Howard Zonana tells me a story of two identical twins. They are psychotic. They both believe they have chips implanted in their brains. One twin helps the other murder his wife. At his trial, he is found not guilty by reason of insanity. Dr. Zonana testifies in his defense.
Vaguely mysterious, viscerally creepy, Hannibal Lecter’s day job — forensic psychiatry sounds like the stuff of fiction. Popular shows like “Bones” and “Law and Order: SVU” fascinate viewers with its application. But for Dr. Zonana, a Yale professor who has developed the leading subspecialty program in the field, forensic psychiatry is no Fox rerun. His work, which focuses on evaluating the competency of individuals to stand trial and the validity of defenses based on mental defects, impacts policy at local, state, and national levels.
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I meet Zonana at his office in the Yale School of Medicine’s Connecticut Mental Health Center, where he has worked for the past 40 years and serves as medical director and president of the medical staff. We sit facing each other in huge, lushly upholstered leather armchairs. I hover on the first four inches of mine, afraid of being swallowed by the chair yet ever-attentive. Zonana, long and lanky with piercing round eyes, fills his space better.
Yale Professor of Psychiatry and Adjunct Clinical Professor of Law at Yale Law School, Zonana tells me he enjoys the teaching aspect of his profession. As we talk, I imagine the attorneys and juries to whom he regularly explains the most criminal edges of the human psyche.
With much hard work, Zonana has had forensic psychiatry accredited as a subspecialty with the American Psychological Association and with the American Academy of Psychiatry and Law, of which he is Medical Director and past president. Besides some clinical work, Zonana performs and monitors psychiatric evaluations of defendants. He also holds positions such as the Chair of the Bioethics Committee at Yale-New Haven Hospital.
“Most doctors don’t like to talk to attorneys,” Zonana tells me, explaining what deters many psychiatrists from his field. But Zonana, it would seem, doesn’t mind the occasional lawyer. He has built a career bridging psychiatry and law, grappling with the dilemmas inevitable at this intersection. The ethical job of a doctor, he explains, is to do no harm. Law, however, is different. In a legal case, there are two sides, and one will be harmed. Justice and treatment, Zonana has learned, rarely agree.
He cites one such conflict: The Supreme Court has ruled that criminals sentenced to death cannot receive their sentence unless mentally competent. As a psychiatrist, Zonana has been forced to decide whether to treat a mentally incompetent criminal so he could be executed.
“We said no,” he concludes. Instead, he recommended a less severe sentence, as is frequently done for adolescents. And with that, Zonana resolved an ethical dilemma that would cripple most.
Zonana tells me he is attracted to the “delicate balances” of his field. Analytic and calm, with the mind of a scientist, he studies people and institutions in immediate danger of collapse. Forensic psychiatry is the science of the precarious.
He describes the American mental health system as “basically in shambles.” Nationally, it has suffered from reduced funding, and responsibility has increasingly been delegated to negligent state governments. Coupled with a resurgent skepticism regarding the insanity defense, problems with the mental health system have led to equally dire problems in prisons.
“The insanity defense is complicated here in Connecticut,” Zonana explains. Through the mid-eighties, about 25 defendants each year were found not guilty by reason of insanity. The Psychiatric Security Review Board was created to monitor those acquitted by reason of insanity. It oversaw a period of growing public worry regarding the insane, heightened by the mid-nineties killing of a nine-year-old girl by an insane escapee in Middletown, Connecticut.
The resultant policies mandated stays in mental hospitals that were even longer than the prison times for those found guilty, so pragmatic attorneys stopped recommending the insanity plea. The number of defendants found guilty by reason of insanity dropped drastically, to about seven or eight per year. The rest went to jail.
“Prisons,” Zonana points out with a sad wryness, “are not a great environment for people who are schizophrenic.” Jails have been flooded with criminals in far advanced stages of psychosis, those who, just 20 years ago, would have been committed to mental institutions. The percentage of the United States population that is incarcerated is notoriously high, higher in fact than any other country’s. Demands for mental healthcare, added to the sheer space requirements, strain the criminal justice system.
In the mid-eighties, the Connecticut Civil Liberties Union engaged Zonana as an expert witness in a case against Connecticut’s York Correctional Institution for women, addressing concerns of inadequate mental healthcare at the facility. After visiting the site to evaluate the situation, Zonana, along with psychiatrists hired by the defense and the judge, agreed on guidelines for adequate mental healthcare that regulated, for example, patient screenings and restraints, staffing, and policy on suicides. A consent decree resolved the case out of court.
Yet Zonana has also influenced policy beyond the scope of York’s. He acted on a committee to weigh in on the Connecticut legislature on the passage of sexual predator statutes, which state that sex offenders must be committed to mental hospitals after they finish serving their sentences. According to Zonana, these laws dangerously loosen the definition of mental illness, perverting the scientific language of psychiatry to punitive purposes. They turn state mental hospitals into forensic facilities, crowding them with the criminally insane just as jails have become filled with the psychotic. Zonana’s committee advised against sexual predator statutes, and the Connecticut legislature followed its advice.
In the wake of events at Abu Ghraib and what he calls “the Bush administration’s changing definitions of torture,” Zonana has also worked with the American Psychological Association and the American Council on Psychiatry and Law to officially denounce the use of psychiatrists as interrogators. This step influenced the American Medical Association to endorse the same policy.
Despite the breadth of his work, Zonana says that his ongoing work with the women at York inspires him most. He continues to check on them every six months and proudly reports one patient’s comment that she received better treatment at the improved facility than she had at a mental hospital.
The law, Zonana tells me, tends to deal in types of people, while he concerns himself with “making sure people are evaluated as a whole person.” The stories of individuals, he has discovered, are much more complicated than attorneys and judges might admit.