S1: My brother took his life. He was 24 years old.
S1: I was 23 years old. I remember it like it
S1: was yesterday. Has it changed everything in the trajectory of
S1: my life and our family's life? Of course. Years ago,
S1: when I was sure I was in another psychotic break
S1: and I ended up running naked in the area here,
S1: doing all these weird sorts of things. And the cops
S1: came and got me and they're like, What's going on?
S1: And I couldn't speak to them. I just said, having
S1: trouble to verbalize. And they came and got me. And
S1: when I got into psych, the psychiatrist was like, This
S1: is an example of a happy psychotic, right? So psychosis
S1: can be a happy type of psychosis. That's how I
S1: present sometimes. So it's not always violent, it's not always scary.
S1: It's doing things that are embarrassing and hard to deal with.
S1: I've experienced a lot of different trauma caused by myself
S1: and caused by others, too. But the times that I've
S1: done things to others in my psychotic state, I don't
S1: have a filter. The filter gets turned off and suddenly
S1: I'm doing whatever the voice commands me to do. I've
S1: hurt myself and I've hurt others and had major jaw
S1: surgery in 2012 because of an accident. Listening to the voices.
S1: It's a struggle because when I'm mentally unwell, those would
S1: be things that I would normally do if I'd been
S1: medicated and stable. I'm completely a different person in my
S1: psychotic state, completely different.
Faydra Aldridge: Well, there's no way to predict whether a person with
Faydra Aldridge: a mental illness will become violent. There's still a common
Faydra Aldridge: understanding that those diagnosed with a serious mental illness like
Faydra Aldridge: schizophrenia are unpredictably aggressive. It's no surprise we see mental illness,
Faydra Aldridge: substance use and violence connected in the news, on TV
Faydra Aldridge: shows and in movies. But unfortunately, this can create fear,
Faydra Aldridge: and this fear can be a driving force for negative
Faydra Aldridge: attitudes towards people living with a serious mental illness. Before
Faydra Aldridge: we get into today's episode, here's a couple facts for
Faydra Aldridge: us to think about. People who experience psychosis are five
Faydra Aldridge: times more likely to be violent than the general population.
Faydra Aldridge: But an individual experiencing psychosis is three times more likely
Faydra Aldridge: to take their own life than another person's life. My
Faydra Aldridge: name is Faydra Aldridge, the host of Look Again: Mental
Faydra Aldridge: Illness Re-Examined a podcast about mental illness brought to you
Faydra Aldridge: by the B.C. Schizophrenia Society and other partner organizations. Today
Faydra Aldridge: we get to speak with Dr. Rakesh Lamba. Dr. Lamba
Faydra Aldridge: is the medical director with BC Mental Health and Substance
Faydra Aldridge: Use Services. He is also a clinical assistant professor of
Faydra Aldridge: psychiatry at the University of British Columbia and has a
Faydra Aldridge: ton of experience doing risk assessments with Correctional Services Canada
Faydra Aldridge: and with the Parole Board of Canada. Dr. Lamba, welcome
Faydra Aldridge: to the podcast.
Dr. Rakesh Lamba: Thank you. Happy to be here and thanks for having me.
Faydra Aldridge: Thanks for taking the time. So before we jump in
Faydra Aldridge: to the questions today, I just want to take a
Faydra Aldridge: minute to hear some clips from people who have or
Faydra Aldridge: are experiencing psychosis. Let's take a listen now.
S1: He did exhibit some violence that was quite scary. He
S1: took a sledgehammer through the TV and he did take
S1: some violence to my mum at the time. It was very,
S1: very difficult. But as I know and what I've learnt,
S1: that was not him. That was the illness when he
S1: wasn't taking care of himself. I don't know if that
S1: was really her when she was that ill. And that's
S1: what I try to see. I try to think that
S1: she didn't know that her brain was hijacked at the time.
S1: That's how it helps me get through, like knowing that
S1: my mom's brain was hijacked and that was really her
S1: when she did pull a knife on people and on
S1: the paramedics that time.
Faydra Aldridge: So, Dr. Lamba, what is psychosis?
Dr. Rakesh Lamba: Psychosis is best understood as a break from reality. Essentially,
Dr. Rakesh Lamba: the highly confused state of mind, which has an alternative
Dr. Rakesh Lamba: reality or a misperception of the environment that they are in.
