My brother took his life. He was 24 years old. I was 23 years old. I remember it like it was yesterday. Has it changed everything in the trajectory of my life and our family's life? Of course. Years ago, when I was sure I was in another psychotic break and I ended up running naked in the area here, doing all these weird sorts of things. And the cops came and got me and they're like, What's going on? And I couldn't speak to them. I just said, having
trouble to verbalize. And they came and got me. And when I got into psych, the psychiatrist was like, This is an example of a happy psychotic, right? So psychosis can be a happy type of psychosis. That's how I present sometimes. So it's not always violent, it's not always scary. It's doing things that are embarrassing and hard to deal with. I've experienced a lot of different trauma caused by myself
and caused by others, too. But the times that I've done things to others in my psychotic state, I don't have a filter. The filter gets turned off and suddenly I'm doing whatever the voice commands me to do. I've hurt myself and I've hurt others and had major jaw surgery in 2012 because of an accident. Listening to the voices. It's a struggle because when I'm mentally unwell, those would be things that I would normally do if I'd been
medicated and stable. I'm completely a different person in my psychotic state, completely different.
Well, there's no way to predict whether a person with a mental illness will become violent. There's still a common understanding that those diagnosed with a serious mental illness like schizophrenia are unpredictably aggressive. It's no surprise we see mental illness, substance use and violence connected in the news, on TV shows and in movies. But unfortunately, this can create fear, and this fear can be a driving force for negative
attitudes towards people living with a serious mental illness. Before we get into today's episode, here's a couple facts for us to think about. People who experience psychosis are five times more likely to be violent than the general population. But an individual experiencing psychosis is three times more likely to take their own life than another person's life. My name is Faydra Aldridge, the host of Look Again: Mental Illness Re-Examined a podcast about mental illness brought to you
by the B.C. Schizophrenia Society and other partner organizations. Today we get to speak with Dr. Rakesh Lamba. Dr. Lamba is the medical director with BC Mental Health and Substance Use Services. He is also a clinical assistant professor of psychiatry at the University of British Columbia and has a ton of experience doing risk assessments with Correctional Services Canada and with the Parole Board of Canada. Dr. Lamba, welcome to the podcast.
Thank you. Happy to be here and thanks for having me.
Thanks for taking the time. So before we jump in to the questions today, I just want to take a minute to hear some clips from people who have or are experiencing psychosis. Let's take a listen now.
He did exhibit some violence that was quite scary. He took a sledgehammer through the TV and he did take some violence to my mum at the time. It was very, very difficult. But as I know and what I've learnt, that was not him. That was the illness when he wasn't taking care of himself. I don't know if that was really her when she was that ill. And that's what I try to see. I try to think that she didn't know that her brain was hijacked at the time.
That's how it helps me get through, like knowing that my mom's brain was hijacked and that was really her when she did pull a knife on people and on the paramedics that time.
So, Dr. Lamba, what is psychosis?
Psychosis is best understood as a break from reality. Essentially, the highly confused state of mind, which has an alternative reality or a misperception of the environment that they are in. As one can imagine, such experiences can generate strong emotions in a person like fear, anger, agitation, and sometimes, unfortunately,
aggression in responding to these experiences. And the individual involves experiencing delusions and hallucinations, feelings and those experiences to be as real as you and me would consider normal experiences. They lose that insight, that ability to pause and think and consider the reality of these experiences.
Dr. Lamba We talked earlier about the association between mental illness and violence. How do you explain the relationship between psychosis and potential violence to your patients and the families that you work with?
The association between psychosis, particularly as a symptom of mental illness and violence, appears to have two common beliefs. I think it's very important to have a very balanced and nuanced view of the relationship between psychosis and violence. As you can imagine, any exaggerated concerns of this violence are indeed stigmatising and further marginalising to a population that is
very vulnerable. On the other hand, if you deny this relationship that leads to missed opportunities to treat individuals, to provide them with the help and support that they need, and may then in some instances lead to more violent incidents that only further stigmatize the group as a whole. That also has not been very clear in defining this relationship. Remote Studies first said that there is the record relationship
between psychosis, schizophrenia and violence. The latter studies were somewhat more economical, but more recent studies that use good methodology have in fact shown a consistent but modest relationship between schizophrenia and violence or the risk of individuals with psychosis. Perpetrating violence is a relative risk to the general population. But it's equally true that very few individuals who suffer
from psychosis or schizophrenia actually commit violence. And when you look at the total burden of violence in society, only about 10% of the violence is accounted for by individuals who are psychotic. Another important aspect to consider about this relationship is that violence committed by individuals who suffer from psychosis occurs most commonly during acute stages of the illness when they are untreated, in fact, even when they are undiagnosed.
So a substantial portion of patients with schizophrenia who commit acts of violence do so before they have presented for treatment. And it is not uncommon for it to come to light that a person suffers from schizophrenia only due to
this serious violent incident. The most extreme example of this is if you consider all homicides, but if untreated by individuals with schizophrenia, 40% of them were committed by patients in their first episode, they had not yet been diagnosed as suffering from the illness and hence they were untreated.
