Aggression and Violent Behavior, Vol. 1, No. 2, pp.

97-122, 1996
Copyright © 1996 Elsevier Science Ltd
Pergamon Printed in the USA. All fights reserved
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SSDI 1359-1789(95)00008-9

"DANGEROUS" PATIENTS: A SURVEY OF

ONE FORENSIC FACILITY AND REVIEW OF
THE ISSUE

Thomas R. Litwack
Department of Psychology, John Jay College of Criminal Justice

ABSTRACT. This article describes the perceived bases for determinations of dangerousness
regarding a representative sample of patients, primarily insanity acquittees, confined on the
grounds of "dangerousness" (and mental disorder) at a secure forensic facility. Accordingly,
the article seeks to elucidate various considerations that often are - - and perhaps should be
- involved in clinical assessments of dangerousness regarding the population under consid-
-

eration, and the various forms by which perceived - - and judicially determined - - danger-
ousness manifested itself in the study population. Some possible implications of the findings
for certain policies regarding the confinement of mentally disordered individuals ~ particu-
larly insanity acquittees ~ on the grounds of "dangerousness" are also discussed.

ASSESSMENTS OF DANGEROUSNESS - - and deprivations of liberty based on such

assessments - - are clearly a common feature of our legal system. Recent Supreme Court deci-
sions (e.g., Jones v. United States, 1983; Schall v. Martin, 1984; United States v. Salerno, 1987)
have reaffirmed the legal legitimacy of depriving individuals of their liberty based on an assess-
ment of their future dangerousness - - at least in certain, limited, circumstances (cf. Foucha v.
Louisiana, 1992). Indeed, in Barefoot v. EsteUe (1983), a majority of the Supreme Court upheld
the constitutionality of a sentence of death that was based, in part, on psychiatric determina-
tions that the defendant would continue to be violent, even in prison, if not executed.
Although not unmindful of the questions that existed regarding the validity of predictions
of violence by mental health professionals, in Barefoot the majority opined that such ques-
tions could adequately be dealt with by the trier of fact: "We are not persuaded," stated the
Court, "that such testimony is almost entirely unreliable [i.e., invalid] and that the factfinder
and the adversary system will not be competent to uncover, recognize and take due account
of its shortcomings" (463 U.S. 899).
Professional doubts about the legitimacy of clinical predictions of dangerous certainly do
remain. As Webster and Menzies (1987) summarized the situation:

Correspondence should be addressed to Thomas R. Litwack, PhD, J.D., Department of Psychology,

John Jay College of Criminal Justice, The City University of New York, 445 West 59th Street, New
York, NY 10019.
97
98 T. R. Litwack

Scholars in this vexed area tend to adopt and adhere to one of two fairly easily identifiable ide-
ological positions. Some maintain that the clinical prediction of violent behavior is essentially
an impossibility and efforts to make such prognostications raise insuperable ethical and moral
issues. Others take the view that the practice of clinical assessment, though far from perfect at
the present, could, with the combined efforts of clinicians and sociolegal researchers, be placed
on a footing defensible from both scientific and moral perspectives. The former position suggests
that clinical forecasts about dangerousness could almost never be justified; the latter proposes
that there is a defense for the use of clinical opinion in issues in prediction of violent conduct,
even if it applies in only selected instances. (p. 160)

Those - - both scholars and judges - - who oppose the validity, legitimacy, or utilization
of assessments of dangerousness commonly argue that research has shown that predictions
of future violence are, at best, wrong at least two times out of three. (See, e.g., Barefoot v.
Estelle, 1983, Blackmun, J., dissenting.) However, recent reviews of the relevant research lit-
erature (Litwack, 1994; Litwack, Kirschner, & Wack, 1993; Litwack & Schlesinger, 1987;
Monahan & Steadman, 1994) have suggested that the validity of clinical assessments of dan-
gerousness in many important contexts - - and, indeed, the validity of such assessments in
general - - has, in fact, never been tested. This was because, it was argued, studies showing
high rates of false positives for determinations of dangerousness (a) dealt with assessees who
were only marginally dangerous to begin with because they were released despite clinical
concerns; (b) did not examine individualized assessments by a representative group of men-
tal health professionals; (c) did not account for undetected violence after release; (d) viewed
as "false positives" assessments of dangerousness that were never definite predictions of vio-
lence to begin with but only, rather, statements that the assessees in issue posed an unusual-
ly high risk of violence; or (e) concerned "predictions that appeared to be "erroneous" only
because the predictions led to interventions (confinement and/or treatment) that significant-
ly reduced the patients' dangerousness. As Monahan and Steadman (1994) have observed,
such are "the problems that have so far hobbled the scientific study of violence amongst he
mentally disordered" (p. 13).
Indeed, certain of these critiques have pointed out that the validity of assessments of dan-
gerousness in many important contexts will never be ascertained, because to determine the
validity of those assessments we would have to release, or refrain from confining, individu-
als strongly believed to be seriously dangerous - - and legally confineable - - and then care-
fully (but unobtrusively) follow them up in the community. (On the point that assessments
of dangerousness should be viewed only as risk assessments, rather than as predictions per
se, and that preventative detentions may be justified even if there is less than a 50/50 chance
that violence would otherwise occur. See also Grisso & Appelbaum, 1992; Litwack,
Kirschner, & Wack, 1993; Litwack, 1993, 1994.) Thus, the research to date on clinical
assessments of dangerousness has left much to be determined about the overall validity and
utility of such assessments.
What may be most striking about the research - - or lack of research - - in this area, how-
ever, is that, remarkably, there appear to be no studies of the specific bases for clinical and/or
judicial determinations of"dangerousness" regarding a well defined group of patients evaluat-
ed for dangerousness by mental health professionals, and legally confined based on those eval-
uations. As Quinsey and Maguire (1986) have observed: "Research has been done on issues
such as interclinician agreement, but little on the criteria they actually use in forming their
opinions" (p. 148). Even simple, yet reasonably detailed, individualized descriptions of repre-
sentative samples of patients determined to be dangerous are woefully lacking in the literature.
Leading to what is probably the most detailed report to date of individualized assessments
of dangerousness, Pfohl (1978) monitored the assessment interviews and discussions of clin-
 Dangerous Patients 99

ical teams evaluating many patients for dangerousness at a forensic facility in Ohio. Based
on his observations, and illustrated by verbatim excerpts from the interviews and subsequent
discussions, Pfohl recounted a number of possible assessment or interpretive errors, or pos-
sibly unjustified assumptions, that he believed colored those assessments. (See Litwack &
Schlesinger [1987, pp. 220-221] for a critical summary of Pfohl's findings, and Webster &
Menzies [1987, pp. 190-196] for a thoughtful list of potential assessment errors in evalua-
tions of dangerousness.) However, Pfohl provided no data for frequency of these supposed
clinical errors, and he reported only generalized observations regarding the bases for clini-
cal assessments of dangerousness. (The diagnosed presence of psychopathy and the diag-
nosed absence of insight regarding the causes of previous acts of violence appeared to be the
most widely used indicia of dangerousness regarding his sample of evaluees.) And, most
importantly, he did not provide any data that would allow the reader to discern precisely
upon what bases a representative sample of findings of "dangerousness" were made at the
facility he studied.
Thus, as Mulvey and Lidz (1985) have pointed out, we have not yet systematically stud-
ied the "elemental components of the clinical prediction process" and yet " . . . it is only by
knowing 'how' the process occurs that we can determine both the potential and the strategy
for improvement in the prediction of dangerousness" (p. 215).

Detailed description of these decisions as they acmaUy occur (using either participant observa-
tion or coded transcripts) could provide a systematic way to limit [the] presently broad range of
potential explanatory variables by isolating those case, clinician, and context variables that
appear most central to the decision-making process. In short, the initial stage of description [ital-
ics added], so critical to the development of grounded theory, has been largely sidestepped in
research on the prediction of dangerousness. It is necessary to go back to basics and to do the
work that ideally would have been the first step to systematic inquiry [italics added]. (Mulvey &
Lidz, 1985, p. 216)

The work to be presented here is intended to be such a first step toward a more systematic
and ecologically valid description w and evaluation - - of clinical assessments of dangerous-
ness than has appeared heretofore. The aim of the research project was to determine - - and
then to report in sufficiently meaningful and individualized detail - - the precise bases for clin-
ical determinations of dangerousness regarding each patient in a representative sample of a
reasonably well def'med group of hospitalized patients who were deemed to be dangerous and
in need of secure confinement by mental health professionals in authority (after extensive clin-
ical evaluations) and who, by and large, were legally confined on the ground of their supposed
dangerousness. Although, if Mulvey and Lidz (1985) are correct, such descriptive studies are
essential if we are to fully and properly understand and evaluate the practice and potential of
assessments of dangerousness, it appears that no such study has been reported in the literature
to date. That is, it appears, there is to date no published report of the precise (perceived) nature
of the dangerousness of a representative group of mental patients confined on the grounds of
their perceived dangerousness. Thus, the ultimate aim of this report is to enable students of the
field of dangerousness to better understand and evaluate the issues involved - - or that should
be involved - - in both research and practice concerning the assessment of dangerousness.

