La grippe A / H1N1 Docteur CUVEILLIER - Médecin du travail Docteur SPIDO - Médecin du travail Anne CLARISSON – Infirmière SST La grippe A H1N1 - INF 027 V1 – 23 septembre 2009 La grippe La grippe est une infection respiratoire aigue virale : - Très contagieuse, - Due aux virus influenzae A, B ou C,
Microsoft word - mi - criminal law handbook.docMENTAL ILLNESS, YOUR CLIENT
AND THE CRIMINAL LAW
A Handbook for Attorneys Representing
Criminal Defendants in Connecticut
TABLE OF CONTENTS
TEN THINGS TO KEEP IN MIND AS YOU REPRESENT A CLIENT WHO MAY HAVE A MENTAL ILLNESS . 1 SECTION 1 WHAT IS MENTAL ILLNESS AND WHY SHOULD YOU CARE SECTION 2 CONNECTICUT PUBLIC DEFENDER SECTION 3 THE INITIAL INTERVIEW . 12 SECTION 4 WAYS TO OBTAIN INFORMA- SECTION 5 PRETRIAL OPTIONS . 24 SECTION 6 COMPETENCY EVALUATIONS AND HEARINGS . 28 SECTION 7 THE "INSANITY" DEFENSE . . 37 TURBANCE" – AN AFFIRMATIVE DEFENSE TO A MURDER CHARGE 41 TABLE OF CITED AUTHORITIES
SECTION 9 USE OF EXPERT MENTAL HEALTH SENTENCING STRATEGIES . 42 SECTION 10 RECENT DEVELOPMENTS . 55 GLOSSARY OF COMMON MENTAL HEALTH TERMS COMMONLY PRESCRIBED PSYCHOTROPIC M EDICAT IONS . 73
TEN THINGS TO KEEP IN MIND AS YOU
REPRESENT A CLIENT WHO MAY HAVE
A MENTAL ILLNESS
RETARDATION ARE NOT THE SAME: Mental
retardation is a permanent condition characterized by
significantly below average intelligence accompanied by
significant limitations in certain skill areas. Mental illness, on
the other hand, usually involves disturbances in thought
processes and emotions and may be temporary, cyclical, or
episodic. Most people with a mental illness do not have
intellectual deficits; some, in fact, have high intelligence. It
is possible for a person with mental retardation to also have a
mental illness. Some of the Connecticut statutes that address
mental illness also address mental retardation, and you should
look carefully at those statutes for the differences in how the
two are addressed. This handbook does not address mental
REPRESENTATION: You have the ethical obligation to
represent your client zealously, which may include exploring
your client's case for mental health issues. It may also include
bringing appropriate motions if your client's mental illness
has affected his or her case in any of the ways discussed in
Section 1 of this handbook. A zealous representation may
also include an awareness of the client's medical and
medicinal needs during their incarceration. A lack of access
to necessary or appropriate medical care and medications can
affect the client's health and demeanor at the early stages of a
criminal proceeding. Many mental illnesses require ongoing
medical treatment, and an interruption or cessation of that
treatment can affect a client and their behavior profoundly.
3. IF YOUR CLIENT IS INCOMPETENT, STOP AND
ORDER AN EVALUATION: If your client is incompetent,
he or she may not be able to make informed decisions about
fundamental issues, such as whether to enter into a plea
bargain agreement or, instead, proceed to trial. Do not allow
your client to accept a plea bargain, or make any other
decisions regarding the case, when you have grounds to
believe that he or she is incompetent. Instead, immediately
request a competence evaluation.
4. MENTAL ILLNESS AND INCOMPETENCE ARE
NOT SYNONYMOUS. YOU SHOULD BE CONCERNED
ABOUT BOTH: Keep in mind that competence to stand trial
is distinct from mental illness, so that some clients who are
fit to proceed to trial may still have serious mental illness.
Even if your client does not have a competence issue, there
may still be significant mental health issues in the case that
you should explore. Remember, however, that if your client is
competent to stand trial, he or she makes the final decision
about how to proceed with the case, whether to explore and
raise mental health issues, and whether treatment should be
part of a disposition.
5. AN INSANITY DEFENSE MAY BE APPROPRIATE:
By taking the time to properly inquire about your client's
mental illness and explore various legal and medical options,
you may obtain information that will help you decide if you
should explore an insanity or " e x t r e m e emotional
disturbance" defense. If your client receives a not guilty by
reason of insanity verdict, he or she will avoid receiving an
unjust conviction. However, as discussed further in Sections 7
and 8 of this handbook, there may be disadvantages to
pursuing these defenses and you should discuss all of the
pros and cons with your client.
conditions that inspire compassion, without justifying or excusing the crime, can be powerful mitigation evidence. Part of your job as an attorney may be to present the judge or jury with evidence that reveals your client as someone with significant impairments and disabilities that limit his or her reasoning or judgment. Mitigation evidence can be used to argue for a shorter term of incarceration or for probation instead of incarceration. In capital cases, mental illness and mental health testimony may mean the difference between life and death. 7. INEFFECTIVE ASSISTANCE OF COUNSEL AND
REVERSIBLE ERROR: An attorney's failure to request the
appointment or otherwise obtain the assistance of qualified
mental health or mental rehabilitation professionals when
indicated can be a violation of a defendant's Sixth
Amendment right to effective assistance of counsel and your
professional responsibilities. This applies to capital cases as
well as other homicide cases and any alleged offense that
suggests mental aberration. A defendant's prior history of
mental impairment may indicate that you need the assistance
of a professional evaluation. Ake v. Oklahoma, 470 U.S. 68
(1985). Ake also asserts the claim of indigent, convicted
defendants to the assistance of mental health professionals at
sentencing proceedings. An appellate judge may find
reversible error if a client's incompetence or mental health
issues are not raised in court.
PREJUDICES BEFORE YOU HURT YOUR CLIENT
AND HIS OR HER CASE: A popular assumption is that
mental-state defenses are attempts by bad persons to "get
off" or deny responsibility for their behavior. Many people
believe that persons with mental illness, by contrast to those
with mental retardation, have the ability to fully appreciate the
nature of their acts and control them. This common attitude
toward psychiatric disability can deeply influence judges' and
juries' receptivity of expert witnesses and mental health
defenses. Part of your job, if you are representing a person
with a mental illness, is to overcome cynicism toward mental
health issues in criminal cases. Mental illnesses are
neurobiological brain diseases. A mental illness is a medical
illness, not "hocus pocus," and the people who experience it
suffer profoundly. Mental illness can be diagnosed, treated,
and sometimes even cured. You do your client a disservice by
presenting it any other way.
9. INCARCERATION IS PARTICULARLY HARMFUL
TO PEOPLE WITH MENTAL ILLNESS: Jails can be very
damaging to the stability, mental health, and physical health of
people with mental illness. Numerous studies show that
placing mentally ill people in single cells, isolation, or "lock
down" can worsen their schizophrenia, depression, and
anxiety. Mentally ill and mentally retarded adults are also
more likely than others to be victimized by other inmates or
jail staff. They are at high risk for suicide. They generally get
inadequate, if any, medication and treatment while in jail. As
set out in Section 5 of this handbook, you should seek to get
your client's case dismissed quickly and, if appropriate, try to
get your client released on bond, though this may be difficult
10. DO NOT LET YOUR CLIENT GET CAUGHT IN
THE "REVOLVING DOOR": Many adults with mental
illness are arrested for minor offenses that directly relate to
their illness, their poverty, or their disturbed behavior. They
cycle repeatedly through the courts and jails, charged with
the same petty offenses. This "revolving door" is not only a
burden to the courts and the criminal justice system, but it is
costly to society, to these individuals, and to their families.
By quickly pleading your client to "time served" without
exploring his or her mental illness, you may lose the
opportunity to help your client get better so that he or she
does not re-offend. Attorneys should do their best to link
mentally ill defendants to appropriate treatment or services
that will help them keep out of trouble. While it is important
to get your client out of jail as soon as possible, it is equally
important to keep him or her from returning to jail. Releasing
persons with mental illness back into the community with no
plan for treatment or aftercare is a recipe for revocation and
recidivism. Don't set up your client to fail.
WHAT IS MENTAL ILLNESS AND
WHY SHOULD YOU CARE
WHAT IS MENTAL ILLNESS?
Connecticut statutes generally use the term "psychiatric
disability" rather than "mental illness." Section 17a-495 of
the Connecticut General Statutes defines a "person with
psychiatric disabilities" as "any person who has a mental or
emotional condition which has substantial adverse effects on
his or her ability to function and who requires care and
treatment." CO N N . GE N . ST A T . § 17a-495 (2006). The
definition expressly excludes individuals dependent on illegal
drugs or alcohol.
However, it is important to note that in Connecticut, there is
no one legal definition of "mental illness" or "psychiatric
disability." Rather, the definition of "mental illness" or
"psychiatric disability" largely depends on the purpose and
context of the statute or regulation at hand. When reviewing a
statute that uses such terms, you should always check
whether there is a "definitions" provision that governs the
statute. In some cases, statutes are silent on the definition
and courts depend instead on administrative regulations or
PREVALENCE AND SIGNIFICANCE OF
Mental disorders are quite common. In fact, one in five
Americans has some type of mental disorder in any given
year. About 15% of all people with mental illness will have
an accompanying substance abuse disorder, although the
percentage in the criminal justice system is much higher.
About 16-20 percent of the jail and prison population has a
significant mental illness (schizophrenia, bipolar disorder, or
major depression) at any given time; this far exceeds the rate
for these disorders in the general population. It is a common
misperception that people with severe mental illness are
significantly more violent than other people. Research shows
this is generally not true. In fact, the vast majority of people
with mental illness in jail are arrested for nonviolent offenses.
Often, it is when people with mental illness are undiagnosed,
untreated or stop taking their medication that they get in
trouble with the law.
SERIOUS MENTAL ILLNESSES
There are a variety of mental illnesses and their severity
ranges from mild to life-threatening. Many serious mental
illnesses, such as those listed below, are chronic in nature,
but can be managed or ameliorated with the proper
medication and treatment.
Schizophrenia is a mental disorder that impairs a person's ability to think, make judgments, respond emotionally, remember, communicate, interpret reality, and/or behave appropriately so as to grossly interfere with the person's capacity to meet the ordinary demands of life. Symptoms may include poor reasoning, disconnected and confusing language, hallucinations, delusions, and deterioration of appearance and personal hygiene. Bipolar disorder or manic-depressive illness is characterized by a person's moods, alternating between two extremes of depression and mania (exaggerated excitement). The manic phase of bipolar disorder is often accompanied by delusions, irritability, rapid speech, and increased activity. Major depression is much more severe than the depression that most of us feel on occasion. People suffering from major depression may completely lose their interest in daily activities, feel unable to go about daily tasks, have difficulty sleeping, be unable to concentrate, have feelings of worthlessness, guilt, and hopelessness, and may have suicidal thoughts. Other mental disorders or mental illnesses are defined in the glossary at the end of this handbook. While less severe than the disorders mentioned above, many of these disorders are also disabling and can profoundly affect the way a person thinks, behaves, and relates to other people. As an attorney, you can help ensure the fair, efficient, and humane administration of justice by paying special attention to those defendants who have a mental illness.
WHAT DIFFERENCE DOES IT MAKE IF YOUR
CLIENT HAS A MENTAL ILLNESS?
