Lindsay Clancy and Postpartum Psychosis

In a Massachusetts courtroom, a jury was asked one of the hardest questions the criminal law poses. Lindsay Clancy, a Duxbury mother of three, did not dispute that she caused her three children’s deaths in January 2023. What her lawyers disputed was whether she was criminally responsible for it. Her defense was legal insanity, rooted in severe postpartum psychosis, and it has revived a debate that most people only half understand: how a person can admit to doing a terrible thing and still, in the eyes of the law, be found not guilty.

For a Texas audience, the case is also a window into how differently this one defense works from one state line to the next. What would happen to a defense like Clancy’s here is not what may happen in Massachusetts, and the reasons go to the core of one of the most misunderstood ideas in American criminal law. Here is what the insanity defense actually is, why conceding the act is not the same as conceding guilt, and how Texas’ insanity standard compares with the one applied in the Clancy trial.

Admitting the Act Is Not Admitting Guilt

Start with the piece that confuses almost everyone. A crime is not just a bad act; it is a bad act committed with a certain state of mind. The law calls these two ingredients the actus reus (the wrongful act) and the mens rea (the guilty mind), and to convict, the State generally must prove both. The insanity defense operates on the second ingredient. It says, in effect: yes, I did the act, but because of a severe mental illness I lacked the criminal responsibility that turns an act into a crime. That is why a defendant can stand up, concede that she caused a death, and still ask a jury to find her not guilty. She is not denying what happened; she is denying that the law should hold her blameworthy for it.

It is also raised far less often, and succeeds far less often, than popular culture suggests. The most cited study on the question, an eight-state survey published in 1991, found the defense raised in roughly one percent of felony cases and successful in about a quarter of those. That study is now more than thirty years old, which is its own commentary on how little attention this corner of the law receives. But no later work has overturned the basic picture: the insanity defense is rare, and most of the time it fails.

What Actually Happens After an Insanity Verdict

The second misconception is that a verdict of not guilty by reason of insanity is a release. It is not. What it does is move the case out of the criminal sentencing track and into a commitment track. The procedures differ meaningfully by state, and commitment is not automatic everywhere, but the ordinary result is confinement in a secure psychiatric facility, subject to periodic hearings on whether the person remains dangerous. People are frequently held longer than a criminal sentence would have lasted.

Massachusetts is a useful illustration precisely because it is not automatic. Under General Laws chapter 123, section 16, a court may order the acquitted person hospitalized for up to forty days for observation and examination. During that window, a district attorney or the facility’s medical director must petition for commitment, and the court must find both mental illness and a likelihood of serious harm. If those findings are not made, the petition is dismissed and the person is discharged. An initial commitment order runs six months and is renewable in one-year periods after that.

Texas routes it differently. Chapter 46C of the Code of Criminal Procedure asks first whether the offense involved what the statute calls dangerous conduct, meaning conduct that caused serious bodily injury, placed someone in imminent danger of it, or consisted of a threat of serious bodily injury through use of a deadly weapon. If the answer is no, the criminal court’s role largely ends and the matter goes to ordinary civil commitment. If the answer is yes, the person is committed to a maximum security facility for evaluation, and a disposition hearing follows at which the court may order inpatient commitment or court-supervised outpatient treatment, renewable, with an outer limit tied to the maximum term for the charged offense.

Neither state simply opens the door. But neither state locks it automatically either, and the difference between those two things is worth knowing before anyone tells you an insanity verdict is a way out.

What Postpartum Psychosis Is, and Why It Matters Here

Postpartum psychosis is the rare and severe end of the spectrum of maternal mental illness, distinct from the common baby blues and even from postpartum depression. Postpartum Support International estimates that it affects roughly one to two mothers per thousand births, though estimates in the literature vary and figures for first-onset cases run lower. It usually comes on quickly in the weeks after delivery, and it can involve delusions, hallucinations, profound confusion, and a frightening loss of contact with reality. In its worst form it can produce command hallucinations, voices that direct the sufferer to act, along with delusional beliefs that reframe a horrific act as somehow protective. It is a genuine psychiatric emergency, not a character flaw.

That clinical picture is what makes these cases so legally fraught. According to the defense in the Clancy case, she was in the grip of exactly this kind of psychosis, and reporting on the case has described a command hallucination, a voice directing her to harm the children. The prosecution has taken the opposite view, arguing that she acted deliberately and was in control. Which account the jury credits will decide the case. The deeper point, for our purposes, is what legal test the jury has to run that evidence through, because that test is not the same everywhere.

