Monday, March 24, 2008

What Does it Mean to be Crazy?

by Lucy Puryear, M.D.

You may be surprised by my title and use of the work "crazy." That's not exactly a politically correct medical term, but when you listen to a psychiatrist's private conversations it's one that's used frequently. It's shorthand for, "Boy, did I just see someone who was really sick." What is meant by that is that the person in front of us is either acting bizarrely (standing in the middle of the street gesticulating wildly and talking to the sky) . . . listening to voices in his head or responding to visions you and I can't see (if you've ever had a really high fever you might have experienced this; it's called delirium) . . . believes something entirely off the wall (the CIA has planted a bug in my head--remember you have to be careful with delusions, one day the CIA may indeed be capable of that!) . . . or his speech is so unintelligible he doesn't make sense to anyone (the technical term is "word salad," a little of this, a little of that . . .) .

So when I'm speaking with a group of psychiatrists I'm pretty sure we all know the shorthand. But when you are trying to translate "crazy" to a courtroom it becomes much more complicated. The medical and legal definitions are entirely different.

In the Andrea Yates trial I was asked to determine if Yates (pictured above) was legally insane at the moment she drowned her children. So I had to put my medical definition through the lens of a legal one: Was Andrea Yates legally insane at the time she killed her children?

There is no standard psychiatric definition of the word insane and it's not one we use in regular conversation. In a courtroom in Texas insane means the following: does the person know at the time the crime was committed the difference between right and wrong? From a medical understanding of psychotic illness (crazy) that definition is hard to interpret. Obviously the jury found it difficult as well. In the first trial she was found guilty, in the second trial, not guilty by reason of insanity.

To make matters more confusing, the legal definition of insanity changes depending on which state you live in. You can commit the same heinous crime and be insane in Texas, but by definition not insane in Connecticut. Excuse me for saying so, but that's CRAZY. Whereas Texas uses a much older and more constricted definition of insanity (McNaughton Rule), Connecticut uses a more modern definition (American Law Institute). The advocates who worked so tirelessly for the defense in the Andrea Yates trial have been working to have the legal definition of insanity changed in Texas to a more modern standard. Good luck getting that passed in a state that still struggles over the execution of those with mental retardation.

There's a new case getting the attention of the media here in Houston that will test the stomachs of those chosen to sit on the jury. Joshua Royce Mauldin (pictured left) is currently on trial for putting his two-month-old baby daughter in a microwave for ten seconds. She suffered second- and third-degree burns over parts of her body and currently is living with relatives. Mr. Mauldin has pled not guilty by reason of insanity. According to the Houston Chronicle, he has a history of mental illness and claims to have heard voices. He felt a "weird sensation" come over him right before he put her in the oven.

I have not interviewed Mr. Mauldin or consulted with any of the psychiatrists who have. Is he legally insane? I don't know. That's going to be for the jury to decide. The jury will have to make sense of a complicated psychiatric history and conflicting testimony from mental health professionals. Is he crazy? No doubt. Is he sick? Absolutely. There's something seriously wrong with someone who can do that to another human being. But in the state of Texas the defense will have to prove that at the time of the crime he didn't know what he was doing was wrong. In this instance, I bet that will be a hard case to make.

19 comments:

Kathryn Casey said...

Fascinating post, Lucy. You're right, that Mauldin case will be a tough one, but then, so was Yates. Really glad to have you here with us!

Pat Brown said...

Mauldin will be a tough case because he is not a woman. Men who kill their kids get life sentences or death penalties and women rarely do. Why? Because we feel sorrier for women's life situations. We tend to believe they were naive when they entered into their relationships, trapped by the men they are with, and unable to extract themselves. Therefore, they can "lose their sanity" and commit "out of character" crimes. This, however, is more social commentary than psychology. Those men who kill their babies may feel just as trapped in their relationships. They may be just as stressed out over having to deal with crying babies and financial burders. They may also have to deal with the pressures from their mates. So what? None of these difficulties in life gives us the right to take the lives of others - our children, our spouses, our girlfriends, our neighbors, or in the case of serial killers, any person that happens to be available. This is why we call these behaviors crimes and they require justice.