Dr. Rakesh Lamba: As one can imagine, such experiences can generate strong emotions
Dr. Rakesh Lamba: in a person like fear, anger, agitation, and sometimes, unfortunately,
Dr. Rakesh Lamba: aggression in responding to these experiences. And the individual involves
Dr. Rakesh Lamba: experiencing delusions and hallucinations, feelings and those experiences to be
Dr. Rakesh Lamba: as real as you and me would consider normal experiences.
Dr. Rakesh Lamba: They lose that insight, that ability to pause and think
Dr. Rakesh Lamba: and consider the reality of these experiences.
Faydra Aldridge: Dr. Lamba We talked earlier about the association between mental
Faydra Aldridge: illness and violence. How do you explain the relationship between
Faydra Aldridge: psychosis and potential violence to your patients and the families
Faydra Aldridge: that you work with?
Dr. Rakesh Lamba: The association between psychosis, particularly as a symptom of mental
Dr. Rakesh Lamba: illness and violence, appears to have two common beliefs. I
Dr. Rakesh Lamba: think it's very important to have a very balanced and
Dr. Rakesh Lamba: nuanced view of the relationship between psychosis and violence. As
Dr. Rakesh Lamba: you can imagine, any exaggerated concerns of this violence are
Dr. Rakesh Lamba: indeed stigmatising and further marginalising to a population that is
Dr. Rakesh Lamba: very vulnerable. On the other hand, if you deny this
Dr. Rakesh Lamba: relationship that leads to missed opportunities to treat individuals, to
Dr. Rakesh Lamba: provide them with the help and support that they need,
Dr. Rakesh Lamba: and may then in some instances lead to more violent
Dr. Rakesh Lamba: incidents that only further stigmatize the group as a whole.
Dr. Rakesh Lamba: That also has not been very clear in defining this relationship.
Dr. Rakesh Lamba: Remote Studies first said that there is the record relationship
Dr. Rakesh Lamba: between psychosis, schizophrenia and violence. The latter studies were somewhat
Dr. Rakesh Lamba: more economical, but more recent studies that use good methodology
Dr. Rakesh Lamba: have in fact shown a consistent but modest relationship between
Dr. Rakesh Lamba: schizophrenia and violence or the risk of individuals with psychosis.
Dr. Rakesh Lamba: Perpetrating violence is a relative risk to the general population.
Dr. Rakesh Lamba: But it's equally true that very few individuals who suffer
Dr. Rakesh Lamba: from psychosis or schizophrenia actually commit violence. And when you
Dr. Rakesh Lamba: look at the total burden of violence in society, only
Dr. Rakesh Lamba: about 10% of the violence is accounted for by individuals
Dr. Rakesh Lamba: who are psychotic. Another important aspect to consider about this
Dr. Rakesh Lamba: relationship is that violence committed by individuals who suffer from
Dr. Rakesh Lamba: psychosis occurs most commonly during acute stages of the illness
Dr. Rakesh Lamba: when they are untreated, in fact, even when they are undiagnosed.
Dr. Rakesh Lamba: So a substantial portion of patients with schizophrenia who commit
Dr. Rakesh Lamba: acts of violence do so before they have presented for treatment.
Dr. Rakesh Lamba: And it is not uncommon for it to come to
Dr. Rakesh Lamba: light that a person suffers from schizophrenia only due to
Dr. Rakesh Lamba: this serious violent incident. The most extreme example of this
Dr. Rakesh Lamba: is if you consider all homicides, but if untreated by
Dr. Rakesh Lamba: individuals with schizophrenia, 40% of them were committed by patients
Dr. Rakesh Lamba: in their first episode, they had not yet been diagnosed
Dr. Rakesh Lamba: as suffering from the illness and hence they were untreated.
Faydra Aldridge: So based on what you said there, it sounds as
Faydra Aldridge: though the key is the untreated mental illness. That seems
Faydra Aldridge: to be the connection between psychosis and violence. Would you
Faydra Aldridge: agree with that?
Dr. Rakesh Lamba: Yes, I would agree with that. And those are important factors.
Dr. Rakesh Lamba: There are some other general factors as well amongst individuals
Dr. Rakesh Lamba: who suffer from schizophrenia that may help assess the occurrence
Dr. Rakesh Lamba: of violence. But very important features are the untreated symptoms.
