Dr.

RAM MANOHAR LOHIYA NATIONAL

LAW UNIVERSITY

PSYCHOLOGY

Final Draft
Of
Mental Health and Criminality

Submitted to Submitted by

2017-2018

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ACKNOWLEDGEMENT:
I have taken efforts in this research work. However, it would not have been possible
without the kind support and help of many individuals. I would like to extend my
sincere thanks to all of them. I am highly indebted to Ms. Tanya Dixit (assistant
professor, psychology) for her guidance and constant supervision as well as for
providing necessary information regarding the research& also for her support in
completing the research work. I would like to express my gratitude towards my
parents & elders for their kind cooperation and encouragement which help me in
completion of this research work. And my special thanks to my college mates and
library staff who have helped me in developing this research work and people who
have willingly helped me out with their abilities.

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Contents
Introduction:.........................................................................................................4

Facts about mental illness and crime....................................................................5

Types of mental illness amounting to Criminal Behaviour..................................7

Mental health care in prisons..............................................................................10

Prison mental health care policy and practice....................................................11

Patients needing transfer to NHS mental health facilities..................................12

Health benefits from admission into prison........................................................14

Recent Developments in Prison Mental Health Services...................................15

The drivers of transformation in mental health services.................................16

Conclusion..........................................................................................................17

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Introduction:
The relationship between mental illness and criminality has long been a subject of
debate and a general course of concern within the mental health profession, the public,
correctional systems, and the criminal justice systems. As a result this has led to an
increase in research being focused on the reasons why mentally ill people commit
crimes. Debate about the need for, the nature of and care of people with mental illness
is based on the idea that most of the individuals with mental illnesses are more likely
to commit criminal and violent behaviors to themselves, their close family members,
close friends and the public than those without mental illnesses, largely due to their
state of mind.

The relationship between mental disorder and violent acts cannot be exaggerated.
Some researchers state that violence is linked to psychosis and that people who have
mental illness also fall into the category and should reflect that connection (Lidz,
Banks, Simon, Schubert and Mulvey, 2007). Some other researchers state that
substance abuse accelerates violent acts among people with mental disorder (Lurigio
and Harris, 2009). After a survey of researches the main question lies thus; what is the
relationship between mental disorder and violence? How can you connect the dots
between mental disorder and violent acts?

People with mental illness tend to be portrayed by the media as violent, unpredictable
and dangerous (Bilić and Georgaca, 2007) and the public fear violence which is
random, senseless and unpredictable, which they associate with mental illness (Stuart,
2003). The perception by the general public of the link between mental illness and
violence has fed the stigma of mental illness, reinforcing discrimination and
victimization among the mentally ill. Experiments have shown a direct link between
exposure to negative television portrayals and the development of negative attitudes
towards mental health issues, affecting viewers' beliefs about their level of safety
(Diefenbach and West, 2007). The fear of crime may also be exacerbated by the
deinstitutionalisation of the mentally ill who are cared instead by health services
within the community (Wallace, Mullen and Burgess, 2004)

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Facts about mental illness and crime
 Mentally ill people are disproportionately victimized by violent crime. The
largest crime-reducing benefit of helping persons with mental illness would be
in reducing crimes against the mentally ill.
 Some types of severe mental illness increase the risk that a person will
perpetrate a violent crime. Risk varies based on many other factors, such as
substance abuse, or unemployment. Many of the risks are from secondary
effects of the mental illness; for example, cognitive difficulties make
employment difficult or impossible.
 Many mental illnesses have a genetic component, although the genetic effects
are far from fully understood.
 Untreated severe mental illness is particularly significant in homicide—the
extreme end of the criminal spectrum. Such illness is even more significant for
mass murders of strangers.
 Treatment of severe mental illness—best accomplished by a combination of
therapy and drugs—can greatly reduce violence by and against the mentally ill.
 Many mental ill persons who seek treatment do not receive it. Mental hospital
beds per capita in the U.S. are lower than they have been since 1850.
 Over the last half-century, mental hospital capacity has dwindled, while prison
and jail capacity has vastly expanded. Mentally ill prisoners comprise a large
fraction of the jail and prison population.
 Compared to imprisonment, treating a mentally ill person in a mental hospital
is at least four times as expensive, on  month-by-month basis.
 Nevertheless, expanded availability of treatment in mental hospitals could be
cost-effective in the long run. Ninety days in a mental hospital might avoid the
need for 10 years in prison. Considering the costs suffered by victims of violent
crime, greater availability of mental health treatment would provide major
savings to society and to crime victims. Besides that, mentally ill persons who
receive appropriate aid can be more constructively productive, and helpful to
others.