So based on what you said there, it sounds as though the key is the untreated mental illness. That seems to be the connection between psychosis and violence. Would you agree with that?
Yes, I would agree with that. And those are important factors. There are some other general factors as well amongst individuals who suffer from schizophrenia that may help assess the occurrence of violence. But very important features are the untreated symptoms.
Now, Dr. Lamba, is there any way to predict whether a person with schizophrenia or an individual experiencing psychosis will in fact become violent?
The short answer is no. And to help understand that, you have to understand the difficulties in predicting violence in general. Firstly, if you consider the word predicting, predicting simply refers to that binary decision of yes or no. Will the person be violent or will a person not be violent? Violence itself is very uncommon. Generally speaking, when you are trying to predict yes or no for an event that is uncommon, that becomes all the more difficult. And so that's no
different for individuals who suffer from schizophrenia. The other thing to consider is that violence is a complex outcome. There are many factors that account for violence, many of which we don't understand. There are some factors that contribute to violence that we still don't know, and that is true for general population as well as individuals who suffer from schizophrenia.
And so that's why it's very difficult to, quote unquote, predict violence in the individual who suffers from psychosis or schizophrenia.
So, Dr. Lamba, what are some signs that could indicate that a person living with schizophrenia may be at risk for violence?
What helps us assess the risk to say that at this particular point a person might be more likely, not necessarily will, but just more likely to go on to be violent is a constellation of symptoms. As a single factor, person who has a history of violence is more likely to be violent in the future as a single stand alone factor. That's the strongest factor. And that's true for individuals who do not suffer from any illness as well
as individuals who suffer from schizophrenia. So keeping that in mind, it's easier to assess the risk of violence in a person who we know has some predisposition to violence and has previously been violent, as opposed to somebody who has never been violent. When we are just trying to predict out of the blue that whether or not this person's
going to be violent. I think what's important to consider is that person who is, for example, in the throes of acute psychosis and experiencing delusions and hallucinations very acutely, a person who is under the influence of substances or in the middle of the run of use of drugs, particularly stimulant drugs, a person who has complete absence of insight, person who has violent fantasies or ideas as part of
their illness or delusions. Those factors will add up to a period of heightened risk to that assessment that this is a time period where the individual is at a heightened risk for violence.
And Dr. Lamba, you talked about this earlier. It must be so incredibly awful for an individual experiencing psychosis because, as you said, they believe it. They are living it. So based on all your years of experience working with people experiencing psychosis and their families, what do you hear from them about what it's like to live with psychosis?
So that reaction to an incident that the person has perpetrated in the midst of a psychotic state varies. They look back at how they behaved in that particular incident and they are absolutely overcome with remorse, shame, guilt. One of those feelings. And then there are other individuals who unfortunately have ongoing persistent psychosis where they are in a mental state where it briefly, if at all, they can
actually reflect on their behaviors in their past. So the severity of the illness and the course of the illness varies. But certainly I have seen many patients who later on in periods of remission, quite horrified about their own behaviour committed while they were psychotic.
You're listening to Look Again. Mental Illness re-examined a podcast brought to you by the Schizophrenia Society and by partner organizations. I'm your host, Ada Aldridge. This podcast would not be possible without the support of the community. From the bottom of our hearts, we want to thank you for caring about serious mental illness and everything that's around it. Together, we truly can make a difference. Welcome back to Look Again.
Mental illness re-examined. We're back with forensic psychiatrist Dr. Rakeysh Lamba. Okay, Dr. Lamba, based on your work with the Correctional Services Canada and Forensic Psychiatric Services, I'm curious about what typically happens to a person with a serious mental illness like schizophrenia if they are arrested for committing a crime.
So when a person is detained, they go to a remand centre or a jail and they are held in custody. What happens in British Columbia, in the provincial correctional system is that all individuals undergo a physical and mental health screening within 24 hours of being detained. And within 24
hours of admission to a correctional centre. The mental health screening includes things like screening for the presence of symptoms of mental illness, including psychotic symptoms like delusions, hallucinations, residents of mood disorders, symptoms like depression, mania, suicidal ideas, intent or planning for suicide. Screening is also very important for
substance use. So they were screened for whether or not a person appears to be under the influence of substances having come recently off the street or whether they are suffering from withdrawal symptoms. The screening process is actually quite detailed. Upon admission to the correctional centres and it runs to achieve two things. The first thing is does this person need any kind of special observation or special placement within
the facility? The second thing that it determines is what sorts of services this person needs to be referred to. Do they need to see a psychologist, a psychiatrist, a general practitioner right away? There's also a process of what
we refer to as medication reconciliation. They try to obtain a bit of a medication history for the person so that there is no break, and that is continuity in giving individuals their medications, whatever conditions that they had been taking medications out in the community once they are detained. Depending on how they present and as they move from that court process, the courts have an ability to refer
these individuals for assessment, for fitness to stand trial. So the court or the lawyers and more with the patient can become interested to know whether this person is fit to stand trial, which essentially means do they understand the nature of the charges against them? Do they understand the consequences of a guilty finding or a guilty plea? Are they able to enter a plea or answer to those charges? Are they able to participate meaningfully in the court process?