Faydra Aldridge: Now, Dr. Lamba, is there any way to predict whether
Faydra Aldridge: a person with schizophrenia or an individual experiencing psychosis will
Faydra Aldridge: in fact become violent?
Dr. Rakesh Lamba: The short answer is no. And to help understand that,
Dr. Rakesh Lamba: you have to understand the difficulties in predicting violence in general. Firstly,
Dr. Rakesh Lamba: if you consider the word predicting, predicting simply refers to
Dr. Rakesh Lamba: that binary decision of yes or no. Will the person
Dr. Rakesh Lamba: be violent or will a person not be violent? Violence
Dr. Rakesh Lamba: itself is very uncommon. Generally speaking, when you are trying
Dr. Rakesh Lamba: to predict yes or no for an event that is uncommon,
Dr. Rakesh Lamba: that becomes all the more difficult. And so that's no
Dr. Rakesh Lamba: different for individuals who suffer from schizophrenia. The other thing
Dr. Rakesh Lamba: to consider is that violence is a complex outcome. There
Dr. Rakesh Lamba: are many factors that account for violence, many of which
Dr. Rakesh Lamba: we don't understand. There are some factors that contribute to
Dr. Rakesh Lamba: violence that we still don't know, and that is true
Dr. Rakesh Lamba: for general population as well as individuals who suffer from schizophrenia.
Dr. Rakesh Lamba: And so that's why it's very difficult to, quote unquote,
Dr. Rakesh Lamba: predict violence in the individual who suffers from psychosis or schizophrenia.
Faydra Aldridge: So, Dr. Lamba, what are some signs that could indicate
Faydra Aldridge: that a person living with schizophrenia may be at risk
Faydra Aldridge: for violence?
Dr. Rakesh Lamba: What helps us assess the risk to say that at
Dr. Rakesh Lamba: this particular point a person might be more likely, not
Dr. Rakesh Lamba: necessarily will, but just more likely to go on to
Dr. Rakesh Lamba: be violent is a constellation of symptoms. As a single factor,
Dr. Rakesh Lamba: person who has a history of violence is more likely
Dr. Rakesh Lamba: to be violent in the future as a single stand
Dr. Rakesh Lamba: alone factor. That's the strongest factor. And that's true for
Dr. Rakesh Lamba: individuals who do not suffer from any illness as well
Dr. Rakesh Lamba: as individuals who suffer from schizophrenia. So keeping that in mind,
Dr. Rakesh Lamba: it's easier to assess the risk of violence in a
Dr. Rakesh Lamba: person who we know has some predisposition to violence and
Dr. Rakesh Lamba: has previously been violent, as opposed to somebody who has
Dr. Rakesh Lamba: never been violent. When we are just trying to predict
Dr. Rakesh Lamba: out of the blue that whether or not this person's
Dr. Rakesh Lamba: going to be violent. I think what's important to consider
Dr. Rakesh Lamba: is that person who is, for example, in the throes
Dr. Rakesh Lamba: of acute psychosis and experiencing delusions and hallucinations very acutely,
Dr. Rakesh Lamba: a person who is under the influence of substances or
Dr. Rakesh Lamba: in the middle of the run of use of drugs,
Dr. Rakesh Lamba: particularly stimulant drugs, a person who has complete absence of insight,
Dr. Rakesh Lamba: person who has violent fantasies or ideas as part of
Dr. Rakesh Lamba: their illness or delusions. Those factors will add up to
Dr. Rakesh Lamba: a period of heightened risk to that assessment that this
Dr. Rakesh Lamba: is a time period where the individual is at a
Dr. Rakesh Lamba: heightened risk for violence.
Faydra Aldridge: And Dr. Lamba, you talked about this earlier. It must
Faydra Aldridge: be so incredibly awful for an individual experiencing psychosis because,
Faydra Aldridge: as you said, they believe it. They are living it.
Faydra Aldridge: So based on all your years of experience working with
Faydra Aldridge: people experiencing psychosis and their families, what do you hear
Faydra Aldridge: from them about what it's like to live with psychosis?
