What effects will the verdict from the murder case against Andrea Yates have on the public's view of the insanity defense?
In certain respects, what happened after Andrea Yates killed her five children last June was no different from what happens in any other murder case. Once her husband left for work, according to her confession taped by police, she methodically drowned her four sons and one daughter, ranging in age from 6 months to 7 years, by placing them one-by-one into the filled bathtub in her home in a Houston suburb. Those acts were followed by the predictable tragic aftermath of sorrow, pain, confusion and bewilderment, and then by the legal system stepping in to bring justice and, finally, retribution.
What it did not do, like every other similar mass murder that came before it, was resolve the seemingly age-old conundrum of criminal responsibility for acts committed while insane. Once again, media pundits raised troubling questions: Was the insanity defense implemented either too harshly or too leniently? Was mental illness treated too aggressively with myriad medications of limited value, or too haphazardly with a startling lack of collaboration among physicians?
The Yates murder case also raised gender issues. Feminist groups rallied around Andrea and her misunderstood postpartum depression, while men's rights groups railed against critics of her husband, Rusty, who was accused of a lackadaisical response to his wife's illness.
Although not in time for the Yates case, these issues may be resolved soon. The American Academy of Psychiatry and the Law (AAPL) is scheduled to release its practice guidelines this summer, a first-ever effort to bring some consistency to forensic evaluations of mentally ill individuals accused of crimes. Two years in the making, the Practice Guidelines for Forensic Psychiatric Evaluation of Defendants Raising the Insanity Defense will catalogue accepted methods for handling such cases, Howard V. Zonana, M.D., told Psychiatric Times. Zonana is AAPL's medical director and professor of psychiatry at Yale University School of Medicine.
"People have argued for hundreds of years about what the appropriate test for insanity is, and there's always a great deal of distress there," Zonana said. "There are a lot of myths about the insanity defense, [such as] how frequently it's used."
That passage of time, even though it has seen major advances in the understanding and treatment of mental illness, still has not resulted in forensic psychiatrists knowing any more about what makes people respond to the symptoms of their disease in certain ways.
"There are a lot of people who hear command hallucinations, but not everybody listens to the commands," Zonana told PT. "You can't just say because someone has command hallucinations that they had to follow those commands. But we don't have any test to know which people do, can or can't follow those things. We are still left to sort of dealing with a certain degree of approximations in those answers." He continued, "Most schizophrenics stop at red lights. Just the fact that you have a disorder doesn't get you over the hump."
Variation in the insanity defense among the 50 states and the federal court reflects the breadth of public attitudes about mental illness and the degree to which it should exonerate criminal behavior, Zonana said. On one end of the spectrum, some jurisdictions allow consideration of volitional aspects of brain diseases. They consider whether mentally ill individuals not only appreciated the difference between right and wrong but also whether they were able to conform their conduct to the requirements of law. Others have, in effect, abolished the insanity defense.
The practice guidelines, Zonana said, will at least help assure some consistency in the way that forensic experts handle cases when criminal defendants assert the insanity defense. At the same time, Zonana said that he hoped the guidelines would also help still some of the misperceptions -- at times advanced by the media -- that arise during high profile cases.
"I think psychiatry takes a beating in the press all the time. All you need is one bad testimony and that's what people remember and think about psychiatry," Zonana said. "Even though the statistics show that most people who get insanity defenses are really very ill and psychotic, [the public] tends to focus on people getting away with something. So I hope [the practice guidelines] will upgrade more the quality of evaluations and testimony and give some sense that these are hard issues but that there are reasonable ways to do these evaluations."
The Yates case had its moment of what the defense will claim on appeal was "bad" testimony. During the trial, for example, Park Dietz, M.D., a forensic psychiatrist from Newport Beach, Calif., who is nationally recognized for his participation in many high profile cases, testified that Yates' conduct bore a resemblance to an episode of the television show Law and Order. In that episode, a woman who killed her children was exonerated by the insanity defense. The prosecution used Dietz's testimony to subsequently argue that Yates followed the model created by the show.
The trouble was that no such episode ever aired, a fact disclosed only after the jury rendered its guilty verdict. No one has accused Dietz, who has acted as a consultant during the show's production, of lying to jurors, and the trial judge refused to declare a mistrial, but an appeal based on the error is likely.
"I would give him the benefit of the doubt and see it as an honest error," said Phillip J. Resnick, M.D., professor of psychiatry at Case Western Reserve University School of Medicine in Cleveland and a past president of AAPL who testified as a defense expert in the Yates case. Resnick further told PT, "I certainly don't see it as malicious. I think it was just a simple error. It turns out since it was used in closing argument it may be problematic with respect to an appeal."
