On a busy road, when the traffic rushes like water breaking through a dam and the lights refuse to turn red, the decision you may make to run across when there is a small break between cars, is a conscious one.
Our ability to make informed decisions is what allows us to take responsibility for our actions. Every choice we make, every action we take is a result of neuronal pathways firing in a particular sequence in various areas of the brain. An area called the pre-frontal cortex is particularly associated with decision-making and planning. But what if the very organ that makes those choices, our brain, becomes damaged? How ethical is it to expect compensation or retribution for actions taken following damage to this decision-making organ?
During my year as a PsychStar - a scheme run by the Royal College of Psychiatrists, awarded to medical students who have shown a commitment and interest in psychiatry - I was fortunate enough to attend the annual NeuroPsychiatry conference held by the Royal College of Psychiatrists. While attending, one particular lecture stood out to me in which the speaker discussed the impact of brain injuries on behaviour, and the association between acquired brain injuries and crime.
An acquired brain injury (ABI) refers to any damage to the brain post-birth. This can include traumatic or medical causes, such as strokes and seizures, in the absence of congenital (present from birth) or genetic disease to the brain. In 2018, approximately 1.3 million individuals in the UK were living with an ABI. Importantly, the damage caused by an ABI can lead to dysfunction in various physical and mental processes including memory and personality.
Additionally, research has shown there is an association between ABI and crime. Approximately 24.7% of individuals in prison have been hospitalised for an ABI, which is significantly more prevalent than in the general population, where 18.2% of people have been hospitalised for ABI's. Additionally, those with ABI's are 2.5 times more likely to be incarcerated than those without.
What could account for these statistics?
ABI’s are associated with a number of factors which may increase the likelihood of criminal behaviour. For example, individuals with ABIs are at greater risk of substance misuse, and antisocial behaviours (behaviours and actions that cause distress, alarm, or harassment to others). Importantly, both substance misuse and antisocial behaviours are also associated with higher levels of criminal behaviours.
Additionally, ABIs can lead to emotional dysregulation, which can impact one’s ability to control impulses and override strong urges or temptations. Difficulty in regulating impulsivity and control has been associated with higher rates of violence, resulting in increases in offensive behaviour.
Whilst we can see an association between the characteristics of patients post-ABI and criminal behaviour, it is important to consider other contributing factors to criminal behaviour which may influence this association.
The personality traits of someone before an ABI, their socioeconomic status and familial relationships, have all been shown to impact rates of criminal behaviour. Additionally, if we look at socioeconomic status, there is a complex bi-directional relationship between head injury and socioeconomic status. Individuals with lower socioeconomic status are more likely to experience a head injury, and individuals with head injuries are more likely to have a lower socioeconomic status following their injury.
Such complicated associations between these factors therefore make it difficult to conclude the exact extent ABIs, as an independent factor, have on an individual’s likelihood to offend. Nevertheless, given that individuals with traumatic head injuries are 2.5 times more likely to be incarcerated compared to those without, the link between ABIs and crime cannot be ignored.
So where do we go from here?
Just as with any medical condition that has a significant impact on a patient's life, it is important for healthcare professionals to consider a preventative approach in the management of offensive behaviour in relation to ABIs. This starts with recognising the impact of brain injuries on patients.
Once a patient has experienced a brain injury, it is important for them to have a formal assessment of not just the physical, but also the mental impact of their injury. Additionally, educating patients regarding possible long-term effects of their condition, and provision of a point of contact to aid in recovery, is also important in providing appropriate patient care. If such approaches are adopted at a wider level and earlier on during the diagnostic process, patients will feel better supported. This support may have a knock-on effect, and potentially reduce first-offence and consequent criminal behaviours.
Mindsource, a charity in Colorado, USA, works with individuals in the criminal justice system who have had ABIs using neuropsychological screening to establish personalised tools to help reduce reincarceration rates. For example, they advocate for the use of written notes during court hearings. This allows individuals to focus on the information being delivered at the time, and have material to take away to review and plan, such as dates of next court hearings and rules of bail.
In England, there is no current national protocol which dictates the follow-up of patients suffering from ABIs. However, there is a sub-speciality of healthcare workers, forensic psychiatrists, who see patients suffering from brain injuries within the prison population. Forensic psychiatrists work closely with individuals in the justice system to aid their recovery and transition. Medical questionnaire’s for measuring the impact of an ABI on physical and emotional disability are now being used by forensic psychiatrists and neuro-psychiatrists for distinct patient groups, such as prisoners with ABIs. However, with approximately 333 consultant forensic psychiatrists in England and 87,900 individuals in prison, it is clear that the doctor-to-client ratio is unbalanced.
Training staff within the healthcare and judicial systems on the management of individuals with ABIs, and developing national guidelines on how to manage patients with ABIs would aid in the delivery of equitable treatment and follow-up for those affected.
Albeit, due to current staffing and financial restraints on the NHS and the global healthcare system in general, this type of intensive care and follow-up is not always feasible. However, further research and education into the association between ABIs and crime is imperative to further our understanding, and develop a better criminal justice system that works to support rehabilitation from the ground-up.
How far Can we go? How far Should we go?
As research moves forward, it is our duty as clinicians to understand the consequences of pathology on the lives of patients and their environment. Part of this includes further research into the consequences of brain damage on behaviour and personality, acknowledging the impact brain damage can have. Thereby, facilitating improved personalised support and care.
Furthermore, it is not only enough to consider the psychological and biological impact of ABIs. The ethics of potential change in treatment and legislation must also be considered. How do we accurately measure the extent of changes in personality and behaviour following an ABI? And how fair on the victims is it to attribute crime to a brain pathology? Hopefully, with future research, the development of systems better supporting those living with ABIs (in and outside the criminal justice system) and those impacted by them, will emerge.