Release Decision-Making (2024)

Forensic Mental Health Assessment: A Casebook (2 edn)

Kirk Heilbrun (ed.) et al.

https://doi-org.libproxy.ucl.ac.uk/10.1093/med:psych/9780199941551.001.0001

Published:

2014

Online ISBN:

9780190261672

Print ISBN:

9780199941551

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Chapter

Kirk Heilbrun,

Kirk Heilbrun

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David DeMatteo,

David DeMatteo

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Stephanie Brooks Holliday,

Stephanie Brooks Holliday

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Casey LaDuke

Casey LaDuke

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https://doi-org.libproxy.ucl.ac.uk/10.1093/med:psych/9780199941551.003.0024

Pages

493–530

  • Published:

    July 2014

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Heilbrun, Kirk, and others, 'Release Decision-Making', in Kirk Heilbrun, and others (eds), Forensic Mental Health Assessment: A Casebook, 2 edn (New York, 2014; online edn, Oxford Academic, 1 Oct. 2015), https://doi-org.libproxy.ucl.ac.uk/10.1093/med:psych/9780199941551.003.0024, accessed 23 May 2024.

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Abstract

The release decision-making process as it relates to the adult criminal justice system is the focus of the two reports in this chapter. In both of these cases, the evaluees had previously been found not guilty by reason of insanity and committed for mental health treatment. The present evaluations for release therefore focused largely on violence risk assessment and recommendations for risk management.

Keywords: forensic evaluation, release decision-making process, insanity, mental health treatment, violence risk assessment, forensic mental health, FMHA

Subject

Clinical Psychology Forensic and Law Psychology

Collection: Oxford Clinical Psychology

The release decision-making process as it relates to the adult criminal justice system is the focus of the two reports in this chapter. In both of these cases, the evaluees had previously been found not guilty by reason of insanity and committed for mental health treatment. The present evaluations for release therefore focused largely on violence risk assessment and recommendations for risk management. Furthermore, the included reports consider the least restrictive setting that meets the evaluee’s ongoing treatment needs while still mitigating future risk to public safety. The principle associated with the first case underscores the importance of obtaining historical information relevant to the evaluation, and the teaching point describes the integration of information from both hospitalization and pre-hospitalization in release decision-making. The second case highlights the importance of using multiple sources of information, while the teaching point outlines specific sources of information that may be informative about the individual’s pre-hospitalization status and current hospitalization. Finally, the principle and teaching point associated with the third case describe the importance of reporting findings in a balanced and accurate manner.

Case One Principle: Obtain Relevant Historical Information (Principle 19)

This principle is discussed in Chapter 7 (this volume), so we turn to the question of how the present report illustrates this principle. The current report provides a good example of what constitutes relevant historical information and how to obtain it in the context of an evaluation for release decision-making. The evaluators reviewed a range of documents that provided historical information relating to Mr. McKay’s legal history, medical history, psychiatric history, and his previous adjustment to living in the community. All sources of information relied upon by the evaluators are clearly identified early in the report (“Sources of Information”), and there is a detailed section of the report titled “Historic Considerations” that provides specific information about Mr. McKay’s psychiatric history, criminal history (juvenile and adult), history of institutional adjustment, and substance use history. The historical information was essential in terms of informing the evaluators’ opinions and recommendations. Specifically, in reaching their conclusions about Mr. McKay’s ability to live in the community—which involves an assessment of his risk—the evaluators cited Mr. McKay’s history of violence, extensive mental health history, and his performance on prior conditional releases, among other factors.

Forensic Psychological Report

Risk Assessment

McKay, Daryll

Reg. No. 11111-111

Date of Birth:

July 20, 1966

Dates of Evaluation:

April 25, 2005, to August 17, 2005

Date of Report:

August 17, 2005

McKay, Daryll

Reg. No. 11111-111

Date of Birth:

July 20, 1966

Dates of Evaluation:

April 25, 2005, to August 17, 2005

Date of Report:

August 17, 2005

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Referral

Daryll McKay is a 39-year-old African American male. In January 1997, Mr. McKay was found not guilty by reason of insanity for threatening the President of the United States. He was subsequently committed for mental health treatment, but was granted a conditional release after stabilizing on medication.

On April 23, 2005, a petition was filed with the court indicating that Mr. McKay had violated the conditions of his release. Following an initial court hearing, the United States District Judge ordered that Mr. McKay be committed for a 45-day evaluation to determine if he was currently dangerous to others (or the property of others) due to a mental illness.

Mr. McKay arrived at this facility on April 25, 2005. This writer met with Mr. McKay on April 26, 2005. At that time, this writer reviewed the nature and purpose of the evaluation with him. This writer explained that any information provided by Mr. McKay would not be confidential, could be included in this report, and would be provided to the risk assessment panel. He was also informed that a copy of the final risk assessment report would be presented to the court and would be seen by any judge, lawyers, and any outside mental health experts who may be involved in the case. Mr. McKay indicated that he understood this information and demonstrated this understanding in subsequent discussions. He indicated that he was willing to cooperate with the evaluation and agreed to proceed.

A risk assessment panel was convened to review Mr. McKay’s assessment, interview him, and render an initial opinion concerning whether his release would present a substantial risk of bodily injury to others or serious damage to the property of others due to a mental illness. The panel was composed of the Chief of Psychology; the Chief of Psychiatry; and the Supervisory Social Worker. Also present was Mr. McKay’s primary clinician, the writer of this report.

The Risk Assessment Panel considered a variety of factors relevant to their predictive effort. These factors are divided into two broad categories of historical issues (static risk factors) and treatment issues (dynamic risk factors). These factors were assessed both by clinical review and via the use of four formalized measures that have been found to be helpful in the assessment of future risk: the Psychopathy Checklist Revised (PCL-R), the Violence Risk Appraisal Guide (VRAG), the History-Clinical-Risk-20 (HCR-20), and the Static-99.

Future violence is difficult to accurately predict. Therefore, this report will focus on identifying factors that may place Mr. McKay at increased risk for engaging in future violence and protective factors that may help him refrain from future criminal acts. This report will also provide some recommendations for possible ways to manage the identified risk factors.

Sources of Information

The evaluation was conducted in the Mental Health Unit from April 25, 2005, to August 17, 2005. This writer made use of several different sources to obtain the information required to complete the present risk assessment. Mr. McKay’s day-to-day functioning on his unit of residence was routinely observed by several staff members, including correctional officers, nurses, psychiatrists, and psychologists during daily rounds. This writer completed three specific risk assessment interviews in addition to several brief contacts with him. A routine admission medical history and physical examination were completed. Several documents were reviewed, including: court orders; prior forensic evaluations; notes, reports, and medical records from an outpatient treatment center where Mr. McKay was treated during his conditional release; memorandums from the United States Probation Office regarding Mr. McKay’s adjustment in the community; letters written by Mr. McKay while he was in the community; available psychological and medical records from prior incarcerations and hospitalizations; and a phone interview with staff from the outpatient treatment center.

Hi Storical Considerations

Prior Psychiatric History

Mr. McKay reported that he first saw a mental health professional at age 13. He said he was initially seen because of behavioral problems. He indicated that his primary problem at that time was difficulty coping with emotions related to his father’s alcohol use, physical abuse, and the divorce of his parents.

Mr. McKay stated that his first adult contact with a psychologist occurred in 1988 after he was convicted of raping a woman at knife-point. He reported that he was actively engaged in devil worship at that time. He originally claimed he viewed the rape victim as a sacrifice for the devil despite the fact that he did not cut or stab her.

Mr. McKay said he engaged in several unusual behaviors during the time of the rape. For example, he said he would cut himself and drink blood. While incarcerated for this offense in the state prison, he experienced auditory hallucinations that told him to break things and kill himself. He reported having attempted suicide by hanging on two occasions.

Mr. McKay completed eight years of a ten-year sentence for rape in 1996. He said that during his incarceration in the state prison, he completed sex offender treatment. No collateral information was available to confirm this, however, or describe the content of any treatment he might have completed.

Mr. McKay’s grandmother noted that after he was released from prison he was as “crazy as a bat.” She reported that he often talked “crazy,” saying, “He’s gonna kill this somebody or that somebody, and somebody’s always trying to take his money.” His grandmother noted that he often discussed moving to Europe to be in the military. An aunt indicated that he repeatedly told his grandmother, “I wish you were dead,” and “When you die, I will spit on your grave.”

In 1989, Mr. McKay wrote a letter predicting world events. He claimed that he was angry with his grandmother because she gave the letter to the government. On several occasions, he expressed the belief that the government was conspiring against him because he had special powers (which included the ability to end the world if he read his letter).

Mr. McKay worked at a “wood plant shop” for several months. While in this job, he severed one of his fingers and received a workmen’s compensation settlement. He took the money and flew to Europe, planning to join the Foreign Legion. Prior to his departure, some of his neighbors noted that he made unusual comments about wanting to leave the country and renounce his citizenship.

While in Europe, Mr. McKay stayed in a hotel, where the staff observed bizarre behavior. He frequently called the hotel switchboard and requested to be put through to the President of the United States. Two fire extinguishers were thrown from an upper-story window at the hotel, and Mr. McKay was observed throwing one of these. He failed to gain acceptance into the Foreign Legion, started drinking heavily, and ultimately left a letter at the United States Consulate stating that he wanted to renounce his U.S. citizenship so that he could travel to Iraq. Additionally, Mr. McKay left letters threatening to kill the President of the United States.

Mr. McKay was apprehended by European authorities and was hospitalized for psychiatric care. He was initially placed in a European mental hospital, where he took medication willingly. He was eventually returned to the United States and sent to this facility for an evaluation to determine his competency and mental responsibility. The forensic staff concluded that Mr. McKay was marginally competent and able to assist in his defense. They also opined that he was legally insane at the time of writing the threatening letters in Europe.

Mr. McKay was returned to this facility for treatment after being found not guilty by reason of insanity. At that time, he was described as a model patient throughout his hospitalization. He had only one incident of violence during his initial commitment—he struck another inmate who had changed a television channel and pulled Mr. McKay’s hand away when he went to change it back. Shortly after that incident, he said to a nurse, “Ms. S, I don’t want any trouble, I’m trying to go home. Dr. G is going to be mad at me but I couldn’t let him hit me.” Mr. McKay completed a brief period of disciplinary segregation without incident. He eventually stabilized on psychiatric medication and was approved for conditional release to the community.

Between 2000 and 2005, Mr. McKay had repeated difficulties with adjusting well in community placements. He was placed in group homes on multiple occasions, but invariably had conflicts with peers or staff. On numerous occasions, Mr. McKay accused others of sexually harassing him, watching him in the shower, and trying to poison his food. Records indicate that Mr. McKay displayed these unusual beliefs even though he continued to take psychiatric medication. He engaged in several behaviors that resulted in a series of supervision violations. These included: “jumping on” a peer who, he believed, had made sexual advances toward him; staff discovering a homemade knife in his room at a group home; an altercation with an inmate while he was being held in a county jail; and a fight with a peer in a group home. Upon being readmitted to a hospital, Mr. McKay was consistently able to stabilize on psychiatric medication and earn approval for placement back in the community on a conditional release.

Records indicate that Mr. McKay was compliant with psychiatric medication and routinely attended outpatient therapy sessions during his most recent conditional release. They also noted, however, that he had difficulties getting along with peers. In particular, Mr. McKay apparently was accused by multiple residents of being threatening, and staff had concerns that he was bullying other residents. One peer accused Mr. McKay of threatening to stab him. Records indicate that Mr. McKay agreed to sign a “no harm” contract, but continued to have episodes of agitation and irritability. The clinic director noted that Mr. McKay was overtly polite and appropriate with staff but had difficulty accepting the rules of the facility. She noted that he was not overtly violent or defiant of the rules but observed that he did not like being told what to do. Mr. McKay was eventually recommended for a violation of supervised release due to his inability to maintain residence in the group home.

Antisocial Behavior and Characteristics

Juvenile History

Mr. McKay reported that he has had problems from a young age. He admitted getting into trouble for fighting before he turned 12. He noted, however, that his first serious problems began at the age of 13 after his parents divorced. He said his father was often drunk and physically abusive. Mr. McKay reported that he burned the family house down to get back at his father for beating him.

Mr. McKay said that he had problems following his parents’ rules and became more difficult as he entered his teen years. He admitted to running away from home and various other placements at least six times. He said he began skipping school at age 15. He stated he joined the Gangster Disciples gang at that time but claimed he gave up being an active member several years ago. He said he was taken out of his home in 1982 and placed in a group home because he was uncontrollable. He denied, however, having any official juvenile criminal records.

Criminal History

Mr. McKay has only three charges on his adult criminal record. He was convicted of aggravated rape in 1986. He served eight years in a state prison for this offense and is currently required to register as a sex offender.

As noted previously, Mr. McKay was charged with making threats to the President of the United States in 1996 while he was visiting France. He was initially committed to a French mental hospital before being extradited back to the United States. He was eventually found not guilty by reason of insanity and he has been under a court order for mental health treatment since that time.

Mr. McKay’s final adult offense was for falsification of a Sex Offender Registration Form in 2001. No further information regarding this offense was available at the time this report was prepared. Mr. McKay has had no further criminal charges since that time, although he has had notable problems while on supervised release in community placements.

Prior Institutional Adjustment

Collateral information noted that Mr. McKay had several incident reports while he was incarcerated in the State Department of Corrections. During the eight years he served in the State, he was charged with possession of contraband, making threats to employees, assaulting a staff member, starting fires, and flooding a cell. During his prior commitments to this facility, Mr. McKay received three incident reports. He was charged with fighting with another (inmate) on two occasions (1999 and 2004). He was also charged with giving or accepting money without authority in 2001 after he was found in possession of another inmate’s property.

Substance Abuse

Mr. McKay said he first began drinking alcohol at age 9 or 10. He said he used to drink a six-pack of beer on weekends. He admitted that he previously had problems in school due to his drinking. He was intoxicated during both his violent offenses (aggravated rape and threatening the President of the United States). He has, however, denied having an alcohol problem. Despite this denial, Mr. McKay has participated in Alcoholics Anonymous sessions during prior incarcerations and he claims he no longer drinks. There is no evidence he was intoxicated during his most recent period of supervised release.

In terms of illegal drugs, Mr. McKay said he began smoking marijuana at age 11 or 12. He noted that he began using Ecstasy at age 15. He described his drug use as primarily social. He denied having a drug use problem. There is no evidence that he was using drugs during his most recent period of supervised release.

Evaluation and Treatment Review

Hospital Course

Mr. McKay was admitted to the Mental Health Evaluation Unit at the Medical Center on April 25, 2005. This was his sixth admission to this facility. His initial mental health assessment was conducted on April 26, 2005. At that time he showed some signs of residual thought disorder (i.e. unusual affect, stilted speech), but his symptoms appeared to be well managed by psychiatric medication. Mr. McKay reported that he was “doing okay” and explicitly denied having any current suicidal or homicidal ideation or intention.

As per standard procedure, Mr. McKay was initially placed under close monitoring on a locked ward until staff could observe him and gain more information. Correctional staff described him as cooperative and quiet. He was quickly able to transfer from a locked unit to general population.

Mr. McKay was able to remain in the open population from May to August of 2005. During that time, the correctional staff assigned to his housing unit initially reported no remarkable behavior. In June, the nursing staff overheard Mr. McKay saying “The end of the world will be about me.” Despite this unusual comment, however, he appeared to be doing well on a day-to-day basis in the open population.

During this period, Mr. McKay was observed socializing with peers in the laundry room and recreation yard. He routinely attended recreation and took his meals in the inmate dining room. He was observed in the halls seeking out contacts with staff members he has known from prior commitments to this facility. He consistently presented as polite and appropriate.

On June 13, 2005, Mr. McKay approached this writer and complained that a male nurse had grabbed his buttocks during the morning medication pass. Although he has a history of delusional ideation about being sexually harassed by males, he was insistent that this really happened. His complaint was investigated, but no support was found for Mr. McKay’s story. Mr. McKay handled the situation by avoiding the nurse whenever possible, but he did not become aggressive or assaultive at that time. By June 31, 2005, Mr. McKay claimed he no longer had any concerns about being harassed at this facility.

On July 3, 2005, Mr. McKay was involved in a physical conflict with a peer on his unit and was temporarily moved to a locked unit pending investigation of the incident. The fight apparently started when Mr. McKay attacked the other patient with a pen. Mr. McKay claimed that the other patient had been hired by his social worker to sexually harass him in the shower and assault him in his room. He said he knew this was true because he had seen his social worker talking with the other patient in her office. He also claimed that he felt the other patient tried to poison him because he developed a rash after eating chocolates provided to him by the peer. He reported that he was only defending himself during the incident.