Resnick said that he read Dietz's "103-page, single-spaced report" and didn't recall seeing any reference to the Law and Order episode, adding that he would have asked Yates about it had he known. Dietz was unavailable for comment.
Resnick told PT that in two discussions with psychiatric professional audiences regarding the verdict of the Yates case, sentiments ran three-to-one in favor of Mrs. Yates, with attendees tending to be "disturbed by the outcome." Nevertheless, it is doubtful that this opinion will result in any changes to the standards used in the insanity defense. "The general public is a bit more mixed, with some people feeling that a mother who killed her children is the ultimate betrayal, but psychiatric audiences tend to be sympathetic to her," Resnick said.
Ultimately, legislators who must consider any reforms are swayed more by the political implications than the medical ones, Resnick said. Legislators perceive their chances of election are greater if they present a tough stand on law and order, and efforts to broaden the insanity defense are most often viewed as soft on crime.
"When a high profile insanity defense is successfulthere tends to be a backlash against the insanity defense and a political demand to either narrow or abolish the defense," Resnick told PT. "When a high profile insanity case like Yates' is unsuccessful there will be a few voices saying that the insanity defense is too narrow, but rarely will it be of sufficient political clout to make a difference."
With two nationally recognized forensic psychiatrists pitted against one another in the Yates case, it was not surprising that questions would again arise as to whether the expert testimony is really something jurors listen to anyway. Legal commentators and others have criticized the prosecutor from Harris County, Texas, who brought Yates to trial, claiming his decision to seek the death penalty was merely a ruse to seat a more conservative jury who would more likely convict rather than exonerate based on an insanity plea.
"It's not really a battle of the experts," said prosecutor Joseph S. Owmby, during a post-trial press conference. "The question of sanity is a question of common senseand the experts are there to help them frame, help present the evidence from the medical side. The jurors can't say that this is a severe mental disease or defect, but lay people can tell you whether they believe a person knew right from wrong at the time."
But it's not that simple, said Saul J. Faerstein, M.D., clinical professor of psychiatry at University of California, Los Angeles, School of Medicine and forensic expert who has consulted in high profile cases, including working for the defense in the O.J. Simpson case. He told PT that he is not convinced that any reform in the procedures by which insanity defenses are governed will ever actually bring any consistency to these emotionally laden cases.
"What's interesting is that the two experts involved [in the Yates case] are two very well-respected, highly credentialed, effective witnesses. I mean Phillip Resnick and Park Dietz are the cream of the crop, so you're not dealing with people who don't know what they're talking about," Faerstein said. "One would have to raise the question, if two people are so smart, and know the history of the insanity defense and know the standards of the insanity defense so well, how could they interpret it in polar opposite ways if they're both using the same data, the same facts, the same reasoning, the same history and the same legal basis for interpreting what the insanity defense was? How could one say black and the other one say white? That's a very troubling concept for me."
The problem with psychiatric defense is who should try them, Faerstein continued. Everyone -- including judges, lawyers, juries and even psychiatrists -- brings their own biases to the process, and nothing will eliminate them. Reflecting on the Yates case, he added, "I don't think that it's ever possible to have totally objective trier of fact on a case of that nature. People will listen to the facts and listen to the law, but their own prejudices will be superimposed on that substrate, and they'll decide whether a person is sane or insane based on their attitudes toward this woman, their attitudes toward fundamental Christianity, their attitudes toward Rusty Yates and how he treated his wife, their attitudes about lots of things that have nothing to do with what [Texas's insanity defense] test says."
Larry H. Strasburger, M.D., assistant clinical professor of psychiatry at Harvard Medical School and AAPL's president, agreed that cases like Yates' do not make understanding the issue easier.
"My sense is that in some ways we've gone backward with verdicts like this," he said in an interview with PT. In addition, he is not convinced that the public is interested in any "improvements" in the statutes, citing an opposite trend that results in the enactment of more restrictive standards, such as guilty but mentally ill or eradication of the insanity defense altogether.
For George Parnham, the Houston lawyer who defended Yates, Texas' insanity defense yielded a harsh result for his client that failed to reflect the reality of her illness. He also criticized the lack of integration among health care providers who failed to provide the level of care that may have averted the tragedy. But even he concedes that, ultimately, jurors decide cases such as these in a way that sometimes ignores the expert testimony.
"What compelled the jury was the pictures of those children in those pajamas," Parnham said in an interview with PT. "We can talk all day long about mental health, medications, delusions and psychosis, but by golly when you take a picture of a 7-year-old boy who is lying face down in the tub, rigor mortis has set in, and you flip him over and you see the agony on his poor face, that's a toughie."