THE RESEARCH STUDY

Setting and Method
The study was conducted at a major forensic hospital facility ("the hospital" or "the facility")
housing former criminal defendants who had been found not guilty by reason of insanity
100 T. R. Litwack

[NGRI]. The facility also houses defendants who have been found to be incompetent to stand
trial and a few civil committees who are considered to be too dangerous to be maintained at
ordinary, "non-secure" facilities. The facility is considered to be a "secure" facility.
During the time this research was conducted, there were six active wards at the facility - -
five male wards and one female ward - - each housing approximately 25 patients. Three of
the male wards were composed largely of men who had been found incompetent to stand trial
and who were not being evaluated, primarily, for dangerousness. The other two male wards
and the one female ward housed almost all of the NGRI patients at the facility. They also
housed a few dangerous civil committees. The one female ward also housed, necessarily, the
female patients who had been deemed incompetent to stand trial, and it was the practice on
the female ward to formally evaluate these patients for dangerousness as well.
It is important to note that all of the NGRI patients and civil committees had not simply
been deemed dangerous by the hospital (i.e., by mental health professionals). Within the past
2 years, at the longest, these patients had either been deemed dangerous by a judge after a
hearing at which the patient was represented by counsel and had the opportunity to cross-
examine witnesses against them and to present testimony on their own behalf; or they had
consented to confinement in a secure facility. The female patients being confined on the
grounds of incompetency who were also deemed to be dangerous were so deemed only after
an extensive evaluation. Thus, in contrast to other studied samples of patients who were con-
fined in secure facilities - - but who were not afforded careful professional, or legal, scruti-
ny (see, e.g., Litwack & Schlesinger, 1987, pp. 211-212; Steadman & Cocozza, 1974, 1980;
Thornberry & Jacoby, 1979), the patients deemed dangerous in this sample were so deemed
only after extensive clinical evaluations that were almost always subject to serious judicial
scrutiny (and/or the scrutiny of independent evaluators).
My method was very simple: To begin with, I met with the designated leader of the pro-
fessional team on each of the three wards that housed significant numbers of patients being
evaluated for dangerousness and asked the team leader to tell me which professional staff
member on the ward - - the team leader, psychologist, psychiatrist, or social worker - - was
most familiar with each of the patients on the ward. I then met with the professional staff
member most familiar with each patient to obtain the professional's explanation of why that
patient was being confined at the facility on the grounds of his or her dangerousness (or, if it
was the case, why the team now felt that the patient could safely be transferred to a nonse-
cure facility).
That is, I obtained from these professionals a preliminary description of the bases for each
assessment of dangerousness regarding my subject population. If there was any question in
my mind about bases or legitimacy of the current assessment - - as there often was - - I also
reviewed the patient's "chart," which usually contain a detailed history of the patient and a
number of written evaluations of dangerousness. (On the other hand, it was sometimes, if
rarely, so clear to me from the information I received during these initial interviews why
patient in question was considered in need of secure confinement that no additional infor-
mation was obtained. The patients who presented such clear evidence of dangerousness are
largely amongst those described below as posing "a definite likelihood of serious violence"
if not restrained.)
If, after reviewing a patient's chart, there was still any question about the patient's dan-
gerousness, or if a staff member indicated to me that there was some disagreement amongst
the staff about a patient's dangerousness - - or even if it was apparent that the patient pre-
sented an unusual diagnostic problem (even if the staff ultimately agreed the patient was dan-
gerous) - - I met with the entire treatment team to discuss the team's evaluation of the patient.
In my discussions with the teams, the team members clearly appeared to be forthright with
me about their disagreements with each other, or with the hospital's administration. (It should
 Dangerous Patients 101

be noted that this research project had the support of the hospital's administration and the
team leaders themselves. Moreover, during previous research at the facility I had developed
what I believe were cordial and mutually respectful relationships with most of the staff mem-
bers I was interviewing.) Certainly, disagreements did freely emerge in team meetings for a
number of patients.
Very importantly - - and as an additional check on quality of the information I was receiv-
ing from the team members - - in most cases where there was some issue about the nature of
the patient's dangerousness, I also attended interview/evaluations conducted by the ward
teams, or by a hospital evaluation committee [the "committee"], with and regarding the
patients in the study population. All NGRI acquittees and civil committees at the facility must
be formally evaluated at least once every 2 years to determine if they remain mentally ill and
dangerous. The formal evaluation is first made by each patient's treatment team and is then
reconsidered by a committee composed of at least one "board certified" psychiatrist and two
other mental health professionals who are not currently on the patient's ward. Typically, the
committee will review the patient's history and most recent treatment team evaluation, inter-
view the patient, and then make its own evaluation of the patient's dangerousness. Thus,
through participant observation at a number of committee evaluations - - and, less frequent-
ly, by attending treatment team meetings with patients - - I was often able to directly observe
the dangerousness evaluation process and the patients who were the subjects of such evalu-
ations. (Whenever I attended a meeting with the patient, the patient was informed that I was
a psychologist who was conducting a study of how evaluations were done in the hospital. In
no case did a patient object to my attending the evaluation.)
One other very important source of data should also be noted. In the charts of patients who
had at one time or another protested their retention there was usually one or more indepen-
dent psychiatric evaluations of dangerousness; that is, evaluations conducted by psychiatrists
hired by the patient's attorney, or chosen by the court. These evaluations - - which sometimes
supported the hospital's findings of dangerousness and sometimes did not - - often helped to
sharpen the issues involved in evaluating the patient's dangerousness.

The Subject Population

At the time this study commenced, there were 61 patients on the three study wards who had
been confined at the facility because of their supposed dangerousness and who were actively
evaluated for dangerousness. Eight of these patients were transferred to other (usually nonse-
cure) facilities before I had an opportunity to obtain adequate information regarding the
patient, and, therefore, these patients have been dropped from further consideration. In addi-
tion, to have a "round number" of 50 study patients, and for the reasons that follow, three other
patients were excluded from further consideration. One of these patients allegedly sexually
assaulted a woman (and, in the more distant past, various family members), but the patient can
neither hear nor speak and is apparently somewhat developmentally disabled and, thus, was
unusually difficult to evaluate (although he knew some sign language). The second of these
three patients was a homeless woman with a history of alcoholism who, while intoxicated, had
repeatedly threatened and assaulted others, and had set small fires, in the community. She was
cooperative on the ward and was viewed as being transferable to a nonsecure - - but super-
vised - - setting once she was willing to agree to treatment for her alcoholism. The third
patient was a male insanity acquittee with a history of assaults, substance abuse, and paranoid
fears (which are apparently impervious to medication) whose "chart" was nevertheless insuf-
ficiently detailed for a satisfactory analysis of the patient's dangerousness. This patient,
though remaining at the facility, could not be observed, by the author, during an evaluation
(by his treatment team or a hospital evaluation committee) during the time period of the study.
102 Z R. Litwack

Thus, data will be presented for 50 patients. Of these patients, 38 were male and 12 were
female. The average age of the male patients was 38; the average age of the female patients
was 40. The median age for all patients was 39. Thirty-seven were on NGRI status; six were
civil committees; and seven - - all women - - were hospitalized at the facility on the grounds
of being unfit to stand trial. Although all of these patients other than the 7 "incompetency"
patients had been confined to the facility because they were recently considered to be too
dangerous to be housed in nonsecure facilities (much less simply released), some of them
were viewed as soon being eligible for transfer to a nonsecure facility, and others were
viewed as being, currently, less certainly dangerous than they had been in the past.
As will also be seen, to allow for better comprehension and evaluation of the data, the 50
study patients are categorized below according to the author's view of the certainty and
severity of their potential dangerousness (based upon the information obtained about each
patient by the methods described above). It must be emphasized that these categorizations are
the author's alone, and were developed, after inspecting the data, to organize the data and,
thereby, to present the data in the most comprehensible and useful fashion. The categoriza-
tions do not reflect any official classifications of the facility (or, for that matter, any other
known classification scheme). Without doubt, other observers would categorize at least some
of these patients differently. Indeed, as will be noted further below, hospital clinicians with
whom I shared my classifications did not always agree with them.
Moreover, it must be recognized that other researchers or clinicians might have sought out
and discovered additional information that would have led to fundamentally different patient
descriptions and conclusions regarding the need for the patients' confinement. That is, other
researchers or clinicians might have discovered, or emphasized, other information about at
least some of the patients in the sample that would make those patients seem less, or more,
dangerous - - and less, or more, in need of confinement - - than the information provided. It
is essential to remember, however, that virtually every patient in the sample - - all but the
seven women who were on "incompetency" status - - had assented to her or his confinement
in a secure facility or was hospitalized under a judicial order of confinement on the grounds
that the patient was mentally ill and dangerous after a court hearing at which the patient was
represented by counsel and had the opportunity to present evidence and the results of an inde-
pendent evaluation by a psychiatrist chosen by the court or the patient's counsel. (Counsel at
these hearings were virtually always state-supported attorney's whose full-time job was that
of representing mental patients and who were well acquainted with their client's case.)
That is, whatever the ultimate legitimacy of the descriptions and determinations of dan-
gerousness described below - - and the confinements based upon them - - may be (by what-
ever criteria), the descriptions do, hopefully, reflect the bases for actual legal determinations
of dangerousness sufficient to legally justify the confinement of these individuals in a secure
hospital facility. (The seven female patients confined on the grounds of their incompetency
to stand trial were not, technically, confined on the grounds of their dangerousness. But they
were evaluated for dangerousness by the clinical staff by the same criteria as those patients
who were confined on the grounds of their dangerousness.) Thus, hopefully, the descriptions
of perceived dangerousness presented below do reflect the various forms of perceived dan-
gerousness of individuals - - particularly insanity acquittees - - who are, in fact, legally con-
fined in secure psychiatric facilities (or, at least, in some such facilities) on the grounds, at
least in part, of their supposed dangerousness.
Also, to check on whether the thumbnail sketches of the patients that follow accurately
reflected the hospital's consensus view of each patient, after my summary descriptions and
classifications were developed I showed them - - with the names of the patients described
included - - to two senior clinicians at the facility who were in administrative positions and
who had at least some familiarity with most of the sample patients. Both clinician/adminis-
 Dangerous Patients 103

trators had very little disagreement with the descriptions of the patients. That is, they believed
the descriptions accurately reflected the bases for the patients' confinement on the grounds
of their dangerousness. However, it must also be noted, the clinician/administrators did not
necessarily agree with my classifications of the patients (or with my classificatory scheme in
general), contending that I sometimes underestimated the certainty of the patient's danger-
ousness, and that my classificatory scheme made overly fine distinctions.