Mr. McKay was given incident reports for assault and fighting. When he was initially placed in a locked unit, Mr. McKay was irritable, agitated, and disorganized. He had some minor conflicts with staff. For example, he refused to receive medications from the nurse whom he had previously accused of sexually harassing him.

On July 23 of 2005, Mr. McKay handed this writer an unusual letter. The text of the letter was as follows: “I Daryll-McKay agree to suck a dick on video and make babies with NP [a staff member from the group home he was in while on supervised release] whenever I leave prison of Prisoners back into society.” When asked about the letter, Mr. McKay reported that he had been getting “colds” from women since he was initially incarcerated in Federal Bureau of Prisons (FBOP) custody. He said the Chief Social Worker had, in fact, instructed his social worker to give Mr. McKay “colds.” He went on to explain that he and everyone else knew about his blood and understood that his sperm could cure the AIDS virus. He was insistent that this belief was not irrational and that he knew it to be true because he had “a feeling.” He said that several women have pursued him because his sperm can cure AIDS, but he is only interested in NP.

A psychiatric consult was requested to determine if Mr. McKay’s antipsychotic medication was still effective. After interviewing him and reviewing his history, psychiatry staff recommended increasing his Geodon dose. Mr. McKay agreed to cooperate with the medication changes. He took the increased dose consistently, and his mental status appeared to improve over time. He once again began presenting as calm, polite, and cooperative with staff.

Mr. McKay was moved to the transitional unit on August 11, 2005. Shortly after moving, however, he became involved in a verbal conflict with the unit officer when she attempted to limit his property to the amount specified by policy. He became verbally aggressive and received a disciplinary report for insolence. Mr. McKay was returned to a locked unit on August 12, 2005.

While on the locked unit, Mr. McKay maintained a good attitude. He was consistently appropriate with staff. He was selected to act as a unit orderly and received good work reviews from the officers. After his sanctions were completed, the officers recommend Mr. McKay return to the transitional unit, and he was moved to that unit on August 25 of 2005 without incident. He subsequently returned to an open unit where he has remained without incident.

Mr. McKay spontaneously enrolled himself in an anger management group being run by the Social Work Department during the evaluation period here. Staff indicated that he participated regularly in group and his comments were good. They noted, however, that his answers seemed “rehearsed” and noted it was difficult to tell how invested he was in the group, given his current legal status.

During the evaluation, Mr. McKay reported that his three warning signs for future violent behavior would be becoming upset, hearing voices, and stopping his psychiatric medications. He noted that he has been taking his psychiatric medications routinely since he returned from France, and this is consistent with collateral information. He noted that he has not experienced auditory hallucinations since 2003. Mr. McKay reported that he used to have a temper problem, but he believes it is now under control. He said he used to be reactive and would react violently when angry rather than rationalizing. He said he now feels capable of containing his anger by isolating himself from others until he can discuss his problems with a counselor, family member, or mental health expert. He said the thing that is most likely to make him angry now is feeling as if others are sexually harassing him or watching him shower.

At the time of this report, Mr. McKay was taking the following psychiatric medications: Geodon (80 mg twice daily for psychosis) and Doxepin (50 mg as needed for agitation, not to exceed 150 mg in 24 hours). As noted previously, he was compliant with his Geodon prescription throughout the evaluation. Records indicate he has rarely taken any of his “as needed” Doxepin medication during his time at this facility.

Community Impressions and Resources

Family

Mr. McKay was born on July 20, 1966, in Jackson, Mississippi. He said his parents argued frequently. He described his father as alcoholic and abusive. He stated his parents divorced in 1974, and it was very hard on him. He said he tried to deal with these problems by keeping to himself, playing basketball, and joining the Gangster Disciples gang. He admitted to playing with matches at age 13 and setting the house on fire to get back at his father for beating him. He said he ran away from home numerous times after age 13 and admitted he was generally hard to manage.

Mr. McKay indicated that his mother and grandmother took care of him between 1974 and 1976. He was then transferred to his father’s care from 1976 until 1982. In 1982, his father placed him in a group home because his behavior had become problematic. He remained in the group home for several months.

Mr. McKay has two brothers and four sisters. He said he got along well with them when he was growing up but lost contact with most of his family members after he was convicted of aggravated rape in 1986. He admitted that his incarceration has been hard on his family, particularly his father. As noted previously, collateral information indicates Mr. McKay made several harsh comments to family members in the past.

Mr. McKay said he resumed contact with his father and his oldest sister when he was last housed in Mississippi. He claimed they have been supportive but acknowledged he had no contact with them while he was in his last group home placement. He said his oldest brother is currently serving a life sentence in the state of Wisconsin for murder and rape.

Relationship

Mr. McKay has never been married and he has no children. He claimed to have two or three close friends but did not identify who they were. He said the longest friendship he has ever had has been two years and noted that he trusts his family more than anyone else.

Community Placement

At the time of his 2003 risk assessment, a social worker contacted Mr. McKay’s case manager from the Mental Health Center. The case manager stated that the group home would not be willing to take Mr. McKay back, due to the nature of his violation.

During the evaluation, Mr. McKay reported that his ideal release plan would be to live in Jackson. He said he would accept living with family, in a group home, or in a homeless shelter. He said he wanted to be in Jackson because he would have family support in that city. He also reported that he would have the support of “the Muslim community.” He indicated that he knew the city well, which would make getting a job easier. He said he was also aware of community mental health resources in Jackson he could utilize. He was able to recognize that the major obstacle to getting him placed in a group home in Jackson would be his history of violence, threats, and rape.

Risk Assessment Measures

This writer administered four formalized assessment measures to help evaluate Mr. McKay’s relative risk for recidivism if he were to be released to the community. These measures are the Psychopathy Checklist–Revised Second Edition (PCL-R; Hare, 2003), the Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 1998), the HCR-20 (Webster, Douglas, Eaves, & Hart, 1997), and the Static-99 (Hanson & Thornton, 2000). The first two instruments are measures of static risk factors for general violent recidivism that are unlikely to change over time. As such, they can provide only a baseline estimate of an individual’s risk for future violence. The HCR-20 measures both static and dynamic risk factors for general violent recidivism. As such, it is capable of identifying both protective factors and risk factors that may be targets for change. The Static-99 is a measure of static risk factors for future sexual offenses. This measure was included in the present assessment because Mr. McKay has a prior conviction for aggravated rape. Therefore, it seemed prudent to evaluate his risk for engaging in future sexual violence using a measure designed specifically for that purpose.

Psychopathy Checklist Revised, Second Edition (PCL-R)

The PCL-R is a 20-item instrument designed to measure negative interpersonal style, limited affect, deviant lifestyle, and antisocial behavior. PCL-R scores are determined based on information obtained from both clinical interviews and review of collateral file information. PCL-R scores range from 0 to 40. Scores below 20 are generally considered indicative of a distinct lack of psychopathic traits. Scores of 30 or more are generally considered indicative of the presence of significant psychopathic traits. Higher scores on this instrument have been found to be associated with higher risk for revocation of parole, revocation of mandatory supervision, being unlawfully at large, and general recidivism. There are also studies linking higher PCL-R scores to higher risk for acting violently when released from prison. Published data have shown that PCL-R scores provide significant improvement in the prediction of violent recidivism over simple chance or the use of historical risk variables by themselves. Research has demonstrated that both inter-rater reliability and test-retest reliability of the PCL-R are excellent.

Mr. McKay’s total PCL-R score was 25. Once error rates have been considered, his true score is probably between 22 and 28. Research with this instrument has found that individuals with similar scores are at moderate risk for recidivism compared to people with higher and lower scores. For example, one study found that 40% of individuals with mid-range PCL-R scores have violated conditional release (as opposed to 10% with low PCL-R scores and 60% with high PCL-R scores).

The PCL-R has four facets that make up two larger factors. The first factor is made up of interpersonal and affective facets that measure selfish, callous, remorseless use of others. Research has shown that individuals with higher Factor One scores are more likely to be disruptive in treatment settings and drop out of treatment prematurely. Mr. McKay’s Factor One score was 12. Based on a normative sample of 5408 male prison inmates, this score is higher than those of 83% of inmates. Based on a normative sample of 1246 male forensic patients, this score is higher than those of 89% of such individuals. In other words, Mr. McKay’s PCL-R Factor One score is high when compared to a sample of his peers.

The second factor is made up of lifestyle and antisocial facets that measure chronic, unstable, antisocial behavior. Research has demonstrated that individuals with higher factor two scores are at increased risk for recidivism when released to community settings. Mr. McKay’s Factor Two score was 11. Based on a normative sample of 5408 male prison inmates, this score is higher than those of 43% of inmates. Based on a normative sample of 1246 male forensic patients, this score is higher than those of 40% of patients. In other words, Mr. McKay’s Factor Two score is low-average compared to his peers.

Summary Scores:

PCL-R Total Score: 25

PCL-R Factor One Score: 12

PCL-R Factor Two Score: 11

Summary Scores:

PCL-R Total Score: 25

PCL-R Factor One Score: 12

PCL-R Factor Two Score: 11

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Violence Risk Appraisal Guide (VRAG)

The VRAG is a 12-item instrument used to assess an offender’s risk to commit a violent crime within 10 years of returning to the community. Each item represents a different historical risk factor that has been demonstrated by research to predict future violent behavior. The risk factors that make up the VRAG are considered static in that each (except marital status) is highly unlikely to change over time.

Each item is weighted based on how predictive of future violence it is. VRAG scores range from –11 to +32, with higher scores indicating a higher risk of violent recidivism. Quinsey et al. (1998) divided VRAG scores into nine categories, each associated with a different risk for future violence. It has been found to be a reliable measure, with higher scores on the VRAG being associated with higher rates of violent recidivism in a variety of samples. It should be noted, however, that some researchers have questioned the validity of making risk predictions for individuals by comparing them to a standardization sample of only 600 criminal offenders. It should also be noted that static risk factors cannot account for protective factors or risk factors specific to individuals. These predictions should, therefore, be considered to be estimates with room for error.

Mr. McKay’s VRAG score was +14, placing him in the seventh-highest of nine risk categories. Based on the standardization sample, inmates with scores in this category are estimated to be at moderately high risk for committing a violent offense within ten years of release (once group error estimates have been considered). Protective factors or improvement on dynamic risk factors may, however, serve to moderate Mr. McKay’s offense risk.

Mr. McKay’s VRAG score was +14, placing him in the seventh-highest of nine risk categories. Based on the standardization sample, inmates with scores in this category are estimated to be at moderately high risk for committing a violent offense within ten years of release (once group error estimates have been considered). Protective factors or improvement on dynamic risk factors may, however, serve to moderate Mr. McKay’s offense risk.

Specific factors indicating that Mr. McKay may be at higher risk for future violence include the fact that he was raised by a single parent, has never been married, has a history of alcohol problems, has had conditional releases revoked, meets criteria for antisocial personality disorder, and has a moderate PCL-R score. Possible protective factors for Mr. McKay include having no significant problems in elementary school and his advanced age.

HCR-20

The HCR-20 is an instrument developed in Canada as way of formalizing risk assessment decisions and generating risk management plans for correctional systems. When using this instrument, the clinician’s goals are (1) to render a probability statement of future risk in a specific setting for a specific time frame based on consistent and known factors related to violence, and (2) to identify problematic areas that may be targets for treatment to reduce risk of violence. The second goal is possible because, unlike the PCL-R or the VRAG, the HCR-20 makes use of items that examine dynamic risk factors that are amenable to change over time.

The HCR-20 has 10 items that measure historical, static risk factors; five items that measure current, dynamic, clinical factors; and five risk items to examine specifically how the person may react to a specific setting. The HCR-20 can be scored, and scores on the HCR-20 range from 0 to 40. The authors of the instrument recommend against using simple cutoff scores to determine if someone is at high or low risk. They emphasize that the instrument is designed as a guide for thinking about how to weight risk factors, rather than a formalized test. As such, they recommend using the instrument to make more general predictions of risk (high, moderate, or low) rather than simply relying on specific scores. Ratings of the individual risk factors identified on the HCR-20 are based on data collected during clinical interviews as well as collateral information from other data sources such as files.

Existing peer-reviewed data support the HCR-20’s usefulness in risk prediction. Specifically, scores on the HCR-20 have been found to have modest but significant correlations with past violence (.44), with the VRAG (.54), and with violence observed in an inpatient setting (.30). HCR-20 scores have also been shown to be predictive of several measures of community violence, readmission to forensic hospitals, and subsequent psychiatric hospitalizations. Recent research has revealed that the HCR-20 is a better predictor of future violence than the PCL-R alone. Risk decisions made using the HCR-20 have been found to predictive of violent recidivism in prior samples.

Mr. McKay had several historical factors that may place him at risk for future violence. These include a history of previous violence beginning at a young age (as documented in file information, prior forensic reports, and by Mr. McKay himself), his history of poor juvenile adjustment, his history of schizophrenia (including paranoid delusions that have played a role in his prior acts of aggression), his prior supervision failures, his limited ability to form close relationships, his moderate PCL-R score, and his history of alcohol abuse. One possible historical protective factor for Mr. McKay is his demonstrated ability to do well in employment settings despite his mental illness.

The clinical scales suggest the presence of both risk and protective factors that might impact Mr. McKay’s risk for reoffending. Mr. McKay has some insight into his problems and triggers for violence. He was able to recognize that his psychotic symptoms place him at risk, and taking medication is one means he can use to help keep himself under control. Similarly, he recognizes that he has displayed poor anger control in the past, and this is an area he needs to address. He has, however, been overly optimistic about his ability to control his temper. Even while medicated, he continues to experience paranoia—and his ability to use reality-testing skills to manage residual symptoms will be important to his ability to succeed in future placements. This is particularly true since his concerns about being “sexually harassed” by peers continue to make him irritable and aggressive.

Mr. McKay’s psychotic symptoms generally appear to be well managed by antipsychotic medication. Mr. McKay has, however, had at least one recent episode of extreme paranoia and disorganization. During this episode, he became convinced that his assigned social worker had hired inmates from the unit to harass him in the shower and attack him. Mr. McKay responded by attempting to stab a peer with a pen. Mr. McKay was briefly disorganized and displayed signs of unusual ideation until his dose of antipsychotic medication was increased.

Mr. McKay has engaged in a variety of treatment programs that target his core risk factors, including anger management and Alcoholics Anonymous. He has been overtly compliant with treatment, and staff members have noted that he makes good contributions in groups. They have, however, questioned his motives for treatment or his ability to internalize the principles he needs to enact real change. To his credit, however, he seems to have remained sober on recent periods of supervised release.

Mr. McKay appears to do better in highly structured settings. Notes from a variety of treatment providers have indicated that he generally responds well to direction. They have also, however, noted that he can become irritable when challenged, and he has a habit of testing boundaries. His biggest clinical risk factor relates to antisocial attitudes. He has a tendency to assume the worst about other people’s motives, and he tends to see women in sexual terms. He seems to have embraced many attitudes that may be effective in correctional settings, but that may make adjustment in community settings more difficult (e.g., “don’t trust people,” “don’t show signs of weakness,” “don’t back down from challenges,” etc).

When assessing the risk management items for Mr. McKay, this writer considered how Mr. McKay would be likely to function in a community setting rather than in a secure hospital setting. Mr. McKay was well aware of the obstacles he is likely to face in transferring back to a community setting. He demonstrated a good understanding of the kinds of resources he will need in order to succeed, including mental health aftercare and psychiatric medication. He demonstrated a willingness to comply with follow-up treatment and he has followed through appropriately during prior periods of supervised release. He is also willing to be flexible about the location and placements to which he is willing to go. He suggested that he will probably do better if he can stay busy in the community; he indicated he would like to obtain a job, and he appears to have done well on job placements in the past.

Mr. McKay does, however, seem to have problems that will be difficult for most group homes to accommodate. He is a registered sex offender, which significantly limits the available placements to which he can go. His specific paranoid ideation regarding being sexually harassed by males means that he is likely to have conflicts anywhere he has a roommate. Finding a group home where he could have a single room could be difficult.

Mr. McKay is likely to experience significant destabilizing influences in the community. He is likely to have increased access to alcohol and weapons. This is of concern given his history of using a knife to threaten others, and reports from a prior community placement that he was suspected of trying to make a homemade knife. His sources of personal support are limited to family members who appear to have limited resources with which to aid him. He has also had significant conflicts with his family members in the past, and at least one of his brothers is incarcerated for serious crimes (rape and murder). He has few sources of social support, and his presentation is likely to make it difficult for him to make friends.

A potentially significant risk factor for Mr. McKay appears to be the stress he will be likely to experience in the community. Although he has responded well to antipsychotic medication, he continues to experience residual symptoms such as odd affect and paranoia. Paranoia has been a significant source of stress for Mr. McKay in the past. This stress is likely to be increased by the fact that his concerns about others “harassing” him are likely to be treated with suspicion by supervising staff and other people he wants to believe him. Being under stress is likely to increase Mr. McKay’s conflict with peers and staff, thus putting him in danger of violating supervision rules in some way.

