Treatment of the Criminally Insane

1a. Mentally insane patient in a straight jacket: Misconceived notion of the mentally ill

The criminally insane are a subset of the prison population who have been deemed to have committed their crimes under the influence of a mental disease/disorder, or who were not in the state of mind during the time of the crime to comprehend the illegality or immorality of their offense (6). Only if the defendant has plead insanity before the court can they be considered a truly "criminally insane" inmate. There are multiple convictions upheld by the judicial system ranging from guilty but insane to not guilty by reason of insanity. This distinction has become a matter of federal law, but once the defendant is convicted, the treatment is left to the discretion of the state. This manner of treatment had been argued since the institution of the insanity plea and while the history surrounding these institutions is unpleasant to say the least, it provides an invaluable clue into the current practices. One of the most shocking surrounding this debate was the escape from the criminally insane patient named Phillip Paul, who was a resident at a mental institution in Spokane, Washington coupled with the brutal murder of a staff member by a criminally insane patient in the Napa State Hospital in California. The cause of the negligences is focused on the various protocol and housing/treatment issues within the state system of control.

Table of Contents

  1. Introduction/Background
    1. Guilty but Insane v. Not Guilty by Reason of Insanity
    2. Historical Treatment of the Criminally Insane
    3. Current Laws Regarding the Criminally Insane Patient
  2. Stigmas About the Criminally Insane
  3. Recent Developments
    1. Phillip Paul: Criminally Insane Patient on the Loose
    2. Orderly Brutally Murdered at Napa State Hospital
  4. Strides Toward More Competent Help
  5. State v. Federal Responsibility
    1. Final Thoughts
  6. References


Guilty but Insane v. Not Guilty by Reason of Insanity

The initial debate in the realm of criminal insanity began with whether to even have this as a viable option in the judicial system. The insanity plea itself dates back to the 1200s, but understanding of mental disease in this time was obviously much more limited and rudimentary (7). By the mid-1800s, the first legal definition for criminal insanity was established, and became known as the M'Naughten Rule. This rules states that the person cannot be convicted id the defendant did not, at the time of the crime, know what they were doing or that it was wrong because of a mental disease which affected them when the crime was committed. Another rule commonly used hails from the American Law Institute and states that the offender cannot be convicted if they did not have the cognitive ability to understand the criminality of the act because of a mental disease. Both of these definitions are used in the case that the offender is not guilty by reason of insanity (6).

The guilty but insane or guilty but mentally ill is used in the case that the defendant is convicted as guilty, but is also "insane". The difference is that the "illness is not severe enough to relieve him of criminal insanity" (6). The treatments for both the guilty and not guilty are somewhat similar, there is no question that the defendant committed the crime, but their paths diverge later in their rehabilitation process (see also "Current Laws Regarding the Criminally Insane Patient").

Historical Treatment of the Criminally Insane

2a. Electroshock therapy

The criminally insane have been historically abused and their illnesses demeaned. There have also been a number of alternative methods of treatment which were used with the criminally insane and the mentally ill alike. One such treatment was metrazol-induced chemical convulsive therapy, a very physically demanding and draining procedure in which convulsions relatable to epileptic episodes are induced on the patient in a "controlled" manner. In some cases, the intensity of the therapy would actually cause spine fractures. Electroshock therapy was and still is more common, but it does cause a form of retrograde amnesia in the patient. Some will say that this practice has shown an incredible success rate for the mentally ill, but others comment on the barbarism of the technique. And this practice is used for a wider range of patients, while the criminally insane have received an even shorter end of the stick (8).

The Bridgewater Hospital for the Criminally Insane in Massachusetts provides one of the most unspeakable examples of the treatment of these offenders. The patients who fell under the category of guilty but mentally ill and not guilty by reason of insanity were subjected to constant abuse and disregard for human decency. They were forced to strip naked, force fed under unsafe circumstances, provided with haphazard treatment and they were constantly harassed by the guards at the facility. This is an extreme example and only came to public attention because of the film Titicut Follies (see Stigmas About the Criminally Insane), however it it not too far off base from typical mistreatments of the criminally insane (9).

Current Laws Regarding the Criminally Insane Patient

The treatment and housing of the criminally insane is currently a state-by-state mandated process. While the definition of criminal insanity has been instituted federally, it is up to the state to decide which of the definitions of not guilty by reason of insanity they want, or if they even want to allow the insanity plea in their courts at all. There are about three states which do not allow the insanity plea in any form (6). Where the states choose to hold these mentally ill inmates, is also an individual decision; most contain them in a forensics ward at a state mental hospital, but the offenders are interspersed with, for the most part, the normal patient population (see also State v. Federal Responsibility).

