Abstract
Forensic evaluators often assess patients who lack insight into their mental illnesses. This lack of insight can have a significant impact on the defendant's ability to make legal strategy decisions that rely on their acceptance of their mental illness. In this article, the relationship between refusing an insanity plea and competency to stand trial will be explored in the context of defendants who lack insight into their mental illness. The authors argue that an adequate competency assessment should take into account the defendant's ability to consider his available pleas rationally. Such evaluations may have the effect of negating the necessity of a Frendak inquiry in those jurisdictions that can impose the insanity defense on defendants.
Theodore Kaczynski, known as the Unabomber, was indicted on capital murder charges for sending homemade bombs through the mail.1 Even before his indictment, his Manifesto raised conjecture about his mental state. Although opinions varied as to his diagnosis, several evaluators concluded that he had a mental illness. His lawyers planned to introduce his mental illness as a defense. However, he resisted his lawyers' plan because he did not want to be labeled mentally ill. Because of this conflict with his attorneys, he wrote a letter to the judge requesting that he represent himself to avoid a mental illness defense. A psychiatrist personally examined him and opined that he had paranoid schizophrenia.2 The defense counsel and the government stipulated that he was competent to stand trial. He continued to tell the judge and his lawyers that he did not want to be labeled mentally ill. In the end, the prosecution offered a life sentence without parole, and he accepted the plea bargain.
We use this well-known case as a backdrop for a discussion of the challenges involved in evaluating competency to stand trial among defendants who lack insight into their mental illness and its effects on their judgment. While we offer no opinion as to Mr. Kaczynski's diagnosis or his ability to assist counsel, we recognize that he did not believe that he was mentally ill and that he did not want to use a mental illness defense in his trial in chief or during death penalty mitigation. It is not an uncommon scenario for forensic evaluators to assess individuals who are seen as having genuine psychiatric diagnoses, yet the defendants fail to believe they have mental illness. A defendant's lack of insight could bear significantly on his trial decision-making, including rejection of mental-state defenses or transfer to mental health court. These individuals may, because of mental illness, be unable to have a rational appreciation of the appropriateness of legal strategies that rely on mental illness determinations. The Kaczynski case, in fact, has been cited in the literature as reflecting one of the cases that highlights the legal confusion over how a court should proceed in relation to “the right of delusional defendants to forego an insanity defense and to represent themselves” (Ref. 3, p 138).
In this article, we explore some of the challenges involved in evaluating competency to stand trial when the defendant lacks insight into his mental illness. We discuss in detail whether a defendant can be competent to stand trial if he, as a result of mental illness, will not consider a plea of insanity in jurisdictions in which this plea is available. We argue that evaluating a defendant's insight into his mental illness is an important aspect of a competency evaluation. When the question of insight has strategic legal consequences, such as when a client should reasonably consider a mental-state defense, the forensic evaluator must consider whether the defendant's mental illness precludes the defendant's ability to provide rational assistance in formulating his legal strategy.
Competency to Stand Trial Standard
Courts in the United States have long recognized a requirement that criminal defendants be competent to stand trial because there are important policy considerations against trying an incompetent defendant. Requiring competence is a protective measure for criminal defendants against wrongful conviction, and it affords defendants some protection in making autonomous decisions. In general, competent defendants are able to assist their counsels in discussing the relevant facts and trial decisions. From a societal standpoint, competency standards protect the accuracy and reliability of the court proceeding. These standards serve a function in preserving the dignity of the court process. To try an incompetent person who could not rationally participate in the adversarial process would negate the balanced adversarial process on which our court system relies. Competency ensures the fairness of the adversarial process.
The common law standard for competency to stand trial required that the defendant understand the proceeding against him and be able to assist in his defense. In 1960, the United States Supreme Court established what is taken to be the minimal standard for trial competence. In Dusky v. United States,4 the Court held that the test for competency to stand trial was “whether [the defendant] had sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding—and whether he [had] a rational as well as factual understanding of the proceedings against him” (Ref. 4, p 402).
