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Many insanity acquittees have a history of psychiatric treatment prior to their offenses, and the insanity defense is usually raised when a defense attorney becomes aware of this. The defendant may have been hospitalized previously, have a known history of psychosis or suicide attempts, or a history of outpatient rehabilitation for chemical dependency and mental health issues.
Not all insanity acquittees have this history, however. Some crimes are committed by individuals with no previous history of violence during the course of a first psychotic episode. When this happens, the general public often wonders why the defendant was allowed to be symptomatic for so long before the offense without receiving treatment. A representative of NAMI recently wrote a letter to the editor of my local newspaper raising this question. She suggested that the offenses represented a failure of the mental health system and indicated a need for outpatient commitment laws and less stringent standards for involuntary treatment.
Certainly, financial concerns and lack of insurance coverage are reasons why many people don’t seek mental health care, but for insanity acquittees, I don’t think this is the sole cause. Many areas of the country have no inpatient psychiatric facilities – or even a psychiatrist. Even when patients are willing to be transported for care, traveling for hundreds of miles with a seriously psychotic person is a risky venture. Sitting in a crowded, noisy, chaotic emergency room is also a challenge for someone in the midst of paranoia.
Lack of insight, or anosognosia, is often cited as a reason why the mentally ill resist treatment. This problem is confounded when there is poor premorbid family dynamics or prejudices. If the caregiver himself has a history of mental illness, he may be reluctant to take someone to treatment if he had a negative experience with it. If there is premorbid family conflict, an oppositional or defiant relationship between the patient and the caregiver will undermine treatment attempts. Finally, family members may deny or resist the thought that a once-promising young adult has been afflicted with a disabling mental disease.
Some psychotic episodes appear gradually, and subtle prodromal symptoms can be missed or overlooked. Negative symptoms such as emotional flattening or apathy may be mistaken for depression. Social withdrawal, loss of appetite, and insomnia may be attributed to stressful life events such as trouble at work, financial difficulties, strained family relationships, or other meaningful events. Poor concentration or difficulties on the job can be written off by employers as evidence that the patient is having personal problems or possibly substance abuse issues. The offense may be motivated by a delusional belief that has been hidden from others and is only uncovered after the fact during a pretrial evaluation. In situations like this, family members or employers may not recognize there is a problem until grossly disorganized or bizarre behavior appears.
Finally, caregivers may not seek care if they underestimate or dismiss the risk of violence posed by the psychotic patient. This is because the treatment-naive offender typically has no co-existing personality disorder, little or no past legal history, and no previous dangerous behaviors. The offense represents a dramatic deviation from the patient’s usual personality and behavior, which is why insanity defenses are often successful in these cases.
Outpatient commitment laws and relaxed civil commitment standards are no substitute for improved access to care. Psychiatrists also need to educate the public about the symptoms of mental illness and available treatments. Early mental health intervention can be an effective crime prevention tool.
—Annette Hanson, M.D.
Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.
Many insanity acquittees have a history of psychiatric treatment prior to their offenses, and the insanity defense is usually raised when a defense attorney becomes aware of this. The defendant may have been hospitalized previously, have a known history of psychosis or suicide attempts, or a history of outpatient rehabilitation for chemical dependency and mental health issues.
Not all insanity acquittees have this history, however. Some crimes are committed by individuals with no previous history of violence during the course of a first psychotic episode. When this happens, the general public often wonders why the defendant was allowed to be symptomatic for so long before the offense without receiving treatment. A representative of NAMI recently wrote a letter to the editor of my local newspaper raising this question. She suggested that the offenses represented a failure of the mental health system and indicated a need for outpatient commitment laws and less stringent standards for involuntary treatment.
Certainly, financial concerns and lack of insurance coverage are reasons why many people don’t seek mental health care, but for insanity acquittees, I don’t think this is the sole cause. Many areas of the country have no inpatient psychiatric facilities – or even a psychiatrist. Even when patients are willing to be transported for care, traveling for hundreds of miles with a seriously psychotic person is a risky venture. Sitting in a crowded, noisy, chaotic emergency room is also a challenge for someone in the midst of paranoia.
Lack of insight, or anosognosia, is often cited as a reason why the mentally ill resist treatment. This problem is confounded when there is poor premorbid family dynamics or prejudices. If the caregiver himself has a history of mental illness, he may be reluctant to take someone to treatment if he had a negative experience with it. If there is premorbid family conflict, an oppositional or defiant relationship between the patient and the caregiver will undermine treatment attempts. Finally, family members may deny or resist the thought that a once-promising young adult has been afflicted with a disabling mental disease.
