved in a process that might serve to deflate his elevated self image. Further, I believe that those individuals that might attempt such an endeavour would place themselves in a potentially dangerous position. INDEPENDENT FORENSIC

PSYCHIATRIST

Thank you for asking me to see Y. I interviewed him at the Regional Treatment Centre in Kingston Penitenitary on . My understanding was that my assessment was to assist you in evaluating his request for access to a treatment programme in A . I was also under the impression that my report might be used when Y's life sentence is subject to judicial review at the fifteen year point. Y, however, vigorously denied consent to be assessed for this latter purpose. Y has been convicted of nine counts of First Degree Murder and sentenced to life imprisonment. The victims of these crimes were seven females and two males. According to police information on file, the murders followed a similar pattern. All the victims, who were typically hitchhiking, were enticed into his vehicle with the promise of work and plied with alcohol and sedatives. They were sexually violated either before or after death by bludgeoning, stabbing or strangulation. At different times Y has clamied to have committed variable numbers of other homicides and the police also believe he tortured his victims prior to their deaths. Y had a long history of criminal convictions from the age of 16, consisting mainly of thefts, break and enters, false pretences, fraud and an armed robbery. He has also been a repeat parole violator. I note that after he was convicted of the homicides, he was charged with rape, buggery and gross indecency by

110

Appendix B

a prostitute but the proceedings were stayed as were several impaired driving and other charges. He developed antisocial behaviours early in his life and after quitting school at 17 was sent to a juvenile correctional facility. During his numerous incarcerations, together amounting to almost thirty years, Y has apparently been a serious management problem with many institutional offenses and he is obviously adept at escaping custody. He also developed a reputation as an informer. It appears that Y has had no previous history of mental illness and has never, as far as I can determine, been treated by a psychiatrist either in or out of prison. He is said to have had a history of alcohol, though not of drug, abuse and I note that he incurred several impaired driving charges at around the time of his arrest in connection with the murders. Y was interviewed through the bars of his cell as he was considered a serious security risk. He behaved amiably during my two interviews. Though he talked a great deal he revealed little of himself that was not already known and he further tried to control the situation by answering questions selectively and on his own terms. For example, he tended either to avoid answering many questions, or to do so indirectly by reference to his various writings or other documents. Grandiosity was readily apparent from his spontaneous remarks such as "I have the top people in North America ... in Europe ... writing to me"; "the world's experts are really lost" (trying to evaluate him). He mentions that a "special law" was proposed in order to have him executed. He stated to another psychiatrist that, at the time of his trial, "psychiatrists were falling all over themselves" to study him and be involved in his case. He wants to lecture to students on what it is like to be a serial killer "because so little is known ... most of them have never seen a serial killer ... they write to me personal letters." He also mentions a number of "famous lawyers" who are in contact with him. Y talks very glibly of being a "serial killer" and describes gruesome details like the "bodies decomposing in the sun" with no appropriate affect or even awareness of how such remarks are likely to be perceived by others, except as a source of celebrity. When confronted about this apparent lack of remorse he drew attention to the fact that he has publicly apologized to the families of the victims, spared them lurid descriptions of his crimes in court and by giving information on the whereabouts of the bodies, thus facilitating his conviction. His inability to see himself as others do is also revealed in his remark that he feels "I'm respected in here" (ie. in prison). His extensive collection of (heterosexual) pornographic pictures was displayed unselfconsciously in front of a young woman in my presence. Paradoxically, he is preoccupied with writing on religious topics and is pursuing biblical studies courses. Y was reluctant to discuss candidly the details of his crimes. He was prepared to admit to me at one point that the murders were sexually motivated