Your client's mental illness may affect various aspects of his
or her case, such as:
• the voluntariness of your c l i e n t ' s statements. Statements that are the product of mental illness or mental retardation will not be excluded from evidence in the absence of impermissible coercive official conduct. However, conduct that is not coercive when used with nondisabled persons may impair the context, content, reliability and voluntariness of the statements of persons who are mentally ill. your client's ability to understand and explicitly receive the rights explained to him or her, including M i r anda rights; your client's mental illness may affect memory, ability to make decisions, reasoning, judgment, volition, and comprehension; your c l i e n t ' s ability to understand cause and consequence or learn from prior mistakes; • the ability of your client to waive rights in a knowing, intelligent, and voluntary manner, including the right to counsel, right to be present, right to trial and appeal, and right to testify; and Choices and option concerning the disposition of his or her case.
CONNECTICUT PUBLIC DEFENDER SERVICES
HOW DO CONNECTICUT'S PUBLIC DEFENDER
SERVICES AFFECT YOU?
Section 51-296 of the Connecticut General Statutes provides
for the appointment of counsel to represent indigent
defendants. CO N N . GE N . ST A T . § 51-296 (2006). Indigent
defendants are defined as individuals "formally charged with
the commission of a crime punishable by imprisonment" who
are not financially able to secure competent legal
representation. CO N N . GE N . ST A T . § 51-297 (2006).
Counsel may not be appointed in misdemeanor cases where
the defendant may not be subject to immediate incarceration
or may be eligible for a suspended sentence of incarceration
with a period of probation. However, where it later appears
that the indigent defendant may, in fact, be subject to
immediate incarceration or a suspended sentence of
incarceration with a period of probation, then the court must
appoint counsel. CO N N . GE N . ST A T . § 51-296 (2006).
The Guidelines on Indigent Defense published by the
Connecticut Public Defender Services Commission contains
several guidelines dealing specifically with clients who may
have mental illnesses. To paraphrase:
• In general, counsel should "make accommodations where necessary" when representing a client with a physical or mental disability, in order to effectively protect and promote the client's rights and interests, and to establish an effective relationship with the client. • At the initial client interview, counsel should try to ascertain both the client's competence to stand trial and/or the client's mental state at the time of the offense. Counsel should advise the client of the right to assert the insanity defense. • When considering conditions of pretrial release, counsel should obtain information from the client regarding the client's physical and mental health. Counsel should additionally obtain from the client names or other sources that counsel could contact to verify the information. If pretrial release is not obtained, counsel should inform the court and the incarceration facility about any medical or psychiatric needs of the client. In investigating the charges, counsel should consult experts and other professionals regarding evaluations of the client. • Counsel should consider seeking discovery of "all results or reports of underlying data regarding relevant physical or mental examinations, scientific tests, experiments and comparisons." S e e CONNECTICUT PUBLIC DEFENDER SERVICES COMMISSION, GUIDELINES ON INDIGENT DEFENSE 1.1(b)(7); 3.1(e); 3.4(c)(5); 3.5(b); 5.1(b), (f); 6.2(b); 6.3(b)(6); 8.4(e) (2002).
HOW ELSE DO CONNECTICUT'S PUBLIC DEFENDER
SERVICES HELP MENTALLY ILL DEFENDANTS?
The Office of Chief Public Defender contains a specialized
unit, the Psychiatric Defense Unit, which is responsible for
the representation of indigent defendants found not guilty by
reason of mental disease or mental defect before the
Psychiatric Security Review Board. The Psychiatric Security
Review Board is a Connecticut state agency that reviews the
status of all insanity acquittees through administrative
hearings and determines the level of supervision and
treatment necessary for them. The Board may recommend
discharge, order conditional release, order confinement in a
hospital for individuals with psychiatric disabilities, order
placement with the Commissioner of Mental Retardation for
"custody, care and treatment," or recommend confinement
under conditions of maximum security. See CO N N . GEN. STAT.
§§ 17a-584, 17a-599 (2006). The Public Defender's office
also offers a very supportive network of social workers who
can often be of service, especially with jail diversion.
As set out earlier, jail can be especially threatening to
mentally ill defendants. Therefore, it is particularly important
that counsel is attune to the issues related to the defendant's
mental illness in order to ensure that the defendant is accorded
the appropriate treatment by the relevant authority, the court or
the Psychiatric Security Review Board.
THE INITIAL INTERVIEW
HOW CAN YOU TELL IF YOUR CLIENT
MAY HAVE A MENTAL ILLNESS?
Here are some signs of a possible mental illness:
Certain types of offenses. Offenses such as criminal
mischief, criminal trespass, prostitution, failure to identify,
and public intoxication may signal an underlying mental
illness. Many defendants with mental illness are also brought
in on charges of "assault of a public servant" because they
fight with police while they are psychotic. These offenses
are frequently related to the client's poverty, homelessness,
substance abuse, or transient lifestyle, but if they are part of
your client's offense history or if your client has been arrested
several times for the same offense, he or she may have a
Behavioral or physiological clues. Your client may exhibit
rapid eye blinking, vacant stares, tics or tremors, or unusual
facial expressions. The symptoms of a mental illness and the
medications your client may be taking may make him or her
appear slow, flighty, inattentive, or sluggish. Your client may
exhibit psychomotor retardation (slow reactions in
movements or in answering questions) or clumsiness. Your
client may be excessively uncooperative or argumentative.
On the other hand, your client may appear very agitated,
tense, or hypervigilant.
Circular nature of your client's conversation. While
talking with your client, you may note the lack of a logical
train of thought. In other words, your client may be unable
to get from point A to point B.
Use of mental health terms. If your client has been in
treatment, he or she may talk about his or her counselor or
case-worker, about various medications, or about being
treated in a hospital. He or she may use terms such as some
of those listed in the glossary.
Paranoid statements. Your client may make paranoid
statements or accusations. Or, he or she may exhibit phobias
or irrational fears, such as a fear of leaving the jail cell.
Reality confusion. Your client may exhibit hallucinations.
He or she may hear voices, see things, or misperceive a
harmless image or situation as threatening or a meaningless
coincidence as meaningful. Your client may be disoriented
and seem confused about people and surroundings. He or she
may have delusions (consistent false beliefs), such as lawyers
who are out to get him or her, guards in love with him or her,
or your client may believe that his or her food has been
Speech and language problems. Your client may exhibit
language difficulties, including incoherence, nonsensical
speech, the use of made-up language, and non sequiturs. Your
client may change the subject in mid-sentence, speak
tangentially, or persistently repeat himself or herself. Or,
instead, he or she may exhibit rapid, racing speech, or give
monosyllabic or lengthy, empty answers. Your client may be
easily distracted or may substitute inappropriate words for
Memory and attention issues. Your client may exhibit a
limited attention span, selective inattention on emotionally
charged issues, or amnesia. These may also be signs that your
client has had a head injury.
Inappropriate emotional tone. Your client may exhibit
emotions such as anxiety, suspicion, hostility, irritability, and/
or excitement; or he or she may appear downcast and
depressed. On the other hand, your client may express little
emotion at all or appear to have a flat affect. Your client may
exhibit emotional instability. If your client has a bipolar
disorder (manic depression), he or she may talk in a very
rapid manner, seem excited, laugh at inappropriate times,
make grandiose statements, or act very irritable.
Personal insight and problem-solving difficulties. Your
client may exhibit self-esteem that seems either too high or
too low. He or she may get easily frustrated or deny that he or
she has mental problems. It may be difficult for your client to
make plans and change plans when necessary. Perhaps most
important, your client may also have an impaired ability to
learn from his or her mistakes.
Unusual social interactions. Your client may have problems
relating to others, including isolation, estrangement,
difficulty perceiving social cues, suggestibility, emotional
withdrawal, a lack of inhibition, and strained relations with
family members and friends.
Medical symptoms and complaints. You should always be
alert for physical symptoms, including hypochondria, self-
mutilation, accident-proneness, insomnia, hypersomnia,
blurred vision, hearing problems, headaches, dizziness, nau-
sea, and loss of control of bodily functions. Some of these
problems can develop as a result of incarceration, but many
point to other more serious or long-standing mental health
WHAT DO YOU DO IF YOU SUSPECT YOUR CLIENT
HAS A MENTAL ILLNESS?
If you have grounds to believe that your client may be
incompetent and/or mentally ill, you should explore further.
Many people want to hide their mental illness. In fact, many
defendants may go to great lengths to hide any indications
that they are mentally ill, especially if they are in a jail setting.
They may fear being committed to a mental hospital or being
forced to take medication. They may not want to admit that
they have not been compliant with their treatment, or they
just may not want to appear different or dependent for fear of
being victimized by others in jail. Just as a person who
cannot read will often mask that inability, so too a person
with mental illness can learn to hide his or her illness.
Other clients, particularly if they have never been formally
diagnosed or treated, may not understand that they are
mentally ill. The stress of the jail environment has been
known to bring on symptoms of a person's illness and
contribute to his or her deterioration, sometimes to the point of
rendering him or her incompetent.
If your client is willing to talk about his or her mental health
history and treatment, ask questions such as:
Have you ever been treated for a mental or emotional problem? Have you ever been treated for substance abuse? Are you currently receiving treatment? If so, with whom? Do you know your diagnosis? What types of medication are you taking? Have you taken medications in the past? What were those medications? Have you ever been hospitalized for a mental health problem? If so, when and where? Did a court or judge order that you be hospitalized? Are there doctors, friends, or family members I can talk with who are familiar with your condition or treatment?
Be familiar with the names of public mental health clinics,
such as local mental health authorities or psychiatric
hospitals, and state mental hospitals in your area. It may be
helpful to use the name of the facility when asking whether a
client has been a patient.
Be delicate, tactful, and resourceful in your questioning
when you sense that your client may not be forthcoming
Mental illness still carries a powerful stigma, especially
among males and among people of certain cultures. Blunt
questions like "do you have a mental illness?" may not work.
Here are some questions you might ask your client instead:
Are you on any medications and, if so, what are they? Have you had any previous medical treatment and, if so, what was it? Do you have a juvenile record and, if so, for what types of offenses? Were you in any special classes in school and, if so, do you know why? Do you receive disability or Supplemental Security Income (551) benefits? Have you ever felt depressed? Have you ever been a patient at the Veterans' Administration (VA)? Have you ever been hospitalized? • Have you ever had any dealings with a local mental health authority? (You may want to tailor this question using the name of the local mental health authority for your city or region). Are there doctors, friends, or family members I can talk with about your case?
Remember to speak simply and be prepared to repeat some
of what you are saying. Ask simple, open-ended questions.
Use eye contact to keep control of the dialogue and to keep
your client focused. Do not impose on your client's "personal
space." Tell your client when you do not understand and need
more information. Paraphrase your client's responses to let
him or her know that you understand. Remember that your
client's delusions are real to him or her. Do not minimize or
try to explain away hallucinations or delusions. You will
likely elicit more information with a response such as, "That's
interesting— tell me more," than to argue the logic of
statements that may appear bizarre or unusual to you.
