Dr. Howard Zonana: Confronting society with science

Despite his title, Dr. Howard Zonana is more heavily involved in social activism than one would expect from a scientist.

Perhaps this is because of the nature of his field: forensic psychiatry. Dealing with mentally ill patients who steal fully-clothed mannequins from department stores or take showers in Yale dorms, the forensic psychiatrist shows a human concern for these victims of mental disease.

Zonana is a professor of psychiatry and clinical professor of law in the Law and Psychiatry Division of the Yale School of Medicine, and has been a prominent figure in the medical and legal worlds of New Haven for almost 40 years. With his relaxed, courteous manner and tall, thin frame, one would not immediately associate Zonana with forensic psychiatry, where experts deal with some of the most difficult cases of mentally ill criminals.

CSI fans might think that all areas of science with the word “forensic” concern blood stains and fingerprints, but forensic psychiatry is another study altogether. Forensic psychiatry is a branch of psychiatry in which law and medicine overlap. Experts in the field complete civil and criminal evaluations of mentally ill defendants, and testify before attorneys, judges and sometimes juries. Their opinions may determine whether these defendants are competent to stand trial, be sentenced, or, in extreme cases, be put to death.

Apart from teaching at the Law and Psychiatry Division, Zonana also works at the Connecticut Mental Health Center (CMHC), a joint Yale-State operation. Each year the CMHC completes around 200 civil and criminal evaluations. Civil matters may include custody disputes in divorce cases and immigration issues, whereas criminal cases involve crimes ranging from minor misdemeanors to major felonies, including sexual crimes and murders.

Zonana admits that his work can be emotionally draining at times because he often has to face difficult ethical questions. In a recent case, a mentally ill criminal was not executed because of his insanity. However, he was felt to be a danger in the prison setting, and was treated. As a result of his treatment, he met the sanity requirements for execution, and was put to death.

“[In this case,] there was the question of whether psychiatrists should treat someone insane so that they can be executed,” Zonana said. “These are tough issues.”

Since 1993, Zonana has worked on the issue of sexual offenders. He has acted as the chairperson of the nationwide Task Force on Sexually Dangerous Offenders and served on the Sexual Offender Policy Advisory Committee. Sixteen states in the nation have a sexual offender commitment law that subjects those criminals who are highly likely to commit another offense to continued commitment after completing their sentences.

Zonana, however, holds that people should not be declared sexual predators, and considers such labeling a misuse of psychiatry. He has been actively fighting against such policies through the committees on which he serves. According to Zonana, to declare a person a sexual predator is less about civil commitment and more about “warehousing” — categorically shelving potential threats to society in institutions where the government can safely forget about them. He believes that there are many other cost-effective ways of monitoring released sexual offenders that would not increase the risk of repeated offenses.

“There are all sorts of social problems, and 60% of all released prisoners will return to prison. But people just don’t tolerate sex offenders at all,” Zonana said.

Zonana is also troubled by the growing conservatism concerning Connecticut’s insanity defense policy. Those who receive “not guilty” verdicts on the basis of insanity defenses now spend an average of 15 years in mental hospitals, whereas the average used to be four years. Many defendants do not want to fall back on an insanity plea — referred to by forensic psychiatrists as the “Twinky defense” — since they would be spending more time confined in hospital than in prison. As a result, he said, prisons house unnecessarily great numbers of mentally ill criminals.

“The prison system has been called the largest mental institution,” Zonana said.

To Zonana, the future seems bleak for the mentally ill in Connecticut.

Like the rest of the country, Connecticut has cut down on its budget for the mental health system. In the 1970s, there were three state-operated mental hospitals: Connecticut Valley Hospital, Fairfield Hills Hospital and Norwich Hospital. Now, CVH is the only one left. In CHMC, half of the twelve acute beds are used by patients who are not in acute conditions, because there is no other place for them. As a result of a lack of staff and facilities, patients have only very short-term hospitalizations, and the quality of treatment suffers.

“There is chaos in the mental health system,” Zonana said.

To combat this, Zonana has been working continually to maintain the quality of services provided in a womens’ facility in York. Under his guidance, the number of staffing was upgraded from 300 to 1300.

“It probably provides the best treatment in the state,” Zonana said, “since the number of staff is maintained.”

But York is a lucky one. Most mental facilities in the state are understaffed. One way to combat this may be to take up a law suit with the government concerning mistreatment of patients, in order to get adequate staffing for mental hospitals.

But perhaps in the face of these financial problems, greater hope lies in the future generations of experts in law and psychiatry. Zonana said one of the most rewarding aspects of his work is watching his students gain expertise in forensic psychiatry.

“We don’t want psychiatrists to detract from the profession,” Zonana said. “Our profession is a very public one, and experts often have a reputation as hired guns. We want to raise the quality of our profession [through the program].”

When the program first started, there were few psychiatrists interested in law.

“Doctors don’t like talking to lawyers,” Zonana said with a chuckle.

However, through Yale’s post-graduate fellowship program in forensic psychiatry, fellows gain an enhanced understanding of both law and medicine and are trained in the practice and ethics of forensic psychiatry.

“While medical students and law students come in with a different perspective,” Zonana said, “they realize that both doctors and lawyers can work together to fulfill a common need.”

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