What are the pros and cons of the insanity defense? I. The Defense of Insanity “It is a bad thing to knock on the door of a deaf-mute, an imbecile, or a minor. He who wounded them is accountable, but they are not culpable if they wound him.” (Babylonian Talmud, Mishna) What should we make of the insanity defense (NGRI- Not Guilty by Reason of Insanity) if mental illness is culture-dependent and largely functions as a structuring social principle?
If a person cannot tell right from wrong (“lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct” – diminished capacity), did not intend to act the way he did (absent “mens rea”), and/or could not control his behavior (“irresistible impulse”), he is not held responsible for his criminal actions. These disabilities are frequently associated with “mental sickness or defect” or “mental retardation.”
Mental health practitioners prefer to refer to a “deficiency in a person’s perspective or knowledge of reality.” They consider a conviction of “guilty but mentally sick” to be a contradiction in terms. All “mentally ill” people have a (usually logical) worldview, internal logic, and standards of right and wrong (ethics). However, these are rarely consistent with how most individuals experience the world. As a result, the mentally ill cannot be held responsible because they have a shaky grasp on reality. However, history has taught us that a criminal may be mentally ill even if he or she passes a faultless reality test and is thus deemed criminally accountable (Jeffrey Dahmer comes to mind).
In other words, “perception and knowledge of reality” can and do coexist with even the most severe types of mental disease. This makes understanding what is meant by “mental sickness” much more complex. If some mentally ill people keep a hold on reality, know what is right and wrong, can predict the repercussions of their actions, and are not subject to irresistible urges (the official position of the American Psychiatric Association), how do they differ from us, “normal” people? This is why the insanity defense frequently collides with socially “acceptable” and “normal” mental health illnesses, such as religion or love.
Consider the following situation: A mother bashes her three boys’ skulls. Two of them are killed. She claims to have followed God’s directions. She is found not guilty due to insanity. The jury concluded that she “did not know right from wrong throughout the murders.” But why was she declared insane? Her faith in the existence of God — a creature with excessive and inhuman characteristics – may be unreasonable. However, it is not insanity in the strictest sense because it adheres to social and cultural creeds and norms of behaviour in her environment.
Billions of people subscribe to the same concepts, follow the same transcendental laws, do the same mysterious rites, and claim to have had the same experiences. This shared psychosis is now so common that it can no longer be classified as pathological. She said that God had communicated with her. So do a lot of other folks. In religious groups, behavior that is considered psychotic (paranoid-schizophrenic) in other situations is revered and admired. Hearing voices and seeing visions, sometimes known as auditory and visual delusions, are regarded as rank manifestations of virtue and sanctity.
Maybe it was the nature of her hallucinations that drove her nuts. She said that God had told her to murder her sons. Surely, God would not allow such evil to occur? Unfortunately, both the Old and New Testaments offer illustrations of God’s thirst for human sacrifice. God commanded Abraham to sacrifice Isaac, his beloved son (though this savage command was rescinded at the last moment). Jesus, God’s own son, was crucified to atone for humanity’s sins. A divine command to kill one’s children would be consistent with the Holy Scriptures and the Apocrypha, as well as millennia-old Judeo-Christian traditions of martyrdom and sacrifice.
Her actions were immoral and violated both human and divine (or natural) rules. Yes, but they were entirely consistent with a literal interpretation of certain divinely inspired writings, millennial scriptures, apocalyptic thought systems, and fundamentalist religious ideologies (such as those advocating the imminence of the “rapture”). Her actions are not mad unless one declares their teachings and writings to be so. We must conclude that the murderous mother is completely rational. Her point of view differs from ours.
As a result, her definitions of good and wrong are unique. Killing her babies seemed like the correct thing to do, in accordance with respected teachings and her own epiphany. Her understanding of reality — the immediate and long-term implications of her actions – was never compromised. It appears that sane and insanity are relative concepts, reliant on cultural and societal frames of reference, and statistically determined. There isn’t – and, in theory, never will be – a “objective,” medical, scientific test that can definitively diagnose mental health or disease.
II. An Overview of the Concept of Mental Disease Someone is considered mentally “ill” if his behavior deviates rigidly and consistently from the typical, average behavior of all other people in his culture and society who fit his profile (whether this conventional behavior is moral or rational is irrelevant), or his judgment and grasp of objective, physical reality is impaired, and his behavior is not a matter of choice but is innate and irresistible. Aside from descriptive criteria, what is the essence of mental disorders?
