Book Review

Management and Treatment of Insanity Acquittees: A Model for the 1990s

N Engl J Med 1994; 330:1765-1766June 16, 1994

Article

Management and Treatment of Insanity Acquittees: A Model for the 1990s
(Progress in Psychiatry. No. 41.) By Joseph D. Bloom and Mary H. Williams. 230 pp. Washington, D.C., American Psychiatric Press, 1994. $31. ISBN: 0-88048-501-9

Bloom and Williams offer as a national model Oregon's method of handling insanity acquittees: defendants found “guilty except for insanity” are placed under the jurisdiction of a state Psychiatric Security Review Board (PSRB) -- made up of five part-time professionals meeting weekly -- that oversees their treatment in the state hospital's forensic wards and community mental health clinics. The PSRB can retain responsibility for acquittees throughout the maximal sentence for their crimes -- their “insanity sentence” -- during which it can transfer them, with appropriate hearings on their clinical condition, from hospital to community care or vice versa, or discharge them altogether. Placing full authority over acquittees with one official group, established solely for that purpose, has substantial advantages over the usual approach of splitting responsibility between the criminal-justice and mental health systems, but it can also shield notorious criminals found not guilty by reason of insanity from campaigns by the public to prevent their release.

Another useful innovation in Oregon is PSRB-authorized hospital discharge with continuing supervised care in community clinics. Those who received supervised care in a clinic were much less likely to require rehospitalization or to commit additional crimes than those who spent all their PSRB time in a hospital: 18 percent versus 86 percent required involuntary rehospitalization, and 34 percent versus 63 percent had additional contacts with the criminal-justice system. The authors are therefore probably correct that “the development of a conditional release program should be a requirement for all state forensic programs charged with the responsibility of caring for insanity acquittees.”

In Oregon, insanity acquittees have detailed treatment plans created for them immediately after hospital admission. “By focusing release decisions on current symptom expression of mental illness rather than on past criminal justice history, the system has functioned in a manner appropriate to its obligations to insanity acquittees and to society.” When released to the care of a community clinic, they see a case manager three times a month, with a monthly medication visit to the psychiatrist and home visit by the case manager.

Oregon has 4 times as many insanity acquittees per capita as does the United States as a whole (Washington, D.C., has 27 times as many). It had 30 hospitalized acquittees in 1974, 120 in 1978 when the PSRB began functioning, and 300 in 1989. These acquittees were long and deeply involved, before their acquittals as well as after, with both the mental-hospital and criminal-justice systems. Sixty-one percent were previously involved with both systems, 32 percent with one or the other, and only 7 percent with neither. After their release, 65 percent were involved with mental hospitals, 50 percent with the criminal-justice system, and only 4 percent with neither. The authors' statement about the criminalization of mental patients suggests that current treatment methods sometimes harm as much as they help. The dependent life fostered by psychotropic drugs is hard to escape.

The PSRB serves as a psychiatric parole board, but its clients are less likely to return to normal functioning than those of criminal parole boards. Acquittees are hampered by long-term use of medications and by being forbidden to drive automobiles. Although community placement before discharge reduces subsequent antisocial behavior, most have apparently required outpatient mental health services indefinitely, one third returned to criminal activity, and one sixth required involuntary rehospitalization. Even under the PSRB system, acquittees can serve as building blocks in mental health and criminal-justice empires.

Statistical analyses of data on insanity acquittees, like those in this book, ignore sensational stories and political criminals like John Hinckley, Jr., who successfully plead insanity after well-planned felonies. Such “psychiatric hunting licenses” were described in 1949 in Frederic Wertham's A Show of Violence (Garden City, N.Y.: Doubleday), unmentioned in this book. Should release depend only “on current symptom expression of mental illness rather than on past criminal justice history,” as Bloom and Williams state -- a view criticized by Wertham? Or should insight also be required -- full understanding, shared with caretakers, of the thought processes of the acquittee at the time of the crime in order to reduce the likelihood of his or her repeating it and to guarantee criminal responsibility if another crime is committed? On Long Island, Peter Burkin, found “not guilty by reason of insanity” after deliberately burning Bill Baird's Hempstead abortion center to the ground in 1979, was released from the hospital in less than two years without any inquiry into his appearance in an antiabortion picket line two months earlier.

Bloom and Williams mention the increasingly harmful experiences with the mental health and criminal-justice systems that create so many acquittals on grounds of insanity but say nothing about the need to understand the thought processes of acquittees like Hinckley and Burkin before releasing them. They do, however, present most persuasively their case for a valuable new way of handling acquittees administratively.

Nathaniel S. Lehrman, M.D.
Roslyn, NY 11576