Little Children

The investigation and prosecution of crimes perpetrated by the mentally ill is an excessively sensitive issue. As you will come to understand, legal systems throughout the world have struggled with the determination of one’s guilt in the face of a coexisting psychotic disorder. One controversial case recently tried in Texas is that of Andrea Yates, an American woman who drowned her five children while suffering from postpartum psychosis. In 2002, she was sentenced to life imprisonment for first degree murder. The jury at her second trial in 2006 found her to be not guilty by reason of insanity. Such a ruling remains an extremely rare one in most nations. In a 1991 study of eight U.S. states, the National Institute of Mental Health found that less than 1% of felony cases involved this mental disorder defense and only a fraction of those were successful.

In Kuwait, the man responsible for slaughtering his fourteen-year-old daughter in front of her siblings, after accusing her of no longer being a virgin, was found not guilty by reason of insanity (irresponsible for his actions). According to the Arab Times article, the man was subsequently referred (they likely meant committed) to the Psychological Medicine Hospital for treatment of schizophrenia (???). More recently, a man who attempted to poison eight of his children, successfully killing five, and then trying to commit suicide, was also found not guilty and was committed to the psychiatric facility until deemed fit for discharge.

Let us analyze this. The first article stressed the fact that the autopsy found the girl to be a virgin, as if the contrary would have made the crime more acceptable or, rather, understandable. Or, perhaps, they wanted to stress the fact that he was acting on his delusions. Psychosis is by no means a reason to dismiss one’s legal responsibilities as long as the perpetrator was aware, at the time of the crime, of the legal implications of his actions. This means that this offense is considered an honor killing regardless of the details. Of note, honor killings are defined as a premeditated murder, unlike crimes of passion.

The second article, which I would describe as an aggregate of disorganized thoughts, states that the court provided its final judgment after reviewing reports from both the Medical School and the Psychological Medicine Hospital. You would expect a report from a medical school to be produced by a distinguished panel of professors in the field of forensic psychiatry or with some expertise in this psychiatric specialty, as we are discussing a matter of legal medicine. The sad reality is that the Department of Psychiatry at the Faculty of Medicine is composed of only two staff psychiatrists and two psychologists. The Chairman, a psychiatrist with no formal training in forensic psychiatry, has no working knowledge of Arabic which, in a nation with no effective medical translation system, significantly limits his input. The second staff psychiatrist shockingly remains an employee of the department despite being dispossessed of his chairman position after being accused of numerous ethical violations including grave transgressions of the patient-physician boundaries. Finally, the department’s psychologists have little role in assessing forensic cases. The sole recommendations that should have emanated from the Department of Psychiatry are to recruit external experts to support the evaluation of these cases.

Although partly relevant to the matter in question, but of importance to the general discussion, the faculty members have been preventing employment by the department of fully trained Kuwaiti psychiatrists as well as qualified psychiatrists-in-training and would rather bare the financial burden of training fresh medical school graduates of whom the first batch will return within a few years with the same qualifications already at their disposition four years ago, halting unnecessarily the development of a critically deficient department for numerous years. After putting this information together, wouldn’t anyone of sound spirit question such reports from the academic institution?

The second report came from the Psychological Medicine Hospital. Being familiar with Hospital’s operations and not knowing of any board certified, or well-trained, forensic psychiatrists or psychologists, there is little doubt in my mind that such ruling was done in an ill-informed manner and with little expert opinion.

The question therefore remains: Why doesn’t the court call in qualified experts to support their decision-making in such sensitive cases?

The article goes on to state that the defendant planned his crime in advance and was trying to force the legal responsibility onto his wife. Could there be a better indication of his knowledge of the legal implications of such actions?

The defendant was diagnosed with severe depression and accordingly was considered irresponsible for his actions. They mentioned that multiple psychological tests were done including an evaluation of his IQ (a test commonly performed by the psychologists in the hospital between their coffee breaks). I remain unsure as to what the indications were for IQ testing in someone who conceived such a master plan for a family murder-suicide.

Despite these few yet important facts pointing to a conscious act perpetrated by the two men, the verdict committed them to an ill-prepared psychiatric institution for further treatment and subsequent release.

