Who Qualifies for the Insanity Defense?

Overlapping Universe: Understanding Legal Insanity and Psychosis

Zachary D. Torry • Stephen B. Billick

Published online: 6 April 2010 Springer Science+Business Media, LLC 2010

Abstract The Insanity Defense of Not Guilty by Reason of Insanity is the defense used by some mentally disordered defendants who do not have the capacity for understanding right and wrong at the time of their criminal act. This defense has perplexed legal and mental health professionals for centuries. Though it has been a part of the legal system since the early Greeks, it has been and continues to be amended, modified, and in some jurisdictions, abolished. Moreover, despite its infrequent use, many in our society hold onto the belief that defendants can evade criminal responsibility by means of this defense. Furthermore, insanity is often equated with psychosis; however, the two are not the same and have different connotations. It is essential for any clinical psychiatrist to understand the concept of the insanity defense and how it differs from psychosis. This paper will clarify the meaning and purpose of the insanity defense and will differentiate insanity and psychosis.

Keywords Insanity defense NGRI Criminal action Mens rea

Introduction

The insanity defense has been a controversial and elusive component of the legal and psychiatric professions for centuries. It has long tantalized defendants and mystified jurors. Furthermore, the concept that certain people may not be held responsible for their actions by reason of their mental state generates feelings of anger and disparity among some individuals. The insanity defense is viewed by some as a ‘‘loophole’’ for defendants and a

Z. D. Torry Saint Vincent’s Hospital, Manhattan, NY 10024, USA

Z. D. Torry (&) 140 West 79th Street, #4B, New York, NY 10024, USA e-mail: [email protected]

S. B. Billick New York Medical College, New York, NY, USA

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scheme that clever attorneys and mental health professionals exploit to acquit their criminal clients and permit dangerous people to roam freely in society. Therefore, at times this defense directs accusatory attention to the field of clinical and forensic psychiatry. The psychiatrist might be viewed as creating excuses for the defendants’ otherwise criminal behavior. Finally, it has been sometimes argued that the insanity defense is inconsistent with the deterrent and punishment purposes of criminal law. The reality is that the insanity defense is used in only 1% of criminal cases, and it is used successfully in only 10–25% of those [1]. Moreover, defendants who are found insane generally spend as much or more time in state custody than their criminally convicted counterparts [2]. Forensic psychiatrists are not the only psychiatrists who need to understand the insanity defense. Patients seen in ongoing clinical psychiatric treatment may commit crimes, and the psychiatrist should have some appreciation for understanding criminal responsibility. It is imperative for any treating clinical psychiatrist to be versed in the applicable state and federal laws on insanity because any treating clinical psychiatrist may be called to testify on the mental status of their patient who has been charged with committing a crime. Furthermore, a clinical psychiatrist might be an unwitting victim in the hands of an attorney who is trained in extracting certain kinds of information from mental health professionals. This will result in the clinical psychiatrist reporting deposition or trial testimony that may be clinically accurate but not legally pertinent. Moreover, a common misconception is to assume that if a patient is psychotic, then that patient will qualify for insanity. It is significant to note the distinction between these two terms as well as their implications. In a legal proceeding, a psychiatrist may be requested to testify as either a ‘‘fact witness’’ or an ‘‘expert witness’’ depending on the circumstance. Therefore, it is helpful to understand the difference between the two roles. A fact witness simply testifies about direct observations. A common example would be a treating psychiatrist who is asked to testify about his or her patient’s symptoms and course of treatment. In this situation, the psychiatrist is not ordinarily asked to give opinions. An expert witness has ‘‘special knowledge’’ that the average person may not possess, and it is the role of an expert witness to educate the court on matters beyond which a layperson might know. The psychiatric expert witness may testify in the form of an opinion about facts directly related to the profession of psychiatry [3]. This role is commonly attributed to a forensic psychiatrist. This paper will serve as a literature review and discussion in the hopes of clearing some of the cloudiness behind the definition, practice, and purpose of the insanity defense. It will also clarify the distinction between insanity and psychosis.

Definition and Purpose

One reason for the controversies surrounding the insanity defense is the different language used in the fields of criminal law and mental health. Each field has varying ways of expressing similar ideas but using different sets of terminology. The temptation is to group these different sets of terms under one definition. However, as will be seen in this paper, there are very different meanings. In order to have a better grasp of the insanity defense, one-first must understand the legal definitions of criminal conduct and insanity. Then, perhaps the purpose of the insanity defense can be better clarified.