111 A Multidisciplinary Correctional Assessment but denied that his victims were tortured as the police surmised. He further denied transvestism, fetishism or cross-gender wishes, that he took photographs of, or "trophies" from, his victims, or gagged or subjected them to bondage. He claims all the victims were involved with him in "consenting sex" before and after they passed out, though he could not explain why then he needed to render them unconscious. He was further prepared to say he became "addicted to murder," that he "enjoyed it and looked forward to it." He claims he is heterosexual and that he has sexually interracted with other males only in prison, though this does not explain why two of his victims were male. He did admit, but did not elaborate, that he had a preference for certain types of victims in terms of their physical characteristics. He claims to have murdered over one hundred people and remembers details of "every one." However, he rejected my suggestion that he relives the memories to re-experience sexual excitement. He denied any psychotic symptoms at the times of the murders or since and stated that "at all times I killed I knew it was wrong." He sees himself as mentally stable. Diagnostically, Y fulfills virtually all the possible criteria for narcissistic and antisocial personality disorders and thus has very prominent "psychopathic" traits. Also from the nature of his crimes, though not by his own admission, he is a hebephilic sexual sadist, or possibly, sadistic necrophile. I could find no evidence of any major mental illness. Y believes he needs treatment for his "anger, hate, alcohol abuse and sex offender" problems. However, at another point in the interviews he said he did not see himself as a sex offender. His lack of candour in discussing his sexual interests, his unwillingness to review his offenses and motivations in detail and his limited cooperativeness with the assessment process at RTC(O) make him an unsuitable candidate for any programme that depends on self motivation and voluntary disclosure. An individual with such a profoundly narcissistic character structure is unlikely to be sufficiently self-critical and self aware to gain anything from any known treatment programme. Treatment of severe and dangerous paraphilias is difficult even with fully cooperative patients and, in the present state of knowledge, no guarantee can be given that society will ever be safe from Y. Given the very many negative views about Y on file, including those of the judge who sentenced him, it seems unlikely that he will ever be allowed to return to the community, I think basically he knows this and consequently will remain a serious security risk. Thank you for asking me to see him.

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Notes

CHAPTER ONE

i 2, 3 4 5 6 7 8 9 10 11 iz 13 14 15 16 17 18

Mustill, "Some Concluding Reflections," 247. Walker, "Fourteen Years On." Parker, "The Garry David Case." Gunn, "Management of the Mentally Abnormal Offender." Glaser, "Admissions to a Prison Psychiatric Unit," 46. Halasz, "Clinical Practice beyond Science." Walker, "Foreword," v-vi. Jung, "The Undiscovered Self," para. 531. Borzecki and Wormith, "The Criminalization of Psychiatrically 111 People." Crawford and Conacher, "Criminalization of the Mentally 111." Hodgins, "Prevalence of Mental Disorders." Motiuk and Porporino, "The Prevalence, Nature and Severity of Mental Health Problems." Report of the Advisory Board, "The General Program." Green, Menzies, and Naismith, "Psychiatry in the Canadian Correctional Service." Livingston, "Saskatchewan Secure Unit." Adapted from Conacher, "Issues in Psychiatric Care," with permission of the Minister of Supply and Services Canada, 1993. Wormith and Gendreau, "Characteristics of Protective Custody Offenders." Friedland, "The Case of Valentine Shortis."

II4 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

Notes to pages 6-15

Joliffe, "Penitentiary Medical Services." Mental Health Act. McCaldon, Conacher, and Clark, "The Right to Remain Psychotic." Menuck, Jones, and Fleming, "Treatment Refusal by Dangerous Patients." Editorial, "Tranquillisers Causing Aggression." Workman and Cunningham, "Effect of Psychotropic Drugs." Dickens, "A Case for Hospital Treatment," 126. Hare, The Psychopathy Checklist - Revised. Hart, Knopp, and Hare, "Performance of Male Psychopaths." Rice, Harris, and Cormier, "An Evaluation of a Maximum Security Therapeutic Community." Hodgins, "Prevalence of Mental Disorders," 3. Hart and Hare, "Discriminant Validity of the Psychopathy Checklist." Hodgins, "Prevalence of Mental Disorders," 4. Harris, Rice, and Quinsey, "Violent Recidivism." Villeneuve, "Predictors of General and Violent Recidivism." Toch, "The Disturbed Disruptive Inmate." CHAPTER

TWO

1 Penrose, "Mental Disease and Crime." 2 Gunn, "Criminal Behaviour and Mental Disorder," 328. 3 Crawford and Conacher, "Criminalization of the Mentally 111." 4 O'Grady, "Community Psychiatry," 329. 5 Teplin, "Criminalizing Mental Disorder." 6 Csillag, "Denmark: Psychiatric Offenders." 7 Borzecki and Wormith, "The Criminalization of Psychiatrically 111 People." 8 Davis, "Assessing the 'Criminalization' of the Mentally 111." 9 Addington and Holley, "Pre-trial Assessment." 10 O'Grady, "Community Psychiatry," 337. 11 Lagos, Perlmutter, and Saexinger, "Fear of the Mentally 111." 12 Teplin, "The Criminality of the Mentally 111." 13 Mulvey, "Assessing the Evidence." 14 Ibid., 664. 15 Gunn, "Criminal Behaviour and Mental Disorder," 317. 16 Csillag, "Denmark: Psychiatric Offenders." 17 Chuang, Williams, and Dally, "Criminal Behaviour among Schizophrenics. " 18 Humphreys et al., "Dangerous Behaviour Preceding First Admissions." 19 De Pauw and Szulecka, "Dangerous Delusions." 20 Rogers et al., "The Clinical Presentation of Command Hallucinations."

