Roesch Lymburner IJLP1999

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/12841854
The insanity defense: Five years of research (1993-1997)
Article in International Journal of Law and Psychiatry · May 1999

DOI: 10.1016/S0160-2527(99)00006-0 · Source: PubMed
CITATIONS READS
29 9,181
2 authors:
Jocelyn Lymburner Ron Roesch

Kwantlen Polytechnic University Simon Fraser University
10 PUBLICATIONS 53 CITATIONS 124 PUBLICATIONS 2,968 CITATIONS
SEE PROFILE SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Evaluation of competence to stand trial View project
All content following this page was uploaded by Ron Roesch on 21 April 2018.
The user has requested enhancement of the downloaded file.

International Journal of Law and Psychiatry, Vol. 22, Nos. 3–4, pp. 213–240, 1999
Copyright © 1999 Elsevier Science Ltd
Printed in the USA. All rights reserved
0160-2527/99 $–see front matter
PII S0160-2527(99)00006-0
The Insanity Defense:

Five Years of Research (1993–1997)
Jocelyn A. Lymburner* and Ronald Roesch†
Introduction
One of the fundamental presumptions of our criminal justice system is that le-
gal responsibility entails both actus reus and mens rea; that is, to be held crimi-
nally responsible a person must have freely chosen to commit a criminal act,
knowing that this act was criminal. As the presence of a mental disorder is
seen by some as rendering a person unable to form criminal intent, the insan-
ity defense was instituted, with the effect of offering mentally disordered per-
sons potential exemption from criminal responsibility. However, because the
insanity defense “purports to draw a line between those who are morally re-
sponsible and those who are not, those who are blameworthy and those who
are not, those who have free will and those who do not, those who should be
punished and those who should not” (Stone, 1975, p. 218), it has been subject
to more debate and criticism than any other criminal law (e.g., Perlin, 1996).
Surprisingly, despite the fact that these controversies have been played out ex-
tensively in philosophical and theoretical debates, empirical research on the
insanity defense is relatively limited in quantity.
The present article reviews research on the insanity defense in the 5-year
period spanning 1993 to 1997. Publications used in this review were obtained
through a search of Psychinfo and MedLine. An initial review of abstracts was
undertaken by the first author to exclude any of the literature that did not in-
clude empirical data.1 No effort was made to search for relevant articles in le-
gal periodicals, nor was any effort made to obtain translations of articles pub-
lished in languages other than English. In addition, some articles were later
excluded, as they included the insanity defense only at the most peripheral
*Doctoral Candidate, Department of Psychology, Simon Fraser University, Vancouver, British Colum-
bia, Canada.
†Professor of Psychology, Simon Fraser University, Vancouver, British Columbia, Canada.
Address correspondence and reprint requests to Dr. Ronald Roesch, Professor of Psychology, Mental
Health, Law, and Policy Institute, Simon Fraser University, Vancouver, British Columbia, Canada, V5A 1S6.
1In cases where a review of the abstract did not yield sufficient information to determine whether the
article was empirical in nature, the full paper was examined.

213
214 J. A. LYMBURNER and R. ROESCH
level.2 Finally, unpublished dissertations were not included in the present re-
view, although a decision was made to include several as yet unpublished works,
as these were deemed to be of potential significance as future publications.
Ogloff, Schweighofer, Turnbull, and Whittemore (1992) identified five gen-
eral categories that account for much of the empirical research on the insanity
defense: (a) demographic characteristics of insanity acquittees, (b) detention
and release patterns for insanity acquittees, (c) recidivism of acquittees, (d)
the impact of the insanity defense standards, and (e) attitudes about the insan-
ity defense. In addition to a review of the empirical research in these five ar-
eas, this article also focuses on recent empirical work in the area of insanity
evaluations, as well as a discussion of the rights of insanity defendants.
Before we turn to a review of the research, we feel it imperative that the
reader understand the relative importance of the insanity defense in the broader
legal picture. The insanity defense is rarely used, and even more rarely success-
ful. A large-scale study of eight states first published in Callahan (1991) reported
an aggregated plea rate of only .85 per 100 felony indictments, though the rate
varied across states from .29 to 1.59 (Cirincione, Steadman, & McGreevy, 1995).
Success rates of the insanity defense also varied across states, ranging from 13.1
to 87.4 acquittals per 100 insanity pleas. Interestingly, Cirincione et al. (1995)
observed an inverse relationship between the plea and acquittal rate, such that
states that used the insanity defense more freely had lower success rates. Conse-
quently, the number of acquittals was relatively stable, averaging .26 acquittals
per 100 felony indictments. The authors speculated that there exists some “ac-
ceptable” number of insanity acquittees, such that when the plea rate increases,
defendants are less likely to receive an insanity verdict. The results suggest that
even in the rare incidences in which the insanity defense is raised, the path to ac-
quittal is not a straight one. Janofsky, Dunn, Roskes, Briskin, and Lunstrum Ru-
dolph’s (1996) examination of all defendants in Baltimore City’s circuit and dis-
trict courts who pleaded not criminally responsible during a 1-year period
provides a detailed picture of what transpires after a defendant pleads insanity.
Their study revealed that 70.5% of defendants withdrew their pleas immediately
after evaluation by the medical office. A further 4.2% were found not compe-
tent to stand trial and, for 17.9% of cases, the charges were dropped. For the re-
maining .04% of the original sample, the insanity defense was not contested and
all were found not criminally responsible.3 Cirincione (1996) also found that the
vast majority of insanity defense cases were handled through plea bargaining
(42.9%) or bench trials (42.7%), with only 14.4% resulting in jury trials. It would
appear that the popularized “battle of the experts” in highly controversial insan-
ity defense cases is a media byproduct and has little basis in reality.
2 For example, Palermo, Smith, Gram, Zier, and Kohler (1996) conducted a study to examine juror per-
ceptions of expert testimony in insanity defense trials. A closer inspection of this article revealed that the
defendant’s in all 10 trials were found guilty. Rather, the focus of the study was on juror’s ideal and actual
perceptions of mental health testimony and added little to our understanding of the insanity defense.
3 This research lays an important foundation for interpreting correlates of successful insanity defenses (to
be discussed in a later section). Given that the vast majority of insanity pleas are dropped before trial, the
reader is cautioned that the factors which differentiate successful insanity acquittees from all persons who
raise the defense may be irrelevant at the trial stage.
THE INSANITY DEFENSE 215
Outside North America, the insanity defense appears to be used even more
rarely. For example, in Ireland, research has shown even lower use and acquit-
tal rates, with an average of one acquittal per year since 1910 (Gibbons, Mul-
ryan, & O’Connor, 1997). Gibbons et al. (1997) state that in Ireland, the insan-
ity defense is reserved for only the most serious offenses and, even then, is
successful in only 2 to 3% of homicides.
Given its infrequent use and low success rate, it has been argued that the at-
tention given to the insanity defense is disproportionate to its actual impact on
the criminal justice system (Blau & Pasewark, 1994). Nonetheless, the insanity
defense remains a topic of much controversy and the seat of numerous mis-
conceptions and myths (e.g., Silver, Cirincione, & Steadman, 1994). The present
review elucidates prevailing issues through a summary of recent empirical re-
search on the insanity defense.
Demographic Characteristics of Insanity Acquittees

A significant amount of research has been devoted to examining the demo-
graphic characteristics of insanity acquittees4 and, for the most part, these
studies paint a fairly consistent portrait. Perhaps the largest single study of not
guilty by reason of insanity (NGRI) acquittees was conducted in the United
States and included data from eight states (Cirincione et al., 1995). The results
of this study as well as research conducted in Canada (Roesch et al., 1997) in-
dicate that the average insanity acquittee is male, between the ages of 20 and
29, unmarried, unemployed, minimally educated, has been acquitted for a vio-
lent offense and diagnosed with a major mental illness, and has had prior con-
tact with both the criminal and mental health systems.
Gender
Female inmates make up approximately 10% of the jail population in the
United States (U.S. Department of Justice, 1998). In Canada in 1997, only
about 17% of criminal charges were laid against females, with this proportion
even lower (approximately 13%) for violent offenses (Statistics Canada,
1998). Thus, it is not surprising that research on the insanity defense in North
America has consistently demonstrated that male insanity acquittees outnum-
ber female acquittees by a ratio of about 10:1 (Bloom & Williams, 1994; Cirin-
cione et al., 1995; Roesch et al., 1997).
Although gender is frequently included as a variable in research on the in-
sanity defense, very few studies have set out to comprehensively compare
male and female insanity acquittees. To our knowledge, the only thorough
comparison of male and female insanity acquittees in the past 5 years was con-
ducted by Seig, Ball, and Menninger (1995) in the state of Colorado. Their re-
search revealed significant differences in terms of mental and criminal history
as well as demographic variables. Generally, females were likely to be older at
4 The reader is cautioned that research in this area frequently includes all defendants who are evaluated
for insanity as opposed to just those who have been acquitted by reason of insanity. Further, this former
group may include all mental health evaluations (i.e., fitness and insanity).
the time of commitment, were more likely to be diagnosed with mood disor-
ders or borderline personality disorder and were less likely to receive diag-
noses of antisocial personality disorder or substance abuse. Females were also
less likely to have a history of violent crime and tended to start their criminal
activity at a later age. On the other hand, the crime for which they were ac-
quitted was more likely to be a serious offense. Despite this, the length of de-
tention for females was significantly shorter than was the case for males.
These findings are consistent with those of Gibbons et al. (1997), who found
that although female insanity acquittees in Ireland were more likely to have
committed a violent offense, especially infanticide, they were discharged sig-
nificantly earlier than men. The research raises concern with respect to differ-
ential treatment of males and females under the insanity defense. To the ex-
tent that such differences reflect true gender differences as well as variability
in the circumstances under which males and females come into contact with
the law, variability is to be expected and is acceptable. However, the possibil-
ity that such differences may arise from gender biases cannot be eliminated
without further research.
Criminal History and Current Offense

Research investigating the criminal history of defendants who plead insanity
has demonstrated that, on average, 75% of defendants have had prior arrests
(Bloom & Williams, 1994; Cirincione et al., 1995). In the course of our review,
we noted that studies varied between citing prior convictions or citing prior ar-
rests as a measure of preacquittal contact with the law. Not surprisingly, those
studies that used prior convictions as a measure of prior contact with the crimi-
nal justice system yielded much lower rates (e.g., 37%; Hodgins, 1993).
Despite popular belief that the typical insanity acquittee has been charged
with murder, research has demonstrated that only a minority has actually com-
mitted murder or even attempted murder. In fact, Cirincione et al. (1995), ex-
amining data across seven states, found that while the majority of defendants
were charged with violent offenses, only 14% involved a murder charge. Bloom
and Williams’s (1994) examination of insanity acquittees in Oregon revealed that
only 8% had been charged with homicide or attempted homicide. In Canada, a
review of all insanity evaluatees in the province of British Columbia over a
2-year period yielded comparable results, revealing that although the majority
of defendants had been charged with violent offenses, less than 10% had been
charged with murder or attempted murder (Roesch et al., 1997). More notably,
in addition to the finding that murder charges are rare for insanity acquittees, re-
search has also demonstrated that approximately 35% of all charges in this pop-
ulation are in fact nonviolent and for the most part trivial, comprised primarily
of charges such as uttering threats, breach of probation, mischief, and possession
of stolen property (Lymburner, 1997; Roesch et al., 1997).
Mental History and Current Diagnosis

