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.  

On Spiritual Illness

In the synaxarion* of the saints of Western Medicine, no name is more luminous than Hippocrates. It was he who came down from Mount Olympus with stone tablets bearing the message that the Gods had changed their minds. In more terrestrial terms, Hippocrates challenged one of the most unassailable beliefs of his age. It had been universally believed in ancient times that when an individual becomes insane, it has been induced by the gods. In other words, mental illness is essentially a spiritual problem. But Hippocrates knew the truth: mental illnesses are diseases of the brain.

The story of Hercules illustrates the contemporary view. We remember him from his heroic exploits, in particular the Twelve Labors: cleaning the Augean stables, Cerberus, the Hydra and so on; these were undertaken to atone for the murder of his wife Megara and his three children. Hercules slew his wife and children after he was made to go mad by his stepmother Hera, a goddess.

That insanity derives from divine will is not unique to the Hellenistic tradition. The story of King Saul from the Old Testament is similar; when Saul becomes paranoid we learn that it is because God has sent an "evil spirit" into him. In the New Testament (Matthew 17:14-21, Mark 9:14-29, and Luke 9:37-42), Jesus heals epilepsy by casting out a demon.

Centuries before the birth of Christ, Hippocrates makes his startling revelation. In his essay "On the Sacred (Spiritual) Disease," he says "It is thus with regard to the disease called Sacred: it appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause which originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like to other diseases." He goes on to say that "Men ought to know that from nothing else but the brain come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations. And by this, in an especial manner, we acquire wisdom and knowledge, and see and hear, and know what are foul and what are fair, what are bad and what are good, what are sweet, and what unsavory; some we discriminate by habit, and some we perceive by their utility. By this we distinguish objects of relish and disrelish, according to the seasons; and the same things do not always please us. And by the same organ we become mad and delirious, and fears and terrors assail us, some by night, and some by day, and dreams and untimely wanderings, and cares that are not suitable, and ignorance of present circumstances, desuetude, and unskilfulness. All these things we endure from the brain, when it is not healthy." Hippocrates described six brain diseases: Melancholia, Mania, Phrenitus, Epilepsy, Scythian Disease and Hysteria.

It is not surprising that in ages without medical and scientific knowledge, individuals would attribute mental disturbances to spiritual forces. They had no knowledge of neurons, synapses, action potentials, dopamine, norepinephrine, serotonin and so on. It is far more suprising that Hippocrates was able to detect the truth without the tools we have in the 21st Century, but then, that's what makes him the Father of Western Medicine. We discern in his writings that he must have been one of the greatest observational minds through all the generations of human kind.

What is more suprising still is that in spite of the wisdom of Hippocrates and Avicenna and many others since, and despite the great volume of science in the 20th and 21st centuries, confusion between what is spiritual illness and what is mental illness remains pervasive.

Several years ago I led a Bible study and fellowship group for Orthodox Christians at a college in Charleston SC. There were many such groups for different faiths and denominations and they were all coordinated by the executive chaplain of the college, a military man and evangelical Christian minister. When he learned I am a psychiatrist, he thrust his chest out and professed the belief that "all mental illnesses are basically spiritual." Now when ignorance gushes from the mouth of a man in Klan robes or a clown suit, we wish for a better world. But when the source is an intelligent person we are in a precarious situation. Unfortunately, it is not an uncommon thing.

The chaplain believes, as do many others, that phenomena such as depression are the result of a spiritual defect, and that if the patient accepts Christ as his or her personal savior, the improvement will be superior to the benefit derived from antidepressants or psychotherapy. To be fair, I agree that individuals with a robust spiritual life tend to suffer less frequently from milder psychological disorders and substance use disorders, and I have seen scientific evidence to that effect. After all, one of the major functions of religion is to effect resiliency and transendence. But let us undertake a thought experiment to carry forth some of the assumptions that mental and spiritual disorders are really of one substance, so to speak.

