Gray Areas in Forensic Psychiatry Miller M. Ryans, MD Petersburg, Virginia
The field of forensic psychiatry is not always compatible with legalities in our court system, causing some cases to be in a "gray" area. A case is presented, demonstrating shortcomings of the M'Naghten rule, which is meant to protect the mentally ill person from being incarcerated when he is not aware of the nature or the seriousness of the crime of which he stands accused. However, this rule is not applicable when there is awareness, even if the patient is laboring under a delusional system. In the case to be considered, the individual suffers by being given a criminal record instead of being found not guilty by reason of insanity, although the end result is the same. The author feels there should be a much broader interpretation of the M'Naghten rule to encompass the full intent of protecting the mentally ill person but to exclude the sociopath and those with character disorders. The Durham rule is not workable because of this inclusion. The following case is presented as an example of a gray area in forensic psychiatry because of the difficulty for the courts of delineating adequately the concept of competency in relation to the M'Naghten rule. This rule states that to establish a defense on the grounds of insanity, it must be clearly proved that at the time of committing the act, the accused was laboring under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know what he was doing was wrong.' The patient was a 27-year-old widowed black female who was admitted to the Forensic Unit for psychiatric evaluation charged with maiming, by seriously stabbing, her boyfriend. She explained she felt the victim was, "controlling my mind with a spell making me feel like a robot."2 She believed that
Dr. Ryans is Chief of Service of the Forensic Unit of Central State Hospital in Petersburg, Virginia, and Clinic Psychiatrist at the East End Mental Health Clinic in Richmond, Virginia. Requests for reprints should be addressed to Dr. Miller M. Ryans, P.O. Box 4030, Petersburg, VA 23803.
the spell had started approximately three years ago and that since then her boyfriend had been able to make her do "bad things." She declined to go into the nature of these things. She claimed she stabbed him in an attempt to make him stop influencing her mind and body. She had a history of two previous hospitalizations for mental disorders in another state, when her conditions were diagnosed as acute schizophrenic episode and depression. After signing out against medical advice the first time, she was given electric convulsive therapy and antipsychotic medication during the second hospitalization. Further, she had a history of suicide attempts by overdosing, and of auditory hallucinations in the form of voices telling her to "do things". After the stabbing, she was treated with thiothixene 5 mg q AM and 15 mg hs until stabilized. She was remanded to the courts as competent and was found guilty. She was returned to the Forensic Unit and maintained on thiothixene 5 mg hs while a presentence report was prepared. Although she no longer had florid symptoms of the belief that a "spell" had been cast on her, she still was not completely disabused of this idea. A total of seven months was consumed
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 8, 1978
from the day of arrest until the date of sentencing. At that time it was decided by the courts that, since the patient had been under psychiatric treatment continuously both in the Forensic Unit and jail, she was further stabilized and should be placed on supervised probation with her family in another state. It was stipulated, in addition, that, as part of her probation, she must remain on her medication and make regular mental health clinic visits. This patient considered herself morally justified in maiming the individual she believed was practicing evil on her.3 Unfortunately for the patient, the M'Naghten rule did not apply because she was aware of what she was doing even though her reason for committing the act was based on spurious grounds. This is clearly an example of an individual who, by history and recent behavior, is a candidate for psychiatric treatment. Although the end resultthat is, adequate treatment for the patient-was achieved, it would have served her interests much better if she had been declared not guilty by reason of insanity, treated, and restored to sanity with the same stipulation as the courts finally decreed. In that manner she would not have had to bear the onus of having a criminal record. It is my opinion that the M'Naghten rule should be given a liberal enough interpretation to encompass cases like the one under discussion, but not so liberal that it would allow sociopaths or people with character disorders to take advantage of the situation. The Durham rule4 which includes these disorders and states an accused is not criminally responsible for his unlawful act if this act was the product of a mental disease or defect, has now been largely abandoned because of this deficiency. Literature Cited 1. Siomopoulos V: The fallacy of legal insanity. Current Concepts in Psychiatry. Nov/Dec, 1977 2. Golden KM: Voodoo in Africa and the United States. Am J Psychiat 134(12):1425-
1427, 1977 3. Foulks E: The Italian evil eye: Mal occhio. J Operational Psychiat 8(2):28-29, 1977 4. Becker LE Jr: Durham revisited. Psychiat Ann 3(8):17-19, 1973 581
