Insanity defense research and treatment of insanity acquittees

This article is a comprehensive review of issues relevant to the insanity defense and the disposition of insanity acquittees. The characteristics of persons found Not Guilty by Reason of Insanity (NGRI) are described. Although the locus of treatment of the NGRI acquittee varies by jurisdiction, at this time, care and detention of insanity acquittees fall mainly to state mental health agencies. Recent reforms, as they relate to locus of treatment, are reviewed and public policy issues are discussed. The author concludes that more clinical research on the insanity acquittee is necessary for the development of more informed public policy on the insanity defense.     

Hospital treatment of persons found not guilty by reason of insanity

After being found not guilty by reason of insanity (NGRI), individuals are typically admitted to a secure forensic hospital for evaluation and treatment. This patient population can pose a challenge to clinicians in the hospital setting due to significant violence risk, complex psychiatric presentations, and scrutiny from oversight boards and the public. This article reviews the scientific literature around several key aspects of hospital-based treatment of insanity acquittees, including the management of inpatient aggression, the provision of specific treatments to acquittees, the assessment of violence risk and readiness for release, and the process of community transition. The authors conclude that the existing literature is heavily weighted toward the study of risk assessment and recidivism, with relatively little attention paid to the study of therapeutic modalities and recovery-oriented care in this population.     

The insanity defense: Legal standards and clinical assessment

Although the insanity defense is used infrequently, it has received significant attention from legal and mental health professionals. In this article, we review the historical development of insanity defense standards and describe the standards currently employed in the United States. We present a model for evaluating a defendant's mental nonresponsibility, and we briefly discuss the legal standards and procedures for the assessment of insanity acquittees for release. Throughout the article, we discuss some scientific, ethical, and jurisprudential issues associated with the insanity defense and nonresponsibility evaluations.     

The detection of malingering in criminal forensic groups: MMPI validity scales

Despite the value of the MMPI to the forensic assessment of malingering (exaggeration) of psychopathology, few studies have assessed the accuracy of the MMPI validity scales in criminal forensic populations. We administered the MMPI to 35 insanity defendants undergoing evaluation for fitness to stand trial and/or sanity at the time of the crime, who stood to benefit from being assessed as psychologically disturbed, and 39 subjects previously found not guilty by reason of insanity (NGRI), who did not stand to gain from such an assessment, Insanity defendants showed significantly more malingering than NGRI subjects, p less than .05. Racial differences did not affect the data. These findings support the efficacy of MMPI validity scales in assessing malingering within criminal forensic groups, and support the generalizability of the scales across race.     

The Detection of Malingering in Criminal Forensic Groups: MMPI Validity Scales

Despite the value of the MMPI to the forensic assessment of malingering (exaggeration) of psychopathology, few studies have assessed the accuracy of the MMPI validity scales in criminal forensic populations. We administered the MMPI to 35 insanity defendants undergoing evaluation for fitness to stand trial and/or sanity at the time of the crime, who stood to benefit from being assessed as psychologically disturbed, and 39 subjects previously found not guilty by reason of insanity (NGRI), who did not stand to gain from such an assessment. Insanity defendants showed significantly more malingering than NGRI subjects, p < .05. Racial differences did not affect the data. These findings support the efficacy of MMPI validity scales in assessing malingering within criminal forensic groups, and support the generalizability of the scales across race.     

Are release recommendations for NGRI acquittees informed by relevant data?

We conducted a retrospective review of factors involved in clinical recommendations for release of patients adjudicated not guilty by reason of insanity (NGRI). Medical records from 91 patients in a maximum security forensic hospital who participated in a formal hearing process to determine suitability for release were reviewed. The purpose of the study was twofold: (1) to examine the process involved in day to day clinical decision-making regarding release from a maximum security forensic hospital and (2) to determine what factors in a patient's clinical and legal history were related to recommendation decisions. Multivariate statistical methods revealed that among the clinical, demographic, and legal information available to clinicians at the time a formal release recommendation was made two factors emerged that were significantly related to release recommendations: PCL-R score and the age at which the patient committed his first criminal offense. Patients with high levels of psychopathy and those who engaged in criminal behavior at a younger age were less likely to be recommended for release from a maximum security forensic hospital.     

The insanity defense: Historical development and present status

This article provides an overview of the historical development of the insanity defense, including a discussion of the standards which have been used to excuse someone from criminal responsibility. The legal issues raised pre-trial and at trial are presented, along with a discussion of current proposals to modify or abolish the insanity defense. The article also focuses on the disposition of insanity acquittees, including both the case and statutory law in this area. Constitutional bases for challenges to differential procedures for insanity acquittees, along with proposals to change the law relating to them are included.     

