Behavioral Sciences and the Law

Behav. Sci. Law 24: 373–383 (2006)

Published online in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/bsl.710

Paranoia in the Criminal

Courts
John Gunn, M.D.*
and Alec Buchanan, Ph.D., M.D.y

It is generally accepted that those who suffer from mental

illness are less responsible for their criminal actions than
others. A fictitious case of a woman suffering from a
paranoid psychosis, who severely injures her legal advisor,
is considered in two different but related jurisdictions,
England & Wales and Connecticut, USA. Four elements
of the criminal process are considered. Significant differ-
ences between the jurisdictions are found in all four
elements. There is greater pragmatism in the English
system and a greater chance of the woman ending up in
long-term hospital care, but both systems aim to prevent
further violence by the use of institutionalisation. Inter-
national and intra-national variations in the care of this
hypothetical woman are briefly discussed, and it is clear
that in both countries medical care is compromised by
attitudinal and political considerations. Copyright #
2006 John Wiley & Sons, Ltd.

At least since Roman times it has been accepted that those who suffer from mental
illness are less responsible for their actions than healthy people, and if they commit
an antisocial act they should suffer less severe consequences. On the other hand,
probably for all of human history, people have been afraid of deranged or ‘‘mad’’
individuals, fearing them to be unpredictable and violent. How does the modern
world reconcile these somewhat conflicting notions?
The editors have given us a fictitious case to consider. The case is based on an
amalgam of the kinds of problem we have seen in clinical practice and is simply a means
of addressing the dilemma posed above. We will take Annie (our subject) through two
different legal systems to see how much universality there is in tackling this fundamental
problem. The legal systems we have chosen, that of England and Wales and that of
Connecticut, U.S.A., have no special significance, but are the ones we know best. When
noting the differences it might also be of interest to note some of the similarities; English
and American law were the same in July 1776. Things have diverged markedly since that

*Correspondence to: John Gunn, M.D., P. O. Box 725, Bromley, BR2 7WF, England.
E-mail: j.gunn@iop.kcl.ac.uk
y
Yale University Department of Psychiatry.

Copyright # 2006 John Wiley & Sons, Ltd.

374 J. Gunn and A. Buchanan

time but the principles of English common law still apply in the United States, and
English common law still holds sway if there is no statute law to override it in both
jurisdictions. In this article we are not concerned with the complexities of aetiology, nor
the subtleties of treatment for paranoia, but simply with the practicalities of the legal and
punitive response to a serious antisocial act in the context of this disorder.

PRESENTATION
As indicated (page 369), Annie Smith was arrested at home, without resistance.
Earlier that day, she had left her legal advisor bleeding in his office. At the police
station, Ms Smith was generally quiet and withdrawn. She answered few questions,
but from time to time expressed indignation that it should be she who was under a
criminal charge. The police asked for a psychiatric opinion on her fitness to be
interviewed.
She was unequivocally identified as the woman who had stabbed the lawyer. She
herself admitted doing so, was charged with grievous bodily harm, and remanded to
prison/jail (according to jurisdiction) to await trial.
Ms Smith was 64 and looked older. In prison/jail, she was held in the hospital wing,
where she held herself aloof from other prisoners. She resisted examination or the
possibility of any treatment for the heart disease she was thought to have. There was
considerable concern that her physical health would deteriorate. Her psychiatric report
indicated the presence of paranoid delusions, but she had no cognitive impairment.

PROCEDURES
Let us for the sake of discussion assume that this lady has some form of paranoid
psychosis. Her psychiatric status could be considered at four points in the criminal
justice process. The four points are:
(i) the police investigation,
(ii) the plea,
(iii) the trial,
(iv) the sentence.
The Police Investigation

England and Wales

First, the question of whether Annie was mentally ill should have been asked by the
police officers dealing with her case. In England if the police have any suspicion or
are told in good faith that a person may have a mental disorder or is otherwise
mentally vulnerable or they are told that s/he is mentally incapable of understanding
the significance of the questions or the replies, they are to treat the person as if she
were mentally vulnerable (Archbold 15-397). It is fairly well understood now that
defendants who have a significant mental disorder or are otherwise mentally
vulnerable may make confessions which are untrue (Archbold 15-275-280 and
15-397), but as Gudjonsson, Hayes, and Rowlands (2000) point out this latter point
is a technical one and best left to a psychologist if the content of any confession that is
extracted is disputed. The initial safeguard to try and prevent this happening comes