Some psychotic episodes appear gradually, and subtle prodromal symptoms can be missed or overlooked. Negative symptoms such as emotional flattening or apathy may be mistaken for depression. Social withdrawal, loss of appetite, and insomnia may be attributed to stressful life events such as trouble at work, financial difficulties, strained family relationships, or other meaningful events. Poor concentration or difficulties on the job can be written off by employers as evidence that the patient is having personal problems or possibly substance abuse issues. The offense may be motivated by a delusional belief that has been hidden from others and is only uncovered after the fact during a pretrial evaluation. In situations like this, family members or employers may not recognize there is a problem until grossly disorganized or bizarre behavior appears.
Finally, caregivers may not seek care if they underestimate or dismiss the risk of violence posed by the psychotic patient. This is because the treatment-naive offender typically has no co-existing personality disorder, little or no past legal history, and no previous dangerous behaviors. The offense represents a dramatic deviation from the patient’s usual personality and behavior, which is why insanity defenses are often successful in these cases.
Outpatient commitment laws and relaxed civil commitment standards are no substitute for improved access to care. Psychiatrists also need to educate the public about the symptoms of mental illness and available treatments. Early mental health intervention can be an effective crime prevention tool.
—Annette Hanson, M.D.
Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.
Many insanity acquittees have a history of psychiatric treatment prior to their offenses, and the insanity defense is usually raised when a defense attorney becomes aware of this. The defendant may have been hospitalized previously, have a known history of psychosis or suicide attempts, or a history of outpatient rehabilitation for chemical dependency and mental health issues.
Not all insanity acquittees have this history, however. Some crimes are committed by individuals with no previous history of violence during the course of a first psychotic episode. When this happens, the general public often wonders why the defendant was allowed to be symptomatic for so long before the offense without receiving treatment. A representative of NAMI recently wrote a letter to the editor of my local newspaper raising this question. She suggested that the offenses represented a failure of the mental health system and indicated a need for outpatient commitment laws and less stringent standards for involuntary treatment.
Certainly, financial concerns and lack of insurance coverage are reasons why many people don’t seek mental health care, but for insanity acquittees, I don’t think this is the sole cause. Many areas of the country have no inpatient psychiatric facilities – or even a psychiatrist. Even when patients are willing to be transported for care, traveling for hundreds of miles with a seriously psychotic person is a risky venture. Sitting in a crowded, noisy, chaotic emergency room is also a challenge for someone in the midst of paranoia.
Lack of insight, or anosognosia, is often cited as a reason why the mentally ill resist treatment. This problem is confounded when there is poor premorbid family dynamics or prejudices. If the caregiver himself has a history of mental illness, he may be reluctant to take someone to treatment if he had a negative experience with it. If there is premorbid family conflict, an oppositional or defiant relationship between the patient and the caregiver will undermine treatment attempts. Finally, family members may deny or resist the thought that a once-promising young adult has been afflicted with a disabling mental disease.
Some psychotic episodes appear gradually, and subtle prodromal symptoms can be missed or overlooked. Negative symptoms such as emotional flattening or apathy may be mistaken for depression. Social withdrawal, loss of appetite, and insomnia may be attributed to stressful life events such as trouble at work, financial difficulties, strained family relationships, or other meaningful events. Poor concentration or difficulties on the job can be written off by employers as evidence that the patient is having personal problems or possibly substance abuse issues. The offense may be motivated by a delusional belief that has been hidden from others and is only uncovered after the fact during a pretrial evaluation. In situations like this, family members or employers may not recognize there is a problem until grossly disorganized or bizarre behavior appears.
Finally, caregivers may not seek care if they underestimate or dismiss the risk of violence posed by the psychotic patient. This is because the treatment-naive offender typically has no co-existing personality disorder, little or no past legal history, and no previous dangerous behaviors. The offense represents a dramatic deviation from the patient’s usual personality and behavior, which is why insanity defenses are often successful in these cases.
Outpatient commitment laws and relaxed civil commitment standards are no substitute for improved access to care. Psychiatrists also need to educate the public about the symptoms of mental illness and available treatments. Early mental health intervention can be an effective crime prevention tool.
—Annette Hanson, M.D.
Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.