Not criminally responsible

Not criminally responsible due to mental disorder

Whenever the media highlights a particularly violent and random crime, questions arise about the perpetrator’s mental state.

It seems hard to imagine that anyone in their right mind would inflict violence on a stranger.

After the question is raised, the inevitable public discussion occurs about our country’s laws and whether the perpetrator should be held criminally responsible for his or her actions.

A lot of misinformation tends to circulate about the nature and prevalence of mental illness and exactly what our laws state when it comes to being found not criminally responsible due to a mental disorder.

Common misconceptions include:

  • that most not-criminally-responsible-on-account-of-a-mental-disorder cases involve serious personal violence
  • that the verdict is used too frequently 
  • and perhaps that people often fake a mental illness to avoid punishment only to be released into the community after a brief hospitalization.

Contrary to some rhetoric, the verdict of not criminally responsible due to mental disorder is quite rare. Only 1.8 in 1,000 criminal cases come to this conclusion.

Data released in the National Trajectory Project and published in the Canadian Journal of Psychiatry provides a longitudinal look at 1800 cases from Quebec, Ontario and B.C. where this verdict was found and gives valuable information about the verdict, the people, their histories and their long-term outcomes.

A few of the interesting findings show 51 per cent had no prior criminal convictions, and 72 per cent had at least one prior mental health hospitalization.

When offences occurred against people, the most common targets were family members followed by police and mental health workers.

Strangers were the target in 22 per cent of cases.

Three quarters of the sample group was on government assistance at the time of their crime and 10 percent were homeless.

Psychotic symptoms were the most common diagnosis and a third of the sample also had a co-occurring substance abuse problem.

This review also showed women were less likely to have a criminal history, less likely to offend against strangers, had fewer risk factors for recidivism so less likely to re-offend when back in the community.

Recidivism is one of the more interesting factors to consider, as it is often the rationale used to support a tough on crime policy.

This review found a 16 per cent recidivism rate at three-year follow up and some differences between provinces.

People whose offense was a serious violent offence had the lowest three-year recidivism rate for any type of re-offense.

An informed debate would have considered some of these facts:

  • most who are found not criminally responsible have not committed offences involving serious violence 
  • the level of violence tells us nothing about the risk of recidivism
  • most are already known to the civic mental health system.

Since recidivism rates are lower than those seen for people being released from prison, the review boards seem to be doing a good job.

It is not helpful to have mentally ill people in jail where they have limited access to proper treatment and supports.

Did you create a narcissist?

All parents have likely had those moments when looking at their child they see limitless potential and are amazed at the talent and wonder before them.

Parental pride surges and gushes out to the budding artist/writer/scientist/mathematician/genius.

A study conducted jointly by researchers at Ohio State University and the University of Amsterdam in the Netherlands and published in Proceedings of the National Academy of Sciences suggests parents who overvalue their kids may risk creating narcissists.

The study surveyed 565 children aged 7-11 from middle-class neighbourhoods in the Netherlands and their parents over an 18-month period to see if they could identify factors causing kids to have inflated views of themselves.

Researchers found parents who overvalued their kids did end up with children who displayed narcissistic tendencies.

The study differentiated between overvaluing (reflected in statements such as “my child is more special than other children”) and parental warmth or encouragement (reflected in statements such as “I let my child know I love him/her”).

Warmth was not associated with narcissism.

Researchers also separated narcissistic tendencies from self-esteem. Questions were designed to determine whether children had good self-esteem (believing themselves to be equal to others) or narcissism (believing themselves to be superior to others).

So what is the difference between parents who overvalue their kids and those who boost healthy self-esteem?

This could lie simply in what parents praise their kids about and how they do it.

Healthy praise is appropriate to a situation and based on behaviour or results. For example – when a child does well on a test at school, parents would praise the child on his or her effort and hard work to earn a good mark.

Overvaluing parents may put too much emphasis on the child’s intrinsic qualities – telling a child they did well because they are inherently smart or talented.

Because children believe what their parents tell them, this kind of statement can teach a chid to expect good results regardless of effort and this can lead to big disappointment later in life when they inevitably learn the error of this assumption.

Of course, it is important for parents to praise and support their children, but praise should be realistic.

When children do well, praise effort and persistence rather than making children feel as though their accomplishments are entitled or inevitable.

It is also helpful for parents to teach children that everyone has strengths and weaknesses and that they are loved for both.

While narcissists believe they are superior, this belief is usually not helpful for them.

When they fail or are not universally admired throughout life, narcissists can lash out. They tend to have difficulties with relationships and are at increased risk for addictions and other mental health problems later in life.

This is early research and more will need to be done to examine children and parenting in other socio-economic settings before conclusions can be made decisively, but this study certainly suggests parenting plays a role in the development of narcissism.

Genetics are likely to also play a role – meaning some people have a higher tendency toward narcissism and may be more susceptible to developing this personality trait regardless of parenting.

In these instances, healthy praise from parents could still be helpful but may not prevent narcissism.

A plan to save billions

Universal drug plan would save billions

As the year draws to a close, I like to think about resolutions that could make our health-care system better.

One idea that has come up a few times in recent years and which I believe deserves a closer look is a national drug plan.