Be patient. If your client has a mental illness, he or she may
be irritated, belligerent, or see you as a threat. If your client
is out of control, he or she may have a mental disorder. Some
of your client's actions, reactions, and mannerisms may be
irritating and/or offensive. Do not take this conduct
personally; your client's mental illness may be influencing
his or her personality. Find out if your client has stopped
taking medication. If your client restarts taking his or her
medication again, and it is appropriate for him or her to do
so, then it will likely make your experience with him or her
Encourage your client to be honest and forthcoming with
you. Tell your client that hiding important medical or mental
health information may hurt his or her case and may hinder
your ability to represent him or her well.
Do not speak about mental illness in a disparaging or
derogatory manner. Do not add to your client's feelings of
help-lessness, embarrassment, or shame about his or her
mental illness. If you believe your client is incompetent, you
should still address him or her as if he or she is competent.
Many clients who get better after treatment remember how
you treated them and what you said to them before treatment.
If your client feels that you have treated him or her with
respect, you are more likely to forge a trusting relationship
with your client, which will help you represent him or her
Do not worry about malingering. It is the mental health
evaluator's role, not yours, to determine who might be faking
mental illness. While it is true that some defendants try to
fake mental illness in order to avoid prosecution or to get a
reduced sentence, defendants who actually have a mental
illness often try to hide their condition.
WAYS TO OBTAIN INFORMATION
If after the initial interview with your client you have grounds
to believe that your client may be mentally ill and/or
incompetent, it is good practice to explore the issue further.
WHERE DO YOU LOOK FOR MORE
MENTAL HEALTH INFORMATION?
Listed below are some steps you can take to gather relevant
information if you suspect your client has a mental illness or
is incompetent. Of course, it is always good to speak to your
client first about the matter and to get him or her to sign a
medical records release form where applicable.
• Call your client's family. The family is often the
best, most current source of information about mental health treatment and history. Family members can also connect you with treatment professionals. • If your client is currently housed in an
incarceration or detention facility, have your client
submit a Release of Information form to his or her
Unit Administrator. This will allow you to access
your client's master file at the facility, which contains
his or her medical and psychiatric information,
including the health and mental health assessment
performed on your client upon intake. You can find
out more about the type of information available on your client by visiting the Department of Corrections website at http://www.ct.gov/doc/site/default.asp. • Upon written request, you have a right to inspect
or copy any reports or results of physical or mental
examinations made in connection with the charged
offense from the state if such reports are "material
to the preparation of the defense" or if the state
intends to use them as evidence in chief at trial.
CO N N E C T I C U T PR A C T I C E BO O K § 40-11(a)(4) (2007).
You may be able to use such examinations to help get
the charges against your client reduced or dismissed,
or to help get your client diverted to a mental health
Talk informally with jail staff. Do they report
bizarre behavior or complaints from other inmates or
staff about your client?
• Find out where your client is housed in the jail
facility. Many jails have special mental health or
observation cells. These may be designated on your
client's file or on a county computer screen.
Look at the police report for any indication of
mental illness or bizarre behavior by your client at
the time of arrest.
• If your client is being charged with a probation
violation, ask your client's probation officer if your
client has a history of mental illness or is currently on
a specialized probation caseload.
If your client has been in court before, look to see
if prior competence proceedings were conducted.
• Look at information about your client collected by
the pretrial release program. These programs may
have collected some information on your client's
mental health status in the course of determining his or
her eligibility for pretrial bond.
WHAT RECORDS WOULD BE HELPFUL?
If it appears that your client has or has had significant mental
disorders or received treatment and that his or her mental
health history will likely play a role at some point in the
proceedings, you may want to obtain the following records:
• Medical records from physicians or clinics. Section
20-7c of the Connecticut General Statutes states that, upon written request, you may review a copy of your client's health record, including bills, x-rays, and copies of laboratory reports. CO N N . GEN. STAT. § 207c (2006). Significantly, this provision does not obligate a doctor or clinic to provide access to information related to your client's "psychiatric or psychological problems or conditions." CO N N . GEN. STAT. ANN. § 20-7c(e). However, the statute does not appear to bar you from at least requesting such information. • Medical records from hospitals and mental health
facilities. You are entitled to examine your client's
health record at hospitals and mental health facilities.
Depending on the type of facility, written consent may
be required from either the patient, the patient's
attorney or the patients authorized representative to obtain the documents. CO N N . GEN. STAT. §§ 4-104; 17a-548(b); 19a-490(b) (2006). You should check these records to see, for example, whether your client has been hospitalized multiple times, or has a history of voluntary or involuntary civil commitments. It is also worth checking the length of your client's typical hospital stays. You should also get the release forms from the hospitals where the person has stayed, as those forms tend to vary. • Pharmacy records. Checking the extent to which
your client has had prescriptions for psychiatric medications filled and refilled may account for erraticism in your client's behavior. In Connecticut, your client must indicate his or her oral or written consent to the pharmacy in order to obtain pharmacy records. CO N N . GEN. STAT. § 20-626 (2006). • Family records. Your client's family may have
records of prior evaluations, prior treatment, prior applications for services, school records, or juvenile records. • School records. Your client may have been enrolled
in special education classes or may have been in special programs while in school. Look for the designation of an emotional disturbance on these special education records. General school records may provide an indication of behavioral illnesses or learning disabilities. Employment records. In Connecticut, your client
must provide written consent in order for the employer
to permit inspection of his or her personnel files or any medical records retained by the employer. S e e CO N N . GE N . ST A T . §§ 31-128a-c (2006). Mental illness may have interfered with your client's ability to hold down long-term, stable employment. Therefore, evaluate your client's employment history. Has he or she had trouble keeping jobs? Has your client participated in the Vocational Rehabilitation program through the Connecticut Bureau of Rehabilitation Services or any other job training program? • SSI or Social Security Disability Insurance (SSDI)
benefit checks from the Social Security office. This
may be your client's only source of income if he or
she has a serious mental illness. You can ask your
client to see applications and paperwork pertaining to
these benefit programs.
Child Protective Services records.
If your client cannot sign a medical records release form because he or she is incompetent or his or her competency is in question, you may be able to sign the release form as an authorized representative. You should read the statute governing the type of information you are seeking in order to determine if this is an option. Additionally, some types of records may be available by subpoena. S e e , e . g . , CO N N . GE N . ST A T . §§ 10-15b(b) (educational records); 17a-548(b) (certain hospital records); 31-128(f) employment records). Be sure to note whether the statute
applicable to the type of information you are looking to
acquire allows the institution any options or imposes any
conditions on the way the institution may respond to a
Finally, you may want to consider hiring a mitigation
specialist who can gather the information discussed in this
section for you. A mitigation specialist can also develop a
bio-psycho-social history of your client. Once you have this
information, see where it takes you. Retaining a mitigation
specialist is also relevant to effective assistance of counsel
TRY TO GET THE CASE DISMISSED
You should be seeking ways to get your client's case
dismissed. What may seem like a minor misdemeanor
conviction could come back to haunt your client down the
road. For example, a family violence assault conviction can
enhance a second family violence assault charge to a third
degree felony and two convictions for prostitution or
shoplifting can enhance the third charge of either of these
two offenses to a state jail felony. Also, a criminal conviction
may make your client ineligible for public housing. You can
attempt to get a dismissal in various ways, but if you have
never represented a person with mental illness before, get
help from someone who has before embarking on any of the
courses of action set out below.
TALK WITH THE PROSECUTOR
If you have an indication that your client's mental illness may
have played a role in the charged offense, you may want to
talk to the prosecutor about dismissing your client's case. The
prosecutor may be more inclined to share your conviction that
your client suffers from a mental illness and that the mental
illness affected your client's judgment at the time of the
alleged offense if you clearly document your client's mental
illness and then provide that documentation to the prosecutor.
However, if you are new to practice or otherwise unfamiliar
with the prosecutor, you should talk to other attorneys in the
community about the prosecutor's sensitivity, or lack of it,
regarding mental health issues. If the prosecutor has a
reputation for being less than sensitive about mental health
issues, you may want to seek out another prosecutor or speak
to the prosecutor's supervisor.
TALK WITH THE COMPLAINING WITNESS
The option of an outright dismissal may be more appealing
to the prosecutor in a case where there is no alleged victim.
If there is an alleged victim and the prosecutor does not seem
inclined to dismiss your client's case, you may want to
directly contact the alleged victim and, with your client's
permission, present evidence of your client's mental illness
to the alleged victim. The alleged victim might then go to the
prosecutor and ask the prosecutor to drop or reduce the
charges against your client. This approach, however, can
backfire. You may end up only aggravating the alleged victim;
so, be sure to discuss the pros and cons of this option carefully
with your client before you proceed.
TALK WITH THE ARRESTING OFFICER
You may want to approach the arresting officer to see if he or
she would be willing to ask the prosecutor to dismiss the
charges, especially if your client is charged with a nonviolent
offense or if the alleged offense is against the arresting officer.
You may be able to get the officer to work with you if you
bring him or her evidence of your client's mental illness.
RELEASE ON A BOND
If a quick dismissal is not an option and your client is
competent to stand trial, you should speak to your client about
whether to seek his or her release on bond. The court might
condition your client's bond on outpatient treatment and your
client may decide to forego release on bond to avoid this or
other conditions that the court may impose. You and your
client may also decide not to pursue a release on bond if your
client is homeless or does not have a safe or stable place to
live. If your client is in danger of picking up additional
charges while on bond or failing to report to court in violation
of his or her bond, it may significantly impair your chances of
getting a favorable outcome to your client's case.
If you are further along in the pretrial process and your client
has been determined to be incompetent, the court can release
your client on bail if the court determines that he or she can
be adequately treated (in order to regain competence) on an
The Connecticut Department of Mental Health and
Addictions Services ("DMHAS") places clinicians in
Connecticut's Superior Courts to be available to assist in
screening eligible detainees for the presence of mental
disorders at or prior to arraignment, evaluate their mental
health, and participate in negotiating with the prosecution,
defense, and the court to develop community-based mental
health dispositions. DMHAS clinicians are available on-site
in nearly all of the Connecticut Superior Courts and propose
and subsequently monitor compliance with a court-ordered
treatment plan.1 The diversion teams consist of one to three
clinicians who spend from one to five days a week in court,
focusing on the arraignment of individuals with mental
disorders. Since DMHAS clinicians are employees of the
mental health center, and not the court, it is important to
remember that they can only represent the client with his or
her consent, and must be provided with written permission
prior to discussing the case with the court. The clinicians
locate potential clients by checking arraignment lists for
repeat offenders and through notice by the judge, the sheriff,
the public defender, the bail commissioner or the state's
attorney. The clinicians evaluate the client and present to the
court a proposed treatment plan, which may include diverting
the client into the mental health system. In deciding whether
to recommend diversion, the clinicians consider the
seriousness of the charge, the treatment plan individuated
for the client, the risk posed by the client and the extent to
which the offense was related to the mental disorder.
1 . S e e www.dmhas.state.ct.us/jaildiversion.htm (last checked Feb. 20, 2007); www.dmhas.state.ct.us/documents/jaildiversion.pdf (last checked Feb. 20, 2007). The court is not required to abide by the clinician's recommendation. If the treatment plan is accepted, the judge typically releases the defendant on a written Promise to Appear with the condition that the client participate in the proposed treatment plan and orders another pre-trial hearing, where the case may be continued or the charges dropped. If you suspect that your client has a mental illness, or if your client has a documented history of mental illness, you should be sure to involve the court DMHAS clinician, if one has not already been assigned to your client. VOLUNTARY HOSPITALIZATION OR COMMITMENT
There may be rare situations in which you want to explore
this option with your client if your client meets the civil
commitment criteria. See CO N N . GEN. STAT. § 17a-502 (2006).