II5 21 22 23 24 25 2.6 27 28 29 30 31 32 33 34 35

36

37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

Notes to pages 15-21

Taylor, "Motives for Offending." Schanda et al., "Premorbid Adjustment." Craissati and Hodes, "Mentally 111 Sex Offenders," 848. Glaser, "Admissions to a Prison Psychiatric Unit," 49. Coid, Lewis, and Reveley, "A Twin Study of Psychosis," 89. Csillag, "Denmark: Psychiatric Offenders," 683. Rice and Harris, "A Comparison of Criminal Recidivism." Villeneuve, "Predictors of General and Violent Recidivism." Porporino and Motiuk, "Conditional Release and Offenders." Coid, "Current Concepts," 113. Lewis, "Psychopathic Personality," 139. Peck, People of the Lie. Wolman, The Sociopathic Personality. Coid, "Current Concepts." A history of failure on conditional release is a single item of the PCL-R but has also been the next best predictor of recidivism, second to the total PCL-R score in one large but as yet unpublished series of released offenders. Personal communication from Ralph Serin, 1993. Expressions of remorse are problematic to the professional assessing the risk of recidivism, since they are so easily feigned, but they are often given some weight by parole boards. Remorse may be defined as an emotion of regret for the consequences of a wrongful act (Conacher, "Guilt or Morbid Remorse?") but to be meaningful in this context should also include evidence of a subsequent, sustained change in behaviour. Blackburn, "On Moral Judgements." Ellard, "The History and Present Status of Moral Insanity," 338. Harris, Rice, and Quinsey, "Psychopathy as a Taxon." Hare, The Psychopathy Checklist - Revised. Cleckley, The Mask of Sanity. Hare, Manual for the Revised Psychopathy Checklist. Ibid., 7. Ibid., 5. Blackburn, "An Empirical Classification." Blackburn, "On Moral Judgements," 510. Serin, "Can criminal Psychopaths Be Identified?" Hart, Knopp, and Hare, "Performance of Male Psychopaths." Harris, Rice, and Cormier, "Psychopathy and Violent Recidivism." Serin, "Psychopathy and Violence in Criminals," 429. Harris, Rice, and Cormier, "Psychopathy and Violent Recidivism," 636. CHAPTER

THREE

i Morrison, "Victimization in Prison."

II6 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 2.6 27 28 29 30 31 32 33 34 35 36 37 38

Notes to pages 22-31

Adapted from Conacher, "The Use of Force." Kjellin and Nilstun, "Medical and Social Paternalism." Schouten and Goutheil, "Aftermath of the Rogers Decision." Rapp, "Chemical Restraint," 20. Tardiff, "Management of the Violent Patient." Ibid., 545. Fisher, "Restraint and Seclusion." Weinberg et al., "The Clinical Use of Chemical Mace." Hu and Christiani, "Reactive Airways Dysfunction." Weinberg et al., "The Clinical Use of Chemical Mace," 103. Ibid., 102. McCaldon, Conacher, and Clark, "The Right to Remain Psychotic," 780. Carson and Goldsmith, "'Gay-bashing' as Possible Risk for HIV Transmission." O'Farrell, Tovey, and Morgan-Capner, "Transmission of HIV-I Infection." Scott, G.D., and Gendreau, P., "Psychiatric Implications of Sensory Deprivation." Grassian and Friedman, "Effects of Sensory Deprivation." Editorial, "A European Committee." Grassian and Friedman, "Effects of Sensory Deprivation," 63. McCaldon, Conacher, and Clark, "The Right to Remain Psychotic." Mental Health Act, c. 37, s. ii. Schouten and Goutheil, "Aftermath of the Rogers Decision." Manchanda, Fernando, and Galbraith, "Consent to Treat." Loebel et al., "Duration of Psychosis and Outcome." Adapted from McCaldon et al., "The Right to Remain Psychotic," by permission of the publisher. Bertrand and Harding, "European Guidelines on Prison Health." Report, "Ethical Issues Concerning Psychiatric Care in Prison." Conacher, "Issues in Psychiatric Care," 13. Hoffman et al. "AIDS: Clinical and Ethical Issues," 850. MacCulloch and Bailey, "Issues in the Management." Ibid., 29. Andrews et al., "Does Correctional Treatment Work?" Eckman et al., "Technique for Training." Grounds, "Detention of 'Psychopathic Disorder' Patients." Collins, "The Treatability of Psychopaths." Quality Assurance Project, "Treatment Outlines for Antisocial Personality Disorder." Rice, Harris, and Cormier, "An Evaluation of a Maximum Security Therapeutic Community." Hare, "Proposal for a Model Treatment Program."