Now, could Yates or Mauldin be insane to the point of not understandin their behaviors? I see none of this in either case. Yates eventually got a deal because she had spent some time going to a mental health facility and acting real depressed. So what? Being very depressed doesn't make us killers. Choosing to kill makes us killers. Andrea Yates "supposedly" heard voices. Oddly, she didn't walk around hearing those voices all the time. She only "admitted" to this a couple of times when she wanted pity or needed a defense. These couple of admissions do not prove she ever heard any voices.

Mauldin's case is no different from Yates. He has an equally pitiful defense to excuse cold-blooded homicide. Actually, his is better than Yates. He actually could have had a moment of loss os sanity. Andrea had to have to keep it up for an hour while she drowned one begging child after the other.

I believe the only time this insanity/schizophrenia defense should be usable is if the defendent spends years of his or her life wandering around talkin about the aliens in his head and everyone knows this person is nuts because one cannot be nuts just once or twice (unless it is convenient for a trial defense).

So, Lucy, we stand on opposite sides of the fence on this one. You believe Mauldin will not be able to prove insanity because he differs from Yates because he is sane and I would say he will not be able to prove insanity because he differs from Yates only because he is a man.





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Lucy Puryear MD said...

Thanks for your spirited words Pat. I appreciate your sentiments and agree to some degree about men and women being treated differently in regard to killing their own children.

But I do see things differently when it comes to mental illness. I think it is very difficult for someone who has not been "crazy" or had a "crazy" family member or friend, or worked with severly mentally ill, unmedicated patients in close quarters to fully understand what it means or looks like to be psychotic.

It is especially difficult because mental illness resides in the brain and at the moment there are no x-rays or blood tests to prove that someone is seeing things or hearing voices. We have to rely on educated practitioners with training and experience to give reasonable opinions based on the best scientific evidence available at the time.

It is easy to say that someone is crazy if they're walking around homeless, talking to God, and wearing their pants on their head. But lots of people with real psychotic illness don't act like that. Some, like Andrea Yates, are catatonic, unable to function, and are having bizarre thoughts they don't tell anyone about.

I do not believe that having a mental illness means that you are automatically not responsible for your behavior. Most people who are mentally ill and commit crimes do have the ability to tell the difference between right and wrong. The Susan Smith case is a prime example. Yes, she was mentally ill, but she was very aware of what she was doing, and was very aware that it was wrong. Maybe in my next blog I'll talk about why I think the Yates and Smith cases are so different.

And who knows, Mauldin may have heard voices at the time of his crime...we'll what and see what evidence is presented.

Diane Fanning said...

Pat and I have argued about the Andrea Yates case with great passion. And as I told her, I cannot comprehend how anyone can be more deserving of an insanity verdict than Andrea was.
I thought it was absolutely criminal of DA Rosenthal to go for the death penalty in this case.

I do think that society as a whole has little understanding of mental illness and many see it as a character flaw rather than a medical condition it is. We have a long way to go to educate people about these disorders and, as a result, many people do not seek the treatment they need because of misconceptions and lack of knowledge.

Pat Brown said...

Lucy,

I actually haved worked in psychiatric units for over a decade, so I am not ignorant of behaviors. I would say that what I have noted was is that, like in criminal profiling as to motive in crimes, the patient's thinking is more inside the psychiatrist imagination than the patient. Likewise, in interviewing of suspect/patients/felons. They often tell you what you want to hear or what will gain them the most sympathy or attention; therefore, often what they claim is dubious.

As as profiler, I lean heavily on behavior, especially past behavior. We humans cannot act 24 hours a day and our true nature and thinking shows up in our actions. Yates did not exhibit psychotic delusions any time in her past as far as I can tell. She once drew a bath and, in retrospect, it is theoried she might have planned to kill herself. Yet she didn't.

So, I guess I would disagree that suddenly we go into psychosis and voices tell us to do evil things to others. I believe it is our own voice telling us we hate our life and this would be a good way to take care of it.

Thanks for the polite "spirited" adjective, Lucy! ::laughs::

Lucy Puryear MD said...

Oh boy, Pat. You and I could have a blast having this conversation. I wonder how much patience others will have for our debate!

I did not mean to imply that you had no experience. I'm sure you have much more than the "average" person. If I may so bold, I would suggest that our experiences are probably very different. That may not be true, but I am guessing that you have much more experience with suspects/patients/felons, and I have more experience with average/next door neighbor/poor souls who did nothing to deserve getting a medical biological illness called psychosis.