After Dusky, state courts adopted the two-prong standard, but states varied in adopting the explicit-rationality component. The American Academy of Psychiatry and the Law (AAPL) Practice Guideline on Forensic Psychiatric Evaluation of Competence to Stand Trial5 includes a table showing each state's competency standard. The table indicates that (as of 2002) eight states had adopted the precise language articulated in Dusky. The extent to which other jurisdictions implicitly require rationality in their standards is not clear. The current federal standard, articulated in the Insanity Defense Reform Act (IDRA) of 1984, does not explicitly mention rationality.6
The topic of rationality is significant because it bears directly on the ability of a defendant to assist legal counsel. The topic is relevant to this article because rational decision-making becomes paramount when assessing a defendant who lacks insight into his mental illness and who faces decisions that bear on the fact that he is mentally ill. This concept of rationality, encompassed in the concept of decisional competence, has been described by Bonnie.7 He proposed that a distinction exists between competence to assist counsel and decisional competence. He described competence to assist counsel as the minimum condition required for a defendant to participate in his own defense, including basic knowledge of the court proceeding and ability to relay important factual information. Decisional competence, according to Bonnie, involves the ability of a defendant to make decisions about defense strategies. He argued that decisional capacity should be contextualized to the specific situation and decisions required by the particular defendant.
Outside of the legal arena, the capacity for persons with severe mental illness to demonstrate decisional competence has been raised in other contexts, such as making adequate treatment decisions8,9 and decisions about research participation.10 In this article, however, we consider only the implications of poor insight and, to some extent, rationality, in persons with severe mental illness, as related to competency to stand trial.
Waiving the Insanity Defense
Certain criminal defendants refuse to consider the insanity defense. One reason for such refusal is the defendant's belief that he is not mentally ill. States vary, however, on the scope of the court's authority to impose the insanity defense on a criminal defendant. As of 2002, at least 17 jurisdictions permitted an insanity defense to be entered over the objections of the defendant.11 According to a study by Miller and his colleagues,12 these jurisdictions included Arkansas, Arizona, Colorado, Delaware, the District of Columbia, Hawaii, Illinois, Maine, Missouri, Mississippi, Montana, Nebraska, New Jersey, Pennsylvania, Vermont, Washington, and Wyoming.
The leading cases on this question have come from the District of Columbia. In Frendak v. United States,13 the trial court imposed the insanity defense on Ms. Frendak over her objection. She appealed the court's ruling in light of North Carolina v. Alford14 (holding that it is constitutional for the court to accept a guilty plea despite the defendant's disavowal of guilt) and Faretta v. California15 (ruling that it is constitutional for a defendant to represent himself). On appeal, the D. C. Court of Appeals emphasized the significance of the defendant's autonomy in making trial decisions. The court held that “the trial judge may not force an insanity defense on a defendant found competent to stand trial if the individual intelligently and voluntarily decides to forego the defense” (Ref. 13, p 366, emphasis in the original). The Frendak standard, then, requires a two-part inquiry: competency to proceed and competency to waive a plea. This approach has been adopted in many federal jurisdictions. Under the standard, a court may impose the insanity defense on a defendant only when the defendant cannot waive his insanity defense intelligently and knowingly.13
Various state courts have articulated less elaborate scrutiny for imposing the insanity defense over the objections of the defendant. For example, Colorado, having ruled on the issue several times in the past, again addressed it in Hendricks v. People.16 In Hendricks, the trial court concluded that Ms. Hendricks was competent and declined to enter an insanity defense over the defendant's objection. The Colorado Supreme Court, however, reversed. Interpreting the state's statute on plea waiver, the court held that a trial court must balance the public's interest in not convicting a defendant who is not criminally responsible against a defendant's autonomy in making court decisions. In making its determination, the court should consider the viability of the proposed mental-state defense and the reasons that the defendant is refusing the defense. The Colorado Supreme Court remanded to the trial court because significant questions remained as to Ms. Hendricks' sanity and the rationality of her reasons for refusing the insanity plea.