Stigmas About the Criminally Insane

The insanity plea was established because centuries ago people believed that there were those who were possessed by
3a. US congressional asylum
demons or the devil, that there were witches who cast spells upon others, and people who were just completely "mad". There needed to be some qualifier for the state of mind of the offender during the crime; a man possessed by evil spirits cannot control his actions in the same way that a sane man can. Thus, the insanity plea was borne, but the public did not see this as a necessarily good thing. The insane, criminal or otherwise, were taunted, ridiculed, shamed, and at times even tortured and abused. Their treatment was horrendous and it was mainly propagated through stigma. The insane were treated as nothing better than animals, and even as the knowledge about mental illnesses has grown, the treatments and stigmas surrounding this group has not changed all that much (7).

One incredible example comes from the documentary film Titicut Follies by Frederick Wiseman produced in 1967. It portrays the treatment of criminally insane patients in the State Prison for the Criminally Insane in Bridgewater Massachusetts. Titicut Follies follows the treatments of these patients and inmates by the guards, social workers, and their psychiatrists and chronicles the abhorrent behavior by the entire institution. This film was actually banned by the Massachusetts State Court and was the first time in the United States that a film had been banned for reasons other than obscenity, immorality, or national security. While the court said that the reasons for the ban were because of a violation of patient dignity, a more likely reason was because of the negative image of a state institution portrayed in the film. The DVD can be bought on the producers' website at for a mere $34.95, but the content of the movie is extremely graphic and can be disturbing to viewers based on the treatments performed by the staff at the correctional facility (see also Introduction/Background: Historical Treatment of the Criminally Insane).

Not all of the stigma-based offenses proliferate in a physical manner, however. Beyond the physical abuse by the staff in the mental institutions, there is also an almost constant barrage of verbal assaults against the criminally insane. As a side note, while the treatment of the criminally insane has become less intolerant to the needs of the patients, many of these people continue to face physical abuse through constraints, alternative therapies such as electroshock therapy, and patient-on-patient assaults. Some of the most common verbal manifestations of these stigmas centers around the idea that the criminal insanity plea is a cop out and that everyone should be required to take responsibility for their actions no matter the circumstance. While many ideas have changed through time, the negative connotations have not, and this severely impedes any progress that can be made to the contrary.

Recent Developments

Phillip Paul: Criminally Insane Patient on the Loose

4a. Escapee Phillip Paul

Due to a lack of standardized measures for holding and maintaining criminal patients, let alone ones that have committed violent crimes, there have been a number of instances of neglect on the part of the hospital management. In Spokane, Washington in October of 2009 a man named Phillip Paul escaped from the care of a mental hospital while on a field trip at a carnival. Paul had been convicted as not guilty by reason of insanity in 1987 after murdering an elderly woman due to a schizophrenic break. He has been in and out of mental institutions ever since. During this particular outing, 30 or more patients were on a field with minimal staff supervision. It took 3 days for authorities to find and detain Phillip; and this was not the first time that he had escaped from a mental institution (3).

This escape sparked immense debate in the Spokane residents and affiliates within the behavioral health system. Many residents spoke out in outrage that the hospital allowed criminally insane patients to "wander" around among civilians, putting the community at risk. Other, including the chief of the Office of Mental Health Services, David Weston, stated that whether you are cognizant or not, murderers are present in our society and that, "[t]he stereotype that [the criminally insane] are the most dangerous people in society is simply not true. They are much less dangerous than many routine criminals" (1).

In response to this escape, the state policies in Washington for the leniency in the forensic units and mental health facilities within the state were tightened and expressed the reality of the situation; a mentally ill man who had committed murder escaped under the direct watch of the hospital's staff due to their lax regulations and insufficient care (4).

Orderly Brutally Murdered at Napa State Hospital

In Napa State Hospital in California, a staff member was beaten to death by a criminally insane patient. But the main at play here was not the volatile nature of the patient, or the fact that he was capable of murder, what instigated this occurrence was the structure of the hospital's units/wings and the lack of state or federal support for the growing patient list. In the past few years, Napa State Hospital has had a steady increase in the number of admitted patients deemed guilty but mentally ill and not guilty by reason of insanity. While these patients are supposed to be held in the forensic unit, the ratio of staff members to patients is far below what it needs to be. On top of this, the staff that are employed are not equipped with the skills or experience to handle this special type of patient, especially the violent offenders. Most of the staff also happens to be female, while the patient base is proportionally more male in nature.