The presence of mental disease, a constant element in all insanity defense
standards is, for obvious reasons, highly relevant in the determination of crim-
inal responsibility. However, the term mental disease encompasses a broad

range of disorders that vary in the extent to which they render individuals
incapable of meeting the legal criteria for responsibility. Not surprisingly, re-
search has consistently demonstrated that the majority of insanity acquittees
have been diagnosed with a psychotic disorder, although diagnoses of person-
ality disorders, depression, anxiety disorders, and substance abuse are not un-
common (Cirincione et al., 1995; Roesch et al., 1997). Roesch et al. (1997) found
that slightly over 50% of all not criminally responsible by reason of mental dis-
order (NCRMD) defendants remanded in British Columbia during the 1993 to
1994 fiscal year were diagnosed with psychotic disorders, the majority of
whom were diagnosed with schizophrenia. In New York, Wack (1993) found
that 62% of NGRI acquittees had been diagnosed with a psychotic disorder,
7% with a major affective disorder, 10% were found to have a schizoaffective
disorder, 4% were suffering from delusional disorder, 7% had organic disor-
der, and 10% had a primary diagnosis of personality disorder. Lymburner
(1997) found that multiple diagnoses were also common, with 59% of a popu-
lation of insanity acquittees in British Columbia receiving more than one diag-
nosis (most commonly a psychotic disorder in combination with personality
disorder or substance abuse). In this Canadian sample, 16% of insanity acquit-
tees had received a primary diagnosis of personality disorder. A closer exami-
nation revealed that, while there tends to be a wider array of psychiatric diag-
noses among those who plead insanity, the range narrows somewhat for those
who are acquitted, with the majority of this latter group diagnosed with psy-
chotic disorders, most commonly, schizophrenia. A study conducted in Que-
bec revealed that of the 79% of evaluatees diagnosed with a psychotic disor-
der, 28% were schizophrenic while the proportion rose to 63% among the
group who were acquitted (Hodgins, 1993). Lymburner (1997) found that,
among a sample of insanity acquittees in British Columbia, 61% were diag-
nosed with a psychotic disorder, the most common of which was schizophrenia
(37%). Data from Oregon similarly indicate a high percentage of schizophre-
nia among insanity acquittees, accounting for 60% of the sample (Bloom &
Williams, 1994).
Given the seriousness of psychiatric diagnoses at the time of the offense, it
is not surprising that the majority of insanity acquittees have been hospitalized
prior to their coming into contact with the law. A study conducted in Quebec
revealed that 70% of those referred for assessments of criminal responsibility
had been previously hospitalized, with 86% of those who were judged to be
unfit or insane having had a prior hospitalization (Hodgins, 1993). Bloom and
Williams (1994) found that 86% of insanity acquittees had previously received
some form of mental health services, and 61% had had previous contact with
both psychiatric and criminal systems. Similarly, Cirincione et al. (1995) re-
ported that 72.2% of their sample has previously been hospitalized in a mental
institution.
General Demographics Outside North America

Research from Europe has yielded slightly different results than that con-
ducted in the United States and Canada. Gibbons et al. (1997) conducted a
retrospective study describing all insanity acquittees in Ireland between the

years 1850 and 1995. Their assessment indicated that the insanity defense is
more broadly used in North America than in Ireland, where it appears to be
reserved for only the most serious cases (95% of acquittees had been charged
with violent offenses, 72% of which were homicide or infanticide). The ratio
of males to females also appeared to be somewhat lower in Ireland, with a
greater proportion of insanity acquittees being female (5:1 as compared to the
10:1 ratio found in North America). Comparable to North America, 75% of
insanity acquittees had a prior criminal history and 56% had been previously
hospitalized. Finally, in Ireland, the insanity defense appears to be more com-
monly used for defendants who have a primary diagnosis of personality disor-
der, comprising 19.1% of all acquittees as compared to 10% in North America
(e.g., Wack, 1993)
In Japan, Satsumi and Oda (1995) studied a group of mentally ill offenders
who were diagnosed with endogenous psychoses (65% of the entire sample)
and had been referred for assessments of responsibility. Although the charac-
teristics of this sample are undoubtedly impacted by the selection of a subsam-
ple with severe mental disorder, they may provide some insight into the char-
acteristics of those assessed for criminal responsibility in Japan. Satsumi and
Oda report that 75% of the sample were male (again, a lower ratio than in the
North America), 57% single, 45% employed, 36% had been previously hospi-
talized, 88% had committed violent offenses (57% murder), 63% had a his-
tory of delinquent behavior and 82% had prior arrest records. In some re-
spects, the data are consistent with that found in North America, though they
suggest that the insanity defense may be reserved for only the most serious of-
fenses, that it is used more frequently with women, and that those who use the
insanity defense in Japan are not generally characterized by a long history of
contact with the mental health system.
In Israel, mental health evaluations encompass both competency to stand
trial and criminal responsibility. Durat, Jabotinsky-Rubin, and Ginath (1993)
examined all forensic evaluations in an 8-year period spanning 1983 to 1990.
Similar to Ireland, the ratio of males to females was lower than in North
America, approximately 5.5:1. In contrast to North America, less than half of
those evaluated were diagnosed with a psychotic disorder (37% schizophre-
nia) and almost a quarter were diagnosed with a personality disorder; it is per-
haps noteworthy that the most common personality disorder was antisocial
personality disorder—a diagnosis seen rarely in North American insanity ac-
quittees. However, as is the case in North America, a significant proportion
(65.3%) of acquittees in Israel had been previously hospitalized.
Assessment Issues
Extensive criticism directed toward forensic practitioners as well as the po-
tentially severe consequences of being found not guilty by reason of insanity
appear to have been driving forces behind recent research on the insanity de-
fense. In the past 5 years, a large number of studies have been conducted to
examine more closely the clinical assessment of those who plead insanity. Re-
search has addressed the issue from a number of angles, focusing on the facili-
ties in which pretrial evaluations are carried out, the qualifications of those
who perform forensic assessments, the instruments that are or should be uti-
lized in this process, and new methodologies to aid in decisions about condi-
tional release, as well as techniques for evaluating and better predicting out-
come of conditional release.
In terms of the pretrial forensic evaluation services provided in the United
States, a national survey revealed substantial variability across states (Grisso,
Cocozza, Steadman, Fisher, & Greer, 1994). While some states utilized strictly
inpatient assessment units, others conducted outpatient assessments through
contracting private practitioners, mental health agencies, or some combina-
tion of the above. Outpatient evaluations account for the majority of pretrial
assessments in 60% of states, with every state supporting at least some outpa-
tient services (Grisso, Cocozza, Steadman, Greer, & Fisher, 1996). Although
inpatient facilities were also common, occurring in 45 of 51 states, they ac-
counted for the predominant number of evaluations in only 10 states (19%).
Grisso et al. (1996) contended that the less frequent use of inpatient evalua-
tions is due to their higher costs and longer time-frame. While variability
across states may serve to more effectively meet the needs of each setting,
Grisso et al. (1994) observed that this variability also makes it very difficult to
ensure quality assessments or to mandate and evaluate continuing education
and specialized training.
With respect to the qualifications of those who offer expert testimony in in-
sanity defense trials, a national survey conducted by Farkas, DeLeon, and
Newman (1997) again revealed consider variability in background and qualifi-
cations of evaluators. First, eligibility to testify differs across states, with psychi-
atrists eligible to testify in 100% of states, psychologists testifying in 90.4%,
general physicians testifying in 36.5%, social workers in 28.8%, and others (in-
cluding nurses) eligible to testify in 17.3% of states. Second, with respect to the
qualifications required of expert witnesses, less than 20% of states required
certification, only 17.3% required training, 11.5% of states required examiners
to pass an exam, and 3.8% required examiners to have had previous experi-
ence. On a positive note, these data demonstrate the supremacy shown to prac-
titioners with specialized training in assessing mental status (i.e., psychiatrists
and psychologists), and also point to the gaining recognition of psychology
within the legal system (to the extent that psychologists are essentially on par
with medicine). However, the lack of national standards and the frequent ac-
ceptance of testimony from individuals who may have no specialized training
and who are generally not required to meet any qualifications, are areas of con-
cern. Promisingly, 26.9% of states indicated that they are moving toward im-
plementing formalized training for those who conduct insanity assessments.
The absence of unified standards for forensic examiners can potentially
lead to problems with respect to the quality of expert testimony and mental
health reports in insanity defense trials. Reichlin, Bloom, and Williams (1993)
examined reports that were used by the court in evaluating a group of insanity
defendants. The results of this study generate concern, indicating that the vast
majority of mental health reports may be wholly inadequate. As many as 17%
of the mental health reports utilized by the court in insanity defense cases, had
not been prepared for the purpose of evaluating criminal responsibility. More-
over, even when written for this purpose, many of the reports did not include
information on the charge, contained few clinical identifiers, did not address
the medical-legal question and/or did not address major elements of the insan-
ity defense. Reichlin et al. (1993) echo the sentiments of Borum and Grisso
(1996) in calling for states to introduce certification and training for forensic
mental health experts who will prepare reports for the court to address issues
of criminal responsibility. On a more positive note, Borum and Grisso (1996)
report that as forensic psychiatrists and psychologists tend to agree on the ap-
propriate content for reports, the development of universal standards seems
feasible. Furthermore, the increasing numbers of graduate programs provid-
ing training in forensic areas (e.g., Bersoff et al., 1997) will undoubtedly im-
prove the quality of forensic evaluations.
Regarding the specifics of how forensic assessments are conducted, Borum
and Grisso (1995) examined psychological test usage by forensic psychologists
and psychiatrists. They report no differences between psychologists and psy-
chiatrists in terms of their perceptions of the importance of psychological test-
ing for the assessment of criminal responsibility though, not surprisingly, psy-
chologists ordered and conducted more tests than did psychiatrists. Overall,
about two thirds of practitioners indicated that psychological tests are impor-
tant for the assessment of criminal responsibility. However, only 25% of fo-
rensic experts conducting criminal responsibility assessments state that psy-
chological testing is essential. The most commonly used test in the context of a
forensic assessment is an objective personality inventory, such as the Minne-
sota Multiphasic Personality Inventory (MMPI; Butcher, Dahlstrom, Graham,
Tellegen, & Kaemmer, 1989) (96%), with intelligence scales used second most
frequently (80%), followed by neuropsychological testing (50%), and projec-
tive measures (42%). With respect to specific forensic assessment instruments,
46% of this sample of forensic psychologists reported never using them, and
another 20% reported that they rarely use them. An even greater percentage
of psychiatrists (i.e., 91%) reported never or rarely using forensic assessment
instruments. Nonetheless, the researchers are hopeful about the fact that al-
most half of the experts surveyed had heard of or had used some of the foren-
sic instruments, suggesting a possible increase in their acceptance and use.
Borum and Grisso (1995) argue that, given the widespread use of psychologi-
cal testing in forensic assessments, it is reasonable to hold this practice as the
norm, in which case psychologists would be accountable to explain why they
have chosen not to use testing in a specific case.
In contrast, outside North America, Durat et al. (1993) report that 84.4% of
insanity assessments in Israel are carried out in inpatient settings. Further psy-
chological testing is used in only 15.5% of forensic evaluations, and almost
40% of reports stem from data collected during a 1-day observation.
Specific Populations
Given the fact that mental disorders vary in the degree to which they influ-
ence behavior (criminal or otherwise), instruments that are designed for the spe-
cific purpose of assessing the facets of a particular mental disorder can have great
utility in forensic assessments. For example, Steinberg, Bancroft, and Buchanan
(1993) conclude that the Structured Clinical Interview for DSM-IV Dissociative
Disorders (SCID-D; Steinberg, 1993) has the potential to reduce the complexi-
ties of differential diagnosis by providing clinicians with a reliable tool for the
assessment of the presence, severity and constellation of dissociative symptoms.
Research on criminal responsibility has also extended beyond the strict con-
fines of the general psychological literature, with researchers attempting to
identify brain dysfunctions associated with criminal behavior. Specifically,
Raine et al. (1994) measured brain functioning through the use of positron emis-
sion tomography (PET) within a group of insanity defendants who had commit-
ted homicide and a group of matched controls. Results indicated that murderers
who are pleading insanity are characterized by a specific prefrontal dysfunction.
As prefrontal dysfunction is associated with loss of inhibition, risk-taking and
rule-breaking behavior, emotional outbursts, loss of self-control, and poor social
judgment it is not unreasonable to assume that such a deficit may predispose an
individual toward violence. While a predisposition toward violence by no means
eradicates individual responsibility, the finding may have implications for the as-
sessment of criminal responsibility as well as the determination of an appropri-
ate disposition for those who are acquitted by reason of insanity.
Malingering
The perception that the insanity defense is commonly used by crafty offend-
ers in an attempt to “get away” with their criminal behavior is pervasive
among the general public (Silver et al., 1994). Our own review of this litera-
ture strongly disputes the veracity of this claim given that only very small num-
bers of defendants successfully plead insanity and, moreover, that the defense
often carries very severe penalties for defendants. Nonetheless, public pres-
sure, however ill-founded, inevitably fuels research and there has been a re-
cent surge in research directed toward the assessment of malingering in the
context of forensic assessments. Hiscock, Rustemier, and Hiscock (1993)
tested the utility of two measures of malingering within a population of prison
inmates and a population of students. Specifically, Hiscock et al. (1993) exam-
ined whether there were differences among naive faking, coached faking, and
“try your best” instruction groups on two-alternative forced-choice tests of
general knowledge and moral reasoning. The researchers found significant
group differences, with both prison inmates and students in the naive faking
group doing most poorly on both tests, followed by coached faking and then
the control group. As no subjects in the control group scored below chance,
the researchers suggest that the tests may be useful in identifying individuals
who are attempting to fake low mental ability or the inability to distinguish
right from wrong. Hiscock et al. (1993) also observe that, as opposed to using
“below chance” as the cutoff, the establishment of norms and cutoffs within
various populations might be feasible so as to increase the sensitivity of the
measure. Finally, the researchers note that differences found between naive and
coached fakers point to the greater difficulty one might have in detecting so-
phisticated fakers. Bagby, Rogers, and Buis (1994) examined the effectiveness
of the MMPI-2 in detecting malingering, defensive, and honest responding in a
student population. As well, they compared MMPI-2 profiles produced by
these three groups with those produced by a psychiatric population. Not sur-
prisingly, the lowest scores were produced by students in the defensiveness
condition, the highest scores were produced by students who were instructed
to malinger, and the honest responders and psychiatric population fell be-
tween these groups, with the latter scoring higher on 7 of the 10 clinical scales.
Bagby et al. (1994) also found that malingers produced a significantly different
validity profile than the other three groups. The researchers suggest that the
results of their study point to the utility of the MMPI-2 validity scales in de-
tecting even sophisticated malingering. However, they also caution that there
is no consensus as to what the cutoff scores for identifying malingering should
be and conclude that for screening purposes it is reasonable to use more lib-
eral cutoffs while the actual determination of malingering demands more
stringent cutoff scores.
Ganallen, Wasyliw, Haywood, and Grossman (1996) conducted a study to
examine the utility of projective tests in defeating the malingering attempts of
insanity defendants. The authors found that although a group of forensic pa-
tients demonstrated strong evidence of malingering psychosis on the MMPI,
they did not differ from nonmalingerers on any of the empirically validated
measures of psychosis on the Rorschach. In fact, the only Rorschach measure
that differentiated malingerers from nonmalingerers was the summary mea-
sure of Dramatic Content. The researchers conclude that a combination of the
MMPI and the Rorschach may be a good psychometric tool for detecting ma-
lingering of psychosis in a criminal population. Further, given the apparent dif-
ficulty of malingering on the Rorschach, this instrument may be a useful as-
sessment tool for evaluating individuals who are referred for criminal
responsibility assessments.
Research in this area has also compared characteristics of a population of
successful insanity malingerers with a nonmalingering insanity acquittee group5
(Gacono, Meloy, Sheppard, Speth, & Roske, 1995). Gacono et al. (1995)
found that malingers were more likely to have a history of murder or rape and,
in general, evidenced more malicious and predatory assaults. Further, malin-
gers scored higher on both factors of the Psychopathy Check List-Revised
(PCL-R; Hare, 1991), evidencing glib, grandiose, and manipulative behavior,
shallow affect, lying, and lack of empathy and remorse as well as a greater
likelihood of institutional misbehavior and a diagnosis of antisocial personal-
ity disorder. In addition to identifying correlates of malingering for assessment
purposes, the research has important clinical and legal implications in that ma-
lingering patients will present severe treatment and management problems for
practitioners as well as a higher risk for dangerous reoffending upon release.
Factors Influencing Verdicts of Insanity

