When Can I Go Home?

In the 1996 Academy Award-winning movie Sling Blade, actor Billy Bob Thornton played the character Karl Childers, a mentally disabled insanity acquittee hospitalized following the murder of his mother and her lover. The story followed Childers as he was abruptly released from the hospital, without warning and without preparation, to return to the community he was raised in. Although the character was portrayed sympathetically, the film nevertheless came to an unsatisfying conclusion when Childers ultimately committed another murder and returned to his bleak, unforgiving hospital ward.

As much as I enjoyed the film, I cringed at the inaccurate and horrendous portrayal of the psychiatric care given to Childers and the cavalier disregard surrounding his release. Given that John Hinckley’s release hearing has been in the news lately, I can imagine the questions raised in the mind of the general public: How can he ever be released? How can those doctors ever know that he won’t be dangerous again? Will the public be safe from him?

The decision making process for the discharge of insanity acquittees is similar to the process for voluntary psychiatric patients in non-forensic facilities and for civilly committed patients. In all cases, the decision to discharge the patient involves an assessment of the patient’s clinical status and safety issues. Doctors consider the patient’s symptoms at the time of discharge compared to admission, the patient’s level of insight, and the aftercare required following release. For non-forensic patients, an admission is often precipitated by a short-term crisis, so a release decision may involve a review of the factors leading up to admission. Since non-forensic admissions are almost always shorter than the lengths of stay for insanity acquittees, patients experience less community disruption and are more likely to have an established support system and outpatient service to return to. Unfortunately, this also means that there is less time to plan for a release or to gather potentially useful information.

Insanity acquittees face a higher barrier to community re-entry. Because lengths of stay may last several years, support systems may become disrupted or disappear entirely. The nature of the acquittee’s offense may bar him from some community services or programs, and a program may be reluctant to accept a patient with a history of violence. An acquittee’s illness may be particularly severe or treatment resistant, which would require more intensive community services or the use of limited supervised housing resources.

Fortunately, a long length of stay also allows time for release preparation. A release decision is based upon months or years of observational data to include information about the patient’s level of insight, willingness to comply with treatment, ability to self-monitor, and problem solve. The patient must be able to consider and address factors leading up to the offense. Substance abuse and personality factors often play a role, and the patient should have a demonstrated willingness to participate in therapy for this. The clinical team considers historical risk factors as well, including previous incidents of violence and the antecedents to these incidents. He must have an identified support system to rely upon in case of relapse, and often during the hospitalization the nature and quality of this support system can be reviewed by the clinical team during visits, special events, and other opportunities for interaction. If the acquittee’s victim was a family member, consideration is also given to the nature of the remaining family members’ relationships.

Although some states do not have a conditional release option, most insanity acquittees are required to follow certain requirements in order to remain in the community. Conditional release orders establish requirements very similar to parole for convicted offenders: to abstain from abuse of drugs and alcohol, to maintain a stable living situation, to comply with required treatment, and to have some type of structured daily activity. Compared to parolees, insanity acquittees typically are monitored more closely in the community, since caseloads are lower for community providers than for parole agents. Acquittees are also aware prior to release that any violation or break in conditions may lead to a quick return to the inpatient unit. Before any release can be considered, the acquittee usually also had to demonstrate a steady progression through a security level system within the facility as well as the ability to appropriately manage limited time off hospital grounds. Each change in security level involves some procedure for review or revision if indicated.

While some release processes do involve the use of formal risk assessment instruments, there is no single test that predicts successful transition to the community. And no release decision can ever be completely risk-free. Given the degree of review and planning leading to a recommendation for release, it is no surprise that insanity acquittees recidivate at a fraction of the rate of non-mentally ill parolees.

The biggest difference between the release of insanity acquittees compared to voluntary non-forensic patients is that ultimately, an insanity acquittee can only be released by a judge. Although the hospital staff and treating psychiatrist can make a recommendation about readiness for discharge, judges can disregard those recommendations. If the offense was particularly egregious or notorious, or if the case was a high-profile event with political fallout, non-clinical considerations can come into play. Some patients may demonstrate decades of symptom-free, non-violent behavior to no effect.

When a forensic patient asks his psychiatrist, “When can I go home?” the answer sometimes may be: “Never.”

