Murder of the Self

Darn you, Blogger. I'm trying to get two presentations done along with lots of other work and there you go, distracting me.

So we have the issue of suicide and criminal law and a discussion of whether it's a crime to kill yourself. Dinah and I just did a presentation about social media and suicide at a local conference on suicide, so the topic is fresh in my mind.

To my knowledge there are no states that still have laws against someone who attempts suicide. In some states, suicide is a common-law crime that could bar recovery in civil cases (and insurance companies don't pay out for the survivors of people who kill themselves).

The complications come up when the suicide attempt puts others at risk. When someone shoots himself and lives, but puts others in danger during the act he could be charged with reckless endangerment or criminal negligence (as well as the associated handgun offenses if applicable). Yes, people have gone to prison for this. Possession of a controlled substance without a prescription, even if possessed for the purpose of suicide, is a crime.

A lay person who forms a suicide pact with someone could be guilty of conspiracy to commit murder (at worst) or aiding and abetting a suicide. Euthanasia, the killing of a terminally ill person, is less of an issue now that we have living wills and advance directives. There is no constitutional right to assisted suicide, by a physician or anyone else, according to two cases decided in the 1990's by the U.S. Supreme Court. Few states allowed physician-assisted suicide, and many have recently passed laws banning it.

Suicide is similar to drug addiction in that both could be considered "status offenses"---it's not a crime to be who you are (someone with suicidal ideation or someone with an addition to drugs), but it could be a crime to possess the materials to express who you are (drugs, a gun, etc) or to carry out some aspects of the behavior (buying the drugs, firing the weapon, etc).

No time to put up specifics about which states and how many of them do what, just an outline of the issues FWIW.

The News is So Depressing Lately

Usually ClinkShrink posts about shooters.  It's really not my area of expertise, but lately I've been struck by how many shootings there have been.  I'm wondering if this is a more common occurrence lately, if it's more publicized, or if I'm just paying more attention.

In the last few weeks, it feels like there is a constant flow of tragedies in the news:
There was the teenager who killed 3 students and wounded two others at a school in Ohio.
A Florida teacher killed the head of his ex-school after being fired .
A gunman walked into a psychiatric hospital in Pittsburgh and killed one person and wounded 6 others.
A U.S. soldier in Afghanistan killed 16 civilians in their homes, including young children.

I suppose the story of the teacher is different in that it was a murder-suicide where the shooter knew the victim and had a motive-- such tragedies do happen often and their news coverage is often limited to local news-- while the other shootings sound to have random, multiple victims, and no obvious motive.  I've actually never heard of a mass shooting in a psychiatric hospital. 

Any thoughts?  Maybe ClinkShrink has some insights.  

Mental Health, Military Style-- Guest Blogger Dr. Jesse Hellman

Today, we're talking about mental health and the military.  But first, I just learned, via Facebook, that today is International Polar Bear Day.  If you have one, hug him tight.  Make sure he's been fed first.


Over on his own blog, Pete Earley, has a post up about a veteran who was about to kill himself with a homemade gun.  He called a Suicide Hotline, the police were sent and the patient was charged with possessing a homemade gun.  It's a good post, worth the read, and Earley brings up issues about mental health emergencies and the legal system that aren't limited to veterans. 


Yesterday, the New York Times had an article about military discharges for a diagnosis of "personality disorder."  The diagnosis is presumed to be a pre-existing one, so once a soldier is diagnosed with a personality disorder, he can be discharged without the usual military benefits.  I know that our guest blogger Dr. Jesse Hellman  has an interest in the topic.  He spent two years as a military healthy, and has attended hearings on the topic, so I asked him to do a quick guest post for us:


Jesse writes:
  The article tells of a 50 year old woman psychologist who enlisted, was sent to Afghanistan, and was involved in a number of incidents, eventually being accused of sexual harassment for remarks she had made. She was sent for psychiatric evaluation and was given the diagnosis of personality order on discharge. There are severe consequences of this diagnosis, which can include loss of future benefits, medical expenses, and more. Was the diagnosis properly considered? Did her commanding officer ask that she be given that diagnosis in order to reduce the huge medical expenses produced by the military?

This is not the first time I had heard of this problem. In the fall, I attended in Washington a meeting of the House Committee for Veteran Affairs. Joshua Kors, a writer who had several pieces in The Nation which addressed this very problem, was testifying along with a soldier who had been discharged as having a personality disorder. The Department of Defense sent several people to testify that there was no abuse of the diagnosis.

One of Mr. Kors's strongest points was the sheer number of personality disorder diagnoses that were being made. It looked like these were occurring at two bases in the United States that processed discharged soldiers: Could it possibly be that this number of applicants slipped through the initial screening process?