The Massachusetts Standard: Two Ways to Be Insane, and the State Must Disprove Both

Massachusetts uses the broader of the two dominant insanity standards, drawn from the American Law Institute’s Model Penal Code and adopted in the state’s landmark decision Commonwealth v. McHoul, 352 Mass. 544 (1967). Under it, a person is not criminally responsible if, because of a mental disease or defect, she lacked substantial capacity to do either of two things: to appreciate the wrongfulness of her conduct or to conform her conduct to the requirements of the law. That second branch is crucial. It recognizes a volitional failure: the person who may know an act is wrong but, because of illness, cannot stop herself from doing it.

Massachusetts also places the burden of proof in an unusual, defendant-friendly spot. Once the defense raises the issue, the Commonwealth must prove beyond a reasonable doubt that the defendant was sane, and it must do so even though she has admitted the act. See Commonwealth v. Kostka, 370 Mass. 516 (1976). The prosecution, in other words, has to disprove insanity to the same demanding standard it uses to prove everything else. For a defendant like Clancy, that combination of a volitional prong and the state’s heavy burden is about as favorable as the insanity defense gets in this country.

The Texas Standard: Narrower, and the Burden Flips

Texas takes a markedly different and much narrower path. Under Section 8.01 of the Penal Code, insanity is an affirmative defense that succeeds only if, at the time of the offense, the defendant, as a result of a severe mental disease or defect, did not know that her conduct was wrong. There is no volitional branch. It does not matter, under the statute, whether the illness made it impossible for the person to control her behavior.

That was not always so. The 1974 version of the Texas code contained a volitional prong of its own: a defendant who knew the conduct was wrong but was incapable of conforming to the law could still prevail. The Legislature eliminated that branch in 1983. What remains is a single cognitive question.

The burden flips here, too. Texas presumes every defendant sane and makes insanity an affirmative defense, which means the defendant must prove it by a preponderance of the evidence. Where Massachusetts makes the state disprove insanity beyond a reasonable doubt, Texas makes the accused establish it herself, on a more-likely-than-not basis. By design, Texas has one of the most stringent insanity standards in the United States.

What “Wrong” Means, and What Juries Are Actually Told

Then there is the question of what the word wrong means, and this is where Texas practice contains a gap that even experienced lawyers overlook.

On appeal, the answer is settled. In Ruffin v. State, 270 S.W.3d 586, 592 (Tex. Crim. App. 2008), the Court of Criminal Appeals stated it flatly: under Texas law, wrong in this context means illegal. The court framed the inquiry as whether the defendant factually knew that society considers the conduct against the law, even though her mental disease or defect may lead her to believe the conduct morally justified. Ruffin drew that from Bigby v. State, 892 S.W.2d 864, 878 (Tex. Crim. App. 1994), where the court reasoned that by acknowledging his act was illegal by societal standards, the defendant understood that others believed his conduct was wrong. So a defendant whose illness convinced her an act was morally right, or even commanded, can still be legally sane in Texas as long as she knew it was against the law.

Here is the part that gets left out. The Penal Code does not define wrong, and Texas juries are not instructed that it means illegal. Terms that are not statutorily defined generally need not be defined in the charge, and courts presume that jurors give an undefined word its common understanding. In McAfee v. State, 467 S.W.3d 622 (Tex. App. Houston [1st Dist.] 2015, pet. ref’d), the court noted expressly that the jury charge did not define wrong, and let stand a prosecutor’s voir dire description of it as legally, socially, or morally impermissible, calling that somewhat broader than the strict legal definition.

So the rule an appellate court applies when reviewing the sufficiency of the evidence and the question twelve people are actually answering in the jury room are not quite the same question. The ordinary meaning of wrong is moral. That gap does not change the law on appeal, but it changes what a defense lawyer should be doing in voir dire, in the charge conference, and in closing, and it is one of the more consequential things about Texas insanity practice that almost nobody writes down.

Texas Has Already Seen This Case: Andrea Yates

Texans do not have to imagine how a Clancy-type defense plays out here, because the state lived through it. In June 2001, Andrea Yates, a Houston mother suffering from severe postpartum psychosis, drowned her five children while in the grip of a delusion, fed by command hallucinations, that she was saving them from damnation. By any clinical measure she was profoundly ill. And in March 2002 a Texas jury convicted her of capital murder anyway, because under the narrow Texas test the prosecution argued she knew the killings were wrong, pointing to the fact that she called the police right afterward. The jury declined to impose death and returned a life sentence. Her illness was not in serious doubt. The problem was that Texas law asked only whether she knew the act was wrong, not whether she could resist it.

Yates was eventually found not guilty by reason of insanity, but only on retrial in July 2006, and only after her first conviction was overturned in January 2005 by the Houston First Court of Appeals because a prosecution expert had given false testimony. See Yates v. State, 171 S.W.3d 215 (Tex. App. Houston [1st Dist.] 2005). Even then she was committed to a state hospital, not freed. The Yates saga is the clearest illustration of the gap between the two standards: the same kind of facts that give a defense real traction under the Massachusetts test produced a capital-murder conviction the first time through in Texas. The law, not just the illness, shaped the result.