Not only is the hospital understaffed and overworked, the patients themselves are at risk. There has been multiple cases of rape, assault, and, now, murder. While the criminally insane patients are not the only ones committing these heinous acts, Napa State Hospital, among others, is unprepared and ill-equipped to handle the added burden of the continually growing number of criminally insane patients admitted to these institutions. This compromises the security of the facility, the rehabilitative capabilities and success of the facility, as well as the overall health of the patients (2).

Strides Toward More Competent Help

There have been attempts as of late to rectify the misconceived notions about the criminally insane and their subsequent maltreatment and neglect. Alphonse Gerhardstein is one such man who has dedicated a good part of his career to this endeavor. Along with a team of people, Gerhardstein attempted to improve the mental rehabilitative programs at the Ohio State Correctional Facility and institute a new system of care. This met with some opposition which he expected and at one point in an interview with Frontline, he says that "[t]here's no right to treatment under constitutional law," demonstrating his practicality in the matter of encouraging others to provide competent care to these patients. His methods proved a great success in that particular facility, but because of the disconnect between state law and federally-mandated care, the results he saw may never amount the widespread improvement desired (5).

State v. Federal Responsibility

5a. What many believe the insanity plea to be: a "get out of jail free" card
At the moment, the definition for the insanity plea is a matter of federal law, but the choice to comply with this definition is left to each individual state. Some states believe that a mental illness should not excuse someone of the responsibility they must take for their actions. Once an insanity plea is established, the states must still decide how to house their criminals and the type and intensity of the rehabilitative programs available to the patients.

Final Thoughts

This division of responsibility may not seem like a big dilemma at first, but the consequences prove otherwise. In many cases, the treatment is lacking and the care is nonexistent. The hospitals are not adequately staffed to be able to produce healthier individuals and to be able to see a quantifiable difference in them from when they entered the facility. It is not debated that some of these patients have committed violent acts and need extra time and attention to work on those unacceptable tendencies, but the lack of a standard manner in which to begin treatment leaves much t be desired. No one can seem to agree about how to handle the issue of treatment for the criminally insane. Each state seems to be making strides toward better programs, but cases like Phillip Paul's and he murder at Napa State prove that something has got to give. The problem with a federally mandated system would be the fact that there would most likely only be one definition for criminal insanity and individual states would not have the option to opt out of the program. But that is not to say that a completely state-run delineation would be appropriate either; this may lead to eve greater disparity in the debate.


1. "Deemed criminally insane, but out on the street." The Associated Press, 18 Oct., 2009. Web. March 2011.
2. Doyle, Jim, Peter Fimrite, and Chronicle Staff Writers. "Criminally insane taking over state hospitals/ Violent patients assault infirm, elderly, even staff---at times with deadly consequences." Hearst Communications Inc., 22 July 2001. Web. 22 March 2011.
3. Geranios, Nicholas K. "Criminally Insane, but out on the street." Fisher Interactive Network, 18 Oct. 2009. Web. March 2011.
4. Geranios, Nicholas K. "State considering criminally insane patients move." The Seattle Times. The Seattle Times Company, 17 Dec. 2009. Web. March 2011.
5. Gerhardstein, Alphonse. Interview by Frontline staff. Frontline. PBS. 23 Oct. 2004. Transcript
6. "Insanity Defense FAQS." Frontline. PBS Online. Web. 3 March 2011.
7. "Insanity Defense-History." Net Industries. Web. 22 March 2011.
8. Sabbatini, Renato M.E. "The History of Shock Therapy in Psychiatry." Brain & Mind. The Edumed Institute, Brazil, 2003. Web. 7 April 2011.
9. Weir, John. Zipporah Films. Zipporah Films, Inc., 2011. Web. 7 April 2011.

Picture References

1a. unknown source
2a. Schmidt, Tollie. ECT therapy: Despression Treatment Electroconvulsive Shock Therapy and ECT Side Effects.3 Sep. 2010. Web. 7 April 2011.
3a. Hogarth, William. The Rake's Progress Scene in Bedlam. 1735. Engraving. Images from the History of Medicine. Web. 7 April 2011.
4a. Spokane County Sheriff's Office. Phillip A. Paul. Web. 7 April 2011.
5a. DabbleDesign. Tie Tack - Get Out of Jail Free Card. 2011. Web. 7 April 2011.