Mr. McKay’s total score on the HCR-20 was 32. Based on the identified risk factors on the HCR-20, Mr. McKay appears to be at high risk to have some negative behavior within the next 12 months if he is released to a standard group home or halfway house. Based on his periods of prior supervision, these violations may be related to conflicts with peers rather than for overt criminal offenses. His recent assaultive behavior, however, suggests that he is also capable of engaging in violent behavior if his psychotic symptoms escalate.

It is worth noting that many of the factors placing Mr. McKay at risk for reoffending are static risk factors that will not change over time. He does, however, have significant dynamic risk factors that could likely be reduced through participation in specialized treatment and supervision. As noted previously, Mr. McKay has developed antisocial attitudes that may interfere with his adjustment in community settings. He may well benefit from programs that target criminal thinking. He has also admitted that he has a history of temper-control problems. Participation in further anger management programming may help him address his ongoing temper problems. He could also benefit from ongoing treatment to prevent relapse into alcohol abuse. Mr. McKay will certainly need to continue taking antipsychotic medication and will need routine follow-ups to insure that his dosages are sufficient to manage his symptoms. He may, however, also benefit from individual therapy designed to help improve his reality testing.

Based on his history, Mr. McKay appears to do better in highly supervised settings. Although he tends to test rule boundaries, he has traditionally responded well to direct orders and consistent limit setting. Due to the content of his delusional ideation, he is likely to have fewer conflicts in settings where he does not have a roommate and where he has access to a private bathroom. To the extent that Mr. McKay receives appropriate supervision, remains on medication, and chooses to make good use of mental health treatment, he will be more likely to succeed in a community placement.

The Static-99

The Static-99 was developed as an actuarial assessment to estimate risk to commit a future sexual offense within 15 years. The instrument contains ten items that have been consistently demonstrated in the research literature to be associated with higher rates of sexual reoffending in a variety of samples. Scores on this instrument range from 0–12, but scores above six do not seem to increase risk for sexual recidivism significantly. As such, scores of six or more are associated with the highest risk for sexual recidivism.

The Static-99 has been shown via peer-reviewed research to be a highly reliable measure. Higher scores on the instrument have consistently been found to be associated with higher rates of sexual recidivism in several samples. Despite this, some researchers have noted that it is difficult to predict a single individual’s risk by comparing them to how groups of individuals did in the validation sample. The items making up the Static-99 are also static, unchanging risk factors. As such, the measure can not account for how protective factors or changes in dynamic risk factors may impact an individual’s risk to commit a sexual offense. For these reasons, scores on the Static-99 should be treated as estimates with room for error rather than precise predictions of future sexual violence.

Mr. McKay’s score on the Static-99 was 2. This score was due to Mr. McKay’s history of no stable marital-like relationships and the fact that his prior victim was unrelated. Based on the sexual recidivism rates of individuals with this score in the previous samples, Mr. McKay’s estimated risk for committing a sexual offense within fifteen years would low.

Interview Impressions

Mr. McKay was interviewed by the risk assessment panel. He was oriented to person, place, time, and circ*mstances. He was polite, cooperative, and responsive to questions. His speech was stilted and repetitive, but coherent and on topic. He was not responsive to internal or fictional stimuli during the interview. During the interview, he displayed no overt delusional ideation. His observed affect was constricted, but anxious. He maintained appropriate eye contact. His concentration and attention appeared to be within normal limits. His memory appeared to be intact, judging by his ability to recall specific details from his prior incarcerations. No psycho-motor agitation or retardation was noted.

Mr. McKay indicated that he understood that the risk assessment panel was interviewing him to determine if he might be dangerous to others or the property of others due to a mental illness. He recognized that the risk assessment panel would make an initial determination as to whether or not he might be stable enough to return to the community.

Mr. McKay acknowledged that he had assaulted another patient recently. When asked about this, he said he did it because he was angry and upset. He admitted that he should not have hit a peer. He said he should have sought help from clinical staff instead. He noted that he has been doing better on an increased dose of anti-psychotic medication. He asserted that he would be “okay” in the future. He did, however, express an understanding of why staff may be uncomfortable discharging him to the community given his recent behavior.

Diagnostic Impression

Axis I:

Schizophrenia, Paranoid Type

Axis II:

Antisocial Personality Disorder

Opinions

It should be noted that the prediction of dangerousness is of limited accuracy at the time of formulation, and the accuracy of a prediction diminishes over time. In an effort to determine if Mr. McKay meets criteria for commitment pursuant to 18 USC 4243, the Risk Assessment Panel attempted to determine whether (1) Mr. McKay is presently suffering from a mental disease or defect, (2) his release would create a substantial risk of bodily injury to another person or serious damage to property of another, and (3) such risk would be due to a mental illness.

Does Mr. Mckay Presently Have an Identifiable Disease or Defect?

Mr. McKay has been diagnosed with schizophrenia (paranoid type). This diagnosis was based primarily on his history of disorganized behavior, auditory command hallucinations, flat affect, and unusual beliefs (such as the belief that he possesses supernatural powers, that others are sexually harassing him, and the like). He had a significant relapse of psychotic symptoms in July of 2005 during which he became paranoid, agitated, and violent. He has responded well to an increased dose of antipsy-chotic medication. He appears to be managing his symptoms better at the moment. He does, however, show some signs or residual paranoia, odd affect, and stilted speech.

Would Mr. Mckay’s Release Create a Substantial Risk of Bodily Injury to Another Person or Serious Damage to Property of Another?

The Risk Assessment Panel considered several factors that may impact Mr. McKay’s ability to succeed upon release. Specific factors that were reviewed included his history of violence, his extensive mental health history, his current compliance with psychiatric medication, his recent institutional adjustment, his performance on prior conditional releases, his specific delusional ideation and its past impact on his behavior, his limited sources of social support, and his plans for returning to the community. The panel noted Mr. McKay’s low Static-99 score, his moderate PCL-R score, his high VRAG score, and the various factors (both risk and protective) identified by the HCR-20. Mr. McKay’s recent assaultive behavior was discussed at length.

Based on the available evidence, Mr. McKay’s risk for sexual offending appears to be relatively low. He has only one documented sex offense in his records and there is no evidence that he has any sexually deviant interests. His score on the Static-99-R was low. He has not engaged in any sexually inappropriate behaviors in prison or hospital settings. He also has not committed any new sexual offenses during his periods of conditional release.

During the current assessment, Mr. McKay denied having any current plans or intentions to harm anyone. He presented as calm during the risk assessment interview. As such, he does not appear to be at significant risk for imminent violence. Based on the available information, however, Mr. McKay does appear to be at risk for engaging in some kind of future violence.

Mr. McKay has a well-documented history of aggression, but it has rarely risen to the point where he has been charged with a criminal offense. His two criminal offenses were, however, very serious (aggravated rape and threatening the President of the United States). A review of his records indicates that there are specific factors that appear to predict when Mr. McKay is most likely to be violent. These factors include using alcohol, not taking psychiatric medications, experiencing command hallucinations that instruct him to attack others, and having current delusional beliefs that others are trying to harm or harass him. The panel believes that Mr. McKay’s risk for becoming violent and the risk for more severe violence would increase as these factors manifest. As such, the degree to which these risk factors can be explicitly addressed is likely to have a significant impact on Mr. McKay’s risk for future violence.

Although Mr. McKay currently appears to be doing better, his recent assault on another patient was of great concern to the risk assessment panel. This assault was considered important because it was an episode of overt violence. It also occurred in a highly structured setting, and Mr. McKay put himself at risk for losing a conditional release by becoming violent. This suggests that Mr. McKay was unable to control his behavior or unwilling to, despite having a great deal to lose. The panel noted that Mr. McKay still has to work on controlling his impulsivity, managing his anger more effectively, having a higher tolerance for the discomfort caused by his delusional ideation, and improving his reality testing. To the extent that he can address these concerns, his ability to succeed in a community placement will increase dramatically.

Is Mr. Mckay’s Risk for Reoffense Related to a Mental Illness?

A review of the records, as well as interviews with Mr. McKay, indicated that his behavior appears to be influenced by both antisocial attitudes and his mental illness. For example, Mr. McKay has negative attitudes towards women, he tends to test rule boundaries, and he does not back down from challenges. These kinds of attitudes do not appear to be related his mental illness, but they do make it harder for him back down from potential fights or develop empathy with others. Such beliefs appear to have played a significant role in the events leading up to Mr. McKay’s aggravated rape charge.

He also, however, has mental health problems that limit his ability to manage his anger and make him prone to believe that others want to harm him. His delusional paranoid ideation clearly played a role in 1996 when he made threats against the President of the United States. It also appears to be a significant factor in his difficulties with peers whom he suspects of “harassing” him. It was certainly a factor in the assault he committed in July of 2005. As noted previously, he appears to be at a higher risk for becoming aggressive when he is not taking medications, or when the medication he is taking is insufficient to address his psychotic symptoms. Therefore, the Risk Assessment Panel concluded that Mr. McKay’s mental illness plays a role in his risk for violence, but it plays a larger role when he is untreated, undertreated, or off medications.

Recommendations

Mr. McKay has been diagnosed with a mental illness (schizophrenia) that has previously made him dangerous to others (or the property of others). The Risk Assessment Panel noted that Mr. McKay is currently stabilizing on medication and does not seem to be at risk for imminent violence. The panel also, however, expressed concerns about his recent relapse into paranoid delusional thinking during which he became assaultive. The panel noted that Mr. McKay has multiple risk factors that increase the risk for future problematic behaviors. They also considered his chronic difficulties in adjusting well in community placements.

After considering the relevant factors, the panel opined that Mr. McKay is not yet stable enough to release to the community. The panel expressed concern that his paranoia and delusional ideation would be likely to make him dangerous to others (or the property of others). They recommended that he be retained for inpatient treatment in a secure hospital setting for the time being. They noted that they expect his stability to improve, provided he remains compliant with treatment. Given the severity of the incident in July of 2005, however, the panel noted that they would not feel comfortable recommending a conditional release until Mr. McKay can demonstrate an extended period of behavioral and mental stability.

Chad Brinkley, Ph.D.

David F. Mrad, Ph.D.

Teaching Point: Integrating Information from Hospitalization and Pre-Hospitalization in Release Decision-Making

The influence of situation on human behavior is given insufficient attention in some assessments of hospitalization release. A hospital is an artificial environment—more structured, highly monitored, intensively resourced, and more restrictive than almost any community environment imaginable. But almost invariably, the behavior resulting in hospitalization occurred in the community, and the individual will be discharged to an environment closer to the original community setting than to the hospital from which he will be discharged. Accordingly, the focus of the anticipated interventions, stresses, and supports should be the community setting to which his discharge is proposed. Whether the individual has reached “maximum benefit of hospitalization” has little relevance in such decisions. If the evidence shows that the individual is likely to adjust favorably, and public safety considerations are addressed, then that person is a good candidate for discharge. If that is not the case, then whether they would continue to benefit from hospitalization is not the point; whether and how they can reach the status described in the previous sentence should be the focus of the discussion.

It is useful, accordingly, to combine information obtained from hospitalization with that covering the person’s pre-hospitalization history. The right kind of hospital information is valuable. Among other things, being hospitalized allows the individual to be more closely observed, more intensively treated, and more fully participatory in graduated release. This is sometimes useful in ruling out a recommendation for release, as individuals who are significantly violent or otherwise antisocial in a secure hospital environment are not good candidates for discretionary release. But hospital information is insufficient to rule in a good candidate for release. For this, the forensic clinician must consider the pre-hospitalization environment and behavior as well as the proposed plan of discharge. Using a measure such as the HCR-20 facilitates this consideration—the “R” (risk management) section focuses on the environment to which the individual will return and the potentially destabilizing influences associated with it.

Case Two Principle: Use Multiple Sources of Information for Each Area Being Assessed (Principle 17)

This principle was Discussed in Chapter 12 (this volume), so we will move directly to showing how the present report illustrates the application of this principle. In the present report, the evaluator relied on a wide range of information, including interview with the defendant, psychological testing (for risk assessment purposes), and a review of various records (e.g., psychiatric, neuropsychologi-cal, medical, forensic, and criminal justice). There was also a review of behavioral observations of this individual, both prior to and during hospitalization. Using multiple sources of information enables the evaluator to corroborate information, generate and test rival hypotheses relating to the relevant functional-legal criteria, and measure relevant clinical functioning in a more robust way. In this case, for example, Dr. Lareau used several measures to assess Mr. Johnson’s risk of future violence— including two risk assessment measures (HCR-20 and START) and a measure of psychopathy— and effectively combined the data obtained from these measures in reaching his conclusion about Mr. Johnson’s risk.

Forensic Psychology Consultation Reason for Referral/Assessment

Mr. Darren Johnson was referred for a forensic psychology consultation by his treatment team at the current state hospital (CSH) to determine his level of violence risk and whether he is appropriate for release to a less restrictive setting through the conditional release program (CONREP). The patient has filed a writ for restoration of sanity pursuant to California Penal Code § 1026.2.1

1

The legal standard set forth in Penal Code § 1026.2 states, “whether the person … would be a danger to the health and safety of others, due to mental defect, disease, or disorder, if under supervision and treatment in the community.” The term “restoration of sanity” is a legal term of art.

Identifying Information

Darren Johnson (a.k.a. “Michael Andrews”) is a 39-year-old single African-American male committed by the Superior Court of Los Angeles County. He was remanded to the California Department of Mental Health and admitted to former state hospital (FSH) on 12/12/08 pursuant to Penal Code § 1026 as not guilty by reason of insanity (NGRI). Mr. Johnson was transferred from FSH to CSH on 8/14/11. His maximum term of commitment is Life. Mr. Johnson’s commitment offense was Penal Code § 187(a), murder. The commitment offense took place on 1/12/04. Mr. Johnson, while allegedly psychotic due to a binge on methamphet-amines, stabbed his live-in girlfriend to death with a steak knife. He also attempted to kill himself using the same knife.

Evaluation Procedures and Dates

Mr. Johnson was interviewed for this evaluation for three hours on 10/16/12. In addition to the clinical interview, the following psychological assessment instruments were administered and scored:

Hare Psychopathy Checklist–Revised-2nd Edition (PCL-R)

Historical-Clinical-Risk Management-20 (HCR-20)

Short-Term Assessment of Risk and Treatability (START)

Also, the following information was reviewed from Mr. Johnson’s records:

CSH Psychiatry Monthly Progress Notes CSH Psychosocial Assessment Update dated 10/18/12

CSH Penal Code § 1026 Court Reports dated 3/22/12 and 10/13/12

Los Angeles County CONREP Hospital Liaison Report dated 7/12/12

CSH Integrated Psychology Assessment dated 10/14/11

CSH Initial Psychosocial Assessment dated 10/13/11

FSH Neuropsychological Evaluation by Neuropsychologist, Ph.D., dated 4/25/10

Los Angeles County Jail Medical and Mental Health Records from 1/04 to 11/08

NGRI Evaluation by Psychiatrist One, M.D., dated 8/19/07

NGRI Evaluation by Psychologist One, Ph.D., dated 3/15/07

NGRI Evaluation by Psychologist Two, Ph.D., dated 2/11/07

Los Angeles County Coroner’s Report by Coroner, M.D., dated 2/12/04

Los Angeles Hospital Medical Records, discharge date 1/29/04

Criminal History Report (CLETS) Generated on 1/17/04

Los Angeles County Sheriff ‘s Department Supplemental Report by Deputy Law dated 1/13/04

Los Angeles County Sheriff ‘s Department Supplemental Report by Deputy Justice dated 1/12/04

Los Angeles County Sheriff ‘s Department Initial Crime Report by Deputy Law dated 1/12/04

Prior to beginning the interviews, Mr. Johnson was notified about the purpose of the evaluation and the associated limits on confidentiality. He appeared to understand the basic aspects of this notification, repeating back the essential parts that he would be evaluated, that a written report would be generated, and that the conclusions of the report could affect the decision regarding his readiness for release.

Relevant History

Child and Family History

Darren Johnson (a.k.a. Michael Andrews) is a 39-year-old (DOB: 7/14/73) single African-American male born in Mobile, Alabama. He is the youngest of three surviving children, with two older brothers. He had a sister pass away as an infant. Both of his parents are alive, and they have remained married. His father worked for the county as a wood shop teacher in middle school, and his mother remained at home. He described his father as the disciplinarian in the family. The family had a lower-middle-class standard of living, with adequate support. He has stated there was domestic abuse in the family home, with his father beating his mother, especially when he had been drinking. He reported also having been physically abused by his father. Mr. Johnson came to California when he was 16 years old, three years after a significant head injury in an accident. He has a brother in Los Angeles, while the rest of his family lives in Alabama.

