The Defense of Insanity

The Idaho Correctional Institution at Orofino.  It was once a psychiatric hospital.

I learned from a story in the Idaho Statesman yesterday that Idaho has no Insanity Defense.  It seems there is an individual named John Delling who, seized by an acute psychosis due to schizophrenia, shot and killed two men and injured a third.  Although there was agreement across both defense and prosecution that his actions took place under the influence of mental illness, he was apparently tried and convicted as if he were not mentally ill.  According to the article in the Statesman, three other states have eliminated the Insanity Defense:  Utah, Montana and Kansas.   

There will be an impulse from the Northeast Corridor to view the absence of this legal pathway as a flannel-shirt-and-bushy-beard kind of frontier justice.  In the Statesman, a somewhat liberal newspaper trying to bring light to the conservative darkness of Idaho, it is detailed that the insanity defense was "banned" in these four states as a reaction to John Hinckley's use of the insanity legal loophole to avoid accountability for shooting Ronald Reagan.   I believe this issue is being unnecessarily politicized.  It may be that the issue of how mentally ill individuals are found culpable of crimes is not a simple matter of compassion or retribution.   

In my mind at least, I've been an advocate for the mentally ill for twenty years.  I've received a "Helper Friend Award" from a local chapter of the National Alliance on Mental Illness (NAMI), and several years ago I spoke at their national meeting in San Diego.  It may seem inconsistent with advocacy in the minds of some, but over the years I have leaned increasingly in the direction of full accountability of the mentally ill for crimes they may commit.   

My clinical experience is unambiguous.  When mentally ill individuals become dangerous to person and property, at least one of two elements is virtually always present.  The first is a refusal to take medications.  Typically these patients are well-compensated and organized but for whatever reason, and many reasons are given such as side effects, they decide to stop taking their medications and then undergo a marked deterioration.  Paranoia takes hold, and the patient begins to perceive threats all around, leading to what they may see as "preemptive" strikes of violence.  

The second element is use of illegal drugs.  This behavior is astonishingly common among the mentally ill, and although one theory is that these patients are "self-medicating," they virtually always destabilize, even with relatively benign substances like cannabis.  Their internal neurochemical environment is much more prone to disarray than those of people without mental illnesses, and many of these drugs can produce paranoia and violence even in people without a diagnosis of mental illness.  While patients who stop taking their medications do not always use illegal substances, those who use illegal substances virtually always stop taking their medications, either before the drug use starts or after it is under way.   

So while the decision to shoot someone may occur under the impairment of decompensated insanity, the decision to stop taking medications and that to use illegal drugs usually happen while the individual is in a much more stabilized state.  Since the outcome is relatively predictable, especially in patients who have previously become violent, it does not seem reasonable to ignore or soft-peddle the decision not to adhere to treatment. 

With the Insanity Defense, we are teaching individuals with mental illnesses that they are at times not responsible for their behavior.  But what concerns me even more is that we may be conveying to them that, as victims of mental illnesses, they are unable to be in control of their behavior in general.  If that is the case, the consequences will be more decompensation and violence and poorer self esteem and hopelessness in the mentally ill.   

The case of Paul Harrington is instructive in this regard.  He was a Viet Nam combat veteran and heroin abuser who murdered his wife and two daughters in 1975.  Because of his Posttraumatic Stress Disorder diagnosis, he was found Not Guilty by Reason of Insanity in 1977 and spent two months in a psychiatric hospital, then was released.  He later remarried and in 1999 killed his wife and 3 year old son.  This unspeakable tragedy recurred because he was given the rather clear message that he was not responsible for his behavior and probably also that there was no point in trying to control himself.  While the second murders would likely have been prevented had he been held accountable for the first, I wonder if Harrington had already internalized an ambiguous set of standards of responsibility in 1975.   

Experience has also taught me that the connection between mental illness per se and dangerous behavior is not as direct as is portrayed in popular media.  Most of the severely mentally ill people I have known are considerate of the rights of others, and many of them have a completely intact sense of humor.  To say that they are dangerous by virtue of their mental illness is to do them a grave injustice.  Most of them are people who are struggling as best they can against internal strife, social isolation and economic desolation; that we project evil onto them as well may explain why there seems to be so little compassion for them in contemporary society.   

To take the point a bit further, almost every disease state is manifested differently in different people.  Tuberculosis might represent a good analogy.  Most people who contract tuberculosis contain the disease within their immunity; they can eradicate the infection with antibiotics but even without antituberculine drugs they are not infectious.  They pose no threat to anyone.  Other patients, however, have "active" tuberculosis, coughing and spreading the bacilli throughout their contacts.  When these patients do not follow treatment instructions closely, they pose a significant risk to others, and sometimes they have to be quarantined under the authority of the state.  I would argue that mental illnesses are exactly the same in that the character of the affliction varies from individual to individual and it is only the minority who are potentially dangerous. 