The present review incorporates both mock jury and archival research in
discussing the current state of knowledge with respect to factors that influence
5 Malingering insanity acquittees were identified through the self-report of exaggeration or malingering
to gain access to the hospital. They did not have an Axis I psychotic disorder and were not prescribed psy-
chotropic medications.
verdicts of insanity. Though a review of the major limitations of mock jury re-
search is beyond the scope of the present article, the reader is reminded of the
potentially limited external validity of such results (cf. Diamond 1997).
Mock Jury Research

Despite extensive criticism directed toward jurors in insanity defense trials,
classic studies such as that of Kalven and Zeisel (1966) consistently demon-
strate that jurors do attend to and understand the evidence, and are not easily
misled or swayed by their own biases. Further, research with mock juries dem-
onstrates that jurors undertake a comprehensive and careful consideration of
a large number of relevant factors before rendering a verdict. Among the fac-
tors cited as important are presence of a psychotic disorder (e.g., Lymburner,
1997), expert witness testimony (Rogers, Bagby, & Perera, 1993; Whittemore
& Ogloff, 1995), police evidence (Rogers et al., 1993), the defendant’s motive
(e.g., Finkel & Groscup, 1997), and the degree to which the index offense was
planned (e.g., Boardman, Stafford, & Ben-Porath, 1996; Lymburner, 1997).
On the other hand, some research has indicated that jurors may also be
swayed by salient, yet irrelevant factors. For example, Whittemore and Ogloff
(1995) noted that jurors were more likely to acquit individuals whom they per-
ceived as displaying psychotic symptoms at the time of the trial. However,
while strictly speaking, the defendant’s mental state at the time of the trial is
irrelevant to the insanity defense, practically, it may have bearing upon the de-
fendant’s mental state at the time of the offense. Thus, one could not conclude
from this research that jurors are attending to irrelevant factors. Further, with
regard to expert testimony, Ziskin and Faust’s (1988) claim that the general
principles of cross-examination would devastate the credibility of the expert
has been disputed by recent research. Rogers et al. (1993) had a sample of jury
eligible persons read mock transcripts in which the type of cross-examination
was varied. The researchers found that cross-examination strategy exerted no
direct influence on individuals’ ratings of the expert’s credibility or on individ-
ual verdicts, although some strategies made their decisions more difficult.
It seems apparent that jurors’ verdicts in the matter of insanity are far from
the indiscriminate, simplistic, and biased decisions postulated by critics. None-
theless, there remain two areas of contention—despite the seriousness with
which jurors approach their task, research indicates that their decisions are:
(a) not impacted by the specific insanity standards, that is, the “definition” of
insanity, they are given; and (b) impacted by their own attitudes toward the in-
sanity defense, their religious beliefs and their political ideology.
Jury Instructions. Evidence suggests that jurors either do not attend to and/
or understand the instructions they are given or that existing insanity stan-
dards assume distinctions that do not have a parallel in “real” life (Ogloff,
1991). Consequently, it is important to determine exactly how jurors are con-
struing insanity and whether this interpretation is consistent with its legal defi-
nition. If not, there are two possibilities: (a) efforts could be made to commu-
nicate more clearly jury instructions and ensure that they are understood and
adhered to, or (b) legal definitions of insanity could be written such that they
correspond with how it is intuitively construed. Consistent with this latter sug-
gestion, Finkel and Slobogin (1995) conducted a study to compare two hypo-
thetical insanity standards: (a) the quasisubjective justification (QSJ), which
forces jurors to evaluate whether, based on the subjective perception of the ac-
tor, the harm caused was greater than the harm prevented (i.e., whether the
act was justified); and (b) Finkel’s relative culpability test in which decisions
about committing the act, the defendant’s mental disorder, the degree to
which the defendant was responsible for bringing about the disorder, and the
defendant’s intent are made in sequence, with two “excuse”-oriented tests cur-
rently in use: (a) American Law Institute (1962; ALI), and (b) Insanity De-
fense Reform Act (IDRA) test (which eliminated the volitional prong from
the ALI). The researchers found that the relative culpability test yielded half
the number of NGRI verdicts as all other tests. The results suggest that jurors
were capable of recognizing the additional culpability associated with bringing
about the disorder only when using a test that specifically called their atten-
tion to this matter. Further, jurors were also capable of focusing on justifica-
tion as distinct from severity of disorder using the QSJ test. However, in two
follow-up experiments in which no insanity standards were given to partici-
pants, Finkel and Slobogin (1995) found that jurors registered culpability dis-
tinctions and considered the degree of justification even without instructions
to do so. The authors conclude that standard tests of insanity may in fact lead
jurors astray from what they would normally consider.
A related area of research has examined the impact of disposition instruc-
tions on verdicts of insanity, with proponents of disposition instructions argu-
ing that this practice is needed to offset jurors’ erroneous presumption that the
insanity acquittee will be automatically released into the community. How-
ever, research by Whittemore and Ogloff (1995) indicates that disposition in-
structions are unimportant to jurors in reaching decisions about insanity. In
fact, they found that only 21% of participants could accurately report what
would happen were the defendant to be found not criminally responsible.
Given the lack of weight jurors give to the legal instructions, recent research
has sought to examine more closely jurors’ implicit notions of insanity and
their preexisting schemas or prototypes about what is insane and what is not
(Bailis, Darley, Waxman, & Robinson, 1995; Finkel & Groscup, 1997; Rob-
erts, Sargent, & Chan, 1993; Whittemore & Ogloff, 1995). As previously stated
it is important to remember that although jurors come to trial with their own
implicit standards, this does not translate into simplistic, subjective decision-
making. Finkel and Groscup (1997) had university students write narratives
about typical and atypical insanity cases with successful or unsuccessful out-
comes. From these narratives there emerged highly complex prototypes that
involved a mixture of subjective (e.g., the defendant’s motive) and objective
(e.g., history of mental illness, psychiatric diagnosis) factors. To further exam-
ine prototypes of insanity and responsibility, Kleinke and Baldwin (1993) had
participants evaluate the responsibility of individuals who offered crazy or
sane explanations for good or bad behavior. Individuals who offered crazy ex-
planations for their behavior were evaluated as having less intent and being
less responsible for their actions. Of these, those who committed bad deeds
were judged as most mentally ill and attributed less responsibility.
Attitudes. Research has demonstrated that favorable attitudes toward the in-
sanity defense are correlated with a greater number of NGRI verdicts. More
specifically, mock jurors’ willingness to incarcerate reflected negative attitudes
toward the insanity defense as well as beliefs about the insanity defense and its
effect on society (e.g., the insanity defense serves as a loophole which allows
criminals to go free; see Bailis et al., 1995; Lymburner, 1997). Given that fa-
vorabe attitudes toward the insanity defense are further associated with reli-
gious commitment (Updike & Shaw, 1995), the results raise concerns about the
extent to which insanity verdicts may be determined by individual beliefs as op-
posed to the facts of the case. It has been suggested (e.g., Updike & Shaw, 1995)
that courts should allow extended voir dires, to permit for more extensive, prob-
ing questions so as eliminate those jurors whose decisions will be biased.
Archival Research
Demographic Characteristics. Research has generally demonstrated that fe-
males are more likely to be acquitted than are males and that defendants under
the age of 20 are less likely to successfully raise the insanity defense than older de-
fendants (Cirincione et al., 1995). In Japan, Satsumi and Oda (1995) found that
within a population of insanity evaluatees diagnosed with major psychoses, those
who were found not responsible were more likely to be married and living with
others in their own homes than those who were found responsible or of dimin-
ished responsibility. However, given the constraints of this sample it is difficult
to generalize these findings to the entire population of insanity evaluatees.
Psychiatric Diagnosis and Psychiatric History. As would be expected, indi-

viduals diagnosed with a major mental illness and who had been previously
hospitalized, were more likely to be acquitted than those diagnosed with less
debilitating disorders (Lymburner, 1997; Roesch et al., 1997). In fact, one of
the most significant and consistent correlates of an NGRI verdict is diagnosis
with a psychotic disorder (Cirincione et al., 1995). Nonetheless, research has
also consistently demonstrated that a small number of individuals who are not
diagnosed with a psychiatric disorder are acquitted by reason of insanity (e.g.,
Cirincione et al., 1995; Lymburner, 1997).
Offense Type and Criminal History. Cirincione et al. (1995) indicate that
along with diagnosis, offense type is one of the most consistent correlates of an
NGRI verdict. More specifically, Cirincione et al. (1995) found the highest
success rate for insanity defendants among those charged with violent crimes
other than murder, followed by those charged with murder, and then all other
offenses. This research also indicated that defendants whom had committed
crimes against persons to whom they were related were more likely to be ac-
quitted than those who had committed crimes against unrelated persons.
The majority of research indicates that, as compared with convicts, NGRI
acquittees tend to have fewer prior convictions and are less likely to have been
previously imprisoned (Cirincione et al., 1995; Hodgins, 1993). The results are
less clear when prior arrest rates are examined, with Cirincione et al. (1995)
finding that defendants with prior arrests were more likely to be successful in
raising the insanity defense in some states, while success rates were lower in
other states.
Beaudoin, Hodgins, and Lavoie (1993) compared three groups who had com-
mitted homicide: schizophrenic NGRI acquittees, convicted schizophrenics, and
convicted nonmentally disordered individuals. Given the finding that convicted
schizophrenics had started crime earlier than those who were found NGRI,
Beaudoin et al. (1993) proposed that those who are acquitted by reason of in-
sanity tend to have commited crimes after they developed a mental disorder,
while those who are convicted are more likely to commit crime before their
mental disorder is fully developed. They also found that 25% of the aggressive
incidents of NGRI acquittees occurred during the active phase of their illness.
Expert Testimony. Research has consistently demonstrated a strong agree-

ment between clinical evaluations of insanity and court verdicts (e.g., Warren,
Rosenfeld, & Fitch, 1994). Janofsky et al. (1996) reported that the opinion of
the court medical office is highly associated with a successful insanity plea. In
fact, 70.5% of insanity pleas are dropped immediately following an unfavor-
able evaluation by a practitioner. Looking at the broader picture, Warren et
al. (1994) found in 100 of 110 cases, clinicians’ evaluations were utilized by de-
fense attorneys, either for plea bargaining, testimony at trial, or testimony at
sentencing. Further, even when defendants were convicted despite clinical
evaluations indicating legal insanity, clinicians’ recommendations increased
the likelihood that the defendant would be ordered to receive treatment as
part of the disposition and decreased the likelihood that the defendant would
be sent to jail. Finally, the high dismissal rate for minor offenses favors the
conclusion that clinicians may be even more likely to have an impact on cases
in which the offense is less serious (Warren et al., 1994).
Trial Type. Cirincione (1996) reports that of the 14.4% of insanity cases
that are adjudicated by jury, three quarters result in conviction. However, the
high conviction rate may be at least partially attributed to the fact that jury tri-
als are more commonly utilized in contentious cases involving severe crimes
and less mental disorder. Plea bargains are used in 42.9% of insanity cases and
are most likely to lead to conviction, with 87.9% of insanity defendants plead-
ing guilty. Bench trials also occurred in a little less than half of insanity cases
but, in contrast with plea bargains and jury trials, led to an acquittal in 54.6%
of insanity cases. The author speculates that bench trials are more likely to oc-
cur when the prosecution agrees to the insanity verdict and/or the judge is
more likely to be swayed by the defense’s arguments.
Using a sample of insanity defendants in Baltimore City, Janofsky et al.
(1996) found that trial court (district vs. circuit) did not differentiate between
successful and unsuccessful insanity defendants though representation by a
private attorney increased the probability of success.
Outside North America

In Germany, until the latter half of the present century, a diagnosis of psy-
chosis was sufficient for a finding of insanity. This paradigm changed in the
1950s and, currently, a defendant’s level of responsibility is carefully assessed

to determine whether he or she is responsible, diminished in responsibility or
not responsible for a criminal offense. A study conducted by Nedopil (1997)
examined the expert assessments of 38 schizophrenic individuals who had
committed violent offenses in Germany.6 Within this subsample, the research-
ers found that alcohol intoxication did not influence the assessment of respon-
sibility though dissocial development clearly differentiated between patients
found completely nonresponsible and those for whom there were doubts
about their responsibility. Specifically, the more dissocial elements that were
observed, the less sure the expert was about the assessment of nonresponsibil-
ity. Nedopil concluded that, while there still seemed to be a great tendency to
regard schizophrenics as not responsible for their acts of violence, this was de-
creased by the presence of dissocial elements.
In Israel, clinicians’ judgments about criminal responsibility were strongly
related to their perceptions of the defendant’s ability to distinguish right from
wrong (Durat, Jabotinsky-Rubin, & Ginath, 1993). Another study of insanity
defendants in Israel revealed results that are much in line with the data from
North America. Heinik, Kimhi, and Hes (1994) found that personality disor-
dered defendants were judged as being more responsible for their criminal be-
havior, psychotics were determined to be less responsible, and individuals di-
agnosed with dementia fell somewhere in between, with approximately half
judged as not responsible and half judged to be responsible.
In Sweden, the laws governing mentally ill offenders are somewhat different
in that everyone is found guilty and held responsible for their criminal behav-
ior, but those who are found to suffer from a severe mental disorder are sen-
tenced to treatment as opposed to a jail term. Nonetheless, similar issues arise
in the consideration of what constitutes a severe mental disorder as do in the
question of what constitutes legal insanity. A large scale study compared all
evaluatees diagnosed with a personality disorder to evaluatees with other di-
agnoses (Kullgren, Grann, & Holmberg, 1996). The researchers found that
while 49% of all evaluatees were deemed by clinicians to meet the criteria for
severe mental disorder, only 10% of those with a primary diagnoses of person-
ality disorder met criteria. Within the group of personality disordered offend-
ers, those with Cluster A personality disorders (i.e., paranoid, schizoid, schizo-
typal), those with low functioning, and those who were experiencing a severe
stressor were more likely to be judged to have a severe mental disorder. Per-
sonality disordered individuals who were charged with serious offenses against
persons were least likely to be found severely mentally disordered.
Detention and Release Patterns for Insanity Acquittees

Following an insanity acquittal, it continues to be the case that many acquit-
tees are committed to institutions, with the length of confinement varying con-
siderably. In some jurisdictions, insanity acquittees account for more than half
6 As this sample represents only 7.5% of all individuals examined for violent offenses, the reader is cau-
tioned about the limited generalizability of these results.