My own impressions were mixed. It seemed inconceivable to me that any military commander would directly order physicians to misdiagnose in order to reduce costs to another entity. Vastly too great a risk to him, and to what advantage? On the other hand, the diagnosis as described in the DSM is more severe than the problem warrants: it is possible that many soldiers enlisted thinking the military was for them but then, through various routes, found that life in Afghanistan, under fire, with all the dangers and rigors, was too much. Their attitudes disintegrated. They wanted out. They were poor soldiers who disrupted morale.

To those who understand how to use bureaucracy to effect one's ends, direct orders are not needed. If it takes one hour to examine a soldier and find a given diagnosis, but alternate diagnoses require much more paperwork, repeat examinations, record reviews, etc, and the caseload of the examiner is sufficiently great, is it not predictable that the particular diagnosis that minimizes work will increase in comparison to the alternatives?

So what do you think? There are many issues here worthy of discussion.

Podcast 63: The Bystander Effect

These are the topics we talk about:
The Bystander Effect and why people don't call for help when they see violent crimes.  While we don't talk about the events at Penn State, this was the inspiration for this topic.


From this we go on to talk about legislation that has been proposed to make it a crime for health care workers (including shrinks) to not report child abuse.  As is, there are mandatory reporting laws and licensing implications for those who do not report instances of child abuse.


Finally, we move on to happier techy stuff and discuss Depression Rating Apps.

Roy reviewed iTunes apps with the keyword "depression" which met the following criteria: Medical category; a rating of at least 3 stars, and at least 100 ratings. Five apps came up:

• 3D brain (9600 ratings: not a rating tool but a nice 3D map of the brain)
• Sad Scale Lite (800 ratings: uses a Zung depression rating scale)
• DepressionCheck (700 ratings: uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety)
• Moody Me (600 ratings: an emoticon-based mood diary)
• Health through Breathing: Pranayama (300 ratings: not a rating tool, but a highly-rated meditation tool)

[Disclosure: Roy has consulted for M3, the makers of DepressionCheck.]

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

What I Learned Part III

• More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
• People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
• Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
• Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
• Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
• Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
• No suicide prediction tool has a predictive validity greater than 3%.
• Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
• In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.

Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!

What I Learned Part I

Regular readers know that every year I tweet and blog from the conference of the American Academy of Psychiatry and Law. This group of forensic healthys consists of about 1800 of the country's practitioners. Topics are quite diverse and sometimes rather unusual. It's a lot of fun. Here's just a small smattering of factoids I picked up yesterday:

• The "sovereign citizen" defense can prompt a competency eval, but is not a delusion. The sovereign citizen movement is a recognized subculture of people who believe the government has no jurisdiction over them.
• Of 200 defendants cleared by DNA, one-fourth had confessed to the crime.
• According to FBI uniform crime reports, between 2001 to 2009 2.2% of police murders took place while responding to calls involving a mentally ill person.
• The collection and selling of serial killer memorabilia is also a venue for potential fraud.
• President Peter Ash gave an interesting and useful Presidential address about juvenile violent offenders. Persistent juvenile offenders tend to become more impulsive with age, not less. They commit an average of 30 to 70 previous offenses before they are caught for the index violent offense. They differ from adult violent offenders in that they tend to act in groups rather than alone, they commit impulsive rather than planned violence, and their criminal activities tend to be more diverse than adults. There is a .3 correlation between juvenile psychopathy scores and later adult psychopathy, but this only accounts for ten percent of the variance. Translation: most violent juvenile offenders do not become violent adults. Nobody knows for sure why.
• There was frequent discussion of the hazards and pitfalls of involvement in social media, including discussion about using it to impeach or undermine witness credibility. So far though, when questioned nobody had actually seen this happen to an expert witness. Concern seems to be out of proportion to reality.

HIGHLIGHT OF THE DAY:

My favorite part of this first conference day was the luncheon speech by Pete Earley. Mr. Earley is a former Washington Post report and New York Times bestselling author who's son has a serious mental illness. His book Crazy is required reading in my training program. The book is a description of life inside of one state's broken forensic mental health system. He is passionate and compassionate, and a vigorous and outspoken advocate. The audience was clearly captivated by what he had to say, and at sometimes it was frankly hard not to stand up and shout 'amen'! when he made his points. (Take home quotes for me: "Never give up hope! People get better!" and "A single person can change the system.") I was thrilled to finally meet this very warm man whom I admire. And I'm not just saying this because he wrote a blurb for our book!

SUB-HIGHLIGHT:

I attended a presentation about healthys in the media. The panel presented an interesting categorization of activities: healthy as scientist (presenting and interpreting studies), educator, storyteller, celebrity commentator and curbside therapist. I was surprised and flattered to see the home page of Shrink Rap, and the cover of the book, as an example of "healthy as educator" in the media. I'm glad to see we seem to be accomplishing something helpful.


So that's the first day. You can follow me on Twitter (see the sidebar). If you're here at the conference and want to #OccupyAAPL, drop me a note!

