Mentally Disordered Offenders

Concomitant with the proliferation during the nineteenth century of asylums to house the mentally disordered, there was an increasing perception that the so-called criminally insane were a distinct class with special needs that could best be met in separate institutions combining therapy with more secure custody for these allegedly dangerous persons. The result was the establishment of separate hospitals for the criminally insane that are more like prisons and that are often administered by corrections departments, rather than by mental health departments. They housed those found not guilty by reason of insanity, defendants found incompetent to stand trial, prisoners who had become severely disordered in prison, and, on occasion, civil patients who were so dangerous that a more secure institution seemed necessary.

In general, these institutions are highly custodial and do not offer high-quality mental health services. Long-term confinement in such institutions is frequently antitherapeutic. Much of the expensive, high-security custodial functioning of these institutions is probably unnecessary. Experience and studies have shown that many allegedly dangerous disordered offenders can be transferred to less secure hospitals where they can be treated like other patients or they may be safely released into the community, either outright or with outpatient treatment. When by court order and against hospital advice these transfers take place, the former inmates appear to make satisfactory adjustments, and only a small fraction later engage in serious criminal behavior.

The plight of inmates in institutions for the criminally insane has been ameliorated by legislative and judicial changes and by therapeutic advances. Newer psychotropic medications are more effective. Incompetence to stand trial and insanity acquittal commitments are much less likely to last for life or even for extremely long periods than in the past, and litigation has reformed some of the worst abuses of these institutions. Furthermore, some jurisdictions maintain a policy of placing selected mentally disordered offenders in special or general wards of civil hospitals or in special outpatient programs. These programs are oriented more toward therapy than custody and some succeed.

Amelioration of physical and emotional abuse and restrictions on the deprivation of liberty that attend secure confinement are surely welcome reforms. But too few resources are provided and therapeutic knowledge for dealing with severe mental disorders and criminal recidivism is still too limited to permit more than cautious therapeutic optimism. Despite criticism of separate treatment of the criminally insane and of treatment of disordered offenders generally, the combination of crime and mental disorder remains especially frightening and punitive responses to disordered offenders are common. As the new quasi-criminal commitments indicate, society's response to disordered offenders will not always be rational.