Friday, June 17, 2011

Budgets, Crime and What Happened to Stephanie

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

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

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

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

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

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

My second reaction is in response to this quote:

"The first time Mr. Chappell secured a state hospital bed — and the treatment that comes with it — was when he ended up behind bars."
And the observation by Chappell's mother:
"In 2007, Mr. Chappell, sentenced to a year in jail but required to serve only three months, ended up at the prison psychiatric hospital. When his mother visited him there, she said, she was heartened to see the effects of an enforced medication regimen. “This was the son I raised,” she said. “He talked about going back to school and getting a college degree.”
I'm going to link back to those quotes the next time I hear somebody comment that "locking people up doesn't do any good." There are some people---fortunately relatively few---who can only be treated in a secure environment because they are just too repetitively assaultive to be treated anywhere else. That's what forensic hospitals and prisons are for.


jesse said...
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jesse said...

So let's say that Chappell is eventually judged able to be tried, is it the case that at the trial he would be judged to 1) actually have or have not committed the act, and 2) if he committed it, he was or was not responsible for his acts because of his mental state? Two different things. If this were not the case would it not be conceivable that he would be released as innocent and then be free to go off his medication again, with predictable results?

Here is a man who is dangerous dangerous but if the crime cannot be proved he would be released, as anyone else would be. The mental illness is relevant only if he committted a crime, which is why he was released (more than likely) when the homeless man failed to show for the trial.

Do I have this right, Clink?

rob lindeman said...

"The news story also suggested that he knew he was committing a crime: he got rid of the body, disposed of the car and changed out of his bloody clothes."

The only way to show true compassion toward Deshawn Chappell, and to respect his humanity, is to acknowledge that he possesses free will, to try him in court, and if he is found guilty, to punish him

ClinkShrink said...

Jesse: Yes, you have it right. Many cases I see are ones in which there is pretty strong evidence that the defendant committed the crime. When there is less strong evidence sometimes lawyers are reluctant to file an insanity plea because there is no telling what could be uncovered during a pretrial evaluation: personal information that could be prejudicial, past offenses that wouldn't otherwise come out during a trial, etc. It's a gamble.

ClinkShrink said...

Rob: A fair amount of my prison work involves reminding my patients that they are still responsible for their behavior even though they have a psychiatric diagnosis.

Anonymous said...

So, with his repetitive history of violent acts against others, no psychiatrist in Massachusetts believed him to be a danger to others?

Meanwhile, they are locking up people who have suicidal thoughts and haven't ever hurt a flea.

What a screwed up system.


jesse said...

from the NY State Office of Mental Health: :An Explanation of Kendra’s Law

November 1999
Revised May 2006

In 1999, New York State Enacted Legislation that provides for assisted outpatient treatment for certain people with mental illness who, in view of their treatment history and present circumstances, are unlikely to survive safely in the community without supervision. This law is commonly referred to as “Kendra’s Law” and is set forth in §9.60 of the Mental Hygiene Law (MHL). It was named after Kendra Webdale, a young woman who died in January 1999 after being pushed in front of a New York City subway train by a person who was living in the community at the time, but was not receiving treatment for his mental illness. In 2005, the law was renewed with several changes, which are noted in this article.

Overview of Assisted Outpatient Treatment

Kendra’s Law establishes a procedure for obtaining court orders for certain individuals with mental illness to receive and accept outpatient treatment. The prescribed treatment is set forth in a written treatment plan prepared by a physician who has examined the individual. The procedure involves a hearing in which all the evidence, including testimony from the physician, and, if desired, from the person alleged to need treatment, is presented to the court. If the court determines that the individual meets the criteria for assisted outpatient treatment (“AOT”), an order is issued to the director of community services (DCS) who oversees the mental health program of a locality (i.e., the county or the City of New York mental health director).

The court orders will require the director to provide or arrange for those services described in the written treatment plan that the court finds necessary. The initial order is effective for up to 6 months and can be extended for successive periods of up to one year. The legislation also establishes a procedure for evaluation in cases where the individual fails to comply with the ordered treatment and may pose a risk of harm.

Lisa said...

ClinkShrink wrote: I'm going to link back to those quotes the next time I hear somebody comment that "locking people up doesn't do any good".