Limitations of the Research Project

Before going on to describe the results of this study, certain additional limitations - - or
potential limitations - - of the study and/or its results should be noted:

1. The patients about to be described were a very representative sample of the patients
who had been confined at the facility on the grounds of dangerousness during the study
period. (The sample includes 37 of the 46 NGRI patients at the facility during the study
period; six of the 16 civil committees; and all seven of the female patients deemed
incompetent to stand trial.) However, the sample patients are not a representative sam-
ple of all insanity acquittees or even all insanity acquittees sent to the study facility;
and they certainly were not representative of all mental patients who are deemed to be
dangerous and in need of confinement.
The study patients were not representative of all insanity acquittees because insan-
ity acquittees who were deemed no longer too dangerous to be transferred had already
been released from secure confinement and hence were under-represented amongst the
patients remaining at the facility. The sample of long-term patients surveyed here were
not at all representative individuals who are civilly committed because of acute dan-
gerousness to themselves or others. (Indeed, as will be seen, several of the sample
NGRI patients confined the grounds of dangerousness would almost certainly not be
civilly committable under current civil commitment standards and practices.)
However, to repeat, the sample is very representative of the mental patients being con-
fined in one secure forensic facility on the grounds of their dangerousness.
2. The facility's clinicians had far more data with which to evaluate dangerousness than
would clinicians in many other circumstances. All the NGRI acquittees had essential-
ly admitted to having committed serious criminal acts (whatever their mental state at
the time) and the patients' treatment teams had the opportunity - - and the responsibil-
ity - - to obtain extensive data about all their patients' psychiatric and criminal histo-
ries. The treatment teams also had the opportunity to observe and interview patients
over extended periods of time before coming to any conclusions about the patients'
dangerousness. The facility was not faced with population pressures of the sort that
might deter findings of dangerousness.
3. Nothing can be concluded from this data about the quality of the treatment the patients
were receiving or whether, therefore, even those patients who were most clearly dan-
gerous (i.e., too dangerous to be released or even transferred) might not have been less
dangerous - - and far more eligible for transfer or release - - had they been given dif-
ferent treatment. The data describes only the patient's relevant (known) past history of
violence and (relevant) current mental state. Similarly, the judgments about danger-
ousness described here are not judgments about the patient's long-term dangerousness.
Rather, they are judgments about the patient's dangerousness in the present and for the
foreseeable future. Indeed, some of the patients who were viewed as most definitely
not eligible for transfer during the study period - - because of their continued violence
on the ward - - have since improved and have been transferred a nonsecure facility.
 104 T. R. Litwack

4. No data are presented, or could be presented, as to the validity of the assessments of

dangerousness at issue. The only way validity data could be obtained would be to
release patients strongly believed to be dangerous and to follow them up carefully - -
but unobtrusively - - in the community. For legal, ethical, and practical reasons, this
obviously would be impossible. It is worth noting again, however, that in virtually
every case the hospital's most recent official finding of dangerousness had either been
confirmed by a judge or had gone unchallenged by the patient.
5. The patients in this sample were being evaluated, by the hospital staff, not simply for
dangerousness in the community, but for whether they could be safely transferred to a
civil facility. Only rarely is an NGRI acquittee or civil committee released from a
secure facility directly to the community. Almost always, if released from the facility,
they are transferred to a nonsecure civil facility. Thus, when evaluating patients for
their dangerousness, the facility's clinicians are supposed to determine if the patient is
too dangerous to be kept safely at a civil facility. Most disagreements amongst the hos-
pital clinicians - - and between hospital clinicians and independent evaluators - - were
about whether or not a patient, though apparently still a danger to the community, could
be safely maintained in a nonsecure facility.

In the descriptions and categorizations of dangerousness that follow, however, I primarily

considered the patients' potential dangerousness in the community. At least some patients who
clearly would pose a serious risk of violence in the community could, arguably, be satisfacto-
rily maintained in nonsecure facilities. The central question, however, is whether the patient
can legitimately be deprived of his or her liberty on the grounds of his or her supposed dan-
gerousness. And only a description of the patients' perceived potential dangerousness in the
community can serve the basic purpose of this study: to present a sufficiently detailed and
meaningful picture of the information and issues that are involved - - or that should be involved
- in actual assessments of dangerousness to guide future research on such assessments.
-

RESULTS
Fourteen of the 50 sample patients (28%) could be described, in the author's opinion, as pre-
senting a definite likelihood of serious violence if released to the community. Essentially,
these are patients with a history of very serious violence who were still very psychotic and/or
antisocial. They will be described, in no particular order, as briefly as possible. It should also
be noted that the patients in all of the groupings will be described in the present tense, even
though these descriptions refer to their condition at the time of the study.

• Patient 1 has a long history of crime and sadistic violence, and drug abuse. At one point,
having eloped from a mental hospital, he ritualistically murdered and mutilated a young
boy. The patient denies being mentally ill and variously admits to and denies having
committed the crime - - the ritualistic murder - - that led to his current confinement.
Although not actively psychotic on recommended dosages of medication, when his
medication has been reduced the patient has suffered decompensations marked by audi-
tory hallucinations commanding him to make ritual sacrifices, and threats of violence.
The patient still attempts to obtain weapons on the ward.
• Patient 2 murdered his roommate in an adult home and, on an earlier occasion, injured
another patient (in another facility) with a knife. He still has bizarre delusions with violent
content and if disturbed in any way becomes very angry and expresses sadistic wishes.
• Patient 3 stabbed her mother in her back, puncturing her lung. The patient remains
grossly psychotic with paranoid delusions and is violent on the ward. She has a history
of suicide attempts and alcohol and drug abuse.
 Dangerous Patients 105

• Patient 4, in 1979, slashed the face of his then girlfriend with a knife. He is still very
psychotic and expresses bizarre, paranoid delusions. He was very assaultive during a
previous stay in a civil hospital. He is HIV positive and attempts to be sexually active
with other males on his ward. He is described by the staff as having no real insight into
the fact that he is HIV positive.
• Patient 5 cut the throat and killed a stranger (with a broken bottle) while bizarrely delu-
sional. He was also involved in two previous murders, holding down the victims while
others killed them. The patient is still delusional and, in particular, believes his purpose
in life is to rid the world of corruption.
• Patient 6 murdered his then roommate because he believed his victim was accusing him
of being homosexual. The patient has a previous history of arrests for robbery and
assaults. Although nonviolent on the ward, the patient remains delusional: he hears voic-
es of demons; claims that other patients on the ward interfere with his body, especially
during his sleep, and want to have sex with him; and maintains that his victim is not dead.
• Patient 7 murdered a neighbor's child to hurt the neighbor (who, the patient believed,
supposedly claimed the patient was a prostitute). The patient still has many paranoid
delusions and says she will get back at her enemies by getting at their children.
• Patient 8 assaulted his mother with a knife and almost killed her. The patient had delu-
sions that his mother had taken away his body. The patient was also a serious drug
abuser since the age of 14. The patient is very psychotic and violent on the ward with-
out antipsychotic medication. Although currently compliant with medication orders and,
with medication, cooperative and pleasant on the ward, he denies that he has any men-
tal illness or problems with illegal drugs and claims that he doesn't need treatment.
• Patient 9 has a long history of attacking family members. On her last release from a civil
hospital she attacked her mother, then set a fire to her apartment while her mother was
unconscious, and her mother died. The patient remains floridly psychotic and attacks
ward staff when she feels her needs are not being met.
• Patient 10 has a history of violence in and out of civil hospitals and experiences ongo-
ing command hallucinations to harm herself or others. The patient has often required
seclusion in the hospital. Her mother was abusive and alcoholic and the patient has a
history of drug abuse.
• Patient 11 stabbed a police officer with a knife because the patient believed the officer
was planning to attack her and rape her daughter. Before she was forced to take med-
ication, the patient was assaultive on the ward and believed that staff members were
having affairs with her husband. She continues to deny any need for medication and
states that she will not take medication when released from the hospital.
• Patient 12, in 1977, was charged with a sexual assault on a young woman. He was hos-
pitalized most of the time through 1987, when he again sexually assaulted a young
woman in the hospital. Although currently not a management problem on the ward, and
although he states that he understands that he should not touch women without their
permission, he chronically hallucinates hearing female voices speaking to him with sex-
ual content, and he frequently talks about how attracted girls are to him. He seems to be
preoccupied with fantasies and his speech is often incomprehensible or autistic.
• Patient 13 set fire to her home because, overtly, the patient was angry about her high
electric bills. In the fire, the patient's mother, who was living with her, suffered second
degree burns and subsequently died. The patient is not regularly compliant with her pre-
scribed medication (lithium) and when not compliant becomes grossly psychotic and
violent on the ward.
• Patient 14 has a history of repeated robberies and sodomy as a juvenile. His instant offense
involved threatening a 14-year-old boy with a knife for his money. After obtaining the
106 T. R. Litwack

boy's money ($14.00), the patient took the boy to a roof top and threatened to throw him
off the roof if he didn't come up with more money. He released the boy only after strip
searching him. The patient has had many psychiatric hospitalizations since childhood and
a history of mixed substance abuse. He has been involved in many violent incidents on
the ward - - including attacking a sleeping patient and attempting to force sex on other
patients - - and the staff feels that many other incidents are avoided only through their vig-
ilance. The patient is hyperactive and childish, often exhibits irrelevant speech, and
reports visual hallucinations and preoccupations with thoughts of the devil and the like.
Nevertheless, the patient refused medication and the hospital had to obtain a court order
to medicate the patient.

Three patients (6%) exhibited, it appeared, a definite likelihood of some violence - - but
not necessarily very serious violence - - if released to the community. These were all patients
with a history of repeated, but not terribly serious, assaults who remained assaultive, impul-
sive, and/or psychotic on the ward and/or would not involve themselves in treatment.