117 Notes to pages 31-43 39 Harris, Rice, and Cormier, "Psychopathy and Violent Recidivism," 636. 40 Quality Assurance Project, "Treatment Outlines for Antisocial Personality Disorder," 545. CHAPTER FOUR

1 Regulation 609. 2 Gunn, "Management of the Mentally Abnormal Offender," 879. 3 Higgins, "The Mentally Disordered Offender in the Community." 4 Gutheil, "Borderline Personality Disorder." 5 Ibid., 599. 6 Nuffield, "The 'SIR Scale'." 7 Scott, P.D., "Assessing Dangerousness in Criminals," 128. 8 Litwack, Kirschner, and Wack, "The Assessment of Dangerousness." 9 Steadman, "Predicting Dangerousness." 10 Monahan, "The Prediction of Violent Behavior," 10. 11 Mullen, "Mental Disorder and Dangerousness," 16. 12 Conacher and Quinsey, "Predictably Dangerous Psychopaths." 13 Monahan, "The Prediction of Violent Behavior," 13. 14 Harris, Rice, and Quinsey, "Violent Recidivism of Mentally Disordered Offenders." 15 Webster et al., The Violence Prediction Scheme. 16 Andrews, "Recidivism Is Predictable." 17 Serin and Amos, "The Role of Psychopathy." 18 Loza and Simourd, "Psychometric Evaluation." 19 Andrews, "Recidivism Is Predictable." 20 Scott, "Assessing Dangerousness in Criminals," 12.9. 21 Prins, "Dangerousness: A Review," 504. 22 Gross et al., "Assessing Dangerousness." 23 Attributed to Wolfgang, but uncited, in Trasler, "Delinquency, Recidivism and Desistance." 24 Rutter, "Resilience in the Face of Adversity." 25 Hubert and Hundleby, "Pathways to Desistence." 26 Werner, "High-risk Children in Young Adulthood," 79. CHAPTER FIVE

1 Higgins, "The Mentally Disordered Offender," 171. 2 "All Tragedy Is the Failure of Communication," Wilson, 1956, cited in Prins, "Some Observations," 157. 3 Higgins, "The Mentally Disordered Offender." 4 Ibid., 184.

118 Notes to pages 44-58 5 Cleckley, The Mask of Sanity. 6 Geller, "Rights, Wrongs, and the Dilemma of Coerced Community Treatment," 12.59. 7 Wiederanders and Choate, "Beyond Recidivism," 65. 8 Dunn, "Community Treatment Orders," 161. 9 Dedman, "Community Treatment Orders." 10 Ibid., 464. 11 Geller, "Rights, Wrongs and the Dilemma of Coerced Community Treatment." 12 Dunn, "Community Treatment Orders," 166. 13 Bloom, Williams, and Bigelow, "Monitored Conditional Release," 447. C H A P T E R six 1 Comfort, "For the Patient's Good." 2 Harding, "Can Prison Medicine Be Ethical?" 3 Harding, "Ethics in Psychiatry," 466. 4 Nadelson, "Ethics, Empathy, and Gender," 1309. 5 Grisso and Appelbaum, "Is It Unethical to Offer Predictions?" 6 Adshead and Smith, "The Dilemma of the Forensic Psychiatrist." 7 Harding, "Ethics in Psychiatry," 467. 8 Adapted from Conacher, "Issues in Psychiatric Care." 9 Report from the Special Committee, "Ethical Issues." 10 Goldman and Jacob, "Anatomy of a Second Generation Tarasoff Case." 11 Adshead and Mezey, "Ethical Issues," 364. 12 Report from the Special Committee, "Ethical Issues," 242. 13 Adapted from Conacher, "The Use of Force." 14 Hundert, "A Model for Ethical Problem Solving," 843. 15 Lever et al., "Use of Physical Restraints." 16 Brewin, T.B., "How Much Ethics Is Needed?" 17 Ibid., 162. 18 Hundert, "A Model for Ethical Problem Solving," 846. 19 Devettere, "Clinical Ethics and Happiness." 20 Ibid., 86. 21 Comfort, "For the Patient's Good." CHAPTER