<[QM—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In the 1996 Academy Award-winning movie Sling Blade, actor Billy Bob Thornton played the character Karl Childers, a mentally disabled insanity acquittee hospitalized following the murder of his mother and her lover. The story followed Childers as he was abruptly released from the hospital, without warning and without preparation, to return to the community he was raised in. Although the character was portrayed sympathetically, the film nevertheless came to an unsatisfying conclusion when Childers ultimately committed another murder and returned to his bleak, unforgiving hospital ward.

As much as I enjoyed the film, I cringed at the inaccurate and horrendous portrayal of the psychiatric care given to Childers and the cavalier disregard surrounding his release. Given that John Hinckley’s release hearing has been in the news lately, I can imagine the questions raised in the mind of the general public: How can he ever be released? How can those doctors ever know that he won’t be dangerous again? Will the public be safe from him?

The decision making process for the discharge of insanity acquittees is similar to the process for voluntary psychiatric patients in non-forensic facilities and for civilly committed patients. In all cases, the decision to discharge the patient involves an assessment of the patient’s clinical status and safety issues. Doctors consider the patient’s symptoms at the time of discharge compared to admission, the patient’s level of insight, and the aftercare required following release. For non-forensic patients, an admission is often precipitated by a short-term crisis, so a release decision may involve a review of the factors leading up to admission. Since non-forensic admissions are almost always shorter than the lengths of stay for insanity acquittees, patients experience less community disruption and are more likely to have an established support system and outpatient service to return to. Unfortunately, this also means that there is less time to plan for a release or to gather potentially useful information.

Insanity acquittees face a higher barrier to community re-entry. Because lengths of stay may last several years, support systems may become disrupted or disappear entirely. The nature of the acquittee’s offense may bar him from some community services or programs, and a program may be reluctant to accept a patient with a history of violence. An acquittee’s illness may be particularly severe or treatment resistant, which would require more intensive community services or the use of limited supervised housing resources.

Fortunately, a long length of stay also allows time for release preparation. A release decision is based upon months or years of observational data to include information about the patient’s level of insight, willingness to comply with treatment, ability to self-monitor, and problem solve. The patient must be able to consider and address factors leading up to the offense. Substance abuse and personality factors often play a role, and the patient should have a demonstrated willingness to participate in therapy for this. The clinical team considers historical risk factors as well, including previous incidents of violence and the antecedents to these incidents. He must have an identified support system to rely upon in case of relapse, and often during the hospitalization the nature and quality of this support system can be reviewed by the clinical team during visits, special events, and other opportunities for interaction. If the acquittee’s victim was a family member, consideration is also given to the nature of the remaining family members’ relationships.

Although some states do not have a conditional release option, most insanity acquittees are required to follow certain requirements in order to remain in the community. Conditional release orders establish requirements very similar to parole for convicted offenders: to abstain from abuse of drugs and alcohol, to maintain a stable living situation, to comply with required treatment, and to have some type of structured daily activity. Compared to parolees, insanity acquittees typically are monitored more closely in the community, since caseloads are lower for community providers than for parole agents. Acquittees are also aware prior to release that any violation or break in conditions may lead to a quick return to the inpatient unit. Before any release can be considered, the acquittee usually also had to demonstrate a steady progression through a security level system within the facility as well as the ability to appropriately manage limited time off hospital grounds. Each change in security level involves some procedure for review or revision if indicated.

While some release processes do involve the use of formal risk assessment instruments, there is no single test that predicts successful transition to the community. And no release decision can ever be completely risk-free. Given the degree of review and planning leading to a recommendation for release, it is no surprise that insanity acquittees recidivate at a fraction of the rate of non-mentally ill parolees.

The biggest difference between the release of insanity acquittees compared to voluntary non-forensic patients is that ultimately, an insanity acquittee can only be released by a judge. Although the hospital staff and treating psychiatrist can make a recommendation about readiness for discharge, judges can disregard those recommendations. If the offense was particularly egregious or notorious, or if the case was a high-profile event with political fallout, non-clinical considerations can come into play. Some patients may demonstrate decades of symptom-free, non-violent behavior to no effect.

When a forensic patient asks his psychiatrist, “When can I go home?” the answer sometimes may be: “Never.”

