Responding to People Victimized by Individuals with Mental Illnesses
Dr. James Reinhard, Carol Dorris  -  2009/5/13
http://ovc.ncjrs.gov/ovcproviderforum
 
 
Do you believe that an offender with a history of severe mental illness should be executed if convicted of a capital crime and receives the death penalty. denver@tcask.org
 
1.  James Reinhard
 I have a personal opinion about that which is no. But also a clinical opinion that a person with a severe mental illness may lack capacity to undestand the punishment.
 
2.  Carol Dorris
 As a crime victim organization, we dont take a formal stand on the death penalty in general. It seems to me that public sentiment would most likely weigh against the execution of a person with a severe mental illness.
 
 
As a law enforcement officer I have observed that many of the victims I deal with who have been been victimized by someone with mental illness are family members and sometimes the suspects only care giver. We have mandatory arrest in cases of domestic violence which often causes much anxiety for the victim who is more concerned about his/her family member than themselves. This is compounded when a no contact order is put in place and now the mentally ill suspect has no place to go. Any recommendations on how to work with the victim on this complicated issue. Victims will often resent the police when this happens.
 
1.  Lucia
 I agree with the discussion at hand. Should a different, independent legal instrument be available, implemented with similar objectives and constraints as the restraining order instrument that society has now for the general public? But, instead of being handled by the criminal justice system, it's managed by psychiatrists in the field, but, also still requiring the go ahead, signature by a judge-so all is balanced and constitutional? It is so sad and difficult seeing all the voids and problems in our pocedures. The cases are complicated and unique.
 
2.  Carol Dorris
 That is a difficult issue. If possible, involving a victim service provider to work with the victim from the start can be helpful. Establishing permanent victim assistance positions enables the victim services staff to develop on-going relationships with other officials and personnel within the system, fostering cooperation and information sharing. Agency efficiency is thereby improved, and victim frustration is reduced because victims are no longer shuffled from person to person as they seek information. Often, however, there is no individual or department charged with the duty to provide victims of individuals confined in a mental health setting with notice of their rights and information about their cases. If thats the case, providing the victim with as much information about what the process involves, the availability of services and crime victim compensation for medical and counseling expenses, and what may happen to their family member helps prepare the victim about what he or she can realistically expect.I also think that there needs to be a continuing dialogue about issues like this. It may be that the laws need to be changed to incorporate exceptions that might be appropriate.Communities can tap the substantial expertise of professionals who work with victims on a daily basis as well as those who treat and supervise mentally ill offenders. Victim service providers can assess existing policies and practices for supervising the mentally ill to determine whether victim issues are adequately addressed, make recommendations for improvement, and promote legislation which grants rights to victims and holds offenders more accountable for the harm they cause. They can review applicable statutes to ensure that the laws clearly designate a party in both systems that is responsible for affording victims their rights which facilitates the smooth transfer of duties between the two systems. In addition, they can help integrate victim services into the context of offender supervision, particularly in cases of individuals who victimize family members.
 
3.  Linda Foley
 AS a victim advocate, we see this too but are dealing with victims not yet working with the police. How do we help them to seek law enforcement intervention when they are more concerned about the family member than themselves? What can we say that would get through?
 
4.  James Reinhard
 A couple of good points are raised here about the issue of violence committed by individuals with mental illness. First that the violence is often directed to family members (this is supported by research) who may often be their primary caregivers. If there is no contact or restraining orders then this interferes often with follow-up and ongoing treatment. This is precisely why for certain offenders with mental illness and sequential intercept model where individuals are intercepted from going through the usual criminal justice process and diverted to better and more appropriate treatment and interventions by the mental health system that can get the person back into their treatment and work with family system to see what is appropriate for ongoing care and contact.
 
 
What guidelines/instruction/support would you give to faculty/staff/students at a university campus, who encounter students with autism spectrum/Asperger's disorders or chronic, unmedicated psychotic disorders, and experience them as hostile/intimidating, invading personal space, unresponsive to social cues signaling discomfort, etc.? How should/can they respond in an assertive/directive yet compassionate way? How can police and counseling staff best help them manage their anxiety/discomfort?
 
