Survival of the Sanest Order and Disorder in a Pre trial
Psychiatric Clinic, 1st Edition
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In memory of John P. Menzies
1912-1979
BIRON: What is the end of study?
KING: Why, that to know, which else we should not know.
BIRON: Things hid and barred, you mean, from commonsense?
KING: Ay, that is study's god-like recompense.
WILLIAM SHAKESPEARE Love's Labour's Lost 1, 1
And now here is my secret, a very simple secret: It is only with the hean that
one can see rightly; what is essential is invisible to the eye.
ANTOINE DE SAINT-EXUPERY The Little Prince
Contents
TABLES AND FIGURES xiii
FOREWORD XV
ACKNOWLEDGMENTS xxi
INTRODUCTION 3
Psychiatric Discretion and Legal Order 3
Researching Psychiatric Decision-Making at METFORS 8
Organization of the Book 15
1 SETTING THE STAGE: CONTEXT, SUBJECTS, AND METHOD 16
An Introduction to METFORS 16
The Research 26
The METFORS Patients 32
A Subject's-Eye View of the Process 38
A panoramic view of the forensic corridor 38
The case of the political paranoid 43
Summary 51
2 OPENING THE DOOR: POLICE ENCOUNTERS WITH THE
METFORS PATIENTS 53
Policing the Mentally Disordered 53
The Police Construction of Psychiatric Categories 59
Police Strategies for Managing Mental Cases 64
The forensic clinic as an institutional resource 64
Moral assessments and normal outrage 67
Tactical drama and tacit messages 69
Summary 77
x Contents
3 TH~ FORENSIC CORRIDOR I: THE METFORS BRIEF ASSESSMENT UNIT 79
Discretion and Disorder in the Brief Assessment Unit 79
An Aggregate Analysis of Decision-Making in the BAU 82
The Imputational Dynamics of Brief Assessments 93
Deactivating subject resistance 94
Maintaining a united front 97
Trials of moral identity 98
Suspending credibility 103
Probing for secret knowledge 106
Cultural and other stereotypes 109
Punitiveness and responsibility 113
Deciding about dangerousness to others 116
Summary 120
4 THE FORENSIC CORRIDOR II: THE METFORS INPATIENT UNIT 122
From Brief to Protracted Assessments 122
Strategies for Securing In-patient Assessments 130
Mobilizing the Psychological Reports 133
Social Workers and Their Informants 139
Monitoring Madness on the Ward 149
Summary 157
5 THE FORENSIC CORRIDOR III: SENTENCING THE METFORS PATIENTS 159
The Forensic Clinic and the Criminal Court 159
METFORS Recommendations and Judicial Dispositions 164
Psychiatric Sentencing in the Brief Assessment Unit 168
Fitness for bail and penal confinement 173
Probation orders 176
Psychiatric detention 178
Fitness to stand trial 180
Not guilty by reason of insanity 183
Dangerousness to self 185
Dangerousness to others 187
Summary 190
6 THE AFI'ERMATH 193
Survival of the Sanest 193
The Outcome Careers of the METFORS Subjects 198
Surveying the subsequent conduct of 571 BAU patients 198
Patterns of institutional confinement 203
xi Contents
Forensic roulette and the phenomenon of multiple remands 206
Assessing the validity of clinical prognostications 215
What Is to be Done about Forensic Assessments? 227
APPENDICES 241
Appendix A: BAU Psychiatric Assessment Summary Form 241
Appendix B: Sample Follow-up Profiles for BAU Subjects 244
Appendix C: Cases Deleted from Two-Year Follow-up 252
Appendix D: Characteristics of METFORS Patients 254
Appendix E: Psychological Tests Administered at METFORS 262
Appendix F: Incidents Recorded during Two-Year Follow-up 263
NOTES 267
REFERENCES 281
NAME INDEX 299
SUBJECT INDEX 305
Tables and Figures
TABLES
1.1 Characteristics of BAU patients 34
1.2 Comparing METFORS patients with the Ontario in-jail remand
population 37
2.1 Decisions by arresting police officers 60
2.2 Police judgment of suspect dangerousness/potential for violence
with background, clinical decisions, and court disposition 62
3.1 Assessments of dangerousness and fitness by BAU clinicians 84
3.2 Principal component analysis of decisions by BAU psychiatrists 86
3.3 Associations between background variables and psychiatrists'
decisions 90
3.4 Multiple classification analysis: psychiatrists' predictions of
dangerousness to others 92
4.1 Frequency and location of in-patient assessments subsequent to
METFORS BAU remand 126
4.2 Comparing subjects referred for in-patient assessment with other
BAU patients 128
5.1 Recommendation in BAU letter by court disposition 165
5.2 Recommendation in in-patient letter by court disposition 167
6.1 Correlations among measures of outcome conduct 201
6.2 Follow-up incidents by time spent in community, prison, and
hospital 205
6.3 Associations between background variables and two-year follow-up
behaviour 218
6.4 Significant breakdowns: total number of outcome violent incidents
by background variables 220
xiv Tables and Figures
6.5 Pearson correlation coefficients between clinical predictions and
outcome conduct 224
6.6 Changes in accuracy of psychiatrists' predictions of violence by
length of follow-up 226
FIGURES
1.1 Path diagram of legal status, police, clinical, and court decisions,
and outcome 40
6.1 Month-by-month follow-up of officially recorded incidents
involving METFORS patients 199
Foreword
The most important sign of civility is how a society treats its marginal
members. In particular, citizens assess the moral authority of the state in
terms of how it deals with accused persons and criminal offenders. The
state's record in this area serves as a barometer of all lesser exercises of
authority.