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A criminal act must have two components: evil intent (mens rea, literally ‘‘guilt mind’’) and action (actus reus, literally ‘‘guilty act’’). The intent requires purposely or knowingly committing the act that is proposed to cause harm. In addition, there cannot be legal evil intent when an offender’s mental state is so diseased, deficient, or abnormal as to have deprived the offender of rational intent. The act itself must be voluntary and conscious. Neither the act, however heinous, nor the intent to do harm, is by itself, a criminal action. Both elements must be proved beyond a reasonable doubt. For example, a prudent reasonable driver might hit an icy patch on the road, causing the car to kill an innocent bystander. This might not be a criminal action as there was no criminal intent. Likewise, a spouse who catches his or her partner in an extramarital affair might become so enraged as to have intent to harm the spouse in retribution. However, merely the intent to harm without actually doing it might not be a criminal action. Insanity is a legal term rather than a psychiatric or scientific one. Black’s Law Dictionary [4] defines it as ‘‘any mental disorder severe enough that it prevents a person from having legal capacity and excuses the person from criminal or civil responsibility. Insanity is a legal, not a medical, standard.’’ It is a disorder that impairs the human mind and prevents distinguishing between actions that are right or wrong. Mental illnesses are disorders of the brain that disrupt a person’s thinking, feeling, moods, and ability to relate to others. They are brain disorders resulting in a diminished capacity for coping with the demands of life (National Alliance for the Mentally Ill)[ 5]. The purpose of the insanity defense is based on two medicolegal forces [6]. The first is the moral imperative; this is the reluctance to hold responsible those who, because of their developmental, psychological, or neurological condition, lack the capability necessary to understand their own actions. In Durham v. United States [7], Judge David Bazelon wrote, ‘‘Our collective conscience does not allow punishment where it cannot impose blame.’’ It is therefore inappropriate to punish unless the person has the capacity to ‘‘make autonomous choices over their behavior’’ [8]. Just as it is morally inappropriate to condemn a child for behavior she or he is not old enough to understand, persons who are ‘‘insane’’ cannot have the intent necessary to perform a criminal act. These persons either do not know that the act is wrong or cannot control their actions even when they understand that the act is wrong. This is the corresponding item to one aspect of the definition of legal evil intent stating that the individual must have rational intent in order for there to be legal evil intent. The second component of the purpose of the insanity defense is the concept of fairness––that is, to not hold those with a ‘‘mental disease or defect’’ (defect is a legal reference to mental retardation or a structural brain problem) to the same standards of a responsible and functional person without a mental illness.

Developmental Competency (To do Wrong)

The age at which our society accords the autonomy in making decisions and in accepting the responsibility for those decisions is also a relevant topic. During earlier times, adult status was usually accorded with the achievement of pubertal maturation [9]. This is at age 13 years for Jewish teenagers at their Bar/Bat Mitzvah. It is also at age 13 years for Christians when they receive confirmation to ‘‘confirm as an ‘adult’’’ their desire to join the church, which their godparents had made for them when younger. Puberty was the biologic marker that coincided with the transition from childhood to adulthood [9]. Piaget [10] also found that age 12–13 years was the time of cognitive achievement of concrete operational

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thinking (concrete logic). Since most people do not actually achieve formal operational thinking (abstract logic), age 12–13 years would be the standard expected for an adult. This can also be seen in current research on the developmental changes of the human brain during this transition period. Using fMRI studies in teens, the amygdala, an area involved in instinctual and emotional reactions, was activated in identifying emotional expressions and decision-making. As the subjects got older, the activation area shifted to the frontal lobe [11]. The frontal lobe regulates behavior and is involved in decisions regarding right and wrong as well as cause and effect. Executive functioning in the frontal lobe helps to distinguish humans from other animals. Therefore, the age at which our society grants decision-making capacity and moral reasoning has roots in biology as well as religion. Society has changed the age of responsibility over time. In the 19th century, it was closer to age 12–14 years, and after 1899, with the first juvenile justice court established, it became 18–21 years of age. In the late 20th century, there was some return to younger ages being held responsible. It is now the state which establishes capacity for mens rea and thus responsibility for criminal actions.