the number of long-term psychiatric hospital beds (e.g., Missouri, see Linhorst
& Dirks-Linhorst, 1997). Literature in this area indicates that there is little
consistency across jurisdictions with respect to the length of time for which in-
sanity acquittees are detained. For example, in Quebec, Hodgins (1993) found
that the average length of hospitalization for insanity acquittees was almost 7
years with a warrant in the community for an additional 15 months. In con-
trast, research conducted in California indicated that the mean length of hos-
pitalization for insanity acquittees was 2.8 years (Marques, Haynes, & Nelson,
1993). Further, while it is sometimes the case that insanity acquittees are con-
fined for longer periods than would be the case had they been found guilty of
the same offense, this is also not a consistent finding. For example, Silver
(1995) reported that, with respect to length of confinement, there existed
much variation across states, with some jurisdictions holding insanity acquit-
tees for longer than convicts, while others showed the reverse trend or no dif-
ferences in length of confinement. Nonetheless, it is evident that at least some
insanity acquittees are being held for disproportionately long periods of time.7
Further, research has also consistently demonstrated that the length of deten-
tion for insanity acquittees is related to the seriousness of the offense, seem-
ingly reflecting an underlying punishment model (Clark, Holden, Thompson,
Watson, & Wightman, 1993; Hodgins, 1993; Silver, 1995). This research and
the implications of these findings will be discussed in the following section.
Using data gathered from seven states, Silver (1995) found that seriousness
of the offense was consistently related to the likelihood of release for insanity
acquittees, with more serious offenses associated with lower rates of release.
Further, persons who raised the insanity defense but were found guilty were
more likely to be released than those acquitted by reason of insanity (Silver,
1995). Alarmingly, mental disorder was related to release in only three of
seven states. Further, offense seriousness was a stronger predictor of length of
confinement than was mental disorder, suggesting that punishment is a higher
priority than is treatment. Silver concludes that, despite the fact that insanity
acquittees are, by definition, found not guilty, they are still being punished ac-
cording to the seriousness of their offense. To the extent that dangerousness
ratings stem from the seriousness of the offense, judgments about dangerous-
ness may be functioning as an indirect mechanism for punishing insanity ac-
quittees.
In support of this hypothesis, McGreevy (1993) found a direct relationship
between NGRI acquittees’ classification as dangerous and length of confine-
ment. Comparing groups of dangerously mentally ill (DMI) defendants with
those classified as mentally ill but not dangerous (MI), or neither mentally ill
nor dangerous (NMI), McGreevy (1993) found that individuals in the DMI
group were detained significantly longer (918 days as compared with 183 for
the MI group and immediate release for the NMI group). Consistent with these
findings, Wack (1993) reports that, in New York, the vast majority (85%) of in-
sanity acquittees are recommended for commitment to secure facilities.
7 It
must be noted that some authors (e.g., Hodgins, 1993) argue that the lengthy confinement arising
from a verdict of insanity may be beneficial to the defendant, allowing him/her the opportunity to receive
needed treatment.
In an effort to understand why NGRI acquittees are frequently hospitalized

for such extended periods despite the increasing legislative shift toward man-
dating similar discharge criteria for NGRI and non-NGRI patients, Shah,
Greenberg, and Convit (1994) examined the level of functioning of 62 NGRI
inpatients as compared to a matched sample of 62 psychiatric patients. Given
that the Krol statute establishes similar legal criteria in New Jersey for the dis-
charge of NGRI acquittees as compared to civilly committed persons, one
might assume that NGRI acquittees who are functioning reasonably well
would be released at the same rate as civilly committed individuals. However,
this was not found to be the case. In fact, although there was no difference in
the current length of hospitalization for NGRI and non-NGRI inpatients, the
NGRI acquittees had spent an average of 3 years in secure facilities prior to
the current hospitalization. Further, a significantly longer regional hospital
length of stay was found for NGRI patients. The authors suggest that this
longer length of stay may be partially explained by the greater seriousness of
offenses or by the higher incidence of paranoid schizophrenia (thus higher
dangerousness) in the NGRI sample. Of greatest interest is the fact that
NGRI patients appear to be functioning better than the general inpatient pop-
ulation with respect to personal care skills and social acceptability, and also
demonstrate a low rate of aggressiveness. Shah et al. (1994) concluded that,
based upon their higher level of functioning, it is difficult to explain why more
NGRI patients are not receiving conditional release. While the authors con-
cede that risk of reoffending is a legitimate concern, they feel that closely
monitored conditional release programs offer a feasible and more ethical al-
ternative to continued hospitalization.
Bloom and Williams (1994) investigated the relationship between psychiat-
ric diagnoses of bipolar disorder, schizophrenia, personality disorder, and
mental retardation and the insanity defense within a group of insanity acquit-
tees who had been assigned to a psychiatric security review board. They found
that individuals diagnosed with schizophrenia and bipolar disorder had a
greater number of past hospitalizations. Despite the absence of differences
with respect to the number of criminal contacts or seriousness of current of-
fense across diagnostic categories, diagnosis was related to release decisions.
Specifically, those diagnosed with personality disorders seemed to be handled
differently than those in the other three categories, with a much greater likeli-
hood of being discharged, particularly granted early discharges. Those diag-
nosed with bipolar disorder were more likely to receive conditional releases.
Outside North America

Data from outside North America may raise even greater concerns about
release practices. For example, the law governing the detention of insanity ac-
quittees in Ireland does not mandate a formal review but rather stipulates that
insanity acquittees may apply for release on the basis of no longer posing a
danger to society (Gibbons et al., 1997). Thus, the decision to release acquit-
tees is made on the basis of potential dangerousness and does not consider
need for treatment or current mental status. Gibbons et al. (1997) expressed
great concern over their finding that the average length of detention for insan-
ity acquittees in Ireland equaled 14.5 years, with 42% having died in custody
at the time of the study. The authors speak to the desperate need for reform of
the insanity defense law in Ireland.
In Germany, statistics from the past 10 years indicate that, although there is
variability across states, the length of time that NGRI acquittees tend to remain
hospitalized is decreasing (Nedopil & Otterman, 1993). Nonetheless, the ab-
sence of limits on hospital orders and the fact that the acquittee’s length of stay
must be related to the severity of the act committed are potentially problematic.
In England, MacKay and Ward (1994) expressed concern that a group of 74
insanity acquittees who had been detained prior to the Criminal Procedure
(Insanity) Act of 1964 were still hospitalized 15 or more years later. Even
more alarming was the fact that 38% of these individuals, including a subset
who had been found unfit to stand trial and for whom guilt was never estab-
lished, had been continuously confined for more than 30 years. The authors’
review of the patient’s files call into question whether the legal criteria for un-
fit and/or insanity had ever been met. MacKay and Ward (1994) observed that
while a number of these patients were legitimately detained for treatment,
many were confined on the basis of “common sense” dangerousness assess-
ments or because the patients indicated a wish to remain in the institution (of-
ten arising from negative self-views or patients’ perceptions that they were not
wanted in the community).
Recidivism
Research on recidivism rates has found that, overall, rearrest rates during
conditional release ranged from 2% to 16%, with these numbers increasing
substantially for longer-term follow-up periods (i.e., 42–56%). In Quebec, Hod-
gins (1993) conducted a follow-up study of all individuals who had been found
NGRI or unfit to stand trial in Quebec from 1973 through 1975. Seven years
postrelease, 37.8% of those alive and living in Canada had been convicted of
another criminal offense, though almost all recidivism had occurred in the first
3 years after discharge. In the 7 years following discharge, 61% of these pa-
tients were rehospitalized. In Heilbrun and Griffin’s (1993) review of the com-
munity-based forensic treatment of insanity acquittees, they found that none
of their sample had committed a violent crime during the 1.5-year follow-up
period. In Oregon only 5% were arrested while on conditional release, though
another study conducted in this state indicated a rearrest rate of 42% after ac-
quittees were released from the review board jurisdiction (Heilbrun & Griffin,
1993). In Maryland, 15% were rearrested though for less serious offenses than
the original indictment. However, over the course of 15 years, 56% of this sam-
ple had been rearrested. In California, a 5-year follow-up revealed that 48% of
acquittees had their conditional release revoked and 16% had been rearrested.
Finally, in New York, Heilbrun, Lawson, Spier, and Libby (1994) found that,
over the course of 3.8 years, 22% of acquittees had been rearrested.
In an attempt to better understand the correlates of a clinical profile of re-
cidivistic violence, Sreenivasan et al. (1997) compared civilly committed indi-
viduals and NGRI acquittees. The researchers found that recidivistic violence
was strongly related to both prior criminal history and antisocial behavior.
More specifically, membership in the violent group could best be predicted by

three factors: (a) impaired reality testing as evident in those with the dual di-
agnosis of psychotic disorder and substance abuse, (b) cognitive inflexibility as
identified by low scores on the Wechsler Adult Intelligence Scale-Revised
(WAIS-R; Wechsler, 1981) Block Design sub-test and perserveration on the
Wisconsin Card Sorting Test (WCST; Heaton, 1981), and (c) low moral con-
trols as suggested by moderate ratings on psychopathy (PCL-R; Hare, 1991).
In countries outside North America, research suggests that recidivism rates
may be much higher. For example, in Finland, Vartianinen and Hakola (1992)
found that for discharged NGRI acquittees, during their first year outside the
hospital, the risk of homicide was approximately 800 times greater than among
the general population. Offender patients who presented the greatest risk were
those who did not continue treatment and showed little insight into their illness.
Heilbrun et al. (1994) examined the impact that the goodness of fit between
the insanity acquittee and the community living placement may have on out-
come of conditional release. Their research suggests that the fit with respect to
level of monitoring and treatment was related to successful outcomes. Para-
doxically, lower patient-to-staff ratios and more frequently scheduled social
support differentiated the unsuccessful group. However, the authors suggest
that such findings be treated with caution given the small number and pilot na-
ture of this study. Nonetheless, goodness of fit may prove to be a useful mea-
sure so as to maximize acquittees’ chances of success.
As previously indicated, the longer detention of insanity defense acquittees
has often been justified on the basis of the supposedly increased dangerous-
ness of mentally ill individuals. However, research has not generally supported
this conclusion. Harris and Koepsell (1996) conducted a study comparing the
criminal recidivism of mentally ill offenders with that of the general popula-
tion and found no differences in time to rearrest. The reader is cautioned that
this research does not specifically compare recidivism for NGRI acquittees
with those who raise the insanity defense and are found guilty, and thus its
generalizability may be limited.
Rehospitalization
Heilbrun and Griffin (1993) found that rates of rehospitalization for insan-
ity acquittees on conditional release varied greatly across studies, ranging
from 11% to 78%, though the majority of estimates fell between 11 and 40%.
In Illinois, 25% of released NGRI acquittees were rehospitalized during the
1.5-year follow-up, while the numbers were slightly higher in Oregon (32%)
and in Maryland (41%). In California, a 5-year follow-up revealed that 48% of
acquittees had their conditional release revoked and 34% had been rehospital-
ized. In New York, Heilbrun and Griffin (1993) found that, over the course of
3.8 years, 28% of insanity acquittees had been involuntarily hospitalized.
The Impact of Changes to Insanity Defense Standards