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 Because many untreated mental illnesses (such as schizophrenia) are
degenerative, early treatment is especially helpful. Preventing a first episode of
psychosis (loss of contact with reality) can have major lifetime benefits.
 In situations where a severely mentally ill person presents a grave danger to
other persons, involuntary commitment may be necessary. Due process should
be scrupulously protected—such as the right to neutral decision-maker.
Involuntary commitment should not require that the danger to others be
“imminent.”
 Instead of commitment to a mental hospital, “involuntary outpatient
commitment” is a less-restrictive alternative for many persons. After hearing
the evidence, a judge may order a person to attend therapy and/or to take
medication, as a condition of not being committed to a hospital. Such programs
have been successful, and should be expanded.
 Some notorious mass murders could have been prevented if persons who knew
about a very dangerous individual had informed the appropriate authorities. For
example, officials at Pima Community College in Tucson, and at the University
of Colorado’s Aurora medical campus, might well have prevented the mass
attacks perpetrated by ex-students, if they had informed law enforcement about
the known danger. The laws of Arizona and Colorado were more than
sufficient for the individuals to have been committed for observation, with
longer commitment possible after the observation.

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Types of mental illness amounting to Criminal Behaviour

Mental disorders are patterns of behavioral or psychological symptoms that impact

multiple areas of life. These disorders create distress for the person experiencing these
symptoms. Mental illnesses have been found in some of the U.S.’s most loathsome
killers throughout history, but it’s important to note that most people suffering from
these illnesses do not commit any violent offenses. These instances of mental
disorders represent only a small fraction of people diagnosed and the majority of
people afflicted do not engage in criminal activity, especially if given proper treatment
and social support. In the wake of a violent assault, robbery, or murder, forensic
psychologists typically examine the mental correlates of criminality. Some of the most
common psychological disorders associated with history’s most infamous criminals
are:

SCHIZOPHRENIA

Schizophrenia, a wide-ranging (and often misdiagnosed) mental illness—lists

symptoms ranging from hallucination and delusions to emotional flatness and
catatonia. It is one of the most common mental disorders diagnosed among
criminals, especially serial killers:

 David Berkowitz, better known as the “Son of Sam” killed six people in the
1970s claiming that his neighbor’s dog had told him to do it. He was diagnosed
with paranoid schizophrenia.
 Ed Gein, gruesome inspiration for fiction’s Norman Bates, Buffalo Bill, and
Leather face, murdered and mutilated his victims often keeping grisly
“trophies.”
 Richard Chase—”the vampire of Sacramento”—killed six people in California
and drank their blood.
 David Gonzalez killed four people in 2004 and claimed he’d been inspired by
“Nightmare on Elm Street.”

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 Jared Lee Loughner, convicted of killing six people and wounding 13 including
U.S. Representative Gabrielle Giffords in 2011, was diagnosed with paranoid
schizophrenia.
 James Eagan Holmes, currently on trial for the 2012 “Batman murders” in
Aurora, has been diagnosed with schizophrenia by 20 doctors.

BORDERLINE PERSONALITY DISORDER

This disease is characterized by impulsive behaviours, intense mood swings, feelings

of low self-worth, and problems in interpersonal relationships. It has also been
diagnosed among some of the most notorious serial killers. Interestingly, this seems
more common among female criminals:
 Aileen Wuornos, the woman who inspired the 2003 film “Monster” starring
Charlize Theron, confessed to seven murders in Florida. She was also diagnosed
with antisocial personality disorder.
 Jeffrey Dahmer, also known as the “Milwaukee Cannibal,” killed seventeen boys
and men between 1978 and 1991. He also struggled with heavy alcohol abuse.
 Kristen H. Gilbert killed four patients at a Northampton, Virginia hospital where
she worked as a nurse by administering fatal doses of epinephrine to induce
cardiac arrest.