Four States Where the Defense Does Not Exist at All

It is worth knowing how far the variation runs. Kansas, Montana, Idaho and Utah have abolished the affirmative insanity defense outright. In those states, mental illness is relevant only to whether the defendant formed the mental state the offense requires. There is no separate question about whether she understood the act was wrong, and no not-guilty-by-reason-of-insanity verdict to reach.

The Supreme Court blessed that approach in Kahler v. Kansas, 589 U.S. 271 (2020), holding six to three that due process does not require a state to adopt an insanity test turning on a defendant’s ability to recognize that her crime was morally wrong. Which is the broader lesson of this entire subject: how much of what we treat as a fixed moral principle is in fact a policy choice each legislature makes, and can unmake.

Why the Standard Matters More Than the Diagnosis

That is the lesson worth taking from the Clancy trial, wherever it ends. Whether an act like this is treated as a crime or as the product of an illness does not turn on the diagnosis alone. It turns on the legal test the jurisdiction has chosen: whether that test recognizes a person who cannot control her conduct, and who carries the burden of proof. A defendant can be unambiguously, severely mentally ill and still be convicted under a narrow standard or acquitted under a broad one. Same illness, different state, different result.

For anyone facing a Texas case in which mental illness is central, that makes several things essential: an early and serious psychiatric evaluation, timely notice under Chapter 46C, a defense team that understands both the science of the illness and the specific contours of Section 8.01, and real attention to how the word wrong will be presented to the jury. The insanity defense is not the cartoon that popular culture makes of it. It is narrow, it is hard, and in Texas it is harder than almost anywhere, which is exactly why it has to be built with care.

The Bottom Line

Not guilty by reason of insanity does not mean a person did not do the act, and it does not mean she goes free. It means the law has decided that a severe mental illness stripped her of the responsibility that turns an act into a crime, and it sends her into a commitment process instead of a prison sentence. Massachusetts, where Lindsay Clancy was tried, asks whether illness robbed her of the capacity to know the act was wrong or to control it, and it makes the state disprove insanity beyond a reasonable doubt. Texas asks only whether she knew the act was wrong, treats wrong as illegal for purposes of appellate review, and puts the burden on her to prove it. The difference between those two frameworks is, quite literally, the difference between a hospital and a prison. It is why the most misunderstood defense in American law deserves to be understood clearly.

Deandra Grant is the managing partner of Deandra Grant Law, a Texas DWI and criminal defense firm. A forensic lawyer-scientist, she has spent three decades working at the intersection of the science, the mental-health evidence, and the law that decide the State’s cases.

If you or someone you know is struggling with postpartum mental illness, the National Maternal Mental Health Hotline offers free, confidential support around the clock at 1-833-TLC-MAMA (1-833-852-6262), by phone or text, in English and Spanish.

Further Reading

• Commonwealth v. McHoul, 352 Mass. 544 (1967), adopting the Model Penal Code insanity standard in Massachusetts.
• Commonwealth v. Kostka, 370 Mass. 516 (1976), on the Commonwealth’s burden to prove sanity beyond a reasonable doubt.
• Massachusetts General Laws chapter 123, section 16, on commitment following a verdict of not guilty by reason of lack of criminal responsibility.
• Texas Penal Code Section 8.01 (Insanity).
• Texas Code of Criminal Procedure Chapter 46C, on procedures, notice, and disposition following an insanity acquittal.
• Ruffin v. State, 270 S.W.3d 586 (Tex. Crim. App. 2008), stating that “wrong” means “illegal” in this context.
• Bigby v. State, 892 S.W.2d 864 (Tex. Crim. App. 1994), the source Ruffin draws on.
• McAfee v. State, 467 S.W.3d 622 (Tex. App. Houston [1st Dist.] 2015, pet. ref’d), noting that the jury charge did not define the term.
• Yates v. State, 171 S.W.3d 215 (Tex. App. Houston [1st Dist.] 2005), reversing the 2002 conviction.
• Kahler v. Kansas, 589 U.S. 271 (2020), on whether due process requires a moral-incapacity prong.
• Callahan, Steadman, McGreevy and Robbins, “The Volume and Characteristics of Insanity Defense Pleas: An Eight-State Study,” 19 Bulletin of the American Academy of Psychiatry and the Law 331 (1991).
• Postpartum Support International, on the incidence and presentation of postpartum psychosis.
• National Maternal Mental Health Hotline, Health Resources and Services Administration.
• The Boston Globe’s coverage of the Lindsay Clancy trial.

This post is an informational synthesis for educational purposes and is not legal advice. The Lindsay Clancy trial ended in a mistrial when the jury deadlocked, and nothing here is a prediction of what comes next in that case. Case citations should be independently verified against the official record before use in any filing.