In the first article of this series, we examined the concept of mental disorder and the overrepresentation of mentally disordered people in correctional populations. The elevated rates of mental disorders in prisoners compared with the general population might imply a causal relationship between mental disorder and crime, so in this article we are going to analyse if there really is a causal link between them with the help of empirical studies. After this we will look into the reaction of the criminal justice system to this issue. The final section will formulate some conclusions.
Relationship between mental disorder and crime
The relationship between mental disorder and crime is an issue of significant empirical complexity. It has been subject of extensive research, using both cross-sectional and longitudinal designs and including samples of the general population, birth cohorts, psychiatric patients, and incarcerated offenders. Nevertheless, findings have been equivocal (Sirotich, 2008).
On the one hand, several studies have found a relationship between mental disorder and crime. Tiihonen et al. (1997) examined the quantitative risk of criminal behaviour associated with specific mental disorders by studying an unselected 1966 birth cohort in Northern Finland until the end of 1992. The results suggest that the risk of criminal behaviour was significantly higher among subjects with mental disorders, regardless of the socioeconomic status of the childhood family. In particular, the higher risk for violent behaviour was associated with alcohol-induced psychoses and with schizophrenia with coexisting substance abuse. Hodgins (1998), who reviewed five epidemiological investigations of post-Second World War birth cohorts, came to the conclusion that persons who develop major mental disorders are at increased risk across the lifespan of committing crimes. However, this increased risk may be limited to generations of persons with major mental disorders born in the late 1940s, 1950s and 1960s, as they do not have received appropriate mental health care. After examining data from national hospital and crime registers in Sweden covering the period 1988-2000, Fazel and Grann (2006) found that the overall population-attributable risk fraction of patients was 5%, indicating that patients with severe mental disorder commit one in 20 violent crimes. Modestin and Ammann (1995) compared Swiss in-patients with the general population and came to the conclusion that patients were more frequently registered in all crime categories, although there were differences between the diagnostic groups: while alcoholics and drug users of both sexes had a significantly higher criminality rate, a higher rate was found among female, but not male, patients suffering from schizophrenia or related disorders. Finally, a study by Eronen et al. (1996) found that homicidal behaviour appears to have a statistical association with schizophrenia and antisocial personality disorder.
On the other hand, there are also studies that discard any relationship between mental disorder and crime. In a study which examined the ability of personal demographic, criminal history, and clinical variables to predict recidivism in mentally disordered offenders in the United Kingdom, Philips et al. (2005) found that reconviction in mentally disordered offenders can be predicted using the same criminogenic variables that are predictive in offenders without mental disorders. Fulwiler et al. (1997) analysed the relationship between violence and substance abuse among patients with chronic mental disorder and found that major mental disorder alone, with no history of alcohol or drug abuse, was associated with a considerably lower risk of violence. Overall, the study showed no difference in the rate of violence between patients with major mental disorders and patients with other diagnoses. Other studies suggest that the diagnosis of schizophrenia and delusional disorder, contrary to previous empirical findings, do not predict higher rates of violence among recently discharged psychiatric patients (Monahan et al., 2001, pp. 77 and 90). Along the same lines, Lindqvist and Alleback (1990) found that the crime rate among male schizophrenic patients was almost the same as that in the general male population. However, the crime rate among females was twice that of the general female population, so the overall results of the study were mixed.
Alternative explanations for overrepresentation
If the causality link between mental disorder and crime is so hard to establish, what other factors may explain the overrepresentation of mentally disordered people in prisons? One possible explanation could be the “criminalization” of people with mental disorder, meaning that they are being processed through the criminal justice system instead of the mental health system (Lurigio, 2013). The criminalization is blamed on the deinstitutionalization of mental health hospitals in the 1960s and 1970s, which led to the replacement of psychiatric hospitals with community mental health centres. Lacking the necessary mental health resources and treatment options in the community, people with mental disorders ended up in prison as a way to access psychiatric care (Peterson and Heinz, 2016).
Another explanation is that people with mental disorder typically reside in poor neighbourhoods, where they are exposed to the same criminal risk factors as people without mental disorder (e.g., unemployment, gang influences, failed educational systems, and housing instability). Because of their illnesses, mentally disordered people have more difficulties to finish education or maintain a job, which in turn complicates upward social mobility. Living in poverty and with no legitimate opportunities for advancement, people with mental disorders have no other choice than to engage in criminal activity (Lurigio, 2012).