ANTISOCIAL PERSONALITY DISORDER

Known in the past as “psychopathy,” this mental disorder is characterized by a total
disregard of the feelings of others. People with APD may lie, act out violently, or
break the law and show no remorse. Reports state that while APD only affects 0.6% of
the population, it may affect up to 47% of male inmates and 21% of female inmates.
It’s also been diagnosed among three of the most ruthless American serial killers:
 Ted Bundy, an infamous killer and necrophile, confessed to 30 murders in the
1970s.
 John Wayne Gacy, known as the “Killer Clown,” raped and killed 33 boys and
young men in the 1970s.

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 Charles Manson, leader of the “Manson Family” cult and mastermind behind the
1969 murders at the home of Sharon Tate, was diagnosed with antisocial
personality disorder.

While these three disorders are commonly seen among violent criminals, there have
also been a number of killers whom were never diagnosed with mental illnesses. For
example, Dean Corll, also known as the “Candy Man” or the “Pied Piper,” kidnapped,
raped, and killed 28 boys between 1970 and 1973 in Houston, Texas and was never
diagnosed. Additionally, Timothy McVeigh, the Oklahoma City bomber of 1995,
killed 168 people and injured over 600, and yet he too never was given a mental
illness diagnosis.
Still, mental illness in prison populations and among criminals continues to be an
issue in the United States today. In order to decrease prison recidivism and rates of
violent crime, it’s essential that rehabilitative services and mental illness treatments be
improved in this dangerous yet vulnerable population.

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Mental health care in prisons
Over 200 years ago John Howard, the prison reformer, noted the very high number of
people with mental illnesses in prison and the poor care they received there: ‘many of
the bridewells are crowded and offensive, because the rooms which were designed for
prisoners are occupied by lunatics’; ‘No care is taken of them, although it is probable
that by medicines, and proper regimen, some of them might be restored to their
senses, and usefulness in life’ ( Howard, 1784). The first full survey of the mental
health of prisoners in England and Wales undertaken by the Office for National
Statistics showed that psychiatric morbidity remains far more common among
prisoners than among the general population ( Singleton et al, 1998). Only one
prisoner in ten showed no evidence of any mental disorder and no more than two out
of ten had only one disorder. Ten per cent of men on remand and 14% of all female
prisoners had shown signs of psychotic illness in the year prior to interview in prison
compared with 0.4% in the general household population ( Meltzeret al, 1994), and
59% of remanded men and 76% of remanded women had a neurotic disorder. Over a
quarter of female remand prisoners reported attempting suicide in the preceding year
and 2% of both male and female remand prisoners reported having attempted suicide
in the week before interview. Fifty-eight per cent of men and 36% of women on
remand met the criteria for previous hazardous drinking, and 66% of remanded
women had misused drugs in the year prior to entry into prison. Comorbidity was the
norm; seven out of ten prisoners had more than one disorder, and those with
functional psychosis were likely to have three or four other disorders.

Reasons for this high prevalence are discussed by Reed; they include higher risk of
arrest for people with mental disorder alleged to have offended, inadequate coverage
by court assessment schemes, too few National Health Service (NHS) psychiatric
beds, and poor identification during reception into prison.

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Prison mental health care policy and practice
A principle of ‘equivalence of care’ for prison health became embedded into
government policy from 1990, advocating a vision that prisoners should receive the
same standard and delivery of health care as they would were they not in prison. The
weaknesses in prison health care services in particular are the shortfalls in the quality
of care provided and links with the NHS, and the professional isolation of prison
health care staff. Neither staffing nor policy in prisons was geared to the provision of
NHS equivalent care. Until June 1999, doctors recruited to work in prisons were
required only to be ‘registered medical practitioners’ rather than having appropriate
specialist training. A quarter of the nursing workforce comprises health care officers,
many of whom have only limited nurse training.

Health care workers in prisons have had little in the way of guidance on policy or
practice in caring for prisoners with mental illnesses. A welcome consequence of the
cooperation between the Department of Health and the Prison Service has been the
publication for the first time of a strategy for mental health services in prison
( Department of Health, 2001b), based on the National Service Framework for mental
health. Equally welcome is the adaptation by Paton & Jenkins of the World Health
Organization's guidelines on mental health in primary care, which, if effectively used
throughout the Prison Service, would transform primary mental health care in prisons
from its present low base.

