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What Should A Psychiatrist Do In A Classic Insanity Case?

The voice at the other end of the line was angry and accusatory: “You didn’t even talk to me! You never knew my son! You didn’t talk to any of us!”

I explained to her that since she had never even met the defendant, there was no way she could have any information that would be relevant to the accused’s state of mind at the time of the crime. The victim and the defendant were total strangers and there was no apparent reason for the killing, which made the crime even more tragic. Her son was dead in a random incident, in a crime that was unquestionably motivated only by the defendant’s untreated psychiatric symptoms.

The defendant’s family was equally shocked and horrified. They were all hardworking solid citizens, with no history of criminal contacts, substance abuse or mental illness. When their daughter started getting sick they knew something was wrong but didn’t know what to do. They were all legal immigrants but because they were working at various temporary manual labor jobs they had no benefits and no insurance. They were still working to pay off the hospital bill from their daughter’s childbirth, and they were worried about leaving their infant grandchild in her care while they worked. Their culture strongly discouraged discussion of emotional problems, and mental illness was considered a spiritual rather than a medical disorder. When their daughter started talking about spirits talking to her from the TV, they consulted a lay counsellor from their spiritual community rather than a doctor. She got worse, and started staying in her room laughing and talking back to the television. She stopped eating her usual foods, and said that she could only eat fruits because this was how God would turn her into a superhero. She lost thirty pounds and looked horrible. She stopped bathing or taking her antihypertensive medicine. In her eyes, the killing was a test to see if she had the strength to become one of God’s warriors in order to save the world. She came across the victim, a ten year old boy, standing at a bus stop. Multiple witnesses were horrified to see the child stabbed to death in front of their eyes. When the police arrived she was still at the scene, holding the knife. At the police station the detective tried to interview her but was stymied by her illogical statements. She repeatedly made the sign of the cross over the detective’s head and tried to bless him.

This is a confabulated story, but it’s a typical scenario for a classic insanity case. We’ve talked a lot recently about involuntary treatment, civil rights issues and the anger people feel about being admitted to a hospital or given medications against their will. What we haven’t heard about yet is the anger associated with a bad outcome—anger at losing a loved one to murder, anger at not being able to get the treatment you need for someone you love, anger at the unfairness of a society in which treatment can only be afforded to those with the education and financial means to obtain it.

This is where I come in. I have treated people involuntarily and testified at civil commitment hearings and requested emergency evaluations on people who needed care. Am I a thug? What alternatives would the psychiatrist in this scenario have, had the defendant been brought in for care against her will before the crime? If she was too disorganized to clean or feed herself, would she be safe to care for a newborn infant? What about her own medical needs? What would you say to the mother of the murdered child? And what should the psychiatrist in the forensic hospital do, knowing that the patient has just killed someone? Would involuntary medication be appropriate in this case? If not, what would you do?

I’m offering this story for discussion, please keep things civil.

*This blog post was originally published at Shrink Rap*

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