An untreated mental disorder can strain relationships with friends and family, which also constitutes a contributing factor to violence and criminal activity. According to a study by Silver and Teasdale (2005), the lack of social support has a negative impact on the psychological well-being of the individual, who has fewer resources to cope with stress and vent frustrations, as well as fewer community ties that protect against criminal activity such as church or community groups. In this way, mental disorders can lead to social rejection, which lead to criminal behaviour (Peterson and Heinz, 2016).
Finally, mentally disordered people become involved with the criminal justice system through substance abuse, which makes them more vulnerable to arrest for drug possession (Lurigio, 2012). Studies of patients admitted to public mental hospitals have consistently found high rates (around 50%) of substance use disorders (Lehman et al., 1994). The odds ratio of having some addictive disorder is 2.7 among those with a mental disorder, that is to say nearly three times higher than in the general population (Regier, 1990). In many cases, it is the result from mentally disordered people’s attempts to self-medicate with drugs or alcohol in order to alleviate the impact of their untreated psychiatric symptoms or to relieve the debilitating side effects of antipsychotic medications (Lurigio, 2012).
Response of the criminal justice system
If there really was a causal relationship between mental disorder and crime, the logical consequence is to treat the mental disorder and to absolve the offender of criminal responsibility. However, there is no sufficient empirical evidence to establish unequivocally the existence of such a relationship, making the issue of what consequences should rightly follow much more complicated. Mental disorder and offending behaviour can coexist within the same person without there being any correlation between the two (Peay, 2010).
In order to determine whether a mentally disordered offender should be send to a psychiatric hospital or to prison, he is examined to assess if he meets the law’s rationality standard in the context in question. This requires him to proof either that he did not know the nature and quality of the act he was doing, or that he did not know that what he was doing was wrong. Offenders who satisfy these criteria are neither criminally responsible nor competent to stand trial because they are not rational (Morse, 2011).
What happens to those mentally disordered offenders who, having been declared mentally fit to face charges, end up in prison? According to some studies, longer periods of incarceration may lead to more mental health symptoms. If they are left untreated, the offender may display an increasing disruptive, noncompliant, and aggressive behaviour in reaction to the stressful life in prison (Simpson et al., 2013). This misbehaviour can result in solitary confinement, which has been found to exacerbate symptoms of mental disorder (Fazel and Baillargeon, 2011). Furthermore, it prevents them from participating in programs that would earn them good-time credits, thus limiting their options for early release (Lurigio, 2001).
Despite the availability of mental health services in prison, many inmates remain reluctant to access them for several reasons: a) self-preservation concerns, which include issues of confidentiality and negative perceptions from other inmates (seen as weak or a snitch); b) procedural concerns, that is, a lack of knowing how, when, and why to access services and anticipated length of services; c) self-reliance, which refers to a reliance on themselves or close others for help; and d) professional service provider concerns, which relate to questions of staff qualifications and dissatisfaction with previous mental health services (Morgan, 2007). In the case of inmates with suicidal tendencies, studies have found that they may intentionally hide their mental state to avoid restrictions on allowable possessions, close monitoring of their behaviour, worse housing status, and perceptions of weakness from other inmates (Bauer et al., 2010).
The most effective criminal justice response to mental disorder includes comprehensive rehabilitative programmes that adhere to the risk-need-responsivity principles (ibid.). According to the risk principle, rehabilitative services are more effective when they match offender’s level of risk for criminal recidivism. The need principle dictates that these services must target the specific risks associated with criminal recidivism (for example peer associations, substance use, and work or school functioning). Finally, the principle of responsivity asserts that rehabilitative services should match offender’s needs and learning styles. Programmes that include all three principles address the holistic needs of mentally disordered people, rather than just focusing on mental health symptoms and treatment (Peterson and Heinz, 2016). Studies have demonstrated that they reduce criminal recidivism in 30%, whereas sanctions alone (incarceration without rehabilitative services) and inappropriate rehabilitative services (services that only target the underlying mental disorders) increase it (Bauer et al., 2010).
Prison inmates have high rates of mental disorders compared with the general population. While this may imply a causal relationship between mental disorder and crime, disparate research results do not allow for such a conclusion to be drawn. However, mental disorders are intertwined with several risk factors for criminal activity, such as poverty, unemployment, lack of social support and substance abuse. It is important to point out that these factors also affect the population without a mental disorder, which further weakens the link between mental disorder and crime. Nonetheless, mentally disordered offenders still require treatment for their own mental well-being, but treatment alone cannot be expected to reduce recidivism and criminality. The most effective rehabilitative programmes in terms of improving criminal justice outcomes are those which address the whole social context of the offenders as well as their clinical symptoms.