1.  Carol Dorris
 There is a lot of information available about the Virginia Tech response to violence on campus. Here is a link to some information on the Virginia Tech Web site that might give you some a place to start: http:www.hr.vt.eduemployeescornerworkplaceviolenceindex.html .
 
2.  James Reinhard
 I would first thank you for your interest in learning more about the disorders about which you mention, such as Autism Spectrum Disorders and untreated psychotic disorders. First, continue to learn as much as you can about these disorders and their risk for violence (it is generally pretty low in the absence of substance abuse and in absence of history of violence) but also to realize that there is a risk and that nobody should be expected to put themselves in the way of risk or feel uncomfortable if they are being threatened or intimidated. Law enforcement should be contacted in these situations. Then the individual can be, if appropriate diverted into emergency treatment or their ongoing treatment program.
 
 
Are you aware of any training available to police for interviewing victims with mental illnesses? If not, are there any plans to initiate training programs?
 
1.  Carol Dorris
 The following publication is available online. It contains two references to training resources which I have cut and pasted here.Improving Police Response To Persons with Mental Illness: A Progressive Approach. http:www.ccthomas.comebooks9780398077785.pdf. Police Response to People with Mental Illnesses, producedby the Police Executive Research Forum, is a training curriculumand model policy for police agencies that wish to educate theirofficers about appropriate responses to situations involving peoplewith mental illnesses. The curriculum includes moduleswhich can be used separately or togetheron the Americans withDisabilities Act, types of mental illnesses, treatment options, voluntaryand involuntary commitment of people with mental illness,psychiatric evaluations and other situations that police mayencounter. It offers techniques and model practices for police officersto deal with a variety of situations, from talking to a personwho is experiencing delusions, to transporting a person to a mentalhealth facility for evaluation. PERF, 1997 ISBN: 1-878734-19-9 Police Response to People with Mental Illnesses: VideoSeries, produced by the Police Executive Research Forum. Thisis a two-part video on improving the police response to peoplewith mental illness. The first part covers basic information aboutmental illness, the Americans with Disabilities Act and tips forpolice dealing with some common types of encounters with peoplewho are mentally ill. The second part focuses on a communitypolicing response to situations involving people with mental illness,including how police can forge partnerships with other serviceproviders to develop long-term resolutions to recurring problems.
 
2.  Hope Glassberg
 A publication from the Center for Problem Oriented Policing (see #13 and #14) discusses police-based responses to crime victims (both with and without mental illnesses): http:www.popcenter.orgproblemsmental_illness4.
 
3.  Rita Mcelhany
 Missouri is expanding the reach of CIT. It is generated by law enforcement agencies that are eager to respond in effective ways to individuals who are having a mental health crisis. very good program!
 
4.  James Reinhard
 There is a nationally known program called Crisis Intervention Training (CIT) first demonstrated in Memphis, TN that is a great model for law enforcement training regarding interface with individuals with mental illness. This training is currently gaining much momentum in law enforcement agencies across the nation.
 
 
What are some good suggestions on how to deal with women who have mental health issues, trouble taking meds,and maintaining safety while in the shelter? This population of victims tend to be more at risk. Thanks.
 
1.  Carol Dorris
 Our organization is actually cohosting The National Professional Training Conference on Responding to Crime Victims with Disabilities September 30, 2009 - October 2, 2009 in Denver. One of the workshops is Working with Victims of Crime Experiencing Mental Illness andor Psychiatric Disabilities. Here is the description. You might also contact the presenters for more information on this issue.Women living with psychiatric disabilities are at greater risk for domestic violence (DV) and more likely to experience multiple forms of abuse across their lives. Yet, the systems to which survivors turn are frequently unprepared to meet their safety and mental health needs. Moreover, stigma associated with mental illness and lack of knowledge about DV reinforce abusers abilities to use mental health issues to control their partners and to discredit them with friends, families and the courts. This session will provide practical strategies for bridging these gaps in services. Analysis of presenters' experiences working with local agencies and city and state systems in developing collaborative service delivery models will be discussed. Critical policy and systems integration issues will also be addressed. Carole Warshaw, MD, & Terri Pease PhD, Office for Victims of Crime Training and Technical Assistance Center, Chicago, IL http:www.register123.comeventprofilewebindex.cfm?PKwebID0x125952abcd&varPagehome
 
2.  Hope Glassberg
 You may be interested in a publication from the Council of State Governments Justice Center on Violence Against Women with Mental Illness, available here: http:consensusproject.orgdownloadsvaw-brief.pdf, which discusses those very issues.
 
