Back in July, I completed a 4-week rotation near Washington, DC with a Forensic Psychiatrist in a state mental hospital. Easily the most intense psych rotation out the gate into 4th year, I was placed with a psychiatrist that had high expectations of his students, boasted a British-style intellect, and was Michael Scott (The Office) type of funny. I really enjoyed this rotation and of course living in NoVa (Northern Virginia) – a 20 minute drive from 1600 Pennsylvania – was pretty cool.
Forensic psychiatry is a specialty that straddles both the legal and medical profession. It requires adequate understanding of the evolution of the Insanity Defense coupled with careful application of psychiatric medicine. Patients that were adjudicated Not Guilty by Reason of Insanity (NGRI) were placed in a specific unit in this hospital and were subjected to ongoing inpatient treatment and restrictions. I expected these NGRI patients to be acutely psychotic, but after months of being held in the state prison and being medicated while awaiting trial, their psychosis was well-managed.
NGRI patients are a very controversial topic. Think of John Hinckley, Jr., the man with delusional thinking and erotomania regarding Jodie Foster that attempted to assassinate Ronald Reagan in the early 1980’s. He was held at St. Elizabeth’s mental hospital for 35 years and recently released to live with his mother, yes she’s old now. Many people were “sickened” by his release and demanded that he remain a ward of the state and never be allowed in polite society again. Which makes sense. He attempted murder and he is mentally ill. But what if he has completed each step of the graduated release process, thereby effectively earning his way out of the treatment facility with each step being approved by the courts?
This is what each patient was tasked with completing. Some patients take 6 months to complete the process and others will take 10+ years. It’s a process that requires that patients earn the trust of the treatment team, adhere to medication, complete daily courses about the risk factors that led to their “index offense” and learn how to deal with interpersonal conflict. Patients are provided regular counseling, access to a psychiatrist, and frequent evaluations of their insight into their index offense. Monthly treatment team meetings were held to assess how the patient was progressing through the graduated release process and how they viewed their index offense.
Here’s a mental break photo: 4th of July in DC this year. Crummy weather, no one could see the fireworks unless you were standing next to the POTUS (President of the United States).
In spite of how I initially viewed NGRI patients, as I became more familiar with the patient as a person and less as their index offense, my perspective shifted. I learned how their psychosis completely warped their world view and influenced their actions.
On my last day, the treatment team conducted a mental status examination on a patient that committed 1st degree murder. At the time, he had untreated schizoaffective disorder leading him to believe that in order to prevent something terrible from happening he was compelled to harm another person. During our interview he was remorseful and ashamed. He appreciated the wrongfulness of his actions and how his mental illness needs constant management. One of our “success” cases, he was slowly making it through the NGRI process with plans to start college and live independently with his mental illness. Outcomes like this were hard to come by, but these were arguably the most beneficial for the patient and society.
If you have any interest in psychiatry, a book that was recommended to me and is an insightful read on schizophrenia is The Center Cannot Hold by Elyn Saks.