On the morning of March 5, 2001, in a scene that would be replayed with increasing and chilling frequency in the coming years, 15-year-old Andy Williams arrived at Santana High School in Santee, Calif.

His father’s loaded revolver was in his backpack.

That morning he would repeatedly open fire on his classmates, killing two students and injuring 13 others.

In the weeks and months ahead, his community, local law-enforcement officials and the criminal justice system all would pore over what led to the tragedy and how Williams should be punished.

His guilt was not at issue. But, for his defense team, there was one crucial question that could mitigate his sentence on conviction: Was Williams legally insane at the time of the crime?

The answer to that question would be explored by the man Williams’ attorneys chose to assess his mental state: Charles Scott, UC Davis clinical professor of psychiatry, who consulted with the defense team.

Williams had no prior record of delinquency. He was often bullied at school and in the years after the shooting he expressed remorse for his crimes.

Nevertheless Scott found that, at the time of the shooting, Williams understood what he was doing —and that it was wrong. For those reasons, he concluded that Williams did not meet the statutory definition of insanity in California.

Because of the nature of the crime, Williams would be tried as an adult. He now is serving a life sentence without the possibility of parole.

Setting high standards in forensic psychiatry

Today, Scott is chief of one of the top forensic psychiatry programs in the nation, the Division of Psychiatry and the Law at UC Davis, intensely focused on raising the bar in a profession where justice — and life — literally can hang in the balance.

The trends of deinstitutionalization of psychiatric patients and lack of parity for mental-health insurance coverage have combined to dramatically increase the incarceration of the mentally ill across a wide variety of offenses, he says.

“The largest single provider of mental-health services in the state of California is the Los Angeles County Jail,” Scott says. “Forensic psychiatrists often are the last hope for these people, who so desperately need psychiatric services.”

Scott and his colleagues teach forensic psychiatry fellows and consult in criminal and civil cases throughout the state and nation, on questions involving a defendant’s competency to stand trial, sanity at the time of his or her acts, malingering of psychiatric symptoms and readiness for release following incarceration.

“It is important that mental illness not be misused to direct people away from the criminal justice system,” Scott says. “On the other hand, for those with real mental illness, society — and the law — have long recognized that this is a very different situation that deserves accommodation in certain circumstances.”

Scott is a leading champion of using structured assessments based on objective criteria — actuarial and historical data and elements of a patient’s psychiatric history — to assess the level of future risk of harm. Other assessments are used to evaluate whether an individual may be helped by psychiatric treatment and would benefit from rehabilitation.

“Our goal is to continually strive for the highest practice standards, so that legal opinions are not based on someone’s gut-level feelings,” Scott says. “Objectivity helps us to ensure that we are providing the best service to protect the rights of defendants and the safety of the public.”

The program also has developed innovative services that assess whether individuals with psychiatric disorders in the workplace and schools pose a threat to themselves or others, against the backdrop of laws that protect their rights such as the Americans with Disabilities Act.

Hands-on learning

The UC Davis forensic psychiatry fellowship program is one of only three in California and 43 nationwide accredited by the American Council on Graduate Medical Education (ACGME). Forensic psychiatry fellows receive intensive training in assessments for psychiatric illnesses, and relentless coaching in the communication necessary to face attorneys during stressful courtroom testimony.

They also gain hands-on experience and insight in their profession by providing direct psychiatric patient care to prisoners at the Sacramento County Jail, which typically holds an average of 2,044 inmates, and to inmates at the Rio Cosumnes Correctional Center, with an average of 1,976. In general, approximately 25 percent of the county’s inmate population suffers from a mental illness.

Scott and his colleagues also assess patients at other facilities, notably Napa State Hospital, the 1,200-bed institution for incarcerated individuals with psychiatric illnesses in Napa, Calif. The assessments aim to improve the communication skills of psychologists and psychiatrists, who frequently must testify to whether an inmate is ready for release. The successful program currently is being expanded to other forensic psychiatric hospitals throughout the state.

Scott’s own appearance telegraphs attorney rather than psychiatrist. He speaks with a drawl that reflects his Mississippi upbringing. During training at Napa State Hospital he is warm and friendly, gently but firmly grilling psychiatrists on their patient assessments in the way an attorney would in court. For some it is not the most comfortable experience — but it isn’t supposed to be.