History and Development of the Insanity Defense

A brief review of the history of the insanity defense might facilitate a better understanding of it. The insanity defense has been well established in the law for centuries. Nonetheless, it has been ratified, amended, and altered many times over and still sometimes brings consternation to the public. The insanity defense has been recognized since the time of Aristotle [12], but it was initially only a way for a defendant to receive a pardon or a way to mitigate a sentence. The first recorded case of outright acquittal by reason of insanity occurred in 1505 [13]. The written law dates back to 1581 when a legal treatise distinguished between those who understood the difference between good and evil and those who did not. William Lambarde stated the first insanity test, ‘‘If a madman or a natural fool (congenitally retarded), or a lunatic in the time of his lunacy (episode of disorder), or a child that apparently hath no knowledge of good nor evil do kill a man, this is no felonious act… for they cannot be said to have any understanding will.’’ In the 1724 English case of Rex v. Arnold [14], Arnold, a known madman killed a nobleman, Lord Onslow, in the delusion that the victim had ‘‘bewitched him.’’ Using this case, the British courts further developed the idea of the insanity defense. Judge Tracy wrote that if a defendant was ‘‘totally deprived of his understanding and memory and doth not know what he is doing, no more than an infant, than a brute, or a wild beast,’’ he would not be held responsible for his crime. This idea became known as the ‘‘wild beast’’ test, and it based the standard on the level of understanding of the act of the defendant.

The M’Naghten Test

Further evaluation of this standard and modification came in 1843 during the case of Daniel M’Naghten [15]. Mr. M’Naghten was a Scottish woodcutter who assassinated Edward Drummond, the secretary to the Prime Minister, Sir Robert Peel. He believed that he was being persecuted by the Prime Minister’s political party and was being spied on. He said, ‘‘(they) have compelled me to do this. They follow, persecute me wherever I go,…’’. He believed that the Prime Minister was responsible for a myriad of personal and financial misfortunes that had befallen him. During his trials, various witnesses testified to his ‘‘odd

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behavior’’ and complaints of persecution in the years prior to the murder. The defense also called medical experts to testify that M’Naghten’s delusions had deprived him of ‘‘all restraint over his actions’’. The jury acquitted him and found him ‘‘not guilty by reason of insanity.’’ The verdict concerned many, and among them was Queen Victoria, who requested that the House of Lords review this with a panel of judges. The House of Lords put five questions before the Court of Common Pleas and asked the judges to give an advisory opinion on the law governing these cases. What emerged became the basis of the standard law governing criminal responsibility in cases of insanity. This stated that ‘‘to establish a defense on the grounds of insanity, it must be clearly proved that, at the time of committing the act, the accused was operating under such a defect of reason, from a disease of the mind, as to not know the nature and quality of the act he was doing, or if he did know it, that he did not know what he was doing was wrong.’’ Furthermore, it must be proved that the accused, at the time of committing the act, did not know the difference between right and wrong. Therefore, this forces the jury to get inside of the mind of the accused and to determine whether the accused is able to understand not only if the accused comprehends his action to be against the law but also if the accused was able to govern his behavior according to the law. Chief Justice Tindal noted in the case of M’Naghten, that if the defendant is acting under the influence of an insane delusion, he is punishable if he knew at the time of committing the crime that he was acting contrary to law. However, if he believed that he was acting in self-defense based on his delusion, he would be excused. This also rejected the moral standard, that is, the accused believed that he was morally justified in his behavior, even though he might have known that his acts were against the law. For example, if a person murders an abortion doctor because he views the doctor’s behavior as morally wrong, the law would not excuse the murderer just because he believed that he was morally justified. This was adopted by most jurisdictions in the United States and Great Britain and became the standard test for insanity. It continues to be the standard for insanity in half of the states today.

‘‘Irresistible Impulse’’

In the late 1880s, there came an alternative to the cognitive only M’Naghten rule in the form of adding a volitional component, the ‘‘Irresistible Impulse’’ Test. This still required that the M’Naghten questions be asked, but it also suggested that an ‘‘insane’’ or ‘‘irresistible’’ impulse could remove reason, and therefore, the ability to know or to choose between right and wrong. This is also referred to as the ‘‘policeman-at-the-elbow law’’ which means that an impulse is irresistible only when it can be determined that the accused would have committed the act even if a policeman had been at the accused’s elbow. This did not gain wide acceptance, as mental health professionals are unable to determine whether a crime was committed because the defendant did not or could not exercise self-control.