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
 Paranoia in the criminal courts 375

from the Police and Criminal Evidence Act 1984 (PACE). The codes of practice to
this Act provide for an ‘‘appropriate adult’’ to be called to the police station whenever
a juvenile or mentally vulnerable person has been detained in police custody. The
appropriate adult will have an important role to play in the custody environment
by ensuring that the detained person whom they are assisting understands what
is happening to them and why. The appropriate adult may be the person who is
normally responsible for the defendant’s care, a mental health worker, a social
worker experienced in dealing with mentally vulnerable people, or another
responsible adult. Such a person cannot act as a lawyer and every defendant is
advised to have a legal representative present at the interview either instead of or as
well as the appropriate adult.
It is likely also that the police would also have her assessed by a police doctor, i.e. a
general practitioner with a police contract (often called a forensic medical examiner).
The police would want to know whether the suspect was fit to be interviewed. No
exact criteria are laid down for fitness to be interviewed, but Gudjonsson (1995) has
suggested three broad criteria for unfitness:

(i) inability to understand the police caution given before the interview,
(ii) disorientation in time, place, and person,
(iii) likelihood of giving answers that could be misconstrued.

These criteria will take into account the individual’s capacity to understand and
answer questions put by the police officer and his/her intellectual capacity. It should
also take into account the impact of the delusional ideas in this case on the woman’s
ability to comprehend the interrogation adequately. The problem is that unfitness to
be interviewed tends to stop the criminal process, or at least the police tend to think it
does, because they now cannot get a statement and have to rely on other evidence. If
the individual is thought unfit to be interviewed, the next question is whether this is a
temporary state and likely to improve or whether it is a permanent condition.
Temporary conditions include intoxication of various types, severe drug withdrawal,
and severe mental illness. Permanent conditions include severe dementia and severe
learning difficulties.
The Crown Prosecution Service guidance when someone is found unfit to be
interviewed (http://www.cps.gov.uk/legal/section3/chapter_a.html) is for the police
to consider diversion to the mental health services without bringing a prosecution or
to take the accused to a magistrate’s court to consider remanding her to hospital
under section 35 of the Mental Health Act 1983 in order for a report on her mental
condition to be prepared (Archbold, 5-567). Home Office Circular 66/90 requires
that certain avenues of diversion for mentally disordered offenders, such as
cautioning and/or admission to hospital or support in the community, should be
considered before deciding that prosecution is necessary. The circular advocates that
wherever possible mentally disordered offenders should receive care and treatment
from health and social services rather than the penal system. The later Home Office
Circular 12/95 (on inter-agency working in relation to mentally disordered
offenders) supplements this with further guidance; for example, Chief Officers of
Police are asked to develop arrangements for the examination by psychiatrists or
other mental health professionals of detained persons and to consider setting up
mental health assessment schemes at selected police stations.

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
376 J. Gunn and A. Buchanan

In this case the suspect was deemed to be fit to be interviewed, even although there
were question marks concerning the validity of the answers given. If the confession
became central to the case and was challenged, Annie’s suggestibility might be tested
by a psychologist (Gudjonsson, 2002). We are not told who was with her when she
was interviewed but she would almost certainly had at least an appropriate adult
present or more likely her solicitor (lawyer).