Dr. Rakesh Lamba: So that reaction to an incident that the person has
Dr. Rakesh Lamba: perpetrated in the midst of a psychotic state varies. They
Dr. Rakesh Lamba: look back at how they behaved in that particular incident
Dr. Rakesh Lamba: and they are absolutely overcome with remorse, shame, guilt. One
Dr. Rakesh Lamba: of those feelings. And then there are other individuals who
Dr. Rakesh Lamba: unfortunately have ongoing persistent psychosis where they are in a
Dr. Rakesh Lamba: mental state where it briefly, if at all, they can
Dr. Rakesh Lamba: actually reflect on their behaviors in their past. So the
Dr. Rakesh Lamba: severity of the illness and the course of the illness varies.
Dr. Rakesh Lamba: But certainly I have seen many patients who later on
Dr. Rakesh Lamba: in periods of remission, quite horrified about their own behaviour
Dr. Rakesh Lamba: committed while they were psychotic.
Faydra Aldridge: You're listening to Look Again. Mental Illness re-examined a podcast
Faydra Aldridge: brought to you by the Schizophrenia Society and by partner organizations.
Faydra Aldridge: I'm your host, Ada Aldridge. This podcast would not be
Faydra Aldridge: possible without the support of the community. From the bottom
Faydra Aldridge: of our hearts, we want to thank you for caring
Faydra Aldridge: about serious mental illness and everything that's around it. Together,
Faydra Aldridge: we truly can make a difference. Welcome back to Look Again.
Faydra Aldridge: Mental illness re-examined. We're back with forensic psychiatrist Dr. Rakeysh Lamba. Okay, Dr. Lamba,
Faydra Aldridge: based on your work with the Correctional Services Canada and
Faydra Aldridge: Forensic Psychiatric Services, I'm curious about what typically happens to
Faydra Aldridge: a person with a serious mental illness like schizophrenia if
Faydra Aldridge: they are arrested for committing a crime.
Dr. Rakesh Lamba: So when a person is detained, they go to a
Dr. Rakesh Lamba: remand centre or a jail and they are held in custody.
Dr. Rakesh Lamba: What happens in British Columbia, in the provincial correctional system
Dr. Rakesh Lamba: is that all individuals undergo a physical and mental health
Dr. Rakesh Lamba: screening within 24 hours of being detained. And within 24
Dr. Rakesh Lamba: hours of admission to a correctional centre. The mental health
Dr. Rakesh Lamba: screening includes things like screening for the presence of symptoms
Dr. Rakesh Lamba: of mental illness, including psychotic symptoms like delusions, hallucinations, residents
Dr. Rakesh Lamba: of mood disorders, symptoms like depression, mania, suicidal ideas, intent
Dr. Rakesh Lamba: or planning for suicide. Screening is also very important for
Dr. Rakesh Lamba: substance use. So they were screened for whether or not
Dr. Rakesh Lamba: a person appears to be under the influence of substances
Dr. Rakesh Lamba: having come recently off the street or whether they are
Dr. Rakesh Lamba: suffering from withdrawal symptoms. The screening process is actually quite detailed.
Dr. Rakesh Lamba: Upon admission to the correctional centres and it runs to
Dr. Rakesh Lamba: achieve two things. The first thing is does this person
Dr. Rakesh Lamba: need any kind of special observation or special placement within
Dr. Rakesh Lamba: the facility? The second thing that it determines is what
Dr. Rakesh Lamba: sorts of services this person needs to be referred to.
Dr. Rakesh Lamba: Do they need to see a psychologist, a psychiatrist, a
Dr. Rakesh Lamba: general practitioner right away? There's also a process of what
Dr. Rakesh Lamba: we refer to as medication reconciliation. They try to obtain
Dr. Rakesh Lamba: a bit of a medication history for the person so
Dr. Rakesh Lamba: that there is no break, and that is continuity in
Dr. Rakesh Lamba: giving individuals their medications, whatever conditions that they had been
Dr. Rakesh Lamba: taking medications out in the community once they are detained.
Dr. Rakesh Lamba: Depending on how they present and as they move from
Dr. Rakesh Lamba: that court process, the courts have an ability to refer
Dr. Rakesh Lamba: these individuals for assessment, for fitness to stand trial. So
Dr. Rakesh Lamba: the court or the lawyers and more with the patient
Dr. Rakesh Lamba: can become interested to know whether this person is fit
Dr. Rakesh Lamba: to stand trial, which essentially means do they understand the
Dr. Rakesh Lamba: nature of the charges against them? Do they understand the
Dr. Rakesh Lamba: consequences of a guilty finding or a guilty plea? Are
Dr. Rakesh Lamba: they able to enter a plea or answer to those charges?
