Taylor Hughes

NURS 616C
Judith McCarthy
May 10, 2014

Mental Health Research Paper: Not Guilty by Reason of Insanity
During this mental health rotation there were four clients who were at New
Hampshire Hospital (NHH) for committing crimes that are unthinkable to most.
These clients have all been found to be not guilty by reason of insanity (NGRI). Their
initial offenses constitute a multitude of offense from mild offenses such a
disruption of the peace to severe offense such as murder. All of these clients though
were not mentally sane when the initial offense was performed. These clients have
all gone through an array of treatments and places before ending up at NNH. Most
have been to jail and then the secure psychiatric unit at the jail before being sent to
NHH. While here at NHH there treatment and behaviors are overseen, not only by
the treatment team, but also with the department of corrections and the New
Hampshire Supreme Court. Having this many people involved in one persons care
makes moving forward and progressing toward discharge nearly impossible.
This semester I took a particular interest in one of the NGRI clients because
he was a part of our team. Every week we would listen to his plan and every week
nothing would change. Then one week different staff members told him that his
discharge was close to happening. However, the next week these staff members
took back what they said because the department of corrections had a different
opinion on his discharge. Upon being told this the client became annoyed and
expressed some anger toward the staff and other patients. This anger was nothing
out of the normal, any person not just a psych person would have expressed this
same amount of anger had this disappointing news been told to them. However,
being an NGRI patient this report of anger got sent to the department of corrections.
They then choice to take away privileges that this client had earned over time.
With NGRI patients this is a constant battle. The department of corrections
gets all progress notes and reads them with a fine toothcomb. If they see anything
that they do not like the client gets punished even if the treatment team does do not
deem it necessary. This works two ways, if the client does something wrong or says
something wrong then they get punished. This also works in the way that if the
client does not say enough the department of corrections thinks that they client is
not healing and not ready to move forward. Therefore it is like a double edge sword
with these patients and the department of corrections, they are damned if they do
and damned if they dont.
The treatment of NGRI patients appears to be more politically influenced
than medically influenced. There needs to be more laws and rules that regulate the
treatment and make it more black and white rather then grey and politically run. I
took this opportunity to look at the literature and see what the research says. I
wanted to know if this is just an issue in New Hampshire or if this happens
everywhere? I also wanted to know how other states handle these NGRI clients and
what their treatment plans are? There has to be a more clear evidence based way to
treat these clients. If not, psychiatric hospitals will soon be filled with all NGRI
patients due to the lack of movement.
During my search of the literature the databases used included, MEDLINE,
PubMed, CINAHL, and Psychinfo. The search engines used were EBSCO HOST,
Elsevier, and NCBI. Key words included, Not Guilty by Reason of Insanity,
Treatment, Political, and Outcome. In MEDLINE 7 citations were identifies, in
PubMed 8 citations were identifies, in CINHAL 11 citations were identified, and in
Psychinfo 15 citations were identified. Eight articles from the review of the
literature were selected; they were further analyzed to find the best evidence on the
treatment plan for NGRI clients.
In the article Prospective study of factors influencing conditional discharge
from a forensic hospital: the DUNDRUM-3 programme completion and DUNDRUM-4
recovery structured professional judgment instrument and risk, the researcher
looked at patients who were in a state hospital for the reason of NGRI. The cohort
study was done on 56 clients who were eligible for conditional discharge. These
clients took a series of tests and questionnaires from the D-3/4 to the GAF. These
tests gave the clients scores, which were indicators of how ready the clients, were
for conditional discharge. An independent Mental Health Review Board judged how
ready they felt each client was for conditional discharge then scored the clients. The
scores of the questionnaires/tests and the review boards scores were compared to
see how accurate he tests compared to the review board (Daveoren 2013).
The results of this study showed that the better the client did on the G-3/4
programme and on the GAF also scored better with the review board. This indicated
that clients who scores well on this programmes are most likely the most ready to
be conditional discharged from the states mental hospital. This tool could help make
decisions about discharge for NGRI clients more consistent and less political
(Daveoren 2013). The strengths of this study were that confounding and bias were