Durham and the Product Test

During the 1950s, there was a growing dissatisfaction with the M’Naghten rule’s being too rigid, perhaps as a result of the growth of medicine and psychiatry. In particular, the ‘‘mind’’ and ‘‘body’’ connection, with the development of the biological aspects of psychiatry, was a popular notion. It was felt that there was not enough medical evidence brought into the insanity defense. Therefore, in 1954, when the United States Court of

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Appeals for the District of Columbia heard the case of Durham v. United States [7], the appellate judge seized this opportunity to discard the M’Naghten rule and the ‘‘irresistible impulse’’ test and apply a broad and more medically based standard to develop a new rule. He stated that ‘‘an accued is not criminally responsible if his unlawful act was the product of mental disease or defect.’’ This was not met with much popularity for the primary reason that it cast a very broad net that could include substance abusers and compulsive gamblers, among others. This was based on the interpretation that mental disease actually causes behavior, and this alone is too controversial to be applied to the defense.

A.L.I. and the Model Penal Code

In 1962, the American Law Institute, a non-governmental organization of lawyers, judges, and academics, set out a proposed statute for use as a model for legislation around the country in an effort to standardize penal law. A key feature is its use of standardized mens rea terms to determine levels of mental states. The model insanity defense statute softened the M’Naghten standard and was based on the District of Columbia’s decision in the federal appellate case, United States v. Brawner, and adopted in 1972. The formulation [Sect. 4.0, 1] of the Model Code states the insanity defense as ‘‘A person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or mental defect, he lacks substantial capacity either to appreciate the criminality [wrongfulness] of his conduct or to conform his conduct to the requirements of the law.’’ The formulation contains elements of all three prior standards––the concept of right and wrong from the M’Naghten standard; the condition of lack of control from the ‘‘Irresistible Impulse’’; and the diagnosis of mental disease of defect from the Durham Rule. There also is a cognitive aspect that addresses the defendant’s capacity to ‘‘appreciate the criminality of his conduct.’’ Additionally, there is a volitional aspect that addresses the defendant’s capacity to ‘‘conform’’ to the ‘‘requirements of the law.’’ The Model Penal Code allowed for the introduction of medical and psychiatric evidence by requiring that the mental disease or defect be a medical diagnosis. All of the previous formulations of the insanity defense require that the defendant be suffering from ‘‘mental disease or defect’’; however, this was not defined until 1962 in the District of Columbia during McDonald v. United States [16]. The definition that emerged was ‘‘any abnormal condition of the mind which substantially affects mental or emotional processes and substantially impairs behavior controls.’’ This was reaffirmed in United States v. Brawner, so the A.L.I. standard also excludes defendants whose mental illness or defect only manifests itself in criminal or antisocial conduct. The model penal code gained wide popularity and as of 1982, the states were roughly split between the two standards: 22 states used some form of the A.L.I. rule, and 26 states used a version of the M’Naghten rule.

The Hinckley Trial and its Aftermath

In 1981, John Hinckley Jr. shot then-United States President Ronald Reagan, a secret service agent, a Washington police officer, and Reagan’s press secretary in an attempt to gain the attention of and impress Jodie Foster, a well known actress. Mr. Hinckley was obsessed with Ms. Foster and, in a letter to the New York Times, described the shootings as ‘‘the greatest love offering in the history of the world…’’ In 1982, a District of Columbia jury acquitted Mr. Hinckley and found him Not Guilty by Reason of Insanity. This caused

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an immediate public outcry. The outrage against the insanity plea provoked immediate calls for the abolishment, or at least a revision, of the insanity plea. In this trial, more than any other up to that time, the psychiatrists and the law that allowed their testimony were made the culprits for this verdict. The American Bar Association and the American Psychiatric Association issued statements calling for a change in the law. Congress responded to this by introducing legislation designed to abolish or modify the insanity defense. The results were that the federal courts shifted from the A.L.I standard to a stricter version for the insanity defense in federal crimes. This became The Insanity Defense Reform Act of 1984 and was the first federal legislation governing the insanity defense and the disposition of individuals suffering from a mental illness involved in the criminal justice system. This version stated that the ‘‘defendant, as a result of a severe mental disease or defect, was unable to appreciate the nature and quality of the wrongfulness of his acts.’’ This eliminated the Irresistible Impulse test (the volitional element) and more closely resembled the M’Naghten rule. It also stated that the defendant must show that his mental disease or defect is ‘‘severe.’’