You may remember the claim from UBC researchers last year that Canada would save billions of dollars if we instituted a national drug plan.

A report was published in the Canadian Medical Association Journal making this assertion and it rightly attracted a lot of attention and conversation across the country.

For years some groups and political parties have advocated for universal drug coverage while others have decried the idea saying it would be prohibitively expensive to administer.

Canadians are proud of our universal health care system in which everyone can visit a doctor or have a hospital stay without personal cost or private insurance.

A drug plan is an extension of this idea – where every Canadian would be covered for medically necessary medications regardless of employment insurance or income.

We are the only developed country with universal health care that does not have a drug plan like this.

Although it sounds like a very expensive prospect, the current research showed a national drug program would likely cost government approximately $1 billion a year, but would save the private sector roughly $8.5 billion a year spent on prescription drugs often through employee drug plans.

Savings would occur through economies of scale – the government, as a large purchaser, would save about 10 per cent through better generic prices, 10 per cent on brand name prices and another 10 per cent by encouraging more cost-effective prescribing.

If Canada managed spending comparable to countries like Switzerland, Italy or Spain and got rates of generic drug use seen in some provincial drug plans, a universal public drug plan would reduce total spending on prescription drugs by $7.3 billion per year.

One in 10 Canadians find medication costs prohibitive. Many Canadians avoid treatments or skip dosages to have their medicine last longer and save money.

Some choose life-saving medicine over food in their budgeting.

Pharmacare does not cover many medications, particularly newer ones that tend to be more expensive. Physicians have to spend valuable time applying for special authority to try to get these medications covered, often unsuccessfully.

This is happening today in our country and is not acceptable. I think most Canadians want to live somewhere that affords everyone the basic right to health and dignity.

Not only would we save money directly through prescription drug costs with a universal drug plan, but we would also save unnecessary acute health care costs.

People would be more likely to take medications as recommended and would likely avoid many hospital stays and emergencies resulting from unmanaged conditions and health complications.

Right now every province manages its own healthcare dollars. For a national drug plan to work, we would need cooperation between provinces and some direction at a federal level.

This may sound daunting, but I believe it is possible if we balance individual interests with the benefit a plan such as this would give to all Canadians.

I encourage everyone to become an advocate. Change doesn’t happen unless we make it happen.

Contact your provincial and federal representatives today. We can have a country with healthcare that is truly accessible for all.

Help for anorexia

Deep brain stimulation and anorexia

In the past year or so, there has been some media attention surrounding research using deep brain stimulation as an experimental treatment for the eating disorder anorexia nervosa.

As you likely know, anorexia nervosa is a challenging condition causing sufferers to have a distorted perception of their body and an unhealthy obsession with being thin.

This results in individuals starving themselves and refusing to maintain a normal body weight.

These behaviours seem often to be tied to a person’s desire to control an area of life when anxiety or emotional symptoms feel overwhelming.

Anorexia affects many more females than males. It often begins in adolescence and tends to have a chronic trajectory – leading to hospital stays, serious health effects and sometimes death by starvation.

Anorexia can be difficult to treat. One of the biggest barriers to treatment is unwillingness by patients. Often, patients are brought in for treatment by worried parents who can’t stand to watch their child wasting away.

When the patient does not believe they have a problem and is not motivated to receive help, treatment can be nearly impossible.

Many treatments have been used to manage this condition. Various forms of talk therapy and some antidepressant medications have been used with different degrees of success.

Unfortunately, the disease can be difficult to manage even in willing patients and not everyone responds well to treatments. For this reason, it is exciting to see new options being developed.

Deep brain stimulation is a process in which doctors surgically implant electrodes in certain areas of the brain and then deliver electric stimulation through a device similar to a pacemaker.

The stimulation encourages activity in these areas of the brain.

Deep brain stimulation has been investigated in the past few years for several conditions including depression, Parkinson’s disease, Alzheimer’s disease and epilepsy with some promising early results.

I have written on studies of this kind of deep brain stimulation for treatment resistant depression.

Research out of Toronto is getting some media attention. This group found that anorexic patients receiving deep brain stimulation for six months saw significant improvement in co-morbid mood and anxiety symptoms.

These improvements lasted for a further six months after treatment and resulted in weight gain.

Researchers believe the study confirms the physical and emotional symptoms in anorexia are inextricably linked. It will be interesting to see what future studies of this kind will show.

In the meantime, if you or a loved one are struggling with an eating disorder, it is important to seek help from an experienced professional.

Talk to your doctor to learn about local resources and options.

More States of Mind articles

About the Author

Paul Latimer has over 25 years experience in clinical practice, research, and administration.

After obtaining his medical degree from Queen's University in Kingston, Ontario, he did psychiatric training at Queen's, Oxford and Temple Universities. After his residency he did a doctorate in medical science at McMaster University where he was also a Medical Research Council of Canada Scholar.

Since 1983 he has been practicing psychiatry in Kelowna, BC, where he has held many administrative positions and conducted numerous clinical trials.

He has published many scientific papers and one book on the psychophysiology of the functional bowel disorders.

He is an avid photographer, skier and outdoorsman.

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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet does not warrant the contents.

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