Blau and Pasewark’s (1994) review of the empirical literature on the effects
of insanity defense statutory changes revealed that, with only a few exceptions,
the research literature arising from both mock jury and archival research has
consistently found that statutory changes to the insanity defense do not appear
to affect the frequency and success of insanity pleas, nor do changes in statu-
tory definitions affect mock-jury decisions.
In contrast, Cirincione (1996) found that, while reforms focusing on trial
procedures were unlikely to lead to definitive changes, reforms at the disposi-
tion stage were more likely to lead to observable changes (Cirincione, 1996).8
Specifically, such reforms tend to increase the number of insanity pleas that
are resolved through plea bargaining, which in itself is strongly related to a
guilty verdict.
Consistent with Cirincione’s (1996) conclusion that reforms at the disposi-
tion stage lead to observable changes, recent amendments to Canada’s Crimi-
nal Code (i.e., Bill C-30) appear to have had a significant impact. Bill C-30
changed the verdict of not guilty by reason of insanity to not criminally respon-
sible by reason of mental disorder. These provisions broadened the potential
scope and ensuing dispositions of the defense, thus rendering it a more appeal-
ing option as the consequences became potentially less severe. Not surpris-
ingly, recent research suggests that psychiatrists’ recommendations for
NCRMD have increased since the introduction of Bill C-30. Roesch et al.
(1997) studied the impact of Bill C-30 in British Columbia, and concluded that
both the use and success of the NCRMD defense seems to be on the rise. In
contrast, Arboleda-Flórez, Crisanti, and Holley (1995) found that Bill C-30 re-
sulted in a decrease in the number of pretrial assessments by 9.6%, though the
majority of these were for fitness assessments (there were too few NCRMD’s
to evaluate separately). Arboleda-Flórez et al. (1995) also found that since the
introduction of Bill C-30, practitioners more commonly had to appear in court
to give testimony. The length of the assessment was not affected and the same
number of NGRI recommendations were made by practitioners. Finally, given
that Bill C-30 does not allow a treatment order, the authors’ finding that more
frequent use is being made of the Mental Health Act to commit people is not
surprising. In Ontario, a study examining the effects of Bill C-30 concluded
that the number of insanity assessments had increased significantly in the year
following the introduction of the amendments (Nussbaum, Malcolmson, &
Dosis, in press).
Callahan, Robbins, Steadman, and Morrissey (1995) examined the impact of
Montana’s 1979 legal reform, which abolished the affirmative defense of insanity
and established a mens rea defense in which the state has the burden of establish-
ing beyond a reasonable doubt that the defendant acted “purposely and know-
ingly.” The results of this change suggest that while the abolition of the insanity
defense resulted in a drastic drop in insanity acquittals as well as fewer guilty ver-
dicts, the number of defendants found incompetent to stand trial increased sub-
stantially postreform. Ironically, the reforms also resulted in a decrease in the
number of individuals who were sent to prison and an increase in the number
who were released. Thus, while this theoretically more strict approach did result
in an increased number of the more serious offenders being incarcerated, it also
8 Interestingly, Cirincione (1996) notes that the single most common reform were changes at the disposi-
tion stage (i.e., a change in the release and commitment procedures for insanity acquittees).
led to the release of more of these criminals. In general, more defendants who
raised mental state at the time of the trail were released after the reform.
In an effort to reduce the number of NGRI verdicts, recent legislative re-
forms in the United States have effectively dropped the volitional prong from
the insanity defense, leaving it an essentially cognitive defense. Bailis et al.
(1995) used a mock jury paradigm to investigate the possible effects of such a
change. In their first experiment, Bailis et al.(1995) gave participants informa-
tion pertaining to the degree of the defendant’s impairment in both cognitive
and volitional spheres. They found that 95% of individuals rendered NGRI
verdicts for cases in which the defendant showed absolute cognitive and con-
trol impairment, while not one participant rendered an NGRI verdict in the
no impairment condition. Despite the fact that the legal test states that abso-
lute impairment on either dimension should be met with an NGRI verdict,
participants were more likely to render NGRI verdicts when the defendant
showed absolute impairment on control as opposed to cognitive dimensions
(76% vs. 57%). The authors concluded that jurors seem to want to see sub-
stantial impairment on both dimensions before they are willing to render an
NGRI verdict. In the second study, Bailis et al. (1995) gave participants infor-
mation pertaining to the defendant’s diagnosis so that they might draw their
own inferences about cognitive and control impairment. Juror’s ratings on
cognitive and control impairment influenced verdicts, with greater degrees of
impairment related to increased likelihood of an NGRI verdict, particularly
for control impairment. Bailis et al. (1995) conclude that jurors implicit stan-
dards are very much in line with legal standards with the exception that jurors
tend not to strictly differentiate cognitive and control impairments and tend to
perceive control impairments as more important.
Guilty but Mentally Ill

The guilty but mentally ill (GBMI) verdict was introduced in the United
States to serve three purposes: (a) to reduce the number of individuals who
plead insanity, (b) to protect the public from further criminal acts perpetrated
by the mentally ill, and (c) to provide treatment for those who need it while at
the same time reducing recidivism rates among the mentally ill population
(Blau & Pasewark, 1994). Blau and Pasewark’s (1994) review of the research
on the GBMI, however, revealed that while the results varied tremendously
across states, there appears to be no evidence to suggest that these goals were
met. In fact, the GBMI verdict tends to draw from both those defendants who
would normally be found guilty and those who would have normally been
found NGRI, creating an entirely new class of, often inappropriate, verdicts.
In essence, the GBMI verdict allows people to avoid grappling with the diffi-
cult issue of guilt. Further, research has demonstrated that nearly half of
GBMI verdicts result in probation sentences and 75% of defendants do not re-
ceive adequate treatment. Roberts et al. (1993) point out that when jurors
have the option of a GBMI verdict, the threshold for a Guilty or NGRI verdict
is raised such that jurors will only render these verdicts in extreme cases (i.e.,
when the defendant is minimally disordered and has intact cognitive abilities
or conversely, when the subject displays blatant symptoms of psychopathology
and shows substantial cognitive impairment). Further, in sharp contrast to the

law, many jurors appeared to believe that the GBMI verdict implies dimin-
ished responsibility and a less punitive disposition. Thus, GBMI verdicts ap-
pear to arise from both an unwillingness to grapple with the more difficult is-
sue of guilt, in addition to ignorance and confusion about the law.
In his review of the literature, Bumby (1993) points out that the rationale be-
hind the GBMI was nonsensical, given the infinitely small number of individuals
who successfully raise the insanity defense. He also concurs with Blau and
Pasewark (1994), stating that the introduction of the GBMI verdict results in
more inappropriate GBMI verdicts when the defendant should be found Guilty
or NGRI. Further, the defense increases the difficulty of jurors’ tasks in that
they are now forced to discriminate between mental illness, insanity, and sanity.
Finally, the bill does not mandate treatment for GBMI defendants but instead
orders only an assessment that is already available for mentally ill defendants.
Callahan, McGreevy, Cirincione, and Steadman (1992) found that the intro-
duction of the GBMI did not influence the plea rate though the number of ac-
quittals dropped substantially. In particular, there appeared to have been a de-
crease in the successful use of the insanity defense for violent crimes. Further
individuals who were found GBMI were more likely to receive life sentences
and were almost always incarcerated as opposed to being hospitalized. While
the GBMI verdict acknowledged the presence of mental illness, it did not ap-
pear that any effort was made toward treatment. Given the harsh reality of
what happens when a defendant is found GBMI, it is likely that lawyers may
be less willing to use the insanity defense.
Rights of the Defendants