Dr. Rakesh Lamba: Are they able to participate meaningfully in the court process?
Dr. Rakesh Lamba: So that's all under the assessment of fitness to stand trial.
Faydra Aldridge: How long does that process typically take?
Dr. Rakesh Lamba: Dr. Lamba So that's a good question. It can take
Dr. Rakesh Lamba: some time. At the first appearance or in subsequent appearances
Dr. Rakesh Lamba: in court, when such a concern may arise, a court
Dr. Rakesh Lamba: may order such an assessment to be done either in
Dr. Rakesh Lamba: custody or out of custody. There is a bit of
Dr. Rakesh Lamba: a wait for these individuals to be admitted to the
Dr. Rakesh Lamba: forensic psychiatric hospital where these assessments are conducted in custody.
Dr. Rakesh Lamba: All in all, the courts have the ability to order
Dr. Rakesh Lamba: these assessments for 30 days with one extension of another
Dr. Rakesh Lamba: 30 days. So there is some wait for admission to
Dr. Rakesh Lamba: the forensic psychiatric hospital. Once they get to the hospital,
Dr. Rakesh Lamba: depending on their condition and depending on whether or not
Dr. Rakesh Lamba: they need treatment for any acute symptoms that are present,
Dr. Rakesh Lamba: it can take some time. The other consideration that may
Dr. Rakesh Lamba: come up during the court process is the court may
Dr. Rakesh Lamba: become concerned about what the mental state of this person
Dr. Rakesh Lamba: was when they committed the act that led to the charges.
Dr. Rakesh Lamba: And that assessment is referred to as criminal responsibility or
Dr. Rakesh Lamba: whether a finding of and see are maybe not criminally
Dr. Rakesh Lamba: responsible due to a mental disorder is warranted in this case.
Dr. Rakesh Lamba: And those assessments also, when ordered in custody, take place
Dr. Rakesh Lamba: at the forensic psychiatric hospital.
Faydra Aldridge: Now going through this process and the assessments, we have
Faydra Aldridge: talked a lot about the impact on family, and I
Faydra Aldridge: don't think the impact on families can be emphasized enough.
Faydra Aldridge: So why do options two families have to keep their
Faydra Aldridge: loved one protected and ensure that they get the proper
Faydra Aldridge: support while they're going through these assessments?
Dr. Rakesh Lamba: So unfortunately, there is not much that families are able
Dr. Rakesh Lamba: to do while the person is going through the assessments.
Dr. Rakesh Lamba: The forensic psychiatric hospital is not like your regular hospital.
Dr. Rakesh Lamba: There are things like visitation, but because these individuals are
Dr. Rakesh Lamba: considered to be in their custodial phase of the treatment phase,
Dr. Rakesh Lamba: there are special rules that apply around visitation. I'm sure
Dr. Rakesh Lamba: that families feel a bit disconnected at this stage of
Dr. Rakesh Lamba: the process. The patients, of course, can contact their families
Dr. Rakesh Lamba: by phone and be in touch with their lawyer, their families,
Dr. Rakesh Lamba: their friends, whether they are at the correctional center or
Dr. Rakesh Lamba: at the forensic psychiatric hospital. But unfortunately that seems to
Dr. Rakesh Lamba: be the extent of their direct support and contact at
Dr. Rakesh Lamba: that stage. And while it's difficult to say a lot
Dr. Rakesh Lamba: about what the families can do while the loved ones
Dr. Rakesh Lamba: are going through assessment, I think in general, the families
Dr. Rakesh Lamba: have a big role to play in their journey by
Dr. Rakesh Lamba: emotionally supporting their loved ones, by encouraging them, monitoring their
Dr. Rakesh Lamba: mental state, monitoring their compliance to medications, watching for signs
Dr. Rakesh Lamba: of acute relapse, helping them through difficult phases of their lives,
Dr. Rakesh Lamba: helping them deal with stressors. Because we know that stress
Dr. Rakesh Lamba: is an important precipitant of an acute episode. So just
Dr. Rakesh Lamba: that kind of support, helping their loved ones abstain from
Dr. Rakesh Lamba: drugs and alcohol, helping them access treatment. And then, of course,
Dr. Rakesh Lamba: advocacy within the system to help support their loved ones.