For example, you may be able to broker a deal by which the
prosecutor agrees to dismiss your client's case conditioned
on your client's mental health commitment through the civil
commitment process. See CO N N . GEN. STAT. § 17a-498 (2006).
COMPETENCE EVALUATIONS AND HEARINGS
The question of competence to stand trial relates to a criminal defendant's mental state at the time of trial — not at the time of the alleged offense. In other words, determinations regarding your client's competence are not determinations on the merits of your client's case, and a determination of incompetence will not excuse the offense against your client. THE INCOMPETENCE STANDARD
Section 54-56d(a) of the Connecticut General Statutes provides that: A defendant shall not be tried, convicted or sentenced while he is not competent. For the purposes of this section, a defendant is not competent if he is unable to understand the proceedings against him or to assist in his own defense. CO N N . GE N . ST A T . § 54-56d(a) (2006). Procedurally, "[a] defendant is presumed to be competent." § 54-56d(b) (emphasis added).2 The burden of proof, and of going forward with the evidence, rests on the party intending to prove incompetence; that party must so prove by a preponderance of the evidence. See id. However, "[t]he burden of going forward with the evidence shall be on the state if the court raises the issue" and "the court may call its own witnesses and conduct its own inquiry." Id. (emphasis added). Under Connecticut case law, the "test for competence to stand trial is whether [the defendant] has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding — and whether he has a rational as well as factual understanding of the proceedings against him." State v. George B., 785 A.2d 573, 579 (Conn. 2001) (quoting 2. It should be noted that this presumption of sanity extends beyond the realm of competence to stand trial into the trial phase of the adjudication. S ee S ta te v. Ro ssier, 175 Conn. 204, 209 (Conn. 1977) (noting "th e state has a right, in the first instance, to rely on the presumption that the defendant was sane at the time of the o ffen ses . ." (citations omitted)). However, once the defendant has put sanity at issue, any mention of this presumption should not be included in jury instructions regarding the insanity defense. Id . at 210. Dusky v. United States, 362 U.S. 402, 80 S. Ct. 788, 4 L. Ed. 2d 824 (1960)). Moreover, evidence of a defendant's mental illness is not determinative of competence; a defendant may suffer from a mental illness and still understand the proceedings against him. Ultimately, your client's competence involves more than his or her ability to correctly identify the different actors in the court process (e.g., the prosecutor, judge, defense attorney, or bailiff). You may want to consider the following questions in determining whether it is appropriate to request a competence examination for your client: Can your client explain the charges against him or her? Can your client explain or understand the legal issues/ procedures in his or her case? Can your client relate pertinent facts about the alleged offense? Does your client understand the available legal defenses? Does your client understand the dispositions, pleas, and penalties possible? Can your client appraise his or her role and the roles of defense counsel, prosecutor, judge, jury, and witnesses in his or her case? Can your client identify and locate witnesses? Does your client comprehend and follow your instructions and advice? Can your client follow his or her own testimony and the testimony of others for contradictions or errors? Can your client testify about relevant information and be cross-examined if necessary? Can your client tolerate the stress of the pre-trial and trial process? Can your client refrain from irrational and unmanageable behavior in court? WHEN IS IT APPROPRIATE TO REQUEST A
Generally, issues relating to your client's competence to stand trial should be resolved before the trial on the merits. However, you can request a competence examination at any point during the proceedings at which you believe your client is not competent to stand trial — even if you are in the middle of trying your client's case on the merits. See CONN. GEN. STAT. § 54-56d(c). (Note that the American Bar Association (ABA) considers it is improper to use competence procedures for purposes unrelated to the determination of competence, such as obtaining mitigation information, obtaining favorable plea negotiations, or delaying proceedings. STANDARDS RELATING TO COMPETENCE TO STAND TRIAL § 7-4.2(e) (1989)). Many attorneys find themselves in an ethical bind when their client objects to having the competence issue raised. Some clients facing misdemeanor charges just want to plead to the charges, spend a short time in jail, and then get out. Often, getting a psychiatric examination means that the client may spend more time in jail pending the examination, plus a lengthy time at a state hospital if he or she is found incompetent. The ABA stresses a lawyer's professional responsibility toward the court and the fair administration of justice as the paramount obligations in such an instance, and expects an attorney to advance the issue even over a client's objection whenever a good faith doubt arises about a defendant's competence to stand trial. STANDARDS RELATING TO COMPETENCE TO STAND TRIAL § 7-4.2(c) (1989). Of course, if your client is competent to stand trial, he or she makes the final decision about how to dispose of his or her case regardless of whether you agree with this decision. If you believe your client is incompetent to stand trial, you should file a motion suggesting that the defendant may be incompetent. You should also seek to get your client's case dismissed as discussed in Section 5, but if the case is not dismissed you should know that competence examinations and hearings can be conducted even if your client is on bond or otherwise out of jail. THE COMPETENCE EXAMINATION
Even though defense counsel usually files the incompetency motion, the court itself or the prosecutor may raise the issue of incompetency to stand trial. See CONN. GEN. STAT. § 54-56d(c) (2006). When the information known to the trial court at the time of the trial or plea bargain is sufficient to raise a legitimate doubt regarding the defendant's competence, the trial court must conduct a competency hearing. Once the court orders a competency examination, the court may do any of the following: • Appoint one or more physicians specializing in psychiatry to examine the defendant. • Order the Commissioner of Mental Health and Addiction Services to conduct the examination by appointing either a clinical team of psychiatric specialists (consisting of a psychiatrist, a clinical psychologist, and either a licensed clinical social worker or a psychiatric nurse with a masters degree in Nursing), or one or more physicians specializing in psychiatry. See Conn. Gen. Stat. § 54-56d(d)(2006). PREPARE
FOR THE EXAMINATION
You need to prepare your client and other supporting evidence for the competence examination. Encourage cooperation. Explain the following to your client: the purpose and nature of the examination; the potential uses of any disclosures made during the examination; o the conditions under which the prosecutor will have access to reports and other information obtained for the examination and the reports prepared by the evaluator; and the conditions under which the examiner may be called to testify during sentencing. • You may want to tell the evaluator why you think your client is unable to assist you or participate in his or her defense, being mindful of attorney/client confidences and attorney work product issues. • Be aware that the attorney is authorized to observe the evaluation if he or she elects to do so. • You should also obtain and submit to the examiner any record or information that the examiner regards as necessary for conducting a thorough evaluation on the matters referred. • Make sure that the examination is conducted promptly after you have made the suggestion that the defendant may be incompetent to stand trial, so that your client does not languish in jail. Be aware of whether or not communications and records are privileged.3 3. Connecticut has a broad psychiatrist-patient privilege that protects the disclosure without the p atien t's consent of confidential communications or records of a patient seeking diagnosis and treatment. The patient's consent is not required prior to the disclosure of records or communications that are made in connection with a court-ordered psychiatric examination, provided that (i) the patient is informed prior to the examination that any communications will not be protected by the privilege; and (ii) the communications are admitted only on issues relating to the p atien t's mental condition. § 52-146f (4); S ta te v. Jen kin s, 856 A.2d 383, 393 (Conn. 2004). C o u n s e l ' s participation in the evaluation may raise questions of attorney-client privilege or attorney work product privilege. Additionally, participation by family, clergy and others may raise other privilege questions. EVALUATE THE COMPETENCE REPORT
You should make sure that the doctor's report or evaluation
is thorough and complete. If it is not, you should call the
examining doctor and ask for a revised report. If you believe
the revised report is still inadequate or inaccurate, you should
ask for a second opinion. Inquire within the legal and mental
health communities about other doctors who may be able to
testify at the competence hearing on behalf of your client.
The competence report should not contain information or
opinions concerning either your client's mental condition at
the time of the alleged crime or any statements made by your
client regarding the alleged crime or any other crime. You
should seek to ensure that the competence report does not
include any offense-related information or express the
opinion of the examiner on any questions requiring a
conclusion of law or a moral or social value judgment
properly reserved to the trier of fact.
THE COMPETENCE HEARING
A thorough review of Section 54-56D of the Connecticut General Statutes, governing the competency hearing, examination, and commitment proceedings, is necessary to ensure an adequate familiarity with the full range of requirements and detailed procedures that the process involves. The hearing must be held by the court no later than 10 days after it receives the written report. Evidence regarding the defendant's competency, including the written report, may be introduced by either the defendant or the state. One of the examiners must be present to testify to the written report unless waived by both parties. Note that defense counsel can waive the hearing only if the report determines without qualification that the defendant is competent. See CO N N . GEN. STAT. § 54-56(d)(e) (2006). If the court finds your client competent, it shall continue with the criminal proceedings; if the court finds that your client is not competent, it shall make a determination of whether there is a substantial probability that your client, if provided treatment, will regain competency. If the court determines that your client will not regain competency, your client may be released or placed in a mental health facility. The court may also find that the defendant will regain competency, and order treatment. See CO N N . GEN. STAT. § 54-56(f)-(g) (2006). CAN YOUR CLIENT "REGAIN" COMPETENCE?
Whatever the particular diagnosis or disorder, your client's condition may be restored, though perhaps not cured, through hospitalization, other treatment, and/or psychotropic medication. Your client's history of response to treatment is the best indicator of whether your client is restorable, and in what time frame, and under what circumastances, you can expect such restoration. Many criminal court judges may be unaware that dismissed cases are handled differently from cases that have not been dismissed. You may be able to use this distinction to your client's advantage, depending on the court you are in and the seriousness of the alleged offense. For example, a judge who handles misdemeanors may have never conducted a civil commitment proceeding — and may not want to start now. If you can impress upon the judge that a dismissal of your client's case will transfer the responsibility of the civil commitment proceeding to another court, the judge might urge the prosecutor to agree to dismiss the case.