Connecticut

The laws governing police behaviour vary across the different U.S. jurisdictions.
Wherever she is, however, one of the first decisions someone has to make after being
arrested is whether or not to talk to the police. In Annie’s case a number of her
symptoms, such as the conviction that she has done nothing wrong, make it likely
that she will and may even lead her to conclude that she has no need of an attorney.
She may then say things that are against her own interests. The Fifth Amendment to
the U.S. constitution provides that someone cannot be compelled to be a witness
against herself. This privilege has little meaning, however, unless the defendant is
aware of it and competent to assert her rights (Miller, 1998).
If a confession is obtained in the absence of the defendant’s legal representative,
the burden rests on the state to show that the defendant ‘‘knowingly and
intelligently’’ waived his privilege against self-incrimination (Miranda v. Arizona,
1969). Several factors have limited the applicability of this Supreme Court ruling to
cases such as Annie’s. The first is the relationship between federal and state laws.
The Fifth Amendment privilege against self-incrimination, for instance, was only
applied to the states following the case of Malloy v. Hogan in 1964.
The second is that the relevant case law is inconsistent. In a series of cases in the
1940s and 1950s the Supreme Court struck down confessions obtained from
defendants whose mental capacities were impaired by mental retardation (Payne v.
Arkansas, 1958) and mental illness (Fikes v. Alabama, 1957). In 1986, however, the
Supreme Court pronounced on the case of a man who suffered from a range of
psychotic symptoms and had confessed to a murder without an attorney present
(Colorado v. Connelly, 1986). His attorney argued that his client’s psychosis had
prevented him from making a proper decision to waive his rights. The court turned
down the appeal, writing that the defendant’s perception of being coerced by the
voice of God was ‘‘a matter to which the Federal Constitution does not speak’’.

The Plea and the Trial

England and Wales

An interview in this case would help give some insight into the thinking behind the
dangerous behaviour. It may have convinced her English solicitor that Annie is unfit
to plead. This is a matter that will have to be put to the court if it is to succeed. The
defence lawyer will then ask a psychiatrist to assess the suspect from this perspective.
Here there are clearer criteria not from the legislation, which is extremely vague,
simply saying that the accused is unfit to plead if s/he ‘‘is under a disability, that is to

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
 Paranoia in the criminal courts 377

say, under any disability such that apart from this Act it would constitute a bar to his
being tried’’. By tradition, however, to be fit to plead a defendant should be able to:
(a) plead with understanding to the indictment (i.e. understand the difference
between pleading guilty and pleading not guilty),
(b) comprehend the details of evidence,
(c) follow the court proceedings,
(d) know that a juror may be challenged,
(e) instruct legal advisors.

These tests come from a 19th century trial of a deaf and mute person (R. v.
Pritchard, 1836) but they have stood the test of time. The criteria are usually assessed
by information from the accuser’s lawyers, background information, and a detailed
conversation with the defendant. Section 36 Mental Health Act 1983 allows the
court to remand an accused to hospital for treatment, instead of being remanded in
custody, pending trial or sentence (Archbold, 5-568). This may enable a defendant
to receive treatment prior to trial, which may proceed at a later date when the
condition of the defendant has improved.
A recent change in the law may have changed the Pritchard criteria slightly (Gray,
O’Connor, Williams, Short, & MacCulloch, 2001). Under the Criminal Justice and
Public Order Act 1994 the right of an accused to stay silent has been modified in
England and Wales. Now adverse comment may be made in a trial, if information
used as part of his/her defence was withheld from the police by silence, unless ‘‘the
accused’s guilt is not in issue; or unless it appears to the court that the physical or
mental condition of the accused makes it undesirable for him to give evidence’’
(Section 35).
In R. v. M (2001) a man was charged with unlawful wounding. He had suffered a
serious head injury as a young man and showed some cognitive deficits. He passed the
Pritchard criteria (given above) and was found to be fit to plead. At a pre-trial hearing,
however, his counsel said that Mr. M. was not able to provide reliable evidence because
of his mental condition and that this should be included as an additional criterion for
fitness to plead. This was agreed, and Mr. M. was found unfit to plead. Whether this
really is a change of the Pritchard criteria or not is debatable: time will tell.
However, the English law relating to the process by which unfitness to plead can
be determined has changed very recently. Under the Domestic Violence, Crime and
Victims Act 2004 the issue of fitness to plead is now decided by the judge, not by the
jury as used to be the case. If the judge finds that the defendant is unfit to plead, a jury
is then empanelled to decide whether the defendant carried out the act or made the
omission that led to the charge. This latter procedure is an attempt to ensure that the
outcome provisions of the verdict are not applied to people who may be ill but who
are the victims of mistaken identity. Archbold 4-166-178 sets out the law governing
the procedure, evidence and burden of proof in the Crown Court.
The new Act (2004) allows three disposals where a defendant is found unfit to
plead but is the person who carried out a criminal act:

1. A hospital order under section 37 of the Mental Health Act 1983, with a
restriction order under section 41 if necessary. To allow this a psychiatrist has
to give evidence that the defendant is suffering from a mental disorder.