Now if all of this is in my "the psychiatrists" mind then I sure did waste a lot of time and an enormous ammount of money getting medical training! And those patients I treat who get better with the medications I prescribe must be also wasting good money.

I could go into great detail about Yates history, and my numerous interviews with her, but that has been hashed and rehashed. Suffice it to say she DID have psychotic delusions for several years prior to the drownings and was in and out of treatment and hosptitals for many years.

I would totally agree with you that no one "suddenly" goes into psychosis and momentarily hears voices telling them to do something evil. Psychiatric is a long, slow, and often insidious decline over many years if not properly treated. That was Andrea Yates plight--to be poorly treated by an uneducated psychiatrist.

I hope you don't think all of us psychiatrist guys are full of "sh..." ::laughing and smiling::

Thanks for "hearing" the good nature with which I am sharing my thoughts.

Anonymous said...

Go ahead! Ask her about her experience. Ask about one case that she worked on. What psychiatric hospitals she worked at.

That should be interesting.

Kathryn Casey said...

Boy, this is one spirited conversation. Yates had been ill for years, Pat. It wasn't sudden at all. She'd been hospitalized repeatedly. Lucy knows more about this than I do, but I believe she was taken off a very strong antipsychotic drug right before she killed those beautiful children.

This may, however, be one of those cases y'all will never agree on. And that's okay. But it sure is interesting to be a fly on the wall for the argument!

Pat Brown said...

Yes, Lucy, we are from opposite sides of the fence on this! I am glad you can retain a sense of humor over it...we would probably blast each other to kingdom come in a court of law! But, this is what makes the world go round and debate an interesting matter!

As to anonymous..oooh, anonymous..gotta love postings by people who wish to remain secretive..

No, I am not a psychiatrist nor have I worked psychiatric cases as a therapist. I was a sign language interpreter which gave me a very unique inside perspective. Often I would interpret what the client said to the psychiatrist and then, when the psychiatrist left the room, the patient would radically change in front of me and mock what they just said! I was an interpeter and bound by the ethics of interpreting, I could not go back to the doctor and say, ya know what? So-and-so just fooled you! Then, when the doctor returned, I could see they often (not always, Lucy) bought into what the patient had told them. It was a fascinating behind-the-scenes look at what most of the time is not known. I was in a unique position. I also worked with the same clients for a decade so I got to watch the scams they pulled year after year, doctor after doctor (sometimes changing institions when someone figured them out). It is a perspective few in the medical or psychiatric profession have an opportunity to see and, if I hadn't been in the position of sign language interpreter and essentially under a gag order), I wouldn't have seen it either. I would love to have the opportunity to bring this perspective to the psychiatric and medical community. Meanwhile, that inside knowledge has served me well as a criminal profiler so I am thankful for the experience.

Pat Brown said...

Oh, Kathryn, yes, we see also see this differently. It is true Andrea Yates was given and antipsychotic drug (Haldol) but this does not mean she was ever psychotic or needed that particular drug. Psychiatrists themselves would disagree as to her psychiatric issues and one might give her this kind of drug and another might think this a rash treatment and see no reason for it. From what I have read, Yates went in for depression but did not exhibit any bizarre delusional behavior (maybe narcissistic behavior and attention-getting behavior, but not psychotic). Could she benefit from getting some kind of help? Sure. I think the woman hated the bargain she had agreed to - marriage and a pile of children. She was pissed off and depressed. I can't say I blame her. But, like many others who kill off their families, she had choices to get out of the situation and she chose not to do so. Instead, she took away ever one else's choices. In my opinion, this is psychopathic. I bet Yates will "recover" shortly and move on in life. She will get out of the institution and live happily husband and child free. Meanwhile, the man who commits such a crime will be in jail for the rest of his life. Karla Holmolka played that card as well...the abused wife. Her husband, Paul, remains in prison while Karla gets out, remarries, and goes on her merry way. I don't know...I can't see Yates as you and Lucy do, a victim. I see the five children as victims of a psychopathic woman. I guess I view the many suffering women around the world who are forced into marriage and childbearing and they don't kill their children even though they are no happier than Andrea Yates. Likewise, there are many men who lose their wives or girlfriends (and women their men) and they don't stalk them and shoot them down. Killing your loved ones is a choice, not a psychosis UNLESS for years one has been seeing devils inside them. Yates apparently saw none of this until the day she offed the kids. End of diatribe::laughs::

Gaye said...