<[QM—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In the 1996 Academy Award-winning movie Sling Blade, actor Billy Bob Thornton played the character Karl Childers, a mentally disabled insanity acquittee hospitalized following the murder of his mother and her lover. The story followed Childers as he was abruptly released from the hospital, without warning and without preparation, to return to the community he was raised in. Although the character was portrayed sympathetically, the film nevertheless came to an unsatisfying conclusion when Childers ultimately committed another murder and returned to his bleak, unforgiving hospital ward.

As much as I enjoyed the film, I cringed at the inaccurate and horrendous portrayal of the psychiatric care given to Childers and the cavalier disregard surrounding his release. Given that John Hinckley’s release hearing has been in the news lately, I can imagine the questions raised in the mind of the general public: How can he ever be released? How can those doctors ever know that he won’t be dangerous again? Will the public be safe from him?

The decision making process for the discharge of insanity acquittees is similar to the process for voluntary psychiatric patients in non-forensic facilities and for civilly committed patients. In all cases, the decision to discharge the patient involves an assessment of the patient’s clinical status and safety issues. Doctors consider the patient’s symptoms at the time of discharge compared to admission, the patient’s level of insight, and the aftercare required following release. For non-forensic patients, an admission is often precipitated by a short-term crisis, so a release decision may involve a review of the factors leading up to admission. Since non-forensic admissions are almost always shorter than the lengths of stay for insanity acquittees, patients experience less community disruption and are more likely to have an established support system and outpatient service to return to. Unfortunately, this also means that there is less time to plan for a release or to gather potentially useful information.

Insanity acquittees face a higher barrier to community re-entry. Because lengths of stay may last several years, support systems may become disrupted or disappear entirely. The nature of the acquittee’s offense may bar him from some community services or programs, and a program may be reluctant to accept a patient with a history of violence. An acquittee’s illness may be particularly severe or treatment resistant, which would require more intensive community services or the use of limited supervised housing resources.

Fortunately, a long length of stay also allows time for release preparation. A release decision is based upon months or years of observational data to include information about the patient’s level of insight, willingness to comply with treatment, ability to self-monitor, and problem solve. The patient must be able to consider and address factors leading up to the offense. Substance abuse and personality factors often play a role, and the patient should have a demonstrated willingness to participate in therapy for this. The clinical team considers historical risk factors as well, including previous incidents of violence and the antecedents to these incidents. He must have an identified support system to rely upon in case of relapse, and often during the hospitalization the nature and quality of this support system can be reviewed by the clinical team during visits, special events, and other opportunities for interaction. If the acquittee’s victim was a family member, consideration is also given to the nature of the remaining family members’ relationships.

Although some states do not have a conditional release option, most insanity acquittees are required to follow certain requirements in order to remain in the community. Conditional release orders establish requirements very similar to parole for convicted offenders: to abstain from abuse of drugs and alcohol, to maintain a stable living situation, to comply with required treatment, and to have some type of structured daily activity. Compared to parolees, insanity acquittees typically are monitored more closely in the community, since caseloads are lower for community providers than for parole agents. Acquittees are also aware prior to release that any violation or break in conditions may lead to a quick return to the inpatient unit. Before any release can be considered, the acquittee usually also had to demonstrate a steady progression through a security level system within the facility as well as the ability to appropriately manage limited time off hospital grounds. Each change in security level involves some procedure for review or revision if indicated.

While some release processes do involve the use of formal risk assessment instruments, there is no single test that predicts successful transition to the community. And no release decision can ever be completely risk-free. Given the degree of review and planning leading to a recommendation for release, it is no surprise that insanity acquittees recidivate at a fraction of the rate of non-mentally ill parolees.

The biggest difference between the release of insanity acquittees compared to voluntary non-forensic patients is that ultimately, an insanity acquittee can only be released by a judge. Although the hospital staff and treating psychiatrist can make a recommendation about readiness for discharge, judges can disregard those recommendations. If the offense was particularly egregious or notorious, or if the case was a high-profile event with political fallout, non-clinical considerations can come into play. Some patients may demonstrate decades of symptom-free, non-violent behavior to no effect.

When a forensic patient asks his psychiatrist, “When can I go home?” the answer sometimes may be: “Never.”

<[QM—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.