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
378 J. Gunn and A. Buchanan

2. A supervision order. This is specified in schedule 2 to the 2004 Domestic

Violence Act, and means an order that requires the defendant to be under the
supervision of a social worker or a probation officer for up to two years. A
supervision order may also require the supervised person to submit to medical
treatment.
3. An absolute discharge.
An outcome of unfitness to plead is rare in England and Wales and is largely
reserved for severely disordered people, and even then the outcome may be capricious.
In spite of the fact that the result is dichotomous, there are no subcategories of fitness
to plead in England and Wales; there is little distinction between the mental health of
people found unfit to plead and those found fit to plead (Grubin, 1996).
In the majority of the cases considered for an ‘‘unfitness’’ verdict in England and
Wales it is likely that the defendant will respond to medical treatment and the trial will
take place within a reasonable period, with the court simply postponing the hearing to
await improvement. The provisions of section 51 of the Mental Health Act 1983
enable the Crown Court to make a hospital order with or without restrictions in the
defendant’s absence and without convicting her if she has been remanded in custody
but has subsequently been transferred to hospital for medical treatment.
If the patient refuses to accept treatment in hospital, then psychotropic
medication can be given without consent of the patient for up to three months
under the provisions of the Mental Health Act 1983; any treatment lasting longer
than three months requires the consent of a specially appointed second opinion
doctor(see Gunn et al., 1993). In England and Wales there would be no question of
hesitating to treat a patient found unfit to plead, even in the face of a murder charge,
but then there are no executions round the corner.
If the defendant is found unfit to plead this is often the end of the matter, but it is
possible for the court or either party in the case to bring the case back for a trial at a
later date, if this is deemed to be in the interests of justice.
In Annie’s hypothetical case we can surmise that she would not be found ‘‘unfit to
plead’’ but would go on to her trial. Why would such a person be found fit to plead?
There is always English pragmatism where the practical considerations outweigh the
theoretical ones. A better explanation might be the English reluctance to either forgo
a trial or have it long after the initial charge. As Grubin (1966) in his book on fitness
to plead in England has argued, a proper trial is much to be preferred to a ‘‘trial of the
facts’’ in the absence of the defendant, so a consideration of fitness to plead should be
a last resort (a ‘‘trial of the facts’’ means a hearing in front of a judge, without a jury,
and without considering responsibility or guilt).
Another possible outcome in a case like Annie’s is a verdict of not guilty by reason
of insanity (NGRI) under the McNaughten Rules (see Gunn et al., 1993). This is
also very rare, so rare that it will not be dealt with here except to say that the disposals
are identical to those for unfitness to plead but this time there is no option for
bringing the defendant back to court.

Connecticut

By contrast to the U.K., outcomes of unfitness to plead, or ‘‘incompetence’’, are not

rare in the U.S.A. One authority estimates that upwards of 25,000 evaluations for

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
 Paranoia in the criminal courts 379

