Forensic Psychiatry Angel M RodriguezChevres M D OTR

Forensic Psychiatry

Angel M. Rodriguez-Chevres M. D. OTR Chief Medical Officer for Emergence Health Network 1

Letter Of Presentation ü Chief Medical Officer - Emergence Health Network ü Medical Director Providence Hospital Geriatric Behavioral Unit ü Qualified Intellectual Developmental Disabilities Professional (QIDDP) ü Consultant/Speaker on Psychopharmacological and Psychotherapeutic Management ü Local, Regional, and National Speaker/Consultant on Issues of Human Development (Child/Adolescent and Adult) ü Registered Occupational Therapist 2

Certifications üSpecialty: Board Certified American Board of Psychiatry and Neurology üSubspecialties: – Forensic Psychiatry – Adolescent Psychiatry –Manage Care Medicine 3

Forensics ü Scientific tests or techniques used in a connection with the detection of crime (or a civil matter!? ) 4

Forensic Psychiatry ü Subspecialty of psychiatry related to criminology and/or any issues that interface psychiatry and the law 5

Correctional Psychiatry ü A subspecialty of Forensic Psychiatry that evolved from the need to provide treatment for the criminal offender with Mental Illness ü Special population: ü Correctional professionals must understand be trained on the unique nature of this population and the environment where they are treated 6

Correctional Psychiatry Rate of Incarceration – Six hundred and ninety eight (698) inmates per 100, 000 (one in every 140 U. S. residents are incarcerated in Federal State Prisons and local jails). – There are 2. 3 million of inmates in the U. S. • U. S. has the highest rates of incarcerated in the World.

Mental Illness and Incarceration – 20% in country jails. – 15% in State prisons. – There approximately 356, 000 inmates with Severe Mental Illness (SMI) in jail and prisons in the U. S. • Ten times more than State Psychiatric Hospitals • 31% refuse to participate.

Substance used involved estimated population of 1. 9 million. – Most commonly ALCOHOL. – Only 11% receive treatment.

The Factors – Changes in civil commitment laws have added more significant criteria based on dangerousness rather than Mental Illness itself, have resulted in shorter and fewer involuntary hospitalizations. (Deinstitutionalization) – Manage care have significantly affected the amount of time that these patients spend in inpatient units resulting in a large number of mentally ill individuals been left in the community, unwilling or unable to pursue outpatient treatment, Increase the likelihood of reoffending and being incarcerated.

Inmates with Mental illness in general have difficulties understanding and following rules and regulations. They tend to commit more violations, spend more time segregated and less likely to be granted early release; parole or probation.

U. S. inmates are the only groups that have a constitutionally recognized right to healthcare. – Landmark care-Supreme court (1976)-Estelle us Gamble – 8 th amendment –Cruel and unusual punishment.

The correctional provider: Challenges – Correctional (security) officers are in charge and form the basis of a correctional facility. – There might be a lack of understanding of Mental illness, may become harsh and unsympathetic towards patients, viewing the attitude of mental health staff as lenient and inexperienced.

The Solution? ? The incorporating of officers into the treatment team, which results increase-disciplinary consultation, assistance in security decisions, it improved staff moral.

Case example #1 Bipolar 1 patient who is intrusive, overtalkative, challenging and aggressive as well as oppositional and defiant. Pressured of speech, will not allow others to state their part- is seen as obnoxious and manipulative.

Case #2 • The basic tenets of Doctor patients relationships, such as confidentiality are compromised by the correctional environment. • Psychiatrist is expected to conduct a unit/ evaluation in a setting in which there are other inmates as well as guards in the proximity.

Case #3 Often times, patients given their defensiveness might refuse Psychiatric treatment and are left to their desire, while they might be in deplorable conditions with delusional thinking leading their non-compliance. A mechanism against their will be in place, or perhaps not.

38 year old male refuses medication as well nutrition and is left in isolation without treatment, although he is encourage by staff to take his medications and eat. • Upon, psychiatric assessment it was discovered that the patient was having delusions in which he had the believe he was made out of titanium and did not need to do any of that. To top it all he sewed his lips shot, so he wouldn’t be forced to do any of it. • This case was finally referred to the Psychiatrist because he also started cutting on self, since the more blood he lost the more the titanium he would posses.

Suicide: The suicide at correctional facilities is five times that of the general population. Patients are likely to kill themselves in the 1 st 24 hours of detention and victims are usually young men arrested for nonviolent offenses, often times intoxicated. – The typical method is hanging. – Suicide ranks as the 3 rd cause of death after natural causes of AIDS (in prisons and jails).

Case #4 28 year old male denied death wishes or suicidal ideations upon being detained. The next morning he had to be stopped from hanging in his cell with a bed sheet.

The Environment • Temperature and medications (Hydration) • Lack of Privacy/Confidentiality – Rules and Protocols • Scheduling of medications • Sleep medications to be given at 4: 00 pm? ? – The pharmacy formulary • Limited, with a cumbersome process to obtain exceptions- (overrides) • Challenges of patients commonly back from state hospitals. Stabilize after, years on medications that might not be available once they get to jail.

APA- Statement on Psychiatric services in Jails and prisons. • Systematic screening/evaluation program to identify inmates who require mental health treatment • Treatment that goes beyond merely segregating the mentally ill inmate and increasing correctional supervision • Treatment by a sufficient number of trained mental health professionals to identify and treat inmates with serious mental illness • Maintenance of accurate, complete, and confidential records of the mental health treatment process • Suicide prevention program • Appropriate use of psychotropic medication (prescription/monitoring by appropriate trained/licensed staff to treat actual mental disorders rather than solely as a means of behavior management).