Mental illness is usually characterized by remissions and relapses. Most of the mentally ill will, at some point, normalize regardless of treatment. In other nations, most defendants judged not guilty by reason of insanity, a very rare occurrence, remain hospitalized for periods that may well exceed a jail term. In Kuwait, discharging a patient against medical advice is a right that is widely abused with no safety assessment undertaken prior to release. As an example, a colleague admitted a patient to the acute psychiatric service four days after he was discharged against medical advice from the forensic psychiatry ward where he was committed for stabbing his cousin. This means that the two criminals, who collectively killed six innocent children, will probably be walking free among us in the not-too-distant future. This should send chills up your spine. It may be a fair prediction that, with the right stressors, the man in the Al-Watan article may end up killing his wife and then attempting suicide again.

This should make you wonder whether in Kuwait a pedophile who sexually abuses a child would equally be found not guilty as pedophilia is listed as a psychiatric condition in the DSM-IV (a diagnostic manual for psychiatric disorders)… Wait and see? Although a subject for a more extensive discussion, reliable sources within the legal system state that child abuse is a common occurrence in Kuwait. However, like many things, it is kept under the radar and not openly talked about in our society.

Being mentally ill, even with a psychotic disorder, at baseline is by no means a reason to dismiss one’s legal responsibilities as long as the individual knew of the illegal nature of the crime at the time of the events. Although I cannot speak to the legal aspects of this case, ethically, I am obligated to question the reliability of the psychiatric evaluation performed. Furthermore, knowing of the poor quality of services provided by our institution, it is unlikely that these individuals will receive adequate treatment and may remain a risk upon their release due to this lack of proper infrastructure supporting mental illness in Kuwait.

These are only two of many crimes committed by mentally ill individuals over the last few years in Kuwait. More can be expected as many remain undiagnosed, untreated and enabled by an uninformed society and corrupt institutions.

In 1982, the American Psychiatric Association endorsed a test of insanity written by Richard Bonnie, a legal expert at the University of Virginia, which states:

“A person charged with a criminal offense should be found not guilty by reason of insanity if it is shown that as a result of mental disease or mental retardation he was unable to appreciate the wrongfulness of his conduct at the time of the offense. As used in this standard, the terms “mental disease” or “mental retardation” include only those severely abnormal mental conditions that grossly and demonstrably impair a person’s perception or understanding of reality and that are not attributable primarily to the voluntary ingestion of alcohol or other psychoactive substances.”

The APA does not endorse the “irresistible impulse” test for insanity.

The most widely accepted set of rules for establishing insanity as a reason to excuse the crime are the M’Naghten Rules, formulated by the British House of Lords in 1873, which state that:

“A defendant may be excused from criminal responsibility if at the time of the commission of the act the party accused was laboring under such a defect of reason, from a disease of the mind, as not to know the nature and the quality of the act he was doing, or if he did know it, that he did not know that he was doing what was wrong.”

Like other fragile health services, mental health is being abused for the benefits of the malevolent. Instead of giving the psychiatric patient a license to kill, we must consider giving them basic human rights including access to standard of care treatment both acutely and for long-term management. I cannot forget the hopelessness and frustration I felt while trying to deal with the innumerable cases of domestic violence and alleged rapes that presented to us. No actions were taken to protect and appropriately treat these vulnerable patients as the legislation was lacking and regulations, if present, were never enforced. Women and children are being abused, raped and killed before our very eyes and the only thing we do is release their perpetrators back onto the streets. Shame on us.

The need to expedite improvement of these services is an absolute priority. The changes need little funds but lots of dedication. Recruiting a handful of qualified specialists instead of the mass transfer of mediocre psychiatrists is the policy that should be adopted by our decision-makers. Updating our psychopharmacotherapeutic practices and providing easier access to medications with better safety profiles is a necessity. Expanding psychiatric services into general and tertiary hospitals should facilitate the delivery of integrated services needed. I could not insist more on the need for qualified and trained mental health workers who are fortunately available but lack incentive. To aid in health planning, good quality research should be implemented and encouraged via easy access to funding. In collaboration with the legal system, we must establish and vigorously enforce protocols regulating mental illness treatment while taking into consideration the patients’ and our public’s safety.