According to Scott, there is an important difference between a treating mental-health provider and an expert who testifies in court in regard to a specific legal issue.

“A treating provider’s understandable alliance is with the patient, whereas a forensic psychiatrist’s alliance is to the truth. This means that those who testify in court should outline the specific evidence to support their opinion— and at UC Davis we strive to train our forensic psychiatry fellows to do exactly that,” Scott notes.

Scott’s team, under the direction of Barbara McDermott of UC Davis’ Forensic Psychiatry Research Program, also steers one of the largest forensic psychiatry research enterprises in the nation. Faculty study a range of topics, from assessing prisoners’ readiness for release back to the community, to identifying common characteristics of women homicide offenders found not guilty by reason of insanity, to assessing malingering — creating false or grossly exaggerated symptoms of mental or other illness — in jail.

Helping prevent crime before it happens

Forensic psychiatrists have also come to play an increasingly important role outside the criminal justice and correctional systems, in assessing the risk of violence from the mentally ill in business and education settings.

Assistant clinical professor of psychiatry Jessica Ferranti directs the UC Davis Workplace Safety and Psychiatric Assessment Clinic, where employees or students who have been identified as potential safety risks are referred.

The need for such a program has increased dramatically in recent decades. Today, 2 million American workers are the victims of workplace violence; the fourth-leading cause of death in the workplace is homicide.

“Several organizations have even referred employees who have made threats using the term ‘going postal’ during an angry outburst or while they were exhibiting other odd behaviors,” says Ferranti, referring to highly publicized incidents of mass shootings committed by disgruntled United States Postal Service employees.

“Employers are directly responsible for the safety of the workplace so they worry about potential violence, and look to a forensic assessment to know whether the threat is credible and what is the actual degree of violence risk.

“But, in spite of the media attention such horrific events generate, extreme acts of workplace violence, such as mass shootings, actually are very rare.”

Ferranti and her colleagues assess the degree of violence risk and provide consultation on employee management and appropriate interventions. At the same time, they guide employers and school officials through the maze of legal and privacy issues associated with psychiatric illness, some of which are triggered by the Americans with Disabilities Act, the Occupational Safety and Health Administration and the Family and Medical Leave Act.

“For example, it is illegal to provide employers or school officials with a patient’s diagnosis because of privacy laws, but they can be given an opinion of the extent of the safety risk that the person poses,” Ferranti says.

Ferranti may recommend an action plan regarding removing the person from the situation or, alternatively, provide guidance on specific interventions or accommodations to help the person safely function in the school or workplace. Ferranti cited one case in which employees became fearful when a young co-worker started exhibiting bizarre behavior. The person turned out to be experiencing the first psychotic episode of schizophrenia, and after psychiatric treatment with medication, was able to return to work.

Extending expertise

Scott feels that an important mission of the UC Davis forensic psychiatry program is sharing the knowledge team members have acquired and promoting the high standards they’ve developed as widely as possible. UC Davis is a prominent presence in the American Academy of Psychiatry and the Law (AAPL), the national professional organization for forensic psychiatry: Scott formerly served as its president, and Ferranti and William Newman, assistant professor of psychiatry at UC Davis, currently are among the nine councilors of the governing body.

The forensic psychiatry program also recently spearheaded a multidisciplinary all-day conference in Sacramento, chaired by Scott and Ferranti, that is aimed at helping employers, human resources directors, mental-health professionals, attorneys and school administrators manage employees and students with mental health problems at work and school. Participants gained real-world guidance on assessing risk, legal parameters, and when and how to get professional help.

Ferranti says sharing such knowledge with others empowers them to confront worrisome situations head-on, and gives them the confidence to act appropriately.

“People frequently ask me if I ever feel I am in personal danger from my work,” she says. “I feel just the opposite, because I am privileged to be able to talk with people in great depth and use my training to understand how behavioral decisions are made and how the pathway to violence unfolds.

“I am armed with the best tools available to assess whether someone really is likely to be dangerous. Then I know how to take action to maintain safety for myself and others too.”

Mental health and the workplace.

Mental health and the workplace

From the idiom-generating postal service shootings of the 1980s and 90s to the crash of Germanwings Flight 9525, workplace killings generate significant media attention, public concern – and stigma. See some facts and trends...