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Patients needing transfer to NHS mental health facilities
Earthrowl et al draw attention to a major problem facing prisons: the presence of
many inmates with acute and severe mental illness who require NHS in-patient care
but whose transfer cannot be arranged expeditiously. This is a problem which is, very
largely, not caused by the prisons, and its solution rests more with the NHS than with
the Prison Service. Some of these severely ill patients have not been identified by the
prisons and are on general location in prison wings ( Birmingham et al, 1998). Her
Majesty's Inspectorate found one prisoner on general location, clearly experiencing
hallucinations and delusions, who had not left his cell or washed for several weeks.
Officers thought that he was ‘acting up’ to stay in his single cell. Even when a
prisoner has been identified as being severely ill, care can be grossly inadequate —
epitomised by a patient whom HM Inspectorate of Prisons found nursed in a health
care centre with no furniture or bedding because the prison had ‘ run out of supplies’.

Transfers to the NHS of prisoners with serious mental illness are often delayed for
months, or even years. A recent audit report ( Isherwood & Parrott, 2002) confirms
that lengthy delays continue despite increased numbers of transfers, and it remains to
be seen what impact is produced by the recent requirement to report to the Department
of Health delays of more than 3 months from acceptance. Consequently such patients
accumulate in prison health care centres. One patient, HM Inspectorate found, was
still waiting for admission to a high-security hospital 5 years after transfer had been
recommended by a special hospital consultant. If the figures from an unpublished
survey of in-patient units in prisons in West Midland and Trent NHS regions (A.
Reed, personal communication, 2002) are extrapolated nationwide, then there are
likely to be up to 500 patients in prison health care centres sufficiently ill to require
NHS admission.

Many reasons have been suggested for these delays. Reports of concern that the Home
Office will insist on an inappropriate level of security in the NHS, a reluctance to
accept those with dual diagnosis, or a fear that transferred prisoners bring a ‘prison
culture’ with them, are anecdotal only and have never been raised with HM

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Inspectorate by prison staff and visiting psychiatrists. Rather, the principal problem
causing delay in transfer reported to the Inspectorate is a shortage of secure
psychiatric beds. A further reason given us for delay in transfer is a belief that,
whatever the deficiencies in prison health care, patients with serious mental illnesses
are safe in a prison health care centre. This is not true. Over 14% of all suicides in
prison take place in the health care centre (HM Inspectorate of Prisons, 1999), and
Dooley has shown that mental illness, as distinct from guilt at their offence or inability
to cope with the pressures of imprisonment, was the main motivation for 22% of all
those who committed suicide in prison. An unpublished Prison Service study of deaths
in prison by suicide between January 1992 and October 1993 showed that three
patients had committed suicide while awaiting transfer to NHS psychiatric care (M.
Piper, personal communication, 2002).

Earthrowl et al ( 2003, this issue) propose a policy and protocol for extending
treatment of non-consenting patients in prison beyond emergencies, and it has been
suggested ( Wilson & Forrester, 2002) that the current practice of restricting to
emergencies the compulsory treatment of patients who do not consent may be based
on a misunderstanding of common law. However, treatment without consent in prison
means that patients would be given psychotropic medication while in the care of a
service that is not staffed, trained or equipped to meet all their needs. For instance,
they would not necessarily be under the care of a fully trained psychiatrist; nurses
trained in mental health would be in the minority; multi-disciplinary care teams would
virtually always not be in place; and staffing levels would make it likely that the
patients would be locked in their rooms for by far the greater part of the day. One of
the suggested revisions to mental health law would make such treatment legal, but
would it make it ethical and compatible with human rights law?

Aside from these risks for individual patients, there is a real danger that if treatment
without consent became common in prisons, the need to ensure that there were
sufficient NHS psychiatric beds to allow prompt admission of all who needed
inpatient care would slip even further down the priority list both of individual services
and of the Department of Health.