Components of psychiatric screening and evaluation of inmates include the following: • Review of accompanying mental health information received from the county jail or arresting/transporting officer • A self-reported history of psychiatric treatment (eg, hospitalization, medications, outpatient counseling) • Current or prior suicidal thoughts/attempts • Intellectual functioning • History of violence and/or victimization • Brief mental status examination “The challenge is how to provide the same treatment you would provide on the outside in an environment that was never designed to treat mental illness

Mental Capacity Act 2005 WHAT IS MENTAL CAPACITY? ü ‘Mental capacity’ means being able to make your own decisions. Someone lacking capacity – because of an illness or disability such as a mental health problem, dementia or a learning disability – cannot do one or more of the following four things: ü Understand information given to them about a particular decision ü Retain that information long enough to be able to make the decision ü Weigh up the information available to make the decision ü Communicate their decision. 10

Who Decides Whether A Person Is Incompetent? The Judge must be persuaded by clear and convincing evidence that the person’s everyday decision making ability is severely impaired and that there is no other alternative to appointing a guardian. Certificate of Medical Examination - (CME) must be provided. 11

Competency vs Capacity ü The experts attest to capacity ü Competency is a decision of the courts 12

Competence DEFINITIONS ü Competency – In the United States law. Competence concerns the mental capacity of an individual to participate in legal proceedings or transactions, and the mental condition a person must have to be responsible for his/her decision or acts ü Competence is an attribute that is decision specific. 13

Competence in General ü Depending on various factors which typically revolve around mental function integrity, an individual may or may not be competent to make a particular medical decision, a particular contractual agreement, to execute an effective deed to real property, or to execute a will having certain terms. Example: Competency to Stand Trial: As determined in Dusky v. United States, is whether the accused (U. S Standard (Texas))"has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and whether he has a rational as well as factual understanding of the proceedings against him. " 14

Competency Requirements ü Requires the mental capacity to reason and deliberate ü Appreciate values and goals ü Appreciate circumstances ü Understand the information given ü Continues quality that may be present or to a greater or lesser degree (proportionality) ü The capacity required for legal competence issues with services of what is at stake ü Legal competence can not be to a lesser or greater extend 15

General Competencies ü ü ü ü To make medical decisions To make a Will To marry To make financial decisions To parent To enter into contract The courts might assign a person, agency, guardian ad litem, to make each decision: Temporary or Permanently 16

What Is Incompetency? ü Mental incompetency; generally, it means that a person has impaired or very limited ability to remember, to reason to see the consequences of actions, and to plan for the future. In law, it means that the person I unable to make legally binding decisions. 17

Certificate of Medical Examination General VS Mental ü General ü Attests to the person’s capacity to make their own decision in different matters. ü Mental ü It is specific for mental health conditions. It requires a probable cause hearing, can not be authorized by a power of attorney only a judge can do this. 18

What About Mental Disorders? A person’s mental illness or mental disorder does not automatically mean that the person is mentally incompetent. Many people who have mental illness can still make good decisions for themselves. Some people with I. D. D. have the capacity to make decisions and to handle their own money. Mental condition as a result as a neurochemical imbalance. 20

Competency Evaluation üCapacity to stand trial üDiminished Capacity 27

Competency Evaluation ü Essential elements ü Disclaimers ü Confidentiality Statement ü Defendants Concerns (Chief Complaint) ü Defendants recollection of the events a the time of the alleged crime-Insanity ü Active Psychiatric Diagnosis and treatment ü History 28

Competency Evaluation üMental status üDefendants understanding of court procedures üDiagnosis or Mental Illness + Intellectual Developmental Disorder üPrognosis – to include likelihood of retaining competency in the future üLikelihood of regaining competency 29

Competency to Stand Trial ü Standard – Article 46 B. 003 ü A person is Incompetent to Stand Trial if the person does not have: ü Sufficient present ability to consult with the person’s Lawyer with a reasonable degree of rational understanding or ü A rational, as well as factual understanding of the proceedings against the person. ü A defendant is presumed competent to stand trial, and will be found competent to stand trial unless proved incompetent by a preponderance of the evidence. 30

The Right to Refuse Treatment ü Forced medications ü Justifications-need for its use ü Type of medications ü Reasons for refusal ü Treatment alternatives 31

Insanity – Criminal Responsibilities üA person is considered to be sane, unless proven not to be beyond and reasonable doubt üA person is considered to be not criminally responsible if by Deficit of the Mind, could not understand that his actions were wrong, at the time of the alleged crime 32

NGRI ü NOT GUILTY BY REASON OF INSANITY 33

Risk Assessment and Sentencing ü Likelihood of a person re-offending ü Sexual Offender ü Violent Offender 34

El Paso (EHN) Correctional Experience 1. Jail MH Clinic through EHN was opened/started providing services November 2014. 2. Services through the Jail MH Clinic include: A. B. C. D. E. F. G. H. I. Intake Assessments Psychiatric Evaluation and Follow Up Appointments Medication Management Individual and Group Therapy Crisis Intervention Case Management Skills Training/Life Skills Psycho-Social Education Discharge Assessment and Referrals Upon Release

3. State Hospital Admissions: 97 4. State Hospital Discharges: 84 5. Diversion Division Referrals from Jail Releasing: This number/ information is unknown as we do not have the capability to capture/collect recidivism rates at this time. 6. Diversion Division Program Census: A. TCOOMMI Monthly Average Census: 325 B. OCR Monthly Average Census: 24 7. We work consistently with CIT to divert individuals who are inappropriate for the jail setting, to begin with; I am in talks with EP county regarding pre-diversion interventions and looking at the general flow and system of practice within each entity that impacts this flow.

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