Are they purely physiological or, more accurately, chemistry-related illnesses of the brain? If that’s the case, may they be treated by restoring the balance of substances and secretions in that enigmatic organ? Is the illness “gone” once homeostasis is restored, or is it still lying there, “under wraps,” waiting to erupt? Are psychiatric issues hereditary, anchored in poor genes (but exacerbated by external variables), or caused by abusive or inappropriate nurturing? These are the concerns of the “medical” school of mental health. Others adhere to a spiritual understanding of the human psyche. They think that mental illnesses are the result of a metaphysical breakdown of an undiscovered medium, the soul.
Theirs is a holistic approach that considers the patient as a whole, as well as his or her surroundings. Members of the functional school see mental health issues as deviations from the correct, statistically “normal” behaviors and symptoms of “healthy” people, or as dysfunctions. The “sick” individual who is unhappy with himself (ego-dystonic) or making others unhappy (deviant) is “mended” when his social and cultural frame of reference renders him functioning again. In some ways, the three schools are like to the three blind men who provide varied descriptions of the same elephant.
Nonetheless, they share not only their subject matter but, to a surprising extent, a flawed technique. As noted by famed anti-psychiatrist Thomas Szasz of the State University of New York in his article “The Lying Truths of Psychiatry,” mental health academics, independent of academic bias, deduce the genesis of mental diseases from the success or failure of treatment approaches. This type of “reverse engineering” of scientific models is not uncommon in other domains of science, and it is not considered objectionable if the investigations fit the scientific method’s criteria.
The theory must be all-encompassing (anamnetic), consistent, falsifiable, logically compatible, monovalent, and sparse. Psychological “theories,” even “medical” ones (such as the involvement of serotonin and dopamine in mood disorders), are typically none of these things. As a result, there is a bewildering assortment of ever-shifting mental health “diagnoses” that are specifically focused on Western culture and its ideals (example: the ethical objection to suicide). Neurosis, a historically important “condition,” disappeared after 1980. Prior to 1973, homosexuality was considered a disease by the American Psychiatric Association.
Almost seven decades after Freud originally characterized it, narcissism was deemed a “personality disorder” seven years later. Personality Disorders III Personality disorders, in fact, are a perfect example of the multicolored terrain of “objective” psychiatry. The classification of Axis II personality disorders [deeply ingrained, maladaptive, lifelong behavior patterns] in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] or the DSM-IV-TR for short has been subjected to sustained and serious criticism since its inception in 1952, in the first edition of the DSM.
Personality disorders, according to the DSM IV-TR, are “qualitatively unique clinical syndromes” (p. 689). This is frequently questioned. Even the line between “normal” and “disordered” personalities is being questioned. The so-called “diagnostic thresholds” between normal and abnormal are either nonexistent or only poorly supported. The polythetic structure of the DSM’s Diagnostic Criteria causes unacceptable diagnostic heterogeneity because just a portion of the criteria is sufficient grounds for a diagnosis. In other words, people with the same personality condition may have only one or none of the criteria.
The DSM fails to explain the precise link between Axis II and Axis I disorders, as well as how persistent childhood and developmental issues interact with personality disorders. The differential diagnosis are hazy, and the personality disorders are not well defined. As a result, there is a high level of co-morbidity (multiple Axis II diagnoses). There is minimal discussion in the DSM about what differentiates normal character (personality), personality traits, or personality style (Millon) from personality disorders. There is a scarcity of documented clinical experience with both the illnesses itself and the efficacy of various treatment approaches.
Numerous personality disorders are classified as “not otherwise specified,” which is a catch-all, basket “category.” Certain illnesses show signs of cultural prejudice (such as the Antisocial and the Schizotypal). The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR: “An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normalcy and into one another” (p.689) The following topics, which have long been overlooked in the DSM, are expected to be addressed in future editions as well as current research.
However, their absence from official discourse is equally surprising and telling: the longitudinal history of the disorder(s) and their temporal stability from early life onwards; Personality disorder(s) genetic and biological basis; The emergence of personality disorders in adolescence and its development during childhood; Interactions between physical health and sickness, as well as psychological disorders; The efficacy of various treatments, including talk therapy and psychopharmacology.