3.  James Reinhard
 Many individuals with mental illness, often women, but men also are themselves victims of violence or have a history of trauma. In the field of mental health treatment we are doing a better job recently of talking about trauma informed care where we recognize this likely history of trauma and gear a kindler, gentler less coercive approach to treating these individuals. A lot more to say on trauma informed care, but main point is to recognize its major prevalence in individuals with serious mental illness.
 
 
How are other states dealing with offenders who have mental illnesses? What is the best approach in working with individuals who have mental illnesses who have been victims themselves and are now victimizing?
 
1.  Hope Glassberg
 The Criminal JusticeMental Health Information Network catalogs criminal justicemental health initiatives across the country: http:www.cjmh-infonet.org.
 
2.  Lucia
 Thank you, Doctor. It is so true nationwide:about not nearly enough efforts and not done very effectively. In California, between the budget cuts, the lack of keeping track of them, monitoring, illegal access to weapons, it will take monumental overhaul to demonstrate that a majority of mentally-ill people are really cared for and quality of life for all is not being jeopardized. The saving grace is the quality of people that do care, and do not give up, even with the state of the system in place.
 
3.  Denver
 check out 2 extremely powerful Frontline documentaries concerning mentally ill offenders and our prisons. Google the Frontline website and you will see both which you can watch online. I highly recommend them.
 
4.  James Reinhard
 The short answer is not nearly enough and not very effectively. In Virginia there is some good work being done across many state agencies and other organizations about Prisoner Re-entry to look at issues individuals face as they leave incarceration with history of mental illness. These initiatives include re-institution of benefits as well as re-connecting with community treatment programs. See below about programs that are doing better job with trauma inforemed care. Can get some good links to this concept through NASMHPD website.
 
 
What special conditions upon Supervised Release from prison do you recommend we request for a mentally ill defendant that has an obsession with a (now) 18 yr. old relative he met briefly? He was ordered not to use the Internet and not to have any contact with the victim for three years, but he continues to violate the rules & posted a journal blog on-line which indicates he is still obsessed with the teen and is mentally very unstable. He also has suicidal ideations and a lot of rage. We would like to set some conditions that will help keep the victim safe. The Internet and social networking sites have made it easy for "stalkers" to locate people. Any suggestions? Is there any way for probation to really monitor whether he is taking his medication?
 
1.  Carol Dorris
 Protection from intimidation, threats, and physical harm is necessary to the peace of mind of all crime victims. Victims of individuals with mental illness have many of the same safety concerns as other victims.Notification of release is one means of protecting victims safety. While notification is important to all victims, it can be particularly crucial where there is a pre-existing relationship between the victim and the individual.States also use no contact orders and court-imposed conditions of release (including the mandatory use of medication) to protect victims of the mentally ill. In Alaska, a person found guilty but mentally ill can be charged with a violation of a no contact condition of release. Missouri has taken steps to protect both victims and communities when an individual with mental illness is released. Before placing any client in a particular residential facility or day program, the department shall consider whether the facility will provide the security necessary to protect the public safety and any crime victim or other witnesses .In Washington, in cases of dangerous individuals, victims may have the opportunity to participate in the development of appropriate release plans. Prior to release of an individual identified as dangerously mentally ill, a team consisting of representatives of the department of corrections, the division of mental health, and, others as necessary,...shall develop a plan,...for delivery of treatment and support services to the individual upon release. ...The team shall notify the crime victimwitness program, which shall provide notice to all people registered to receive notice...of the proposed release plan. ...Victims, witnesses, and other interested people notified by the department may provide information and comments to the department on potential safety risks to specific individuals or classes of individuals.You might also contact the Stalking Resource Center which is affiliated with the National Center for Victims of Crime for more ideas. Their site can be accessed through www.ncvc.org.
 