SEVEN

1 Sagarin, "Prison Homosexuality." 2 Conacher, "AIDS, Condoms and Prisons." 3 Roth "Territoriality and Homosexuality." 4 Adapted from Conacher, Lowe, and Proctor, "The Predatory Facultative Homosexual of Prisons."

119 Notes to pages 58-70 5 6 7 8 9 10 11 12 13 14 15 16

Roth, "Territoriality and Homosexuality." Wiggs, "Prison Rape and Suicide." Mezey, "The Effects of Sexual Assault on Men." Sagarin, "Prison Homosexuality." Thome, "Education the Main Weapon." Sagarin, "Prison Homosexuality," 246. Power et al., "Sexual Behaviour in Scottish Prisons." Dye and Isaacs, "Intravenous Drug Misuse." Kennedy et al., "Drug Misuse and Sharing of Needles." Donoghue and Power, "Household Bleach as Disinfectant." Douglas et al., "Risk of Transmission." Andrus et al., "HIV Testing in Prisoners." CHAPTER EIGHT

1 Feldman, "The Challenge of Self-Mutilation." 2 Bach-Y-Rita, "Habitual Violence and Self-Mutilation." 3 Conacher and Westwood, "Autocastration in Ontario Federal Penitentiaries." 4 Adapted from Conacher, Villeneuve, and Kane, "Penile Self-Mutilation." 5 Conacher and Westwood, "Autocastration in Ontario Federal Penitentiaries." 6 Waugh, "Autocastration and Biblical Delusions." 7 Adapted from Conacher and Westwood, "Autocastration in Ontario Federal Penitentiaries." 8 Greilsheimer and Groves, "Male Genital Self-Mutilation." 9 Graff and Mallin, "The Syndrome of the Wrist Cutter." 10 Virkunnen, "Self-Mutilation in Antisocial Personality," 347. 11 Rieger, "Suicide Attempts in a Federal Prison," 534. 12 Weekes and Morison, "Self-Directed Violence," 14. 13 Bach-Y-Rita, "Habitual Violence and Self-Mutilation," 1020. 14 Dooley, "Prison Suicide in England and Wales," 42. 15 Topp, "Suicide in Prison," 26. 16 Simeon et al., "Self-Mutilation in Personality Disorders." 17 Murphy and Guze, "Setting Limits." 18 Taylor, "Managing the Manipulative Therapist." 19 Haycock, "Manipulation and Suicide Attempts," 94. 20 Murphy and Guze, "Setting Limits," 33. 21 Haycock, "Manipulation and Suicide Attempts," 95. CHAPTER NINE

i Adapted from the original of an article published in condensed form as Conacher, "The Issue of Suicide."