competence to stand trial are conducted every year (Grisso, 2003). Many of these
lead to findings of incompetence and are followed by periods of ‘‘restoration’’ before
further assessments are conducted. The usual justification is that the fairness of
the criminal proceedings cannot be assured when one party is unable fully to participate
in the adversarial process (Group for the Advancement of Psychiatry, 1974).
An attorney acting for Annie in the U.S. would almost certainly suggest to her that
her competence to stand trial should be evaluated. Annie’s symptoms are such that
she might object. In these circumstances the prosecuting attorney not infrequently
makes the request (Stone, 1976). The court will then almost always order an
evaluation of the defendant’s competence to stand trial.
A number of considerations motivate the actors in such cases, however. Until
Jackson v. Indiana (1972) people found incompetent to stand trial could be committed
indefinitely and prosecutors sometimes found this an acceptable alternative to
conviction. After Jackson a defendant could only be committed for a ‘‘reasonable
period’’ while it was established whether or not his competence could be restored.
Prosecutors retain an interest in competence evaluations, however, to help prevent
the overturning of convictions on appeal (Miller, 1998). Competence evaluations
are easy to obtain and some defense attorneys use them to screen for abnormalities
that may warrant a fuller assessment prior to offering a defense of insanity. Finally,
research in New York and Wisconsin suggests that in-patient competence evaluations
have been used to circumvent the difficulties of admitting people compulsorily
through civil procedures (Dickey, 1980; Miller, 1991; Rachlin, Stokman, & Grosman,
1986).
The U.S. evaluation will usually be conducted by a psychiatrist reporting alone or
by a team that includes a psychiatrist, a social worker, and a psychologist. The
criteria for competence to stand trial vary little from one jurisdiction to another.
These criteria require that a defendant have a rational, and not just a factual,
understanding of the charges against him (Dusky v. United States, 1960) and be able
to assist his attorney (Drope v. Missouri, 1975). The relevant Connecticut Statute, for
instance, states that ‘‘a defendant is not competent if he is unable to understand the
proceedings against him or to assist in his own defense’’.
The seriousness of the charge in Annie’s case means that the court will require the
initial evaluation to be conducted in prison. In cases where the charges are less
serious, several U.S. states permit competence to stand trial evaluations on
defendants in the community.
Competence to stand trial, like other competences, exists on a continuum, and the
thresholds that are applied vary with the evaluator, the court and the circumstances.
Annie would be found not competent to stand trial in most U.S. jurisdictions. Her
delusions and, in particular, her surprise that she is the one being prosecuted would
be regarded as calling into question whether she has a rational understanding of the
charges. Although she has cooperated with an attorney in the past, the nature of the
cooperation, based on an agreement to pursue damages in relation to actions that
probably existed only in her imagination, would not reassure an evaluator that she
could be similarly cooperative in relation to the present proceedings. Annie would
then be committed to an in-patient psychiatric unit.
The reforms that followed Jackson v Indiana have not removed the possibility that
Annie will remain in a unit for the restoration of competence for a long time. A
‘‘reasonable period’’ is usually measured in relation to the seriousness of the charge

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
380 J. Gunn and A. Buchanan

and, as is the case in the U.K., most defendants are initially charged with offences
more serious than those of which they are subsequently convicted.
Her stay is also likely to be longer than would otherwise be the case because she is
unlikely to agree to be treated and the statute that authorized her commitment will
usually not have authorized her to be treated compulsorily. Separate legal procedures
and adjudications will be required. Some attorneys resist treatment that will improve
their clients’ condition on the basis that the jury will thereby be prevented from
seeing the defendant as he was when he committed the offence (Miller, 1998).
The procedures for returning Annie to court vary from state to state. Those in
Connecticut are typical. Here the hospital will provide regular reports to the court on
her clinical condition and competence to stand trial. If she regains competence she
will return to prison. If she does not, her commitment can be extended for up to
18 months or for the period for which she remains liable to be prosecuted, whichever
is the shorter. If it is concluded, on the basis of her clinical condition, that she will
not regain competence within that time, the court must release her or, provided
she meets the relevant criteria, arrange for her to be civilly committed. Because
Annie has committed an offence that could have resulted in ‘‘death or serious
injury’’, she is liable, should she fail to regain competence within 18 months, to
periodic re-examination until the time limit for prosecution is reached. If she is again
found competent she can then be tried.

The Sentence

England and Wales

By far the likeliest outcome in the English jurisdiction in Annie’s case would be a
guilty plea and fairly substantial psychiatric evidence to be offered in mitigation. The
judge would then have a full range of sentencing options available. These would
include prison sentences, a hospital order (with or without a restriction order), and a
community rehabilitation order, which may have a condition of inpatient or
outpatient psychiatric treatment attached. In addition the court may make an
interim hospital order under section 38 of the Mental Health Act 1983 (Archbold, 5-
569). For this to happen the court must be satisfied on written or oral evidence of two
registered medical practitioners that the defendant is suffering from mental disorders
and that there is reason to suppose that it may be appropriate to make a hospital
order. The interim order should be for a period not exceeding 12 weeks. It may be
further renewed thereafter for 28-day periods, subject to an overall maximum period
of 12 months. This provision is to test out the suitability of a convicted offender for a
hospital order
The proper and likeliest disposal in Annie’s case is a hospital order under section
37 of the Mental Health Act 1983. The unrestricted hospital order involves handing
over the offender, now patient, to a hospital for compulsory psychiatric treatment.
The psychiatrist in charge of the case will be able to determine treatment (with all the
same safeguards for the patient as in a civil compulsory admission) and length of
stay subject only to appeals to and reviews by the Mental Health Review Tribunal.
There is, however, provision under section 41 of the Mental Health Act 1983 for the
Crown Court to make a ‘‘restriction order’’ when making a hospital order (Archbold,

