Forensic Patients Deserve Treatment—And Our Advocacy

"I thought you wanted to help people," my brother said when I told him I was applying for a fellowship in forensic psychiatry. I was too incredulous to respond and shrugged off the comment with a sigh of despondence. Nonetheless, the comment reverberated through my thoughts long after the short conversation.

Although my sibling has little knowledge of what a forensic psychiatrist does, his statement aroused many feelings and questions about my future career choice.

The following week, I was perusing books in the library at the Center for Forensic Psychiatry and found several titles that depict forensic psychiatry as evil. I couldn’t believe entire books had been written warning the public of forensic psychiatry’s contribution to the decline of Western civilization! Perhaps I was being misled by my naiveté. I saw a career in forensic psychiatry as a journey along the dynamic interface of psychiatry, the law, and the forces of politics and economics. But was my academic view of the profession obscuring the obvious? Was I about to become a "gun for hire"?

Being a doctor, I of course went to the literature. I found, for example, that the length of stay of NGRI (not guilty by reason of insanity) acquittees is most closely related to the severity of the crime they committed. This was intuitively reassuring. In addition, I found several studies comparing the length of stay of forensic patients with the length of incarceration for defendants found guilty of similar offenses. There was some inconsistency. Some of the studies showed equal lengths of institutionalization for the two groups. Others found longer lengths of stay for either the acquittees or the guilty, but there clearly was no consensus. It appeared that being committed to a forensic hospital wasn’t necessarily going to provide quicker freedom for the perpetrator. Finally, I looked at the data for Michigan’s Center for Forensic Psychiatry. Under 1 percent of the evaluations for criminal responsibility recommended the defendant not be held responsible. It became clear to me that a plea of NGRI was very well scrutinized.

Nonetheless, I couldn’t escape the echoes of my brother’s comment. Assuring myself of the integrity of forensic psychiatry wasn’t enough. As a doctor and a psychiatrist, I still had the somewhat narcissistic desire to "help people." Clearly, treating the mentally ill rather than incarcerating them for acts committed without an "appreciation of wrongfulness" is helpful to that person. It is also easy to extrapolate that providing good psychiatric care will decrease the likelihood that a person will commit another criminal offense. Therefore, discriminating between the truly mentally ill person and the malingerer is helpful to all of society.

But what really convinced me that I could help people through forensic psychiatry was much more basic than that. It went back to why I entered psychiatry in the first place.

One of the most disturbing things to witness is the suffering of another human being. Early in medical school, the pain that psychosis caused its victims moved me. The demons and voices that psychotic patients perceive are horrifying. Listening to the voice of your mother telling you how evil you are or feeling the relentless pursuit of an assassin is, I’m sure, pure torture. It is a pain that is often alleviated by lethal means and that in our penal system often goes untreated. Yet it is a pain that good psychiatric care can usually diminish.

The patients who end up in a forensic psychiatric facility are, in some ways, the lucky ones. They receive treatment for their torturous pain.

But in prison, where psychoses among inmates are not rare, appropriate treatment is not often provided. Those who are quietly psychotic, but no less tortured, often lack the cognition needed to access the treatment they deserve. They are unable to negotiate the legal system appropriately and therefore are ignored. They sometimes spend their entire lives being ravaged by their demons in a cold prison cell. Long forgotten and making little trouble for correctional officers, they are sentenced to a terrified life behind bars.

It is easy to dismiss this population as "deserving" their sentence. After all, they likely committed a criminal act to get where they are. And their illness may not have played a part in their crime. To allow their psychosis to go untreated, however, is not only unconstitutional, but also morally unjust.

As a result of this situation, I find myself advocating for those who cannot advocate for themselves. I’ve reasoned myself into the corner of murderers, rapists, and thieves. Nevertheless, it is still a corner inhabited by humans—humans who need help.