Education History

Mr. Johnson reported that he attended school through the ninth grade in Alabama, at which time he came to California. He stated he had low average grades in his schooling, but did not attend any type of remedial or special education training. He reported problems both behaviorally and academically following his head injury at age 13, including getting expelled from two schools for fighting and disrespecting his teachers. He quit school at age 16 and moved to Los Angeles to live with his older brother. He had no other formal education.

Employment History

Mr. Johnson stated in a CSH Initial Psychosocial Assessment that before moving to California, he worked delivering newspapers. He also reported working as a gardener and in different construction jobs. He further described having worked as a limousine driver. In the interview, he stated he has worked about four years in landscaping, and he has held different construction jobs. He also stated he worked for two years in an automobile detailing business with his brother. He commented that when working in construction he made between $3,000 and $4,000 per month. Mr. Johnson said that he also made money selling illegal drugs.

Medical/Trauma History

Chart information suggests a motor vehicle accident at age 13 that resulted in a serious head injury with loss of consciousness, for which he was hospitalized for nearly two weeks. His mother has reported that he was unconscious for “six or seven days,” and when he regained consciousness she noticed alterations in behavior. Initially he did not recognize family members and became confused. He demonstrated concentration and memory problems, and soon thereafter he performed very poorly in school. A number of records suggest significant alteration in his personality, with an increase in anger and aggressiveness following the head injury. He reported additional head injuries as well, including a motorcycle accident at age 18, getting hit in the head with a pipe during a fight at age 23, and another period of unconsciousness following a car accident at age 26. In the instant offense he suffered from self-inflicted, multiple stab wounds to the throat, chest, abdomen, and arms. During his medical hospitalization, he was maintained on a tracheotomy. Presently he is diagnosed with diabetes mellitus, hypertension, and hyperlipidemia.

Criminal History

According to the CSH Initial Psychosocial Assessment (10/13/11), shortly after his head injury at the age of 13, Mr. Johnson got into numerous fights at school, and he began engaging in criminal activities, including theft and destruction of property, although he was not arrested for those offenses. Due to his problems in Alabama, at the age of 16 Mr. Johnson moved to California to live with his brother. Although his juvenile history was not available for review for this evaluation, in the initial psychosocial assessment he endorsed having been found delinquent for robbery and later for DUI. Mr. Johnson’s criminal history includes numerous arrests and convictions for various types of crimes. His adult history includes the following:

NGRI for murder (offense in 2004, NGRI in 2008)

Conviction for domestic violence (2003)

Conviction for robbery (1999)

Four convictions for auto theft (1992; 1994; 1997; 2001)

Conviction for possession of stolen property (1997)

Conviction for possession of cocaine for sale (1993)

Conviction for possession of cocaine (1998)

Conviction for DUI (1996)

Conviction for false information to police (1996)

Arrest for possession of cocaine (1994)

Arrest for DUI (1995)

Arrest for reckless driving (1996)

Arrest for public intoxication (1993)

For the instant offense (described more fully below), he killed his girlfriend by stabbing her numerous times with a steak knife, and then mutilated her corpse. Four years later he was found not guilty by reason of insanity.

Substance Abuse History

During the interview for this evaluation, Mr. Johnson endorsed a history of significant substance abuse. He began alcohol abuse by age 12, drinking shots of rum and vodka, and shortly thereafter he was drinking alcohol multiple times each week to the point of intoxication. When he came to California, his alcohol abuse accelerated, with binge drinking described by late adolescence. He began marijuana abuse somewhere between ages 10 and 13, smoking about twice per week, which increased to daily abuse when he moved from Alabama. He began to abuse cocaine by age 17. He reported having stopped using marijuana around age 24, which was when he began to abuse methamphetamines, describing daily use of cocaine and methamphetamines. He admitted to binging on cocaine and methamphet-amines for several days at a time. Once he began use of methamphetamines, it quickly became his drug of choice. He had multiple methamphetamine binges lasting several days. During those periods of abuse he experienced notable weight loss and increased anxiety.

Psychiatric History

There is little corroborative evidence of psychiatric history or problems prior to the instant offense, despite some records where there are reports of a vague history of prior psychiatric symptoms and treatment. For instance, during an insanity evaluation with Psychiatrist One in 2007, Mr. Johnson’s family had described the presence of vague psychotic symptoms as an adolescent. The same report noted the presence of some paranoia prior to the crime, but the paranoia was most notable when he was abusing methamphetamines.

Also in that 2007 psychiatric evaluation report, Mr. Johnson endorsed having experienced years of psychotic symptoms, both before and after the crime, including auditory hallucinations, visual hallucinations, ideas of references, and paranoid delusions. Based upon his report of symptoms, he was prescribed both antidepressant and antipsy-chotic medications in the jail, but he did not continue to take them regularly. Notably, there was no corroboration of any psychotic symptoms reported in observations in the jail mental health records.

Despite Mr. Johnson’s having described experiencing nearly constant auditory hallucinations and other psychotic symptoms in the absence of any substance abuse during his time in jail, in a neuropsychological assessment from 2010, Mr. Johnson denied ever having any psychotic symptoms. In that report, it noted that his admission to FSH was his first psychiatric hospitalization.

In two separate insanity evaluation reports completed by psychologists in 2007, Mr. Johnson was administered intelligence tests. In both, his scores for full-scale IQ were between 60 and 65, with no appreciable differences noted between Verbal and Performance scores. In neither evaluation was there any effort testing administered; he was assumed to be putting forth a full effort. Subsequently, during his hospitalizations, there has been no evidence of significant intellectual deficits noted in the records. During a neuropsychological evaluation in 2010, the evaluator did not find evidence of any intellectual deficits.

Hospital Course

Mr. Johnson was admitted to FSH in 12/08, almost five years after his commitment offense in 1/04. What is most notable during his present course of hospitalization is the dramatic difference in Mr. Johnson’s reported symptoms during his hospitalization when juxtaposed with his alleged symptoms during his years of incarceration prior to the evaluations for his NGRI defense. When Mr. Johnson was being evaluated for his NGRI defense by different evaluators, he reported experiencing ongoing psychotic symptoms that had existed prior to the murder. That is, despite not having access to illicit substances that could account for the presence of psychotic symptoms, Mr. Johnson continued to report daily psychotic symptoms, which evaluators concluded to be evidence of the presence of a psychotic disorder.

Since the start of his hospitalization, and continuing to the present time, Mr. Johnson reports to not be experiencing any psychotic symptoms, and presently he is not prescribed any antipsychotic medications.

Comment: Why Wouldn’T Mr. Johnson’s Mental Health Symptoms be Observed by the Evaluator Over the Course of His Time Spent in a Facility for the Evaluation?

In California, all criminal responsibility evaluations are completed by “alienists,” who are psychiatrists and psychologists in the community, either court-appointed or retained by a party in the case. Defendants are not evaluated at a centralized forensic facility, such as in Michigan or in the federal prison system, where the defendants can be observed and evaluated over an extended period of time.

Comment

The honesty of his report of prior psychotic symptoms is important for two reasons: (1) it suggests that psychosis may not be a relevant consideration in his violence risk; and (2) it provides information about pathological lying and conning and being manipulative for purposes of scoring the PCL-R-2nd Edition.

A neuropsychological assessment from 2010 described Mr. Johnson’s functioning at that time. It quoted a March 2010 treatment plan that stated, “Mr. Johnson continues to report no psychiatric symptoms, such as auditory or visual hallucinations. He denies having heard voices. It appears that whatever psychotic symptoms were present were as the result of substance use. No problems with sleep or other symptoms.” The report also noted recent behavioral problems, including curfew and contraband violations. On 2/1/10, he was found in possession of a cellphone, and he was under investigation for the incident. Ultimately the incident resulted in the discovery of an inappropriate relationship with a female nurse who had provided him with the cellphone. She ended up losing her job over her relationship with Mr. Johnson.

In a hospital report to the court from October 2012, it states that since Mr. Johnson’s admission to CSH in September 2011, “he has been involved in strong-arming vulnerable patients (those with cognitive disabilities such as mental retardation) for their canteen [ration], as well as using patients to run errands and do his bidding in illegal trading of contraband. He was observed filling out a peer’s canteen list and taking the peer’s food when it came. Mr. Johnson also took quarters from that individual.” Regarding other behaviors, the report continued, “A tattoo kit was found in his room. Staff suspected that he had access to black market items (contraband) and was involved in selling and controlling the distribution of contraband goods on the unit and on grounds. Although confronted and reprimanded by staff, he refused to stop engaging in these antisocial behaviors.”

At the time of the October 2012 report, Mr. Johnson was denying having a mental illness, and was displaying no evidence of positive or negative symptoms of psychosis. He displayed euthymic mood and a full range of affect. Mr. Johnson was considered a high risk for illegal substance use due to both a history of substance use disorder and antisocial personality disorder. He has undergone substance abuse treatment in the hospital, and accepted that he has a substance abuse problem. Although acknowledging an extensive history of drug use, he clarified he has not used drugs in more than eight years. He placed responsibility for his crime on his substance use.

In a psychosocial assessment update from 10/12, Mr. Johnson acknowledged that he continues to receive phone calls from the former female nurse from FSH. He speaks to her frequently, especially before and after his treatment conferences where they decide about making recommendations for release. Thus, it is important to note that he is privy to counsel from a former state hospital staff member about how to act, how to speak, and what to say to appear appropriate for release from a state hospital. He had been told that he needed to stop this relationship, but he reported not understanding why the relationship was inappropriate. He added the former FSH employee “has gotten to know his family and she has developed a relationship with them. Mr. Johnson stated that he would discontinue the relationship” (CSH Psychosocial Assessment Update, 10/18/12). However, to date he has not done so.

During his hospitalization, Mr. Johnson had not committed any acts of violence. He was described in the psychosocial update as “charming, deferential towards staff and eager to please. The veracity of his demeanor is dubious given that this behavioral style is characteristic of individuals diagnosed with Antisocial Personality Disorder” (CSH Penal Code § 1026 Court Report, 10/13/12).

Commitment Offense

The commitment offense occurred on 1/12/04. According to a Los Angeles County Sheriff’s Department Initial Crime Report (1/12/04), Mr. Johnson assaulted his girlfriend, stabbing her to death with dozens of stab wounds. He also mutilated her body by cutting off her thumbs (it is not known whether this occurred before or after her death). He wrote something illegible in her blood on the wall, and then he cut his own throat and abdomen. Mr. Johnson had a history of domestic violence against his girlfriend (who was the mother of his child). The victim’s five-year-old daughter found the crime scene and called a maternal uncle. She reported that her mother “was asleep” and covered with blood and could not wake up. She said that her mother’s hand was cut and the defendant had cuts on his throat and abdomen. The victim’s mother and uncle reported to the scene, where they saw the victim lying dead in the bed. The defendant was allegedly bleeding profusely from self-inflicted wounds to his throat and abdomen. The family was able to remove the victim’s daughters (one and five years old) from the crime scene.

When the police arrived they noted that the defendant was wounded but semi-coherent, presumably due to loss of blood. He was transported to a medical facility for emergency care. When police searched the apartment they found methamphet-amines and a rolled dollar bill used to inhale the drug. A drug screen at the hospital was positive for methamphetamines. Police spoke with neighbors, who noted the defendant had a history of polysub-stance abuse, but none observed significant drug use prior to the murder.

Mr. Johnson was hospitalized for 17 days before being cleared for admission to jail. His medical release records note he admitted stabbing both himself and his girlfriend.

According to all three insanity evaluation reports, three years after the offense, Mr. Johnson reported having no recollection of the events leading up to the victim’s death. He claimed to have been very intoxicated at the time of the offense, but could recall neither which drugs he had used nor how much he had used. He described a problematic relationship with the victim. He stated she was quite jealous, and she feared he was involved in other relationships. In the report by Psychologist One (3/15/07), he admitted to many instances of domestic violence, which he considered to be “mutual combat,” often initiated by the victim due to her jealousy. He admitted to two instances of incarceration prior to the instant offense, both as a result of domestic violence against his partner.

Another report (Psychologist Two, 2/11/07) indicated that Mr. Johnson was jealous of his girlfriend, believing she was cheating on him. In two instances when this occurred (February 2002 and early November 2003), he physically attacked her. By the time of the August 2007 evaluation by Psychiatrist One, Mr. Johnson had recalled a history of “disembodied voices,” i.e., auditory hallucinations, which reportedly had been present for many years. He was clear that the voices did not tell him to harm anyone, but would tell him to watch for others who wanted to harm him, including believing his girlfriend wanted to harm him.

Interview Behavior and Appearance

Mr. Johnson is a 39-year-old African-American male of average height and build. He presented as exceptionally well-groomed, with a neat goatee, fashionable white Kangol hat, expensive sunglasses, clean clothes, and new sneakers. He willingly participated in the interview. Mr. Johnson appeared notably calm and relaxed throughout the interview; his posture was slouched in his chair, and his infrequent movements were smooth and deliberate. What was most noticeable during the evaluation was his level of confidence and ease, coupled with apparently average cognitive abilities (his scores on intellectual tests during his evaluations in 2007 suggested severe intellectual limitations). He also reported that he believes staff members are jealous of him, due to his looks and how “stable” he is, noting he is “respectful and athletic.” He appeared proud when discussing how a female staff from FSH became attracted to him, noting she wanted him sexually.

Mental Status Examination

Mr. Johnson was alert and oriented in all spheres. Eye contact remained good throughout the interview. His speech was normal in rate, rhythm, and volume. There was no evidence of a formal thought disorder. He denied experiencing hallucinations of any type, and attributed his alleged psychotic symptoms during the crime to his drug use. He denied experiencing any beliefs of a delusional nature. He denied experiencing suicidal or homicidal ideation. His affect was full in range and appropriate to content of speech. Intellectual functioning was not formally assessed but is estimated to be in the Low Average to Average range. His memory appeared to be grossly intact, with no obvious deficits in immediate, short-term, or long-term recall. Judgment appears slightly impaired, compromised by overconfidence.

Diagnosis

Mr. Johnson’s current mental status and reported history of compromised psychological functioning related to methamphetamine abuse suggests the following diagnosis:

Axis I:

292.11 Amphetamine-Induced Psychotic Disorder with Delusions, with Onset During Intoxication

V65.2 Malingering (by history)

305.70 Amphetamine Abuse

305.00 Alcohol Abuse

305.60 Cocaine Abuse

305.20 Cannabis Abuse

Axis II:

301.7 Antisocial Personality Disorder

Axis III:

Diabetes Mellitus; Hypertension; Hyperlipidemia

Axis IV:

Problems related to interaction with legal system/Incarceration

Axis V:

GAF (Current)—60

The Axis I diagnostic presentation of this man is problematic. The various records, reports, self-report, and present functioning require diagnostic compromise, as the available information cannot be diagnostically reconciled. According to the insanity evaluation report by Psychiatrist One (8/19/07), Mr. Johnson has endorsed significant psychotic symptoms for years prior to the offense. In all three NGRI evaluations in 2007, which took place more than three years after the offense, Mr. Johnson complained of experiencing ongoing symptoms of psychosis on a daily basis. If this were true, it would suggest either permanent psychosis secondary to methamphetamine-related brain damage, or a chronic psychotic disorder, and the ongoing symptoms would negate the possibility of a diagnosis of a transient substance-induced psychotic disorder. The following information is from the criminal responsibility evaluation from Psychiatrist One, M.D., dated 8/19/07:

I am of the opinion that Mr. Darrin [sic] Johnson was experiencing psychotic symptoms during the time around the instant offense. The defendant’s psychosis was associated with a Psychotic Disorder that did not primarily originate with the use of amphetamine shortly before the instant offense. Rather, the available evidence indicates that Mr. Daren [sic] Johnson began to experience psychotic symptoms sometime after the defendant’s head injury, but before he arrived in California. The available evidence also indicates that the defendant has continued to suffer from psychotic symptoms long (i.e., several years) after the instant offense and years after discontinuing amphetamine or other illicit drugs. However, I am also of the opinion that amphetamine use had an important role in the exacerbation of the defendant’s psychosis during and around the time of the instant offense. I am of the opinion that the most psychiatrically-legally relevant of the defendant’s symptoms were his paranoid delusional thinking and auditory hallucinations (emphasis in original).

Despite his comments to the evaluators in 2007, in a neuropsychological evaluation from 2010, Mr. Johnson reported having experienced psychotic symptoms only associated with binging on metham-phetamines during the time just prior to killing his girlfriend; this would suggest a substance-induced psychotic disorder diagnosis. Both at the time of the 2010 evaluation and continuing through this assessment, Mr. Johnson reported experiencing no ongoing psychotic symptoms, and stated that he has never experienced psychotic symptoms when not using substances, which includes the years he was in jail after the offense. These statements cannot be reconciled with his earlier reports of ongoing psychotic symptoms from prior to the crime until at least 2007. Presently Mr. Johnson is not prescribed antipsychotic medication, and he continues to report being free of any psychotic symptoms. His present functioning suggests that if Mr. Johnson has ever had psychotic symptoms, they probably were substance-induced. What is less clear is whether he experienced the psychotic symptoms he complained of at the time of the crime.