THE "INSANITY" DEFENSE
Under Connecticut law, a defendant charged with a crime may assert an affirmative defense predicated on his lack of mental capacity at the time of the crime's commission. CO N N . GEN. STAT. § 53a-13 (2006). In Connecticut, the term "mental capacity" refers to the Insanity Defense judged at the time of the allegedly wrongful acts or omissions to act, and should not be confused with competence or capacity to stand trial, which is a distinct legal formulation relating to the client's mental state at the time of the pre-trial and trial proceedings, as outlined in Section 6 of this Handbook. The Connecticut General Statutes states: In any prosecution for an offense, it shall be an affirmative defense that the defendant, at the time he committed the proscribed act or acts, lacked substantial capacity, as result of mental disease or defect, either to appreciate the wrongfulness of his conduct or to control his conduct within the requirements of the law. CO N N . GEN. STAT. § 53a-13(a) (2006). As indicated above, the statute lists two instances where a defendant's culpability may be vitiated: (i) when a defendant cannot appreciate the wrongfulness of his conduct; or (ii) when a defendant is unable to control his conduct within the requirements of the law. It is important to note that while the state must prove beyond reasonable doubt that the defendant is guilty of the accused crime, the defendant must prove the affirmative defense of insanity by only a preponderance of the evidence. State v. Steiger, 590 A.2d 408, 425 (Conn. 1991). "Wrongfulness," above, is interpreted according to both society's moral standards and to the defendant's perception of those standards in relation to his own conduct. A defendant may satisfy the first prong of the insanity defense if, because of a mental disease or defect, he did not have substantial capacity to appreciate that his actions or omissions to act were contrary to social morality—even though he might have known that his conduct violated the criminal code. Emphasis is on the defendant's cognitive state at the time of the alleged crime's commission. Showing that a defendant was "unable to control his conduct" is a difficult standard to quantify, and will be based heavily on the facts supporting the defendant's impaired mental condition, as well as the facts surrounding the alleged crime's commission. PREPARE YOUR CASE EARLY
If you are contemplating asserting the Insanity Defense, be sure to make the necessary preparations: • Find a reputable doctor (psychologist or psychiatrist) as quickly as you can and have that individual immediately interview your client. Have the interview videotaped if you can, especially if your client exhibits signs of psychosis. Once your client has been given medication that alleviates the symptoms of his or her mental illness, the demeanor evidence of his or her mental state may be diminished or lost. The symptoms of your client's mental illness need to be preserved as evidence for the jury before this medication takes effect. • If you and your client intend to rely upon the Insanity Defense, the defendant must notify the prosecuting authority in writing of such intention and file a copy of such notice with the clerk no later than 45 days after the first pretrial conference. CONNECTICUT PRACTICE BOOK § 40-17 (2007). Also, "[i]f there is a failure to comply with the requirements of this rule, such affirmative defenses may not be raised." Id. • In addition, if you are planning on using expert testimony to support the affirmative defense of mental disease or defect or extreme emotional disturbance, you must file notice with both the prosecuting attorney and the clerk no later than 45 days after the first pretrial conference. CONNECTICUT PRACTICE BOOK § 40-18 (2007). You must also provide the prosecuting attorney with copies of reports of physical and mental examinations of the defendant prepared by any expert the defense intends to call as a witness within five days of receiving the report. Id. EMPHASIZE LEGAL STANDARDS
TO DISPEL MYTHS
There is a popular myth that a person who is found not guilty by reason of insanity ("NGRI") just "walks away". It is true that, like a simple not-guilty verdict, an NGRI verdict is considered a full acquittal of all charges. However, if you try your client's case to the judge, the judge might be reluctant to find your client not guilty by reason of insanity if he or she is operating under the myth that your client will automatically go free upon such a verdict — especially if your client is charged with a violent crime. However, in reality, unlike a simple not guilty verdict, when a defendant is found NGRI, the court retains jurisdiction over the person and orders the person to be detained in a mental health facility. Custody is handed over to the Commissioner of Mental Health and Addiction Services where your client will be confined, or to the Commissioner of Mental Retardation, where your client will undergo an examination to determine his mental condition. See CO N N . GEN. STAT. § 17a-582(a). Upon completion of the evaluation, the facility sends a report of your client's present mental condition to the trial judge, the prosecutor and you, the defense attorney, addressing whether the acquittee should be discharged. § 17a-582(b). Your client is entitled to a separate examination. CO N N . GEN. STAT. § 17a-582(c) (2006). The court must then hold a hearing to determine whether your client will be confined or discharged. CO N N . GEN. STAT. § 17a582(d)-(e) (2006). Unfortunately, the foregoing myth is not just shared by the public at large, but by many judges, defense lawyers, and prosecutors. You will have a large advantage if you emphasize the legal standards and procedures and demonstrate considerable familiarity with both. The judge may feel that a guilty verdict, coupled with probation, will allow your client to get treatment while allowing the court to retain some degree of control over your client. By advising the judge that the court can likely both reach a verdict of not guilty by reason of insanity and maintain jurisdiction over your client, you can go a long way toward giving your client a zealous defense. At the present time, the psychiatric security review boards and psychiatric hospitals have been conservative in the release of individuals who have been found to be not guilty by reason of insanity. The defendant may therefore spend much longer in a hospital than if he/she pleads guilty, so you need to both weigh options very carefully and make sure the client is aware of the potential for long term confinement.
"EXTREME EMOTIONAL DISTURBANCE" –
AN AFFIRMATIVE DEFENSE TO A
Connecticut law allows for an affirmative defense to murder
where "the defendant committed the proscribed act or acts under
the influence of extreme emotional disturbance for which there
was a reasonable explanation or excuse, the reasonableness of
which is to be determined from the viewpoint of a person in the
defendant's situation under the circumstances as the defendant
believed them to be."4 CO N N . GEN. STAT. § 53a-54a(a) (2006).
Such ‘extreme emotional disturbance' "constitutes a mitigating
circumstance reducing murder to manslaughter in the first degree .
. ." CO N N . GEN. STAT. § 53a-55(b) (2006).
This affirmative defense can be differentiated from an insanity
defense in that the insanity defense "require[s] proof of a mental
disease or defect" while the extreme emotional disturbance
defense "require[s] proof only that the defendant acted under
the influence of an extreme emotional disturbance." State v.
Hodge, 726 A.2d 531, 562 (Conn., 1998).
As with all affirmative defenses under Connecticut law, the
burden to prove extreme emotional disturbance lies with the
defendant,5 who must prove to the jury by a "fair preponderance
4. Additionally, Connecticut law allows evidence that the defendant suffered from a mental disease, defect or abnormality to be used to argue that the he or she did not possess the requisite intent to cause the death of another. CO N N . GEN. STAT. § 53a-54a(b) (2006). 5. Under Connecticut statue, when a defense declared to be an affirmative defense is raised at a trial, the defendant has the burden of establishing the defense by a preponderance of the evidence. CO N N . GEN. STAT. § 53a-12(b) (2006).
of the evidence" that, "(a) the emotional disturbance is not a
mental disease or defect that rises to the level of insanity as
defined by the Penal Code; (b) the defendant was exposed to
an extremely unusual and overwhelming state, that is not
mere annoyance or unhappiness; and (c) the defendant had an
extreme emotional reaction to it, as a result of which there
was a loss of self-control, and reason was overborne by
extreme intense feelings, such as passion, anger, distress,
grief, excessive agitation or similar emotions." State v. Elliot,
411 A.2d 3, 12-13 (Conn. 2006), See also, State v. Aviles,
891 A.2d 935, 953 (Conn. 2006); State v. Zdanis, 438 A.2d
696,698 (Conn. 1980). The reasonableness of the defendant's
act is determined from the "viewpoint of a person in the
defendant's situation under the circumstances as the
defendant believed them to be." Elliot, 411 A.2d at 13.
USE OF EXPERT MENTAL HEALTH WITNESSES,
MITIGATION, AND SENTENCING STRATEGIES
EXPERT MENTAL HEALTH WITNESSES
HOW THEY CAN HELP YOU
Information obtained from mental health experts can help you make informed decisions about: the manner in which you work with your client; your client's competence to proceed; your client's mental state at the time of the offense; plea negotiations; • jury selection; whether your client should testify; medical treatment or other services for your client while the case is pending; what types of assessments or evaluations are needed; and the selection of witnesses for the trial, including the penalty phase.
HOW YOU CAN GET THEM
The incremental approach set out below may not always be
practical. Some judges may determine that a misdemeanor
case does not warrant the use of an expert witness or that
one expert is all you get. This may even be true in some
felony cases. Consult with attorneys in your community about
how to get experts appointed in your case. Ask the court clerk
to learn if the court has developed standard form applications
or motions you should use. It should be noted that the
Connecticut statues related to the Public Defender Services
provides for reimbursement of reasonable expenses related
to "witnesses summoned" by attorneys representing indigent
defendants. See, e.g., CO N N . GEN. STAT. § 51-292 (2006). The
attorney needs to get prior approval for funds related to
experts. Be sure to make a record if you cannot get the experts
or resources you need.
THE INCREMENTAL APPROACH—START WITH A
When deciding on your mental health expert(s), you may
want to consider first consulting a mitigation specialist, who
will often be a licensed social worker. The mitigation
conduct a thorough bio-psycho-social history investigation of your client; interview your client; conduct collateral interviews; gather your client's medical records; and determine what cultural, environmental, and genetic circumstances might have factored into your client's case. Mitigation specialists are superior in many cases to traditional law-enforcement type investigators in developing mitigating evidence because they have training in the human sciences and an appreciation for the variety of factors that may have affected your client's development and behavior. At any rate, the person conducting the investigation should have training, knowledge, and skill to detect the presence of factors such as: mental disorders; neurological impairments; cognitive disabilities; physical, sexual, or psychological abuse; substance abuse; and other influences on the development of your client's personality and behavior.
Mitigation investigations should be thorough and extensive,
especially in capital cases where the whole of the defendant's
life needs to be judged in order to determine whether to spare
her or him from execution. Moreover, the U.S. Supreme
Court has held that failure to investigate such matters in a
capital case can constitute ineffective assistance of counsel.
See Wiggins v. Smith, 539 U.S. 510 (2003). On the other hand,
if your client is charged with a misdemeanor, it may be
enough to use the social worker mitigation expert, or another
qualified investigator, as your only expert in the case.
THEN, YOU MAY WANT TO MOVE ON TO A
The mitigation expert may then confer with a consulting
psychologist, who will review the records and be able to
determine the kinds of expert witness(es) you may need and
the role they can play. In some cases, you need a professional
with specialized expertise in testing intellectual functioning.
Other times, you will want a person with specialization in
personality testing, or you may want someone trained in the
area of sexual trauma to interview your client. The consulting
psychologist can refer specific aspects of your client's case
to the testifying experts, who will interview your client in
preparation for courtroom testimony.
NEXT, FOCUS ON YOUR TESTIFYING EXPERTS
You need to pay attention to the testifying expert's
qualifications and select someone who will be credible and
persuasive to the court and jury. It is important for testifying
experts to be forensically trained since they will have a better
understanding of the legal questions that need to be answered.
You should thoroughly investigate the expert's background
and prior testimony. It is good to have someone who has
testified before and knows how to handle cross-examination.
If your client's primary language is not English, you should
consider hiring an expert who is fluent in your client's
primary language. Testifying expert witnesses fall into several
categories, and you should pick one who can best meet your
• For testimony related to diagnosis, treatment, and medication for mental disorders and medical issues, you should obtain a psychiatrist as your testifying expert witness, preferably one with a forensic specialization. • For testimony related to personality or behavioral disorders, intellectual or cognitive functioning, or administering and interpreting tests, you should obtain a psychologist as your testifying expert witness. You often need both a psychologist and a psychiatrist to enhance credibility. • If your client has a brain injury or has problems with memory, language, or orientation functions, you may want neuropsychiatrist neuropsychologist. • You may also want to use a pharmacologist, or a specialist in addiction medicine or in sexual trauma if appropriate. Local mental health professionals may not have the expertise you need. Also, some experts may feel beholden to local authorities for future income. If any circumstances arise that cause you to question the objectivity of the local health professional in question, you should seek expert assistance elsewhere. This incremental approach to developing mental health evidence is considered by some to be superior to the "complete psychological evaluation" that attorneys often request, particularly in capital cases. This suggested approach may be more cost efficient, more likely to produce information that will advance your theory of the case, and less likely to generate information that will be of no use or, worse, will harm your theory and your client. Ideally, the same professional should not fill more than one role (evaluator, consultant, or treatment provider). ABA STANDARDS RELATING TO GENERAL OBLIGATIONS TO DEFENDANTS WITH MENTAL ILLNESS § 7-1.1 (1989).