The question of sanity restoration in jail

Severe mental illness, especially psychotic disorders that are worsening, acute or complicated, normally require intensive psychiatric care and treatment that is most appropriately provided in a mental hospital. For criminal defendants, transfer to a forensic security hospital has traditionally been the means of achieving hospital care for mentally disordered defendants who have been found incompetent to stand trial or not guilty by reason of insanity. In recent years, with the shortage of intermediate and long-term hospital beds in the United States, including forensic security hospital beds, jail-based competency restoration programs are being established, seemingly obviating hospital transfer. Potential advantages of and concerns about jail-based, as opposed to hospital-based, competency restoration programs are discussed in the literature. If defendants with severe mental illness traditionally treated in a forensic security hospital for competency restoration are now treated for competency restoration in jail, it is not inconceivable that insanity acquittees could one day be treated in jail for sanity restoration. With the premise that it is better to consider the potential consequences before this becomes a serious proposal and is implemented, this analysis examine the advantages and concerns that have been put forth for jail-based competence restoration programs as they may or may not apply to jail-based sanity restoration programs. Substantial commonality is recognized, but also some differences, as well as reason for skepticism of the purported virtues of either alternative to care and treatment in forensic security hospitals.     

Homicide and the insanity defense: A comparison of sane and insane murderers

A sample of 50 homicide defendants acquitted by reason of insanity (NGRI) was compared with a group of 50 defendants who were evaluated for insanity and found to be criminally responsible (CR). Significant differences were found between the two groups in terms of prior psychiatric and criminal histories and nature of the homicide (i.e., relationship to victim). The dispositions of those found NGRI were also examined on the above variables.     

The insanity plea: Szaszian ethics and epistemology

The traditional legal verdict of ‘not guilty by reason of insanity’ as well as the more recent verdict of ‘guilty but mentally ill’ rest on often unquestioned epistemological assumptions about human behavior and its causes, unjustified reliance on forensic psychiatrists, and questionable, if not deplorable ethical standards. This paper offers a critique of legal perspectives on insanity, historical and current, based on the altermative epistemological and ethical assumptions of Thomas S. Szasz. In addition, we examine Szasz's unique rhetorical analysis of ‘mental illness’ and its implications for forensic psychiatry.     

Religious Beliefs,Religious Contexts,and Perceived Interactions with Ex-Offenders

Religious institutions can provide a means of support and resources for many people, particularly, individuals who have criminal histories, specifically parolees, sex offenders, and insanity acquittees. When these individuals are released into the community, they often face difficulties in acquiring shelter, work, and social support. Out of their own volition or as a result of faith-based prison programs, they might turn to religious institutions for help reintegrating into the community. However, whether congregation members are more or less accepting of these individuals is unaddressed in the current literature. Two studies assess the relationship between religious beliefs, religious contexts, legal attitudes, and perceived social interactions with parolees, sex offenders, and insanity acquittees. Results suggest that religious beliefs, legal attitudes, and religious contexts play an important role in individuals’ perceived interactions with these individuals. Religious contexts, specifically, might facilitate more positive social interactions with parolees. Implications are discussed.     

Posttraumatic stress disorder and criminal violence: Basic concepts and clinical-forensic applications

In a small number of felony murder cases, posttraumatic stress disorder (PTSD) has been used as an affirmative defense to plead not guilty by reason of insanity or to argue for diminished capacity as a mitigating factor at sentencing. This article traces the history of PTSD as a legal defense; describes the clinical criteria for diagnosing and assessing PTSD; outlines the legal criteria for the affirmative defense of not guilty by reason of insanity (NGRI) and mitigation on the grounds of diminished capacity; and discusses the applications and pitfalls of using PTSD as an exculpatory factor in crimes of violence, including murder.     

The effects of neuroimaging and brain injury on insanity defenses

Although neurological evidence is used with increasing frequency in criminal trials, there is limited research examining the effects that this evidence has on juror decision-making in insanity trials. Participants (396) were presented with a case summary and psychological testimony and asked to render either a verdict of guilty or not guilty by reason of insanity in a 2 (psychosis or psychopathy) x (presence or absence of an MRI indicating a brain lesion) x (presence or absence of testimony describing a car accident that caused injury to the brain) factorial design. Defendants diagnosed with a psychotic disorder, defendants who could demonstrate the existence of a brain lesion via MRI, and defendants who had a history of brain injury were more likely to be found not guilty by reason of insanity than those defendants who did not present any neurological testimony. Participants who reported they were more influenced by the psychological and neurological testimony were almost six times more likely to render a verdict of NGRI than those participants who reported that the psychological and neurological testimony and evidence did not influence their decision regarding verdict.     

The Impact of the Guilty but Mentally III Verdict on Juror Decisions: An Empirical Analysis

The present study attempted to determine the impact of alternative verdict choices on the decisions of mock jurors. Subjects used in this study as mock jurors were all college undergraduates. They were shown one of two versions of a videotaped simulated murder trial. Both films presented a defendant who appeared to be suffering emotional difficulties, but in one film the defendant had clearly committed the act while in the other film the defendant's actions were less certain. Subjects than gave their individual verdicts and, after deliberation with other subjects, a total jury verdict. The verdicts available to the subjects varied across three conditions such that the subjects in one condition were only allowed to find the defendant to be innocent or guilty. In another condition the subjects could find the defendant innocent, guilty or not guilty by reason of insanity (NGRI). In the third condition the subjects were allowed to choose between innocent, guilty, NGRI, and guilty but mentally ill (GBMI). The results indicated that the addition of the "mental health" verdicts had a significant impact on the decisions of the jurors. In particular, it appears that only defendants who would otherwise have been found innocent were likely to be found NGRI. This study also indicated that the GBMI verdict is very attractive to mock jurors. Indeed, even innocent defendants were found to be GBMI, a form of guilt, when this alternative was made available. These findings raise potentially important constitutional and practical issues for the trial of emotionally disturbed criminal defendants.     