The multiple substance abuse diagnoses simply record what Mr. Johnson has described about his severe substance abuse with multiple difference substances. The information is not available to diagnose dependence on any of the substances individually or as a group.

Malingering has been diagnosed because it appears that Mr. Johnson intentionally produced the false symptoms of intellectual deficits repeatedly during psychological testing in 2007, to the point where his scores suggested mild mental retardation, which is in contrast to his average performance on similar testing in 2010. Furthermore, for years he endorsed symptoms of a psychotic illness while in jail awaiting his trial, but after the trial and hospitalization, his symptoms not only have disappeared, but also he denies having ever experienced those symptoms. For these reasons it appears probable that Mr. Johnson has malingered both psychotic and cognitive symptoms to benefit him in his legal proceedings.

Mr. Johnson’s pre- and post-conviction behaviors suggest the presence of antisocial personality disorder. He had engaged in behavior consistent with evidence of conduct disorder prior to the age of 15, in that he frequently got into fights, was expelled from two schools, and admitted to both property destruction and theft. As an adult, Mr. Johnson has evidenced a pervasive disregard for and violation of the rights of others in multiple domains, including domestic violence, robbery, property crimes, and driving while intoxicated, while more recently engaging in strong-arming of low-functioning patients, repeated rules violations, and possession of contraband.

Psychological Testing

Mr. Johnson was administered three instruments relevant to violence risk: the Psychopathy Checklist–Revised, 2nd Edition; the Historical, Clinical, Risk Management-20; and the Short-term Assessment of Risk and Treatability. Each will be discussed in turn.

Psychopathy Checklist–Revised, 2nd Edition (PCL-R)

Mr. Johnson’s history and information were used to rate him on the PCL-R, a psychological testing instrument used to rate a person on the construct of psychopathy. The instrument allows for scores ranging from “0,” which is the complete absence of any signs of psychopathic traits (and which virtually nobody ever scores), to “40,” which is consistent with severe psychopathy. Total scores above 30 are generally consistent with “severe” psychopathy. Severe psychopaths rate high in two general areas of pathology. The first area is defective interpersonal and affective traits, and the second is antisocial behaviors. A severe psychopath is a problematic and dangerous individual. Interpersonally, psychopaths are grandiose, egocentric, manipulative, dominant, forceful, and cold-hearted. Affectively they display shallow and labile emotions; cannot form long-lasting bonds to people, principles, or goals; and lack empathy, anxiety, and genuine guilt or remorse. Behaviorally, psychopaths are impulsive and sensation-seeking and tend to violate social norms, the most obvious expressions of which involve criminality, substance abuse, and a failure to fulfill social obligations and responsibilities. These individuals tend to victimize others without regard for the others’ welfare, and are expert liars. Psychopaths are likely to recidivate with their criminal behaviors, and severe psychopathy is a robust risk factor for violence of all types.

Mr. Johnson’s overall score was 33 (out of a possible 40), which places him in the very high range for the overall construct of psychopathy, and is consistent with the classification of a psychopath (which generally is given with scores over 30). His score of 33 places him in the 97th percentile when compared to other male forensic patients. The overall psychopathy score is comprised of two separate “factor” scores. Factor 1 represents deviant interpersonal and affective traits, while Factor 2 represents a deviant lifestyle and antisocial behaviors. Mr. Johnson’s score on Factor 1 was 15, which places him at the 99th percentile when compared to male forensic patients. Mr. Johnson’s Factor 1 score is in the very high range for deviant interpersonal and affective traits, and is suggestive of psychopathy. His score on Factor 2 was 18, which places him at the 97th percentile of male forensic patients. His Factor 2 score also is in the very high range, and is consistent with psychopathic behaviors.

In summary, Mr. Johnson’s scores on the PCL-R are very high and are consistent with the personality construct of psychopathy.

Historical, Clinical, Risk

Management-20 (HCR-20)

The HCR-20 is a structured professional judgment risk assessment guide that helps evaluators focus on risk-relevant factors when performing a violence risk assessment on an individual patient. The tool includes 10 historical items, 5 clinical items, and 5 risk management items to assist the evaluator who is performing the evaluation. The tool is not “scored” per se, but rather risk-relevant items are noted as “present,” “partially present,” or “absent.” On the HCR-20, most historical risk items are present for Mr. Johnson, including previous violence, relationship instability, substance use problems, psychopathy, and personality disorder. Similarly, some clinical items are present, including impulsiv-ity and unresponsiveness to treatment. As for risk management items, some items include plans lacking feasibility and likely exposure to destabilizers. Given the severity of the items that are present in Mr. Johnson, the overall “Final Risk Judgment,” assuming Mr. Johnson was in the community through the conditional release program, is rated as “High.”

Short-Term Assessment of Risk and Treatability (START)

The START is a newer structured professional judgment tool that looks at short-term risk for violence, self-harm, and suicide, among other things. The tool includes 20 items that can be rated as either a strength (potentially lowering risk) or a vulnerability (potentially raising risk). The purpose of the tool is to allow an individualized assessment of short-term risk while being able to capitalize on potential strengths present in the patient. Analysis of Mr. Johnson’s strengths reveal potential protective factors related to: social skills, recreational activities, self-care, present mental state, and social support. Vulnerabilities include: relationships, substance use, impulse control, external triggers, material resources, attitudes, rule adherence, conduct, insight, plans, and treat-ability. Overall he is estimated to be at a moderate risk for short-term violence (i.e., over the next three months) towards others.

The risk formulation using the START suggests, based on Mr. Johnson’s prior conduct, that he is an inherently impulsive and self-focused individual with little tolerance for those who do not value his needs over their own. Generally in a supervised environment he can avoid overt violence, but his manipulativeness and disrespect for the needs of others result in his compromising their well-being for his own. When substance use further degrades his impulse control, he can become more openly aggressive and violent. Due to his grandiose plans and relative lack of insight, he is likely to become frustrated, but he is apt to blame his failures on others rather than accept responsibility. As this continues, he can become more volatile with an increased risk for engaging in targeted violence, especially when under the influence of substances.

Violence Risk Analysis

The primary purpose of this evaluation is to assess Mr. Johnson to determine whether he would be a danger to the health and safety of others while under supervision and treatment in the community through CONREP. He has filed a writ for restoration of sanity, and if successful he would be sent to supervised release in the community. It is concluded that Mr. Johnson is not appropriate for release to a less restrictive setting; that is, he would be a danger to the health and safety of others if under supervision and treatment in the community. This conclusion is based in large part upon four factors: (1) Mr. Johnson continues to suffer from severe personality pathology; (2) he has routinely engaged in rules violations; (3) he remains dishonest with staff; and (4) he has not substantially benefitted from treatment for his primary risk issues.

Mr. Johnson Continues to Suffer from Severe Personality Pathology

Mr. Johnson has a lengthy criminal history involving acts demonstrating a pervasive disregard for the rights of others. In addition to the committing offense of murder, he has had criminal involvement in domestic violence, robbery, auto theft, reckless driving, selling cocaine, possession of cocaine, public intoxication, DUI, giving false information to a police officer, and a probation violation. His behaviors suggest that Mr. Johnson focuses only on what he wants and what is in his best interests at the time, while disregarding the welfare of others in his pursuit of those goals. This characterological deficit is seen most readily in his diagnosis of antisocial personality disorder, and his very high score on the PCL-R, suggesting severe psychopathy. In addition, Mr. Johnson’s violence risk is increased through his impulsivity and affective instability, which he has demonstrated in the context of relationships. He is easily angered and can behave impulsively and violently, especially when abusing substances.

Comment

The testing suggests somebody who is at an elevated risk for being violent. However, how does one reconcile the information that he has not been violent during his hospitalization? Considerations include: (1) the highly structured setting of the hospital limits his violent tendencies; (2) his affective violence is facilitated by substance abuse; and (3) his violence that is instrumental is within his control.

Prior to the murder of his girlfriend, Mr. Johnson had multiple arguments and disputes with her, including a recent domestic violence charge against him. He has stated that the reason that he killed her was that at the time he believed she was trying to harm him. However, the horrific nature of her injuries, coupled with his own attempted suicide, suggests that the killing probably was not in self-defense, but rather in the context of a violent and impulsive fight, most likely fueled through substance abuse and intoxication. This appears to be more a combination of uncontrolled anger, substance abuse, and a severe personality disorder than behavior affected by a psychotic thought process. That he attempted suicide after her murder not only suggests that he knew his behavior was wrong, but also that he is impulsive and emotionally labile, especially when under the influence of substances.

Since the crime, Mr. Johnson has been able to control most of his angry outbursts in the context of a highly structured and supervised setting. Clearly substance abuse reduces his ability to control his behaviors, and there is no indication he has used substances since the crime. That notwithstanding, there continues to be evidence of a pervasive disregard for the rights of others, including how he had used the FSH nurse both for her cellphone and then for her knowledge about how to appear appropriate for conditional release. It did not matter to him that she lost her job because of how she broke rules for him, and he currently has another girlfriend at CSH while the nurse waits for his potential release. He has been known to be active with illegal contraband trading and sales on the compound; he has been seen strong-arming and manipulating lower-functioning patients; and he has been found in possession of contraband goods. If he is released, there is reason to believe that Mr. Johnson will probably continue to manipulate, deceive, and capitalize on the weaknesses of others. When those things do not work, he may use whatever force is necessary to get his needs met, especially if he returns to abusing substances.

Mr. Johnson Has Routinely Engaged In Rules Violations

Successful transition into supervised treatment in the community requires vigilance in adhering to the treatment program’s requirements and rules. While at CSH and previously at FSH, Mr. Johnson has demonstrated that he will follow only those rules that he wants to follow, which are those it is in his best interest to follow. Generally speaking, Mr. Johnson realizes that he cannot cause too much trouble, lest he risk significant opposition to his petition to be released. If one truly were dedicated to successful transition into the community, it would be expected that one would scrupulously follow all rules and requirements prior to that transition. Mr. Johnson has not done so. Capitalizing on relatively lax supervision at times, he has helped himself to the benefits of illegal contraband trading and taking advantage of more vulnerable peers. With his impressive charm and interpersonally facile style, he is able to deflect most responsibility from himself so that he does not face the consequences of his rule-breaking behaviors. It is a testament to his impressive psychopathic charms that he has caused a former FSH employee to not only lose her job because of a relationship with him, but to continue to pine for him after leaving her state employment. She is useful to him. That he is able to convince staff and evaluators that he is doing well and is approaching readiness to leave suggests that he is accomplished in presenting only the façade that he wants others to see. He is quite cautious with his impression management, and he handles it artfully.

Comment

Violence-risk research literature has consistently shown that psychopathy can substantially increase risk for committing interpersonal violence. In this particular patient, given his domestic violence history and his pervasive disrespect for others, it appears likely that psychopathy may be a primary risk factor for violence.

Mr. Johnson Remains Dishonest with Staff

Another positive marker for successful community transition is a willingness to be candid and truthful, even in the face of potential negative consequences. However, the available evidence regarding Mr. Johnson shows a pattern of deceitfulness over a period of many years. When he was speaking to evaluators about the crime while he was in jail, he told them about a long standing problem with psychotic symptoms that exacerbated near the time of the crime due to methamphetamine binging. However, once successful in avoiding criminal responsibility for the crime, Mr. Johnson changed his story to the point that he now variably reports never having had any psychotic symptoms, or having had symptoms due to methamphetamines only at the time of the crime. He does not account for his different story that assisted him with his NGRI defense. Also, Mr. Johnson has not been candid during psychological testing for intellectual abilities and limitations. His scores have placed him squarely in the mildly mentally retarded range of functioning, but his actual day-to-day functioning belies those scores. It appears that he believed it useful for others to think he was intellectually limited, and he perpetuated that ruse to his benefit over several years.

During the present interview for this evaluation, Mr. Johnson told implausible stories about how he came into possession of the cellphone at FSH. He stated he did nothing to encourage the female nurse, and that she essentially threw herself at him in trying to win his affections. He remarked that she had some psychological difficulties, and he was helping her work through her wounded self-esteem, providing her with support, adding he “approved and validated her.” He notes she simply was taken by his trajectory as a model patient to the present time, which “captivated her.” Very little of what Mr. Johnson says can or should be taken at face value, unless it is in his best interest to be truthful at that moment. He uses both truth and lies in his attempts to get what he wants at the moment. He continues to break rules and be dishonest about it. He continues to manipulate lower-functioning patients and be dishonest about it. The cautious staff member should not assume that Mr. Johnson is telling the truth.

Mr. Johnson has Not Substantially Benefitted from Treatment for His Primary Risk Issues

Mr. Johnson has frequently stated since his hospitalization that he became psychotic due to a meth-amphetamine binge, and that due to his belief that his girlfriend was going to harm him, he repeatedly stabbed and sliced her body, later removing her thumbs. It was never discussed in the forensic evaluators’ reports why he felt it was legally or morally appropriate to attack his girlfriend in the manner that he did. Assuming for the sake of argument that Mr. Johnson’s only mental health issue was becoming psychotic when binging on methamphet-amines, his treatment focus on substance abuse issues would have been appropriate, and his attendance in such treatment would have suggested the possibility of benefit. However, Mr. Johnson’s mental health functioning is strongly influenced by his severe personality disorder, and he has paid virtually no attention to how his personality functioning has caused significant problems throughout his life and has contributed to his substantial violence risk. Furthermore, the presence of his personality disorder has probably diminished the potential impact of any treatment he has received, as he does not see himself as flawed or in need of change; rather he goes through the motions necessary to affect the impression others have of him when they can have an impact on his potential for release. To benefit from treatment, one usually needs to acknowledge that one has a significant problem that must be addressed. Mr. Johnson does not see himself as flawed. He believes he can convince others that all of his problems were substance-related, and by going to substance abuse groups and being able to repeat back some of the information, he will have addressed the issues necessary to gain his release.

Comment: How Does Foucha v. Louisiana Affect the Conclusion Regarding Continued Involuntary Hospitalization in this Case?

Foucha indicates that an individual must be both mentally ill and dangerous to meet the criteria for continued involuntary hospitalization as NGRI. Under California law, once a patient has been found NGRI and hospitalized as mentally ill and dangerous, the hospitalization can continue if the patient remains dangerous by reason of ANY mental disorder, not just the disorder that was instrumental in the commitment offense. Thus, personality disorders and substance abuse disorders can serve as foundational mental disorders for purposes of a violence risk analysis for continued hospitalization, even when the original commitment offense occurred by reason of the symptomatic effects of a psychotic disorder. In other words, being mentally ill and dangerous, as the basis for ongoing commitment, is not limited to the symptoms of psychotic or other severe mental illnesses.

However, unaddressed in his treatment are his highly dysfunctional interpersonal relationships, his proclivity towards domestic violence, his criminogenic attitudes and thinking, and his pervasive disregard for other people. Unless and until these issues are thoroughly addressed in treatment, Mr. Johnson will remain at a markedly elevated risk for future violence. These issues are known to his treatment team, and Mr. Johnson has been scheduled for treatment groups addressing several of these issues. Although Mr. Johnson regularly attends his treatment groups, he is not an active participant in these groups. Rather, in these types of groups he prefers to watch other group members participate, while occasionally making critical comments about the contributions of other patients. His level of participation is substantial enough to get “credit” for his attendance, but not enough to benefit from the content. He appears to his treatment providers to go through the motions while obtaining little or no benefit.

It is the conclusion of this evaluator that Mr. Johnson remains at an elevated risk for violence. He would be a danger to the health and safety of others, by reason of his severe personality disorder in combination with his substance abuse disorders, if under supervision and treatment in the community.

Craig R. Lareau, J.D., Ph.D., ABPP (Forensic)

Forensic Psychology Consultant,

Forensic Evaluation Department

Current State Hospital

repeat back some of the information, he will have addressed the issues necessary to gain his release.

However, unaddressed in his treatment are his highly dysfunctional interpersonal relationships, his proclivity towards domestic violence, his criminogenic attitudes and thinking, and his pervasive disregard for other people. Unless and until these issues are thoroughly addressed in treatment, Mr. Johnson will remain at a markedly elevated risk for future violence. These issues are known to his treatment team, and Mr. Johnson has been scheduled for treatment groups addressing several of these issues. Although Mr. Johnson regularly attends his treatment groups, he is not an active participant in these groups. Rather, in these types of groups he prefers to watch other group members participate, while occasionally making critical comments about the contributions of other patients. His level of participation is substantial enough to get “credit” for his attendance, but not enough to benefit from the content. He appears to his treatment providers to go through the motions while obtaining little or no benefit.