God, according to the chaplain, is a specialist in medical terms. He has the power to halt and reverse psychiatric disorders, but he has much greater difficulty healing general medical conditions, such as diabetes. In my experience people who attribute psychiatric disorders to spiritual defects, or sinfulness, have without exception this same dyssynchronous view that God has an easy time healing mental conditions but he has limited power over "medical" illnesses. These individuals believe that psychiatric disorders are rare or nonexistent among those who share their "true" version of the faith, but they do not view heart disease or cancer among their parishioners as having the same implications.

I disagree with these believers in two ways. First, I believe that God has just as much ability to heal general medical illness as he does psychiatric illness. The modest but unmistakeable impact of religion on psychiatric health can also be seen in some of the scientific data on general medical health. I remember one study in particular that statistically linked longevity to regular church attendance, for example.

Second, mental illnesses do not conform as well as certain general medical illnesses to the notion of having a spiritual dimension. Christian tradition holds that there are "Seven Deadly Sins," and however many serious sins you think there are, most Christians will agree that these seven are important: Lust, Envy, Sloth, Gluttony, Pride, Avarice and Greed. It is rather difficulty to draw a direct line between any of these and anxiety of depression. Adult-onset diabetes, by far the most common type of diabetes, is essentially a product of too little exercise and excessive caloric intake. In other words, it is the result of gluttony and sloth, despite the fact that we tend to view it as a genetic error of some kind. In fact, most of what we treat in the primary care setting is related to various manifestations of gluttony and sloth: obesity, hypertension, hyperlipidemia, heart disease, and many others. Even the most common cancers, such as colon cancer, breast cancer and prostate cancer are related to overweight. Truly, gluttony and sloth are deadly.

But the frontier between mental illness and moral illness cannot be sufficiently clarified by unmasking certain glitches in the cognitive software of Evangelical Christians. For in the ivory tower of academia, an equally perfidious line of code smudges the line between moral illness and mental illness, and it is the mentally ill who are victimized.

Academics are almost all non-believers. They view religion as a waste of time at best, at worst a dangerous delusion and like cigarette smoking, an important cause of preventable suffering. They view Good and Evil as superstitious attributions created to explain complex social and psychological phenomena. There is no Evil in their cosmos, only mental derangement or bad social policy. This view is just about as widespread in public imagination as the Evangelical one I have just refuted.

The notion that mental illness and evil behavior are one phenomenon is wrong, for I have worked with seriously mentally ill individuals for twenty years, and I have not found them more evil or dangerous than people who do not have mental illnesses. An exception is mentally ill patients who abuse alcohol and/or drugs, but interestingly, individuals without mental illnesses who abuse alcohol and/or drugs also have tendencies toward violence and problematic behavior. And yet, mental hospitals are closed and the patients are left to fend for themselves in the streets, and there does not seem to be any compassion for them in our culture. The only way to explain the lack of feeling for the mentally ill is that Americans must have accepted the notion that they are evil and therefore not worthy of our help. Certainly in film and television the mentally ill are almost without exception portrayed as murders and rapists, a misconception that has been imprinted on the American mind.

Take the case of Anthony Capozzi. He was convicted of rapes and murders he did not commit and he spent 22 years in prison. The evidence against him could not have been substantial, for he did not rape or kill anyone. He was, however, guilty of schizophrenia, he is insane, and therefore he is almost certainly capable of violent crimes. The jury and the three victims who wrongly identified him as their assailant were programmed by cinema and television and print media to believe that an individual who is mentally ill is also evil. Like university professors and religious bigots, Scientologists also have called mentally ill individuals "unethical" and "immoral;" with Scientology's influence in Hollywood, what chance does a patient with schizophrenia have in American society? Precious little.

It is ironic that in our hypersensitive era where we police our thoughts and actions to avoid being perceived as without feeling for our fellow man, we have no empathy for the most devastated among us. How revolting the image of politicians struggling to produce tears for the television cameras as they profess their capacity to feel our pain, spending incalculable sums on football stadiums while schizophrenics have nowhere to sleep. The first victims of the Holocaust were not Jews or Gypsies or homosexuals; they were the mentally ill. They have no monument to remember them, for we have not yet decided whether anything of value was lost.

*Synaxarion is Greek for "Book of the Worthy." It is a collection of biographies of the Saints of the Orthodox Church.

Copyright 2009 Robert Albanese