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
 Paranoia in the criminal courts 381

5-574). This is in order to protect the public from serious harm. To do this the court
will have regard to the nature of the offence, the antecedents of the offender and the
risk of his/her committing further offences if released. The court can order that
the patient be subject to special restrictions either with or without limit of time.
The effect of this order is to restrict the patient’s discharge, transfer, or leave of
absence from hospital for a specified or unlimited period without the consent of the
Home Secretary or a decision by a special mental health review tribunal chaired by a
crown court judge. In the current climate of opinion prevailing in the U.K., Annie
would probably receive a restriction order without limit of time (time limited ones
are extremely unusual).

Connecticut

Hospital orders have no equivalent in most U.S. jurisdictions. At the sentencing

stage psychiatric input, usually in the form of a pre-sentence report, can address
treatment issues and, in particular, whether psychiatric treatment as a condition of a
probation order is likely to benefit the patient and protect the public. In serious cases
such as Annie’s, however, the question of probation will not usually arise. Psychiatric
evidence will typically then address the presence or absence of mitigating factors that
relate to the defendant’s condition. In theory, these are very limited. The Federal
Sentencing Guidelines state that ‘‘mental and emotional conditions are not usually
relevant in determining whether a sentence should be outside the applicable
guideline range’’. In practice, defense attorneys frequently use psychiatric evidence
in mitigation. The most likely consequence in the event of Annie’s been found
competent to stand trial in the U.S. is that following conviction she would be sent to
prison and receive psychiatric treatment there.

DISCUSSION

The procedures and the possible consequences for Annie Smith set out here
illustrate that there are wide transatlantic differences in the way a dangerous but sick
woman who has been violent is managed, even though both U.K. and U.S.A. laws
are based on the old English common law system. There would also be marked
differences in management between each of these systems and any of the
jurisdictions on the mainland of Europe, since those are mostly derived from
Roman law. Thus there is a good deal of chance in the way the problem set out here is
handled. It is not caprice; the law in each case is carefully considered. The chance is
related to address; where a person happens to live when illness strikes is probably
more important than any other variable. The differences relate to all kinds of legal
nicety, which may not be the crucial variables in the determination. One pragmatic
reason for the infrequent use of unfitness to plead and NGRI in England may be that
it has the hospital order as an alternative and straightforward route for moving
mentally disordered offenders into psychiatric hospital care at the end of criminal
proceedings. Such differences are related to history, social attitudes, politics, and
resources. Nevertheless, the differences should not be exaggerated; most jurisdic-
tions would want to control Annie and most would do this by institutionalization.

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
382 J. Gunn and A. Buchanan

Do other diseases have similar differences in management according to address?

Well, yes they do. In the National Health Service in the U.K., there is something that
is disparagingly called the ‘‘postcode lottery’’; infertility treatment varies widely
between one area and another as does treatment for strokes. Treatment for such
conditions varies even more widely between countries. There is a preoccupation with
postcode lotteries in health in Britain amongst politicians and electors alike.
Government efforts to reduce the geographical disparities do not succeed
(Holloway, 2002). Nevertheless, there is a general agreement that postcode lotteries
should be minimized. Does a similar agreement about minimizing the differences in
the management of mentally disordered offenders exist? Probably not.
Variations in the management of the violent mentally ill could be the basis of an
interesting international discussion. Such an exchange would help focus on the fact
that problems such as Annie Smith’s are largely medical issues. It would also make it
clear that efforts should be directed towards raising the standards of care of such
individuals and disentangling these problems from the non-medical matters. Such
discussion would probably highlight social attitudes, politics and resources. No
disease can be entirely separated from its social and political context, just think of
AIDS or malaria, but doctors are united in other branches of medicine in their efforts
to minimize the attitudinal and political responses to such disorders. Forensic
psychiatry has some catching up to do.