It is the conclusion of this evaluator that Mr. Johnson remains at an elevated risk for violence. He would be a danger to the health and safety of others, by reason of his severe personality disorder in combination with his substance abuse disorders, if under supervision and treatment in the community.

Craig R. Lareau, J.D., Ph.D., ABPP (Forensic)

Forensic Psychology Consultant,

Forensic Evaluation Department

Current State Hospital

Teaching Point: Using Multiple Sources for Relevant Hospitalization and Pre-Hospitalization Information

Using multiple sources of information is a very basic part of FMHA. In this context, it is particularly important as the forensic clinician seeks to develop a detailed version of the individual’s pre-hospitalization environment and behavior, current hospitalization, and proposed conditions of discharge. In doing this, there are two particularly important questions that arise. How similar is the environment in the proposed release to that of the individual’s pre-hospitalization? What safeguards are in place to avoid recreating the risk factors that were present prior to hospitalization?

It is always useful to have the individual’s perspective on each of the three domains identified earlier—pre-hospitalization, hospitalization, and release. But this account may be affected by poor self-awareness, motivation to leave the hospital, minimization of symptoms and deficits, and other considerations. Records and third party observations are a helpful antidote for these limitations. Accordingly, they are essential in the attempt to meaningfully address the relevant considerations related to hospital discharge.

Gathering this is the kind of information need not be deferred until prospective release is approaching. On the contrary, obtaining it early in hospitalization may be very helpful in identifying treatment targets and rehabilitation needs that are not clear from other kinds of assessment and staff review.

Case Three Principle: Describe Findings and Limits so that they Need Change Little under Cross-Examination (Principle 31)

As this principle was discussed in detail in Chapter 6 (this volume), we move directly to discussing the present report. This report provides an example of how the results of FMHA reports and testimony should be communicated in a release-decision-making evaluation. The first step in effective communication that would change little upon cross-examination is an understanding of the forensic issues and relevant legal questions. In the present case, the legal issue was whether Mr. Doe remains a mentally ill individual subject to court-ordered hospitalization. The legal issue is identified early in the report, which ensures that there is no confusion regarding the purpose of the evaluation.

This report contains several features that make it likely it would survive adversarial challenge. First, the effective communication of FMHA reasoning and conclusions is directly related to the quality and accuracy of the data gathered for the evaluation, and the reliability and validity of results can be strengthened through the use of multiple sources of information. In this case, the evaluator’s conclusions relied on multiple sources of information (e.g., interview, testing, collateral interview, records), which increased the accuracy of the findings. Second, the evaluator is careful to attribute information to sources, which enables the court and attorneys to identify and confirm the source of the data. Third, the evaluator appropriately uses qualifying language to highlight limitations in the data (e.g., “Based upon the available data …”). Each of these elements strengthens the evaluator’s conclusions and ensures that he will be prepared for cross-examination.

Evaluation of John Doe

Case Number: 03-CR-XYZ

Reason for Examination

Mr. John Doe is a 27-year-old African American male who was referred to the Netcare Forensic Psychiatry Center by the Honorable William Smith, Judge in the Rural County Court of Common Pleas, for a psychological evaluation pursuant to Section 2945.401 (D) of the Ohio Revised Code: the local Forensic Center shall complete a second opinion regarding a recommendation that Mr. Doe be advanced to Level 3 (Unsupervised on grounds), Level 4 (Supervised off grounds), Level 5 (Unsupervised off grounds) movement privileges, and Conditional Release. At the time of the evaluation, Mr. Doe was hospitalized at Central State Behavioral Healthcare (CSBH) pursuant to Section 2945.40 of the Ohio Revised Code and by court order.

Confidentiality Limitations and Notification of Purpose

Before proceeding with the interview, I provided Mr. Doe with a verbal and written explanation of the nature and general purpose of this evaluation, as well as the limitations on confidentiality. He stated that he understood the information provided to him, including the limits of confidentiality and his rights concerning the evaluation. He was informed that his CSBH treatment team has recommended Level 3, 4, 5 movement and Conditional Release and that I was asked to provide a second opinion as to whether or not he remains a mentally ill individual subject to court-ordered hospitalization, and if so, what would be the least restrictive alternative for his continuing care, balancing his needs and the safety of the community. I explained that based upon the evaluation, I would prepare a report, copies of which would be distributed to the presiding judge, and with the permission of the court, to his attorney and the prosecuting attorney. I indicated that if I were called to testify in his case, this report would also form the basis for my testimony. I also explained that the evaluation was to help answer legal questions and not to provide any counseling or psychotherapy. He indicated that he understood, and with prompting, was able to repeat this explanation back in an accurate fashion in his own words. I also reviewed his rights, as described in the Netcare Clients Rights Policy, with him. He was able to summarize these rights, then signed the disclosure and client rights forms and agreed to participate in the evaluation.

Evaluation Procedure

I, Terrance J. Kukor, Ph.D., ABPP, Diplomate in Forensic Psychology, of Netcare Forensic Center, interviewed Mr. Doe in a private office at CSBH on 08/26/04. This interview lasted approximately 1.25 hours. In addition, the following records were reviewed:

1)

A review of documentation from CSBH, which included various court entries related to his commitment, a CSBH Violence Risk Factor Checklist/Progress form (dated 05/26/04), a Comprehensive Psychiatric Examination (dated 04/23/04), a History and Physical Examination (dated 4/23/04), a Psychosocial Assessment (dated 05/03/04), a Psychology Assessment (dated 04/26/04), a Substance Use Assessment (dated 04/28/04), a series of Comprehensive Treatment/Recovery Plans (the most recent dated 07/20/04), and a series of Multidisciplinary Progress Notes (the most recent dated 08/25/04);

2)

A report (dated 07/12/04) pursuant to a request that Mr. Doe be advanced to Level 3, 4, and 5 privilege movement, as well as Conditional Release, completed by Melinda Blaire, M.D., his treating psychiatrist at CSBH;

3)

Previous competency and sanity evaluations (both dated 02/16/04) that I performed. These evaluations were based upon the following:

a.

The Court Entry and judgments ordering these evaluations;

b.

A review of the information provided by the prosecuting attorney, which included but was not limited to demographic information, a transcript of Officer Barker’s interview with the victim of the alleged incident, a Supplementary Investigation Report completed by Patrolman Lori Dutton; a Journal Entry dated 07/11/03 documenting Mr. Doe’s plea of guilty to a prior domestic violence charge, Rural Police Department Incident Summary, and a Domestic Violence Field Report;

c.

A telephone conversation with Mr. Alberto Rohos, Defense Counsel. Mr. Rohos provided a copy of Mr. Doe’s records from New Hope Family Center;

d.

Psychological testing consisting of the Minnesota Multiphasic Personality Inventory–2;

e.

A review of the defendant’s records from New Hope Family Center;

f.

A review of Mr. Doe’s records from Central Psychological Services, which were provided by his case manager, Mr. Francis Clarke;

g.

I made several attempts to contact Mr. Doe’s mother, by telephone, but was unable to reach her by the time these reports were due;

4)

A telephone interview with Ms. Jasmine Beck, the defendant’s probation officer;

5)

A “Post Acquittal by Reason of Insanity” evaluation (dated 03/23/04) that I performed;

6)

The Historical, Clinical, Risk Management–20 (HCR-20), a violence risk assessment instrument.

Relevant History

Note: Detailed background information and history were provided to court in previous reports regarding Mr. Doe’s competency to stand trial, mental condition at the time of the alleged offense, and post-NGRI evaluations, and will not be repeated verbatim here. What follows is a brief summary of the information pertinent to this evaluation that is reported in greater detail in those earlier reports.

Concerning family history, Mr. Doe was born to Jane and Jonathan Doe. Mr. Doe reported that he was not certain if his biological parents were married, but indicated that he has had no contact with his biological father and does not know him. He has two half-siblings: Johnny Doe (age 21) and Janie Doe (age 17). Mr. Doe said that he was born in Indiana and that when he was approximately one year old, his family moved to Michigan, where they lived until he was about 9 or 10 years old. Reportedly, his family has lived in Ohio for approximately the last eight years. Mr. Doe previously reported that he had “a pretty good childhood” during which time he had friends and was happy. He denied having ever suffered any physical or sexual abuse as a child or adolescent. Mr. Doe previously reported that, to the best of his knowledge, no one in his family had ever had psychiatric treatment; he described his biological father as an “alcoholic,” but was uncertain if he had ever received substance abuse treatment.

In terms of educational history, Mr. Doe previously reported that he attended public schools in Indiana, Michigan, and Ohio, where he graduated from high school. He said that he earned mostly Bs in school, and although he had some friends, he was shy and didn’t like to talk to many people. He indicated that he was suspended one time in the tenth or eleventh grade when he was caught with drug paraphernalia, but did not have to repeat any grades, was never expelled, and was never truant. He denied any history of special-education classes, and indicated that he tended to get along well with teachers. He previously reported that he reads and writes well.

Concerning employment history, Mr. Doe reported that he had his first job in a grocery store at the age of 15. He reported that he quit this job after about six months, and then took several successive jobs at local fast food restaurants. In one such job, he reported that he got fired when he accidentally spilled hot water on a manager’s leg. Typically, however, he quit these jobs. His last job was at a local light manufacturing plant, where he was working just prior to his arrest. Mr. Doe previously reported that he typically got along well with co-workers and bosses. He denied having ever received any benefits from SSI/SSD.

In terms of interpersonal and family history, Mr. Doe indicated that he has never married and to his knowledge has not fathered any children. He indicated that he has had girlfriends in the past, but did not characterize any of these relationships as long-term or serious to him. He has been sexually active. He reported that as an adolescent, he occasionally socialized with peers, but tended to be somewhat of a passive and shy loner. With the exception of his eighth-grade football team, he never belonged to any clubs, teams, or organizations. He denied having ever been a member of a gang. Concerning early antisocial behavioral patterns, Mr. Doe denied that he ever forced sexual activity on another, was cruel to animals, or engaged in vandalism, fire setting, truancy, runaway behavior, stealing, or excessive lying; he acknowledged starting one fight in school and one fight in jail, and acknowledged one incident of shoplifting.

Concerning medical history, Mr. Doe previously denied any childhood or adolescent history of severe or chronic illness, accidents, or surgeries. He indicated he has never suffered any head injuries, and has never been knocked unconscious. When asked about seizures, Mr. Doe previously reported that a maternal aunt has epilepsy, and described several episodes in which his body “phases out.” During these episodes, he described diminished control of his body, but denied having ever fallen to the ground or losing consciousness. When previously asked about the reference to Wilson’s disease in the police report, Mr. Doe said that he’d heard of it but was not certain if he had it or not.

In terms of mental health history, Mr. Doe previously reported that in February of 2002 he had his first psychiatric hospitalization. He was unclear about the reason for the hospitalization, which he said had been prompted by his telling a teacher that he did not feel safe around him. Mr. Doe was at a loss to explain this, saying that he had previously got along well with this teacher. Mr. Doe was somewhat unclear about the chronology of his post-discharge follow-up with mental health services. Mr. Doe explained that he received outpatient psychiatric treatment at one mental health center and management services from another. Mr. Doe reported that as a result of his arrest, his case was closed and that since early 2004, he has not had any of his antipsychotic medication.

In terms of drug and alcohol history, Mr. Doe reported that he has used alcohol only three or four times, the first use being at age 16, when he and a friend drank some hard liquor. He reported that he has been intoxicated on alcohol only one time. In terms of drugs, Mr. Doe’s drug of choice appears to be cannabis, which he began using at the age of 14 or 15. Mr. Doe reported that his heaviest use of cannabis was approximately a quarter-ounce per week. Mr. Doe also indicated that he has used LSD on three occasions at the age of 16 or 17. He indicated that he stopped using LSD because it was “too dangerous to use on a regular basis.” His mother thought that this self-report was accurate. When specifically asked, he denied any and all use of amphetamines, sedatives-anxiolytics, cocaine, opiates, PCP, or inhalants. He indicated that he smoked tobacco for approximately one month at age 15 or 16, and quit because he did “not want to get addicted.”

Concerning criminal history, Mr. Doe previously reported no arrests as a juvenile. As an adult, he indicated that he had been arrested a total of four times, each time for domestic violence. He reported that after his third domestic violence charge, all three were combined into one case, for which he received 18 days’ time served and one year “intensive supervised probation” in late 2003. He successfully completed this probation without further incident. Mr. Doe indicated that the prior domestic violence charges were attributable to getting into physical altercations with his mother, his mother’s boyfriend, and his half-brother. According to information provided by the prosecuting attorney, Mr. Doe entered a guilty plea to a charge of domestic violence on 07/11/03. Interestingly, the Journal Entry from that date indicates the following additional term: “take medications as prescribed.”

Concerning employment history, Mr. Doe reported that he has had a series of jobs at local fast food restaurants, all of which he quit, citing difficulty in keeping up with the required pace. His most recent job was at a local factory, where he was working just prior to his arrest. Mr. Doe indicated that he typically did not have disciplinary issues, and got along reasonably well with co-workers and supervisors despite his preference to keep to himself. He recently began receiving benefits from SSI/SSD.

In terms of military history, Mr. Doe has never served in the armed services. He reported that at one time he had spoken with a Navy recruiter about enlisting, but was not able to do so since he was on probation at the time.

In terms of his post-NGRI commitment to the Ohio Department of Mental Health, the instant offense took place on 12/04/03, when police received a call that John Doe had assaulted his brother (Johnny Doe) in a residence that they were sharing at the time. He was subsequently charged with domestic violence, a felony of the fifth degree. In a court hearing dated 02/27/04, Mr. Doe was found not guilty by reason of insanity on the charge of domestic violence. In a court hearing dated 04/05/04, Mr. Doe was ordered to be admitted to Central State Behavioral Healthcare, where he has remained since that time.

Current Mental Status

Mr. Doe, a 27-year-old left-handed African American male, was wearing casual clothing that was neat and clean. He is approximately 5’9” and 165 pounds with a medium build. His hair was worn short and he was clean-shaven, giving him a reasonably neat appearance. He did not exhibit any noticeable problems with respect to his personal hygiene or grooming. There were no observable scars, piercings, or tattoos.

Mr. Doe was eager to speak with me, and presented in a much more engaging fashion than in previous evaluation meetings. Although he made few spontaneous comments, he was responsive to my questions, speaking without undue latency. He read the notification and rights forms carefully, but not with the suspiciousness he had previously exhibited. He established and maintained consistent eye contact, which lacked the fixed, staring quality he exhibited in previous evaluations. Mr. Doe appeared relaxed and at ease, and did not display any behavioral agitation or other signs of acute distress. He did not appear to be confused, and was fully oriented to person, place, time, and situation. There were no problems noted with his immediate memory or recent memory; since it was not necessary to take a history, remote memory was not formally assessed. His speech was typically normal in tone, rate, and rhythm, and no articulation difficulties were evident.

Mr. Doe did not appear to have any difficulty understanding my questions. His vocabulary, fund of general information, and verbal abstraction were suggestive of at least average intellectual functioning. Answers to questions regarding interpersonal problem-solving were free of any bizarre or idiosyncratic elements, and not characterized by antisocial or self-serving themes. His attention and concentration were within normal limits, as evidenced by his ability to track and keep up with the give and take of a conversation. He expressed a much fuller range of emotion than in previous evaluations. At no time was his affect (i.e., expressed emotion) inconsistent with the content of his thinking. He did not appear to have any difficulty modulating emotion. His mood appeared to be euthymic—that is, neither unduly elevated nor depressed. In terms of current affective symptoms, he either denied or did not exhibit the following symptoms commonly seen in depression: low mood/loss of interest, sleep disturbance, diminished appetite, diminished energy, and feelings of worthlessness. He specifically denied any current suicidal ideation, plan, or intent. He also expressed some future orientation, describing his hopes to one day go to college. He did acknowledge some difficulty in concentration. He denied any current or past homicidal thoughts, plans, and intentions. He neither exhibited nor acknowledged symptoms typically associated with mania, including periods of persistent euphoria and irritability that have been associated with decreased needs for sleep, pressured speech, racing thoughts, and increased energy.