considered before starting the study. The limitations of this study were the small
sample size and having been only performed in one hospital with one review board.
The article, An outpatient psychiatry program for offenders with mental
disorders found not guilty by reason of insanity, the researchers looked NGRI clients
who were discharged and their outcomes after discharge. A retrospective chart
review was completed on 43 NGRI clients who were enrolled in outpatient
treatment following discharge. Outpatient treatment ranged from 5 months to 18
years. Of the chart review 43 NGRI patients were selected to study. Of the 43
patients 20 clients (47%) were rehospitalized and 8 clients (19%) were rearrested
or committed new crimes. Only 9 clients (24%) were in full remission and 26 clients
(68%) showed indicators on difficult reintegrating into the community (Kravitz
1999).
The results of this study showed that even after a specific NGRI treatment
program not all NGRI clients remain asymptomatic and /or functional (Kravitz
1999). This study makes one wonder what the speculations around their discharge
were. Had there been a standardized assessment tool to see whether or not
discharge was the right thing the results of this study may have been different. The
strength of this study was the length of time the study was conducted over. The
limitations of this study were that all of these patients were from the same hospital
and the small sample size.
In the article, Punishment or Treatment? Comparing the Length of
Confinement or Successful or Unsuccessful Insanity Defendants, the researchers
looked at seven states stands on NGRI clients versus people found guilty. The study
found that in all seven states the length of stay for NGRI patients varied greatly.
NGRI clients in New York spent nine times longer in a state psychiatric hospital than
NGRI clients in Wisconsin. The study also showed that people who were found guilty
had a lot less variability in the time they spent in jail than clients who were NGRI
(Silver 1995). The bases of this study showed that there is no standard for the
discharge of NGRI clients. The fate of these patients potential discharge changes
state-by-states and hospital-by-hospital.
In the article, Insanity Defense Research and Treatment of Insanity
Acquittees, the researchers explored Michigan and Oregon state reforms for NGRI
clients and their effectiveness. In Michigan they tried a new reform by enacting a
Guilty But Mentally Ill verdict. There hopes were to decrease the amount of NGRI
clients in states hospitals and hopefully early release of these dangerous clients.
However, the researchers found that this plan did not work. There was still the same
amount of NGRI patients in Michigan state hospitals. The reform actually just
created another populations of jail patients; the GBMI clients resembled other sex
offenders in jail (Steadman 1985).
In Oregon they tried a new reform to decrease the amount of time NGRI
patients spent in the state hospitals by emphasizing longer treatment outpatient.
The major part of this reform was creating a review board that would decide when
clients were ready from discharge and take the decision away from the mental
health team and the department of corrections. This reform in Oregon proved to be
effective. The length of stay for NGRI patients decreased, the focus of treatment
changed, and costs were also decreased (Steadman 1985). This study showed that
more research across the country is needed to determine what types of reforms are
needed to improve the focus of treatment for NGRI clients.
In the article, Empirical Research on the Insanity Defense and Attempted
Reforms: Evidence Toward Informed Policy, the researchers compared to groups of
NGRI clients who were released in California. In one group of clients they were
unconditionally released and the other group of clients were conditionally released.
During follow up of the clients 27% of the unconditional clients were rearrested
where as only 5% of the clients in the conditional release group were rearrested.
This is believed to be due to the increase surveillance on these clients with
conditional discharges (Borum 1999). This study showed that NGRI patients need
additional follow up and support upon discharge in order to increase their success
once in the community.
In the article, Treatment of Forensic Patients: An Expanding Role for Public
Psychiatric Hospitals, the researchers compared 415 NGRI clients and 320
voluntary clients in the state of Missouri. The researchers found the NGRI clients
were more likely than voluntary clients to have diagnosis of schizophrenia,
personality disorders and poly-substance abuse issues. NGRI clients also were
higher functioning than voluntary clients. They also found that NGRI patients are
found to be less hostile and to be restrained much less than voluntary clients.
However, NGRI clients in this study were discharged much later than voluntary
clients. The criteria for NGRI discharge are much harder than voluntary clients.
NGRI clients need to have convincing evidence proving that they are not likely to
commit another dangerous act. This is complicated because there is in standard
assessment tool to determine ones dangerousness. This has slowed down the