12O

Notes to pages 70-80

2 Green, Menzies, and Naismith, "Psychiatry in the Canadian Correctional Service." 3 Backett, "Suicide in Scottish Prisons," 22,1. 4 Dooley, "Prison Suicide in England and Wales." 5 House, "Prison Suicides." 6 Rieger, "Suicide Attempts in a Federal Prison," 532,. 7 Levey, "Suicide," 604. 8 Dooley, "Prison Suicide in England and Wales," 40. 9 Backett, "Suicide in Scottish Prisons." 10 Hurley, "Suicides by Prisoners." 11 Salive, Smith, and Brewer, "Suicide Mortality." 12 Green et al., "A Study of 133 Suicides." 13 Salive, Smith, and Brewer, "Suicide Mortality," 369. 14 Haycock, "Manipulation and Suicide Attempts," 85. 15 Levey, "Suicide," 609. 16 Report of the Working Group on Suicide Prevention; Her Majesty's Prison Service, 1986, cited in ibid., 609. 17 Backett, "Suicide in Scottish Prisons," 221. 18 Hurley, "Suicides by Prisoners," 190. 19 House, "Prison Suicides," 587. 20 Levey, "Suicide," 608. 21 Lawlor and Kosky, "Serious Suicide Attempts," 477. 22 Morgan, "Books Reconsidered," 576. 23 Hawton and Fagg, "Suicide, and Other Causes of Death." 24 Rieger, "Suicide Attempts in a Federal Prison," 534. 25 Haycock, "Manipulation and Suicide Attempts." 2.6 Bynoe, "The Prison Medical Wing," 256. 27 Caldwell and Gottesman, "Schizophrenics Kill Themselves Too." 28 King, "Suicide in the Mentally 111." 29 Schwartz, Flinn, and Slawson, "Suicide in the Psychiatric Hospital," 153. 30 Liebling and Hall, "Seclusion in Prison Strip Cells." 31 Levey, "Suicide," 609. 32 Little, "Staff Response to Inpatient and Outpatient Suicide." 33 Farmer et al., "Railway Suicide." 34 Chemtob et al., "Patients' Suicides." 35 Alexander, "Stress among Police Body Handlers." 36 Hurley, "Suicides by Prisoners." 37 Cox and Skegg, "Contagious Suicide." 38 Rosen and Walsh, "Patterns of Contagion." 39 Phillips, "The Influence of Suggestion on Suicide." 40 Skegg and Cox, "Impact of Psychiatric Services." 41 Botterell et al., "Report of the Study Team." 42 Skegg and Cox, "Impact of Psychiatric Services."

121 Notes to pages 81-93 CHAPTER TEN

i 2, 3 4 5 6 7 8 9 10 11 12 13 14 15

Stuart-White, "The 'Inadequate' Offender," 69. Parker and Knoll, "Partial Hospitalization." Ibid., 157. Ibid., 157. Editorial, "Day Hospitals for Psychiatric Care." Holloway, "Day Care in an Inner City." Ibid., 814. Ibid., 814. Creed, Black, and Anthony, "Day-Hospital and Community Treatment." Barkley, Fagen, and Lawson, "Day Care." Carney, Ferguson, and Sheffield, "Psychiatric Day Hospital and Community." Karterud et al., "Day Hospital Therapeutic Community." Gendreau, Tellier, and Wormith, "Protective Custody." Ibid., 61. Porporino and Motiuk, "Conditional Release." CHAPTER ELEVEN

1 Pepino et al, "Report of Preliminary Recommendations," 15. 2 Conacher and Quinsey, "Predictably Dangerous Psychopaths." 3 Harris, Rice, and Quinsey, "Violent Recidivism." 4 Walker, "Dangerous Mistakes." 5 Pepino et al., "Report of Preliminary Recommendations," 43. 6 Segal, "Civil Commitment Standards." 7 Conacher and Shaw, "The Use of the Ontario Mental Health Act." 8 Adapted from ibid. 9 Harris, Rice, and Quinsey, "Violent Recidivism," 333. 10 Appelbaum, "The New Preventive Detention." 11 Ibid., 783. 12 Ibid., 785. 13 Gunn, "Management of the Mentally Abnormal Offender," 879. 14 Walker, "Dangerous Mistakes," 754. 15 Ibid., 753. CHAPTER TWELVE

1 Banerjee et al., "An Integrated Service," 775. 2 Lloyd and Benezech, "The Psychiatric Service in French Prisons," 71. 3 Skegg and Cox, "Impact of Psychiatric Services," 1437. 4 Haycock, "Manipulation and Suicide Attempts," 85-6.

122 Notes to pages 93-4 5 Selby, "HMP Grendon," 99. 6 Sensky, Hughes, and Hirsch, "Compulsory Psychiatric Treatment." 7 Geller, "Rights, Wrongs, and the Dilemma of Coerced Community Treatment." 8 Dedman, "Community Treatment Orders." 9 Appelbaum, "The Right to Refuse Treatment." 10 Mustill, "Some Concluding Reflections," 239.

