An Expert Explains the Complexities and Confusion of Insanity Defenses for Juvenile Killers

Sixteen-year old Philip Chism sat perfectly still in a Salem, Massachusetts courtroom Monday, his hands on his knees, staring blankly ahead as Assistant District Attorney Kate MacDougall described in horrific detail how he raped and murdered his math teacher two years ago.

"The defendant strangled Colleen. The defendant used the box cutter. He cut Colleen Ritzers's throat," said MacDougall, recalling the brutal scene in the Danvers High School women's bathroom. He stabbed her at least 16 times, she said, with enough force to chip a vertebrae.

Chism continued to sit, frozen except for his quickly blinking eyes.

He raped her twice, said MacDougall, once in the bathroom with his penis, and once in the woods with a stick after carting her off in a recycle bin. He went back to school with blood running down his pants, and changed into his soccer uniform before ditching practice to go shopping with her credit card and catch a movie. Police found him later that night, walking by the side of the highway.

When it was Chism's attorney's time to speak, she didn't deny any of his actions. Chism is a killer who did "unspeakable things," admitted Denise Regan.

"This is about why did this happen," the lawyer argued. "The answer is he was severely mentally ill."

Chism, who was 14 at the time, had been suffering from a psychotic disorder since the age of ten, said Regan. Because of his mental state she wants the jury to find Chism not guilty by reason of insanity.

In Massachusetts this means that throughout the trial—which is expected to take weeks—the onus will be on the prosecution to prove that at the time of the murder, Chism was sane. If he is found not guilty, he will spend the rest of his days in a mental health facility where the possibility of his release will rest on mental evaluations and dangerousness hearings.

To learn more about the insanity defense and how it applies to juveniles I spoke to forensic psychiatrist Judith Edersheim the cofounder and co-director of the Massachusetts General Hospital Center For Law, Brain and Behavior. Edersheim has no direct relationship to the case, but agreed to speak with me on general terms.

VICE: Chism's attorneys say he has been diagnosed with a psychotic disorder and is currently on medication. Could someone be seriously mentally ill from the point of view of a psychiatrist but still lose a not guilty by reason of insanity plea?
Judith Edersheim: Insanity isn't a concept at all in psychiatry or psychology. Psychiatry and psychology have diagnostic categories like mood disorders or thought disorders. But the concept of insanity is something that grew out of the law and it has moral and political dimensions as well as psychiatric.

There could be someone who is profoundly mentally ill but whose mental illness has no nexus to the crime. It varies by state, but the standard generally requires that the defendant be either unable to conform their behavior to the requirement of the law—that's the volitional prong of the insanity test—or, depending on the state, be unable to appreciate the criminality or the wrongfulness of what they're doing.

Someone can be mentally ill and still form intent to commit a crime. Someone can be mentally ill and still appreciate that what he or she is doing is wrong. So the insanity standards focus a great deal on volition and reasonableness and those two things can still be maintained in the face of even a serious mental illness.

There is a classic example that you can have schizophrenia but still rob a bank because you need money.

Which came first, the legal definition of insanity or our modern understanding of psychology?
Oh my goodness, it's almost a chasm, it's almost a never the twain shall meet situation. The legal standards for insanity have been around since the at least the 17th century. In terms of the evolution of insanity defenses it started with concepts like the "wild beast" test, the M'Naughten Rule—all of these old English tests that attempted to capture what kind of mental state should excuse someone from doing a very serious thing.

Just the question embeds moral concepts. Who is the most blameworthy in society? People who can't help themselves? People who have lost their ability to behave as reasonable citizens? All of those questions were imbued with religion and morality and had political expediencies attached.

From a legal standpoint is it more difficult to determine if the defendant is insane at the time of the crime if they are a juvenile?
This is the chasm of diagnostic categories versus legal categories. If you were going to diagnose a 14-year-old, there would be some requirements that you actually not fix a permanent diagnosis because children and adolescents change so quickly.

Does the psychological complications regarding diagnosing juveniles play a role in the insanity defense?
The most superficial cut is, not really. The law has an insanity standard that is premised on an examination of behavior. Is this person at the moment of this offense behaving in a folk-psychology way that indicates that he or she has a defect of reason or volition, an inability to control themselves, or an inability to think reasonably? You could ask those same questions of juveniles or adults.