discharge of many NGRI clients in this study (Linhorst 1999). This study has shown
an issue that has been seen in many other studies, that discharge for NGRI clients in
greatly delayed due to the lack of information and standardization of issues
surrounding their discharge.
In the article, Stopping or Slowing the Revolving Door: Factors Related to
NGRI Acquittees Maintenance of a Conditional Release, the researchers looked at the
records of 125 NGRI clients who were discharged from a psychiatric state hospital
in Missouri. Of those released 75 percent had their conditional discharge revoked
after 32.1 months. Of those 25 percent who kept with their conditional discharge
their average time on conditional discharge was 79.8 months. The researchers
looked into the factors that may have been the reason that individuals getting their
conditional discharge revoked or not. They found that clients discharged to home or
to live with family were less likely to have their conditional discharge revokes.
Clients that were a minority race or had prior arrests/offenses were more likely to
have their conditional discharge revoked (Monson 2001). This study showed that
other factors besides the clients current mental state may need to be taken into
consideration prior to conditional discharges from a psychiatric hospital.
In the article, Are Release Recommendations for NGRI Acuittess Informed by
Relevant Data, the researchers came up with a review panel that would interview
91 NGRI clients in a Louisiana state hospital and determine what should happen to
them. The panel interviewed each client and their family and assessed a number a
things before coming up with their recommendations. The panel recommended 4
different things for each of the 91 clients. The recommendations included
conditional release to the community, transfer to a civil hospital, remain at the
current hospital, or release due to no mental illness. This panel was created due to
the fact that too many people are currently involved in these patients discharge and
it slows down their release. After interviewing these 91 patients the panel thought
28 clients (31%) were ready for conditional discharge, 30 clients (33%) were ready
for civil hospitalization, 24 clients (26%) were recommended to remain where they
are, and 9 clients (10%) were recommended to be release due to no mental illness
(Manguno-Mire 2007). This study showed that 74% of the patients in a psychiatric
state hospital were ready for some sort of discharge yet due to conflicting opinions
between department of corrections and the treatment team these patients were not
being discharged.
All eight of these studies showed a lot of insight to what is or is not
happening to clients who are NGRI. A majority of the data showed that there are
inconsistencies around the determining factors for discharge of an NRGI client. The
clients who had the best success were ones that were discharged based off of the
recommendation of an independent review panel and were conditionally
discharged.
There is no way to determine 100 percent whether or not a NGRI patient will
commit another offense like their initial one. However, discharging a NGRI client
when they are ready and with the appropriate resourcing in the outside world can
help decrease the chance of the client committing another offense. I think that as
nurses working with these patients it is our job to make sure these two things
happen. Nurses are a clients first line of defense to be an advocate and it is our
responsibility to make sure the best outcome happen for this population of clients.
There needs to be legislative changes as well surrounding these NGRI clients.
With all of the people involved in these clients care it becomes more of a political
decision rather than a fair and evidence based decision. With laws emplace to help
set foundations around conditional discharges it could help these clients move
forward and start a new life. If the laws do not change then these clients are going to
continue to stay in state hospitals much longer than is actually needed. This is not
beneficial for anyone. The client will never get the chance to start having a true life.
The hospital looses money because there is not turn over. Lastly, clients who
actually need psychiatric help are not getting it because these NGRI clients are
taking up bed while they wait for politics to decide their fate.
Overall I believe that there needs to be law changes stating when and how
these clients should be discharged. Nurses need to be advocates for these clients to
help push for their conditional discharges when they are ready. There also needs to
be an independent review panel that determines when a client is ready for
discharge, not have the department of corrections determine when they think the
client is ready. This eliminates bias and politics in clinical matters. Lastly, these
clients need to be set up with services upon discharge that will help them succeed in
the community and stick with their conditional discharge. NGRI clients are people
too and they deserve the proper treatment and care despite their initial actions. The
only way they will start receiving this care is if there are major changes like the ones
I stated above.








