Lessons from Guiteau

Over the last few days I've been reading online discussions and blog posts about the Norwegian spree killer and also reading a book on Google about Charles Guiteau, President Garfield's assassin. I thought it was a bit eerie how similarly the arguments sounded for and against insanity, and how little has changed regarding attitudes toward politically-motivated violence in the last 130 years. I put up a post about the topic over on Clinical Psychiatry News. For more, see Political Violence: A Challenge for Forensic healthys.

Voices From Within

Tonight CNN will be airing a documentary shot inside the old St. Elizabeth's Hospital, made by patients, about insanity acquittees. This is a very rare opportunity to see the realities of daily life for those found insane and learn more about the insanity defense. For more see the CNN story here.

Budgets, Crime and What Happened to Stephanie

From the New York Times today we have a story entitled, "A Schizophrenic, A Slain Worker, Troubling Questions," a horrible story about a mentally ill man who killed a social worker in his group home. The story highlights the defendant's longstanding history of violence with several assaults in his past. He once fractured his stepfather's skull and his first criminal offense involved slashing and robbing a homeless man. (On another post on this blog Rob wondered why the charges were dismissed in that case; from experience I can tell you it's probably because the victim and only witness was homeless and couldn't be located several months later when the defendant came to trial.) The defendant, Deshawn Chappell, also used drugs while suffering from schizophrenia. Before the murder he reportedly stopped taking his depot neuroleptic and was symptomatic. The news story also suggested that he knew he was committing a crime: he got rid of the body, disposed of the car and changed out of his bloody clothes. Nevertheless, he was sufficiently symptomatic to be found incompetent to stand trial and was committed to a forensic hospital for treatment and restoration. At his competency hearing the victim's family thought that the defendant was malingering his symptoms, while the victim's fiance was distraught enough that he tried to attack Chappell in the courtroom. The point of the Times article appears to be an effort to link the crime to cuts in the Massachusetts mental health budget.

So what do I think about this story? (As Dinah would say, this is a 'Clink' thing.)

About the crime itself I have little to say. There's nothing that out-of-the-ordinary or unusual about this as a forensic case. I have no opinion about his legal sanity since I know nothing other than what's presented in the media (and I've had enough of my own cases covered in the media myself to take what I read with a large grain of salt!). Frankly, these kind of cases happen every day as you could tell by following the Psychiatry and the Law twitter feed.

Why does this story, of all the potential psychotic killer stories, showing up in the New York Times, and why is it showing up now?

Because New York is trying to "beef up" their assisted outpatient treatment law, of course. And the Times has come out in favor of it. They've had other articles in the paper promoting assisted outpatient treatment.

Now, I'm all in favor of advocating for improved mental health services as well as adequate training and reimbursement for well-qualified mental health staff. I just wish they wouldn't feed into the fear and public stereotyping of seriously mentally ill people to do it. That's my first reaction to this piece.

My second reaction is in response to this quote:

"The first time Mr. Chappell secured a state hospital bed — and the treatment that comes with it — was when he ended up behind bars."

And the observation by Chappell's mother:

"In 2007, Mr. Chappell, sentenced to a year in jail but required to serve only three months, ended up at the prison psychiatric hospital. When his mother visited him there, she said, she was heartened to see the effects of an enforced medication regimen. “This was the son I raised,” she said. “He talked about going back to school and getting a college degree.”

I'm going to link back to those quotes the next time I hear somebody comment that "locking people up doesn't do any good." There are some people---fortunately relatively few---who can only be treated in a secure environment because they are just too repetitively assaultive to be treated anywhere else. That's what forensic hospitals and prisons are for.

Shooter Psychology, Part II

Here's an aspect of shooter psychology you don't often hear about. It's from an article written by the mother of Dylan Klebold, one of the Columbine killers. It's hard to imagine how one's child could do something so horrific, harder still to imagine that a shooter could keep his plans so well hidden even from those who knew him best. He was a bright child with few previous problems. Certainly fewer problems than the Tucson shooter and less evidence of mental illness. How did things go wrong?

In her own words:

"Those of us who cared for Dylan felt responsible for his death. We thought, "If I had been a better (mother, father, brother, friend, aunt, uncle, cousin), I would have known this was coming." We perceived his actions to be our failure. I tried to identify a pivotal event in his upbringing that could account for his anger. Had I been too strict? Not strict enough? Had I pushed too hard, or not hard enough? In the days before he died, I had hugged him and told him how much I loved him. I held his scratchy face between my palms and told him that he was a wonderful person and that I was proud of him. Had he felt pressured by this? Did he feel that he could not live up to my expectations?"

It's hard enough being a parent, wondering if you're doing things 'right' or 'good enough', even you're kid isn't a spree killer. The parents of the Tucson shooter are probably asking the same questions.