Vol. 15 No.1 (January 2005), pp.39-41

SELF-MADE MADNESS:  RETHINKING ILLNESS AND CRIMINAL RESPONSIBILITY, by Edward W. Mitchell.  Hampshire, England: Ashgate  Publishing Limited,  2003.  272pp. Hardback $99.95 / £55.00.  ISBN: 0754623327.

Reviewed by Dan A. Lewis, Department of Human Development and Social Policy, Northwestern University.  Email: dlewis@northwestern.edu .

SELF-MADE MADNESS is not for the faint of heart.  It suffers from all the problems of turning a thesis into a book.  It could and should have been heavily edited.  The language is stilted and difficult to follow.  It is very repetitive and wanders about.  There is a chasm between the theoretical section of the book and the empirical.  Still, for those interested in mental health policy, it is worth a read. 

Edward W. Mitchell has a point to make – which he makes over and over again – but the point is an important one, and his inability to think his way through that point does not make the issues raised any the less important.  The issue is criminal responsibility of the mentally ill and the age-old problems of the insanity defense.  Mitchell suggests that the mentally ill ought to be held responsible in those cases when volition led to the occurrence of the mental illness.  His central example is the mentally ill person that fails to take his medication and the consequent return of symptoms leading to a criminal act.  The point is an interesting one, and the author circles it for the whole book trying to get some leverage on the issues and think through the implications of what he calls “meta-responsibility.”

Most readers who are interested in these issues are well aware of the problems with the insanity defense both in theory and practice.  The author recounts this discussion without breaking new ground.  He travels over this territory and makes the now obvious point that the medical liberal perspective that supports the insanity defense has been challenged persuasively from both the left and right.  Yet, there it still stands, a monument to something other than logic. The author, at times siding with those on the left, seems to argue that we are all idiots for continuing to rely on the illogical insanity defense.  If the author were a follower of Oliver Wendell Holmes, he would argue that the insanity defense is a prime example of how the law follows experience rather than logic. Clearly the logic of the defense has not stood up to the theoretical or empirical challenges of the last two generations of scholars that show that those who are found innocent by reason of insanity (a nice phrase in and of itself) often serve more time institutionalized than those who are found guilty.  The notion of not being able to form intent or not knowing the difference between right and wrong has not served juries or judges well in applying the insanity standards.  Indeed, many studies show that jurors do not think much about intent at all.  The author suggests that the decision to stop taking one’s medication shows a disregard for others and since the assumption is that the medication is “working,” meaning the person is capable of telling right from wrong when [*41] medicated, that he or she (mostly he) should be held responsible for the harm done after medication compliance breaks down.  Unfortunately, the distinction between medicated and sane and un-medicated and insane is not thought through.  Rather, much of the reasoning is done by analogy, a road that is fraught with difficulties.  Not taking your medication is like drinking too much alcohol in some ways, in that one could reasonably know that behaving in that way has foreseeable consequences, but there are also real differences between being drunk and schizophrenic.  Indeed, the author seems to stumble over this limitation when in his empirical work he discovers some of his respondents suggesting that the decision to stop medicating one’s self might reflect being ill rather than being sane.

The real problem with the book stems from the author’s failing to ground his ruminations on responsibility in one of the several theoretical frames available.  If the liberal scientific approach is flawed, then are we better off with a constructionist or existential frame?  From what perspective does meta-responsibility make sense?  Does criminalizing the behavior of the mentally ill make the society safer or the mentally ill more responsible?  It seems that at least in the United States, this criminalization has already taken place.  Our jails and prisons are filled with inmates with severe mental illness.  With the decline of state hospitals as an alternative incarceration setting for the mentally ill, our jails and prisons have become the setting of choice for society.  We got tough on crime resulting in longer sentences and less discretion for judges.  These two trends have led to the criminalization of the mentally ill. In the United States, we seem long on personal responsibility and short on justice and care.

When the author moves from the theoretical to the empirical, he suggests that at least Cambridge University students find something reassuring in the insanity defense when faced with decision-making scenarios.  This study is clearly one of convenience in both the sampling frame and the content. The analysis of scenarios raises as many questions as they answer.  Data analysis is unfocused, and I am not sure what we are to make of the results except to reaffirm that we know little about how faux juries or individuals think through the questions of guilt, innocence and insanity.  Clearly, subjects are not paying too much attention to the instructions they are being given, but we already knew that.

The important empirical questions that follow from the theoretical discussion of responsibility focus on the decision not to comply with medication prescriptions and other decisions concerning managing a serious mental illness.  Are the non-compliers more likely than the compliant to commit crimes?  The author’s discussion of responsibility is flawed since we do not know how many non-compliers stay out of trouble. We do not know whether it is the medication compliance itself that leads to better behavior or whether the compliance is a function of other factors that are not being measured—e.g. self concept, facility placements, education, family context, and so on).  Indeed, we are in the dark as to how people with serious mental illness think through their medication compliance and whether they differ, [*41] and in what ways they differ, from those non-compliers with other illnesses. Those are the studies that need to be done if meta-responsibility is going to have legs in the research community. 

While SELF-MADE MADNESS has severe limitations, it still is worth a read for those interested in mental health policy.  Mitchell is grappling with a set of issues that are very important and not easily mastered.  The question of responsibility lies at the center of American jurisprudence, and the medical model has severe limitations as a framework for linking mental illness to personal responsibility. Medication compliance is an area where there has been research on other maladies, and studying the connection between compliance and behavior could be very useful.  The author is struggling to open up a discussion of the nexus between the law, public opinion, and the psychology of the mentally ill.  What is needed is a series of studies that unlock the decision-making processes of the mentally ill.  From there we can begin to build a knowledge base that could shape whom we hold responsible for what acts.  This book is an important, if flawed, part of that construction process.

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© Copyright 2005 by the author, Dan A. Lewis.