Public attention to violent acts involving mental illness has surged, and television dramas like Law & Order: SVU and Criminal Minds often blur the line between entertainment and reality. Before diving into specific diagnoses, it’s essential to understand the foundational forensic psychiatry concepts that shape how these cases are evaluated.
At its core, forensic simply means “related to the law.” In criminal forensic psychiatry, two concepts dominate: competency to stand trial (CST) and criminal responsibility (CR). They answer two very different questions.
- CST asks about the defendant’s mental state now, at the time of trial.
- CR asks about the defendant’s mental state then, at the time of the offense.
A finding of lack of criminal responsibility can lead to a verdict of Not Guilty by Reason of Insanity (NGRI) — or in some states, Guilty But Mentally Ill (GBMI). These determinations have been shaped over time by constitutional law and evolving statutory standards.
Competency to Stand Trial
Regardless of the defendant’s mental state at the time of the crime, at the time of trial they must be able to participate in their defense. The modern standard comes from Dusky v. United States (1960), which requires that a defendant have both a rational and factual understanding of the proceedings and the ability to consult with counsel.
Competency does not require high intelligence or full symptom resolution. A defendant may have active symptoms and still be competent if those symptoms do not interfere with participation in their defense. Conversely, someone with disorganized, incoherent thinking may be unable to meet the Dusky standard.
When a defendant is found incompetent, the court must decide whether to dismiss charges or attempt restoration. For serious charges, most defendants are remanded to a forensic hospital for treatment.
It is ethically permissible to involuntarily medicate a defendant for two parallel reasons — one grounded in the state’s obligations, and one grounded in the defendant’s rights. The state has a compelling interest in public safety and in ensuring that serious criminal charges can be adjudicated fairly. A trial cannot proceed if the defendant cannot understand the proceedings or assist counsel, and the state has a legitimate duty to resolve criminal allegations rather than leave them in limbo.
For the defendant, involuntary medication is equally protective. An incompetent defendant is effectively voiceless: unable to participate in their defense, unable to challenge the state’s evidence, and unable to exercise the presumption of innocence in any meaningful way. Restoring competency returns agency — the ability to understand what is happening, to work with counsel, and to make informed decisions about one’s own case. In that sense, treatment is not punitive; it is restorative, rights‑preserving, and essential to a fair process.
Competency is fluid. A defendant may be incompetent at one hearing, restored at the next, and decompensate again later. But competency has nothing to do with an insanity defense. Insanity — a legal determination, not a psychiatric one — refers exclusively to the defendant’s state of mind at the time of the crime, and it is ultimately decided by the trier of fact — whether judges or juries — not by expert witnesses. Expert testimony can guide the court, but judges and juries may give it great weight, little weight, or treat conflicting experts as essentially canceling each other out.
Standards and Burden of Proof
The burden of proof always begins with the state, which must prove guilt beyond a reasonable doubt — the highest standard in criminal cases and often described in legal education as requiring near‑certainty, about 95% or higher. This makes sense, because a person’s liberty is at stake. However, if the defense raises insanity, the burden of proof shifts to them. That’s known as an affirmative defense, meaning the defendant must prove it rather than the state. Most states require proof by a preponderance of the evidence — just over 50% — while a smaller number require clear and convincing evidence, often explained as roughly 70–75% certainty.
Criminal Responsibility and NGRI/GBMI
Criminal responsibility focuses exclusively on the defendant’s mental state at the time of the offense. Most states ask whether a mental disease or defect impaired the defendant’s ability to understand the wrongfulness of their act. Some also ask whether the defendant could conform their behavior to the law.
Importantly, mental illness alone is not enough. As Rex v. Arnold (1724) cautioned, “Not every kind of frantic humour or something unaccountable in a man’s actions will show him to be such a madman as to exempt him from punishment.”
The backbone of modern insanity law is the 1843 M’Naghten rule, which requires that the defendant either did not understand the nature and quality of the act or did not know it was wrong. Many states still use this strict right-wrong test.
The American Law Institute (ALI) standard, developed in the 1960s, broadened this approach by adding a volitional prong — whether the defendant lacked substantial capacity to conform their conduct to the law. Some states adopted this; others, like South Carolina, split the volitional prong into a separate verdict: Guilty But Mentally Ill, which is still a conviction and does not shield a defendant from prison or even the death penalty.
Forensic Psychiatry in Action: A Recent Example
In August 2025, 23‑year‑old Iryna Zarutska was fatally stabbed on a Charlotte light‑rail train. Police arrested 34‑year‑old Decarlos Brown Jr., whose family reports a history of mental illness and a diagnosis of schizophrenia.
How might this play out under North Carolina law?
North Carolina uses a strict M’Naghten standard with no volitional prong. If evidence suggests Brown planned the attack, targeted a victim, or attempted to evade capture, those behaviors point toward an understanding of right and wrong — and therefore toward criminal responsibility.
However, at the time of arrest and initial hearings, he may have been actively psychotic and unable to communicate meaningfully with counsel. That raises competency, not criminal responsibility. He could be incompetent now but still legally criminally responsible then. With treatment, competency is often restored, allowing the case to proceed — protecting both the defendant’s rights and the state’s interest in public safety.
The Broader Landscape
Mental illness exists along a spectrum, but legal insanity is a narrow and rarely met legal standard. Most defendants with psychiatric symptoms remain fully criminally responsible under the law’s rigorous criteria. And this case represents only one doorway into a much larger discussion. There is far more to explore about how different psychiatric conditions affect judgment, risk, and behavior — and how the legal system interprets those effects, sometimes wisely and sometimes imperfectly. The relationship between mental illness and criminal law is layered and complex, and understanding the rules is only the beginning of understanding the world behind them.
Renée S. Kohanski, MD, is a board‑certified psychiatrist with fellowship training in forensic psychiatry. Her work spans clinical practice, expert testimony, and public commentary. She writes about the intersection of mental health, ethics, and culture, bringing a psychodynamically informed lens to contemporary debates.
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