As we have seen, the decision to raise an insanity defense carries serious con-
sequences for defendants, which may include lengthier detentions than would
be imposed upon individuals convicted of similar offenses. However, despite the
potentially serious consequences of pleading insanity, a formal evaluation of the
defendants’ competency to raise an insanity defense is often not conducted, nor
are competency to stand trial assessments routinely carried out for those who
plead insanity. While some have argued that the legal process ensures that a de-
fendant must necessarily be competent to raise the insanity defense, recent re-
search appears to dispute this assertion. In fact, studies suggest that the vast ma-
jority of defendants are both ill-informed about the insanity defense as well as
incompetent to make a decision at the time of the trial. Elliott et al. (1993) con-
ducted a retrospective study of NGRI acquittees currently residing in a mental
hospital to examine defendant’s knowledge about the consequences of an insan-
ity defense and the severity of defendant’s symptoms at the time of the trial.9
They concluded that 76% of defendants were likely incapable of making a com-
9 The authors point out that although retrospective data renders an evaluation of mental state and knowl-
edge at the time of the trial difficult, it is not unreasonable to assume that their assessments would in fact un-
derestimate the number of incapable defendants. This assumption rests on the premise that knowledge at
the time of the interview would in fact be greater than knowledge at the time of the trial due to the defen-
dant’s exposure to subsequent evaluation hearings and discussion with treatment teams.
petent decision to raise the insanity defense at the time of the trial. The authors
also found that, despite the obvious issues around mental state, competency to
stand trial was assessed in only about half of the cases. Furthermore, in eight of
the cases that were subsequently found NGRI, defendants had previously been
found incompetent to stand trial with no evidence to suggest that they had been
restored to competency before going to trial. Elliott et al. (1993) recommended
that information be provided to members of the legal system with respect to: (a)
the importance of defendants making informed decisions about pleading insan-
ity, and (b) the consequences of a successful insanity plea. Finally, the authors
recommended that a formal evaluation of a defendant’s capability be under-
taken before an insanity plea is entered.
Given concerns about the competency of forensic psychiatric populations,
Smith and Broughton (1994) conducted a study to specifically focus on mentally
retarded offenders. They found that mentally retarded offenders are being un-
deridentified and, moreover, that 62% of those mentally retarded offenders who
were judged not competent were also judged to be criminally responsible.
To further complicate this matter, a recent U.S. national survey indicated
that 35% of jurisdictions permit the insanity defense to be imposed on an un-
willing defendant (Miller et al., 1996). There was some variation across states
regarding whether the defense could be imposed upon competent defendants,
though at least 9 of 14 jurisdictions responded affirmatively. Thus, even those
defendants who are competent to make an informed decision regarding
whether they wish to utilize the insanity defense are not always free to choose.
Further, the study also revealed that many defendants who do not wish to
raise the insanity defense do so under pressure from their lawyers. The au-
thors conclude that it is not unreasonable to infer that the actual incidence of
involuntary insanity pleas may be much higher than this study indicates and is
not confined to those states in which the practice is legally condoned.
Other researchers have addressed this issue from the opposite angle, hold-
ing that some individuals, who may in fact be better served by using the insan-
ity defense,10 do not have the opportunity to do so. Neumann, Walker, Wein-
stein, and Cutshaw (1996) examined the relationship between psychotic
patients’ insight into their mental illness and current symptoms, and their will-
ingness to raise the insanity defense. Consistent with past research, they found
that 42% of a population of psychiatric inpatients denied having a mental ill-
ness and that insight was related to patients’ willingness to consider an insanity
defense. Specifically, 77% of the insightful patients were open to using the in-
sanity defense while only 31% of the noninsightful patients would consider
this defense. The authors concluded that psychotic patients’ lack of insight
might influence their ability to secure the most appropriate defense in a court
10 Itis a matter of debate whether in fact the insanity defense can benefit defendants who utilize it. Neu-
mann, Walker, Weinstein, and Cutshaw (1996) argue that an insanity acquittal allows defendants to access
needed treatment. A survey of attorneys conducted by Blau and McGinley (1995) indicated that lawyers
(particularly defense lawyers) perceived some benefit to defendants from using the insanity defense, partic-
ularly when raised prior to the preliminary hearing, as it can be used in a negotiated disposition. However,
given that the same authors also report that lawyers tend to have a generally poor understanding of the de-
fense and its consequences, one must be cautious in interpreting these results.
of law. With respect to the appropriateness of court ordered referrals for men-
tal health assessments, research has yielded mixed conclusions. Leong and
Silva’s (1995) finding that clinicians supported the insanity defense in 38.5%
of referred cases led them to conclude that courts are making appropriate re-
ferrals within a sample of serious offenders. Warren et al. (1994), on the other
hand, suggest that courts frequently make inappropriate referrals for the eval-
uation of insanity. In their study of defendants who were evaluated for mental
state at the time of the offense, the authors found that only 32% were diag-
nosed as having a mental disease or defect, with only 9% of these meeting Vir-
ginia’s criteria for legal insanity.
Conclusion
While a considerable, and perhaps disproportionate, amount of psycholegal
research has focused on the insanity defense, it appears to be the case that nei-
ther this research nor the many changes in law and policy that have been made
over the years have satisfied the public’s concerns about the insanity defense.
These concerns, however, appear to be based on a number of misconceptions.
Empirical research has consistently demonstrated that the insanity defense is
rarely used, is generally only successful for the most severely disordered de-
fendants, and that insanity acquittees are often detained for extended periods.
Thus, it would appear that our attention need not be directed toward further
empirical research in this area, but rather toward disseminating our current
state of knowledge. Of particular importance is the finding that it is not just
the general public that misunderstand the insanity defense, as even members
of the legal profession are frequently uninformed as to the consequences of an
insanity verdict.
Promisingly, the extensive criticism directed toward forensic practitioners
as well as the potentially severe consequences of being found not guilty by rea-
son of insanity appear to have instigated a change in the direction of research
on the insanity defense. In the past 5 years, research has shifted from a focus
on topics such as demographics and recidivism to a closer examination of the
clinical assessment of those who plead insanity. After years of being over-
looked in the mass hysteria surrounding the use of the insanity defense, the
rights of defendants have now taken a more central focus. Recent research has
focused on the pretrial evaluation facilities, the professional qualifications of
those who perform forensic assessments, the instruments that are or should be
utilized in this process, and new methodologies to aid in decisions about condi-
tional release as well as techniques for evaluating and better predicting out-
come of conditional release. The competence of insanity defendants has also
been considered. We believe that this newer line of research will lead to im-
provements in the procedures used to evaluate and treat individuals whose
criminal responsibility is at issue.
References
American Law Institute (1962). Model penal code. Philadelphia: American Law Institute.
Arboleda-Flórez, J., Crisanti A., & Holley, H. L. (1995). The effects of changes in the law concerning men-
tally disordered offenders: The Alberta experience with Bill C-30. Canadian Journal of Psychiatry, 40,
225–233.
Bagby, R. M., Rogers, R., & Buis, T. (1994). Detecting malingered and defensive responding on the MMPI-2
in a forensic inpatient sample. Journal of Personality Assessment, 62, 191–203.
Bailis, D. S., Darley, J. M., Waxman, T. L., & Robinson, P. H. (1995). Community standards of criminal lia-
bility and the insanity defense. Law and Human Behavior, 19, 425–446.
Beaudoin, M. N., Hodgins, S., & Lavoie, F. (1993). Homicide, schizophrenia and substance abuse or depen-
dency. Canadian Journal of Psychiatry, 38, 541–546.
Bersoff, D., Goodman-Delahunty, J., Grisso, J. T., Hans, V. P., Poythress, N. G., & Roesch, R. (1997).
Training in law and psychology: Models from the Villanova conference. American Psychologist, 52, 1301–
1310.
Blau, G. L., & McGinley, H. (1995). Use of the insanity defense: A survey of attorneys in Wyoming. Behav-
ioral Sciences and the Law, 13, 517–528.
Blau, G. L., & Pasewark, R. A. (1994). Statutory changes and the insanity defense: Seeking the perfect
insane person. Law and Psychology Review, 18, 69–108.
Bloom, J. D., & Williams, M. H. (1994). Management and treatment of insanity acquittees: A model for the
1990s. Washington, DC: American Psychiatric Press.
Boardman, A., Stafford, K., & Ben-Porath, Y. (1996). A comparative investigation of insanity acquittees and
unsuccessful insanity evaluatees. Paper presented at the biennial conference of the American Psychology
Law Society, Hilton Head, South Carolina.
Borum, R., & Grisso, T. (1995). Psychological test use in criminal forensic evaluations. Professional Psy-
chology: Research and Practice, 26, 465–473.
Borum, R., & Grisso, T. (1996). Establishing standards for criminal forensic reports: An empirical analysis.
Bulletin of the American Academy of Psychiatry and Law, 24, 297–317.
Bumby, K. M. (1993). Reviewing the Guilty But Mentally Ill alternative: A case of the blind “pleading” the
blind. Journal of Psychiatry and Law, 21, 191–220.
Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Manual for the
administration and scoring of the MMPI-2. Minneapolis: University of Minnesota Press.
Callahan, L. A. (1991). The volume and characteristics of insanity pleas: An eight state study. Bulletin of the
American Academy of Psychiatry and Law, 19, 331–338.
Callahan, L. A., Robbins, P., Steadman, H. J., & Morrissey, J. P. (1995). The hidden effects of Montana’s
“abolition” of the insanity defense. Psychiatric Quarterly, 66, 103–117.
Callahan, L. A., McGreevy, M. A., Cirincione, C., & Steadman, H. J. (1992). Measuring the effects of the Guilty
But Mentally Ill (GBMI) verdict: Georgia’s 1982 GBMI reform. Law and Human Behavior, 16, 447–462.
Cirincione, C. (1996). Revisiting the insanity defense: Contested or consensus? Bulletin of the American
Academy of Psychiatry and Law, 24, 165–176.
Cirincione, C., Steadman, H. J., & McGreevy, M. A. (1995). Rates of insanity acquittals and the factors
associated with successful insanity pleas. Bulletin of the American Academy of Psychiatry and Law, 23,
399–409.
