civil commitment and criminality

Weisman, Sahgal & Sharma (2007)Weisman, Sahgal & Sharma (2007)

CIVIL COMMITMENT AND CIVIL COMMITMENT AND CRIMINALITYCRIMINALITY

THE FINE LINE BETWEEN INPATIENT TREATMENT FOR THE FINE LINE BETWEEN INPATIENT TREATMENT FOR DANGEROUSNESS AND CRIMINALITYDANGEROUSNESS AND CRIMINALITY

Adam M. Weisman, Ph.D., Sanjay M. Sahgal, MD and Kaushal K. Sharma, MDAdam M. Weisman, Ph.D., Sanjay M. Sahgal, MD and Kaushal K. Sharma, MDUSC Institute of Psychiatry, Law and Behavioral ScienceUSC Institute of Psychiatry, Law and Behavioral Science


Civil Commitment in CaliforniaCivil Commitment in California

• Lanterman-Petris-Short Act (LPS): Lanterman-Petris-Short Act (LPS): Involuntary commitment statute for Involuntary commitment statute for indeterminate commitmentindeterminate commitment

• Three key time periodsThree key time periods– Initial 72-hour hold for observation & Initial 72-hour hold for observation &

treatmenttreatment– Additional 14-day hold, following certification, Additional 14-day hold, following certification,

to allow intensive treatmentto allow intensive treatment– Additional 180-day hold (danger to others) for Additional 180-day hold (danger to others) for

additional treatment; conservatorship optionadditional treatment; conservatorship option


Involuntary AdmissionInvoluntary Admission

• Criteria for 72-hour hold: probable causeCriteria for 72-hour hold: probable cause– A danger to othersA danger to others– A danger to himself or herselfA danger to himself or herself– Grave disability (unable to provide for basic Grave disability (unable to provide for basic

personal needs than endangers self) without personal needs than endangers self) without intent of harmintent of harm

• Criteria for 14-day hold (review hearing)Criteria for 14-day hold (review hearing)– Danger to self, others or gravely disabledDanger to self, others or gravely disabled


Danger to OthersDanger to Others

• Dangerousness and Mental IllnessDangerousness and Mental Illness– Threats or Acts: Historical ContextThreats or Acts: Historical Context– Clear and Present Danger: Imminent Threat Clear and Present Danger: Imminent Threat – Pre-hold violence: Hold and Release to PolicePre-hold violence: Hold and Release to Police– Post-hold violence: Facility OptionsPost-hold violence: Facility Options

• Release to jail forensic unit for prosecutionRelease to jail forensic unit for prosecution

• Hold for extended commitment without prosecutionHold for extended commitment without prosecution

• Extended commitment then prosecutionExtended commitment then prosecution


Inpatient Facility OptionsInpatient Facility Options

• Public Facility (state hospital)Public Facility (state hospital)– MedicationMedication– Seclusion and/or RestraintSeclusion and/or Restraint– Intensive treatmentIntensive treatment– Extended CommitmentExtended Commitment

• Private Facility (private hospital)Private Facility (private hospital)– Seclusion and/or RestraintSeclusion and/or Restraint– Discharge to Law EnforcementDischarge to Law Enforcement


Research QuestionsResearch Questions

• Is a person legally culpable for violent acts Is a person legally culpable for violent acts when civilly committed for dangerousness when civilly committed for dangerousness to others?to others?

• To what degree do such violent acts To what degree do such violent acts represent a treatment and containment represent a treatment and containment responsibility on the part of the psychiatric responsibility on the part of the psychiatric inpatient facility?inpatient facility?


Case PresentationsCase Presentations

• Two cases presented of violence within Two cases presented of violence within private psychiatric facilityprivate psychiatric facility– Violence toward other patientViolence toward other patient– Violence toward treating staffViolence toward treating staff

• Cases referred for criminal prosecutionCases referred for criminal prosecution

• Forensic evaluations for defense counsel Forensic evaluations for defense counsel


Case A: Flashing LightsCase A: Flashing Lights

• 29-y-o, single, disabled (SSI), Hispanic male29-y-o, single, disabled (SSI), Hispanic male

• 6/30/05: self-admitted for suicidal ideation6/30/05: self-admitted for suicidal ideation

• 7/3/05: assaults male patient in med line for 7/3/05: assaults male patient in med line for causing “flickering lights” in bedroomcausing “flickering lights” in bedroom

• Victim: facial lacerations & cranial contusions; Victim: facial lacerations & cranial contusions; treated & released back to psychiatric unittreated & released back to psychiatric unit

• Defendant: seclusion & release to police on Defendant: seclusion & release to police on 7/6/05 (liability issues?)7/6/05 (liability issues?)


