by Steven D. Targum, MD, and Ronald Ebert, PhD, ABPP
Dr. Targum is Scientific Director, Clintara LLC; Consultant, Massachusetts General Hospital, Psychiatry, Boston, Masschussetts; Chief Medical Advisor, Prana Biotechnology Ltd., Melbourne, Australia; Acting Chief Medical Officer, BrainCells Inc., San Diego, California; Chief Medical Officer, Methylation Sciences Inc., Vancouver, British Columbia, Canada; and Chief Medical Officer, Functional Neuromodulation Inc., Toronto, Canada); and Dr. Ebert is from McLean Hospital, Belmont, Massachussetts, and Harvard University, Cambridge, Massachussetts.

Innov Clin Neurosci. 2012;9(7–8):48–50

Funding: There was no funding for the development and writing of this article.

Financial disclosures: Dr. Targum has served as a consultant to, received grant/research support/honoraria from, owns stock options in, or owns copyrights to the following companies: Acadia, Affectis, Alkermes inc., Amgen, AstraZeneca, BioMarin, BrainCells Inc., CeNeRx, Cephalon, Cypress, CTNI MGH, Dynogen, EnVivo Pharmaceuticals, Euthymics, Forest Research, Functional Neuromodulation inc, Eli Lilly and Company, Johnson & Johnson PRD, INC Research, Methylation Sciences Inc., Memory Pharmaceuticals, Naurex Inc, NeoSync, Neurophage, Novartis Pharmaceuticals, Novartis Bioventures, Nupathe, Prana Biotechnology Ltd., Sunovion, Targacept, TauRx, Transcept, Wyeth labs.

Dr. Ebert has no relevant conflicts of interest to disclose.


Courtroom drama has always fascinated the public. Fictional dramas, movies, and theater are often based on thinly disguised true stories as well as “real” celebrity cases. In recent times, many of these cases have become prime time television entertainment. Sometimes, the focus of attention commands national headlines when bizarre acts are committed by mentally ill individuals, such as the shooting of Representative Gabrielle Giffords by a mentally ill man a year ago or the shooting of President Reagan years ago.

Unfortunately, the perpetrator is often cast as evil by the press, and the genuine plight of the mentally ill is rarely addressed. According to Ronald Ebert, PhD, a forensic psychologist practicing in Boston, Massachusetts, the presumption of evil, rather than sensitivity to mental illness, is often dominant in the “real” courtroom as well.

Dr. Ebert got his doctorate from Pennsylvania State University in State College, Pennsylvania, and joined the clinical staff at McLean Hospital in Boston, Massachussetts. While at McLean, he became Assistant Medical Director at the Bridgewater State Hospital where for eight years he ran a forensic unit to evaluate and treat dangerous mentally ill men. During that time, he began to provide testimony on behalf of these patients as well. He has been a forensic psychologist for the past 35 years.

I spoke with Dr. Ebert about his work in the courtroom and his efforts to educate the public about the realities of mental illness.

Dr. Ebert, what is a forensic psychologist?

Dr. Ebert: A forensic psychologist or psychiatrist operates as a member of the legal team conducting a clinical assessment of the mental state of the accused individual. I serve the role of an expert witness whose job is to gather data and report my clinical findings and opinions to the court. As a forensic clinician, I do not make legal decisions—this is the role of the judge and jury. I view myself as the intermediary between a knowledge base and lay legal systems that need to be educated in order to make an informed decision.

What is your role on the legal team?

Dr. Ebert: Forensic clinicians are usually asked to consider two primary legal issues: 1) Is the accused currently competent to stand trial? and 2) What was the mental state of the accused individual at the time of the crime, and did that state substantially affect his or her behavior?
A person who is competent to stand trial must be relatively stable and cognizant of the charges placed against him or her. I try to determine if the accused person can actually help his attorney to organize a defense and whether he can fully participate in the courtroom. Sometimes, the accused person cannot be fully present because of his mental disabilities, in which case, by law, he cannot go to trial.

What happens if someone is not competent to stand trial?

Dr. Ebert: For starters, the legal system does not like this outcome because it slows down or even stops the process. Obviously, judges want to resolve cases and prefer that people be competent to stand trial. Otherwise, the accused individual might linger in jail, without a finding of guilt or innocence. So, if I form an opinion that a person is not competent, I have to determine whether this person will ever be competent to stand trial and how and when that might happen.

Do your clinical opinions ever get challenged?

Dr. Ebert: Of course they do. I usually get challenged because the legal system is adversarial—there is always the other side of every case. Because of this, my job differs from the usual clinical practice: people are always reviewing, questioning, and sometimes criticizing my opinions in a public setting. Consequently, I insist on substantive data to support my opinions. In addition to clinical interviews, I collect historical records, do psychological testing, and interview collaterals, including treaters. Although I am an expert witness offering a professional opinion, I must always be prepared for cross-examination. When an effort is made to discredit my clinical evaluation, the realities of mental illness may get blurred.