• Patient 15 has a history of repeated arrests and hospitalizations for repeated, though rel-
atively minor, assaults and arson. He continues to assault and threaten staff and other
patients (in an infantile manner) and has attempted to set fires in the hospital. He
exhibits borderline intelligence and signs of brain damage. (He has a history of child-
hood meningitis and seizures.) More recently this patient became less violent and more
cooperative and was being considered for transfer to a nonsecure facility. Indeed, he was
recommended for transfer, but then regressed as his transfer date drew near.
• Patient 16 has a history of frequently attacking people without provocation - - usually
from behind and sometimes with objects - - because of delusions and alcohol or sub-
stance abuse. She has also has a history of assaultiveness in, and elopements from, civil
hospitals. She evidences no remorse for her assaults in the past and does not believe her-
self to have any problems. She continues to intimidate weaker patients; however, on
medication, she has now been significantly less assaultive than she had been in the past.
The ward staff had some disagreement about this patient. The staff completely
agreed that she could not safely be released to the community. At least one staff mem-
ber felt, however, that if taking proper medication the patient could safely be maintained
in a civil facility or even, possibly, in a supervised group residence. This staff member
also maintained that there were more assaultive patients housed in nonsecure facilities.
Other staff members argued that the patient's assaultiveness had decreased recently pri-
marily because the staff had learned to intervene quickly to calm her or control her when
she became angry and because she had learned to tell the staff when she felt someone
was bothering her whom she might assault without staff intervention. They also point-
ed out that the patient would be likely to elope from a nonsecure facility and that she
would have greater access to alcohol and illegal drugs in a community residence.
• Patient 17 has a history of repeated robberies - - most commonly purse snatchings - - and
self-destructive behavior in the community. Institutionalized on and off since he was 8
years old, the patient suffered a head trauma at the age of 10, and is diagnosed as having
an organic personality disorder. He has had frequent psychotic episodes during which he
evidences incoherent or irrelevant speech, a flight of ideas, and outbursts of rage. Recently
he has voiced hearing voices telling him to kill himself, and in the past he has swallowed
sharp objects to experience pain. He has a history of eloping from nonsecure facilities.

One patient (2%) posed a definite likelihood of committing criminal acts (but not neces-
sarily violent acts) if returned to the community.
 Dangerous Patients 107

• This patient (Patient 18) had often attempted to rob banks by passing threatening notes
to tellers. He has a long history of arrests, hospitalizations, elopements, and drug abuse.
He reports auditory hallucinations and delusions of being "king of the universe" and
sometimes exposes himself to female staff. He states that he does not want to be trans-
ferred; that if transferred he would elope; and that after eloping he would go back to
drugs and alcohol and would rob banks again so he could get into prison.

Thus, it is worth noting, 18 of the 50 patients (36%), it appeared, were virtually certain to
commit serious criminal acts if released to the community.
Five of the patients (10%) posed, I believe it could fairy be said, at least a high risk to
commit serious violence if released to the community. While their violence was neither so
repetitive in the past nor so continuing into the present as to make it virtually certain that they
would be violent again if released, the risk of violence they posed was manifest and, it would
seem, clearly unacceptable.

• Patient 19 raped an elderly lady and is still obsessed with sex. He is of borderline intel-
ligence with evidence of organic deficits and states: "If you need sex you get it."
• Patient 20 stabbed and killed his college roommate because of paranoid delusions that
his victim was planning to attack him. He still believes that he can read people's minds
and tell if they are against him, and he believes he has the right to attack his enemies.
He resists treatment and has no insight into having a mental illness.
• Patient 21 repeatedly stabbed his father's girlfriend with an ice pick due to delusions and
hallucinations. The patient had previous hospitalizations for assaults and suicidal
attempts stemming from hallucinations and demonic delusions. Although he is coherent
and accepting of medications, the patient continues to suffer from delusions regarding
demons, shadow governments, and the like; and he claims that "Lucifer" talks to him
and dominates him, Generally cooperative and pleasant despite his illness, the patient
occasionally becomes menacing and hostile; and in group sessions often brags that he
raped many women.
• Patient 22, while an outpatient assigned to an apartment, stabbed and dismembered her
roommate. The patient states that she received a telepathic message to kill her roommate
and that she was further justified in doing so because of an unflattering portrait of the
patient that was telecast on HBO. (The patient also states that her roommate did not like
her.) The patient is calm, friendly, and polite on the ward and discusses her crime with
a smile on her face and in a pleasant, matter-of-fact manner. Although quite coherent,
she has encapsulated, unshakable delusions. For examples, she still believes in the real-
ity of the delusions that led to her crime, and she believes she has special powers to
influence important people (including anyone who might try her for any crimes).
• Patient 23, at age 17, attempted to rape a woman on, and throw her off, a moving sub-
way train. The patient says he "has a lot of remorse" about what he did, and claims
it was because he was on angel dust at the time. However, he also expresses doubts
that he committed his alleged crime at all. The patient has a childhood history of
schizophrenia and antisocial behavior and has occasionally attacked, and frequently
threatened, staff members and other patients during his 10 years of hospitalization
following his NGRI acquittal. The patient is calmer under antipsychotic medication
- without medication he becomes irritable, tangential, and suspicious - - but he
-

denies that he has a mental illness or any emotional problem whatsoever. Indeed, the
patient denies having any problems in childhood - - despite a history clearly to the
contrary - - and claims he would have no problems at all if he was released immedi-
ately to the community.
108 T. R. Litwack

One patient (2%) could be classified as presenting a high risk of criminal - - but not nec-
essarily violent - - behavior.

• This patient (Patient 24) repeatedly robbed banks using threatening notes - - but with-
out a weapon - - because he believed he was owed money and that if he is owed money
he has a right to take it from someone else. The patient exhibits borderline intelligence
and a silly, hypermanic manner. Once before, he was transferred to a civil hospital after
promising not to rob banks again. He eloped and then robbed banks again. He still
believes various wrongs have been done to him and that he deserves to get the "dam-
ages" owed to him. More recently, he has stated that he won't rob banks anymore
because getting caught is "too much of a hassle" and because he is sure that he is about
to make a million dollars for selling the story of his life to Hollywood.

Another group of 12 patients (24%) represented what I would deem a quite substantial,
but unspecifiable risk of serious or deadly violence to self or others. That is, the risk that they
would act violently if released was perhaps not as high as it appeared to be for the "high risk"
patients. More specifically, I believe, it could not be said with confidence that, if released,
these patient would be more likely than not to commit serious violence again. But, for these
patients, the risk remained palpable and, given the magnitude of the patient's violence in the
past and, accordingly, the patients' perceived potential for violence in the future, it is fairly
clear to see why these patients were considered to be too dangerous to be released.

• Patient 25 is a 70+-year-old man who, some years in the past, shot and killed his upstairs
neighbors because he believed they were bombarding him with electric rays through his
television set. The patient is cooperative and pleasant on the ward but still feels he did
the right thing because, he feels, he had no other recourse. He still has somatic delusions
of suffering from electric rays.
• Patient 26 attempted to murder her abusive father after he berated her for attending
group therapy and after she heard voices telling her to kill him. She is very depressed
and decompensates whenever the possibility of transfer approaches. Thus, the patient
was perceived to be seriously at risk for suicide if transferred (or released). Moreover,
her family is her only support network and she remained masochistically attached to her
father.
• Patient 27 has a long history of fire setting and in-hospital assaults (though, most recent-
ly, she had been nonassaultive for over a year). Her instant offense was setting fire to a
group home to burn it down so she would have to be sent back to her family. As a result
of the fire, another resident died. The patient, who exhibits borderline intelligence, now
says she would not set a fire again, and that she knows it is wrong to do so, but she
retains grossly unrealistic expectations of returning to her family: She wants and expects
to live with her mother and sister although they do not want her home and do not even
visit her. The staff felt that this patient would be transferrable if she genuinely accepted
the reality of her family situation.
• Patient 28 murdered and decapitated his mother while on drugs. Previously he had
repeatedly threatened and attacked his brother. Actively psychotic for a year after his
crime, he is now diagnosed as a schizoid personality and is nonviolent, though some-
what hostile on the ward. Moreover, he still expresses very angry feelings toward
women and sneers at attending AA or NA groups. When transfer to a nonsecure facility
was nevertheless raised as a possibility, the patient said he would only accept an outright
release from confinement because he feared he would have to elope from a nonsecure
facility to resist the drugs he knew were available at civil hospitals. Yet, the patient was
 Dangerous Patients 109

certain he would resist drugs in the community. When the patient was scheduled to
appear before the evaluation committee, he refused to be interviewed.
• Patient 29, while being rehabilitated after a gunshot wound that left him paralysed
below the waist, developed the delusion that a certain woman had put a spell on him and
he stabbed her very seriously. The patient still believes that he is under a spell and that
is why he cannot walk. He often refuses medication and has said that he believes that
certain hospital aides are trying to kill him.
• Patient 30 killed his elderly landlord because the patient believed his victim was trying
to rape him. Prior to the offense, according to the patient's mother, the patient com-
plained of voices telling him to set himself on fire and that his mother and sister were
part of a conspiracy to kill him and take away his manhood. In the hospital the patient
has been very psychotic and verbally abusive when not taking his medication, but on
medication is friendly and helpful on the ward. However, even on medication the patient
remains psychotic and delusional. He had recently claimed that he was a CIA agent and
had a license to kill. In his interview with the Committee, when asked if he still believed
he had a license to kill, the patient became incoherent, disorganized, and grossly delu-
sional. (He claimed, for example, that he was King Solomon and that he was married to
the daughter of Elijah Muhammed.)
• Patient 31 has a history of repeated arrests over the past 5 years for assault, criminal pos-
session of a weapon, menacing, and drug possession. His family is described as being
"terrified of him." He was floridly delusional when first admitted to the hospital but,
without medication, is no longer psychotic. He is nonassaultive on the ward, but sleeps
much of the day and does not involve himself in any therapeutic activities. He admits to
mugging people whenever he needed money to buy "reefer" which, he says, he wanted
to smoke all day long.
• Patient 32 has a multiply confirmed and very long history of repeated assaults, includ-
ing at least one rape, and threats of assaults, in the community. He also has a history of
repeated elopements from civil facilities (including from locked wards in civil facili-
ties). The patient also has a black belt in karate. Diagnosed as suffering from bipolar
disorder (manic), the patient has been nonassaultive in the hospital and, although fre-
quently agitated and sometimes tangential, cooperative with ward routines. However,
the patient denies any history of assault or threats of assaults and states that he hasn't
had any mental problems for over 10 years. Moreover, he continues to telephone fami-
ly members and acquaintances from the hospital even though these individuals have
informed the hospital, which in turn informed the patient, that they do not want to hear
from him. (The patient continues to claim, however, that these individuals welcome his
calls.) The patient also claims that he has a million dollars in a bank account and owns
a town house in New York City. (Not long after the data for this study was collected,
this patient was transferred to a nonsecure facility by a judge against the advice of the
hospital staff. Shortly thereafter, the patient eloped from the nonsecure facility.)
• Patient 33 shot three female neighbors and one died. The patient claims amnesia for
what occurred and says he must have been under a spell. The patient had no prior his-
tory of arrests and hospitalizations, and he was 60 years old at the time of the offense.
The patient refuses treatment of any kind and even resists being interviewed, so it is dif-
ficult to discern if he is still experiencing delusions. Also, although he is generally calm
and quiet - - indeed, reclusive - - on the ward, as long as he is let alone, he becomes
enraged if he is challenged or pressured in any way.
• Because of the notoriety of this Patient 34's crime, his case must be presented in very
general terms to protect the patient's right to privacy. Patient 34 shot and killed several
people, all strangers, and without any actual provocation, because he felt they were part
110 T. R. Litwack

