Offenders sentenced to forensic psychiatric care do not consider their mental illness to be the main reason for their crime. Instead, they point to abuse, poverty or anger toward a particular person.

This is shown in a new doctoral thesis by Pontus Höglund, PhD student at Lund University in Sweden, and ethics coordinator within forensic psychiatry in Skåne. Pontus Höglund has conducted interviews with patients and staff within Swedish forensic psychiatry about the relationship between mental illness and the ability to assess reality, make moral judgments and control one's actions.

The patient group consisted of 46 patients from different clinics of forensic psychiatry. Only four patients considered their mental illness as the sole cause for their actions. Some found the disease to be a contributing factor, but the majority did not believe the disease to be the cause at all. (One patient, who murdered his wife when she wanted to leave him stated: "you don't have to be ill to do it -- it's more than enough to be sad and angry." )

According to the patients, substance abuse and social destitution were important background factors to the crimes. This is consistent with epidemiological studies of the relationship between violence and mental illnesses. The relationship which can initially be seen in these studies disappears if you take into account factors such as alcohol and social circumstances.

"Extremely few of the people who are mentally ill commit crimes. The connection between alcohol and violence is on the other hand clear, which means that anyone who wants to be safe should first and foremost beware of alcohol and not those who are mentally ill," says Pontus Höglund.

Having difficulty controlling one's actions and finding alternative measures was present in many of the patients' stories, regardless of their psychiatric diagnosis. Yet it is mainly the diagnoses that determine whether a person who committed a crime is considered to have done so because of a "severe mental disorder" and is to receive forensic psychiatric care rather than prison.

"In the worst case scenario, we focus on the wrong factors using the wrong methods -- both within psychiatric diagnostics, liability assessment, and care and treatment," says Pontus Höglund. He believes that we should listen far more to the individuals' own assessments of their abilities/inabilities and actions.

"Many of the staff members believed that the patients would be both unwilling and unable to answer my questions. But it turned out that they were happy to share their experiences, and were most capable of discussing these relatively complex matters," he says.

Pontus Höglund's thesis also include an interview study with forensic psychiatric staff. Informants were initially asked to assess 12 psychiatric diagnosis potential to damage one´s accountability. The result showed almost no significant differences: schizophrenia, dementia and mental retardation was regarded as most potential to damage one´s accountbility; bipolar disease and autism spectrum disorders as moderately potential and personality disorders were attributed low damage potential.

When asked to describe their way of resoning, two thirds of the interviewees responded that they had not thought about these issues before. Pontus Höglund finds this to be a bit worrisome.

"A majority of the 150 professionals that I interviewed, had never thought about the relationship between mental illness and responsible actions -- a correlation which forms the cornerstone of forensic psychiatry. Adding the almost identical rating of the diagnoses, you get what I call "unconscious consensus," a quite dangerous state, almost on the verge to madness," Pontus Höglund concludes with a big smile.

This dissertation is available online at: http://lup.lub.lu.se/luur/download?func=downloadFile&recordOId=8230955&fileOId=8230956