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The Mental Health Professional in the Courtroom

Attorney: Dr. Szasz, you haven’t examined the defendant, have you?
Szasz: No.
Attorney: Would it assist you in testifying to examine her now?
Szasz: No.
Attorney: You understand that what we are concerned with is her mental state on February 5 of last year?
Szasz: That is my understanding.
Attorney: Why would it not help you to examine her now to determine what her mental state was on February 5, last year?
Szasz: Because I could only determine by examining her now what her mental condition is now.
(California v. Cromer, 1980)

As the renowned psychiatrist Thomas Szasz (1961) pointed out first more than fifty years ago, the discipline of psychiatry (and the related mental health professions) serves two separate but related social roles: to confine the innocent (in the form of preventive detention or “involuntary psychiatric commitment”) and to excuse the guilty (in the form of the “insanity defense”).

John Hinckley, confined to St. Elizabeth’s Hospital for more than 30 years after being found not guilty for reasons of insanity.

A sociological analysis of psychiatry reveals that the profession has always functioned as an arm of the state, a mechanism of government-sanctioned social control used to deal with deviant persons. This is most clearly evidenced by the fact that most psychiatrists historically (and many presently) serve as government employees in state hospitals or are reimbursed through government-funded medical programs. Additionally, psychiatrists remain the only physicians who routinely exercise their state-granted authority to hospitalize and treat patients against their will for “mental illness”. Readers are directed to the works of Szasz as well as Erving Goffman and Michel Foucault for a more thorough discussion of the sociological functions of psychiatry.

(Please note that my comments above refer to coercive, medical psychiatry and not to the private, voluntary, and consensual outpatient practice of psychotherapy, psychoanalysis, or psychopharmacology.)

Because much of my writing thus far has detailed the medicalization of human suffering in the form of “mental disorders” amenable to professional, medical treatment, I find it necessary to say a few words about the use of psychiatry in the courtroom.

A cadre of mental health professionals has emerged in recent years purporting to specialize in the forensic application of their disciplines. This includes, most notably, forensic psychiatrists, psychologists, and clinical social workers. It is not unusual, for instance, to find a psychiatrist (or other mental health professional) testifying in court as to a defendant’s mental state at the time of a crime. Because of the lack of biological testing in psychiatry, and because much of psychiatry rests on subjective value-judgments, it is common to find one psychiatrist hired by the defense and one psychiatrist hired by the prosecution, both offering contrasting professional opinions.

Another major problem faced in the application of psychiatry to legal settings is the fact that the examining professional is generally limited to information obtained via an examination conducted weeks or months after the incident in question. As Szasz so bluntly expresses in his testimony above, it is a clinical and logical absurdity to believe that a psychiatrist has the ability to determine the past mental state of an individual. Nevertheless, mental health professionals routinely offer retrospective analyses of individuals involved in legal cases—without any consideration of the fact that such analyses amount to biography, not psychology.

The use of psychiatry in the courtroom rests upon the (faulty) assumption that there exists a category of persons who are rendered not responsible for their behavior due to the presence of mental disorder. Since even patients diagnosed as having schizophrenia can be and are held responsible for their conduct, psychiatric diagnosis is irrelevant in determining criminal culpability. Like Szasz, I assert that even apparently nonsensical psychotic behavior possesses meaning as a method of communication, and that the psychotic person retains volitional control of their behavior at all times. See Szasz’s Schizophrenia: The Sacred Symbol of Psychiatry (1976) and Insanity: The Idea and Its Consequences (1987) for a full review of these ideas.

Perhaps the most famous case in the entire history of forensic psychiatry is the case of John Hinckley, the man who attempted to assassinate President Reagan. On March 30, 1981, Hinckley shot Reagan outside of a Washington, D.C., hotel, wounding four, including the president, and paralyzing one—James Brady. Hinckley was subsequently charged with 13 offenses and found not guilty for reasons of insanity after psychiatrists diagnosed Hinckley with schizophrenia, narcissistic personality disorder, and borderline personality disorder, among other conditions.

Famously, Hinckley claimed to have shot Reagan to impress and win the love of the actress Jodie Foster. The result: Hinckley was hospitalized for more than 30 years at St. Elizabeth’s Hospital in Washington, D.C., where doctors “studied” and “treated” his condition. What they were studying, and whether they cured him, is open to debate. He was released in 2016.

What does the Hinckley case teach us? As Szasz offered so eloquently shortly after the shooting in 1981, it is that “we live in an age in which right and wrong, guilt and innocence, are hopelessly confused, especially by psychiatrists. For example, Time magazine quotes a Harvard psychiatrist, Thomas Gutheil, referring to Hinckley as a ‘victim’ of a disease—’erotomania’—manifested by ‘obsession with celebrity.’ Crime is a disease. Punishment is a crime. The criminal is a victim. And America, poverty, and, of course, mental illness are the ’causes’ of everything that interferes with unremitting human happiness” (Szasz, 1981, p. 9).

It is time we stop confusing human behavior with disease, guilt with innocence, and psychiatry with medicine. We must start by excluding psychiatry from the administration of criminal law. Only then will lawbreakers be held accountable and victims receive the justice they deserve.


Szasz, T. S. (1961). The myth of mental illness: Foundations of a theory of personal conduct. New York, NY: Harper & Row.

Szasz, T. S. (1976). Schizophrenia: The sacred symbol of psychiatry. New York, NY: Basic Books.

Szasz, T. S. (1981, July 11). The case of John Hinckley. The Spectator, p. 9.

Szasz, T. S. (1987). Insanity: The idea and its consequences. Hoboken, NJ: Wiley.

The Mental Health Professional in the Courtroom

Mark L. Ruffalo, LCSW

Mark L. Ruffalo, LCSW, is a psychoanalyst in private practice in Tampa. He serves as an affiliate assistant professor of psychiatry at the University of South Florida, where he teaches courses on psychopathology, psychotherapy, and the history of psychiatry. His practice website is tampapsychoanalyst.com.

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APA Reference
, . (2018). The Mental Health Professional in the Courtroom. Psych Central. Retrieved on May 24, 2018, from https://blogs.psychcentral.com/medicalization/2018/04/the-mental-health-professional-in-the-courtroom/


Last updated: 28 Apr 2018
Last reviewed: By John M. Grohol, Psy.D. on 28 Apr 2018
Published on PsychCentral.com. All rights reserved.