A brief history of the criminalization of mental illness.

This article traces the history of the way in which mental disorders were viewed and treated, from before the birth of Christ to the present day. Special attention is paid to the process of deinstitutionalization in the United States and the failure to create an adequately robust community mental health system to care for the people who, in a previous era, might have experienced lifelong hospitalization. As a result, far too many people with serious mental illnesses are living in jails and prisons that are ill-suited and unprepared to meet their needs.

The psychiatrist's duty to protect.

Responding to the California Supreme Court's decision and its related legal obligations in Tarasoff v. Regents of Univ. of California over 30 years ago has become a standard part of mental health practice. This case influenced legal requirements governing therapists' duty to protect third parties in nearly every state in the country. The final ruling in Tarasoff emphasized that therapists have a duty to protect individuals who are being threatened with bodily harm by their patients. This article will provide a brief overview and update on duty to protect legal requirements. Clinical guidelines for addressing threats and the duty to protect will be discussed, along with risk management approaches. The article will conclude with a sample vignette illustrating these principles.

The Concept of Identification in Threat Assessment.

Identification is one of eight warning behaviors--superordinate patterns of accelerating risk--that are theorized to correlate with targeted violence, and have some empirical validation. It is characterized by one or more of five characteristics: pseudo-commando behavior, evidence of a warrior mentality, a close association with weapons or other military or law enforcement paraphernalia, wanting to imitate and often surmount previous attackers or assassins, or believing oneself to be an agent to advance a particular cause or belief system. The authors briefly explore the history of the psychology of identification, its current usage, and its application to threat assessment. Four cases are used to illustrate identification as both a process and a product, and a likely motive for targeted violence in some subjects. Its operational relevance for threat assessment is suggested.

The case of Anders Behring Breivik - language of a lone terrorist.

Anders Behring Breivik carried out a massacre in Norway on July 22, 2011, killing a total 77 persons and leaving 42 others severely wounded. He detonated a bomb in Oslo and then drove to the island of Utøya, where he shot and killed youngsters gathered at a youth camp. The authors performed an analysis of Breivik's writing style in his extensive manifesto which he published hours before the attacks, and also referred to the two psychiatrists' reports. The first report concluded that he suffered from paranoid schizophrenia. The authors concurred with the second report. Breivik seemed to be a person with narcissistic personality disorder, whose grandiosity might have caused him to be regarded initially as mentally deranged; however, closer examination revealed his deliberate attempt to methodically indoctrinate and deceive potential readers, to alarm potential targets and to terrorize a nation.

Balance and Change in Forensic Psychiatry.

The practice of forensic psychiatry requires balance; the forensic psychiatrist encounters the need for balance routinely and in a variety of areas. Balance is necessary for sound judgment and objectivity when striving for excellence in the field. It is also necessary to effectively balance a career in forensic psychiatry with one's personal life. The American Academy of Psychiatry and the Law (AAPL) has stressed the virtue of balance in the preamble of its ethics guidelines, noting the importance of balancing competing obligations to the individual and society. Keeping in mind the importance of balance will assist forensic psychiatry with the many challenges of a postinternet era, such as rapidly changing technology, culture, and society. A substantial challenge for forensic psychiatry, now and in the future, involves data overflow and the so-called big data explosion. Information now flows too fast and in such vast amounts that a single individual can no longer keep pace. Balance may be pursued by adapting and leveraging certain skills to confront these challenges more effectively. The current inflection point of rapid technological, social, and cultural change, stresses the importance of balance through teamwork, technology, and prioritizing civil discourse.

Suicidal ideation among inmate-patients in state prison: prevalence, reluctance to report, and treatment preferences.

This study examined the prevalence, willingness to report, and treatment preferences for suicidal ideation among state prison inmates. The Beck Scale for Suicide Ideation (BSS) and a novel questionnaire were completed by 67 inmate-patients. The BSS score was in the high range for 15% of general population (GP) and 40% of Intermediate Care Program (ICP) patients, with 19% of ICP inmates reporting a "moderate to strong" desire to commit suicide. A majority (64% GP, 86% ICP) had prior suicide attempt(s). Forty-two percent of GP and 31% of ICP inmate-patients were unlikely to tell mental health staff about suicidal thoughts. Family contact and talking with mental health staff were preferred interventions. ICP inmates preferred staff visits and observation in their own cells, but GP inmates did not. Only a small minority (14% GP, 21% ICP) favored transfer to a crisis observation cell, but the least desired option was talking to a corrections officer. While many inmate-patients reported experiencing suicidal thoughts, they preferred not to inform staff. Almost 80% did not favor the current primary intervention: the observation cell. Alternative or supplementary options should be considered.