of a group that was conspiring against him. The patient also has a history of cocaine and
alcohol abuse, and arrests for forgery, assault, and illegal possession of a weapon. Since
being hospitalized several years ago after being adjudicated NGRI, the patient has been
nonviolent in the hospital and has not evidenced any clear signs of psychosis. The
patient is also intelligent and articulate and expresses remorse for his crime. The patient
does not require medication.
However, the patient continues to describe his crime as an essentially impulsive act
triggered by drug abuse and committed in a dissociated state although the facts of the
crime - - and the patient's statements to the police after his arrest - - clearly indicate that
the crime was planned well in advance. Thus, the patient has yet to confront the true
inner wellsprings of his grossly violent actions. Moreover, the patient continues to voice
concerns like those that led to his attack and often expresses rage - - and even makes
violent threats - - towards other patients and staff. And, despite his statements of
remorse - - and the severity of his criminal actions - - the patient has generally viewed
himself as being victimized by his hospitalization, and has not evidenced a dedicated
motivation to confront and overcome the inner problems that led to the deaths of a num-
ber of innocent people.
• Patient 35, after drinking heavily, beat his 5-year-old son and placed him on the door of
a lighted oven because he believed his son was warning him that he would burn in hell.
The patient has a history of alcoholism and substance abuse. (The patient was appar-
ently abused himself in childhood by his alcoholic parents.) During a previous transfer
to a civil facility the patient would have good periods without medication only to be fol-
lowed by episodes in which he violated rules and became agitated, menacing, and even
psychotic. Finally, after he assaulted a staff member, he was returned to the secure facil-
ity. (The patient has always claimed that he assaulted the staff member because that
individual had treated him contemptuously.) At the hospital the patient has not evi-
denced psychotic symptoms, but has occasionally required restraints. Moreover, he
menaces and bullies other patients to get his way on the ward, and has not involved him-
self in therapy. In general, his attitude has been that his confinement is unjustified and
that he does not have any serious problems apart from those caused by his unfair treat-
ment at the hands of others.
• Patient 36: killed his wife 20 years ago because he believed she was having sex with
other men and planning to kill him. (He slashed his wife's throat and nearly decapitat-
ed her.) The patient still maintains he did the right thing because, after his wife's broth-
er refused the patient's request to take his wife back to Italy (their native country),
killing his wife was, he believes, the only "dignified" option he had.
The patient has also had other delusions: When depressed he has seen the Virgin
Mary telling him he was bad and had to be punished; he has complained that his food
was being poisoned; and during more elated moods he has heard radio and television
messages telling him how his family should conduct its affairs. In addition, the patient
has a persistent and fixed delusional idea that he has a special relationship with a cer-
tain supposedly powerful (but, in fact, utterly imaginary) figure in the Italian Community
who, the patient believes, sends the patient messages over the radio or television warn-
ing the patient about dangers to himself or his family and giving instructions to the
patient. The patient then calls his family insisting that they follow the advice his has
been given; and he becomes very angry at them when they don't follow the directions
he claims he has received.
The patient's family wants the patient to remain hospitalized; and the patient had
been violent toward his (still living) sister in the past. The patient also blames his fam-
ily for the death of his mother (from a brain tumor). However, although the patient often
 Dangerous Patients 111

loudly expresses anger toward various family members - - and family members have
claimed that he has threatened them - - when asked if he would physically harm other
family members if he were with them and they did not follow his directions, the patient
indignantly responds: "How can you think that I would kill someone of my own blood?"
The patient has no insight into the fact that he is mentally ill and takes medication
only when, and because, he is pressured to do so. Without medication he has been occa-
sionally violent in the hospital. The patient believes there is nothing wrong with him and
strongly desires to be returned to his family.

Four patients (8%) were viewed by their treatment teams as posing some risk of violence
but an assumable risk if certain conditions were met. That is, these patients were viewed as
being transferable to a nonsecure facility - - and perhaps even released - - if they maintained
their current stability somewhat longer and were provided with suitable supervision if trans-
ferred or returned to the community.

• Patient 37 has a history of repeatedly robbing elderly people to obtain money to buy
drugs. She evidences no signs of psychosis, attends therapy groups regularly, and voic-
es a strong commitment to change. This patient is one of the relatively few NGRI
patients at the facility - - about 10% of that population, according to interviews with the
hospital staff conducted by the author - - that the hospital staff believed should not have
received an NGRI disposition. (Patients 34, 35, 42, and 45 were amongst the others.)
The patient is diagnosed as an antisocial personality. The patient's family wants her
back with them and say they will monitor her compliance with any conditions of release.
• Patient 38, some years in the past, repeatedly stabbed his father in bed with a knife
because of paranoid and bizarre fears of being attacked. For years after his hospitaliza-
tion, the patient continued to attack other patients because of fears of attack. However,
after being placed on lithium the violent incidents ceased, although the patient remains
very regressed and still has delusions that other people are severely harming him (stab-
bing him, taking body parts from him, and the like). However, as just noted, the patient
is no longer acting on his delusions and his family wants him home and says they will
see to it that he takes his medication.
• Patient 39 has a history of one known serious assault in the community: He held the
victim while others robbed him and then the patient punched the victim several times
in the face. (He was probably found NGRI because his long history of psychiatric hos-
pitalization stemming from childhood.) The patient is diagnosed as suffering from
chronic, undifferentiated schizophrenia and exhibits severely limited intelligence. (He
has difficulty computing his own age.) Originally violent on the ward, the patient is
now compliant with medication and nonviolent, although still actively psychotic. The
patient complains of hallucinations and intrusive thoughts, often involving sexual and
aggressive feelings. Without medication, he voiced grandiose delusions, murderous
auditory hallucinations, and threats to kill his parents. Though, as noted, now compli-
ant with medication, the patient still exhibits no insight into the fact that he is mental-
ly ill.
• Patient 40, in a manic state (perhaps drug induced), attacked and seriously injured three
police officers. Before complying with medication orders, he would have manic
episodes and accompanying violent incidents on the ward. Now compliant with med-
ication, his mental state and behavior have improved considerably. However, he has
varying insight into the nature of his condition and his problems with drug abuse. (For
quite a while he refused to attend the "mentally ill chemical abusers" [MICA] group
because they didn't serve coffee,)
112 Z R. Litwack

Ten patients (20%) could perhaps best be characterized as presenting a questionable but
worrisome risk of serious violence. While these patients represented an articulable risk of
severe or repetitive violence, they also presented important ego strengths and some good
prognostic signs. I would differentiate these cases from those I have labelled as posing a
"substantial, but unspecifiable risk of serious violence" by the fact that the individuals about
to be described are less or nonpsychotic, show more ego strengths, and/or have more insight
into their vulnerabilities than the former group. I believe it is fair to say that most of these
patients were viewed by the clinical staff as presenting unusual - - or unusually difficult - -
diagnostic challenges. It is noteworthy that if these patients were serving ordinary criminal
sentences that were expiring, they would almost certainly not be civilly committable under
generally accepted civil commitment standards and practices.

• Patient 41, 10 years in the past, stabbed and attempted to murder his then girlfriend
because he believed she was conspiring in a life-threatening plot against him. He is
bright and artistic and for some time has been nonviolent on the ward and shows no
signs of psychosis. However, although he has friendly relationships with members of the
nonprofessional staff, he refuses to be interviewed by the professional staff.
• Patient 42 shot his parents while under the influence of "angel dust." Diagnosed as an
antisocial personality with severe narcissistic features - - and another of the relatively
few NGRI patients at the facility who were viewed by the staff as not deserving of an
insanity acquittal and as a patient who would more properly be confined in prison - - he
had a history of assaultive behavior and drug abuse well prior to his present hospitaliza-
tion. Originally assaultive on the ward for some time, he has now been nonassaultive for
over a year, although he still occasionally makes threats (and threatening gestures) which
he says are not important because he doesn't act upon them. The patient participates very
actively in many programs and is a dedicated student in the hospital's education program.
However, as noted, the patient evidences extreme narcissistic features. For example,
he will spend half an hour in front of the bathroom mirror each morning to comb his hair
to perfection - - intimidating other patients who might want space before the same mirror
- - and he can become enraged if what he believes to be his territory is interfered with or
if he is not given the attention or deference he feels he deserves. Moreover, although the
patient states that he realizes now that he "can't handle" illegal drugs, he denies that he
ever "needed" them or, therefore, that he would have a problem resisting them in the com-
munity. (The patient's attendance and participation at NA meetings has been sporadic.)
Thus, there is a serious question whether the patient could and would resist drugs in
the community - - or even in a nonsecure facility - - and whether he could control his
anger when, as inevitably would be the case (perhaps quite often), his narcissistic expec-
tations and demands were challenged, or at least not met, in an unsupervised environ-
ment. (One clinician raised the additional point that the patient would need considerable
funds to fulfill his narcissistic needs, and that, in all likelihood, he could obtain such
funds only by selling drugs or engaging in some other form of criminal activity.) On the
other hand, it is generally recognized that the patient is not very different from many
convicted offenders who are released from prison after their sentences expire.
• Patient 43 murdered two strangers and attempted to murder (and seriously injured) sev-
eral other people in response to command hallucinations. He has a history of prior hos-
pitalizations in his native Latin American country (from which records cannot be
obtained) but also apparently had long stretches of relatively good functioning before
his offense. He is now very cooperative, helpful, and even altruistic on the ward, takes
his medication willingly, shows no current signs of psychosis, and readily states that he
was mental ill and that he knows he must continue to take his medication. Exhibiting
 Dangerous Patients 113