Clark, C. R., Holden, C. E., Thompson, J. S., Watson, P. L., & Wightman, L. H. (1993). Forensic treatment
in the United States: A survey of selected forensic hospitals. Treatment at Michigan’s Forensic Center.
International Journal of Law and Psychiatry, 16, 71–81.
Diamond, S. S. (1997). Illuminations and shadows from jury simulations. Law and Human Behavior, 21,
561–572.
Durat, R., Jabotinsky-Rubin, K., & Ginath, Y. (1993). A look at court appointed psychiatric evaluations in
Israel with special reference to criminal liability. Medicine and Law, 12, 153–163.
Elliott, R. L., Nelson, E., Lawrence Fitch, W., Scott, R., Wolber, G., Singh, R. (1993). Informed decision
making in persons acquitted Not Guilty by Reason of Insanity. Bulletin of the American Academy of Psy-
chiatry and Law, 21, 309–320.
Farkas, G. M., DeLeon, P. H., & Newman, R. (1997). Sanity examiner certification: An evolving national
agenda. Professional Psychology: Research and Practice, 28, 73–76.
Finkel, N. J., & Groscup, J. L. (1997). Crime prototypes, objective versus subjective culpability, and a com-
monsense balance. Law and Human Behavior, 21, 209–230.
Finkel, N. J., & Slobogin, C. (1995). Insanity, justification, and culpability: Toward a unifying schema. Law
and Human Behavior, 19, 447–464.
Gacono, C. B., Meloy, J. R., Sheppard, K., Speth, E., & Roske, A. (1995). A clinical investigation of malin-
gering and psychopathy in hospitalized insanity acquittees. Bulletin of the American Academy of Psychia-
try and Law, 23, 387–397.
Ganallen, R. J., Wasyliw, O. E., Haywood, T. W., & Grossman, L. S. (1996). Can psychosis be malingered
on the Rorschach? An empirical study. Journal of Personality Assessment, 66, 65–80.
Gibbons, P., Mulryan, N., & O’Connor, A. (1997). Guilty but insane: The insanity defense in Ireland, 1850-
1995. British Journal of Psychiatry, 170, 467–472.
Grisso, T., Cocozza, J. J., Steadman, H. J., Fisher, W. H., & Greer, A. (1994). The organization of pretrial
forensic evaluation services: A national profile. Law and Human Behavior, 18, 377–393.
Grisso, T., Cocozza, J. J., Steadman, H. J., Greer, A., & Fisher, W. H. (1996). A national survey of hos-
pital- and community-based approaches to pretrial mental health evaluations. Psychiatric Services, 47,
642–644.
Hare, R. D. (1991). Manual for the Hare Psychopathy Checklist-Revised. Toronto: Multi-Health Systems.
Harris, V., & Koepsell, T. D. (1996). Criminal recidivism in mentally ill offenders: A pilot study. Bulletin of
the American Academy of Psychiatry and Law, 24, 177–186.
Heaton, R. K. (1981). A manual for the Wisconsin Card Sorting Test. Odessa, FL: Psychological Assess-
ment Resources.
Heilbrun, K., & Griffin, P. A. (1993). Community-based forensic treatment of insanity acquittees. Interna-
tional Journal of Law and Psychiatry, 16, 133–150.
Heilbrun, K., Lawson, K., Spier, S., & Libby, J. (1994). Community placement for insanity acquittees: A
preliminary study of residential programs and person-situation fit. Bulletin of the American Academy of
Psychiatry and Law, 22, 551–560.
Heinik, J., Kimhi, R., & Hes, J. (1994). Dementia and crime: A forensic psychiatry unit study in Israel. Inter-
national Journal of Geriatric Psychiatry, 9, 491–494.
Hiscock, C. K., Rustemier, P. J., & Hiscock, M. (1993). Determination of criminal responsibility: Applica-
tion of the two-alternative forced-choice stratagem. Criminal Justice and Behavior, 20, 391–405.
Hodgins, S. (1993). Mental health treatment services in Quebec for persons accused or convicted of criminal
offenses. International Journal of Law and Psychiatry, 16, 179–194.
Janofsky, J. S., Dunn, M. H., Roskes, E. J., Briskin, J. K., & Lunstrum Rudolph, M. (1996). Insanity defense
pleas in Baltimore City: An analysis of outcome. American Journal of Psychiatry, 153, 1464–1468.
Kalven, H., & Zeisel, H. (1966). The American jury. Boston: Little, Brown.
Kleinke, C. L., & Baldwin, M. R. (1993). Responsibility attributions for men and women giving sane versus
crazy explanations for good and bad deeds. Journal of Psychology, 127, 37–50.
Kullgren, G., Grann, M., & Holmberg, G. (1996). The Swedish forensic concept of severe mental disorder as
related to personality disorders: An analysis of forensic psychiatric investigations of 1498 male offenders.
International Journal of Law and Psychiatry, 19, 191–200.
Leong, G. B., & Silva, J. A. (1995). A psychiatric-legal analysis of psychotic criminal defendants charged
with murder. Journal of Forensic Sciences, 40, 445–448.
Linhorst, D. M., & Dirks-Linhorst, P. A. (1997). The impact of insanity acquittees on Missouri’s public men-
tal health system. Law and Human Behavior, 21, 327–338.
Lymburner, J. A. (1997). Exploring the impact of offense characteristics and mental disorder on verdicts of
insanity. Unpublished master’s thesis, Simon Fraser University, Burnaby, British Columbia, Canada.
Marques, J. K., Haynes, R. L., & Nelson, C. (1993). Forensic treatment in the United States: A survey of
selected forensic hospitals. Forensic treatment at Atascadero State Hospital. International Journal of
Law and Psychiatry, 16, 57–70.
MacKay, R. D., & Ward, T. (1994). The long-term detention of those found unfit to plead and legally
insane. British Journal of Criminology, 34, 30–43.
McGreevy, M. A. (1993). A description of the forensic outpatient and the opinions of mental health profes-
sionals who work with these clients. Psychiatric Quarterly, 64, 235–245.
Miller, R. D., Olin, J., Johnson, D., Dodge, J., Iverson, D., & Fantone, E. (1996). Forcing the insanity
defense on unwilling defendants: best interests and the dignity of the law. Journal of Psychiatry and Law,
24, 487–509.
Nedopil, N. (1997). Violence of psychotic patients: How much responsibility can be attributed? Interna-
tional Journal of Law and Psychiatry, 20, 243–247.
Nedopil, N., & Otterman, B. (1993). Treatment of mentally ill offenders in Germany: With special reference
to the newest forensic hospital—Straubing in Bavaria. International Journal of Law and Psychiatry, 16,
247–255.
Neumann, C. S., Walker, E. F., Weinstein, J., & Cutshaw, C. (1996). Psychotic patients’ awareness of mental
illness: Implications for legal defense proceedings. Journal of Psychiatry and Law, 24, 421–442.
Nussbaum, D., Malcolmson, S., & Dosis, O. (in press). Summary of research on Bill C-30 Implementation in
Ontario during 1993 and 1994. In D. Eaves, J. R. P. Ogloff, & R. Roesch (Eds.), Mental disorders and the
Criminal Code: Legal, clinical, and research perspectives. Burnaby, BC: Mental Health, Law, and Policy
Institute.
Ogloff, J. R. P. (1991). A comparison of insanity defense standards on juror decision making. Law and
Human Behavior, 15, 509–531.
Ogloff, J. R. P., Schweighofer, A., Turnbull, S., & Whittemore, K. (1992). Empirical research and the insan-
ity defense: How much do we really know? In J. R. P. Ogloff (Ed.), Psychology and law: The broadening
of the discipline (pp. 171–210). Durham, NC: Carolina Academic Press.
Palermo, G. B., Smith, M. B., Gram, L. C., Zier, W., & Kohler, M. E. (1996). Trial by jury: A pilot study of
juror perception of mental health professional testimony in NGRI pleas for first degree intentional homi-
cide. Medicine and Law, 15, 17–42.
Perlin, M. L. (1996). “Dignity was the first to leave”: Godinez v. Moran, Colin Ferguson, and the trial of
mentally disabled criminal defendants. Behavioral Sciences and the Law, 14, 61–81.
Raine, A., Buchsbaum, M. S., Stanley, J., Lottenberg, S., Abel, L., & Stoddard, J. (1994). Selective reduc-
tions in prefrontal glucose metabolism in murderers. Biological Psychiatry, 36, 365–373.
Reichlin, S. M., Bloom, J. D., Williams, M. H. (1993). Excluding personality disorders from the insanity
defense: A follow-up study. Bulletin of the American Academy of Psychiatry and the Law, 21, 91–100.
Roberts, C. F., Sargent, E. L., & Chan, A. S. (1993). Verdict selection processes in insanity cases: Juror con-
struals and the effects of Guilty But Mentally Ill instructions. Law and Human Behavior, 17, 261–275.
Roesch, R., Ogloff, J. R. P., Hart, S. D., Dempster, R. J., Zapf, P. A., & Whittemore, K. E. (1997). The
impact of Canadian Criminal Code changes on remands and assessments of fitness to stand trial and crim-
inal responsibility in British Columbia. Canadian Journal of Psychiatry, 42, 509–514.
Rogers, R., Bagby, R. M., & Perera, C. (1993). Can Ziskin withstand his own criticisms? Problems with his
model of cross-examination. Behavioral Sciences and the Law, 11, 223–233.
Satsumi, Y., & Oda, S. (1995). Mentally ill offenders referred for psychiatric examination in Japan: Descrip-
tive statistics of a university unit of forensic assessment. International Journal of Law and Psychiatry, 18,
323–331.
Seig, A., Ball, E., & Menninger, J. A. (1995). A comparison of female versus male insanity acquittees in Col-
orado. Bulletin of the American Academy of Psychiatry and Law, 23, 523–532.
Shah, P. J., Greenberg, W. M., & Convit, A. (1994). Hospitalized insanity acquittees’ level of functioning.
Bulletin of the American Academy of Psychiatry and Law, 22, 85–93.
Silver, E. (1995). Punishment or treatment? Comparing the lengths of confinement of successful and unsuc-
cessful insanity defendants. Law and Human Behavior, 19, 375–388.
Silver, E., Cirincione, C., & Steadman, H. J. (1994). Demythologizing inaccurate perceptions of the insanity
defense. Law and Human Behavior, 18, 63–70.
Smith, S. A., & Broughton, S. F. (1994). Competency to stand trial and criminal responsibility: An analysis
in South Carolina. Mental Retardation, 32, 281–287.
Sreenivasan, S., Kirkish, P., Eth, S., Mintz, J., Hwang, S., Van Gorp, W., & Van Vort, W. (1997). Predictors
of recidivistic violence in criminally insane and civilly committed psychiatric inpatients. International
Journal of Law and Psychiatry, 20, 279–291.
Statistics Canada. (1998). Youths and adults charged in criminal incidents: Criminal Code, federal and pro-
vincial statutes, by sex 1997. Ottawa: Statistics Canada.
Steinberg, M. (1993) Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Washing-
ton, DC: American Psychiatric Press.
Steinberg, M., Bancroft, J., & Buchanan, J. (1993). Multiple personality disorder in criminal law. Bulletin of
the American Academy of Psychiatry and Law, 21, 345–356.
Stone, A. (1975). Mental health and law: A system in transition. Rockville, MD: National Institute of Mental
Health.
Updike, C. E., & Shaw, G. A. (1995). Differences in attitude toward the temporary insanity defense and the
insanity defense. The American Journal of Forensic Psychiatry, 13, 59–67.
U.S. Department of Justice. (1998). Prison and Jail inmates at midyear 1997. Bureau of Justice Statistics Bul-
letin NCJ 167247. Washington, DC: NCJRS.
Vartianinen, H., & Hakola, P. (1992). Monitored conditional release of persons found Not Guilty by Rea-
son of Insanity. American Journal of Psychiatry, 149, 415.
Wack, R. C. (1993). Forensic treatment in the United States: A survey of selected forensic hospitals. Treat-
ment services at the Kirby Forensic Psychiatric center. International Journal of Law and Psychiatry, 16,
83–104.
Warren, J. I., Rosenfeld, B., & Fitch, W. L. (1994). Beyond competence and sanity: The influence of pretrial
evaluation on case disposition. Bulletin of the American Academy of Psychiatry and Law, 22, 379–388.
Wechsler, D. (1981). Manual for the Wechsler Adult Intelligence Scale-Revised, (WAIS-R). San Antonio,
TX: Psychological Corporation.
Whittemore, K. E., & Ogloff, J. R. P. (1995). Factors that influence jury decision making: Disposition
instructions and mental state at the time of the trial. Law and Human Behavior, 19, 283–303.
Ziskin, J., & Faust, D. (1988). Coping with psychiatric and psychological testimony (4th ed.). Marina del
Rey, CA: Law and Psychology Press.
View publication stats

