The insanity defense does not ask whether someone was mentally ill or even psychotic; it asks a legal question about understanding wrongfulness or, in some places, controlling behavior. The traditional cognitive test is far cleaner than a volitional one, it excludes antisocial personality disorder, and hearing a voice and obeying it is not enough. It is rarely raised, usually leads to long commitment, and a legal verdict is not a moral one.
What it is
The question is not whether the person has a mental illness, or even whether they were psychotic. Depending on the jurisdiction, it is whether they understood the act was wrong or whether they could control their behavior.
“the question isn't does she have a mental illness? The question isn't was she psychotic? The question is could she control her behavior? And that's what's being answered”
9:00Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 The traditional framework: not understanding the nature or wrongfulness of the act, because of a mental illness. A psychopath who does not know right from wrong because they do not care does not qualify.
“So if you're a psychopath, antisocial and you don't understand right from wrong because you don't care, doesn't qualify. That was the framework for a long time”
16:02Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025 Standards vary by state. Using moral wrongfulness is more permissive and lets more people plead insanity; legal wrongfulness alone admits a very small minority. California separated the two, so not understanding the moral wrong qualified even if the legal wrong was understood.
“Now, whether or not you want to do legally wrong only or morally wrong as well, that's up to the state. But if you do moral wrongfulness, that's more permissive. That's going to let more people plead insanity. If you do legal wrongfulness, it's going to be a very small minority”
11:32Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026 Also said in 1 more episode
“In California, the wrongfulness was further separated out into legal versus moral. That as long as you didn't understand the moral wrongfulness, That qualified, even if you could understand the legal wrong”
17:23Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025 Burden of proof matters. At least one jurisdiction makes the prosecution prove the absence of mental illness and insanity beyond a reasonable doubt, which is a crazy standard.
“I think it is the only jurisdiction that Requires the prosecution to prove a negative, to prove the absence of mental illness and insanity, and to prove it beyond a reasonable doubt. That is a crazy standard”
8:20Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026 Release in most states requires the illness to be in total remission, full medication and treatment adherence, and a lack of dangerousness.
“most states to my knowledge, they require your mental illness to be in total remission. And they require you to be basically fully medication adherent and treatment adherent. And finally, they need you to have a lack of dangerousness”
38:45Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026
Pitfalls and myths
It is rare: only about 1 percent of felony cases raise it at all. With long commitments and long hearings, most people would rather take a deal, and the outcome is often not favorable.
“the estimate is that only about 1% of felony cases raised in Sanity 8 defense at all. And that shouldn't surprise you. Because of the long commitment times and the long hearing times required, most people would rather take a deal”
37:28Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026 Also said in 1 more episode
“the actual classical insanity defense is, is extremely rare. Okay, it's extremely rare. So most cases don't go to the insanity defense. It's just the outcome is not necessarily favorable for a lot of people”
19:34Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025 A volitional prong is murky. There is no scientific test of who can or cannot control their behavior, and no uniform, accepted medical way to say whether someone could conform their conduct to the law. The cognitive test of knowing it was wrong is much cleaner.
“The prosecution then has to prove that a person was able to conform their conduct to the law, which I've said before, there's no uniform, readily acceptable medical way of determining that. It's so subjective”
10:46Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026 Also said in 1 more episode
“we have no scientific test to say who can or cannot control their behavior. We can basically point at certain facts that we know in medicine, but it's not anywhere as clean cut as the cognitive test of whether someone knows it's wrong”
8:12Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 Hearing a voice and following it is not enough. What the person believed at the time has to justify following the voice in a way that means they did not understand it was wrong.
“it's not enough to hear a voice and follow the voice. What you believe at the time has to justify you following that voice in some sense, in a manner that would mean that you didn't understand it was wrong”
40:03Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 Voices can come from a lot of different mental conditions, and some ordinary people simply hear an internal monologue.
“Just like psychosis, voices can come from a lot of different mental conditions. It can come from being an ordinary person. Some people simply hear an internal monologue, for example”
41:43Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 Behavior far outside the norm does not by itself make someone mentally ill. A psychiatrist has to say in what particular way they are outside the norm.
“being outside of the norm is not enough to say if someone is mentally ill for a professional, for a psychiatrist. We need to say in what particular way is he outside of the norm”
11:40Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 The defense traditionally excludes antisocial personality disorder. Anyone trained in why it exists knows it cannot apply there.
“the insanity defense. traditionally excludes antisocial personality disorder. Everyone who has been trained appropriately and understands fundamentally why the insanity defense exists and who it applies to knows that it cannot apply to antisocial personality disorder”
13:29Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025 Do not confuse your moral reasoning with legal conclusions. A legal test is a statute applied to evidence; a moral judgment weighs blame, agency, intention, capacity and the effects of mental illness. They are very different things.
“you should not equate or confuse your moral reasoning and your moral ideas and wishes with legal conclusions. And I do think a responsible forensic expert working in a case, they are giving an opinion based on the legal conclusion”
3:54Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026 Also said in 1 more episode
“It's a statutory test that's applied to evidence. And a moral one is a philosophical or ethical judgment about A whole host of things, blame, agency, intention, capacity, in this case, the effects of mental illness. And they're two very, very different things”
5:16Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026
Pearls
Whether something is part of a disorder, whether the person did it willfully, and whether they should be held responsible are three separate questions.
“whether or not something is part of a mental disorder or a diagnosis is different from whether or not someone does it willfully or that they don't have control over it. And even that is a separate question from whether or not someone should be responsible for it in some way”
2:21The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?Oct 2026 If society holds people responsible for the results of untreated illness, it owes them early detection of when illness makes a rational treatment decision impossible, and then intervention. We do not do that.
“I think as a society, we have a obligation to detect early on when someone's mental illness makes them unable to actually make a rational decision about treatment. And then we have to intervene, but we don't”
23:29Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025
It also comes up on
From these episodes
- The Psychology of Elizabeth Holmes in You Can See Everything: Narcissism, Autism, or Manipulation?Oct 2026 · 1 point
- Lindsay Clancy Case: Biggest Misconceptions After the Mistrial Explained by a Forensic PsychiatristSep 2026 · 7 points
- Lindsay Clancy Trial: A Forensic Psychiatrist Explains Psychosis, Malingering, & the Insanity DefenseSep 2026 · 5 points
- Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025 · 5 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.