Between Two Worlds

"It would be very hard outside brief reactive psychosis or schizophrenia -- psychotic conditions -- to prove insanity." -- Dr. Reyes

Sisa, a minor character from Noli Me Tángere, has become the de facto national image model of mental illness—inadvertently, since providing popular culture with an emblematic depiction of a psychiatrically troubled individual is not a part of Rizal’s agendas. It is just unfortunate that despite massive developments in the scientific front, people continue to believe that all forms of mental illness involve filthy people who roam absentmindedly, switching from one emotional response to another in the space of seconds, every now and then screaming “Basilio! Crispin!” Instead of clearly understanding that Sisa occupies but a small portion of the whole spectrum of mental illness, people choose to see her as a synecdoche for it.

     Even worse is the image of all mentally ill people as instigators of crime. Anybody who commits a heinous crime is alternately called a devil, an animal, or insane—as in “Only a devil/an animal/an insane person can commit such an atrocity.”

     And related to that is the notion that pleading insanity in the courtroom setting is a convenient way to avoid serving jail time or being sentenced to capital punishment. Soap operas and komiks have regularly used the familiar scenario of evil people, when finally cornered for all their sins in the form of a criminal case, faking insanity so they could go, scot-free. This is a misconception. For one, anybody who pleads “not guilty by reason of insanity” and actually wins the case isn’t sent forth into the world; they have to be committed to an institution—which, sometimes, may last longer than recommended jail time if a guilty plea had been taken instead. For another, proving insanity in the courtroom setting is difficult. Dr. A. Efren Reyes, in a lecture he delivered at the 2000 Philippine Psychiatric Association annual convention, confirmed this. In a 1999 study of 166 cases, only 42 or 25 percent used “not guilty by reason of insanity” as a plea. Of the 42 cases of which five were still ongoing at the time, 15 were dismissed, 11 were successfully defended, and 11 were found guilty anyway. 

     In the United States the situation is even more stringent. A 1991 report from the US National Institute of Mental Health showed that from a representative sample of criminal cases filed in the county courts of eight states, less than one percent used the insanity plea. The report, published by the Bulletin of American Psychiatry and the Law, showed that those who pleaded not guilty by reason of insanity were only successful 26 percent of the time, even if nine-tenths of them had actually been diagnosed with mental illness.

     Why is this so? A posting from the American Psychiatric Association web site pointed out that “insane” at present is less a medical term than a legal one. It explains: “Because research has identified many different mental illnesses of varying severities, it is now too simplistic to describe a severely mentally ill person as ‘insane.’ In fact, the vast majority of people with a mental illness would be judged ‘sane’ if current legal tests for insanity were applied to them.”

     From a legal standpoint, using the insanity plea puts a heavy burden on the defense. The plea practically amounts to an admission on the part of the defendant—that he or she admits to physically, bodily, committing the crime. The proof to the defendant’s state of mind should very nearly be ironclad; the question, “Is the accused legally insane?” should be answered categorically, without qualifications. As upheld by the Supreme Court in People vs. Yam-Id (1999), “[it] is a defense in the nature of confession and avoidance, and as such must be proved beyond reasonable doubt.”

     It gets complicated when the fact arises that the behavioral sciences don’t always see things in the clear-cut, either-or way of the law. Medical Observer’s April 2000 issue (“Insanity in the Law”) put it as a problem “arising from the lack of a one-to-one correspondence in the frameworks, concepts, and language used in both [law and medicine].” Analogically, one might as well establish Shakespeare’s literary genius by mathematical deduction. 

     The law upholds normality and innocence—again, terms that are subject to some definitional hairsplitting in both professions—in everyone, unless there is incontrovertible proof to the contrary. And given the presumption of normality, an unlawful act, as expressed in People vs. Ambal (1980), will be viewed as “done with deliberate intent, that is, with freedom, intelligence, and malice.” 

     Insanity is an exempting circumstance, in which the instigator, at the exact moment of the commission of the unlawful act, has “complete deprivation of intelligence or discernment” and the lack of “freedom of will.” Under Article 12 of the Revised Penal Code, it goes with imbecility, acting under the compulsion of an irresistible force, and being under nine years old, among others. 

How is insanity established in court? To win a case using a “not guilty by reason of insanity” plea, several tests are employed. Traditionally there’s the M’Naghten Rule, which, simply put, involves determining whether the defendant understood the nature of his act, and whether he knew that what he did was wrong. To supplement this, the Irresistible Impulse test was implemented, which involves the establishment of a person’s inability to control the conduct of the crime as a result of mental illness. Then came the Brawner Rule, or the substantial capacity test, which is an integration of the two earlier-mentioned tests as proposed by the American Law Institute. It declares that a person “is not responsible for criminal conduct if at the time of such conduct, as a result of mental disease or defect, he lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to requirements of the law.”

     But aside from material evidence and eyewitness accounts, an expert witness, ideally a forensic psychiatrist, is summoned by the court to give testimony on cases involving the insanity plea.

     What does an expert witness do? First of all, “expert” as far as the law is concerned does not necessarily mean the best or the most respected in the field—what matters is that the judge, as well as the opposing camps, must agree that the expert witness being summoned will adequately serve the purposes of the court.  Most trials don’t just rely on one expert witness. Given the adversarial setup of the judicial system, both the defendant and complainant hire an expert witness. This naturally results in a clash of opinions.

     In addition, expert testimony is just one component on which judgment is based. Meaning, all other evidence presented in court must be able to wipe out all reasonable doubt on the guilt or innocence of the accused.