Discussion
As forensic evaluators, it is not uncommon for us to evaluate defendants who refuse to consider an insanity plea or other mental state defense. One possible reason for a defendant's refusal of the insanity plea is that he lacks insight into his mental illness. Some defendants may know that they have a mental illness, but have no insight into its impact on their judgment, even when their psychotic symptoms are in remission. Traditionally, poor insight has been listed as a symptom in only one of several systems for diagnosing schizophrenia.17 However, a recent review suggests that lack of insight into one's mental illness is very common among individuals with schizophrenia and may include a complete disbelief that they have a disorder.18 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)19 considers lack of insight to be a symptom associated with schizophrenia.
A defendant with schizophrenia or other serious mental illness, perhaps in remission from his psychotic symptoms, nevertheless may not believe that he has a mental illness. Such a defendant may have actually committed the offense in question and may have been psychotic at the time. The psychosis may have had a direct bearing on the unlawful behavior. Although these circumstances do not guarantee that the insanity defense would be successful, as the defendant may or may not have known (or appreciated) the wrongfulness of his actions, the insanity defense clearly is one option that the defendant should be capable of rationally considering. The question then becomes whether the defendant who lacks the ability to consider the insanity defense rationally is competent to stand trial.
Resnick20 wrote in 1979 that a mentally ill defendant's refusal to consider an insanity plea casts doubt on his ability to appraise his available defenses. He presented a case of a man who perceived himself as being politically persecuted rather than mentally ill, despite having a diagnosis of paranoid schizophrenia. The defendant refused to consider an insanity plea, both because he did not believe he was mentally ill and because he believed that an insanity plea would negate his cause. Resnick wrote: “A defendant who refused to enter a NGRI plea because of psychotic, illogical reasoning or irrational self-defeating goals is not able to rationally participate in the preparation of his defense. Such defendants should be adjudicated not competent to stand trial” (Ref. 20, p 8).
Similarly, Miller11 wrote that defendants, like Resnick's politically oriented offender and Mr. Kaczynski, should be evaluated for trial competence with an eye toward their rational abilities to waive (or enter) a particular plea. Miller stated: “After all, if defendants lack the capacity to consider all available pleas because of a mental disorder, then they lack a rational understanding of the proceedings and cannot assist meaningfully in their own defenses” (Ref. 11, p 297).
Litwack3 makes the interesting observation that three appellate courts have ruled very differently on competence and whether the insanity defense can be imposed when the defendant, despite mental illness, refuses to consider the insanity defense. As already discussed, the Colorado Supreme Court in Hendricks ruled that such a defendant may be found competent to stand trial, but that an insanity defense may be imposed. The rationale for this ruling was, in part, that it is the court's responsibility to ensure a fair outcome in cases in which the insanity defense is rejected by the defendant for grossly irrational reasons. In People v. Morton,21 “The New York appellate court ruled that such a defendant is competent to stand trial and that an insanity defense should not be imposed” (Ref 3, p 138, emphasis in original, referring to Ref. 21). Finally, in Commonwealth v. Simpson,22 the Massachusetts Appeals Court, in contrast, ruled that this type of defendant be found incompetent to stand trial and that the insanity defense should not be forced on the defendant. It is in the context of this type of disagreement, and perhaps confusion, that the current authors wish to contribute opinions that may help both to clarify the issues and to provide meaningful recommendations.
An emphasis on a defendant's rational abilities to make a plea is consistent with the policy implications of competence to stand trial. As already stated, an important policy consideration for the requirement of competence to stand trial is the fairness of the legal proceeding. Grisso wrote:
The rationality of an adversarial trial system requires that the accused must have a fair opportunity to mount any reasonable, available defense against the charges brought by the state. This opportunity is threatened when mental incapacities seriously reduce the defendant's ability to meet the demands of this role in the trial. To proceed to trial under such circumstances would threaten the fairness of our criminal trial process [Ref. 23, p 2].