The "Pseudocommando" mass murderer: part II, the language of revenge.

In Part I of this article, research on pseudocommandos was reviewed, and the important role that revenge fantasies play in motivating such persons to commit mass murder-suicide was discussed. Before carrying out their mass shootings, pseudocommandos may communicate some final message to the public or news media. These communications are rich sources of data about their motives and psychopathology. In Part II of this article, forensic psycholinguistic analysis is applied to clarify the primary motivations, detect the presence of mental illness, and discern important individual differences in the final communications of two recent pseudocommandos: Seung-Hui Cho (Virginia Tech) and Jiverly Wong (Binghamton, NY). Although both men committed offenses that qualify them as pseudocommandos, their final communications reveal striking differences in their psychopathology.

The "pseudocommando" mass murderer: part I, the psychology of revenge and obliteration.

The pseudocommando is a type of mass murderer who kills in public during the daytime, plans his offense well in advance, and comes prepared with a powerful arsenal of weapons. He has no escape planned and expects to be killed during the incident. Research suggests that the pseudocommando is driven by strong feelings of anger and resentment, flowing from beliefs about being persecuted or grossly mistreated. He views himself as carrying out a highly personal agenda of payback. Some mass murderers take special steps to send a final communication to the public or news media; these communications, to date, have received little detailed analysis. An offender's use of language may reveal important data about his state of mind, motivation, and psychopathology. Part I of this article reviews the research on the pseudocommando, as well as the psychology of revenge, with special attention to revenge fantasies. It is argued that revenge fantasies become the last refuge for the pseudocommando's mortally wounded self-esteem and ultimately enable him to commit mass murder-suicide.

The recurrence of an illusion: the concept of "evil" in forensic psychiatry.

The author notes an increased interest in the concept of "evil" in the fields of psychiatry and psychology. In particular, there is some interest in defining and testifying about evil. It is argued that evil can never be scientifically defined because it is an illusory moral concept, it does not exist in nature, and its origins and connotations are inextricably linked to religion and mythology. Any attempt to study violent or deviant behavior under the rubric of this term will be fraught with bias and moralistic judgments. Embracing the term "evil" into the lexicon and practice of psychiatry will contribute to the stigmatization of mental illness, diminish the credibility of forensic psychiatry, and corrupt forensic treatment efforts.

Understanding Homicide-Suicide.

Homicide-suicide is the phenomenon in which an individual kills 1 or more people and commits suicide. Research on homicide-suicide has been hampered by a lack of an accepted classification scheme and reliance on media reports. Mass murder-suicide is gaining increasing attention particularly in the United States. This article reviews the research and literature on homicide-suicide, proposing a standard classification scheme. Preventive methods are discussed and sociocultural factors explored. For a more accurate and complete understanding of homicide-suicide, it is argued that future research should use the full psychological autopsy approach, to include collateral interviews.

The Homicide-Suicide Phenomenon: Findings of Psychological Autopsies.

Homicide-suicide represents a single episode of violence which may decimate an entire family. This study aimed to further describe motives and context of these tragedies. Psychological autopsies were completed for 18 homicide-suicide cases in Dallas, Texas. This included postevent interviews with surviving family members and review of police and coroner records. Two-thirds of perpetrators had made either verbal or written threats prior to the homicide-suicide. A simplified typology describing victim-perpetrator relationship and motive type is suggested for future studies and clinical ease. Two-thirds of perpetrators fell into the category of Intimate-Possessive, most of whom were depressed men who were abusing substances and undergoing separation. Additional categories included Intimate-Ailing, Filial-Revenge, Familial-Psychotic, and Friend-Psychotic. Further, implications from this psychological autopsy study regarding risk assessment include use of collateral interviews regarding threats and past violence.

Profiling School Shooters: Automatic Text-Based Analysis.