REFERENCES
Archbold. (2003). J. Richardson, & D. A. Thomas (Eds.), Criminal pleading, evidence and practice. London:
Sweet and Maxwell.
Colorado v. Connelly 479 U.S. 157 (1986).
Dickey, W. (1980). Incompetency and the non-dangerous mentally ill. Criminal Law Bulletin, 16, 22–40.
Drope v. Missouri 420 U.S. 162 (1975).
Dusky v. United States 362 U.S. 402 (1960).
Fikes v. Alabama 352 U.S. 191 (1957).
Gray, N. S., O’Connor, C., Williams, T., Short, J., & MacCulloch, M. (2001). Fitness to plead:
Implications from case-law arising from the Criminal Justice and Public Order Act 1994. Journal of
Forensic Psychiatry, 12, 52–62.
Grisso, T. (2003). Evaluating competencies. Forensic assessments and instruments, 2nd ed.. New York:
Kluwer.
Group for the Advancement of Psychiatry (GAP). (1974). Misuse of psychiatry in the criminal courts:
Competency to stand trial. Formulated by the Committee on Psychiatry and Law. New York: GAP.
Grubin, D. (1996). Fitness to plead in England and Wales. Hove: Psychology.
Gudjonsson, G. H. (1995). ‘‘Fitness for interview’’ during police detention: A conceptual framework for
forensic assessment. Journal of Forensic Psychiatry, 6, 185–197.
Gudjonsson, G. H. (2002). The psychology of interrogations and confessions: A handbook. Chichester: Wiley.
Gudjonsson, G. H., Hayes, G. D., Rowlands, P. (2000). Fitness to be interviewed and psychological
vulnerability: The views of doctors, lawyers and police officers. Journal of Forensic Psychiatry, 11, 74–92.
Gunn, J., Briscoe, O., Carson, D., d’Orban, P., Grubin, D., Mullen, P., Stanley, S., & Taylor, P. J., with
Browne, F., Chiswick, D., Humphreys, M., Dooley, E., McPherson, J., & Noble, P. (1993). The law,
adult mental disorder, and the psychiatrist in England and Wales. In Forensic Psychiatry, Clinical, Legal
and Ethical Issues. Oxford: Butterworth-Heinemann.
Holloway, F. (2002). Outcome measurement in mental health—Welcome to the revolution. British
Journal of Psychiatry, 181, 1–2.
Jackson v. Indiana 406 U.S. 715 (1972).
Malloy v. Hogan 378 U.S. 1 (1964).
Miller, R. (1991). Economic factors leading to the diversion of the mentally disordered from the civil to the
criminal commitment systems. International Journal of Law and Psychiatry, 15, 1–12.
Miller, R. (1998). Criminal competence. In R. Rosner (Ed.), Principles and practice of forensic psychiatry
(pp. 186–212). London: Arnold.

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl
 Paranoia in the criminal courts 383

Miranda v. Arizona 396 U.S. 868 (1969).

Payne v. Arkansas 356 U.S. 560 (1958).
R. v. M.,R. v. Kerr, R. v. H. CA, CD 5 October 2001.
R. v. Pritchard (1836) 7 C & P 303 (173 ER 135).
Rachlin, S., Stokman, C., & Grosman, S. (1986). Incompetent misdemeanants—Pseudocivil commit-
ment? Bulletin of the American Academy of Psychiatry and the Law, 14, 23–30.
Stone, A. (1976). Mental health and law: A system in transition. New York: Aronson.
U.K. Government, Home Office. (1990). Provision for mentally disordered offenders, Circular 66/90.
U.K. Government, Home Office. (1995). Mentally disordered offenders, Inter-Agency Working Circular 12/95.

Copyright # 2006 John Wiley & Sons, Ltd. Behav. Sci. Law 24: 373–383 (2006)
DOI: 10.1002/bsl