Predicting outcome of insanity acquittees released to the community

This research developed a model for forensic release decisions that incorporated actuarial and psychiatric predictors. The model was based on research that compared 127 insanity acquittees in the State of Maryland with a matched control group of 127 convicted felons and a comparison group of 135 mentally disordered prison transfers. The three cohorts were followed for an average of 10 years after release from hospital or prison. Findings on two outcome indicators are reported in this article: rearrests within 5 years after release and overall functioning in the community during 2½ years after release. Discriminant analysis was performed on the outcome variable of rearrest; it was found to accurately predict the outcome of 75% of the subjects with the following six variables: adjustment in hospital, clinical assessment of hospital staff, Global Assessment Scale score at release, functioning prior to instant offense, heroin addiction, and birth order. A second discriminant analysis identified seven variables that accurately predicted the overall functioning of 80.4% of the insanity acquittees.     

Does the Onset Controllability of Diagnostic Labels Affect the Perceived Appropriateness of an Insanity Verdict?1

The present study attempted to look at reactions to an insanity verdict by asking participants to rate the appropriateness of an insanity verdict already handed down by a jury. A sample of 196 adults read a short vignette describing the defendant's crime, a courtappointed psychiatrist's diagnosis, and a jury's verdict (guilty; or not guilty by reason of insanity, NGRI). Using Weiner's (1995) responsibility model, it was predicted and found that an insanity verdict was deemed less appropriate when the defendant was construed to have an onset controllable disorder. Path analyses indicate that onset controllability, responsibility judgments, and affective reactions do not account for the perceived appropriateness of guilty and NGRI verdicts in the same way.     

The New Orleans Forensic Aftercare Clinic: a seven year review of hospital discharged and jail diverted clients

This paper provides a review of the Forensic Aftercare Clinic Conditional Release Program (FAC), which has been operating since December, 1995, in New Orleans, LA. The FAC is a community based program that provides clinical, rehabilitative, and supervisory services to individuals who have been found not guilty by reason of insanity or unrestorably incompetent to proceed and who have been discharged from inpatient settings or diverted from jail settings and placed on conditional release by district court orders. 119 clients participated in FAC over a 7 year period. Forty-one (34.4%) had their conditional release revoked. Of the total population, 12 (10.1%) were re-arrested on at least one charge, 3 (2.4%) were arrested on felony charges, and 9 (7.6%) on misdemeanors. Only two of these charges were violent, resulting in no significant harm to victims. Twenty (16.8%) were hospitalized at least once due to relapse. Clients diverted from jail to community settings did not differ significantly on most variables from clients who were discharged from long-term hospitalization. Data related to public safety and client diversion demonstrate that clients, when appropriate, can be safely diverted to the community in lieu of hospitalization. The number of statewide clients who have been discharged from the forensic hospital into the community has increased steadily from 13 in 1995 to 29 in 2002, and statewide diversion clients have steadily increased from 0 in 1992 to 20 in 2002. The increase in statewide diversion clients and forensic discharges over this 7 year period indicates that stakeholders see the viability of the program as an alternative to as well as a step-down from long-term forensic hospitalization.     

Oregon's Gun Relief Program for Adjudicated Mentally Ill Persons: The Psychiatric Security Review Board

This article describes the State of Oregon's implementation of two programs designed to comply with federal gun laws regarding reporting individuals who have received mental health adjudications in criminal and civil courts. One mandate requires that states submit names of adjudicated individuals to the National Instant Criminal Background Check System (NICS) while the second requires that the state establish a qualifying gun restoration program for those disqualified from gun ownership. In 2009, Oregon's Legislature developed an administrative approach to gun restoration and assigned the responsibility for conducting these hearing to the Oregon Psychiatric Security Review Board (PSRB). The PSRB is a state administrative board that has existed since 1977 and has been primarily focused on the supervision and treatment of adult and juvenile insanity acquittees. The gun restoration program began in 2010, but to date has only received three completed petitions requesting restoration of firearm rights. The article concludes with a discussion that surmises why very few of the Oregonians who are listed in NICS have submitted petitions for relief. Copyright © 2015 John Wiley & Sons, Ltd.     

Psychological evaluations in the criminal justice system: Basic principles and best practices

Forensic psychologists are frequently called upon to conduct evaluations for competency to stand trial, insanity defense, or prediction of future dangerousness. Psychological evaluations for the court typically include record review, clinical examination of the defendant, interview of collaterals, psychological testing, and preparation of a written report. Psychological forensic examiners may also be called upon to testify in court. In rendering their conclusions, forensic examiners should conduct a careful analysis of each individual case, not rely on the mere presence, absence, or severity of any mental disorder to make a legal determination.