Inquiring Minds: Barry Wall on the mentally ill and the legal system

Andrea Yates, the Texas mother charged with the murder of her five children, has a documented history of postpartum depression and psychiatric hospitalization, yet the district attorney prosecuting her case recently offered to take a possible death penalty off the table if she would withdraw her insanity plea. In the meantime, debate rages nationwide over whether Yates should be held responsible for the killings and punished accordingly. GSJ reporter Mary Jo Curtis recently asked Clinical Assistant Professor of Psychiatry and Rhode Island Psychiatric Society President Barry Wall, M.D., about the handling of the mentally ill in the American legal system.

It seems there is little sympathy for the mentally ill in our courts, and juries seldom acquit defendants because they are mentally ill. Why do you think this is the case?

The insanity defense itself is much maligned and misunderstood. The public often believes that insanity pleas are commonly used, particularly by the rich, to "fake" illness to elude punishment, and that it’s wildly successful. The opposite is true: It is used in less than 1 percent of cases, it fails 75 percent of the time, and it’s rarely used by fakers. If you’re found to be insane, in many states you actually risk spending more time locked up in a mental hospital than you would if you’d been found guilty and served jail time.

Regarding the sympathy that the mentally ill receive in our courts, I think that there are distinctions to be made between judges and juries. Judges often have a highly sophisticated understanding of the issues involved when dealing with persons with mental illness. After all, judges have to deal every day with the mentally ill being criminalized, which is a tragic side effect of the "deinstitutionalization" movement. Starting in the 1960s and continuing today, many state hospitals closed or cut back their beds and put the mentally ill on the streets.

Across most of America, society failed in it promise to provide adequate community mental health treatment to those discharged from mental hospitals. We failed them because funding for treatment was — and remains — abysmal. As a result, the untreated or undertreated often get arrested. This happens even in Rhode Island, which has a really good mental health system. Because the mental health system is broken, judges know that there are lots of people who would not be in jail had they received mental health treatment.

Juries, on the other hand, often don’t know about the devastating effects of mental illness unless they’ve experienced mental illness themselves, or with their family, friends or co-workers. They can be less sympathetic toward people with mental illness because they have inaccurate perceptions about the use of the defense, and they may not believe that mental illness is real.

Does the current political climate affect this process? Does the stigma of mental illness?

Yes and yes. The law is conservative in many ways, and a more conservative political climate — combined with some notorious psychiatric cases — have limited the use of the insanity defense. For instance, after John Hinckley shot President Reagan to impress Jodie Foster, Congress and many state legislators restricted the definition of insanity to make it even harder to use. A couple of states have eliminated the insanity plea or have replaced it with a "guilty but mentally ill" plea. These are, I think, nonsensical ways of allowing juries to avoid deciding responsibility. The particular shame of the "guilty but mentally ill" plea was its failed promise to provide better treatment for mentally ill offenders in jail.

Stigma is another big factor. Some people have the false notion that all mentally ill persons are dangerous just because they have a psychiatric diagnosis. As I said earlier, some people think mental illness doesn’t exist because you can’t detect it like you would a broken bone by X-ray or anemia by a blood test. These types of false impressions make it harder to look at a situation more objectively.

Should people with mental illness be treated any differently than anyone else charged with a crime?

Well as I mentioned, the law defines the circumstances under which people are to be held responsible, and juries, as society’s agents, decide the fate of a particular defendant in a particular case. Mental illness can explain a person’s behavior, but it rarely excuses it. The law will allow for mentally ill persons to be treated differently — typically by treating them in a state hospital instead of putting them in jail — only if they meet the criteria for insanity. In reality, juries have a tendency to convict instead of to acquit, perhaps for some of the reasons that I’ve already mentioned.

Because the laws are strict, and because juries are conservative, and especially because we have a created a public health tragedy by not providing adequate treatment for mental illness, we have unintentionally shifted the burden of treatment of many seriously mentally ill persons from the mental health system onto the criminal justice system. Since most mentally ill people won’t be found insane, they’ll be mentally ill and in jail — they’ll have two problems instead of just one. Treatment during incarceration is essential, but treatment conditions in jails vary widely across the country — some places have a long way to go to make treatment acceptable. Did you know that the two largest places where the mentally ill are housed aren’t mental hospitals, but jails? One is the L. A. County Jail, and the other is Riker’s Island Jail.

Are there better ways of handling the mentally ill who commit crimes?

Absolutely. The best way is to provide good psychiatric treatment in the community to stop criminalization from happening in the first place. Medications and psychotherapy and other forms of treatment can allow many people with serious mental illness to live and work in their own communities. For those whose have poor insight into their illness or who don’t take their medications as they should, providing court-ordered mental health treatment is helpful. Now, mental health court is a civil matter and is not part of criminal court, and it can be effective — but only when there are adequate treatment resources in the community to provide services, which goes back to funding. The big message here is the need for funding, because treatment for mental illness works and actually saves money.

Even if we were able to fund enough outpatient services, of course there would still be some people who would still end up in jail. Those mentally ill people need good correctional services, as well as hospitalization when appropriate. And when those people are released from jail, their return to outpatient treatment in the community should already have been coordinated between the correctional mental health staff and the outpatient treatment staff. Without support and treatment post-release, the criminalized mentally ill are at risk for re-arrest, and the revolving door keeps turning.

The bottom line is that people who have mental illness should be treated no matter where they end up in the system. We have overburdened the criminal justice system with too many mentally ill offenders because our politicians failed to fund society’s promise to provide community treatment. This is a national public health tragedy. It’s really sad.