The field of forensic psychiatry is not always compatible with legalities in our court system, causing some cases to be in a "gray" area. A case is presented, demonstrating shortcomings of the M'Naghten rule, which is meant to protect the mentally ill person from being incarcerated when he is not aware of the nature or the seriousness of the crime of which he stands accused. However, this rule is not applicable when there is awareness, even if the patient is laboring under a delusional system. In the case to be considered, the individual suffers by being given a criminal record instead of being found not guilty by reason of insanity, although the end result is the same. The author feels there should be a much broader interpretation of the M'Naghten rule to encompass the full intent of protecting the mentally ill person but to exclude the sociopath and those with character disorders. The Durham rule is not workable because of this inclusion. The following case is presented as an example of a gray area in forensic psychiatry because of the difficulty for the courts of delineating adequately the concept of competency in relation to the M'Naghten rule. This rule states that to establish a defense on the grounds of insanity, it must be clearly proved that at the time of committing the act, the accused was laboring under such a defect of reason from disease of the mind as not to know the nature and quality of the act he was doing, or if he did know it, that he did not know what he was doing was wrong.' The patient was a 27-year-old widowed black female who was admitted to the Forensic Unit for psychiatric evaluation charged with maiming, by seriously stabbing, her boyfriend. She explained she felt the victim was, "controlling my mind with a spell making me feel like a robot."2 She believed that
Dr. Ryans is Chief of Service of the Forensic Unit of Central State Hospital in Petersburg, Virginia, and Clinic Psychiatrist at the East End Mental Health Clinic in Richmond, Virginia. Requests for reprints should be addressed to Dr. Miller M. Ryans, P.O. Box 4030, Petersburg, VA 23803.
the spell had started approximately three years ago and that since then her boyfriend had been able to make her do "bad things." She declined to go into the nature of these things. She claimed she stabbed him in an attempt to make him stop influencing her mind and body. She had a history of two previous hospitalizations for mental disorders in another state, when her conditions were diagnosed as acute schizophrenic episode and depression. After signing out against medical advice the first time, she was given electric convulsive therapy and antipsychotic medication during the second hospitalization. Further, she had a history of suicide attempts by overdosing, and of auditory hallucinations in the form of voices telling her to "do things". After the stabbing, she was treated with thiothixene 5 mg q AM and 15 mg hs until stabilized. She was remanded to the courts as competent and was found guilty. She was returned to the Forensic Unit and maintained on thiothixene 5 mg hs while a presentence report was prepared. Although she no longer had florid symptoms of the belief that a "spell" had been cast on her, she still was not completely disabused of this idea. A total of seven months was consumed
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 8, 1978
from the day of arrest until the date of sentencing. At that time it was decided by the courts that, since the patient had been under psychiatric treatment continuously both in the Forensic Unit and jail, she was further stabilized and should be placed on supervised probation with her family in another state. It was stipulated, in addition, that, as part of her probation, she must remain on her medication and make regular mental health clinic visits. This patient considered herself morally justified in maiming the individual she believed was practicing evil on her.3 Unfortunately for the patient, the M'Naghten rule did not apply because she was aware of what she was doing even though her reason for committing the act was based on spurious grounds. This is clearly an example of an individual who, by history and recent behavior, is a candidate for psychiatric treatment. Although the end resultthat is, adequate treatment for the patient-was achieved, it would have served her interests much better if she had been declared not guilty by reason of insanity, treated, and restored to sanity with the same stipulation as the courts finally decreed. In that manner she would not have had to bear the onus of having a criminal record. It is my opinion that the M'Naghten rule should be given a liberal enough interpretation to encompass cases like the one under discussion, but not so liberal that it would allow sociopaths or people with character disorders to take advantage of the situation. The Durham rule4 which includes these disorders and states an accused is not criminally responsible for his unlawful act if this act was the product of a mental disease or defect, has now been largely abandoned because of this deficiency. Literature Cited 1. Siomopoulos V: The fallacy of legal insanity. Current Concepts in Psychiatry. Nov/Dec, 1977 2. Golden KM: Voodoo in Africa and the United States. Am J Psychiat 134(12):1425-
1427, 1977 3. Foulks E: The Italian evil eye: Mal occhio. J Operational Psychiat 8(2):28-29, 1977 4. Becker LE Jr: Durham revisited. Psychiat Ann 3(8):17-19, 1973 581
