From the perspective of "ideas" as "memes in the mind" that control the behavior of their hosts, it is not always easy to see if one is in reality or not; Insane or not. Narcissistic Injury or "Identity Issue" (aka an unwanted often inferior belief about themselves that is a driving force for an osscilating pattern) is one such example. The psychological term "Narcissistic Injury" implies that it was some traumatic event during the narcissism phase that gave rise to a narcisstic trigger or injury in the persons personality. An area they are sensitive about perhaps and must go around proving they are not what they think of themselves. So while psychology blames mom and dad or some other mean family member, structural dynamics and reality therapy puts the accountability in the hands of the person feeling this way. I strongly believe that most individuals in the criminal justice system such as NPD's must in some form or another think they are "bad." Thus their pattern puts them in conflict with their values and thus the law. Today on the phone I spoke to my mother about this and we recalled a recent NPD "friend of mine" who thought they were bad. SO mom, what leads these people to the criminal justice system, what is the structural pattern leading them there? "a sense of unable to accept powerlessness and entitlement maybe" she responded.
Pondering NPD further, we see these types in the AA community a lot. Yet while substance abuse doesn't constitute insanity, that is usually what indeed we are dealing with: A disease. If anyone who is an alcoholic knows that an AA meeting is based on the 12 steps to recovery which is an admission of powerlessness. It requires an admission of powerlessness, something Narcissists are incapable of doing with out the help of another and a belief of something outside of themselves such as a higher power. It requires humility, and humility is the humble pie of getting in touch with the truth and with reality. Another interesting movie on reality was that of "a beautiful mind" when the character played by Russel Crow, struggling from schizophrenia, is able to tell himself reality that the voices and the people are not real. My sense is that a lot of people are just in the wrong structure and that humble reality that one is indeed insane, an alcoholic, or mentally ill or narcissistic, or PTSD, or dissociative, or maybe has a dangerous memetic idea parasite in their brains, is the first step to recovery. (I'm not talking about brain tumors here, that is different and we don't always know why people do the things they do.) These are mental states that are based around things that are not in reality. PTSD is a big and real fear about the past, dissociative states feel safer and are the brains way of protecting a human being from perceived or real threats, hosts for bad ideas need reality therapy and to be de-brainwashed, alcoholics and narcissists need a higher power and a reality check that the world doesn't revolve around them or owe them anything in life. I think when making assessments about mental illnesses, its so important to remember that we are dealing with human beings who are just self medicating, dealing with real or imagined fears etc and are just lost and severely out of touch with reality. Of course if they really didn't know what they were doing or that it was wrong, we try to see why and understand mental illness, but I feel the forensic department has another important task of making sure that while a mentally ill patient may confirm impairment after due process and product testing etc, that the insanity defense does not negate or act as an "excuse" for the criminal sentencing they should still be held accountable for and that "getting back to reality" is the goal, in whatever way that looks for the criminal-patient. A key factor in this I believe is how strong the defendants desire is to "change their behaviors" in any way, or any strong desire for change within the defendant is a key factor in deciding their fate, and will give clues into feigning or other tricks they use to deflect and avoid their actions and take responsibility for them. I feel a type of reality therapy and a strong look at belief systems, ideas, identity issues, or substance abuse issues could be great clues into what is going on structurally that is causing them to act out of alignment with reality and the law.