relatively good insight, I believe (and certainly more insight than is exhibited by most
of the patients), he also attributes the psychotic break he suffered, at least in part, to the
fact that shortly before the episode in question he had lost his father, his girlfriend had
left him, he had become homeless and, therefore, he felt "destroyed as a person."
However, the patient has a history of complying with, and then resisting, medication.
For some time, he resisted the idea that he could still be vulnerable to mental illness even
if he felt well. Moreover, he has no social supports in the community and he claims he will
avoid romantic relationships with women in the future to be sure he will not have to suf-
fer the pain of rejection again. In addition, despite having spent many years in the United
States, the patient, who is Spanish speaking, has yet to learn to speak English (and thus
can be interviewed only via an interpreter). All in all, therefore, it is very difficult to assess
whether the patient can sufficiently avoid the stress of loneliness - - and other communi-
ty and financial stresses - - to avoid a reoccurrence of his psychosis (which, it must be
noted again, let to great harm in the past) if he is released to the community without a guar-
antee of sufficient social supports and supervision. (Note: At the hearing, the judge refused
to transfer this patient to a nonsecure facility and the patient exercised his right under the
law to have a jury decide upon his request for transfer. The jury decided in his favor.)
• Patient 44 stabbed another man in the face because, in the patient's words, "he was
messing with me." The patient has a previous history of assaults and a characterologi-
cal attitude that violence is a legitimate way to respond to people who "mess with you."
The patient refuses treatment and has eloped from nonsecure facilities in the past.
However, he is not psychotic, has been cooperative and nonviolent on the ward, and is
even very caring of other patients who are physically ill.
• Patient 45, probably while on drugs, cut his sister with a knife to get her to tell him
where his 4-month-old son was. (His son's mother was hiding from the patient.) To
escape the patient's attack, his sister jumped out of her window and died. The patient
has a history of attacking family members, and subsequent hospitalizations, since he
was 6-years-old. He also has a history of paranoid thinking (that people were reading
his mind and/or conspiring against him) but, while on high doses of haldol, the patient
has been free of overt psychosis. Except for frequently engaging in provocative "horse-
play" with other patients, the patient has been nonviolent and cooperative on the ward
and even protected the ward psychiatrist from an attack by another patient.
However, the patient denies having a mental illness and approximately a year in the
past developed an erotomanic attachment to a female member of the professional staff.
Although he recognizes that he has had "disturbed thinking" in the past, he considers
that a thing of the past and says he has "no problems" with his feelings now. The patient
attributes his attack on his sister entirely to his use of illegal drugs. Although he accepts
his prescribed medication because, he says, it helps him to sleep and to feel calm, he
also says he would prefer not to take his medication because it impairs his ability to
adhere to Islam. He has a history of elopement from nonsecure facilities.
• Patient 46 decapitated his uncle, in the street, with a hatchet. For years after the crime the
patient stated that he did so because a vision showed the patient that his uncle was having
sex with the patient's wife and because the vision told the patient to kill his uncle. More
recently, the patient has denied that he was mentally ill and states that he killed his uncle
because his uncle had "disrespected" the patient for years and because his uncle had raped
him as a child. (This may well be true.) In any event, some years earlier, the patient was con-
victed of manslaughter for participating in a robbery during which the victim died. There is
also evidence that he sexually abused his then 10-year-old daughter. (For a time the patient
expressed the fear that if released he would sexually abuse his granddaughter, but more
recently he has refused to discuss the subject, saying that it was a thing of the past.)
114 T. R. Litwack

Presently, the patient is not overtly psychotic and not on medication. He is intelligent,
articulate, coherent, and an excellent worker in the hospital's housekeeping program. (In
the community, prior to his hospitalization, the patient apparently operated has own busi-
ness.) He is nonviolent and generally cooperative on the ward, although he often express-
es anger toward the staff when he feels he is being slighted and is generally angry about
what he feels to be his unnecessary hospitalization. He denies that he has any need for treat-
ment - - he claims he has had enough therapy - - and angrily insists that he has a right to
be released solely because he has been perfectly well behaved in the hospital. He resists and
resents efforts by the treatment staff to explore his feelings - - even though he admits to
having many "negative thoughts" - - arguing that he is in complete control of himself. The
patient's family is very hostile to him, and he has no other supports in the community.
• Patient 47 killed a women after they had sex together because he saw her lighting can-
dies and believed she was using witchcraft against him. The patient also has a history of
bizarre suicide attempts (at one time he lied down in a street in the midst of passing traf-
fic) and suicidal command hallucinations. For some time, the patient has shown no overt
signs of psychosis, is not on medication, and is nonviolent on the ward. However, the
patient blames his crimes entirely on the fact that he had been fasting at the time. Indeed,
he denies having had any emotional problems in his past - - despite his history of sui-
cide attempts - - and states that he was "almost a perfect person" until he fasted (and
that he fasted to become even more perfect). The patient says that he will avoid future
problems by not fasting and by not having women to his apartment. He refuses to dis-
cuss his crime in therapy, saying he is sure it could not happen again.
• Patient 48 killed his grandmother by hitting her with a chair because he believed she had
put semen in a plate of food that she had served to him. Initially violent on the ward, he
has been a cooperative patient for some time now although, partially because he is very
effeminate and partially because he can be verbally provocative, he has sometimes been
attacked by other patients. He is not on medication, and is not grossly psychotic, but he
still evidences severe borderline features (or possibly transient psychotic states). For
example, he has claimed that his parents are not his real parents and that he is Prince
Charles. Later, however, he will say that it was just a fantasy.
The patient remains very angry toward his father. Prior to his crime his parents had
banned him from their home. He sometimes talks about the murder of his grandmother,
when he is willing to talk about it at all, in a bias6 manner and with few signs of genuine
remorse. At other times, evidencing borderline "splitting," he has voiced suicidal thoughts
over her murder (and at still other times he has variously claimed that his supposed sui-
cidal thoughts were just a fantasy or part of a government plot to keep him confined).
It is also noteworthy that whenever the patient has approached eligibility for trans-
fer, he has deteriorated. For example, at his last court heating (during the pendency of
this research), which the patient requested to obtain a transfer to a nonsecure facility, the
patient, while simply waiting for his somewhat delayed hearing to begin, spontaneous-
ly began to shout incoherent accusations at the judge and had to be removed from the
courtroom. And during his next meeting with the Evaluation Committee, the patient
claimed that there was no need for him to talk about his murder of his grandmother and,
when pressed to do so, stormed out of the room.
• Patient 49, now 70 years old, at the age of 60 beat and killed another man who had come
up to his room in a rooming house. The patient claims the other man was trying to rob
him. Significantly, however, the patient castrated his victim, after killing him, and then
stayed in his room with the body for 3 days. Approximately 20 years earlier, while hos-
pitalized in another psychiatric facility, the patient was convicted of killing another
patient and was incarcerated for 18 years. The patient views both murders as accidents,
 Dangerous Patients 115

or otherwise not his fault, and says that his second victim asked him to kill him as he
was dying from his injuries inflicted by the patient.
Although he denies he ever was mentally ill, the patient had several hospitalizations
since the age of 22, and was twice convicted of robbery. The patient is in good physical
shape for his age and says, proudly: "I was always a fighter and I ' m still a fighter."
However, the patient is nonviolent - - if withdrawn and guarded - - on the ward, takes
his prescribed antipsychotic medication willingly - - because, he says, its helps him to
sleep - - and is currently free of symptoms of psychosis. The patient denies that he needs
medication to help him remain free of violence.
Note: The question in this case is whether the patient can be counted on to be nonvi-
olent in a nonsecure facility. He is not viewed as an elopement risk: For many years he did
not even want to be transferred, saying that he was content to be in the hospital and that
he had a "good life" in prison after his f'wst murder conviction. Moreover, when asked if
he would like to be released outright, he says: "Where could I live? I wouldn't want to
sleep on the street." And, in a civil hospital, he could be monitored for compliance with
his medication regime. But given the patient's history of two murders and the lack of any
change in his personality structure, can the risk to patients in a nonsecure facility be taken?
• Patient 50 shot and killed a stranger while under the delusion that he, the patient, was a
police officer and that the victim was about to shoot him. The patient also had the delu-
sion that he was "born to be a police officer and to carry a gun." In addition, the patient
has a history of repeated arrests for pedophilia (performing fellatio on young boys).
(There is some, but uncertain, evidence that the delusions that led to his instant offense
were triggered by a sexual episode with a boy.)
Prior to receiving medication the patient had no insight into his illness and claimed
that he felt he was helping his young victims become better husbands. He also (then)
claimed that what he did was legal in England and Canada. Since receiving medication - -
upon a court order - - the patient has shown no signs of psychosis, recognizes that he was
psychotic in the past, and that it is widely illegal to have sex with children. The patient is
now cooperative on the ward and thanks the staff for getting a court order to medicate him.
However, the patient still evidences an interest in young boys (for example, pictures
of young boys were found in his locker). He does not speak of his pedophiliac sexual
experiences with apparent remorse, and does not evidence any real understanding of
why it is wrong to have sex with boys. (He knows that it is illegal but doesn't see why
it is "wrong" except that his doctors say it is.) He also states that he wants a "true love
affair" with a woman and is "sure" he will have it, even though the patient has never
had a relationship with a woman.
The patient seems to well understand the consequences to him should he elope from a
nonsecure facility, but he also has a history of escape attempts from nonsecure facilities. The
patient wants to return to his family and his family has said that the patient can live with
them, and that they would monitor his compliance with his medication orders. However, his
family is itself disturbed: His mother has a history of experiencing persecutory delusions
and the gun the patient used to kill his victim was given the patient by his uncle.

