You’re running, but they seem to be catching up. Guns. You think you saw them carrying guns.
“Excuse me,” you mutter as you push up the street. You look over your shoulder and see one of them speaking into a cell phone. You mutter under your breath and dive onto a close bus. He’s calling for reinforcements.
Salvation. You think you’ve escaped them. The bus doors shut close and the vehicle begins moving. That’s when you notice a man reaching into his pocket. He’s reaching for a gun.
You take out a knife you’ve been carrying to keep you safe, since these guys started chasing you a few months ago.
The voice is overpowering. You bring your arm forward and the blade sinks into the mans abdomen. The bus comes to a halt before people can even process what happens, and you make a bolt for it,
* * *
It’s a sunny day and you decide to head to the mall and meet some friends. You step out of your apartment and take a breath of fresh air. The bus soon pulls up and you step on. It’s a red light so the bus stays stopped for a little while with the doors open. You hear some commotion down the street and see a guy running.
“Oh great,” you mutter to yourself. These guys are never good company. And of course, he jumps onto the bus. You’re standing with your hands in your pocket and try and not make eye contact.
The guy gets off the bus. And your bleeding. You sink to the floor and everything goes black.
* * *
Psychosis is among the most debilitating of psychiatric illnesses. Psychosis sets in at an early age, and often rears its head in resistance to many of our best treatments.
But was is psychosis?
In broad strokes, psychosis can be defined as a severe abnormality in perception. These abnormalities can come in two forms. Delusions are fixed, false beliefs that are inappropriate in a given context. Hallucinations are sensory experiences unique to an individual not otherwise experienced by others. Psychosis is also accompanied by cognitive symptoms, which can include problems thinking, disorganization of thought, and disorganization of behaviour. Finally, negative symptoms may also occur, such as flattened emotional response, and troubles with motivation.
It sounds nice on paper. In reality, individuals with psychosis experience a different subjective reality than most. And that’s OK. Usually. I don’t see much difference in believing you have microchips in your back than believing there are God’s in the sky. As a physician, it isn’t my job to tell you what to believe.
Many people with psychosis experience it pleasantly. They hear voices that others do not, which do not bother them. They see connections in the world that I can’t begin to compute and they love it. Sometimes, and not unusually, psychosis can be unpleasant. It can be depressing. It can be downright terrifying. It is at these points, that danger occurs.
As you can see in the scenario above, these are times we have to intervene.
Scared people act in self defense. This is true whether you have psychosis or not. When you have psychosis, you may suffer from a delusion of persecution. In other words, this would be the belief that people are after you. In the scenario above, the first person believes they’re being followed. They run up the street, they dive onto a bus and even have been carrying a knife. Finally, they commit an act of violence, and stab the person in the second scenario. Not out of malicious intent, but out of a true belief of self defense. To the second person, they were simply standing on the bus.
Even more worrisome can be command hallucinations. These are a form of auditory hallucination, or “voice,” that a person hears. These voices give orders or commands to a person, and often times, the person feels compelled to listen. This can be entirely “out of their control.” In the first scenario above, the person experiences a form of command hallucination, and this plays a role in causing them to stab the second person.
So is person one responsible for the murder?
But this doesn’t mean they are criminally responsible.
Every few months, it appears. The latest headline and protest, lauding complaints that the most vile among us have been completely exonerated for their heinous crimes. “Not criminally responsible.” The uproar is usually dramatic. The disgust even more. From my seat, I simply try and waft away the stench of ignorance, and hope that some understanding will finally come from the news story of the day.
That time of the year has arrived again, as featured here, You can thank Joe Warmington
for inspiring today’s blog post, so let’s set the record straight.
What is Not Criminally Responsible (NCR)?
The easiest way to explain NCR, is to explain what it isn’t. It is not a complete and total exoneration (sorry Donald Trump). It is not a get out of jail free card. And it is not a failure of the justice system.
When someone is found NCR, they are basically found to be guilty of their crimes, but because of their illness. Presumably, someone who commits a crime and who is found NCR would not commit a crime while well.
Why does it matter?
The NCR system is designed to get people well, so that they can exit the system, and begin reclaiming their life. From a sociological perspective, they begin, “contributing,” to society again. To achieve this, a finding of NCR allows the courts the compel you to take physician prescribed medications, and to comply with any drug safety monitoring required. You are typically detained in a high security psychiatric hospital, and given limited benefits, only titrated along with medication effect. Ideally, with the proper treatment, you achieve remission.
So how long does an NCR last? Well, that depends. And the system isn’t perfect. Unlike the traditional justice system, NCR findings typically do not carry sentences. To be released from an NCR, you need to have the approval of a board (here in Ontario, the Ontario Review Board), to be released. For them to be satisfied, your symptoms typically have to achieve remission. This can take a wildly different amount of time for different individuals, since everyone’s condition responds uniquely. The detention typically lasts years, followed by a step-down outpatient monitoring system. Eventually, you achieve an absolute discharge, and you have no more restrictions than your average citizen.
Like I said the system isn’t perfect. Vincent Li was infamously discharged after only nine years, following a gruesome bus beheading. Anecdotally, I’ve heard of NCR findings for robberies lasting decades longer than a regular robbery sentence. At the end of the day, the system usually works, and does a fairly good job at balancing victims rights, with human rights, and acknowledging the terrible impact these life changing illnesses may have on not only the ill individual, but all of us.
And it could use some tweaks.
Editor’s note: The focus of this post was NCR findings, therefore I focused on the risk of violence in cases of psychosis. Violence remains very rare in people with psychosis. Much more commonly, psychosis puts a person’s own safety at risk, through an overwhelming desire to complete suicide, and through personal neglect.
Dr. Travis Barron is a resident physician in Toronto, Canada.