Family HistoryFamily History

• Born in Los Angeles, parents & siblings (1 Born in Los Angeles, parents & siblings (1 brother, 2 sisters) gainfully employedbrother, 2 sisters) gainfully employed– Family criminal history (father, brother-DUI)Family criminal history (father, brother-DUI)– Family substance use history (father, brother-Family substance use history (father, brother-

alcohol, cannabis, cocaine)alcohol, cannabis, cocaine)– Family psychiatric history (aunt/uncle-Family psychiatric history (aunt/uncle-

psychoses, depression)psychoses, depression)– Child abuse history (mother-stabbing; Child abuse history (mother-stabbing;

brother-fondling)brother-fondling)


Background HistoryBackground History

• Education: 8Education: 8thth grade; GED 1994 grade; GED 1994

• Lifestyle: transientLifestyle: transient– 1998-1999 in Seattle with sister; fish 1998-1999 in Seattle with sister; fish

processor, warehouse workprocessor, warehouse work– 2002: board & care homes < 2 years; SSI2002: board & care homes < 2 years; SSI– 2005: living on own with parental assistance; 2005: living on own with parental assistance;

self-payeeself-payee



• Medical History: 1995 drive-by shooting, Medical History: 1995 drive-by shooting, stomach & left hip surgerystomach & left hip surgery

• Substance Use HistorySubstance Use History– Cannabis & Cocaine: age 14-15 to 1999Cannabis & Cocaine: age 14-15 to 1999– Beer: age 12 to 2005Beer: age 12 to 2005– Rehabilitation programs: 2002-2004: 3 Rehabilitation programs: 2002-2004: 3

programsprograms


Criminal HistoryCriminal History

• Juvenile: vandalism, receiving stolen Juvenile: vandalism, receiving stolen property, assault, grand theft personproperty, assault, grand theft person

• Adult: second-degree robbery, inmate Adult: second-degree robbery, inmate assault (stabbing), cocaine possession, assault (stabbing), cocaine possession, battery (father)battery (father)– 1999-2002: Dangerous Mentally-Ill Offender 1999-2002: Dangerous Mentally-Ill Offender

(2684 PC), parole hold at Atascadero (2684 PC), parole hold at Atascadero


Psychiatric HistoryPsychiatric History

• Juvenile: outpatient family therapy, no medicationsJuvenile: outpatient family therapy, no medications• AdultAdult

– 1997: Prison; paranoia toward cellmate & guards1997: Prison; paranoia toward cellmate & guards• Belief: being hypnotized or poisonedBelief: being hypnotized or poisoned• Dx: paranoid schizophrenia; enhanced outpatient (EOP)Dx: paranoid schizophrenia; enhanced outpatient (EOP)

– 1999: Prison1999: Prison• Belief: raped in his sleep; hypnotized by guardsBelief: raped in his sleep; hypnotized by guards

– Suicide attempt (hanging): moved to AtascaderoSuicide attempt (hanging): moved to Atascadero• Dx: schizoaffective disorderDx: schizoaffective disorder

– Rx: Loxitane, Remeron & ZyprexaRx: Loxitane, Remeron & Zyprexa– 2000: Region III Parole Outpatient Clinic: follow-up 5 months2000: Region III Parole Outpatient Clinic: follow-up 5 months– 2001: Prison; suicide attempt (wrist cutting)2001: Prison; suicide attempt (wrist cutting)

• Belief: girlfriend murdered & he was a suspect; raped in his sleep, others Belief: girlfriend murdered & he was a suspect; raped in his sleep, others could read his thoughtscould read his thoughts

– Moved to Atascadero as dangerous mentally ill offender, held until 2002Moved to Atascadero as dangerous mentally ill offender, held until 2002


Psychiatric History continuedPsychiatric History continued

• 2002: three outpatient mental health 2002: three outpatient mental health centerscenters