It has been found that forensic evaluators in the community tend to give inadequate consideration to decisional competence.24 Thus, defendants such as those discussed herein may be found competent to stand trial or restored to competency despite having inadequate decisional competence. The practical consequence of this seeming contradiction is that a defendant found competent to stand trial may ultimately be found guilty rather than not guilty by reason of insanity. Accordingly, forensic evaluators should attempt with those defendants who lack insight into their mental illness to explore the advantages and disadvantages of pleading insanity and the probable outcomes with and without the insanity plea. If the defendant can engage in such a rational evaluation and discussion (with the evaluator or his attorney), perhaps he could be considered competent to stand trial; but if no such rational discussion can take place as the result of lack of insight caused by mental illness, the defendant should be considered incompetent to stand trial. In this instance, the mental illness robs the defendant of crucial information necessary to evaluate potential defenses rationally. The defendant is unaware that he was mentally ill at the time of the offense and thus may be unaware that the insanity defense is likely to be highly relevant in his case and could provide the best available defense.
We propose that forensic evaluators faced with assessing defendants who lack insight into their mental illnesses consider the following approach: assess whether the defendant's refusal of the mental-state defense flows from a rational basis. The question of refusal of the insanity defense, for example, may emerge during a competency evaluation because, in clinical forensic practice, questions of competency and sanity often are raised simultaneously. There are valid reasons that a defendant would refuse to use an insanity defense. The Frendak court identified several arguably rational reasons for refusing an insanity defense, including that the defendant may believe that an insanity acquittal would result in commitment for a longer period than the potential prison sentence. The defendant may object to the type of confinement afforded in a psychiatric hospital compared with that in a prison. A defendant may want to avoid the stigma of an insanity acquittal that is accompanied by the fear of the stigma associated with mental illness. The defendant in Resnick's example and possibly Mr. Kaczynski might refuse an insanity defense because they view the crime as a political or religious protest that a finding of insanity would denigrate. Essentially, the stigma associated with mental illness would detract from the message the defendant is trying to convey. (Paradoxically, though, the very awareness of the stigma associated with mental illness suggests some degree of insight.) In addition, some defendants are not willing to admit that they committed the act in question, a presupposition to the insanity defense.25 If the state has only equivocal evidence, it may be prudent to decline an insanity defense. If an insanity plea is successful, the defendant is likely to lose his freedom for an indefinite time.
As forensic evaluators, we often assess defendants whose judgment or decision-making is impaired by psychotic beliefs or mood symptoms. For these patients, we inquire into the extent of the defendant's psychotic beliefs or mood symptoms and assess, in light of the symptoms, whether the defendant can make rational choices. A similar inquiry should be performed with defendants who lack insight into their mental illnesses, to determine the motives for their choices and their ability to consider alternatives at the advice of legal counsel.
In conducting the clinical evaluation, it is important to explore thoroughly the defendant's insight and rational-thinking ability. Does the defendant know he is mentally ill? Does he see a need for treatment? Is the defendant delusional or, particularly in a competency restoration setting, is the defendant still delusional? How do the delusions and lack of insight affect the defendant's judgment? How does the thought disorder affect the defendant's ability to make rational decisions or converse rationally with his attorney? If the defendant has a deficit in rational decision-making or delusions about the legal system that impair ability to trust and work with an attorney, incompetency to stand trial must be strongly considered. A specific persecutory delusion about the attorney, for instance, may make it impossible for the defendant to consider and benefit from the rational advice of an attorney, contributing to rejection of a viable, appropriate insanity defense. Strong paranoid delusions, almost by definition, suggest that the defendant does not have the insight to recognize that the delusion is a sign of mental illness.
It is important for the forensic evaluator to inquire into whether the insanity defense (or other mental state defense) is viable for the defendant who is refusing to consider the defense. The assessment may necessitate obtaining collateral information from the defendant's attorney or reviewing records. It would also include a determination of the defendant's belief about his mental state at the time of the alleged offense. Based on collateral reports, for example, does the defendant accept that there is evidence to suggest symptoms of mental illness at the time of the offense?
Apart from the negative consequences to the defendant, the justice system is diminished when truly incompetent defendants are recommended by evaluators essentially to fend for themselves in court, with impaired rational thinking ability and grossly impaired insight. Such a defendant may reject the best advice an attorney has to offer, leaving the defendant alone in an adversarial environment to face potentially dire consequences.
