Today's blog post is by Katérine Aminot, Tara J. Ryan, and Alicia Nijdam-Jones who summarise their new paper, Delusion or conspiracy?, published in Criminal Justice and Behavior (2024).
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| Katérine Aminot, Tara J. Ryan, and Alicia Nijdam-Jones |
It's critical to properly diagnose mental disorders, such as those that cause psychosis (e.g., schizophrenia; delusional disorder), in legal settings. In the United States and Canada, criminal defendants must not be experiencing symptoms of a mental health disorder that impacts their ability to understand and make rational decisions, otherwise they are likely to be found incompetent to proceed with their case. Incompetent defendants are typically court ordered to receive treatment (e.g., mental health medications) in order to be restored to competency before proceeding with their legal case.
Delusional beliefs and conspiracy theories can look very similar. For instance, conspiracy theories and delusions both consist of odd beliefs that are not shared with mainstream society. However, conspiracies tend to be shared in small groups and are not typically distressing, whereas delusions are usually individualistic and can cause significant distress (Cunningham, 2018; Pierre, 2021; Starcevic & Brakoulias, 2021). Although delusional beliefs could result in a finding that a defendant is incompetent to proceed, conspiratorial beliefs are typically not due to a mental illness and such defendants would proceed with their legal case without interventions or treatment. It is unclear whether mental health professionals providing expert opinions to the courts can consistently differentiate between these types of beliefs.
To address this gap, we surveyed 198 forensic psychologists and psychiatrists across the United States and Canada to explore which factors they consider when distinguishing delusional beliefs from conspiratorial beliefs. In our online survey, participants read a brief mock scenario describing Mr. Smith, a defendant arrested for harassment who expressed odd beliefs. In this scenario, Mr. Smith’s lawyer requested a psychiatric evaluation to assess his competency to stand trial (i.e., whether he could understand the legal proceedings, the consequences of these proceedings, and properly communicate with his lawyer).
We presented participants with different versions of the scenario to assess how these factors influenced their diagnoses:
- The social context of his belief: In one situation, Mr. Smith’s beliefs were shared with others; in the other, they were not shared.
- The rigidity and distress associated with his beliefs: In one case, Mr. Smith’s beliefs were strongly held and caused him significant distress; in the other, his beliefs were less rigid and caused minimal distress.
- Mr. Smith’s racial identity: He was either described as White or Black.
These factors were informed by a review of the research and literature, which showed that rigidity, distress caused, and whether many people hold the belief can differentiate delusions from conspiracies (Bortolotti et al., 2021; Cunningham, 2018; Pierre, 2021; Starcevic & Brakoulias, 2021). In addition, minority groups’ lived experiences of systematic racism and historical injustices may cause expressed mistrust and cynicism of the legal system, which can be misinterpreted as delusional or conspiratorial thinking by clinicians (Dixon et al., 2023; Paradis et al., 2018; Parker, 2014). To examine whether cultural mistrust influenced diagnostic decisions, we included racial identity as a variable.
Overall, participants were more likely to diagnose Mr. Smith with a psychotic disorder when his beliefs were individualistic, caused significant distress, and were highly rigid. When Mr. Smith’s beliefs were shared with others, more flexible, and caused minimal distress, participants were more likely to attribute his beliefs to a conspiracy. Mr. Smith’s racial identity did not impact participants’ diagnostic decisions.
These findings align with existing research highlighting the differences between delusions and conspiracies and demonstrates that clinicians can recognize and agree on these differences. However, participants with more formal training in this area reported greater confidence in their diagnostic decisions than those with less training. This suggests that formal training can improve assessments of these beliefs and reduce disagreements between clinicians.