DISCUSSION
The aim of this survey project was to describe the nature of the perceived dangerousness of a
representative sample of a reasonably well defmed group of "mental patients" who were legal-
ly confined in a secure facility on the grounds of their supposed "dangerousness." More specif-
ically, the aim of this evaluation was: (a) to provide information that would usefully guide future
research projects regarding the evaluation of dangerousness by detailing the variables and con-
siderations that clinicians often focus upon in evaluating (and determining) "dangerousness";
116 T. R. Litwack

and (b) to provide a more detailed and comprehensive picture of the dangerousness of a sample
of "mental patients" confined in a secure psychiatric facility on the grounds of their supposed
dangerousness (under current legal requirements) than has heretofore appeared in the literature.
The study was not designed to confirm or disconflrm any particular hypotheses. Nevertheless,
certain, necessarily tentative, propositions may appear to emerge from the data.

Regarding Previous Reseach

However accurate, or inaccurate, predictions of violence may be on the whole (and this study
certainly did not scrutinize a representative sample of patients who are confined to hospitals
on the grounds of their dangerousness) there may well be subgroups of mentally ill individ-
uals - - such as those characterized above as posing a "definite likelihood" or even "high
risk" of serious violence - - that can be determined, with reasonable confidence, to be too
dangerous to be at liberty in the community. On the face of things, at least, many of the
patients in this sample of patients confined in a secure facility would clearly appear to pose
too great a risk of violence - - given their (then) current mental state - - to warrant any seri-
ous consideration of release. And, as noted above, the only way to test the validity of such
suppositions would be to release such manifestly dangerous patients and await the results.
Studies that have been done in the past of the (relatively little) actual violence committed
by supposedly dangerous patients who were, nevertheless, released from secure institutions do
not contradict the notion that at least some identifiable mental patients pose a very high risk
of violence. Indeed, the findings of these earlier studies cannot properly be taken to refute the
legitimacy of confining any of the patients described in this study (though, of course, the legit-
imacy their confinements could still be questioned on a variety of other grounds).
For example, in the well known "Baxstrom" studies (Steadman & Cocozza, 1974, 1980),
only a small percentage of a large number of supposedly dangerous patients transferred from
a secure correctional facility to civil facilities as a result of a court order subsequently exhib-
ited sufficient violence to require their return to a secure facility. But the determinations of
dangerousness at issue were not extensive, individualized clinical assessments of dangerous-
ness but, rather, "administrative decisions" (Baxstrom v. Herald, 1966, n. 3) or "global assess-
ments" (Steadman & Cocozza, 1980, p. 212). Moreover, the great majority of the Baxstrom
patients - - many of whom were quite elderly to begin with - - did require continued confine-
ment (albeit in ordinary civil facilities); and, in the reports of the Baxstrom research, no details
were provided regarding the clinical conditions of a representative sample of the Baxstrom
patients, and the outcomes of their cases, such as would allow for meaningful comparisons
with the sample of patients, and the determinations of their dangerousness, described here.
It may be particularly noteworthy to compare the determinations of dangerousness described
here with those at issue in the study reported by Thornberry and Jacoby (1979), a study which
investigated a situation, and yielded results, comparable to that of the Baxstrom studies. The
Thornberry and Jacoby study is perhaps the most detailed study reported to date of the conse-
quences of releasing supposedly dangerous mentally ill individuals from secure confinement.
Over a 4-year period, Thornberry and Jacoby followed up 586 men who had been confined for
an average of 14 years in a secure "psychiatric" facility and who were transferred to civil facil-
ities after a court order required that the men - - largely convicted, mentally ill offenders whose
sentences had expired - - were constitutionally entitled to be evaluated in a regular civil facili-
ty for proper placement, or possible discharge. The secure facility - - Farview Hospital in
Pennsylvania - - had not transferred the men on its own initiative, though it had the authority
to do so, because the hospital had concluded that the men were too dangerous for transfer.
Within 6 months after transfer, 31% of the patients had been released to the community;
within a year, 48%; and, ultimately 65% were discharged (30% of the study patients were never
discharged during the study period, and 4% escaped). Among the patients at risk for violence in
 Dangerous Patients 117

the community (including the escapees and patients on long-term leave from the "transfer" hos-
pitals) only 23.7 were rearrested during the follow-up period, and only 11% for violent offens-
es (which, however, included arrests for three homicides, one rape, 17 robberies, and 17 charges
of aggravated assault and battery). When the authors added rehospitalization, as well as arrests
for violent acts as indicia of violent recidivism, only 18% of their sample were considered to
have recidivated "after forty-eight months of exposure to risk" and "regardless of the serious-
ness of the a c t . . , many [of which] were relatively minor" (Thomberry & Jacoby, 1979, p. 192).
And within the civil hospitals, the "transfer" patients as a group committed few acts of violence.
The findings of Thornberry and Jacoby (1979), like those of the Baxstrom studies, cer-
tainly do indicate that, in the relatively recent past, many mentally ill individuals have been
needlessly and wrongfully confined in secure facilities because of erroneous assumptions
and/or claims that they were too dangerous to live in less restrictive conditions, and that con-
finements on the grounds of dangerousness deserve careful judicial scrutiny. Again, howev-
er, it is important to contrast the patient population studied by Thoruberry and Jacoby with
the patient population assessed as dangerous here. Many striking differences appear.
To begin with, the patients studied by Thoruberry and Jacoby had far less violent histories
than the patients described here, who have been confined to secure facilities under current,
stricter legal standards: Only 6.5% of Thornberry and Jacoby's (1979) sample had been con-
fined for committing a homicide, 46% were confined for nonviolent crimes, and 13% were
confined for committing simple (i.e., nonaggravated) assaults or threats. By contrast, 44% of
the sample of patients described here were confined for committing a murder, and most oth-
ers could be considered to have committed attempted murder or very serious assaults. (It is
also noteworthy that Thornberry and Jacoby's sample had exhibited little reported violence
during their many years in Farview. The mere fact that nearly half of their sample was
released from confinement within 1 year of their transfer to civil facilities indicates that their
sample was indeed far less at risk for violence than the sample described here.) Moreover,
the mean age of their sample was 47 (median age = 46) at the time of their transfer from
secure confinement - - nearly 10 years older than the mean and median ages of the sample
presented here - - and the average age of their discharged patients (at discharge) was 46.
Not surprisingly, "assessments" of dangerousness upon which Thornberry and Jacoby's
(1979) sample was kept confined in secure facilities were also far different from the assess-
ments that led to confinement for the sample of patients presented here. Until the lawsuit that
led to their transfer to secure facilities (Dixon v. Attorney General of the Commonwealth of
Pennsylvania [1971]), the "Dixon" patients were afforded no judicial review or monitoring of
their confinement. Indeed, "the law did not require periodic review of each case, even by the
Farview staff" (I'hornberry & Jacoby, p. 6) and it allowed for indefinite commitments, without
stated criteria, at the discretion of the hospital director. Thus, Thornberry and Jacoby observed:

A patient could be kept indefinitely and the state did not have to justify the continued confine-
ment of the patient. Indeed, an examination of Farview records suggests that a patient's mere
presence at Farview constituted prima facie evidence that he should remain. (p. 6)

And, after observing that the predictions of dangerousness at Farview could best be termed
"political predictions" (p. 26), rather than clinical or statistical predictions, Thornberry and
Jacoby (1979) went on to observe that:

Because the state maintained a policy of continued confinement from the criminally insane, and
because negative consequences would follow the erroneous prediction of nondangerousness, the
Farview staff predicted that most of the Dixon patients would be dangerous after release and
accordingly retained these patients at Farview. (p. 33)
118 T. R. Litwack

Obviously, therefore, the validity, or invalidity of the "predictions" of dangerousness at

issue in the study of the Dixon patients are utterly irrelevant to evaluating the validity and/or
legitimacy of the assessments of dangerousness described here.
It may also be worth noting potentially significant data which Thornberry and Jacoby
(1979) did not report. According to the authors, "during the two years that the Dixon case
was in litigation, members of the Dixon class were evaluated by the Farview staff" and 107
patients "were considered to be too dangerous for release to a civil hospital or the commu-
nity" (p. 22). Thus, it should also be noted in passing, once even a semblance of an indi-
vidualized examination was performed by Farview on the Dixon patients, only a distinct
minority were still deemed to be dangerous. Three descriptions of such patients are provid-
ed - - two of which are not very different from the descriptions of patients deemed serious-
ly dangerous in the present sample (although Thornberry and Jacoby did not indicate the
ages of these patients). Unfortunately, however, no information is provided regarding the
outcomes of these cases. Such information might have been very instructive. 1
Contrasting the findings of this study with one other often cited study of assessments of dan-
gerousness by mental health professionals, that of Kozol, Boucher, and Garafalo (1972) - -
which supposedly found that two-thirds of patients released by judges despite psychiatric
assessments of dangerousness did not act violently in the community - - it must be emphasized
that the patients followed up in that study were, indeed, patients released by judges (against
psychiatric advice) and, therefore, must have represented a very different group of patients from
those who have been described here (all of whom accepted confinement or had fairly recently
been confined by judges.) It is also noteworthy that the patients released by judges and followed
up in the Kozol et al. study - - presumably a group of patients of "borderline" dangerousness
- - numbered only 49 of a total of 257 patients viewed as dangerous by the facility under study;
and even the assessments deemed in error were not necessarily erroneous "predictions" of vio-
lence but, rather, perhaps only assessments that the patients at issue posed an unacceptably high
risk of violence - - even, perhaps, if that risk was only one in three!