Faydra Aldridge: And Dr. Lamba, I know this is a big question,
Faydra Aldridge: but I'm curious, what changes would you as a forensic psychiatrist,
Faydra Aldridge: like to see within the criminal justice system in terms
Faydra Aldridge: of how people with a mental illness are viewed and treated?
Dr. Rakesh Lamba: That is a big question. I mean, we speak about
Dr. Rakesh Lamba: the criminalization of the mentally ill. That's essentially what's happened
Dr. Rakesh Lamba: over the last two or three decades with the deinstitutionalization
Dr. Rakesh Lamba: movement when the big psychiatric institutions closed down and no
Dr. Rakesh Lamba: services or resources were added to address the needs of
Dr. Rakesh Lamba: the ill population. What we saw is a few negative outcomes,
Dr. Rakesh Lamba: and the biggest one of them was the criminalization of
Dr. Rakesh Lamba: the mentally ill. Jails and forensic psychiatric facilities became the
Dr. Rakesh Lamba: default mental institutions. That's been the unfortunate experience, of course,
Dr. Rakesh Lamba: over the last couple of decades. Criminalization of the mentally ill.
Dr. Rakesh Lamba: The reverse of this process will take some time, obviously,
Dr. Rakesh Lamba: and a lot of coordinated effort and resources it will
Dr. Rakesh Lamba: take to reverse the trend.
Faydra Aldridge: Thank you. And I have one final question, Dr. Lamba.
Faydra Aldridge: And as we said earlier, we know through media that
Faydra Aldridge: there is that fueling a fear when it comes to
Faydra Aldridge: the connection between people experiencing psychosis and violence and the
Faydra Aldridge: widespread public perception that everyone who has schizophrenia is going
Faydra Aldridge: to be violent. How do we address that and how
Faydra Aldridge: do we combat that automatic connection that seems to be
Faydra Aldridge: in our society today?
Dr. Rakesh Lamba: That's a difficult one. How to combat this widespread perception.
Dr. Rakesh Lamba: I think everybody has a role that the mental health
Dr. Rakesh Lamba: professionals role is to keep highlighting at every available opportunity
Dr. Rakesh Lamba: that this relationship is not automatic. Keeping in mind that
Dr. Rakesh Lamba: while there is a correlation as a group, individuals with
Dr. Rakesh Lamba: schizophrenia may be at more risk for violence as compared
Dr. Rakesh Lamba: to the general population. Only few of the individuals who
Dr. Rakesh Lamba: suffer from schizophrenia are actually violent. And looking at the
Dr. Rakesh Lamba: broader picture, you look at all of the violence, the
Dr. Rakesh Lamba: load of the burden of violence in society. Only a
Dr. Rakesh Lamba: small amount of that is accounted for by individuals who
Dr. Rakesh Lamba: suffer from schizophrenia. And I think that puts it best
Dr. Rakesh Lamba: in perspective.
Faydra Aldridge: Yeah, I think it's important to emphasize that there's not
Faydra Aldridge: an automatic connection between violence and somebody experiencing psychosis. But
Faydra Aldridge: we also have to be very real and very cognizant
Faydra Aldridge: of the fact that there is a connection and people
Faydra Aldridge: who are untreated can be violent. And that's why I
Faydra Aldridge: am so happy we are having this conversation today. Dr. Lamba,
Faydra Aldridge: I would agree.
Dr. Rakesh Lamba: Thank you.
Faydra Aldridge: And a huge thank you to you, our audience, for
Faydra Aldridge: joining us for this episode. Together, we can change the
Faydra Aldridge: narrative around mental illnesses like schizophrenia and put an end
Faydra Aldridge: to the many myths and stereotypes that we were talking
Faydra Aldridge: about today. If you have any questions or comments, tweet
Faydra Aldridge: us at b c schizophrenia. Get our latest episode. Be
Faydra Aldridge: sure to hit follow on Apple Podcasts, Spotify, or anywhere
Faydra Aldridge: you listen to podcasts. We hope you can join us
Faydra Aldridge: next episode. Talk to you soon.
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