In your opinion, do the members of the jury understand the potential role of mental illness in contributing to criminal behavior?

Dr. Ebert: No, they usually do not understand it. The members of the jury are subject to the same biases and misunderstandings that the general public is when it comes to mental illness. We know that there is a significant stigma in the public about mental illness. The stigma about mental illness is carried right into the courtroom.

I view my courtroom task as providing factual information to help jury members grasp the reality, the gravity, and the behavioral implications of mental illness. Unfortunately, it often goes against the grain of many people to appreciate and acknowledge the unpredictability that can be caused by severe mental illness.

Many people prefer to think that bad things are done by bad people. Of course, life is more complicated than that. Attributing responsibility for criminal acts in the presence of mental illness is not a black or white matter.

Most people who have not been affected by severe mental illness cannot accept that psychotic patients really believe the voices they are hearing are real. In some ways, acknowledging that hallucinatory voices can command behaviors strikes at the heart of our belief that we are really in control of our behavior.

Have you been successful in educating the jury about mental illness?

Dr. Ebert: Over the years, I have gotten much better at communicating the facts in a clear way and can usually get my point across to the jury members. I try to get them to understand the world through the eyes of a disabled person. This is not easy and I am not always successful.

Can you give me any examples?

Dr. Ebert: Recently, I evaluated a young autistic man who was placed by a disability program as a dishwasher in a local restaurant. Although he was able to work well in this basic and repetitive job, his lack of engagement with others and appreciation of social nuances were obvious. His boss kept telling him not to put the dirty pots in the dishwasher but he refused to follow her direction. After many reprimands, he finally murdered his boss. When I asked him why he did it, he said, “What could I do? I could not fire him so I killed him.” He simply did not understand the gravity of his actions and thought that he could just say he was sorry and go back to work. Although I believed he would never be competent to stand trial and was not guilty by reason of insanity (his mental illness), the judge found him competent and the jury convicted him of murder. In this case, I obviously failed to educate the judge or the jury about the impact of his autism.

Can you give me an example of a guilty verdict that was handed down despite an obvious case of psychotic behavior?

Dr. Ebert: Sure. Twenty years ago I was asked to see a man who had killed two people by running them down in his car while they were walking in a park. He had a lengthy history of psychotic behavior and hospitalizations and was actively hallucinating when he committed the crime. In fact, he believed that the devil had specifically instructed him to commit a violent act and that he was only following this command when he veered off the road and hit these innocent victims. Earlier, while driving he had read a sign for “Woburn” (a nearby Massachusetts town) and believed it meant “woe” and “burn” and that the devil lived in that town. As far as I was concerned, this man was obviously psychotic when he committed this violent act, which had been precipitated by command hallucinations and delusional thinking. However, the jury did not agree and convicted him of murder. In fact, some members of the jury laughed when I explained his delusional view about the devil, and the local newspaper wrote the headline “Devil lives in Woburn, says doctor.”

I learned a lot about jury biases after that case and have become much smarter about explaining the nature of psychosis. I also have a better understanding of the sustained public antipathy toward mental illness because it is both frightening and very different from the public’s experience.

How often do attorney’s use the “not guilty by reason of insanity” defense?

Dr. Ebert: Actually, the majority of “not guilty by reason of insanity” cases do not win: when challenged, it fails more often than it succeeds. Because of the low likelihood of success, together with insufficient evidence of mental illness, this plea is not used very often. Research shows that people think it is used in about half of all felonies, but it is actually used in less than half of one percent of cases.1 Even when the case is obvious, and both sides can agree that the individual has mental illness, the case may not be decided by the insanity defense.

In your practice of 35 years, have you ever been frightened by a criminally insane patient?

Dr. Ebert: Yes. In fact, I am working on two cases right now where I am extremely cautious in my dealings with my clients. In one case, the man slips very quickly into an angry psychotic state and I monitor his status very carefully. I have terminated meetings when he tells me the voices tell him to hurt me or when I feel uncomfortable. In the other, the gentleman has expressed his desire to be a “mass murderer” and, while awaiting trial for an alleged double murder, tried to kick a forensic psychiatrist in the head (he injured him, but not seriously). I now interview him through reinforced glass and over a phone—the jail (and I) will not allow more contact.

After all these years, what have you learned from evaluating and representing the criminally insane in the courtroom?

Dr. Ebert: Overall, It is all much more complex than a determination of just guilty or not guilty because these are people who are trapped in their illnesses or disabilities. Unfortunately, it is hard for anyone to see the world through the eyes of another person. When an accused person is also mentally ill, there is an inherent fear of differences that fosters misunderstanding that may adversely affect a fair verdict. My role as an educator in the court is critical for helping the system truly mete out a just verdict.

1.     Ablow KR. The Strange Case of Dr. Kappler. New York: The Free Press; 1974.
2.    Melton G,Petrila J, Poythress N, Slobogin C. Psychological Evaluations for the Courts. 2nd ed. New York: Guilford; 1997.