• 2003: suicidal attempt (pills)2003: suicidal attempt (pills)

• 2003-2005: treatment noncompliance, 2003-2005: treatment noncompliance, decompensation, hospitalizationdecompensation, hospitalization– High Utilization Patient (> 10 involuntary High Utilization Patient (> 10 involuntary

hospitalizations)hospitalizations)


Preoffense EventsPreoffense Events

• Proceeding EventsProceeding Events– 1/7/05: Crime Scene hospital-danger to others 1/7/05: Crime Scene hospital-danger to others

(roommate) with delusion of sexual assault, released (roommate) with delusion of sexual assault, released with medicationswith medications

– 4/18/05: found in El Paso, Texas in underwear4/18/05: found in El Paso, Texas in underwear• refused medication & returned to Californiarefused medication & returned to California

• 5/17/05: crime scene hospital-danger to self: released with 5/17/05: crime scene hospital-danger to self: released with Zyprexa & EffexorZyprexa & Effexor

• 6/13/05: danger to others & self (hanging, wrist cutting)6/13/05: danger to others & self (hanging, wrist cutting)

• 6/14/05: released to area hospital until 6/20/05 with follow-6/14/05: released to area hospital until 6/20/05 with follow-up appointment scheduled for 6/28/05 at mental health up appointment scheduled for 6/28/05 at mental health centercenter


DispositionDisposition

• Charge: Assault with deadly weaponCharge: Assault with deadly weapon

• 10/10/05: Forensic report issued10/10/05: Forensic report issued

• 07/31/06: No contest plea07/31/06: No contest plea

• 11/6/06: Four year state prison, 753 days 11/6/06: Four year state prison, 753 days credit; term suspended. Formal probation credit; term suspended. Formal probation 3 years, $200 restitution; locked forensic 3 years, $200 restitution; locked forensic inpatient facility for probationinpatient facility for probation


Case B: A Nurse’s NightmareCase B: A Nurse’s Nightmare

• 19-year old male19-year old male

• Emergency Room: disorganized thoughts, Emergency Room: disorganized thoughts, persecutory delusions > 2 weekspersecutory delusions > 2 weeks

• No mental health historyNo mental health history

• No medical historyNo medical history

• No drug historyNo drug history

• No criminal historyNo criminal history



• Danger to others: threatening parents for Danger to others: threatening parents for “harassing him” and he would “get them “harassing him” and he would “get them soon!”soon!”

• Nurse administers Haldol, Ativan & Nurse administers Haldol, Ativan & Benadryl for agitation during processingBenadryl for agitation during processing

• During injection, subject hits nurse in faceDuring injection, subject hits nurse in face

• Nurse: bruised but continues work shiftNurse: bruised but continues work shift



• Nurse & supervisor calls policeNurse & supervisor calls police

• Subject charged with assault, held 72 Subject charged with assault, held 72 hours and then sent to jailhours and then sent to jail

• Jail: Risperdal and general population Jail: Risperdal and general population modulemodule

• Subject assaulted by other inmates, Subject assaulted by other inmates, moved to psychiatric modulemoved to psychiatric module



• Adjudicated as incompetent to stand trial Adjudicated as incompetent to stand trial (1368 P.C.)(1368 P.C.)

• Sent to Patton State Hospital; status Sent to Patton State Hospital; status pendingpending

• Review of hospital records: labor dispute Review of hospital records: labor dispute among nurses due to understaffing; case among nurses due to understaffing; case used as negotiation ployused as negotiation ploy


SummarySummary

• Dangerousness to self or others can include Dangerousness to self or others can include fellow patients and support staff after admissionfellow patients and support staff after admission

• Complete social history is essential in managing Complete social history is essential in managing such patientssuch patients

• Forensic evaluations: Durham (product) Rule Forensic evaluations: Durham (product) Rule (New Hampshire) or GBMI is helpful in (New Hampshire) or GBMI is helpful in addressing disposition “not criminally responsible addressing disposition “not criminally responsible if unlawful act is the product of a mental disease if unlawful act is the product of a mental disease or defect”or defect”

• Liability and labor issues influence criminal Liability and labor issues influence criminal prosecutionprosecution

civil commitment and criminality

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