The more complicated answer is philosophical moral and neuroscientific. Adolescents are so different [from adults] that we ought to have different standards for them in light of the emerging adolescent neuroscience and how that intersects the moral underpinnings of law.

Beginning in 2005, there was trilogy of United States Supreme Court cases; Roper v. Simmons [in which the court ruled juveniles can't get the death penalty], Graham v. Florida [in which the court ruled juveniles can't get life without parole for a non-homicide crime], and Miller v. Alabama [in which the court ruled juveniles can't get a mandatory life without parole sentence.] In those three cases the Supreme Court took up the idea, from an enormous body of beautiful neuroscience, that adolescents' brains are different from fully-developed brains in ways that the law is going to have to take account of.

In the Chism trial, the prosecution is trying to argue that the murder was premeditated: He brought the murder weapon with him, he allegedly knew Ritzer's bathroom routine, and he knew to hide the body. Meanwhile the defense appears to be arguing that running back and forth into his high school covered in blood is a sign of his disconnected mental state. What role does planning and forethought typically play in an insanity defense?
If you ask Stephen Morse, a great professor of philosophy law and neuroscience, what he would say is behavior trumps everything. But I should say that I have seen many cases in which planning can occur, but everyone would agree that this person should be held not criminally responsible.

I'll give you an example of a case: If you attempt to harm someone because you believe that they are the incarnation of Satan, that they have kidnaped your younger sister and that they are holding her and are about to end her life if you don't save her, then it's a complete psychotic motive. The explanation for that crime is that you have lost your ability to reason through even the most basic reality around you. The fact that you were able to plan to carry out such a psychotically motivated exercise doesn't really negate your ability to mount an insanity defense.

Jury selection was delayed after Chism was found banging his head in a prison cell and reported hearing a voice. He was evaluated and found competent to stand trial. What is the difference between competency and insanity?
Competency is the notion that it would be unethical and unconstitutional to put someone on trial if they are not able to participate in the process and understand what they are doing. That's not at the moment of the crime, that's the moment of the judicial process. For example a delusion that really you are being persecuted for being the son of God, that would knock you out of the box for competency.

The defense has been careful to depict Chism as someone with a family history of mental illness who just moved to a new state and school. Is that a situation that could lead to a break for someone who might already be prone to mental illness?
How do you know in a 12-, 13-, 14-year-old whether a major mental illness is emerging? I'm afraid clinically it is a billion-dollar question because schizophrenia is such a terrible disorder.

Psychosis in general is a break with reality that is usually characterized by hallucinations, delusions, abnormal thought structure. It can have many causes. Psychosis is a symptom, schizophrenia is a disease. The symptom of psychosis can be caused by anything from a primary thought disorder like schizophrenia to substance-induced psychosis.

Chism is accused of attempting a similar attack on a clinician at a state juvenile facility after he was arrested. Could you argue that anyone who could commit such horrible acts would have to be mentally ill? Is being a serial killer, or serial rapist, a mental illness in itself?
I think it's a mistake to work backwards and say anyone who did such a thing must be insane, because "insane" is a legal category. The act of doing something heinous can have all kinds of context and society is making a decision with the insanity law that some people should not be held responsible.

There is a diagnostic category called psychopathy. These are the Dexters of the world, they're the methodical, emotionless, unempathetic people who break the rules for their own purposes and feel fine—sometimes that means homicide.

Serials killers have been typically cast as psychopaths. There is some controversial literature about whether psychopathic personalities or psychopaths really have a particular kind of illness that is genetic and neuro-imagable and should be exculpatory in criminal cases. For now in the US legal system, we exclude antisocial disorder as a defense to almost everything.

But could psychopathy be defined as a mental illness even though it doesn't fit into the criminal system?
Yes, that's a place where legal and medical or psychological characterizations don't map onto each other. It's a moral and ethical conundrum. CLBB had a symposium called "Psychosis vs Psychopathy" where we discussed what would happen if you hospitalized people for pure psychopathy what would happen in the hospital what would happen in the legal system.

Is it possible to rehabilitate someone who is a psychopath? What about a adolescent psychopath?
The literature on psychopathy is not robust; it's a new and emerging area. The old wisdom on this issue was that psychopathy was exceedingly treatment-resistant. There are all kinds of reasons why psychopathy is difficult to treat. But the only good evidence for the treatment of psychopathy in terms of being able to make a dent and change the course of that syndrome is for young people.

This interview has been edited for length and clarity.

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