WHY IS MITIGATION IMPORTANT?
Mitigation is not a defense to prosecution. It is not an excuse
for committing the crime. It is not a reason the client should
"get away with it." Instead, it is evidence of a disability or
condition that invites compassion. Mitigation is the
explanation of the influences that may have converged in
the years, days, hours, minutes, and seconds leading up to
the crime, the way information was processed in a damaged
brain, and the behavior that resulted.
Human beings can react punitively toward a person whom
they regard as defective, foreign, deviant, or fundamentally
different from themselves. A client's bizarre behavior or
symptoms may be misunderstood by jurors or may engender
such fear that this behavior becomes an excuse to punish the
defendant rather than a basis for mercy. Good mental health
experts can provide testimony at the punishment phase to
help the judge and jury understand who your client is, how he
or she experiences the world, and why your client behaves as
he or she does. They help you humanize your client so that
the judge and jury see him or her as a person who deserves
empathy and compassion. Many lives are spared in capital
sentencing proceedings when jurors come to understand
empathetically the disabilities, brain damage, and tormented
psyche that may have led to a client's behavior. When
presenting mitigation evidence, you must show the
relationship between the disability and the conduct. It is not
the "What?" It is the "So what?" If you cannot answer the
"So what" question that each juror will be asking, the
evidence of disability will look like an excuse, not an
When thinking about sentencing with your mentally ill client,
there are a number of things you should consider and weigh.
MENTAL HEALTH INFORMATION AS MITIGATION
CAN SOMETIMES HURT YOU.
You need to consider carefully the decision to present your
client's mental illness to the jury. Some jurors do not believe
in mental illness. Some jurors will not want your client to be
out in the community on probation. Your client's mental
illness may become fair game for argument; the state may
try to use it against you. The prosecutor might say, "What's to
keep this person from going off his medications again?" Or
the prosecutor might imply that "We have to keep mentally ill
people locked up for our own safety." On the other hand, you
must remember that failing to raise the issue of your client's
mental illness may result in a probated sentence that your
client cannot comply with or in a period of incarceration that
will further damage your client's mental health.
IF YOU DECIDE TO RAISE YOUR CLIENT'S
MENTAL ILLNESS AT THE PUNISHMENT PHASE,
BE SURE YOU HAVE SUFFICIENT EVIDENCE AND
You need to be able to say more than that your client is
depressed. You need to talk about the extent of the depression.
Was your client depressed for a short period or was it more
serious? Unless it is a very serious case that can be
substantiated, jurors may think, "We've all been depressed" or
"Everyone's depressed while they're in jail." Remember, the
scope of inquiry at the punishment phase is much broader than
at the guilt/innocence phase. There are different types of
mental health experts, diagnoses, and resources that may be
helpful. Simply interviewing your client or submitting him
or her for a single mental health exam will almost always
result in an incomplete picture.
YOU MAY BE BETTER OFF ADVISING YOUR
CLIENT TO WAIVE A JURY AND TAKING THE
MENTAL HEALTH EVIDENCE DIRECTLY BEFORE
The decision to go to the jury or the judge for sentencing
depends on several things, including the charges involved,
the judge, and how much the prosecutor is willing to work
with you. If your client decides to go to the judge for
sentencing and you are seeking probation, you should have a
plan for the judge to consider — a stable place for your
client to live, a doctor to go to, and a program to provide
supervision to help your client stay out of trouble. Be an
advocate for your client. Bring in witnesses who know your
client, such as his or her psychiatrist, caseworker, and family
members. If your client is on probation and the state has filed
a motion to revoke or a motion to adjudicate guilt, you should
seek the above-mentioned sources to keep the judge from
revoking your client's probation or entering a conviction on
the record against your client and sending him or her to jail.
You can also have the probation officer handling your client's
case testify about whether your client is on a specialized
ACCURATE AND COMPLETE MENTAL HEALTH
If you are going to bring your client's mental illness before
the judge or jury for sentencing purposes, make sure that the
experts you use do more than conduct a mental status
examination and offer a diagnosis. You should work with
the expert to ensure that he or she conducts a wider-ranging
inquiry into your client's mental health history and its
implications. For example, your client may have incurred a head injury at an early age, causing brain damage. Or there may be a familial history of mental illness or a generational pattern of violence and abuse in the home. It is important to interview outside sources such as family members, former teachers, physicians, etc., as well as to request all available records, and to consider the testimony and evidence they can provide. A comprehensive mental health examination should include: a thorough physical and neurological examination; a complete psychiatric and mental status diagnostic studies, including personality assessment; neuropsychological testing; appropriate brain scans; and a blood test or other genetic studies.
In capital defense litigation, it is especially important to make
sure your client has thorough and comprehensive mental
examinations that evaluate each area of concern as indicated
by the client's bio-psycho-social history.
MANY MENTALLY ILL OFFENDERS CAN HAVE CO-
OCCURRING SUBSTANCE ABUSE PROBLEMS.
Many persons with mental illness have addictions to drugs
and/or alcohol; others "self-medicate" the symptoms of their
mental illness with drugs or alcohol. Under either scenario, it
is likely that this type of client will have problems staying
clean and/or being successful on probation. Both substance
abuse and mental illness are chronic, relapsing illnesses that
need treatment. If your client has a substance abuse problem
and also a serious mental illness, you should look into the
availability of dual diagnosis treatment programs in your
community. Some clients would rather accept a plea bargain
agreement for jail time than wait to get into substance abuse or
dual diagnosis treatment. Your client makes the ultimate decision
about whether to get treatment, but you should talk candidly
with your client about it. Try saying something like, "Look, you
have this problem and you're probably not going to make it on
probation. You're going to end up in the penitentiary—but we
can get you some treatment to help you avoid that." Talk to your
client about doing what is best for him or her over the long term
rather than the short term.
YOUR CLIENT'S MENTAL ILLNESS SHOULD BE
FACTORED INTO DECISIONS ABOUT PROBATION.
Your client may need special attention if he or she is seeking
probation: Remember that your client may not be able to hold
down full time employment, pay probation fees, keep track of
community service, or complete schooling the way that other clients can. Special arrangements may need to be made and extra help may need to be provided if these tasks are part of the successful completion of your client's sentence. If your client is taking probation, you should work to assure that your client gets probation with treatment or gets conditions placed on his or her probation that will help him or her successfully complete the probation. If your client is facing revocation of his or her probation, you should educate the court about your client's mental illness and the treatment options that could be made part of the conditions of his or her probation.
The judge's ability to condition probation on treatment:
The Connecticut General Statutes authorizes judges to require
certain offenders suffering from mental illness to undergo
medical or psychiatric treatment and remain in a specified
institution as a condition of community supervision stemming
from probated or suspended sentences. CO N N . GE N . STAT.
§ 53a-30(a)(2) (2006). Judges may also require defendants to
live in a residential community center or halfway house. §
The judge can amend the conditions of probation: Under
the Connecticut General Statutes, judges may modify or
enlarge the conditions for probation at any time during the
probationary period. § 53a-30(c) (2006). In order to amend
the conditions, the court must hold a hearing, and there must
be "good cause shown" for such modification. Id. There is a
great deal of flexibility to tailor the appropriate conditions of
treatment for offenders suffering from mental illness.
Although mental health treatment may include medication,
attorneys and judges are generally not in the best position to
make judgments about specific medication options. However,
you should advocate for the best available treatment for your
YOUR CLIENT MAY NOT WANT TREATMENT.
You cannot force your client to get treatment if he or she
does not want it, even though you know it may be in his or
her long-term interest. You may be limited in what you can
do for your client. If your client's charges are minor and he
or she has a supportive family, has a safe place to live, is
usually relatively stable, and is competent, it may be better
for your client to plead to jail time if you can negotiate a
good deal rather than pursuing the insanity defense, even if
applicable, or accepting a probated sentence. However, you
have an obligation to set out all the pros and cons of any
plea bargain agreement for your client. If your client is
considering straight jail time, you should tell him or her the
possible benefits of taking probation with conditions that
require treatment. Tell your client what you believe the
chances are of him or her staying out of trouble if he or she
does not get treatment, and what penalties might await your
client if he or she re-offends.
GO THE EXTRA MILE FOR YOUR CLIENT.
Persons with mental illness who are not linked with
appropriate services at sentencing are likely to re-offend,
perhaps with more serious consequences and penalties
attached to the second or third arrest. Try to set up your client
with ongoing treatment and services to enhance the likelihood
that he or she can stay out of trouble. If your client is going to
the penitentiary, you can recommend that he or she be sent to
a specialized mental health unit. If your client is being
released on probation, stable housing is especially important.
Talk with the probation department about the resources it
uses. Call the local Mental Health Association, the local
chapter of the National Alliance for the Mentally Ill (NAMI),
or the local mental health authority for recommendations
In this section, we call your attention to recent cases that
attorneys need to be aware of when representing criminal
defen-dants with mental illness.
Atkins v. Virginia
In Atkins v. Virginia, 536 U.S. 304 (2002), the United States
Supreme Court held that the execution of mentally retarded
persons constitutes cruel and unusual punishment in violation
of the Eighth Amendment to the United States Constitution.
Writing for the Court's majority, Justice Stevens stated:
"Those mentally retarded persons who meet the law's
requirements for criminal responsibility should be tried and
punished when they commit crimes." But then he pointed out
that "[b]ecause of their disabilities in areas of reasoning,
judgment, and control of their impulses . they do not act
with the level of moral culpability that characterizes the most
serious adult criminal conduct," and in addition, "their
impairments can jeopardize the reliability and fairness of
capital proceedings against mentally retarded defendants." Id.
Attorneys representing defendants with serious mental illness
in capital cases may want to consider filing motions and
making arguments to the effect that, as a logical extension of
Atkins, the execution of persons with serious mental illness is
Sell v. United States
In Sell v. United States, 539 U.S. 166 (2003), the United States
Supreme Court held that in cases of "serious criminal
charges," the Government may involuntarily administer anti-
psychotic drugs to a criminal defendant solely to render him
competent to stand trial, at least in those cases meeting the
criteria set out by the Court. In deciding whether the
involuntary medication is appropriate, the court must balance
the following factors: (1) whether there is a substantial state
interest in having a criminal trial, taking into account any
civil confinement for the mental condition; (2) whether the
medication is substantially likely to render the defendant
competent without offsetting side effects; (3) whether the
medication is necessary or whether a less intrusive alternative
procedure would produce substantially the same result; and
(4) whether the drugs are medically appropriate.
Since the inception of the Sell factors, other federal courts
have made the point that these factors are difficult to apply
due to their amorphous and vague nature. Many cases have
attempted to clarify the application of the factors. In United
States v. Gomes, the Second Circuit noted that the Supreme
Court had failed to provide a standard of proof by which to
analyze the factors, and held that in order to involuntarily
administer psychiatric drugs to render a defendant competent
to stand trial, the Sell factors must be established "by clear
and convincing evidence." 387 F.3d 157, 160 (2nd Cir. 2004).