In my town, the most efficient way to commit suicide is to let the police know that you have a mental illness. If they know (or think)this they will shoot to kill.

Mental illness is poorly understood, even by those that are mentally ill. It is a real illness, like any other; and sometimes you feel better than others.

I don't think mental illness should give an automatic Get Out of Jail Free card though. The kind of mental illness that prevents one from knowing right from wrong, or doing anything to stop doing wrong, must be of such magnitude that it surpasses my understanding.

I have posted to this blog in the past as anonymous, not because I was hiding, but because I was short on time and did not have enough of it to take time to register. Just so you know.

Pat Brown said...

Good points, Gaye. The issue over mental illness is a tough one.

As to anonymous posting, I don't mind them unless there are pointed attacks within them (I don't know if you were the anonymous above but this is just a standard concern). While we at WIC no doubt will have spirited debate (we have many a strong woman contributor here and likewise for the visitors), we discourage personal attacks. This is supposed to be a fun, informative, and thought-provoking site, so I hope you enjoy visiting and we are glad to have you.

Lucy Puryear MD said...

Okay, I can't help myself. It's so hard for me to let you have the last word Pat! But after this I'm going to try!!!

I agree there are patients who lie, disemble, make-up, over do their symptoms and laugh at us poor gullible psychiatrists behind their backs.

In the ER we had a file for such "frequent fliers," people who came over and over again, feigning mental illness to get some type of social service. So yes, I would again agree with you that there are people who abuse the system. There are also people with antisocial personality disorders who are bad and maybe evil people.

I hope you would agree with me that there are also people who are legitimatlly sick.

TxMichelle said...

I don't dispute that there are some truely mentally ill people out there. (I am not a psychiatrist or a profiler, but I have been around the block a few times.) Anyway, I agree with Pat here in the regard that if a man committed the same crime as Yates, and it has been done, he would be tried for straight up murder.
One case that shows an example (I can't remember his name). He murdered his wife and children, left them in the ballroom, and then took off and lived a "normal life" until he was caught many, many years later. I am sure you all know the case I am talking about.
I can't see as how this is any different. According to him he suffered from depression because of his wifes mental illness, his chldren were not following the law of God, he lost his job. I would say he had some pretty serious mental health issues. Yet, he was tried for murder and jailed.

He should have been jailed. He knew what he did was wrong that is why he left.

Pat Brown said...

Well, yes, Lucy, I do agree there are truly mentally ill people. But, I guess I differentiate more between those with completely altered realities and those who simply hate the reality they are in. I guess this is what I think the law is about: awareness, not "despairness." If you know what you are doing you you are guilty even if you make the choice because despairing was the reason you did it.

So, you gave me the last word, but now I will give YOU the last word, Lucy, and I will shut up and let you close the debate::smile::!

Lucy Puryear MD said...

You are too kind Pat, and I will take your offer to close this down.

I was hoping we could come to some mutually agreeable place before this was over.

We agree there is a difference between altered reality and despair. My job in a courtroom would be to convince you that Andrea Yates had altered reality and did not act out of despair. Where it despair then she is a very bad person indeed. If you could tolerate my presenting the evidence to you over several days, I might be able to get you to rethink your position on her (not so sure though, you and I are touch cookies).

I want you to know I turned down a case around the same time of a woman who drowned her two children in the bathtub. She was in great despair but did not have altered reality. She had a terrible childhood, but again was in full control of her faculties. I told the defense that I wouldn't be much help to them. They gave me a dollar and went on their way.

All to point out, I hope, that there are psychiatrists who are able to tell the difference between right and wrong.

Thanks for listening. best, Lucy

Kathryn Casey said...

Just an update on the Maudlin case: He was found guilty and sentenced yesterday to 25 years.

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BuQue Lady said...

I've enjoyed this lively discussion very much. I've interned in the mental health field and seen malingerers, as well as the truly disturbed.

I often wondered why Andrea Yates was given anti-psychotics when depression was the chief presenting complaint initially. I know that some drugs, such as Ablifiy, is used for impulsive behavior, although that's not what's it's marketed for. But never heard of Haldol for depression.

Would like to see a discussion between Andrea Yates and Susan Smith.