IV. Mental Health Biochemistry and Genetics Certain mental health problems are either associated with statistically aberrant biochemical activity in the brain or are treated with medication. However, the two facts are not inextricably linked to the same underlying phenomena. In other words, just though a certain medicine decreases or eliminates certain symptoms does not always imply that they were produced by the processes or chemicals affected by the drug. Causation is just one of many conceivable linkages and events sequences. Designating a behavior pattern as a mental health disorder is a value judgment, or at most a statistical observation.
This label is made regardless of brain science facts. Furthermore, correlation does not imply causality. Deviant brain or body biochemistry (formerly referred to as “polluted animal spirits”) does exist, but are these the true origins of mental perversion? It is also unclear which causes which: does abnormal neurochemistry or biochemistry produce mental disease, or the other way around? It is undeniable that psychoactive medications impact behavior and emotions. Drugs, both illegal and legal, some meals, and all interpersonal interactions fall into this category. It is arguable whether the modifications brought about by prescription are beneficial, and this entails tautological thinking.
If a given pattern of behavior is regarded as (socially) “dysfunctional” or (psychologically) “sick,” then any change would be hailed as “healing,” and any agent of transformation would be referred to as a “cure.” The same might be said of mental illness’s claimed ancestry. Single genes or gene complexes are regularly “linked” to mental health illnesses, personality traits, or behavioral patterns. However, there is insufficient information to create unassailable sequences of causes and effects.
Even less is known about the relationship of nature and nurture, genotype and phenotype, brain plasticity, and the psychological consequences of trauma, abuse, upbringing, role models, peers, and other environmental factors. Moreover, the line between psychotropic medications and talk therapy is not that apparent. Words and interactions with therapists have an effect on the brain, its processes, and chemistry, albeit more slowly and potentially more profoundly and irreversibly. As David Kaiser points out in “Against Biologic Psychiatry” (Psychiatric Times, Volume XIII, Issue 12, December 1996), medications treat symptoms rather than the fundamental processes that cause them.
V. The Variability of Mental Illness If mental disorders are physiological and empirical, they should be invariant across cultures and societies, both temporally and spatially. To a certain extent, this is correct. Although psychological disorders are not context dependent, the pathologizing of specific behaviors is. Suicide, substance addiction, narcissism, eating disorders, antisocial behavior, schizotypal symptoms, depression, and even psychosis are all deemed sick in certain cultures and completely normal or advantageous in others. This was unsurprising. Around the planet, the human mind and its dysfunctions are similar. However, values change with time and from location to place.
As a result, conflicts over the appropriateness and usefulness of human actions and inactivity are unavoidable in a symptom-based diagnostic system. As long as pseudo-medical definitions of mental health problems rely solely on signs and symptoms, i.e., primarily on observed or reported behaviors, they will be susceptible to such conflict and lacking of much-desired universality and rigor. VI. Mental Illness and Social Order The mentally ill are treated in the same way that those infected with AIDS, SARS, the Ebola virus, or smallpox are.
They are occasionally forced to be isolated against their choice and subjected to involuntary treatment with medicine, psychosurgery, or electroconvulsive therapy. This is done for the greater good, primarily as a preventive measure. Regardless of conspiracy beliefs, it is impossible to overlook the vast interests invested in psychiatry and psychopharmacology. Multibillion-dollar businesses involving drug corporations, hospitals, managed healthcare, private clinics, academic departments, and law enforcement organizations rely on the spread of the concept of “mental illness” and its corollaries: treatment and study, for their continuous and exponential growth.
VII. Mental Illness as a Valuable Metaphor All disciplines of human knowledge are built around abstract concepts. Nobody has ever seen a quark, unraveled a chemical bond, ridden an electromagnetic wave, or visited the unconscious. These are valuable metaphors, theoretical concepts that can explain or describe anything. “Mental health disorders” are no exception. They are abbreviations for the unsettling quiddity of “the Other.” They are useful as taxonomies, but they are also tools of social compulsion and conformity, as seen by Michel Foucault and Louis Althusser.
Relegating both the dangerous and the quirky to the communal outskirts is an important social engineering approach. The goal is to achieve progress through social cohesiveness and the control of innovation and creative destruction. As a result, psychiatry reifies society’s choice for development over revolution, or, worse, mayhem. It is a noble purpose, pursued unscrupulously and dogmatically, as is often the case with human endeavor.