Roesch Lymburner IJLP1999

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Roesch Lymburner IJLP1999

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

The insanity defense: Five years of research (1993-1997)

Article in International Journal of Law and Psychiatry · May 1999

Jocelyn Lymburner Ron Roesch

SEE PROFILE SEE PROFILE

Evaluation of competence to stand trial View project

The user has requested enhancement of the downloaded file.

The Insanity Defense:

article was empirical in nature, the full paper was examined.

Demographic Characteristics of Insanity Acquittees

Criminal History and Current Offense

Mental History and Current Diagnosis

inal responsibility. However, the term mental disease encompasses a broad

General Demographics Outside North America

retrospective study describing all insanity acquittees in Ireland between the

Factors Influencing Verdicts of Insanity

Mock Jury Research

Psychiatric Diagnosis and Psychiatric History. As would be expected, indi-

Expert Testimony. Research has consistently demonstrated a strong agree-

Outside North America

1950s and, currently, a defendant’s level of responsibility is carefully assessed

Detention and Release Patterns for Insanity Acquittees

tioned about the limited generalizability of these results.

In an effort to understand why NGRI acquittees are frequently hospitalized

Outside North America

More specifically, membership in the violent group could best be predicted by

The Impact of Changes to Insanity Defense Standards

Guilty but Mentally Ill

and shows substantial cognitive impairment). Further, in sharp contrast to the

Rights of the Defendants

View publication stats

You might also like