Of all the reasons I favor accountability for the mentally ill, however, one far surpasses the rest.  Some years ago I was listening to a story on National Public Radio; it was a feature precisely on this topic.  A nurse who identified himself as having bipolar disorder was interviewed.  "We can't have it both ways," he said.  He observed that if people with mental illnesses demand full integration into society, they will have to assume the same accountability for their behavior as those who do not have mental illnesses.  One cannot demand to be accepted and assimilated into a collective society or culture on one's own strictly individual terms.  That would be kind of like saying:  "Henceforth I shall be considered by all to be a black American, despite the fact that I have no African heritage."   

One fact threatens to obscure my point, though.  It is widely believed that as the state psychiatric hospitals have closed since the 1950s, the mentally ill have streamed into the prisons.  In fact a Department of Justice report from 2006 details that over half of the inmates in state prisons have mental illnesses.  So how can it be true that we do not hold mentally ill people accountable enough, at the same time unfairly holding them too accountable?   

While some people think that the purpose of incarceration is punishment and others think that it is rehabilitation, the fact is that the prisons serve one function:  Quarantine.  Individuals who believe that they are not responsible for their behaviors eventually wind up in prison, generally after an escalating pattern of serious crimes.  In my experience this concept applies to three groups of inmates:  The criminals per se, the nonviolent drug offenders, and the mentally ill.   

The first group, who are sometimes called sociopaths, tend to blame others for the crimes they commit.  They lack compassion for their victims and they have no conscience, so there is almost no psychological obstacle to violence against person and property.  They do not take responsibility for their actions, so they are quarantined.  Similarly, those who become addicted to heroin or crack cocaine come to the realization that their desire to obtain and use drugs surpasses every other drive or instinct, occasionally provoking monstrous behaviors.  Therefore they, too, are quarantined.   

The mentally ill, however, contend with a more complex set of circumstances.  They are frequently homeless, often victims of assault themselves, and sometimes afflicted with superimposed substance use disorders.  They do not always have access to mental health care, let alone general medical care.  Generally it begins with misdemeanors like trespassing, progresses to illegal drugs use and assault, eventually sometimes culminating in violent crimes.  It is possible that because a compassionate court excuses minor crimes on the grounds of mental illness, the perpetrator acquires the sense that he or she is not responsible.  Released therefore from the accountability constraints of civil society, their infractions become progressively more serious, advancing to crimes so violent the jury is no longer inclined toward mercy.  Had we held them accountable at an earlier time and given them access to adequate care, their behaviors might not have progressed to the level of felonies.   

There is a more rational, and in my opinion, less expensive way.  We could build state psychiatric hospitals, as we did a century ago, and make available to patients long-term treatment for substance use and mental illness.  We could make outpatient treatment of mental illness and addiction available in a meaningful way, and in the former case implementation of real case management.  With case managed, when a schizophrenic patient with a history of violence stops coming to his appointments, he is at least in theory quickly located and treatment reinitiated. 

We have closed the mental hospitals and opened the prisons.  It is often said that of all the nations in the world, the U.S. has the highest absolute number, and the greatest percentage of her population in jail or in prison.  If it is true, this statistic is a dramatic challenge to the notion that we are a "free" country.  It might not gratify the emotional need, as Bill Clinton said, to "send a message" to drug users and those who commit crimes.  But we would be safer, freer, and less fiscally strained if we closed the prisons and opened the mental hospitals.   

Everyone, including the mentally ill, should be accountable for his or her behavior.  Reason and compassion dictate, however, that we not expose mentally ill individuals to inhumane conditions; that they not be held accountable under such a different set of circumstances than society at large.  Even those not motivated by moral consciousness will probably concede that since contraction of mental health care was followed by an explosion in homelessness and dramatic increases in prison populations, a reciprocal effect could be induced by investing in mental health care.  If it is true as the NAMI has suggested that the prison system is the new mental health system, it would be cold reason itself to replace it with a more effective and yet also less expensive one.    


Update:   On 12/7/2011 I had a conversation with my colleague Dr. John Hubbard.  We co-authored a textbook some years ago:  "Primary Care Medicine for Specialists and Subspecialists:  A Practitioner's Guide."  We were discussing this topic, that of culpability of the mentally ill.  He made an interesting observation.  He said that people should not be found Not Guilty by Reason of Insanity but rather Guilty by Reason of Insanity.  Such a legal finding would, it seems to me, make it possible to hold patients accountable but also emphasize quarantine and treatment over quarantine and punishment. 

(c) copyright 2011 Robert Albanese

Update:  On 4/20/16 I attended Baylor College of Medicine Grand Rounds.  The speaker, Christina Treece MD, an expert on postpartum psychiatric disorders, noted that Andrea Yates had discontinued her haloperidol (an antipsychotic) without consulting with her psychiatrist not long before the horrific murders of her five children.