Perceptions of Mental Health Conditions in Criminal Cases: A Survey Study Involving Swedish Lay Judges

Date01 June 2020
Published date01 June 2020
Subject MatterArticles
910774CJBxxx10.1177/0093854820910774Criminal Justice and Behaviorsörman et al. / Perceptions of Mental Health conditions
PercePtions of Mental HealtH
conditions in criMinal cases

a survey study involving swedish lay Judges
Karolinska Institutet
The University of Alabama
Ministry of Justice, Government Offices of Sweden
The University of Alabama
Stockholm University
Karolinska Institutet
Karolinska Institutet
National Board of Forensic Medicine

Perceptions of mental health conditions influence how individuals with psychiatric diagnoses are treated within the com-
munity, in the legal system, and at different institutions. we examined perceptions of mental health conditions among lay
judges (N = 643), working at district and appellate courts throughout Sweden. Participants read a web-based survey includ-
ing a crime vignette in which the person charged with a crime was described as having schizophrenia (n = 186), antisocial
personality disorder (ASPD) with psychopathic traits (n = 219), or intellectual disability (n = 238). Participants’ perceptions
of schizophrenia were largely in line with Swedish legislation regarding the medicolegal concept of severe mental disturbance
(SMD). Findings were more varied for the other two conditions, however. Perceptions of individuals with ASPD with psy-
chopathic traits were not consistent with the Swedish SMD legislation. The results highlight the complexity of legislation
addressing mental illness and criminality.
Keywords: lay judge; mental health evidence; legal decision-making; forensic; psychiatry
autHors’ note: The authors thank the anonymous reviewers and the Criminal Justice and Behavior edi-
torial staff for their thoughtful insight and recommendations in the preparation of this article. They would also
like to acknowledge the participating courts for facilitating data collection. Correspondence concerning this
article should be addressed to Karolina Sörman, Centre for Psychiatry Research, Department of Clinical
Neuroscience, Karolinska institutet, Norra Stationsgatan 69, SE-113 64 Stockholm, Sweden; e-mail: Karolina.

CRIMINAL JUSTICE AND BEHAVIOR, 2020, Vol. 47, No. 6, June 2020, 688 –711.
DOI: 10.1177/0093854820910774
Article reuse guidelines:
© 2020 International Association for Correctional and Forensic Psychology

The general public’s understanding of mental illness is reported to have improved over
recent decades. However, this understanding does not seem to have been followed by
increased social acceptance of individuals with mental illness (Markowitz, 2011;
Schomerus et al., 2012). Cross-cultural research has demonstrated that the public holds
negative perceptions about individuals with schizophrenia including low social accep-
tance, distrust, and desire of social distancing (Durand-zaleski et al., 2012; Vilhauer,
2016). In clinical settings, a medical history of schizophrenia is negatively associated with
expected treatment adherence and management as well as the ability to understand educa-
tional materials from treatment providers (Sullivan et al., 2015). There also seems to be a
public perception that schizophrenia is related to violence and dangerousness (Angermeyer
& Matschinger, 2004; Durand-zaleski et al., 2012; Jensen et al., 2016; Markowitz, 2011).
This perception is partly incongruent with meta-analytical work demonstrating that,
although schizophrenia and other psychoses are associated with violent behavior, in par-
ticular homicide, this association seems to be largely driven by concurrent substance abuse
(Fazel et al., 2009).
Lay people’s perceptions of mental illness may influence how individuals with psychiat-
ric disorders are treated within the community, and whether they seek and comply with
treatment (Corrigan et al., 2014). The past decade has seen an exponential increase in inter-
national research on the stigma of mental health diagnoses in relation to different constructs
such as “dangerousness” and incompetency (Corrigan, 2016; Corrigan et al., 2014). Stigma
broadly refers to social rejection through preconceptions and discrimination of individuals
with mental illness. It can be manifested through self-stigma (i.e., affected individuals’
internalization of negative self-images), provider stigma (i.e., health care providers’ nega-
tive attitudes toward individuals with mental illness) and structural stigma, which can
impair availability of various community resources (Sheehan et al., 2016).
PercePtions of Mental illness in a criMinal Justice context
Accumulated evidence of stigma associated with different types of mental health condi-
tions prompts the need to investigate whether such attitudes also influence legal decision-
making. Research from North America has demonstrated that preconceptions about legal
concepts (e.g., insanity defense) can substantially impact jurors’ general information pro-
cessing and sentencing recommendations (Louden & Skeem, 2007). According to the attri-
bution theory, people tend to infer attributions of others’ behavior in relation to controllability,
which then impacts the degree to which they sympathize with or want to punish the indi-
vidual (Corrigan et al., 2003). Research with college students and police officers suggests
there is a higher tendency of social rejection, coercive treatment, and punitiveness when the
criminal behavior is perceived to be associated with a mental illness under the person’s
control (e.g., due to substance abuse). In contrast, offenses that are perceived to be the result
of an organic cause outside the control of the person charged with a crime (e.g., due to head
injury), are more likely to evoke sympathy and result in less punitive sentiments (Corrigan
et al., 2003; Markowitz & watson, 2015).
In the United States, psychopathy evidence may be presented to the court to address a
variety of legal questions (DeMatteo, Edens, Galloway, Cox, Smith, & Formon, 2014;
DeMatteo, Edens, Galloway, Cox, Smith, Koller, & Bersoff, 2014; Edens et al., 2015;
although see DeMatteo et al., 2020). when introduced, this evidence appears to impact