Our recommendations are in line with those of Litwack,3 who put forth six criteria to be used in determining whether a defendant with psychotic delusions is incompetent to stand trial. In addressing these criteria, however, we argue that Litwack's emphasis on delusional defendants should be expanded to include defendants who lack insight into their mental illness for any reason. Also, we argue that this inquiry is relevant to defendants who fail to consider any mental illness defense, not only insanity. Litwack's six conditions (all must be met) are as follows:
1. The defendant refuses an insanity defense against the advice of counsel. 2. The defendant insists on maintaining a defense that is based on a delusion … or another diagnosable mental impairment … that interferes with rational understanding. 3. The defense the defendant wishes to maintain has no realistic chance of succeeding. 4. There is overwhelming evidence that the defendant committed the act(s) charged. 5. The defendant is charged with a serious crime … that would entail a very significant sentence upon conviction. 6. The defendant has a viable insanity defense [Ref. 3, p 144].
These criteria are consistent with the Dusky4 requirement that to be competent to stand trial, the defendant must be able to “consult with his lawyer with a reasonable degree of rational understanding” (Ref. 3, p 144, emphasis in original).
It has been discussed in the trial competency literature that situational factors are applicable in a competency evaluation and that a person's competency to stand trial may be a function, in part, of the particular demands on the defendant in a given legal situation.23 This notion has been discussed in the context of the so-called interactive objectives of an examination to determine competency to stand trial.23 The demands for competency of a defendant facing a long trial may be different than the demands placed on the same defendant facing a brief hearing.23 According to this line of thinking, competency to stand trial is not an absolute, based only on the attributes of the defendant. It suggests that there is a relativistic element in competency that may be applied to evaluations in some states, depending on whether the insanity defense is available at all or is available, but can be pursued only if endorsed by the defendant, versus the states where the insanity defense can be forced on a defendant by the attorney or court. Similarly, a defendant facing serious charges or punishment may have different demands than a defendant facing minor charges or punishment, identified by Litwack3 as one of the factors to consider in competency evaluations. Frendak13 also addresses the ability of a defendant to understand the significance and consequences of a particular decision in question, thus suggesting a relativistic aspect to competency to stand trial. The notion that a defendant's decisional capacity is relative to the context of the legal situation and specific decisions to be made is also consistent with Bonnie's conceptualization.7
Under Frendak, a trial court's finding of competence to stand trial is not in itself sufficient to show that the defendant is capable of rejecting the insanity defense; but should it be? If our recommendation is followed, a competency examination would encompass an assessment of the defendant's ability to decide to waive an insanity plea. We argue that these courts artificially separate trial fitness from competency to waive the plea. A competent defendant, in collaboration with his attorney, is in a better position to assess the merits of entering or waiving an insanity plea than is the court, although it is acknowledged that the judge always has the final word with regard to any questions before the court. If competency includes the ability to select a plea rationally, a competent defendant should not be forced to submit an insanity plea.
Respecting the autonomy of a competent defendant in legal decision-making is in accord with other areas of criminal law that give deference to the defendant's decisions. These include the cases cited in Frendak, including North Carolina v. Alford14 and Faretta,15 that gave criminal defendants more control over the decisions in their trials. It would also be consistent with Godinez v. Moran,26 which held that a defendant who is competent to stand trial is also competent to plead guilty and waive counsel.
Summary
Mr. Kaczynski provided a high-profile example of a defendant considered competent to stand trial who refused to entertain a mental-state defense. Although he had an understanding of the legal system and his charges, it is unclear whether he had decisional competency about a mental-state defense. If he lacked insight into a mental illness that prevented him from considering a mental-state defense or from reasonably consulting with his counsel about a mental state defense, one might question his competency to stand trial. One also might wonder whether a fear of the stigma of mental illness and its deleterious impact on one's credibility might affect an ideologically motivated defendant's ability to admit to himself or others that he is mentally ill. It must be kept in mind, though, that many individuals who are ideologically or politically motivated who commit violent acts in the name of their ideology or cause are not severely mentally ill27 and thus may be both competent and sane. Assessments of trial competence, however, should take into account the defendant's ability to assess rationally his legal options related to his mental illness, including an insanity defense or other mental illness defenses.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2013 American Academy of Psychiatry and the Law
