Case File Friday, on Wednesday.
Forensic Madness
Mental illness within forensic populations rarely fits into neat categories. Yes, personality disorders, particularly antisocial traits, are common, but they’re only part of the story. Many individuals also experience severe psychiatric conditions: psychosis, delusions, hallucinations. Sometimes these overlap, what clinicians once called “comorbidity” under the old DSM-IV classification system, where Axis I and Axis II diagnoses coexisted. While the DSM-5 has moved away from that framework, the clinical reality remains the same, complex, layered, and often volatile.
Working with someone diagnosed with Antisocial Personality Disorder is challenging in itself. Add an untreated psychiatric disorder into the mix, and the unpredictability can escalate quickly.
Let me illustrate.
Robert’s Story
Robert was incarcerated following a series of violent assaults. His history was consistent: chronic aggression, poor impulse control, and repeated contact with the justice system. While in Remand, he was diagnosed with bipolar disorder and prescribed medication to stabilize his mood. This wasn’t new, while in the community, he had previously been admitted multiple times to the Centennial Centre for Mental Health and Brain Injury, in Ponoka, AB often after discontinuing treatment.
Given his diagnosis, he was placed in the mental health unit, and I was assigned to assess him.
Our first meeting was brief.
He refused to engage, refused to sign the consent form, and made it abundantly clear, in colourful language he didn’t need psychology. He only wanted to speak with Jesus.
I told him I couldn’t help with that. A referral to the chaplain was made, and, if I’m being honest, I felt a sense of relief washed over me. Cases like Robert’s are demanding at the best of times, and without medication, often exceptionally difficult to manage. At that moment it didn’t matter, he wasn’t interested in talking with me.
That didn’t last.
The Shift
Days later, I received a written request: Robert wanted to see psychology after all.
When I arrived on the unit, the correctional officers filled in the gaps. He had stopped taking his medication, and the shift in his behavior was concerning. He was increasingly disruptive and erratic (yelling during the night, threatening staff) and it wasn’t going unnoticed. Tension on the range was building; other inmates were pissed off and threatening to take matters into their own hands.
When Robert entered the interview room, his energy was unmistakable, restless, agitated, unfocused.
I asked what he wanted to talk about.
“Shit and stuff,” he replied.
When prompted to discuss what was going on for him, he began listing his diagnoses, OCD, bipolar disorder, mood disorder, but dismissed them all as labels imposed by society. The real issue, he explained, was demonic possession. That was why he had stopped his medication.
He spoke openly about the “demons,” then shifted abruptly to his girlfriend, who he said was in a psychiatric institution and therefore unable help with his possession. Then he stopped, looked directly at me, and asked if I was a Christian.
I said no.
His demeanor changed instantly, contempt, dismissal. He asked for a chaplain, someone who would “actually understand.”
I encouraged him to resume his medication. He was clear: I was of no use to him.
He denied any thoughts of suicide, and became angry when I asked, insisting, he would never harm himself due to being Christian. So I referred him to both psychiatry and the chaplain.
Decompensation
I assumed that would be the end of our interaction.
It wasn’t.
Within a week, Robert had fully decompensated.
I was called to the unit after reports of escalating behavior: yelling, kicking the walls and his door, and eventually licking the metal surface of his cell door. By the time I made my way down to meet with him, the situation had already spiraled. Two officers were dragging him down the hallway toward health care.
The officers were struggling to contain him. He was frothing, physically resisting, completely overtaken by whatever internal reality he was experiencing. A mental health nurse rushed down the hallway, syringe in hand.
Robert saw me and lunged.
“I’m going to devour you!”
The officers brought him to the ground. The nurse administered the injection through his clothing into his thigh. Within moments, the fight drained out of him.
He was quickly transferred to the regional psychiatric facility.
Aftermath
Years passed before I heard his name again.
By chance, one evening I was introduced to a correctional manager from the Remand. We got to talking shop, comparing notes on particularly violent inmates, when he mentioned a newly admitted prisoner, charged with second degree murder and being held without bail. The prisoner had broken into a elderly man’s home and slashed his neck.
It was Robert.
Reflection
Cases like Robert’s leave more questions than answers. Was his violence driven by untreated mental illness? Or was it a personality disorder that combined with a mood disorder amplified his violence?
I don’t know.
He never remained on medication long enough for that question to be meaningfully explored.
What I do know is this: when severe mental illness and entrenched patterns of violence intersect, the result can be as unpredictable as it is dangerous, and when intervention is refused the results can turn deadly.