Mr. Chappell sought out assistance prior to committing his crimes signifying that he voluntarily wished to treat and medicate himself. This is not the same as forcing involuntary treatment. Furthermore, one can assume that he also voluntarily accepted treatment after he was apprehended for another crime. Locking up this individual did nothing to stop the murder of Ms. Moulton. In this case, one can conclude that locking people up doesn't do any good.

Locking up a person from a poor background with a statistically high likelihood of criminal behavior could prevent crime and be a good thing. But of course we don't do that either.

It was mentioned in the article that the model of mental health treatment has changed from one of long-term disability to one of 'recovery'. I've never understood this model of treatment. One does not 'recover' from severe mental illness. A bipolar will always be bipolar, a schizophrenic will always be schizophrenic. Why does a model of 'recovery' exist when there is apt evidence to prove that recovery and eradication of severe mental diseases isn't an option? Learning to live with symptoms is, but not recovery. Obviously isolated instances of illness exist.

Sarebear said...

It may be your conclusion that "in this case" locking someone up did no one any good, but I think that you can't say that getting locked up doesn't do some people some good.

You could say it, of course, because you can say anything, but I don't think it would be true.

ClinkShrink said...

Lisa: One of the problems I have is that after writing on this blog for five years I sometimes repeat my points so often I take it for granted that readers know what I'm talking about and don't explain myself fully. That's what happened here.

When I referred to 'locking up' Chappell I didn't mean involuntary admission or involuntary treatment. I agree with you that in this case it certainly would have been best if treatment had been available in free society, before the crime, when he wanted it voluntarily.

My comment about prison not doing any good was an (admittedly a bit snarky) response to people who dismiss correctional facilities---and correctional healthcare---as a waste of money. Some people think we shouldn't "waste" money by fixing correctional facilities because Group X (name your group: misdemeanor drug offenders, juveniles, women, people with psychiatric disorders) shouldn't be locked up anyway. It's an easy rationalization to avoid improving the system and it's a bit of a pet peeve of mine. You don't fix a problem by dismissing it. And for some people, incarceration is lifesaving.

jesse said...
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jesse said...

Re: Lisa's point about "recovery" as opposed to "learning to live with the illness," I suspect all of us psychiatrists agree with you. Is "recovery" a more politically useful term, is it reflective of the amount of time budgeted for each patient, or is it reflective of a theory that does not square with the facts today? Perhaps in the future severe mental illness will be indeed be short term.

Anonymous said...

"One does not 'recover' from severe mental illness. A bipolar will always be bipolar, a schizophrenic will always be schizophrenic."

Assuming my diagnosis of bipolar disorder was correct, I'm living, breathing proof that people can, and do recover.

Lisa said...

Ah, Clink, I get what you are saying now.

Anon, if you have 'recovered' from bipolar, meaning you are free from medications, therapies, and ALL symptoms, then you didn't have bipolar disorder to begin with and your illness was an isolated instance.

It's likely you feel well NOW and perhaps have for a few years but if you truly have bipolar disorder then it means you will experience problems from it throughout your life.

Ladyk73 said...

AOT, assertive outpatient treatment was indeed a law in response to a violent crime, however, it is used to keep people at serious risk to themselves and others. Mostly, it is used for people at risk to themselves. I like the model because it allows people to live in the community, instead of in the hospital.
Recently, there was a ruling that stated Hipaa outranked Kendra. If a client refused to sign the consent, they cannot be placed on AOT.
It is nearly impossible to get someone admitted to our state hospital. No beds, no funding. Which is another reason aot is used.

Anonymous said...

"Anon, if you have 'recovered' from bipolar, meaning you are free from medications, therapies, and ALL symptoms, then you didn't have bipolar disorder to begin with and your illness was an isolated instance."

Ahh, well, there's the rub, as Shakespeare said. Did I have bipolar disorder to begin with? A very well-respected academic phsychiatrist said I did. Repeatedly. But here I am, all these years later, sympton and drug free. Psychiatrist free too.

Anonymous said...

This using fear as a political tool to get more mental health services funded is why I don't like NAMI. They have their Stigmabusters program, but then their spin off group, Treatment Advocacy Center, plays up fears of violence, totally undoing the work of stigmabusters. I guess it is just too nuanced an argument to point out that the dangerous people with mental illness are a small subgroup? And once they have made an appeal to fear, who is going to notice the caveat, when their emotions have been heightened?

And the people with mental illness who have never been victimized are in treatment alongside the dangerous victimizers (who themselves had bad lives, but hey, they are dangerous).