 
I am working on a report based on interviews with families of victims killed by individuals with mental illness and families of individuals with mental illness who have been executed. We have found the Council of State Governments report very useful. I am interested in your thoughts about victims’ right to notification (of an offender’s release from a psychiatric facility, for example, and also perhaps of follow-up supervision and treatment) and how that might conflict with HIPAA regulations. I am specifically interested in this with regard to murder cases. Thanks very much.
 
1.  Susannah
 Hope, good to see your response. My understanding from the guide is that such notification is rare, for exactly the reason you give here (the individual's no longer being under the purview of the CJ system). I'm looking at the line from the guide: victims of crimes committed by individuals in the custody of mental health systems are not allowed to be notified of custody status, diagnosis, treatment plan, or change in treatmentplan. I understand that Missouri is a good exception to this; I'm glad to hear that Virginia is as well. Thanks for all the replies.
 
2.  Carol Dorris
 The right to be notified of events and proceedings throughout the criminal justice process is vital to all crime victims because it keeps them informed about what is happening in their cases and allows them to participate when appropriate. Notification can take on new meaning for victims of individuals with mental illness. Whether the person is a stranger who attacks at random or a family member who assaults his or her caregiver, the uncertainty of how the individuals illness may influence his or her actions can create an additional element of concern for these victims. States have enacted laws to notify such victims of competency petitions and proceedings, review hearings, changes in the offenders status, offender transfers to mental health facilities during the course of incarceration, discharge or release proceedings, conditional and unconditional releases from confinement, and of the offenders escape from custody. In many of the States that do provide notice to victims of individuals with mental illness, victims must request notification. Approximately half the States have adopted provisions to notify victims when the individual who committed the crime is released from a mental health treatment facility. Advance notification of an offenders release from a mental health treatment facility benefits victims in a number of ways. Prior warning of scheduled discharges gives victims time to prepare and develop safety plans, if necessary. In cases where the individual is a family member, notification allows time for arrangements for outpatient treatment and family counseling to be made prior to the offenders reentry into the home. Several States, including Arizona, Minnesota, and South Dakota, also inform victims of individuals with mental illness of any conditions of release when they are notified of their release. A victims safety may be jeopardized when an individual with mental illness escapes, making immediate notification crucial. While victims are provided notice of the escape of a convicted offender from a correctional setting in almost all of the states, only about half require victim notification when an individual escapes from a mental health facility, institution, or state hospital. In many of these States, victims must request such notification. Only a few States provide victims with notice of competency or release hearings related to an individual with mental illness. It can be beneficial to a victim to be present at hearings at which the individuals mental health is evaluated because information presented at the hearing, such as treatment progress reports and risk assessments, can contribute to the victims understanding and acceptance of the dispositions made in the case. Of course, there may be privacy considerations that interfere with this.
 
3.  James Reinhard
 I gather that your question refers to individuals who would have been found Not Guilty by Reason of Insanity (NGRI). In Virginia, our process of treatment and review of a persons readiness to progress through stages of privileges and ultimate return to community are based, in part, of their recognition of the impact of their actions on the victims. I think this has to be an integral part of the recovery of the person as a result of their treatment. This may include voluntary release of information, perhaps even some form of personal communication from the individual with the illness. The concept of restorative justice has much merit. Good clinicians understand the need to work, even within HIPAA, to incorporate family, community into the eventual treatment plan.
 
4.  Hope Glassberg
 I co-authored the guide, so I am pleased to hear it was useful to you. My sense is that if the information provided to victims is not health oriented (e.g. they are only informed of conditional release hearings or actual releases), there wouldn't be a HIPAA conflict. The greater question is whether there is a legal mandate to notify victims. Because the individual has been found not guilty by reason of insanity or incompetent to stand trial, they are no longer under the purview of the criminal justice system. Other states (like Virginia and Missouri) have gotten around this issue by writing into statute that the mental health agency is required to notify victims in particular instances.
 
5.  Denver
 I serve with an organization that works with murder victims family members who do not believe in the death penalty. I do not know if any of our members had a loved one killed by an offender with severe mental illness but would like to talk with you further. You can e-mail me at denver@tcask.org.
 