United States v. Ghane, clarified the second Sell factor, stating
that a mere five to ten percent chance that the psychiatric
medication would render defendant competent to stand trail
did not meet the "substantially likely" requirement meted out
by the Supreme Court. 392 F.3d 317, 320 (8th Cir. 2004). In
United States v. Evans, the Western District of West
Virginia noted that the Supreme Court failed to provide
guidance regarding what constituted "serious criminal
charges." 293 F. Supp. 2d 668, 673 (W.D. Va. 2003). The
court in Evans went on to note that, in examinations of the
Sixth Amendment right to trial by jury (which only extends
to those persons charged with "serious" offenses), the
Supreme Court defined "serious" offenses as those for which
"a term of imprisonment exceeding six months may be
imposed." Id. Therefore, the Evans court concluded that for
the purposes of applying the Sell factors, the definition of a
‘serious criminal offense' would be determined by the crime's
Singleton v. Norris
The United States Supreme Court declined to review the
Eighth Circuit of Appeals case of Singleton v. Norris, 319
F.3d 1018 (8th Cir.), cert. denied, 540 U.S. 832 (2003), which
held that it is neither cruel and unusual punishment nor a
violation of due process to execute an inmate who had
regained competency through forced medication for
legitimate reasons of prison security or medical need, even if
the effect was also to render him competent to be executed.
The Eighth Circuit majority avoided the question whether the
Supreme Court's prohibition on executing the insane in Ford
v Wainwright, 477 U.S. 399, 106 S.Ct. 2595, 91 L.Ed.2d 335
(1986), applied to the situation where the State's sole purpose
in forcefully medicating an inmate is to render him competent
for execution, something which the State conceded in its
Singleton brief it could not do and which two state supreme
courts have found unconstitutional under their state
Wiggins v. Smith
Criminal defense lawyers need to be aware of Wiggins v
Smith, 539 U.S.510 (2003), in which the United States
Supreme Court determined that a capital defendant was
denied his Sixth Amendment right to effective assistance of
counsel by his lawyer's failure to investigate the troubled
background which would have revealed evidence that could
have mitigated the punishment. Thus, any evidence such as
mental illness or mental retardation that might mitigate the
defendant's crime or punishment should not be overlooked
by the defense lawyer who wants to avoid a claim of
ineffective assistance of counsel.
Bell v. Thompson
When reviewing a habeas corpus petition for a convicted
first-degree murderer sentenced to death, the Supreme Court
found that, where defense counsel made a strategic decision
not to present mental health evidence as a mitigating factor at
sentencing, after making a "reasonable investigation" the
defendants background, a claim of ineffective assistance of
counsel did not meet the "miscarriage of justice" standard as
applied in Sawyer v. Whitley, 505 U.S. 333, 345-47 (1992).
Bell v. Thompson, 545 U.S. 1158 (2006).
Clark v. Arizona
The Supreme Court upheld a conviction under Arizona's
insanity test, which, as an abbreviation of the M'Naghton
rule, is expressed solely in terms of whether or not the
defendant had the capacity to determine if the act charged as a
crime was right or wrong. The court stated that such a test did
not violate due process. The Court also held that due
process was not violated by Arizona's ruling in State v. Mott
(187 Ariz. 536, 931 P. 2d 1046 (en banc), cert. denied, 520
U. S. 1234 (1997)), which held that defense evidence of
mental illness or defect could not be considered when
determining whether or not the defendant had the requisite
mens rea for any charged offense. Clark v. Arizona, 126 S.
Ct. 2709 (2006).
Panetti v. Quarterman
Scheduled to be argued in April of 2007, this case raises the
question of whether the 8th Amendment permits the
execution of an inmate factually aware of the reason for his
execution, but who, due to the severity of his mental illness,
has a delusional belief as to why the state is executing him,
and as such, does not appreciate that his execution is intended
to seek retribution for his capital offense. Panetti v.
Quarterman, 127 S. Ct. 852 (2007).
GLOSSARY OF COMMON MENTAL HEALTH TERMS
ADD — see attention deficit/hyperactivity disorder. ADHD
— see attention deficit/hyperactivity disorder.
Affect — a person's immediate emotional state or mood that
can be recognized by others.
Affective disorder — a mental disorder characterized by
Depression, mania, "manic- depression," and bipolar disorders in which the individual experiences both extremes of mood are examples. Also called mood disorder. Antisocial personality — a type of personality disorder
marked by impulsivity, inability to abide by the customs and
laws of society, and lack of anxiety, remorse, or guilt
Anxiety — a state of apprehension, tension, and worry about
future danger or misfortune. A feeling of fear and foreboding.
It can result from a tension caused by conflicting ideas or
motivations. Anxiety manifests through symptoms such as
palpitations, dizziness, hyperventilation, and faintness.
Anxiety disorders — a group of mental disorders
characterized by intense anxiety or by maladaptive behavior
designed to relieve anxiety. Includes generalized anxiety and
panic disorders, phobic and obsessive-compulsive disorders,
social anxi-ety, and post-traumatic stress disorder.
Antidepressants — medications used to elevate the mood of
depressed individuals and also to relieve symptoms of
Antipsychotic medications — medications that reduce
psychotic symptoms; used frequently in the treatment of
Attention Deficit/Hyperactivity Disorder (ADHD)
a disorder, usually of children but also present in adults,
characterized by a persistent pattern of inattention and/or
hyperactivity and impulsivity that is more frequent and severe
than is typically found in individuals of a comparable level
of development. Symptoms might include impatience,
fidgetiness, excessive talking, inability to focus or pay
attention, and distractibility.
Atypical antipsychotics — a new group of medications used
primarily to treat schizophrenia with broader effectiveness
and few side effects. Also called new generation
Auditory hallucinations — voices or noises that are
experienced by an individual that are not experienced by
Autism — a mental disorder, first evident during early
childhood, in which the child shows significant deficits in
communication, social interaction, and bonding and play
activities, and engages in repetitive behaviors and self-
Behavior therapy — a method of therapy based on learning
principles. It uses techniques such as reinforcement and
shaping to modify behavior.
Behavioral health — a term used to refer to both mental
illness and substance abuse.
Benzodiazepines — a class of anti-anxiety medications that
have addiction potential in some people.
Bipolar disorder — a mood disorder in which people
experience episodes of depression and mania (exaggerated
excitement) or of mania alone. Typically the individual
alternates between the two extremes, often with periods of
normal mood in between. Also called manic-depression.
Borderline personality disorder — a mental disorder in
which the individual has manifested unstable moods,
relationships with others, and self-perceptions chronically
since adolescence or childhood. Self-injury is frequent.
Clinical psychologist — a psychologist, usually with a Ph.D.
or Psy.D. degree, trained in the diagnosis and treatment of
emotional or behavioral problems and mental disorders.
Cognitive behavior therapy — a therapy approach that
emphasizes the influence of a person's beliefs, thoughts, and
self-statements on behavior. It combines behavior therapy
methods with techniques designed to change the way the
individual thinks about self and events.
Cognitive impairment — a diminution of a person's ability
to reason, think, concentrate, remember, focus attention, and
perform complex behaviors.
Compulsion — the behavioral component of an obsession. A
repetitive action that a person feels driven to perform and is
unable to resist; ritualistic behavior.
Conduct disorder — a childhood disorder characterized by a
repetitive and persistent pattern of behavior that disregards the
basic rights of others and major societal norms or rules.
DSM-IVR — the fourth edition of the Diagnostic and
Statistical Manual of the American Psychiatric Association,
revised. This is a nationally accepted book that classifies
mental disorders. It presents a psychiatric nomenclature
designed for diagnosing different categories of specific
Decompensation — a gradual or sudden decline in a person's
ability to function accompanied by the re-emergence of
Delusion — false beliefs characteristic of some forms of
psychotic disorder. They often take the form of delusions of
grandeur or delusions of persecution.
Dementia — a chronic organic mental illness which produces
a global deterioration in cognitive abilities and which usually
runs a deteriorating course.
Depression — an affective or mood disorder characterized
by a profound and persistent sadness, dejection, decreased
motivation and interest in life, negative thoughts (for
example, feelings of helplessness, inadequacy, and low self-
esteem) and such physical symptoms as sleep disturbances,
loss of appetite, and fatigue and irritability.
Disruptive behavior disorder — a class of childhood
disorders including conduct disorder, oppositional defiant
behavior, and attention deficit/hyperactivity disorder.
Dissociative identity disorder — see multiple personality
Electroconvulsive therapy — a treatment for severe
depression in which a mild electric current is applied to the
brain, producing a seizure similar to an epileptic convulsion.
Also known as electroshock therapy. It is most often used to
treat severe, persistent depression.
Electroshock therapy — see electroconvulsive therapy.
Family therapy — psychotherapy with the family members
as a group rather than treatment of the patient alone aimed at
addressing family dysfunction and leading to improved
Fetal alcohol syndrome — abnormal development of the
fetus and infant caused by maternal alcohol consumption
during pregnancy. Features of the syndrome include retarded
growth, small head circumference, a flat nasal bridge, a small
midface, shortened eyelids, and mental retardation.
Generalized anxiety disorder — an anxiety disorder
characterized by persistent tension and apprehension. May be
accompanied by such physical symptoms as rapid heart rate,
fatigue, disturbed sleep, and dizziness.
Group therapy — a group discussion or other group activity
with a therapeutic purpose participated in by more than one
client or patient at a time.
Hallucination — a sensory experience in the absence of
appropriate external stimuli that is not shared by others; a
misinterpretation of imaginary experiences as actual
Hypomania — an affective disorder characterized by elation,
overactivity, and insomnia.
Illusion — a misperception or misinterpretation of a real
external stimulus so that what is perceived does not
correspond to physical reality.
Impulse control disorders — a category of disorders
characterized by a failure to resist an impulse, drive, or
temptation to perform an act that is harmful to the person or
to others. A number of specific disorders, including substance
abuse disorders, schizophrenia, attention deficit/hyperactivity
disorder, and conduct disorder have impulse control features.
Learning disorders — learning problems that significantly
interfere with academic achievement or activities of daily
living involving reading, math, or writing. They are typically
diagnosed from achievement on standardized tests.
Lithium carbonate — a compound based on the element
lithium that has been successful in treating bipolar disorders.
MRI (magnetic resonance imaging) — a computer-based
scanning procedure that generates a picture of a cross-section
of the brain or body.
Malingering — feigning or significantly exaggerating
symptoms for a conscious gain or purpose such as to get a
change in conditions of confinement.
Mania — an affective disorder characterized by intense
euphoria or irritability, exaggerated excitement, and loss of
Manic-depressive disorder — a mood disorder in which
people experience episodes of depression and mania
(exaggerated excitement) or of mania alone. Typically the
individual alternates between the two extremes, often with
periods of normal mood in between. Also called bipolar
Mental illness — a generic term used to refer to a variety of
mental disorders, including mood disorders, thought
disorders, eating disorders, anxiety disorders, sleep disorders,
psychotic disorders, substance abuse disorders, personality
disorders, behavioral disorders, and others.
Mental retardation — a permanent condition usually
developing before 18 years of age that is characterized by
significantly subaverage intellectual function accompanied
by significant limitations in adaptive functioning in other
areas such as communication, self-care, home living, self-
direction, social/interpersonal skills, work, leisure, and
Mood disorder — a mental disorder characterized by
disturbances of mood. Depression, mania, and bipolar
disorders, in which the individual experiences both extremes
of mood, are examples. Also called affective disorder.