There are signs that we in Canada are civilized, especially in comparison
with other places and previous times. Even the most despicable people are
not entirely written off: as a sign of our civility, we have abolished the
death penalty. Indeed, I think analysis would show that in Canada, the
more someone offends moral sensibilities through horrific acts of violence
and disorder, the more health, welfare, and penal resources we devote to
dealing with the offensive person. We mark our civilization by holding
out eternal hope to the offender - and more significantly, to ourselves -
that although he has gone wrong, our advanced scientific knowledge and
enhanced legal system can remake him as a thoroughly respectable citizen.
Even with the contemporary emphasis on the rights of victims, and the
punitive mentality that emphasis urges, our moral sensibilities maintain
respect for the offender's legal rights and rehabilitative potential.
Professor Robert J. Menzies' project is to question whether, in con-
gratulating ourselves about our civility, we are letting our institutions do
our thinking for us. He considers how the coercive power of the state is
increasingly justified through claims to scientific expertise blended with
expressions of legal authority. He queries whether these claims and expres-
sions are directing our perceptions into grooves compatible with the social
relations the institutions of state, science, and law wish to authorize. He
contemplates how these claims and expressions might be fixing our gaze
and thereby limiting the range of questions we ask and solutions we seek.
xvi Foreword
Menzies pursues his project by getting inside a pre-trial forensic clinic
mandated to deal with, and provide recommendations about, some of the
most wretched members of Canadian society. He lifts the veil of admin-
istrative decency that normally cloaks such institutions to pick its com-
ponents apart, to learn about its organizations, its programs, its knowledges,
and its communications. He shows that the clinicians, in concert with the
police who feed them, and the prosecutors and judges whom the clinicians
feed in turn, are primarily knowledge brokers. Their essential task is to
manufacture formal knowledge that will articulate with exercises of coercive
power. In analysing the manufactory at work - how its various agents
make and move knowledge in the concrete circumstances of their daily
tasks - Menzies documents the micropolitics of knowledge and power in
meticulous and disturbing detail.
It is made evident that the formal knowledge of the clinicians, while
based in common sense, is elite knowledge in that it is not part of everyday
speech. As elite knowledge, the professional activities it authorizes and the
decisions it legitimates are not open to participation by non-specialists,
especially the accused persons who are the subjects of the clinicians' ac-
tivities and decisions. As elite knowledge, the formal knowledge of the
clinic is not democratic, and signifies the more general trend in society
away from democracy and toward technocracy. Menzies feels that de-
mocracy should be at the heart of the clinic. He is centrally concerned
with the ways in which the technical knowledge manufactured by the
clinicians may not be serving justice, or fostering the human potential of
those they capture and process.
The clinic is mandated to serve the needs of the accused persons it houses
and to protect them from the more unjust and punitive excesses of the
criminal law system. It is thus focused not only on the particular legal
predicament of the accused, but also on his medical condition and moral
character. As such the clinic is to operate with an individualized conception
of good and evil, normality and abnormality, situating the causes of crime
in the manners and morals of flawed individuals. It is to find out what is
wrong with the individual qua human being and to activate whatever may
be helpful in putting him right.
Menzies discovers an institution that exceeds its mandate in many ways.
The clinic derives its primary legitimacy from the legal institution and
therefore shifts its own institutional discourse and practice to meet the
needs of the legal institution. For example, while the clinic's primary official
function is to assess the fitness of accused persons to stand trial, it is
preoccupied with making sentencing recommendations to judges even
xvii Foreword
at the pre-trial stage. Central to these sentencing recommendations are
assessments of the 'dangerousness' of the accused, even though such
assessments are not officially mandated. 'Dangerousness' criteria are often
paramount in spite of the well-established fact that psychiatrists and other
clinicians cannot predict 'dangerousness.' Indeed, by means of a sophis-
ticated follow-up investigation, Menzies discovers that psychiatrists are
wrong more than half the time in predicting future violent conduct. In
Menzies' words, 'In the peculiar alchemy of forensic discretion, clinical
authority is largely founded upon a task at which practitioners are alarm-
ingly inept.'
Clinicians offer such predictions routinely because the courts find them
to be a powerful vehicle for justifying punishments. Clinicians tailor their
knowledge to fit the formats of the legal institution to the point where
their recommended prescriptions - whether for imprisonment, psychiatric
confinement, or alternative dispositions - are routinely accepted by the
courts. The concurrence between the clinicians' recommendations and ju-
dicial decisions increases with the intensity of the recommended punish-
ment! Clinicians are expert advisers on punishment, helping the court to
justify and legitimate its most coercive sanctions in terms of scientific
knowledge and medical expertise. In the process clinicians fundamentally
abandon their traditional medical orientations and commitments in favour
of pre-trial confinement of criminal defendants, dramatizing the danger-
ousness of accused persons, rationalizing judicial labels, and legitimating
the allocation of penal measures. Not incidentally, clinicians also help
themselves, establishing a legitimate place and launching prestigious careers
in the medico-legal complex.
Menzies finds an institution that is obsessed with itself. The organizations
involved with the clinic are clients of each other, mutually dependent for
referral of subjects and conferral of authority. The clinic's programs 'pro-
gram' it to serve its own needs over and above its medical and legal ob-
ligations to both the accused and the public. Thus programmed, the clinic's
only source of knowledge is itself. Like the journalist who turns to yes-
terday's newspaper to decide what is newsworthy and thus make more
news, the clinician turns to the documents and classifications of the medico-
legal complex to judge accused persons and to recommend what should
be done to them.
While clinicians are well aware that reality is a fluid, they treat it as if
it were a solid. They objectify their knowledge in documents in expressions
of authoritative certainty to the courts. Disagreement about classifications
is rare. When disagreement occurs, the accused is held in custody for an