 
Specialized Safety planning would be helpful for people living with someone with bipolar disorder etc. Manic episodes and other related behavior can be emotionally abusive and lead to physical violence. This is especially concerning for those who may be cycling or having a first manic episode (since it may be totally abnormal behavior & leave the wife/family at a loss for what to do)
 
1.  Carol Dorris
 We also have some information on safety planning for victims on our Web site (www.ncvc.org) which might give you some ideas that could be applied.
 
2.  James Reinhard
 Good point. First, no one should have to stay in harms way and remain vulnerable as a potential victim. Education is key. Second, Psychiatric advance directives (PAD) are increasingly being used to help individuals who may be at risk for de-compensation to plan for how they want to be treated and for family members to clarify what they are going to do to protect themselves and the person with the illness. WRAP plans, or Wellness, Recovery, Action Plans are also useful for this purpose and much information is available on both PADs and WRAP plans.
 
 
What is your role with working with NAMI (National Alliance of Mental Alliance) with respect to this topic? Do they also have a current project in motion? and, if so, do they have some published findings yet as well?
 
1.  Kathryn
 GREAT! Do you know where it may be published? I would love to see those findings, both on a whole and with respect towards domestic violence victims.
 
2.  Carol Dorris
 I'm also sorry to say that I don't know the answer to this. I would agree with Dr. Reinhard that it would be best to contact them directly.
 
3.  Susannah
 The report I described briefly in the question below is being co-published by NAMI, and there will be a panel at their upcoming convention on the topic. This is specifically about, and from the perspective of, families of victims killed by individuals with severe mental illness
 
4.  James Reinhard
 I am not aware of a specific program NAMI has on this topic but dont want to speak for them. I would urge you to contact your local chapter to ask.
 
 
In our local Mental Health Court, participants sign an ongoing release of information to the treatment team members including the judge, defense and prosecuting attorneys, psychiatrist, case managers, psych social worker - not complainants/victims. Half the cases involve stranger-victims; half involve family member-victims who are generally involved in a support role to participants. Do you handle disclosure/ information sharing about the advantages of treatment over traditional prosecution for this individual differently for these different types of victims? What about when these victims seek updates on "how treatment is going"? -treat them the same or differently?
 
1.  Carol Dorris
 I addressed the right to be informed to some extent in an earlier question posted by Susannah. I think to the extent that victims want to participate in the process they should be provided with the information necessary to do so. That said, I do know that there are privacy concerns involved when you are talking about treatment options that may not be appropriate without the individual's consent. It may be possible to do both. For example, Washingtons law addresses both issues. To prevent wrongful disclosure of information related to mental health services, a court may take only those steps necessary during a sentencing hearing or any hearing in which the department presents information related to mental health services to the court. The court may seal the portion of the record relating to information relating to mental health services, exclude the public from the hearing during presentation or discussion of information relating to mental health services, or grant other relief. Any person who otherwise is permitted by law to attend any hearing shall not be excluded from the hearing solely because the department intends to disclose or discloses information related to mental health services.In a number of states, victims are permitted to attend certain proceedings for the limited purpose of presenting victim impact statements.
 
2.  Hope Glassberg
 The Council of State Governments Justice Center has released a publication on working with victims in mental health courts: http:consensusproject.orgdownloadsguidetocvinmhc.pdf that may be of interest.
 
 
We work with victims of Sexual assault victims and many times they suffer from mental illness and have been revictimized, what would be a good approach to give them back control after a lifetime of victimization?
 
1.  James Reinhard
 This is precisely why the attention to Trauma Informed Care is taking off so rapidly and resonating among many good clinicians. An understanding of the cyclical nature of abuse, trauma, and re-victimization. We have not done a very good job in the past of recognizing the history of trauma among those with mental illness and therefore we, often unknowingly re-traumatized. This was obvious with things like seclusion and restraint use and misuse. But we often do it in other more subtle ways in the clinical settings. We do have to pay attention to empowering the people we serve in treatment, letting them take and gain more control than we have in past. There is good information on trauma informed care, recovery movement, which includes helping people take more responsibility for their illness and their treatment.
 