Multiple personality disorder — the existence of two or
more distinct identities or personalities within the same
individual. Each identity has its own set of memories and
characteristic behaviors. The identities are believed to
develop as a way of protecting the individual from the effects
of severe abuse or trauma. Also called dissociative identity
Neuroimaging — newly developed computerized techniques
that can create visual images of a brain in action and indicate
which regions of the brain show the most activity during a
particular task. Two common neuroimaging techniques are
positron emission tomography (PET) and magnetic resonance
Neurosis (pl. neuroses) — a mental disorder in which the
individual is unable to cope with anxieties and conflicts and
develops symptoms that he or she finds distressing, such as
obsessions, compulsions, phobias, or anxiety attacks. This is
no longer a diagnostic category of DSM-IVR.
Nervous breakdown — a non-technical term used by the lay
public, usually referring to an episode of psychosis.
Neuroleptic drugs — a category of older medications used to
treat psychoses. Many have been linked to neurological side
New generation antipsychotics — see atypical
Obsession —An unpleasant or nonsensical thought that
intrudes into a person's mind, despite a degree of resistance
by the person. Obsessions may be accompanied by
compulsive behaviors. A persistent, unwelcome, intrusive
Obsessive-compulsive disorder — an anxiety disorder
involving recurrent unwelcome thoughts, irresistible urges to
repeat stereotyped or ritualistic acts, or a combination of both
Oppositional defiant disorder — a childhood disorder
characterized by a recurrent pattern of negativistic, defiant,
disobedient, and hostile behavior toward authority figures
that persists over time.
Panic attack — a sudden onset of intense apprehension,
fearfulness, or terror often associated with feelings of
impending doom, imminent heart attack, or other fears which
often drive someone to seek medical care.
Panic disorder — an anxiety disorder in which the individual
has sudden and inexplicable episodes of terror and feelings
of impending doom accompanied by physiological symptoms
of fear (such as heart palpitations, shortness of breath, muscle
Paranoia — a pervasive distrust and suspiciousness of
others; suspiciousness or the belief that one is being harassed,
persecuted, or unfairly treated.
Paranoid schizophrenia — a schizophrenic reaction in
which the patient has delusions of persecution.
Personality disorder — an enduring pattern of perceiving,
relating to, and thinking about the environment and oneself
that begins by early adulthood, is exhibited in a wide range
of personal and social contexts, and leads to impairment or
distress; it is a constellation of traits that tend to be socially
Phobia — excessive fear of a specific object, activity, or
situation that results in a compelling desire to avoid it.
Phobic disorder — an anxiety disorder in which phobias are
severe or pervasive enough to interfere seriously with the
individual's daily life.
Positron emission tomography (PET scan) — a newly
developed technique that can create visual images of a brain
in action and indicate which regions of the brain show the
most activity during a particular task.
Post-traumatic stress disorder — an anxiety disorder in
which a stressful event that is outside the range of usual
human experience, such as military combat or a natural
disaster, induces symptoms such as a re-experiencing of the
trauma and avoidance of stimuli associated with it, a feeling
of estrangement, a tendency to be easily startled, nightmares,
recurrent dreams, and disturbed sleep.
Psychiatrist — a medical doctor specializing in the treatment
and prevention of mental disorders both mild and severe.
Psychoactive drugs — drugs that affect a person's behavior
and thought processes, including non-prescription or "street"
Psychotropic drugs — prescribed medications that affect a
person's behavior and thought processes.
Psychoanalysis — a method of intensive and in-depth
treatment for mental disorders emphasizing the role of
unconscious processes in personality development and
unconscious beliefs, fears, and desires in motivation.
Psychologist — a person with a Masters degree, Ph.D.,
Ed.D., or Psy.D., and a license in psychology, the study of
mental processes and behavior. Psychologists can specialize
in counseling and clinical work with children and/or adults
who have emotional and behavioral problems, testing,
evaluation, and consultation to schools or industry, but cannot
Psychopathic personality — a behavior pattern that is
characterized by disregard for, and violation of, the rights of
others and a failure to conform to social norms with respect
to lawful behavior.
Psychosis (pl. psychoses) — a severe mental disorder in
which thinking and emotion are so impaired that the person
is seriously out of contact with reality.
Psychosomatic disorder — physical illness that has
Psychotherapy — treatment of personality maladjustment or
mental disorders by interpersonal psychological means.
Psychotic behavior — behavior indicating gross impairment
in reality contact as evidenced by delusions and/or
hallucinations. It may result from damage to the brain or from
a mental disorder such as schizophrenia or a bipolar disorder,
or a metabolic disorder.
Repression — a defense mechanism in which an impulse or
memory that is distressing or might provoke feelings of guilt
is excluded from conscious awareness.
Schizoaffective Disorder — a mental disorder in which a
mood disturbance and the active symptoms of schizophrenia
Schizophrenia — a group of mental disorders characterized
by major disturbances in thought, perception, emotion, and
behavior. Thinking is illogical and usually includes delusional
beliefs; distorted perceptions may take the form of
hallucinations; emotions are flat or inappropriate. The
individual withdraws from other people and from reality.
Shock therapy — see electroconvulsive therapy.
Social phobia — extreme insecurity in social situations
accompanied by an exaggerated fear of embarrassing oneself.
Sociopathic personality — a behavior pattern that is
characterized by disregard for, and violation of, the rights of
others and a failure to conform to social norms with respect to
Stress — a state of arousal that occurs when people encounter
events that they perceive as endangering their physical or
Stress reaction or stress response — reactions to events an
individual perceives as endangering his or her well-being.
These may include bodily changes as well as psychological
reactions such as anxiety, anger and aggression, and apathy
Stressors — events that an individual perceives as
endangering his or her physical or psychological well-being.
Tangential — a word used to describe thoughts or words
that are only marginally related to the issue at hand.
Tardive dyskinesia — an involuntary movement disorder or
muscular activity that sometimes develops as the result of
taking strong antipsychotic medication over a period of time.
Thought disorder — a disorder where associations between
ideas are lost or loosened but are not perceived as such by
Tic disorders — childhood disorders characterized by
sudden, rapid, recurrent, involuntary motor movements or
vocalizations. An example is Tourette's syndrome.
Tourette's syndrome — a childhood disorder characterized
by multiple motor tics and one or more vocal tics that causes
marked distress or significant impairment in social, academic,
or other important areas of function.
The medications glossary is intended to help you better
understand information you may see in your client's records
or medical reports. Lawyers should always consult with
medical professionals for a more complete understanding of
these medications and their effects and for information about
new medications not listed on these pages.
Medications used to treat symptoms of depression. Many of
these medications are also now considered the medications
of choice for anxiety disorders.
Generic Name Brand Name Other Uses/Notes
also used to treat ADHD in children also used to decrease cigarette smoking in adults also used to treat obsessive-compulsive disorder also used to treat ADHD and Tic disorders in children sometimes used to encourage
Generic Name Brand Name Other Uses/Notes
fluoxetine Prozac approved for use with children; higher doses used for obsessive-compulsive disorder. also used for obsessive- compulsive disorder treat bed-wetting Tofranil Triptil, Vivactil also used with children to treat ADHD in Tourettes syndrome sertraline Zoloft also used to treat anxiety disorders and obsessivecompulsive disorders in children tranylcypromine Parnate also used to treat ADHD and anxiety disorders in children also used to treat insomnia Rhotrimine, Surmontil 5 ANTIANXIETY OR
Medications used to treat anxiety, tension, excitation. Many of these medications are classified as benzodiazepines. Many of the antidepressants are also considered to be the medications of choice for anxiety disorders. Generic Name
hydroxyzine lorazepam oxazepam prazepam temazepam chlordiazepoxide
Libritabs, Librium Medications used to manage the symptoms of psychotic disorders such as schizophrenia and manic-depressive disorder. Many are used as chemical restraints for aggressive, agitated, and self-abusive behaviors in children and adults. The new generation (atypical) medications tend to have fewer side effects. Generic Name Brand Name Other Uses/Notes
chlorpromazine Largactil, Thorazine chlorprothixene Taractan clozapine Clozaril new generation (atypical) medication; requires weekly blood tests comes in longer-acting comes in longer-acting injectable form Loxapac, Loxitane, Daxolin new generation (atypical) medication Trilafon, Etrafon also used to treat burette's disorder in children
Generic Name Brand Name Other Uses/Notes
new generation (atypical) new generation (atypical) medication Mellaril used any longer Navane new generation (atypical) MOOD STABILIZER
Medications used to treat acute manic episodes and to prevent relapse of manic-depressive symptoms. Most of the following except lithium and olanzapine are also anti-seizure medications. Generic Name
Brand Name Other Uses/Notes
also used with children also used with children not for use with children Carbolith, Duralith, Eskalith,Lithane, Lithizine, Lithobid, Lithonate, Lithotabs
Generic Name Brand Name Other Uses/Notes
also used to treat hyper-aggressive behavior in children new generation (atypical) medication oxcarbazepine Trileptal also used with children (valproic acid) Valrelease
Medications used to treat symptoms of obsessive-compulsive
disorder. They are also used as anti-depressant and anti-
Generic Name Brand Name Other Uses/Notes
MEDICATIONS USED TO TREAT ADHD (Attention
Deficit/Hyperactivity Disorder) IN CHILDREN
Brand Name Other Uses/Notes
clonidine Catapres also used to treat burette's disorder, ADHD, aggression, self-abuse, and severe agitation in children dextroamphetamine Dexedrine dextroamphetamine Adderall also used to treat Tourette's disorder propranolol Inderal also used to treat Tourette's disorder, disorder, and severe agitation in children ANTI-SIDE EFFECT MEDICATIONS
Medications usually used to treat the neurological side effects of many, especially older, anti-psychotic medications. Side effects, also called extrapyramidal symptoms, include tremors and rigidity. Also see ANTI-SEIZURE MEDICATIONS below. Generic Name
Brand Name Other Uses/Notes
also used to treat some behavior disorders ANTI-SEIZURE MEDICATIONS
Medications used to treat side-effects such as seizures. Many are also used to treat bipolar or manic-depressive disorder. Benzodiazepines are often prescribed as anti-seizure medications as well. Generic Name Brand Name Other Uses/Notes
carbamazepine Epitol, Tegretol also used to treat anxiety Rivotril disorders, psychosis, mania, severe agitation, severe insomnia and Tourette's disorder in children also used to treat bi-polar valproate (valproic acid) also used to treat bi-polar disorder also used with children MEDICATIONS USED TO TREAT ALCOHOLISM
Medications used to help people resist drinking. Generic Name
Brand Name Other Uses/Notes
also used to block the effects of MEDICATIONS USED TO TREAT INSOMNIA
Medication used to help people sleep better. Some of the
benzodiazepines (tranquilizers) are also used to treat
Brand Name Other Uses/Notes
Noctec, Somnos, Felsules also used with children also used with children triazolam zaleplon RESO URCE S FOR HELP
International Journal of Medicinal Mushrooms, 15(5): 435–448 (2013) Cytotoxicity of Blended Versus Single Medicinal Mushroom Extracts on Human Cancer Cell Lines: Contribution of Polyphenol and Polysaccharide ContentKsenija Durgo,1 Mladen Koncar,1 Drazenka Komes,1 Ana Belscak-Cvitanovic,1 Jasna Franekic,1 Ivan Jakopovich,2* Neven Jakopovich,2 & Boris Jakopovich2