School shooters present a challenge to both forensic psychiatry and law enforcement agencies. The relatively small number of school shooters, their various characteristics, and the lack of in-depth analysis of all of the shooters prior to the shooting add complexity to our understanding of this problem. In this short paper, we introduce a new methodology for automatically profiling school shooters. The methodology involves automatic analysis of texts and the production of several measures relevant for the identification of the shooters. Comparing texts written by 6 school shooters to 6056 texts written by a comparison group of male subjects, we found that the shooters' texts scored significantly higher on the Narcissistic Personality dimension as well as on the Humilated and Revengeful dimensions. Using a ranking/prioritization procedure, similar to the one used for the automatic identification of sexual predators, we provide support for the validity and relevance of the proposed methodology.

Treatment of the psychotic patient who is violent.

Aggression among patients with serious mental illness occurs relatively infrequently, but it is a significant concern for patients, relatives, mental health professionals, and the public. Recognition of this risk and providing access and continuity of appropriate psychiatric care should be major clinical and administrative objectives in the management of violence in psychotic patients. To date, pharmacologic approaches have been unclear and inconsistent. At present, typical antipsychotics continue to have a primary role in acute management and in long-term management, in which noncompliance necessitates the use of long-acting depot neuroleptic preparations. Atypical antipsychotics in acute and long-acting intramuscular forms doubtless will influence and expand the choice for acute management of hostile psychotic patients and the long-term management of poorly compliant patients who are at risk to become violent on relapse. Persistent aggression should be managed by atypical antipsychotics with a preferential indication for clozapine, for which the most data on efficacy are available. The role of adjunctive medications is presently unclear. A major focus of care should be to refine legal processes and to conduct intervention studies aimed at enhancing treatment compliance. Violence risk reduction is not only crucial from a societal perspective, but also it is a humanitarian necessity to alleviate the burden and stigma for patients with serious mental illness.

Open access journals and forensic publishing.

Open access (OA) publishing makes articles available over the Internet at no charge. The OA movement had its official start in 2002 with the establishment of the Budapest Open Access Initiative. The goal of the OA movement is to remove access barriers, accelerate research, and thereby achieve its broader mission of promoting global welfare. The OA movement has made swift progress over the past decade, but has introduced a disruptive change into the scientific community. The early stages of OA publishing have raised strong apprehensions, such as reliability concerns and the emergence of so-called predatory journals. The OA initiative is both inspiring and unsettling. For the discipline of forensic psychiatry, research findings must be reliable enough to be proffered as testimony in court. The methods used by OA publishing make the resolution of the reliability problem somewhat unclear. Nevertheless, given the momentum of OA publishing, a substantial change in traditional publishing appears inevitable. The discipline of forensic psychiatry must keep abreast of this change and find innovative methods of preserving the integrity of the forensic science database.

Mass murder: causes, classification, and prevention.

This article discusses common psychological and social factors in mass murders and outlines a proposed classification system to coordinate future research efforts. The final communications of two mass murderers are analyzed to demonstrate that the forensic psycholinguistic approach may assist in providing an enhanced understanding of the motives, psychopathology, and classification of mass murderers whose offenses can seem similar from a purely behavioral perspective.

Survey of forensic mental health experts on pro se competence after Indiana v. Edwards.

In Indiana v. Edwards (2008) the U.S. Supreme Court held that a higher standard may be required for pro se competence (PSC) than for competence to stand trial (CST), but provided little guidance for the trial court judge. This survey of forensic mental health experts studied potential PSC criteria. Sixty-eight (22.7%) forensic evaluators replied. Three McGarry criteria were reported as requiring a much higher standard for PSC: to appraise the available legal defenses (45.6%), to plan a legal strategy (51.5%), and to question and challenge witnesses (44.1%). Sixty percent agreed that standby counsel should be mandatory. Respondents opined that average abilities were sufficient for intelligence (77.9%), literacy (69.1%), and verbal ability (70.6%) were sufficient. PSC examiners may wish to assess appraisal of available legal defenses, planning a legal strategy, and questioning and challenging witnesses for a higher standard than CST. Evaluators should also assess the defendant's willingness to accept standby counsel (SBC) and the defendant's motivation for attempting a pro se defense.