Mr. Doe’s thought process, as reflected in his speech, was logical, sequential, and goal-directed. Furthermore, he did not display symptoms of a formal thought disorder such as tangentiality (i.e., responses that veer off topic), circ*mstantial speech (taking a circuitous route to reach a point), or loose associations (responses that are not logically connected to conversation or questions asked). Mr. Doe described past experiences with auditory hallucinations (sensory perception in the absence of an external stimulus), and both the form and content of his descriptions were highly consistent with the known phenomenology of authentic auditory hallucinations. He also acknowledged apparent tactile hallucinations, which appear to be a rather long standing and treatment-refractory psychotic symptom. When given the opportunity to do so, he did not endorse any persecutory, somatic, referential, or grandiose delusions (i.e., fixed false beliefs that respectively involve thoughts that one is being persecuted; that one’s body injured or altered; that ordinary events, objects, or behaviors of others have particular and unusual meanings for one; or that one is person of great importance, power, or knowledge). He indicated that he no longer believes that family members are responsible for the uncanny experience that his mind is “crowded” with someone else’s thoughts or that someone is mysteriously touching his head. Although the progress notes clearly indicate that Mr. Doe’s expressed acceptance that he has a mental illness was quite recent (i.e., the day before this evaluation), Mr. Doe asserted that he has believed this since pleading NGRI and being admitted to the hospital. It was my impression that Mr. Doe was likely exaggerating both the duration and depth of his conviction about accepting his psychiatric diagnosis. That said, he did impress me as having made progress in terms of insight, which proved to be rather resilient to mild interpersonal challenges that I made. There was no evidence of compulsions (i.e., rigid behavioral rituals), obsessional thinking (i.e., repeated unwanted thoughts), or phobias (i.e., specific fears). His judgment and his insight into his current legal situation were thought to be good; his judgment about and insight into his clinical situation were thought to be improved.

Collateral Information

In my previous competency report, I noted that there was an abundance of evidence that Mr. Doe’s mental disease (paranoid schizophrenia) and mental defect (Wilson’s disease) had historically impaired his occupational and interpersonal functioning in a significant manner. However, at the time of the evaluation, he was reasonably stable, such that he had an accurate understanding of the nature and objective of the legal proceedings against him. In terms of his capacity to assist in his own defense, he did not express any undue mistrust or unrealistic expectations towards his lawyer. He expressed an appreciation for the need to tell his lawyer the truth, and based upon the behaviors exhibited during this evaluation, it was my opinion that he was capable of providing his lawyer with details related to the alleged offense in a rational fashion, capable of challenging prosecution witnesses, and could testify relevantly. His then-present mental condition was such that he had the capacity to comprehend instructions and evaluate legal advice, and that he was capable of meaningfully participating in the legal proceedings and behaving in an appropriate fashion while doing so.

According to my previous sanity report, based upon all the available information, including his own account of the alleged offense, Mr. Doe was confused, disoriented, and laboring under auditory hallucinations and paranoid thinking at the time of the alleged offense. There were multiple indicators that suggested the defendant’s thinking and perception were impaired by symptoms of active psychosis. Specifically, the entire behavioral sequence exhibited by the defendant (i.e., assaulting his brother for no apparent reason; following his brother out of the house while staring at him in a menacing fashion; calling the police and reporting that he was the victim of a sexual assault, then taking it back and reporting that perhaps he had dreamed it), was bizarre and pointed to cognitive disorganization, an inability to guide and direct his behavior in a meaningful, goal-directed fashion, and severely compromised cognitive functioning. It was my opinion that his severe mental disease and mental defect resulted in his not knowing the wrongfulness of the act he was charged with committing.

According to my previous post-NGRI evaluation, at that time, Mr. Doe exhibited poor insight into his mental illness. He was questioned in great detail about mental disorder and associated symptoms, and he acknowledged only that he has had past difficulty concentrating and developed some unwarranted suspiciousness. He minimized the behavioral aggression associated with past auditory hallucinations and persecutory ideation, and from his point of view, could not think of a single reason to continue taking psychiatric medication. Furthermore, he had a poorly articulated plan for avoiding future behavioral aggression and potential legal trouble, indicating that he was “older now” and more likely to think before acting. He did not express any appreciation for the connection between symptoms of an active mental illness and past behavioral aggression. Due to his history of noncompliance with treatment in the community, along with his then-current poor degree of insight, it was my opinion that continued stabilization should take place in a secured treatment facility. This would allow for gradual transition back into the community, with a full spectrum of supports in place and a realistic aftercare plan that would enhance his chances for success when returned to the community. It was my opinion, therefore, that the least restrictive commitment alternative available that is consistent with his therapeutic treatment needs and the safety of community was the Central State Behavioral Healthcare–Civil Unit.

Summary of the NGRI Offense

According to the police reports, on 12/04/03, police received a call from the defendant’s step-brother, who reported that he had been assaulted by the defendant in his residence. While the victim was on the phone with the police, the defendant called police from a pay phone via 911; the police dispatcher had difficulty understanding him, as the defendant was “real slow with his speech.” The defendant reported that someone had broken into his house and had sexually assaulted him. When police officers arrived at the scene, they were flagged down by the victim, who told them that he and the defendant were in the process of moving into the residence together. A large number of boxes and items were stacked about the house, and the victim reported that the defendant approached him from behind when he was leaning over the boxes organizing items, and pushed him into the boxes and over some furniture. The victim told police that as he was lying on the floor and trying to get up, the defendant was standing over him, just staring at him. The victim was reportedly concerned for his safety; the police report noted that the defendant has had three prior domestic violence arrests, and one conviction, on his record. The victim reported that as he got up, the defendant never said anything to him and just stared at him. The victim said that he then walked out of the house toward a restaurant and that the defendant followed him all the way to the restaurant and then turned around and went back to the residence. Police subsequently found the defendant sitting in his vehicle in the parking lot of another nearby restaurant. According to the police report, the defendant “apparently did not remember what had happened,” and when he was asked why he had called the police department, he said that he “just wanted to see how things were going.” He reportedly made no mention of any kind of domestic violence, burglary, or sexual assault. When he was subsequently questioned about the alleged burglary and sexual assault that he had reported earlier on a 911 call, he “stated that he thought that maybe it had happened but apparently it hadn’t. He was very lethargic. He acted like a zombie as we were talking to him. There was no emotion of any sort at all. He was very deliberate in his movements.”

The victim then told police that his brother had been on medication for psychosis and that he had not been taking the medication. When questioned at the police department, the defendant reported that he and his brother had been arguing, but did not know what they were arguing about. He indicated that there had been no physical contact, and he didn’t understand why he was under arrest. Police noted that the defendant could still not provide them any information on the alleged burglary or sexual assault, and defendant indicated that he “probably was dreaming the incident had happened.”

Course of Treatment During the Current Hospitalization

According to records from Central State Behavioral Healthcare, Mr. Doe was adjudicated not guilty by reason of insanity on charges of domestic violence, in violation of Section 2919.25 (A) of the Ohio Revised Code, a felony of the fifth degree. He subsequently was admitted to CSBH on 04/05/04, where he has remained throughout the course of his treatment.

Since the time of his admission, Mr. Doe has not presented any behavioral aggression, and has routinely been described as pleasant, behaviorally appropriate, and medication compliant. He has been involved in a wide variety of therapies, though his participation in groups was often described as passive. Earlier notes from individual psychotherapy tend to depict him as having difficulty accepting that he had a mental illness. By the end of June, it was noted that he continued to experience tactile hallucinations, in which he felt that someone had been touching his head. Reportedly, in the past he had attributed this to family members, but had come to appreciate that such an attribution was illogical. In July, it was noted that he was using his movement privileges (Level 2, Supervised on grounds) without any problems, and was exhibiting good skills related to activities of daily living. Although he was described as medication compliant, it was noted that he did not feel the antipsychotic medication had made any significant difference in his mood or behavior, and that he was taking medication because it had been ordered and he wanted to be compliant. Tactile hallucinations diminished in intensity but remained present. He participated in an ongoing anger management group, and continued to exhibit friendly, non-aggressive behavior with staff and peers. His individual therapist noted that when provided with diagnostic criteria for psychotic disorders, he acknowledged auditory hallucinations as well as delusions of persecution, reference, somatization, and grandiosity, but was reluctant to endorse the idea that he had a mental illness. By mid-July, he was described as “stable” on his antipsychotic medication, with no delusions of control, but continued tactile hallucinations that interfered with his focus and concentration. His participation in a group on substance abuse was described as “passive.” His individual therapist noted that although he was willing to acknowledge psychiatric symptomatology, he did not want to attribute such symptoms to a mental illness. By early August, it was noted that he was not overtly delusional, had not exhibited any violence, and that the intensity of the tactile hallucinations had diminished. At the same time, however, it was also noted that his “continued lack of insight was readily apparent.” On 08/11/04, his individual therapist noted that he continued to exhibit poor insight, and expressed concern about the potential long-term consequences in terms of the likelihood of future clinical decompensation. On 08/25/04, his individual therapist noted that Mr. Doe continued to report tactile hallucinations, which were apparently linked to past delusional thinking. For example, he would experience a sensation that someone had touched his head, then have the experience that a delusional thought (e.g., that his brother had raped him) had been inserted into his mind. It was on this same date that Mr. Doe, for the first time, indicated that he believed he had a mental illness for which he had to take medication, and had to abstain from alcohol and drugs. Interestingly, this assertion was the day before I saw him for this evaluation.

Clinical Formulation/Risk Assessment

The available information, as well as the clinical interview, indicates that Mr. Doe does have a serious mental illness, most likely in the psychotic spectrum, that is complicated by a mental defect (Wilson’s disease). In the past he has been diagnosed by his outpatient psychiatrist with paranoid schizophrenia. More recently, he has been diagnosed by his inpatient psychiatrist at CSBH with psychosis not otherwise specified. There is no evidence that indicates that Mr. Doe is intellectually disabled.

For the court’s information, according to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) published by the American Psychiatric Association, the essential feature of the paranoid type of schizophrenia is the presence of prominent delusions or auditory hallucinations in the context of a relative preservation of cognitive functioning and affect. Delusions are typically persecutory or grandiose, or both, but delusions with other themes (e.g., jealousy, religiosity, and somatization) may also occur. The delusions may be multiple, but are usually organized around a coherent theme. Hallucinations are also typically related to content of the delusional theme. Associated features may include anxiety, anger, aloofness, and argumentativeness. The individual may have a superior and patronizing manner and either a stilted, formal quality or extreme intensity in interpersonal interactions. Persecutory delusions are typically organized around a central theme in which the individual believes he or she is being attacked, harassed, cheated, persecuted, or conspired against. The persecutory themes may predispose the individual to suicidal behavior, and the combination of persecutory and grandiose delusions with anger may predispose the individual to violence.

According to information from the National Institute of Neurological Disorders and Stroke, Wilson’s disease is an inherited disorder in which excessive amounts of copper accumulate in the body. Although the accumulation of copper begins at birth, symptoms of the disorder appear later in life, between the ages of 6 and 40. The primary consequence for approximately 40% of patients with Wilson’s is liver disease. In other patients, the first symptoms are either neurological or psychiatric or both, and include tremor, rigidity, drooling, difficulty with speech, abrupt personality change, grossly inappropriate behavior and inexplicable deterioration of schoolwork, and neurosis or psychosis.

The essential feature of a psychotic disorder not otherwise specified is psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis or about which there is contradictory information. This diagnosis is also used for disorders with psychotic symptoms that do not meet the criteria for any specific psychotic disorder.

The HCR-20 was administered to assist in assessing Mr. Doe’s risk of future violence. This instrument consists of 20 items, organized around ten past (historical) factors, five present (clinical) variables, and five future (risk management) issues. All items are coded on a three-point scale according to the certainty that the risk factors are present. A rating of 0 indicates that, according to the assessment information gathered, the risk factor is absent (or, put another way, there is no information to suggest that the risk factor is present). A rating of 1 indicates that the risk factor is possibly or partially present: that is, the assessment information indicates there is some, but not conclusive, evidence for its presence. A rating of 2 indicates that the risk factor is definitely or clearly present. If no information is available concerning a given item or if the information is considered unreliable, an item may be omitted. Research on the HCR-20 in a forensic psychiatric setting indicates that HCR-20 scores predicted readmission to a forensic hospital and subsequent psychiatric hospitalizations. Although the historical item called “Psychopathy” on the HCR-20 could not be scored, Dr. Kevin Douglas, one of the authors of the instrument, suggests that the HCR-20 can be scored and interpreted without utilizing this item.2

2

Douglas, K., & Guy, L. (2008, December), Violence risk assessment and management using structured professional judgment and the HCR-20. Presented for the Ohio Department of Mental Health, Columbus, OH.

HCR-20 Historical Items

Previous Violence

Historically, Mr. Doe does have a history of violent behavior. As an adult, Mr. Doe has been arrested a total of four times, each time for domestic violence. His most recent arrest was considered a felony in light of the number of previous domestic violence incidents. Mr. Doe has not exhibited any behavioral aggression since the index offense. He has not been violent towards peers or staff since his most recent admission to CSBH. His hospital records indicate that he has no episodes of seclusion or restraint in the current inpatient hospitalization. Taken as a whole, his history of violence increases risk.

Young Age At First Violent Incident

A history of serious aggressive behavior during adolescence, particularly with early onset (below age 12) would be a primary concern in terms of increased violence risk. In Mr. Doe’s case, there is no such known history. However, due to his current age, he is still considered a younger individual— which increases his risk.

Relationship Instability

“Relationship instability” applies only to romantic or intimate, non-platonic partnerships and excludes relationships with friends and family. Of concern is whether the individual can maintain stable long-term relationships and engage in these when given the opportunity. Mr. Doe indicated that he has never married and to his knowledge has not fathered any children. He indicated that he has had girlfriends in the past, but did not characterize any of these relationships as long-term or serious to him. He has been sexually active. He reported that as an adolescent, he occasionally socialized with peers, but tended to be somewhat of a passive and shy loner. He denied having ever forced sexual activity on another. He indicated that he is not particularly interested in developing a long-term romantic relationship at this time. In response to direct inquiry, Mr. Doe has not considered the role his mental illness has had in his ability to establish a lasting romantic relationships. Thus, the protective factor of a long-term relationship is not present in this case, and his relationship history raises risk.

Employment Problems

Mr. Doe has had various short-term employments. Mr. Doe reported seeking jobs for short-term instrumental reasons. For example, he said that he often he sought employment to earn enough money to purchase video games, which for him were solitary activities. On multiple occasions he quit the jobs because he had difficulty keeping up, and he has always done so without having previously lined up another job. He acknowledged that on one occasion, he quit a job as he was becoming suspicious that his work peers were plotting against him to get him fired. His case manager indicated that he recently became a recipient of Social Security benefits, adding that he has expressed an interest in pursuing vocational rehabilitation and possibly employment. Overall, his lack of steady employment in the past moderately increases risk.

Substance Abuse Problems

In this domain the focus is on whether there is impairment in functioning in the areas of health, employment, recreation, and interpersonal relationships attributable to substances. Mr. Doe acknowledged past use of alcohol, cannabis, and LSD. He denied experiencing any problems related to drinking or drug use. His use of alcohol and drugs has not been of sufficient severity or chronicity that it would meet diagnostic criteria for substance dependency. He has never been court-ordered into substance abuse treatment, nor has he been mandated to participate in Alcoholics Anonymous or Narcotics Anonymous meetings. Records from prior mental health treatment do not offer formal diagnoses related to his use of drugs or alcohol, and do not note such as areas of concern. At the present time, Mr. Doe expressed an understanding that indulging in either alcohol or drugs of any kind “might cause problems with my medication.” Although substance use problems do not appear to represent a significant risk factor for Mr. Doe at this time, any future use of alcohol and cannabis would reasonably be expected to erode behavioral controls and increase the risk of future violence.

Major Mental Illness

The empirical literature suggests an increased risk of violence for individuals with certain serious psychiatric diagnoses, particularly when they are complicated by drug or alcohol abuse. In this case, Mr. Doe’s behavioral history and mental status, as described above, suggest that he has a serious mental illness (in the psychotic spectrum) complicated by a mental defect (Wilson’s disease). There is no evidence for intellectual disability. Past violence appears to have been associated with active psychotic symptoms (e.g., hallucinations and persecutory delusions). In Mr. Doe’s case, hallucinations and delusions have responded reasonably well to antipsychotic medication, such that his risk for future violence associated with psychotic symptoms decreases with his medication compliance. At the present time, there is no evidence to suggest current delusional thinking or auditory hallucinations. There is evidence for current tactile hallucinations that have been reduced in intensity. Importantly, Mr. Doe appears to have abandoned the persecutory delusion that family members were somehow responsible for these tactile hallucinations. Records indicate that Mr. Doe has been medication-compliant for some time. Mr. Doe expresses an understanding of the importance of medication compliance. When queried in detail about medication compliance, Mr. Doe did not complain about any unwanted side effects, and when directly asked, indicated that if for any reason he stopped taking this medication, “the delusional thoughts would come back.” When asked how long he would have to take this medication, Mr. Doe said, “I hear for the rest my life,” and when challenged on this, said, “The reason I’m feeling so good now is because I’m taking the medication.” Overall, the defendant has a serious major mental illness, which increases his risk.

Psychopathy

This item calls for the Hare Psychopathy Checklist– Revised (PCL-R) to be administered. The PCL-R is a tool that assesses psychopathy, which refers to a specific constellation of deviant traits and behaviors that constitute a particular personality pattern identified by research as being associated with violence, criminality, and aggression. This item was not scored due to the unavailability of a PCL-R rating by a trained psychopathy assessor.