Regarding Commitment Criteria

The ultimate issue in determining whether (or to what degree) an individual can legally, and
ethically, be confined on the grounds of his or her dangerousness is, indeed, not whether it
can be predicted with a specified and verified certainty that the individual would be violent
if released but, rather, whether the individual poses a sufficient risk of sufficient harm to jus-
tify the confinement at issue and the resulting deprivation of liberty (Schall v. Martin, 1984;
U.S.v. Sahhar, 1991; Commonwealth v. Rosenberg, 1991; Grisso & Appelbaum, 1992).
Thus, the legitimacy of all the confinements described here must be judged by this standard.
Readers can judge for themselves, based on the information presented, whether, or to what
degree, the patients described here meet that standard. It does appear, however, that all of the sam-
ple patients (who, after all, have been confined for some time) do present clear, concrete, and
articulable reasons for concern regarding their potential for violence were they to be released to
the community in their described condition. And particularly for those patients classified as pos-
ing a "high" or "substantial" risk of violence - - together, approximately one-third of the sample
- - (much less those patients described as posing a "definite likelihood" of violence if released)
given the patients' histories of violence, their continuing psychotic and/or characterological
pathology, and the manifest and serious possible danger they would pose, if released, to the com-

lThe "Dixon" research project did not obtain separate outcome data for these apparently most danger-
ous patients. And, it should also be noted, many Dixon patients were confined in locked wards in the
transfer hospital (Joseph Jacoby, personal communication, March 14, 1995.)
 Dangerous Patients 119

munity, the question must be asked whether their continued confinement is unjustified simply
because it cannot be demonstrated with certainty that these patients would be violent if at liberty.
It must also be emphasized that we cannot rely (or realistically hope to be able some day to
rely) on actuarial studies to determine the likelihood that these patients (and other patients like
them) will be violent if at liberty. Because such patients are not likely to be released into freedom,
we do not have - - and most likely never will have - - a study that truly determines their recidi-
vism rates. (As discussed above, the results of "natural experiments" regarding patients released
from secure confmement, such as the Baxstrom and Dixon studies, are essentially irrelevant to
judging the actual dangerousness of the sample of patients at issue here.) Similarly, while actuar-
ial studies based on other patient groups may demonstrate that the presence (or absence) of cer-
tain variables may increase (or decrease) the likelihood of violence, the presence or absence of
such variables (e.g., male sex, young adult age, current paranoid delusions) cannot approach
determining the actual risk of violence presented by these, often highly idiosyncratic (and often
formerly homicidal) patients who often present risk factors that are interacting with one another.
For example, recent research reported by Link and Stueve (1994) and Swanson (1994) indi-
cates that individuals with serious psychiatric disorder have rates of violence approximately
three times those of the general public; and that mentally ill with a history or arrests or hospi-
talizations for psychotic symptoms involving feelings that one's internal controls are being
overridden by "external" factors or that one is threatened with harm from others (what Link &
Stueve term "threat/control-override symptoms") have rates of violence that are far higher than
those of the general public (or mentally ill people in general). However, while such research
clearly indicates that many of the patients in the sample described can be demonstrated, actu-
arially, to be significantly at risk for violence, such research may still underestimate the degree
of risk - - and potential for harm - - posed by individuals who exhibit threat/control-override
symptoms (or a history of such symptoms) and a history of murder or attempted murder. To be
sure, adding, in actuarial fashion, the predictive power of a history of very violent behavior to
the predictive power of the presence (or history) of threat/control-override symptoms would,
theoretically, strengthen the predictive equation. But because individuals who evidence (a) a
history of homicidal behavior, (b) psychotic symptomatology related to previous violence, and
(c) other indications of dangerousness (such as lack of insight regarding the need for medica-
tion) are not likely, or regularly, to be released from confinement, we cannot truly test the pre-
dictive power of the interaction effects of such variables.
Conversely, person-centered variables that have been shown to reduce the risk of violence
in the general population (e.g., femalehood and older age) may not sufficiently reduce the
risk of violence and potential for harm to negate a determination of dangerousness concern-
ing an individual, of whatever sex or age, who has committed murder and still has the delu-
sions (and physical abilities) that led to murder in the past (consider, e.g., Patients 7, 22, and
25). Moreover, it is questionable whether actuarial findings can adequately help to estimate
the potential magnitude of a patient's violence, if it does occur, as well as the risk of some
violence occurring, in determinations of a patient's overall dangerousness. (A patient who
poses any significant chance of committing multiple murders, for example, may well be
regarded as more dangerous than a patient who poses a 90% chance of slapping people with-
out cause.) And, most importantly, apart from the obvious relationship that can be demon-
strated between a history of violence and the risk of future violence, it is difficult to imagine
actuarial studies being much help at all in ultimately determining the dangerousness of the
most idiosyncratic sample patients (e.g., Patients 28, 34, 41, 43, 45, 46, 47, 48, and 50).

Regarding Insanity Acquittees

In Jones v. United States (1983), the Supreme Court ruled that insanity acquittees could, con-
stitutionally, be required to bear the burden of proving that they were no longer dangerous
120 T. R. Litwack

before being released from confinement. The data presented raises the possibility (though it
in no way demonstrates) that judicial decisions to release or retain insanity acquittees could
well be determined, in certain cases, by which party bears the burden of proof.
Particularly for patients such as those characterized above as presenting a questionable risk
of serious violence, it is not difficult to imagine a judge deciding that the government could not
prove that such patients posed a suffic&ntly definite likelihood of violence, were they to be
released to the community, to justify their confinement; even if it was clear that significant rea-
sons for concern remained. Conversely, it would seem, if insanity acquittees had the burden of
proving their suitability for release it would quickly resolve matters in favor of retention, in
almost all cases, if the acquittee had not been willing to fully engage himself or herself in psy-
chotherapy, regardless of how well behaved, and nonpsychotic, the patient was in the hospital.
(Such a presumption might motivate insanity acquittees to involve themselves meaningfully in
therapy.) And, it might be added, after a defendant (now the patient) has argued, via an insani-
ty defense, that she or he should be given extraordinarily lenient treatment, regardless o f the
severity of her or his criminal acts, because he or she was mentally ill at the time - - and after,
because of a successful insanity defense, the defendant has indeed received unusually lenient
treatment - - is it unreasonable to require the patient to prove, via a serious and committed
engagement in psychotherapy, that she or he no longer has the psychological and charactero-
logical vulnerabilities that led to violence in the past in order to justify her or his release?
However, a very different policy option regarding insanity defense acquittees may also be
considered to emerge from the data. Perhaps it would be asking too much of insanity defense
acquittees who have committed serious crimes to demonstrate that they are no longer even
significantly vulnerable to recidivism before they are eligible for release. Perhaps, rather,
insanity defense acquittees should be sentenced to fixed sentences commensurate with the
crimes they have committed. However, insanity acquittees - - unlike individuals found to be
"guilty but mentally ill" - - would serve their entire sentences in minimally punitive environ-
ments. 2 After their sentences had expired, they would simply be released, unless, of course,
they were so patently mentally ill and dangerous that they could be civilly committed.
Consider, more specifically, the patients I have characterized as presenting a "question-
able, but worrisome" risk o f future violence (20% of the sample). Barring a miraculous refor-
mation of their personalities (whether through psychotherapy, religion, or any other means),
because of their continuing character traits that were at least associated with their violence in

2In Foucha v. Louisiana (1992) a five to four majority of the Supreme Court declared unconstitutional
a Louisiana law that allowed for the continued confinement of insanity acquittees in a psychiatric hos-
pital until the acquittee "proves that he is not dangerous.., whether or not he is then insane" (118
L.Ed. 2d 437). A four-member plurality, in an opinion by Justice White, arguably concluded that an
insanity acquittee could no longer be confined once he or she was no longer either mentally ill or dan-
gerous. The four dissenters (particularly the dissent of Justice Thomas) argued that there was no con-
stitutional bar to confining insanity acquittees after they had regained their "sanity" at least until the
time of the maximum sentence(s) for the crime(s) they had committed had expired.
However, in her deciding opinion concurring in the judgment that the statute at issue was unconsti-
tutional, Justice O'Connor emphasized that she considered it to be unconstitutional only because it
allowed-for the "'indefinite confinement of sane insanity acquittees in psychiatric facilities" (Id. at
452, italics added). But, she wrote, "it m i g h t . . , be permissible.., to confine an insanity acquittee
who has regained sanity i f . . . the nature and duration of detention were tailored to reflect pressing
public safety concerns related to the acquittee's continuing dangerousness" (Id. at 453). Thus, in
Foucha, a majority of the Supreme Court - - the four dissenters and Justice O'Connor - - concluded or
leaned toward concluding that it would be constitutional to sentence insanity acquittees to fixed sen-
tences commensurate with the severity of their criminal acts, as long as they were confined in appro-
priate facilities - - which might or might not be psychiatric facilities.
 Dangerous Patients 121

the past, it is difficult to imagine any of these patients proving that they were no longer even
vulnerable to psychopathological regressions and a reemergence of violent behavior. Yet,
unless we wish to make the protection o f society our only important goal, perhaps at some
point such patients should be given a chance at liberty - - j u s t as convicted offenders are gen-
erally given a chance, regardless o f their perceived dangerousness, when their sentences
expire. (But cf. Brooks [1992], In re P u g h [1993], and In re Young [1993] regarding and sup-
porting the legitimacy o f continuing to confine "high risk" sex-offenders after their sentences
have expired.)
Such a system o f fixed sentences for insanity acquittees would also guard against the
grossly premature release o f insanity defense acquittees who committed very serious crimes
and who, though a p p a r e n t l y rehabilitated, remain dangerous. On the other hand, it would
require far longer periods o f retention than at least some insanity aequittees, who could
indeed demonstrate that they could be safely released, truly require. And, conversely, a pol-
icy o f fixed sentences for insanity acquittees would also require the release o f acquittees who,
though in fact dangerous, do not pose sufficient evidence of mental illness and dangerous-
ness to be civilly committed. Perhaps the conundrums that surround assessments o f danger-
ousness - - and the often conflicting values o f individual liberty and public safety - - allow
for no easy or unambiguous solutions.

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