Burden of Proof

Furthermore, Congress enacted some provisions that toughened the barriers to the insanity defense. One of these is the Burden of Proof, specifically, on whom the burden of proof should be placed. This is the legal obligation of one side––prosecution or defense––to convince the judge or jury (decision maker) to some specified degree of certainty that their depiction is true. In this defense, it will determine which side will lose if the jury finds itself unable to determine (with whatever degree of certainty the law may specify) whether the defendant was or was not legally insane [8]. Before Hinckley, the burden of proof in federal cases was on the prosecution to prove beyond a reasonable doubt that a defendant was sane. In the aftermath of the Hinckley trial, the position has shifted. Of the states that continue to allow the insanity defense, two-thirds of which assert that the defendant bears the burden of convincing the jury that she or he was insane by a preponderance of evidence (lowest level of proof). Similarly, under federal law, the defendant bears the burden but by a more demanding standard, clear and convincing evidence (stricter requirement). The state bears the burden of proof on mens rea.

State Responses

In the wake of the Hinckley case, many states made changes to their insanity defense statutes. Four states (Kansas, Idaho, Montana, and Utah) dropped the insanity defense altogether; although two of those four (Montana and Utah) have the alternate ‘‘Guilty but Mentally Ill’’ (see below). Most others adopted various standards, such as a stricter version of the insanity defense or shifted the burden of proof, in ways to make it more difficult to sustain an insanity plea. In addition, some states enacted laws providing for more restrictive confinement options for those acquitted by reason of insanity.

Guilty but Mentally Ill

In addition to abolishing the insanity defense and adopting stricter standards to apply or prove the defense, about one-fourth of the states have established a separate verdict of ‘‘Guilty but Mentally Ill’’ (GBMI). This is used as an alternative (not instead of) the

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insanity defense. The consequence of receiving GBMI is that the individual is convicted and given a criminal sentence. It is a verdict available to the jury when the conclusion is that the defendant committed the act charged but suffers from a mental disorder, however, not at the level necessary to meet the insanity defense.

Psychosis

Psychosis is a scientific term. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [17] defines it as ‘‘Delusions and prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathologic nature.’’ In the Comprehensive Textbook of Psychiatry [18], Benjamin Saddock, M.D. defines psychosis as a ‘‘mental disorder in which the thoughts, affective response, ability to recognize reality, and ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality; the classical characteristics of psychosis are impaired reality testing, hallucinations, delusions, and illusions.’’ The cause is a variety of psychiatric and medical problems. There is no mention in this definition of psychosis of preventing a person from distinguishing between actions that are right or wrong. Therefore, for the clinical psychiatrist, it should be made clear that psychosis does not equal insanity. It is very possible for a defendant to be psychotic but not considered insane. It is equally possible, though less likely, for a defendant to be found insane but not meet the qualifications for psychosis. In most cases of Not Guilty by Reason of Insanity, the defendant is in an active state of psychosis at the time of the crime. This is to say that crimes committed by those found to be psychotic are not excused on the basis of the psychotic diagnosis. In fact, the diagnosis is not as important as ‘‘how it affected (a person’s) ability to do certain things at the time of the allegedly criminal act’’ [19]. Furthermore, agreement on whether or not a defendant has psychosis rarely approaches a level as high as 90% even when the clinicians come from the same background [20]. It is imperative to understand the difference between psychosis and insanity and to be able to apply this difference. Consider the case of a defendant who is having persecutory delusions and paranoid ideation and kills his psychiatrist for having him hospitalized. The defendant might have known at the time of the act that it was wrong but still committed the act. In 1998, Andrew Goldstein was a defendant with a known psychiatric history and who claimed to be having auditory hallucinations at the time of the crime. Nonetheless, a jury found him guilty of second-degree murder for pushing Kendra Webdale in front of an oncoming Manhattan subway train. Similarly, in the controversial 2006 Supreme Court Case of Clark v. Arizona [21], the defendant suffered from Schizophrenia, Paranoid Type and was actively psychotic at the time of the crime. Nevertheless, he was convicted of firstdegree murder of a police officer. Additionally, there are cases such as the Dan White murder trial of San Francisco Mayor George Moscone and Supervisor Harvey Milk. In this case, the defendant was convicted of manslaughter rather than murder on the basis of his symptoms of severe depression (not psychosis).

