Delusion or Conspiracy? How Forensic Mental Health Professionals Differentiate Delusional Beliefs From Extreme Radicalized Beliefs

• Published date: 01 October 2024
• DOI: http://doi.org/10.1177/00938548241262490
• Author: Katérine Aminot,Tara J. Ryan,Alicia Nijdam-Jones
• Date: 01 October 2024
• Subject Matter: Articles

CRIMINAL JUSTICE AND BEHAVIOR, 2024, Vol. 51, No. 10, October 2024, 1548 –1569.

DOI: https://doi.org/10.1177/00938548241262490

Article reuse guidelines: sagepub.com/journals-permissions

© 2024 International Association for Correctional and Forensic Psychology

1548

DELUSION OR CONSPIRACY?

How Forensic Mental Health Professionals

Differentiate Delusional Beliefs From Extreme

Radicalized Beliefs

KATÉRINE AMINOT

University of Manitoba

TARA J. RYAN

Northwest Forensic Institute, LLC

ALICIA NIJDAM-JONES

University of Manitoba

A growing body of research is beginning to highlight the difficulty clinicians have in distinguishing delusional beliefs from

conspiratorial beliefs. This mixed-methods study examined how 198 forensic mental health professionals in Canada and the

United States differentiate delusional beliefs from conspiratorial beliefs. Participants were presented with an experimental

vignette describing a forensic patient’s symptoms and were asked to diagnose the individual and, if qualified, opine on the

defendant’s competency to stand trial. Results showed that idiosyncratic and highly rigid and distressing beliefs significantly

predicted the diagnosis of a psychotic disorder, whereas shared beliefs held with low/moderate rigidity and distress signifi-

cantly predicted the identification of conspiratorial beliefs. Despite participants’ abilities to differentiate delusional and

conspiratorial beliefs, some participants reported that they lacked sufficient training in this area. Future research should

examine if factors other than the social context and rigidity of the belief influence the differentiation of delusional and con-

spiratorial beliefs.

Keywords: delusional beliefs; conspiracy theories; clinician decision-making; competency to stand trial

AUTHORS’ NOTE: We would like to thank William J. Newman for his assistance with recruiting participants

and reviewing this manuscript. This article is based on an undergraduate research project by Katérine Aminot,

for which Alicia Nijdam-Jones served as the research advisor. This work was partly supported by an AP-LS

Undergraduate Student Grant-in-Aid from the American Psychology-Law Society and an Undergraduate

Research Award from the University of Manitoba. A portion of these data was presented at the American

Psychology-Law Society Conference, March 2023, Philadelphia, PA and at the Canadian Psychological

Association 5th North American Correctional and Criminal Justice Psychology Conference, June 2023,

Toronto, ON. Correspondence concerning this article should be addressed to Katérine Aminot, Department of

Psychology, University of Manitoba, 66 Chancellors Circle, Winnipeg, Manitoba R3T 2N2. e-mail: aminotk@

myumanitoba.ca. This study was not preregistered. For access to study materials and deidentified data, please

contact the corresponding author.

1262490CJBXXX10.1177/00938548241262490Criminal Justice and BehaviorAminot et al. / Differentiation of Delusions and Extreme Beliefs

research-article2024

Aminot et al. / DIFFERENTIATION OF DELUSIONS AND EXTREME BELIEFS 1549

INTRODUCTION

Accurately assessing the presence and severity of mental disorders is crucial in forensic

evaluations. In most jurisdictions, a diagnosis of a statutorily defined qualifying mental

disorder is required for defendants to meet the legal criteria for certain findings, such as

competency to stand trial (CST), criminal responsibility, and more (K. S. Douglas et al.,

2012). Forensic mental health professionals (FMHPs) often use the Diagnostic and

Statistical Manual of Mental Disorders (DSM), to guide diagnostic decisions and increase

diagnostic reliability. Recently updated in 2022, the DSM (5th ed., text rev.; DSM-5-TR;

American Psychiatric Association [APA], 2022) is widely accepted by clinicians and courts

in North America, despite recent criticisms surrounding its lack of transparency and scien-

tific validity, risk of false positives, and concerns with diagnostic legitimacy (Cohen et al.,

2021; Mehdi et al., 2022; Wakefield, 2016). Although the DSM was designed primarily for

clinical settings, rather than forensic contexts, FMHPs often utilize this manual when pro-

viding evaluation and treatment of individuals with mental illness (Al-Rousan et al., 2017;

Bradley-Engen et al., 2010; Diamond et al., 2001; Fries et al., 2013; Prins, 2014).

The growing prevalence of mental disorders and substance use disorders among criminal

defendants has led to increases in court-ordered CST evaluations (Tussey et al., 2022). The

competency crisis, or the imbalance between referrals for CST evaluations and trained pro-

fessionals who can conduct these evaluations, has resulted in unadjudicated defendants

languishing in custodial environments, lawsuits, and millions of dollars in fines paid by

state governments (Gowensmith, 2019). Psychotic disorders are particularly common

among individuals found incompetent to stand trial (Pirelli et al., 2011). Given the preva-

lence of psychotic disorders among legally involved individuals, the possible implications

of these disorders on a defendant’s legal circumstances, and the impacts on overburdened

forensic mental health systems, diagnostic accuracy is of great importance.

Empirical data show that FMHPs have varied interrater reliability across all diagnostic

categories, but high agreement when diagnosing psychosis (Gowensmith et al., 2017). Despite

this reliability, FMHPs are increasingly completing evaluations that require diagnostic clarifi-

cations between delusions expressed as part of a psychotic disorder, and beliefs related to

conspiracy theories (Cunningham, 2018). This differentiation can be crucial in determinations

of CST, criminal responsibility, and more, and recent research highlights the difficulties that

clinicians face when differentiating delusional beliefs and conspiratorial beliefs.

DELUSIONAL BELIEFS

Accurately differentiating delusional and conspiratorial beliefs is essential as severe and

persistent mental illness, such as schizophrenia spectrum disorders, are particularly com-

mon in forensic mental health systems (Gulayets, 2016; Pirelli et al., 2011). Unsurprisingly,

defendants diagnosed with psychotic disorders are more likely to be found incompetent to

stand trial and to present successful insanity defenses (Gulayets, 2016; Pirelli et al., 2011).

Delusional beliefs secondary to delusional disorder, a schizophrenia spectrum disorder, are

fixed, false belief(s) that persist in the face of conflicting evidence (APA, 2022). Delusions

typically manifest within one individual, emerge from abnormal subjective experiences,

and are often directly related to that individual (Pierre, 2021; Starcevic & Brakoulias, 2021).

Those with delusional disorder typically do not experience marked functional impairments;

however, inherent to the involvement in the legal system, forensic patients with delusional