Early Maladjustment

This item is concerned with maladjustment at home, at school, or in the community before the age of 17. There is no known history of early neglect or abuse in Mr. Doe’s background, and Mr. Doe did not report any specific traumatic events from childhood. He has no juvenile legal history, and his early school history is without evidence of significant maladjustment. There is no evidence that he has been a member of a gang. A history of serious aggressive behavior during adolescence, particularly with early onset (below age 12) would be a primary concern. In Mr. Doe’s case, there is no such known history. There does not appear to be significant risk associated with this factor.

Personality Disorder

It has been found that antisocial and borderline personality disorders have predictive links of violence. The key clinical factors associated with these diagnoses are anger, impulsivity, and hostility, all of which can elevate the risk for general and violent criminal behavior. Individuals with a history of antisocial behavior, including impulsivity, delinquency, and adult criminal behavior are at greater risk for violent criminal behavior. In this case, based upon the collateral information and Mr. Doe’s self-report, a history of adolescent delinquent activity does not appear to be present. Per his self-report, there was some evidence of adolescent impulsivity, but this does not appear to have become a pervasive pattern of developmentally inappropriate impulsiv-ity or inappropriate risk taking that extended into interpersonal, occupational, or cognitive domains. There is some evidence of adult antisocial activity, but his past episodes of domestic violence appear to be related to the onset of symptoms of mental illness. Mr. Doe has not been diagnosed with a specific personality disorder, which decreases risk.

Prior Supervision Failure

Since the time of his admission, Mr. Doe has not presented any behavioral aggression, and has routinely been described as pleasant, behaviorally appropriate, and medication compliant. There have been no elopement attempts. He has a history of successfully completing probation, and his probation officer reported that he did not present problems while on probation. His overall success while under formal supervision decreases risk.

Clinical Risk Factors

Lack of Insight

This item concerns the degree to which an individual believes he or she has a mental disorder and/or substance abuse problem and has awareness of the effect of medication on the mental condition, and appreciates the social consequences of having a mental disorder or a substance abuse problem and the possible violence potential that the individual may have. Mr. Doe has made therapeutic gains in this area. However, the progress notes from CSBH clearly do not support his assertion that acceptance of his diagnosis and need to remain medication compliant are as long-standing as he would have one believe.

Negative Attitudes

This area relates to prosocial versus antisocial attitudes. Mr. Doe did not express any attitudes that support and/or rationalize crime or violence, and there is no evidence in the collateral information that suggests he has espoused such attitudes in the past. He does not appear callous or lacking in empathy. No sad*stic, paranoid, or homicidal attitudes were apparent. No grudges were identified. Overall, the lack of negative attitudes decreases risk.

Active Symptoms of Mental Illness

At the present time, Mr. Doe is exhibiting a significant reduction in active signs or symptoms of mental illness. In Mr. Doe’s case, hallucinations and delusions have responded reasonably well to antipsychotic medication, which means that his risk for future violence associated with psychotic symptoms decreases with his continued medication compliance. At the present time, there is no evidence to suggest current delusional thinking or auditory hallucinations. There is evidence for current tactile hallucinations that have been reduced in intensity. Importantly, Mr. Doe appears to have abandoned the persecutory delusion that family members were somehow responsible for these tactile hallucinations. Overall, his mental condition is rather stable at this point in time. He has no known history of malingering, and malingering is not suspected at this point in time. Since there is minimal evidence for current active symptoms of mental illness, risk associated with this factor is low.

Impulsivity

This refers to behavioral and affective instability such as emotional instability. “Impulsivity” basically refers to an inability to remain composed and directed when under pressure to act. Currently, Mr. Doe is not presenting as hot tempered, emotionally unstable, quick to overreact, reckless, impulsive, or affectively unstable. Rather, his current behavioral presentation is relatively stable. Of note, when he is not taking antipsychotic medication, his reality testing (i.e., his ability to accurately perceive reality and reason about it) is significantly impaired. At such times in the past, he has exhibited behavioral and affective instability and has acted without due regard for likely consequences. Per his case manager, when he is medication complaint, Mr. Doe is emotionally and behaviorally stable.

Unresponsive to Treatment

This refers to whether or not the individual has sought help and accepted it, rejected it out of hand, or agreed to it in order to be viewed in a positive light by the court, review board or authority. According to his report and collateral information, at this time, Mr. Doe is symptom-free but for occasional tactile hallucinations. Since his most recent admission to the hospital, Mr. Doe has not required recent emergency medications or placement in seclusion or restraint. Nor has he exhibited recent outbursts of poorly modulated anger. By all accounts, his response to treatment while in the hospital has been very positive. He does not exhibit attitudes that could be characterized as pro-criminal or pro-substance use. Importantly, he has recently expressed an interest in receiving vocational rehabilitation services and seeking employment post-discharge. His motivation for continued outpatient psychiatric treatment post-discharge is difficult to gauge with any precision at this point. Although he indicates that he is willing to continue with prescribed medication, as noted elsewhere, his insight is neither deep nor long standing. In this regard, his appreciation for the impact acute symptoms of mental illness have had on his functioning is minimal.

Risk Management Risk Factors

This section considered factors related to developing an estimate of how an individual will adjust to future circ*mstances. It is recognized that future risk depends heavily upon the context in which the individual will live or can be expected to live.

Plans Lack Feasibility

At this point, it has not been formally determined where Mr. Doe will begin his period of supervision as an insanity acquittee. Prior to the index offense, Mr. Doe lived with his step-brother (the victim of the index offense), who has indicated some willingness to have him return post-discharge. His step-brother has been invited to participate in discharge planning meetings, but of the three scheduled, he has attended only one. Although Mr. Does has expressed a willingness to return to New Hope for continued outpatient mental health care, hospital records indicate that his involvement in discharge planning has been passive; at times indifferent. In this regard, I had difficulty engaging him in a problem-solving discussion about how he might manage various contingencies in the implementation of the details of his discharge plan. His conditional release plan is thorough and appropriately focused on management of dynamic risk factors for violence, and proposes outpatient treatment at a clinically appropriate level of intensity to manage the estimated level of risk. Mr. Doe has no known learning style or abilities that would constitute a barrier to his ability to understand his discharge plan. He expresses a positive regard for his proposed treatment providers at New Hope, who are willing and able to provide the proposed behavioral health interventions on the discharge plan. Considering all the available factors, there is a moderate to high probability that the plan will succeed.

Exposure to Destabilizers

This item assesses for situations in which an individual is exposed to the hazardous conditions to which he is vulnerable or that may trigger violent episodes. Hazardous conditions are unique to specific individuals but include such concerns as the presence of weapons, substances, or certain individuals or victim groups. The discharge location being proposed—Mr. Doe’s step-brother’s residence—is not known to have any available weapons. In this regard it should be noted that Mr. Doe’s past acts of discrete violence have never involved weapons, but have been focused exclusively upon family members as victims. His step-brother has expressed a willingness to have Mr. Doe again live with him; he does not harbor any grudge or enduring resentment about the index offense. His step-brother has said, however, that he is reluctant to remove alcohol from his residence. In this regard, Mr. Doe does not currently express any concern about exposure to alcohol. In terms of peer support, as previously noted, Mr. Doe has no known gang involvement, and per his step-brother and probation officer, there is no shared concern that individuals with whom Mr. Doe would like to reforge relationships are antisocial. Basic life skills (e.g., leisure skills, ability to cook, clean, etc.) are intact. As previously noted, his case manager indicated that he recently became a recipient of Social Security benefits. Hospital progress notes indicate that he has recently expressed an interest in pursuing vocational rehabilitation and possibly employment. This is important in that Mr. Doe expressed concern about the financial costs about associated with meeting his deductible payment for his medications. Lastly, Mr. Doe has the benefit of positive and trusting relationships with an interdisciplinary team at New Hope Mental Health Center. There is low to moderate risk associated with exposure to destabilizers at this time.

Lack of Personal Support

Networks of available social support can serve as an effective interpersonal buffer against life stressors, thereby aiding in positive adjustment and constructive coping. In this case, Mr. Doe’s perceived social support centers primarily around family members. In addition to his step-brother, his mother has been strongly supportive of his consistent involvement in mental health treatment. Importantly, Mr. Doe is willing to accept such interpersonal encouragement and support from his family. It should also be noted that Mr. Doe had some difficulty articulating a realistic and meaningful coping plan for dealing with unexpected conflict with family members.

Likewise, he expressed a limited understanding of the relationship between medication compliance and his ability to remain nonviolent. Mr. Doe’s personal support systems could be enhanced via participation in mental health support groups at New Hope and formal participation in the Bureau of Vocational Rehabilitation. These venues would afford him the opportunity to expand his social network by meeting and interacting with other people in the community who share similar interests, and with others who could assist him with job training, placement, and linkage to other resources. There is low risk associated with lack of personal support at this time.

Noncompliance with Remediation Attempts

Since being admitted to CSBH as not guilty by reason of insanity, Mr. Doe has been an active participant in treatment. Importantly, hospital records indicate that he has participated in groups on both anger management as well as recovery skills training, which indicates that he has been exposed to a variety of methods and techniques for managing stress and successfully coping with potentially provocative situations, which mitigates the overall risk associated with this factor. Even though Mr. Doe has only partial insight into the importance of medication compliance, hospital records do not indicate any episodes in which he has refused prescribed psychiatric medication. There is low risk associated with noncompliance with remediation attempts at this time.

Stress

It is important to understand the sources of stress Mr. Doe is likely to encounter and how he may react or cope with that stress. At this time, he is moderately anxious about the possibility of being granted a conditional release. Hospital progress notes indicate that he discloses such concerns to his treatment team, and has been willing to practice—with moderate success—cognitive-behavioral techniques for symptom management that he has learned while in the hospital. In this regard, Mr. Doe has exhibited the ability to seek out and utilize the support systems readily available to him. There is low risk associated with foreseeable sources of stress at this time.

Other Risk Considerations

A higher risk of violence is associated with multiple assaults on a narrow class of victims who remain readily available (e.g., significant others) or a broad range of victims. In this case, the primary concern appears to be Mr. Doe’s family, who continue to be readily available, which increases the overall risk level. A related factor is concerned with the individual’s current thoughts, feelings, and attitudes (including fantasies) regarding others, particularly in terms of resolving perceived conflicts. In this case, Mr. Doe denied any current intentions or fantasies about harming others, including his family members who have been involved in past episodes of domestic violence. He also denied any brooding resentment or grudge towards his family members, and denied any angry or aggressive feelings towards them. This is consistent with the results of the mental status examination, during which there was no evidence of irritability or underlying edginess. There was no evidence of minimization of victim impact.

Additionally, risk tends to be enhanced, particularly for more lethal forms of violence, when weapons are readily available. In this case, Mr. Doe denied any history of owning or using firearms or other weapons, and weapon use does not appear to have played a part in past episodes of domestic violence, which also mitigates risk.

In summary, concerning the questions asked by the Court in terms of overall risk assessment, it is my opinion, with a reasonable degree of psychological certainty, that although the risk of future violence cannot be ruled out, the probable risk of future behavioral aggression is relatively low, in the minimal to moderate range. There is some concern about risk associated with the following risk factors: history of previous violence, relationship instability, employment problems, a major mental illness complicated by Wilson’s disease, and passive involvement in discharge planning. Additional risk is associated with a history of alcohol and cannabis abuse, a history of impulsivity, and victim availability.

However, significant mitigating roles are played by: no violence at a young age, lack of substance use problems, lack of early maladjustment, lack of personality disorder, lack of prior supervision failure, lack of negative attitudes, improvement in active symptoms of mental illness, lack of current impulsivity, responsiveness to treatment, feasible discharge plan, personal support, compliance with remediation attempts, and lack of significant current stress. Additional protection is afforded by lack of minimization of victim impact or any brooding resentment towards the victim of the index offense.

There is equivocal evidence about potential exposure to destabilizers and insight. With respect to the latter, it should be noted that Mr. Doe expressed at least a superficial understanding of the need to be compliant with psychiatric medication, which in the past has been problematic for him. Historically, his medication non-compliance has led to the development of acute psychotic symptoms that appear to have been directly related to subsequent interpersonal violence. Psychopathy was not formally assessed.

To the extent that Mr. Doe is fully compliant with prescribed medication, and openly works with professional treatment staff and family members in constructing, maintaining, and refining a realistic and meaningful coping plan, the probable risk of unprovoked behavioral aggression will be acceptably low, and Level 3 (Unsupervised on grounds) and Level 4 (Supervised off grounds) movement could be granted without undue risk to public safety. Naturally, should there be significant changes in risk factors, the overall risk assessment could change as well. This risk assessment should be carefully reevaluated if Mr. Doe experiences break-through psychotic symptoms, becomes behaviorally aggressive to others, or experiences a significant change in his support system. The risk of behavioral aggression taking place would be accelerated by medication non-compliance and the development of openly paranoid attributions towards others. Therefore, this examiner is in agreement with Mr. Doe’s treatment team that he should be granted Level 3 (Unsupervised on grounds) and Level 4 (Supervised off grounds) movement privileges to be used in the manner and for the purpose prescribed by his treatment team and any other conditions added by the Court.

I do not concur that Mr. Doe is ready for Unsupervised off grounds movement privileges (Level 5) or Conditional Release at this time. Although he has made progress, the progress notes clearly do not support his assertion that acceptance of his diagnosis and need to remain medication compliant are as long standing as he would have one believe. Additionally, there is concern about Mr. Doe’s: 1) passive involvement in the discharge process, 2) difficulty describing how he might constructively manage challenges in the full implementation of the discharge plan, and 3) indifference to being in the presence of a destabilizer such as alcohol. Additional therapeutic focus on these issues would be of risk-reduction benefit to Mr. Doe.

In light of these concerns, it would seem only prudent to provide an additional period of inpatient services, and to carefully evaluate how successfully Mr. Doe deals with increasing degrees of movement privileges prior to consideration of his clinical suitability for Conditional Release. Should he successfully complete several months of these privileges with no significant clinical deterioration while maintaining the clinical progress he has made, he would be an appropriate candidate for Conditional Release.

Forensic Conclusion

Pursuant to Section 2945.401 (D) of the Ohio Revised Code, it is my opinion, with a reasonable degree of psychological certainty, that Mr. Doe does have a serious mental illness, which continues to render him subject to hospitalization by court order, with the least restrictive setting consistent with his need for treatment and safety of community being inpatient hospitalization at Central State Behavioral Healthcare. It is also my opinion that Mr. Doe is ready to be granted Level 3 (Unsupervised on grounds) and Level 4 (Supervised off grounds) movement privileges.

Should he successfully complete several months of these privileges with no significant clinical deterioration while maintaining the clinical progress he has made, he would be appropriate for Level 5 (Unsupervised off grounds) movement privileges. Conditional Release can be considered should he consistently manage Level 5 privileges without incident or evidence of any clinical deterioration for a sustained period of time. The use of any increased movement privileges granted by the Court should be suspended at any sign that he has ceased complying with treatment recommendations or that his mental condition has deteriorated.

Respectfully submitted

Terrance J. Kukor, Ph.D., ABPP

Psychologist

Board Certified in Forensic Psychology

American Board of Professional Psychology

Director, Netcare Forensic Services

Teaching Point: Achieving Balance and Facilitating Accuracy in Reporting Findings

A fundamental goal in FMHA is to describe findings from the evaluation in a way that allows them to be considered, interpreted, and weighed in a transparent fashion—and then combined to reach conclusions that serve as the evaluator’s opinions regarding the referral questions. Recognizing and prioritizing this goal is an important first step in achieving the necessary balance to facilitate accurate reporting of findings and impartial reasoning about their meaning.

There is sometimes the temptation to write reports in a way that is affected by two well-known social science phenomena: the “halo effect” and the “reverse halo effect.” That is, if the evaluator concludes that an individual does not appear to have the necessary capacities to waive Miranda rights, or stand trial, or be conditionally released (for example), there is some implicit pressure to describe various findings as consistent with this conclusion. Competence to stand trial is composed of functioning in the domains of understanding the legal system and assisting counsel. Some defendants who have a reasonable understanding but are impaired in their capacity to assist might nonetheless be described as also impaired in the former area.

Beyond cultivating an awareness of this kind of potential influence, there are three steps that can be taken to manage it. First, the evaluator should be committed to describing findings that are, simply, what they are—without striving to make them consistent with an eventual conclusion. Second, the evaluator should avoid drawing any conclusions prematurely. If data are truly to drive conclusions, then the evaluator must collect and weigh the data before meaningful conclusions can be drawn. Finally, the evaluator can avoid answering the ultimate legal question whenever possible. Legal questions are “either-or,” while describing data can often be more effectively captured on a continuum.

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