Conclusion

Although one of the most controversial and elusive components of the legal and psychiatric professions, the Insanity Defense, nevertheless, has great significance. Summarized briefly,

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a criminal act consists of the illegal act itself and the intention to commit the illegal act. The insanity defense is some variation of: A defendant must be found not guilty by reason of insanity if, at the time of the alleged offense, and as a result of severe mental disease or defect, he did not know what he was doing or that what he was doing was wrong. As simple as this might sound, a cursory look into it’s history reveals a glimpse of the inherent complexities. Nevertheless, despite the confusion and the infrequent use, its application must be clearly understood by any treating mental health professional. Moreover, the temptation to understand insanity as psychosis is present but completely unfounded. The two terms are not only different but also are the products of the use of different languages in the fields of law and psychiatry. This contributes to the confusion and can result in the misrepresentation of information in criminal proceedings, which clearly, will have significant consequences. The clinical psychiatrist who finds himself or herself with a patient charged with a crime needs to be quite careful to understand how the patient’s mental illness may have or may have not contributed to the commission of the crime. It might be prudent to get a consultation from a forensic psychiatrist to help the clinician clarify the important issues and determinants.

References

1. Callahan LA, Steadman HJ, McGreevy MA, Robbins PC: The volume and characteristics of insanity defense pleas: an eight-state study. Bulletin of the American Academy of Psychiatry and Law 19(4):331–338, 1991 2. Rodriguez J, Lewinn L, Perlin M: The insanity defense under siege: legislative assaults and legal rejonders. Rutgers Law Journal 14:397–430, 1983 3. Resnick PJ, Knoll J IV: Being an effective psychiatric expert witness. Psychiatric Times 24(6), 2007 4. Garner BA: Black’s Law Dictionary, 8th edn. Thomson West, 2004 5. National Alliance of the Mentally Illness (NAMI) 6. Saddock BJ, Saddock VA: Kaplan and Saddock’s Synopsis of Psychiatry, 9th edn. Philadelphia, 2003 7. Durham v United States: 214 F.2d 862, D.C. Cir. 1954 8. Bonnie R, Jeffreis JC Jr, Low P: A Case in the Insanity Defense: The Trial of John W. Hinckley Jr, 3rd edn. New York, Thomson/Foundation Press, 2008 9. Billick SB: Developmental competency. Bulletin of the American Academy of Psychiatry and Law 14(4):301–309, 1986 10. Inhelder B, Piaget J: The Growth of Logical Thinking. New York, Basic, 1958 11. Baird AA, Gruber SA, Fein DA, et al.: Functional magnetic resonance imaging of facial affect recognition in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38(2):195–199, 1999 12. Irwin T (translator): Nichomachean Ethics, Book III, 2nd edn. Indianapolis, Hackett Publishing Company, Inc., 1999 13. Robitscher J, Haynes AK: In defense of the insanity defense. Emory Law Journal 31:9–60, 1982 14. Rex v. Arnold: 16 How. St. Tr. 695, 1724 15. M’Naghten’s Case: 8 Eng. Rep. 718, 1843 16. McDonald v. United States: 312 F.2d 847, 851 1962 17. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text revision. Washington, DC, 2000 18. Saddock, BJ: Signs and Symptoms in Psychiatry. In: Saddock BJ, Saddock VA, Ruiz P (Eds) Kaplan and Saddock’s Comprehensive Textbook of Psychiatry, 9th edn., Vol. 1. Philadelphia, Williams & Wilkins, 2009 19. Reid WH: The insanity defense: bad or mad or both? Journal of Psychiatric Practice 69–172, 2000 20. Field SJ: Book review: conducting insanity evaluations. American Journal of Criminal Justice 111–114, 1986 21. Clark v. Arizona: 548 U.S. 735, 2006

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Author Biographies

Zachary D. Torry M.D. is currently a Chief Resident in the Department of Psychiatry at Saint Vincent’s Hospital, Manhattan, New York. He will be a fellow in Forensic Psychiatry at The University of Pennsylvania School of Medicine in 2010–2011.

Stephen B. Billick M.D. is Clinical Professor of Psychiatry at New York Medical College and Associate Chair for Faculty Development in the Department of Psychiatry at Saint Vincent’s Catholic Medical Center/ New York Medical College. He is President of The American Academy of Psychiatry and the Law as well as a practicing Forensic and Child and Adolescent Psychiatrist in New York City.

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