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Health benefits from admission into prison
Admission to prison offers a unique opportunity to assess and to start to meet the
health care needs of a population with high levels of physical and psychiatric
morbidity, many of whom rarely come into contact with the NHS. Drug and alcohol
problems can be addressed, blood-borne viral infections identified and treated, dental
health improved, and mental health problems assessed and treatment started.
However, prisons are not hospitals, and (unlike prisoners with serious physical illness)
many prisoners with serious mental illnesses requiring NHS in-patient care remain in
prison. A senior medical officer in prison summed up the situation neatly: ‘I have
always found it strange that a patient [in prison] suffering from a medical emergency
can be in the nearby general hospital within 30 minutes, but if they are floridly
psychotic it takes 30 days at least to find an appropriate disposal.

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Recent Developments in Prison Mental Health Services
Despite the various reviews and developments over the years, prisoners suffering with
mental health issues are still a huge concern. A number of concerns are raised over the
safety and welfare of prisoners. It found that staff have insufficient training to identify
prisoners with mental health problems and the knowledge to refer them for
assessment, with primary mental health care services in 25 per cent of prisons
identified as being insufficient to meet the demand. Further challenges for services
included not being able to transfer patients with serious mental health problems from
prison to a hospital within the expected transfer time of 14 days. Most worrying is the
rise in deaths in custody, with a 67 per cent increase in self-inflicted deaths, and a
dramatic increase of 38 per cent in serious assaults involving adult male prisoners.
These statistics are of concern. It suggests that investment in prison mental health
services be prioritized and that there should be a national focus on equity in prisons,
with a national development of a framework for inter-prison healthcare service
comparison. Also considering the development of mental health services in the
criminal justice system, The Bradley Report Five Years On (Centre for Mental Health,
2014) independently reviewed the progress of The Bradley Report (Department of
Health, 2009). It is pleasing to see that some of the recommendations have been
implemented, with the responsibility for prison healthcare being passed over to NHS
allowing for a more standardised approach to prison mental health services. It also
noted that prison mental health services were developing a broader focus; however an
“absence of a national blueprint” was one of the key challenges faced by services. One
key recommendation was that an operating model of prison mental health and learning
disability care be developed. Additionally, it is important to support prisoners from
prison to the community by offering, through the gate services. The proposal from the
Care Quality Commission (CQC) that they would be jointly monitoring the care
provided in all prisons with HM Inspectorate of Prisons was very much welcomed.
The outline of the new approach to regulate health and justice services, provide ‘a
more cohesive joint view of healthcare with secure settings’. Moreover, it is
encouraging that the National Institute for Health and Care Excellence (NICE) has

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launched the development of two sets of clinical guidelines; Physical Health of People
in Prison and Mental Health of Adults in Contact with the Criminal Justice System.
The scope of the first document, addressing physical health, will focus on improving
health and wellbeing in prison targeting areas such as; coordination and
communication between healthcare professionals, the use of medication, urgent and
emergency management in prison and the continuity of healthcare on admission to
prison, transfer or on release to the community (NICE, 2014). The second set of
guidelines focusing on adults within the criminal justice system is covering a range of
areas, including; identification and assessment of mental 20 health problems, adapting
existing interventions for the criminal justice system, improving the organization and
provision of services for people with mental health problems and providing training to
criminal justice professionals and practitioners to provide good quality services.

The drivers of transformation in mental health services

The transformation of mental health services has not happened easily or consistently
and was by no means a linear process. At different points there has been considerable
energy and enthusiasm for change as well as resistance among some professional
groups, relatives and carers. A clear message The following themes emerged as the
drivers:

 the impact of social movements and voices for change

 growing therapeutic optimism
 innovations in service delivery
 case management and care co-ordination
 changing professional roles and cultures
 financial models

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Conclusion
Psychological disorders can cause disruptions in daily functioning, relationships,
work, school, and other important domains; in these types of cases, even induce
criminal behavior. With appropriate diagnosis and treatment, however, people may
find relief from their symptoms and discover ways to cope effectively in many cases.

To diagnose people with mental disorders leading to Criminal Behaviour, firstly, the
followings questions are to be answered:

 Did the accused have a troubled childhood?

 Does (s)he exhibit empathy for others?
 Does (s)he self-medicate with drugs or alcohol?

By deriving the answers to the above mentioned questions, by a professional, the

criminal behaviour of the mentally ill people can be controlled and the very possibility
of the consequences may be terminated….

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