When a mother kills her children, how much does mental illness matter when the mother’s guilt is judged in the courtroom? The case of Andrea Yates, who drowned her five children on June 21, 2001, suggests that in some cases the verdict falls before the trial starts. Although abundant evidence exists to prove that Ms. Yates suffered severe mental illness in the 2 years before and at the time of the tragedy, psychosis and delusional hopelessness were not enough for her to be judged not guilty by reason of insanity in court.

The case took an unexpected turn recently when the trial court’s verdict was overturned on appeal. Although the appeals court’s reasoning focused on an error by the testifying forensic psychiatrist, it is a reasonable inference that the court’s ruling was based on the assumption that, other things being equal, the jury was at a tipping point. Given the facts presented, for the jury to have been at a tipping point can be understood as a reflection of a folk psychology whereby people are predisposed by the horror of an act itself to use judgmental heuristics. It is thus no wonder that Andrea Yates’s acts are understood more easily as bad rather than mad, regardless of the fact pattern.

The puzzling story of Andrea Yates has now received a much needed recounting from journalist Suzanne O’Malley. "Are You There Alone?" is a heartfelt account of the events that led to the tragic deaths of Noah, John, Paul, Luke, and Mary Yates. O’Malley argues that psychosis with manic features, combined with medical mismanagement, stressful circumstances, and religious obsessions masking delusions, resulted in the tragedy. Her reading of the health records presents Andrea Yates’s treatment as a litany of misdiagnoses, poor treatment, wrong medications, and the role of the health insurance company rather than the clinician as the key decision maker in care. Nonetheless, despite being fragmented and confusing, the medical records documented that Andrea Yates suffered serious psychotic illness and delusions before and after she drowned her children. Mentally ill or not, however, she appeared to admit to knowing that what she did was legally wrong in videotaped interviews shown in court, and the death-qualified jury found her guilty and sane according to Texas laws.

The verdict will continue toward further appeal and a potential retrial or plea bargain. O’Malley’s account gives rise to questions on which a potential appeal ruling or any retrial could turn. One such question is, How valid are videotaped interviews for forensic purposes with psychotic individuals? Especially when the psychoses of those individuals before they committed the acts in question included that they were being videotaped! Moreover, by the time the videos were shot, Andrea Yates had already been repeatedly interviewed. In her aloneness with the terror of psychosis, with her delusions masking guilt and grief over her abhorrent deed and unimaginable loss, might she not seek nonverbal cues and guidance for how to maintain connection? We do not read that there was any serious exploration as to whether, in her suffering, she might have had a natural need to turn her interviewers into unwitting directors to absolve her of an otherwise unbearable confrontation with the horror.

Although forensic psychiatrists are trained to examine accused persons such as Andrea Yates for feigning madness, it is far more difficult to detect the accused feigning badness or filling in the blanks as we might expect them to. Some accused would rather present themselves as bad than mad, more terrified of the aloneness of the latter than the legal consequences of the former. In this instance, if a trained, thoughtful, and experienced forensic psychiatrist could, as any human being might, become confused in the heat of cross-examination between what he was told and his observations, then is it not as likely that Andrea Yates, in the midst of the unbearable grief that the death of her children brought to the surface, might have become confused between what she imagined she was supposed by society to say to the videotape-directing interviewer and what she actually remembered? Neither Andrea Yates nor Dr. Park Dietz should be scapegoated for the failures of the mental health and medicolegal systems.

O’Malley succeeds in providing detailed, memorable descriptions of the horror, and she explicates formerly mysterious issues of the religious influences of Mr. Woroniecki, the role of Randy Yates, and the political and financial aspects of the trial. Psychiatric ethics courses can use "Are You There Alone?" to raise haunting questions regarding the injustice of a social and medical system where psychotic patients feel they need to present themselves as bad rather than mad.