An insane system: how our judicial and public health systems are failing the mentally ill.

Ever since 1760, when London's Dr. John Monro testified as to the temporary insanity of a man accused of killing his servant, medical experts have argued whether "lunatic killers" should be held responsible for their actions. Dr. Barbara Kirwin, a New York psychologist specializing in issues of crime and sanity, has written an entertaining contemporary account of this genre. She utilizes material from over 300 cases in which she examined the accused (including individuals like Joel Rifkin, who murdered 17 Long Island prostitutes) as well as public records from the trials of John Hinkley, Erik and Lyle Menendez, Susan Smith, Colin Ferguson, John Salvi, and virtually every other high-profile case from the last 20 years.

Dr. Kirwin is at her best in describing the attempts by some defendants to fake insanity and the attempts by some defense lawyers to concoct a "designer defense" (Kirwin's apt term) to get their client off on an insanity plea. She has testified for the prosecution in all except two of her cases and has little sympathy for the his-deprived-childhood-made-him-do-it argument. She includes a solid chapter on the mechanics of examining and testing individuals to determine sanity and is clearly a competent forensic psychologist.

But although entertaining, the book is flawed by poor organization (individual cases are partially described, disappear, then reappear in later chapters), intermittent factual errors, and fuzzy logic when it comes time for solutions. For example, the author says that tardive dyskinesia, a side effect of some antipsychotic medications, "is irreversible and usually progressive," when in fact it is reversible in the majority of cases when the medication is stopped and is only rarely progressive. Mirroring the mantra of politically correct (and almost always politically liberal) mental health professionals, Dr. Kirwin blames "the policy of deinstitutionalization in the Reagan years" for the homeless mentally ill and the sad state of contemporary public mental illness services. In fact, deinstitutionalization moved into full stride under President Kennedy and continued under Presidents Johnson, Nixon, Ford, Carter, and Reagan. Politically it has been an equal opportunity disaster.

Dr. Kirwin's solutions are reasonable as far as they go, but they only reach first base. She provides compelling arguments for keeping television cameras out of the courtroom in cases involving insanity and raises the fundamental question of whether the adversarial system is even appropriate for such trials. She would also abolish juries in these trials and leave the decisions up to judges alone. I question the wisdom of this, as I believe that the public in general, and juries in particular, often have more common sense on these issues than judges, most of whom have trained as lawyers.

More fundamentally, Dr. Kirwin decries New York's failed public mental illness system and its relationship to the problems she describes, but offers no solutions. She criticizes New York Governor George Pataki's recent cuts in the state's mental health services budget, but fails to note that in 1993 (the most recent figures available) New York state spent $131 per capita in this area -- three times as much as the median for all other states and $45 more per capita than Alaska, the next-highest spender. Clearly, money alone is not the answer. Nor does Kirwin address the fact that some of the psychiatrists and psychologists working in forensic psychiatric units in state hospitals are among the most inept members of their professions. The sickest and most difficult to treat patients have, in essence, been turned over to some of the least competent practitioners. Why not require all psychiatrists and psychologists trained with public funds to work for two years in public facilities (as Dr. Kirwin did) as a payback for their publicly financed training.

Finally, Dr. Kirwin denounces the increasingly frequent sentencing of mentally ill offenders to prisons rather than to psychiatric hospitals, but does not connect this to the overall failure of the public mental illness system. Judges and juries sentence such individuals to the penal system precisely because the mental illness system is failing. From the point of view of judge and jury, at least a prison sentence ensures a minimum period of incarceration, however inappropriate the venue. This point was driven home to me when I testified in defense of an extremely psychotic individual who had killed a man. I urged the jury to sentence the man to the state psychiatric system rather than to prison despite the fact that the psychiatric system had failed to properly treat the man on several admissions and had discharged him without ensuring that he would take the medication he needed. As I made the appeal to the jury, I could see an overriding but unspoken question in their eyes: "Doctor, just who is crazy here?" The jury sentenced the man to life in prison.