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Opinion:
Andrea Yates and the Reality of Psychosis
More than 20 years ago, during my psychiatry training, I did a tour through a state hospital in the northeastern corner of Massachusetts. This gothic institution, situated on what was reputed to be one of the Salem witch-burning hills, housed a plump, graying, soft-spoken woman who, some years earlier, had killed her son.
She described what she had done as a mercy-killing. He was damaged, she said, poisoned; she needed to end his suffering. Years after the act, her psychiatric illness remained relatively unmodified by the treatments available at the time. But she did not appear distressed. She was convinced she had done right. Having been found, in a Massachusetts courtroom, not guilty by reason of insanity, she was living out her life in a state-run psychiatric hospital, unlikely ever to be released.
Andrea Yates, controlled by a similarly deluded definition of mercy when she killed her 5 children, has received a more Biblical brand of justice from the Texas legal system. She will live out her life in a penal institution instead of a hospital. Her celebrity may help her receive more than the average amount of psychiatric care accorded the typical prison inmate.
A community's laws and its system of justice are a reflection of its moral standards. In the case of Andrea Yates, it is also a sad example of the wider community's failure to appreciate the nature of mental illness.
You have heard that Andrea Yates was psychotic. The legal system's struggle to understand how psychosis affects human will and behavior is seen in the multifarious ways it has defined the relationship between mental functioning and moral responsibility for criminal actions. One early notion was that a person should not be held morally responsible if he "doth not know what he is doing, no more than ... a wild beast." This "wild beast test" connotes the least accurate view of mental illness - that a person should become so disorganized, so primitive that he ceases to be human.
The problem, of course, is that psychosis is quite human and not all that rare. One in a hundred people has schizophrenia, an illness defined by the presence of psychotic symptoms, at least some of the time. An equal number have major disorders of mood. These two large groups account for tens of millions of people worldwide. Other psychiatric, neurological, and medical illnesses can cause psychosis, too.
Psychosis is a poorly understood concept. In psychosis, there is a fundamental disruption in a person's ability to recognize reality. Like any symptom, a psychotic symptom can be mild or severe. The flaw can be in one's thinking (for example, delusions, which are false beliefs, like believing that people can read your thoughts) or perceptions (for example, hallucinations, such as hearing voices). People who suffer psychotic symptoms almost never appear less than human. They do, however, appear less than themselves. They can and sometimes do lose control of their capacity to make prudent decisions or be in control of their actions.
Since the 19th century, courts have grappled with psychosis. When Daniel M'Naghten killed a secretary to the English Prime Minister Sir Robert Peel in 1843, he did so because he thought the government was plotting against him. He was acquitted by reason of insanity because the English court concluded that a finding of guilt depended upon his knowing "the nature and quality of the act ... or if he did know it, that he did not know he was doing what was wrong." In time, other courts subscribed to the idea that a mental illness can induce impulses that are impossible to resist.
Many states have modeled their insanity statutes after a test authored by the American Law Institute a half century ago: this standard asks courts to determine if a person "lacks substantial capacity to appreciate the wrongfulness of his conduct or to conform his conduct to the requirements of the law." The word "appreciate" implies that sometimes "knowing right from wrong" is a subtle and complicated business.
As a person devoted to religion by personal conviction and delusionally obsessed with religious ideas, Andrea Yates certainly understood the literal meaning of the words, "Thou shalt not kill." The power of her psychotic thoughts was such that she probably did not appreciate the wrongfulness of her conduct. Her illness also probably interfered with her ability to conform her conduct to the requirements of the law.
But Texas law is specifically contrived to ask juries not to understand the nature of a defendant's illness and its effect on the person's self-control. It only asks, does the defendant understand what the words mean? To know, by definition, that killing is wrong or illegal does not take into account the impact of one's perception of reality -"death by my hand is a better than life with the devil." Since the intellectual functioning of most psychotic people is not impaired, virtually all will be found criminally responsible under Texas law.
Fortunately, psychotic killings are rare events. In contrast, the tragedy of psychotic illness is very, very common.
The failure to recognize the reality of psychosis limits access to care. Family members in a position to help often don't recognize the presence of disease. Some professionals, health administrators, insurance companies and legislators minimize its impact. Throughout society, not just during murder trials, psychosis (and mental illness in general) is more likely to be seen as a moral problem rather than a medical one.
If psychosis is human, society's ignorance of psychosis, by its prevalence, must also be human. The horrible story of Andrea Yates could have no happy ending. The post-trial interest in her story, if it leads to more education about psychosis, may be salutary. We can only hope that some day - just as we no longer burn witches in Massachusetts - attitudes toward psychiatric disorders will become more levelheaded and informed. And that medical treatment and moral judgments will be based on reality rather than superstition.
--Michael Craig Miller, MD, editor-in-chief of The Harvard Mental Health Letter.