 
I am from Indian Country and also a Native American Tribal Victim Advocate under the TVA Grant. I am faced with working with a cycle of generational domestic violence, sexual assault and substance abuse. Post Traumatic Stress is a standard summary based on historical trauma and childhood trauma into adulthood. Most often the victim themselves are mentally ill and the offender as well, they are living together or in some type of living arrangement possibly a grandparent and grandchild. Often times both the offender and victim in reversed roles end up in a federal/state court and also have to face a tribal court if it is non-280 reservation. What is your definition of mental illness? How would you respond to a victim who is mentally ill themselves?
 
1.  James Reinhard
 I admire the work and challenges that you are facing. You are a step ahead by recognizing the cycling and re-traumatizing factors in your work. Regarding the definition of mental illness: the definition is based on the setting. There are often legal definitions for the purposes of state and federal law. Clinicians may define it in different ways, including those diagnoses that are listed in the Diagnostic and Statistical Manuals (DSM) now in its fourth edition. As you know there are spectrums of mental illness and so we often refer to serious mental illness (SMI) which usually refers to psychotic illnesses (Schizophrenia, Bipolar, or mood disorders) where there is a break from reality with psychotic thoughts or severe impairment of functioning.
 
 
Do victims with brain injuries suffer with anything accept speach that would either make them appear to have a mental illness, or can they have a mental illness as a result of a brain injury?
 
1.  linda sorenson
 How can we hold offenders with mental health issues accountable to their victims, especially when they can hardly take care of themselves? Most often the victims are thier own family members. Are they capable of understanding the real harm they cause by thier choices?
 
2.  James Reinhard
 Certainly brain injury can be the cause of mental illness. In fact, many mental illnesses are the result, (we are increasingly finding out) of some structural brain disease or neurotransmitter problem - but not a result of injury. So brain injury does affect more than just speech and can impair cognition, mood, thoughts, behavior, etc. Organic or brain injury is always a part of the differential diagnosis of mental illness. It may be more difficult to treat and have a different prognosis than other mental illnesses, but treatment is still available and effective for individuals with brain injury and behavioral or mental illnesses.
 
 
Any suggestion of best language or methohd to use in discussion with heads of mental health facilities and advocates, when trying to create and/or enhance their understanding of the victims' rights and need to have access to inmate/patient's information?
 
1.  Carol Dorris
 It is a challenge. One thing that I learned from working on this issue with the CSG project is that the terminology used in the mental health setting may be very different than that used in the criminal justice system. I think that mental health professionals and criminal justice and victim assistance professionals can learn a lot from each other. It starts with getting folks around the table and sharing their knowledge and expertise. As a person with knowledge of victims rights, I can help share that crime victims have many of the same concerns whether their perpetrators are committed to a secure mental health facility or sentenced to a term of incarceration in a correctional facility. Most victims want to be notified when offenders are released or escape from confinement and to have an opportunity to participate in proceedings that relate to their cases. They may have reason to be concerned about their personal safety upon the defendants release or escape. Many victims suffer financial losses related to the crime. Those with mental health expertise can inform me of the special needs and concerns faced by people with mental illness. Together we can come up with a solution that benefits both parties.
 
2.  James Reinhard
 I would just emphasize, as noted in a previous response, that the awareness of impact on victims has to be an important part of treatment and recovery for those with mental illness who have committed acts of violence and are in treatment. Recovery oriented treatment cannot occur in a vacuum and true integration of individuals with mental illness back in the community recognizes this.
 
 
We deal with identity theft and sometimes the perpetrator is a member of the family, such as a spouse, parent, child, etc. They may also be abusive or simply cannot understand they are hurting someone. Any suggestions on how to advice a victim who is making the hard decision on whether to report the perp to the police?
 
1.  Carol Dorris
 When working with crime victims one of the first things we address is their safety. Are you safe now? If not, what will it take to make you safe? We also stress presenting victims with their options and the resources available so that they can make their own well-informed decisions on what their next steps will be.
 
2.  James Reinhard
 This is a good, but tough clinical question that is often hard to answer without knowing a lot of the details of the individual and family situation. A general clinical point would be that it is rarely helpful to enable a family member to continue to be abusive or display their symptoms without confronting them. This can be done in the context of treatment and perhaps family therapy for support and guidance through this.
 
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