     Our April 2000 article presented the argument that some of the ambiguities in the law—given that “sufficient standards and clear-cut procedures” in the trial of the insane are not finely honed—leave much to the discretion of the judge, hence leading them to “rely solely on the expert opinion of court-appointed psychiatrists without giving due consideration to other evidence vital to the determination.” However, the number of cases that successfully employed the insanity defense, as presented earlier, somehow disproves this. Dr. Reyes in a recent interview qualifies: “It would be very hard outside brief reactive psychosis or schizophrenia—psychotic conditions—to prove insanity.” Since the manifestations of psychotic conditions are more obvious, going into the grayer areas of mental illness becomes even more challenging. For a system that upholds the importance of clarity, the nuances and ambiguities of the behavioral sciences—after all, it is a continuously evolving field of discipline—may sometimes be a legal liability.

     Unlike the other fields of medicine, psychiatry relies highly on patterns of behavior, coping styles, and other factors, which to a mind trained in the concrete and definite concepts used by the law, may seem like pure abstraction. “The lawyers and judges [usually] think in the medical sense of, ‘Ano ba ang X-ray? Ano ba ang CT-Scan?’ ” explains Dr. Reyes. “We don’t have that in psychiatry.” Even in noncriminal cases such as annulments and custody battles, a “psychological incapacity” clause is an even more complex matter to tackle. Says Dr. Reyes: “When we say that an individual is psychologically incapacitated because of certain patterns of behavior, sasabihin [ng court] ‘E nakakatrabaho naman siya e.’ Hindi nila makita na that particular facet of an individual’s functioning is enough to really affect relational issues.”

     Case in point, Andrea Yates. In mid-March a Texas jury found Yates guilty of drowning her five children in their bathtub June last year. Her insanity plea was rejected, and although prosecutors could push for the death penalty, she received a life sentence instead.  Yates’s lawyers cited her having been diagnosed with postpartum depression and psychosis by the time her fourth and fifth kids had been born. In a report from the New York Times, Yates said she had drowned her children—who were between the ages of six months and seven years—“because Satan was inside of her and she was killing her children to save them from ‘hellfire and damnation’.”

     Although psychiatrists have seen the serious mental illness Yates suffers from, this doesn’t necessarily conform to the jury’s and the judge’s interpretation of the legal concept of insanity. As a 1996 information material of the APA said: “The vast majority of people with mental illness would be judged ‘sane’ if current legal tests for insanity were applied to them. A mental illness may explain a person’s behavior. It seldom excuses it.”

     A somewhat similar case was Evonne Rodriguez’s, who in 1998 was found not guilty by reason of insanity for her 1997 killing of her four-month-old child, because she believed the “child was possessed by demons.”

     In contrast is the 1995 execution of Mario Marquez, who had an IQ below 70—an antideath penalty organization put it at 65, while a prodeath penalty organization stressed that IQ scores have a plus or minus 10 point variable, hence putting Marquez’s IQ at possibly 75—and who murdered his wife, niece, and mother-in-law. While it has been argued by death penalty advocates that IQ alone does not categorically measure one’s mental development, New York Times columnist Bob Herbert pointed out that Marquez had suffered abuse as a child, and that during his trial, all he could talk about with his lawyers were animals and the things he had liked to draw.

     All these cases, like Yates’s, had been tried in Texas, which has a media reputation as rigorous in handing over the death sentence—an Associated Press report says that between 1982 and the present, there have been 262 executions. Harris County, where Yates’s trial was held, has 157 death row convicts—more than in any other state. 

     Although citing the above examples moves from “merely” the medical and the legal planes to the societal, it just goes to show that the issue of mental illness as well as mental development could polarize opinion and sometimes result in confusion. That medical truth may sometimes not be judicial truth, that what the law perceives as just and fair may, to some degree, not be fully the case from a different point of view, and vice-versa.

     As earlier mentioned, the Philippine judicial system is perceived to be in need of some more fine-tuning. Unlike in say, the United States where most people practically litigate on a daily basis, Filipinos are not very active in pursuing court cases. There are a variety of reasons behind this, but one of its end results is the fact that some cases that could “change” the face of society don’t.

     The Philippine Psychiatric Association, notes Dr. Reyes, has “attempted to communicate with the Supreme Court. [It] has offered its time and expertise, so to speak, to [hold] a seminar for the judges to understand human behavior. Not illness, but human behavior. If they understand human behavior, they would understand why an individual would suddenly change as a result of a stress, for example.”

     He continues: “It’s difficult to make a paradigm shift—like tayo, kung ano yung nakikita yun ang totoo.  Ganun ang law. What you can prove is truth. But you cannot prove feelings; you cannot prove thoughts that go aberrant. They’re intangible.”

     But change, in some forms, is underway. As far as the legal profession is concerned, a stronger foundation on the behavioral sciences is now part of the law curriculum, at least at the University of the Philippines and the Ateneo de Manila. The younger lawyers, Dr. Reyes says, have an improved grasp of psychological issues.

     Although formal subspecialty training in forensic psychiatry is not yet available in the country, the Philippine Psychiatric Association has actively informed the courts with a list of qualified psychiatrists who may be asked to testify. The organization has a “professional regulatory board” which determines who may be fit to stand as an expert witness.

     All the work being done may not necessarily lead to more people winning their cases by reason of insanity, but it works twofold: the legal concepts of fairness and justice will be more securely upheld, and human behavior will be better understood and appreciated—which, humanistically speaking, are also components of fairness and justice.