So that's all under the assessment of fitness to stand trial.
How long does that process typically take?
Dr. Lamba So that's a good question. It can take some time. At the first appearance or in subsequent appearances in court, when such a concern may arise, a court may order such an assessment to be done either in custody or out of custody. There is a bit of a wait for these individuals to be admitted to the forensic psychiatric hospital where these assessments are conducted in custody. All in all, the courts have the ability to order these assessments for 30 days with one extension of another
30 days. So there is some wait for admission to the forensic psychiatric hospital. Once they get to the hospital, depending on their condition and depending on whether or not they need treatment for any acute symptoms that are present, it can take some time. The other consideration that may come up during the court process is the court may become concerned about what the mental state of this person was when they committed the act that led to the charges.
And that assessment is referred to as criminal responsibility or whether a finding of and see are maybe not criminally responsible due to a mental disorder is warranted in this case. And those assessments also, when ordered in custody, take place at the forensic psychiatric hospital.
Now going through this process and the assessments, we have talked a lot about the impact on family, and I don't think the impact on families can be emphasized enough. So why do options two families have to keep their loved one protected and ensure that they get the proper support while they're going through these assessments?
So unfortunately, there is not much that families are able to do while the person is going through the assessments. The forensic psychiatric hospital is not like your regular hospital. There are things like visitation, but because these individuals are considered to be in their custodial phase of the treatment phase, there are special rules that apply around visitation. I'm sure that families feel a bit disconnected at this stage of
the process. The patients, of course, can contact their families by phone and be in touch with their lawyer, their families, their friends, whether they are at the correctional center or at the forensic psychiatric hospital. But unfortunately that seems to be the extent of their direct support and contact at
that stage. And while it's difficult to say a lot about what the families can do while the loved ones are going through assessment, I think in general, the families have a big role to play in their journey by emotionally supporting their loved ones, by encouraging them, monitoring their mental state, monitoring their compliance to medications, watching for signs of acute relapse, helping them through difficult phases of their lives, helping them deal with stressors. Because we know that stress
is an important precipitant of an acute episode. So just that kind of support, helping their loved ones abstain from drugs and alcohol, helping them access treatment. And then, of course, advocacy within the system to help support their loved ones.
And Dr. Lamba, I know this is a big question, but I'm curious, what changes would you as a forensic psychiatrist, like to see within the criminal justice system in terms of how people with a mental illness are viewed and treated?
That is a big question. I mean, we speak about the criminalization of the mentally ill. That's essentially what's happened over the last two or three decades with the deinstitutionalization movement when the big psychiatric institutions closed down and no services or resources were added to address the needs of the ill population. What we saw is a few negative outcomes, and the biggest one of them was the criminalization of the mentally ill. Jails and forensic psychiatric facilities became the
default mental institutions. That's been the unfortunate experience, of course, over the last couple of decades. Criminalization of the mentally ill. The reverse of this process will take some time, obviously, and a lot of coordinated effort and resources it will take to reverse the trend.
Thank you. And I have one final question, Dr. Lamba. And as we said earlier, we know through media that there is that fueling a fear when it comes to the connection between people experiencing psychosis and violence and the widespread public perception that everyone who has schizophrenia is going to be violent. How do we address that and how do we combat that automatic connection that seems to be in our society today?
That's a difficult one. How to combat this widespread perception. I think everybody has a role that the mental health professionals role is to keep highlighting at every available opportunity that this relationship is not automatic. Keeping in mind that while there is a correlation as a group, individuals with schizophrenia may be at more risk for violence as compared to the general population. Only few of the individuals who
suffer from schizophrenia are actually violent. And looking at the broader picture, you look at all of the violence, the load of the burden of violence in society. Only a small amount of that is accounted for by individuals who suffer from schizophrenia. And I think that puts it best in perspective.
Yeah, I think it's important to emphasize that there's not an automatic connection between violence and somebody experiencing psychosis. But we also have to be very real and very cognizant of the fact that there is a connection and people who are untreated can be violent. And that's why I am so happy we are having this conversation today. Dr. Lamba, I would agree.
Thank you.
And a huge thank you to you, our audience, for joining us for this episode. Together, we can change the narrative around mental illnesses like schizophrenia and put an end to the many myths and stereotypes that we were talking about today. If you have any questions or comments, tweet us at b c schizophrenia. Get our latest episode. Be sure to hit follow on Apple Podcasts, Spotify, or anywhere you listen to podcasts. We hope you can join us next episode. Talk to you soon.
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