Bauer, R., Morgan, R. and Mandracchia, J. (2010). Offenders with Severe and Persistent Mental Illness. In: T. Fagan and R. Ax, ed., Correctional Mental Health: From Theory to Best Practice. Thousand Oaks: SAGE.
Eronen, M., Hakola, P., and Tiihonen, J. (1996). Mental disorders and homicidal behavior in Finland. Archives of General Psychiatry, 53(6), 497-501.
Fazel, S. and Baillargeon, J. (2011). The health of prisoners. The Lancet, 377(9769), 956-965.
Fazel, S., and Grann, M. (2006). The population impact of severe mental illness on violent crime. American Journal of Psychiatry, 163(8), 1397-1403.
Fulwiler, E., Grossman, H.; Forbes, C. and Ruthazer, R. (1997). Early-onset substance abuse and community violence by outpatients with chronic mental illness. Violent Behavior & Mental Illness, 48(9),1181-5.
Hodgins, S. (1998). Epidemiological investigations of the association between major mental disorder and crime: Methodological limitations and validity of the conclusions. Social Psychiatry and Psychiatric Epidemiology, 33, 29-37.
Lehman, A., Myers, C., Corty, E. and Thompson, J. (1994). Prevalence and patterns of “dual diagnosis” among psychiatric inpatients. Comprehensive Psychiatry, 35(2), 106-112.
Lindqvist, P., & Allebeck, P. (1990). Schizophrenia and crime: A longitudinal follow-up of 644 schizophrenics in Stockholm. British Journal of Psychiatry, 157, 345-350.
Lurigio, A. (2013). Criminalization of the mentally ill: Exploring Causes and Current Evidence in the United States. The Criminologist, 38(6), 1-8.
Lurigio, A. (2012). Responding to the needs of people with mental illness in the criminal justice system: an area ripe for research and community partnerships. Journal of Crime and Justice, 35(1), 1-12.
Lurigio, A. (2001). Effective services for parolees with mental illnesses. Crime & Delinquency, 47(3), 446-461.
Modestin, J., and Ammann, R. (1995). Mental disorders and criminal behaviour. British Journal of Psychiatry, 166, 667-675.
Monahan, J., Steadman, H. J., Appelbaum, P. S., Robbins, P. C., Mulvey, E. P., Roth, L. H., et al. (2001). Rethinking risk assessment: The MacArthur study of mental disorder and violence. Toronto: Oxford Press.
Morgan, R., Steffan, J., Shaw L. and Wilson, S. (2007). Needs for and barriers to correctional mental health services: inmate perceptions. Psychiatric Services, 59(6), 1181-1186.
Morse, S. (2011). Mental Disorder and Criminal Law. Journal of Criminal Law and Criminology, 101(3), Article 6.
Peay, J. (2010). Mental Health and Crime. Abingdon: Routlegde.
Peterson, J. and Heinz, K. (2016). Understanding Offenders with Serious Mental Illness in the Criminal Justice System. Mitchell Hamline Law Review, 42(2), Article 2.
Phillips, H., Gray, N., MacCulloch, S., et al. (2005). Risk assessment in offenders with mental disorders: Relative efficacy of personal demographic, criminal history, and clinical variables. Journal of Interpersonal Violence, 20(7), 833-848.
Regier, D., Farmer, M., Rae, D., Locke, B., Keith, S., Judd, L. and Goodwin, F. (1990). Comorbidity of Mental Disorders With Alcohol and Other Drug AbuseResults From the Epidemiologic Catchment Area (ECA) Study. JAMA, 264(19), 2511-2518.
Silver, E. and Teasdale, B. (2005). Mental Disorder and Violence: An Examination of Stressful Life Events and Impaired Social Support. Social Problems, 52(1), 62-78.
Simpson, A., McMaster, J. and Cohen, S. (2013). Challenges for Canada in meeting the needs of persons with serious mental illness in prison. Journal of the American Academy of Psychiatry and the Law, 41(4), 501-509.
Sirotich, F. (2008). Correlates of Crime and Violence among Persons with Mental Disorder: An Evidence-Based Review. Brief Treatment and Crisis Intervention, 8, 171-194.
Tiihonen, J., Isohanni, M., Räsänen, P., Koiranen, M., and Moring, J. (1997). Specific major mental disorders and criminality: A 26-year prospective study of the 1966 Northern Finland birth cohort. American Journal of Psychiatry, 154(6), 840-845.