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hh

abuses of power, 29, 76 actuarial instruments, prediction of recidivism, 36-7, 93 ambulatory services, 8, 70 anti-social personality disorder (ASPD), 24, 69; as day patients, 84; and psychopaths, 9; treatment, 30-1 "banishment pressure": on mentally disordered offenders, 33, 90 benzodiazepines: as currency, 8; and violent incidents, 8 chemical agents, use of, 2-4-5 Cleckley, Hervey, 19—20, 44 community mental-health services, 17, 41, 43; and psychotic offenders, 31-3; and public safety, 45 community treatment orders, 44

confidentiality: as ethical duty, 39; and public safety, 50-2; at RTC(O), 8, 95-7 consent: to release information, 51-2; to treatment, 6, 2.2,—3, 50 consultations, psychiatric, 8 counselling, in suicide prevention, 77 criminalization, of the mentally ill, 5, 14 dangerousness, 36-9, 90; and mental illness, 14 day-care centres (DOCS), for inadequate inmates, 82-4 desistance, 39-40 diagnosis: on discharge from RTC(O), 7; multiple, 9, 92 emergency-response team, 23, 26, 65 family support, 39-40 force: ethical issues, 534; use of, in treatment, 22-9

forensic psychiatry, 5, 51 Fridays, 45 gender dysphoria, 63-4 habitual offenders, 31 Hare, Robert, 9, 19-20 hostage-taking, 28, 65, 88 human immunodeficiency virus (HIV): and condoms in prison, 58-9; and contaminated needles, 59; transmission of, during violent incidents, 25, 29 inadequate offenders, 7, 81-4 Jung, Carl, 5 Kingston Penitentiary, 4, 6, 77, 82 manipulation, 67-9, 77 mass hysteria, 79 media coverage, 29, 79 mental-health-care team, in penitentiaries, 76 mental retardation 7, 81-2

136 Index Millhaven Penitentiary, 13 National Parole Board, 13, 16, 32., 85; detention to warrant-expiry date, 86; need for independent assessments, 34 "Now look what you have made me do," 69 objectivity: loss of, with psychopaths, 33-4, 36 Ontario Mental Health Act (OMHA), 6, 27; and confidentiality, 95; RTC(O) and, 32; use in preventive detention, 86-90 parole, conditions of release, 17, 32, 44 parole services, liaison with community mental health, 32, 41-2 patients' rights, 22-3; costs, 23, 27 peer groups, for suicide prevention, 77 Penetanguishene Mental Health Centre, 36, 85-6 "Penrose effect," 14 pragmatism, 50, 54 preventive detention, 8591, 93—4; and community treatment, 44 Prison for Women, 77, 79 prison medicine, and ethics, 49-50 protective custody, 6, 84 psychiatric services: in prisons, 3-6, 92; in the community, 33

psychopathy, 8-9, 17-21, 55, 105-6; and "burnout," 20; Checklist Revised ( P C L - R ) , 1920, 31; cognition in, 19, 35; in hospitals, 21; influence on others, 31, 33-4; management, 20-1; as mental illness, 9, 19, 21; in predators, 55; reaction to alcohol, 44; and recidivism, 20; supervision, 44; unreliability of treatment, 20, 30-1, 106 public safety, 4, 32, 45, 93; versus confidentiality, 50-2; versus individual rights, 85, 94 Regional Treatment Centre (Ontario) (RTC[O]), 4, 6-8, 25, 70, 94; incidents at, 28—9; treatment programs, 30 remorse, 18, 35, 115^6 restraint: chemical, 24; mechanical, 25 risk assessment, 36 sadism, 9 schizophrenia, 7; forensic aspects of, 14-17; paranoid, 8-9; and recidivism, 15 seclusion, 24 sensory deprivation, 25-6 self-mutilation: and benzodiazepines, 8; compulsive, 65-7; epidemic, 79; isolated but serious acts, 60-5; in

prisons, 60-9; wristslashing, 60, 67, 74 sentences: fixed term, indefinite, or life, 32 sex offenders: assessment, 107-9; treatment, 30 sexual assault, effect on victims, 58 sexual behaviour, in prisons, 55-9 solitary confinement, 256; legal safeguards, 26; and suicide prevention, 76-7 special-needs unit (SNU), 7, 82-3 stigmatization, of the mentally ill, 22 suicide in prisons, 58, 667, 70-80; attempted, 67, 73-4; "cry for help," 69; effect on staff, 77-8; epidemic, 78-9; by hanging, 71, 75; numbers in Ontario region, 71; prediction, 70-2; prevention, 72-4 "survival crimes," 15, 43 team supervision unit, 33, 42, 63 treatment: correctional programs, 30; effectiveness, 30-1; institutions, 29-30; of sex offenders, 30 violence: incidents at RTC(O), 28-9; in psychopaths, 20 "Werther effect," 79 "whistle-blowing," 52-3