legal decision-making (Edens & Cox, 2012). Drawing on the attribution theory, psychopa-
thy could be used as either a mitigating or aggravating factor in court proceedings (Aspinwall
et al., 2012; Edens & Cox, 2012; Remmel et al., 2019). There is a general tendency, how-
ever, to suggest harsher sentencing based on a view of the condition as a “moral illness”
where the individual is capable of separating right from wrong and has chosen to commit a
wrongful act (Berryessa & wohlstetter, 2019; Edens, Clark, et al., 2013). Research has also
demonstrated that lay people seem to associate psychopathic traits in people charged with
crimes with both semiadaptive (i.e., bold and intelligent) and maladaptive (i.e., dangerous
and evil) features (Edens, Davis, et al., 2013). A recent meta-analysis investigated percep-
tions of the psychopathy label in relation to various punishment outcomes (i.e., dangerous-
ness, treatment amenability, legal sentence/sanction) across 22 studies (Berryessa &
wohlstetter, 2019). In studies comparing people charged with crimes that meet criteria for
psychopathy and people charged with crimes with no such label, the psychopathy label has
been weakly, but significantly associated with stronger support for punitive sanctioning and
negative perceptions of treatment potential. In studies comparing people charged with
crimes that meet criteria for psychopathy versus those with another psychiatric label (i.e.,
conduct disorder, antisocial personality disorder [ASPD], paraphilic disorder), the effect
sizes have been weak and nonsignificant. Overall therefore, the results have demonstrated
a general labeling effect of psychiatric disorders, rather than psychopathy specifically
(Berryessa & wohlstetter, 2019). Considering psychopathy assessments are commonly
used as part of a larger risk-assessment of life-sentenced prisoners within the Swedish legal
system (Sturup et al., 2014), these discrepant findings bolster the need to further study per-
ceptions of the psychopathy label among lay people.
Although psychopathy may be viewed in some instances as a mitigating factor (i.e.,
when viewed as a mental illness; Aspinwall et al., 2012), research suggests it is generally
considered aggravating (Boccaccini et al., 2008; Edens et al., 2004, 2005). A meta-analysis
of simulation studies suggests jurors who perceive a person charged with a crime exhibiting
psychopathic traits also believe the person to be dangerous and evil (Kelley et al., 2018).
Jurors may also be more likely to recommend more punitive sentencing. In a recent study
specifically regarding juveniles, where study participants encompassed community mem-
bers summoned for jury duty (n = 326), the fictitious young person charged with a crime
was perceived as particularly evil and dangerous when described to exhibit affective psy-
chopathic traits (e.g., lack of remorse or guilt, shallow affect, callousness, lack of empathy;
Edens et al., 2016). Furthermore, population-based surveys have indicated that the general
public tends to view individuals with psychopathic traits as crime-prone, yet socially...

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