References

Borum, R., & Fulero, S. (1999). Empirical Research on the Insanity Defense and
Attempted Reforms: Evidence Toward Informed Policy. Retrieved from
http://eds.a.ebscohost.com.libproxy.unh.edu/ehost/pdfviewer/pdfviewer?vi
d=11&sid=1679c7f6-6ce2-4287-afa8-
c55551561490%40sessionmgr4003&hid=4205

Davoren, M., Abidin, Z., Naughton, L., Gibbons, O., Nulty, A., Wright, B., & Kennedy, H.
(2013, July). Prospective Study of Factors Influencing Conditional Discharge
From a Forensic Hospital: The DUNDRUM-3 Programme Completion and
DUNDRUM-4 Recovery Structured Professional Judgment Instrument and Risk.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710275/

Kravitz, H., & Kelly, J. (1999, December). An Outpatient Psychiatry Program for
Offenders With Mental Disorders Founds Not Guilty by Reason of Insanity.
Retrieved from
http://ejournals.ebsco.com.libproxy.unh.edu/Direct.asp?AccessToken=7DIT
DT3B3FMFN5XRNIOJL35TVMMRBOOIT&Show=Object

Linhorst, D., & Turner, M. (1999). Treatment of Forensic Patients: An Expanding Role
for Public Psychiatric Hospitals. Retrieved from
http://eds.a.ebscohost.com.libproxy.unh.edu/ehost/pdfviewer/pdfviewer?vi
d=11&sid=1679c7f6-6ce2-4287-afa8-
c55551561490%40sessionmgr4003&hid=4205

Manguno-Mire, G., Thompson, J., Bertman-Pate, L., Burnett, D., & Thompson, H.
(2007). Are Release Recommendations for NGRI Acuittess Informed by Relevant
Data?. Retrieved from
http://eds.b.ebscohost.com.libproxy.unh.edu/ehost/pdfviewer/pdfviewer?vi
d=6&sid=d0f2dd12-a17f-4c96-84e5-
9b2d5712e89e%40sessionmgr112&hid=115

Monson, C., Gunnin, D., Fogel, M., & Kyle, L. (2001). Stopping or Slowing the Revolving
Door: Factors Related to NGRI Acquittees Maintenance of a Conditional
Release. Retrieved from
http://eds.b.ebscohost.com.libproxy.unh.edu/ehost/pdfviewer/pdfviewer?si
d=d0f2dd12-a17f-4c96-84e5-
9b2d5712e89e%40sessionmgr112&vid=4&hid=115

Silver, E. (1995). Punishment or Treatment? Comparing the Length of Confinement or
Successful or Unsuccessful Insanity Defendants. Retrieved from
http://eds.b.ebscohost.com.libproxy.unh.edu/ehost/pdfviewer/pdfviewer?si
d=1f460b62-e56a-4dd3-a21b-
6dbbdce34c03%40sessionmgr115&vid=7&hid=109

Steadman, H. (1985). Insanity Defense Research and Treatment of Insanity Acquittees.
Retrieved from
http://eds.b.ebscohost.com.libproxy.unh.edu/ehost/pdfviewer/pdfviewer?vi
d=6&sid=1f460b62-e56a-4dd3-a21b-
6dbbdce34c03%40sessionmgr115&hid=109