National Crime Victims' Rights Week - Part II

by Lucy Puryear, M.D.

As evidenced by our readers' comments in Part I, my patient Elizabeth is not unique. There are many women who have been victims of incest, and other sexual assaults. As I see primarily women in my practice, I know their stories very well; but men are also victims of incest as well as victims of rape. Unfortunately their stories are often never heard due to shame and skepticism. It's been recently that we've come to know the darkness of priests assaulting young boys, revealing more about the impact of sexual abuse on men.

When I first began to see Elizabeth she was very anxious and depressed. Her depression was the primary problem and was potentially life-threatening. She was unable to eat and had lost a great deal of weight in a short period of time. She was tired all the time, felt guilty about all the trouble she was causing her mother, and believed that she had been a problem to her family for a long time. She thought that maybe they'd be better off without her around.

At the least, she said, "If I'm dead, the pain will stop. I'm so tired of trying so hard to be good enough, and always screwing up. I just don't want to be here anymore."

My first job in treating Elizabeth was to make sure that she was safe to be on her own and didn't need to be hospitalized for her own safety. I asked her, "Do you think about ways you might hurt yourself?" Fortunately, she said, "No. I just think about not being here anymore. Like if I could just go to sleep and not wake up, that would be great. But I couldn't do that to my mother. I think it would kill her."

Many people with depression have thoughts of death but no plans to actively hurt themselves. This is critical information in order to continue to treat someone as an outpatient. I started Elizabeth on antidepressant medication and recommended she see me once a week for therapy. I also referred her to the rape crisis center in Houston for support, and possible group therapy.

There are themes common to all incest victims and victims of sexual assault that I often hear in therapy. For Elizabeth, she had to deal with the shame and responsibility she felt for the abuse by her stepfather. She wondered, "Why didn't I tell him no, or run out of the room? Why didn't I tell my mom? She would have believed me and it would have stopped. He was mean to her too. Maybe there was part of me that wanted that? Is that possible? I always took the ice cream or candy afterwards."

As an adult looking back, a survivor of sexual abuse might find it hard to understand why s/he didn't say no . . . why s/he didn't run away . . . why s/he didn't tell someone . . . anyone. But a child's mind does not function like an adult's.

A child assumes that adults are there to protect them from harm. It's confusing when the stepfather you are told to love and trust hurts you. You want attention, but the attention is confusing. You are young and he is old; you do what you're told. And it doesn't stop because the person who tells you that he will kill your mother if you tell is more powerful than you and you believe him. You are small and he is big. And you're afraid that if you tell you might be taken away from your mother. So you pretend that there's no problem and you try to be really, really good. But as an adult you feel ashamed and guilty for your participation. You've forgotten how helpless you felt as a five year old. Elizabeth must learn to forgive herself for being five and doing the best she could at the time.

Women who are victims of sexual abuse often grow up feeling dirty and damaged. There is something broken in them that will color how others see them and treat them. It's why often women who have been abused will tolerate being partnered with another abuser. They believe that they are somehow worthless and when someone gets in close they will know how awful they truly are. The abuse, whether verbal or physical, makes sense.

Some women who are abused go on to lead ruined, damaged lives. Elizabeth was walking down this path with her promiscuity and drug and alcohol abuse. The unconscious belief is, If I treat myself this way I am making that choice, I am not powerless, what happened to me was not that big of a deal, I am in control.

If this behavior doesn't stop, lives become more and more desperate and sad. Many women though, like Elizabeth, tell themselves that they will not let the abuse ruin their lives, they will be successful and prove that they have value. But without therapy or some type of working through the abuse the feelings I have described remain. These feelings can have long-term effects on future relationships with friends and loved ones. They remain vulnerable and hurting.

Once someone has been through a traumatic event another traumatic event is much harder to process. It's as if the brain has been primed to respond to trauma. Elizabeth processed the rape in much the same way she internalized the sexual abuse. She believed that the rape was somehow her fault. That there was some flaw in her that made the rapist chose her. That if she hadn't been so stupid as to be walking alone at night, it wouldn't have happened. She had a hard time blaming the rapist for his actions; she was more responsible than he. The rape confirmed her fears that she was damaged and dirty. She didn't report the assault to the police because she was ashamed of herself.

Elizabeth and I spent many months together talking about how a child is not responsible for an adult's abuse. She didn't run away because she was confused and scared and didn't have the maturity to process other choices. She was a child, she was blameless. We talked about the sexual assault on campus being similar to what happened to her as a child. A man bigger and more powerful than she took control and abused her. At the time she was helpless to stop him. We talked about her allowing herself to be angry at her stepfather and the rapist for hurting her. She even allowed herself to express anger at her mother for not realizing what was happening to her as a young child and stopping it.

I am still seeing Elizabeth. She is no longer depressed and has graduated from law school. She is employed and volunteers as a child advocate at the court. We are working on her acknowledging her worth and value and allowing her to have a close relationship with a man who respects and cherishes her. That is still hard for her.

All stories are different and people react differently depending on earlier life experiences. But victims of sexual crimes are left with a particular set of feelings about themselves and their worth as women. There is healing for those feelings and women can recover and lead healthy and productive lives. It is an honor to work with these women and to help them to heal.

Tweet

National Crime Victims' Rights Week - Part I

by Lucy Puryear, M.D

In honor of National Crime Victims' Rights Week, I would like to present a case of mine that tells the inside story of someone suffering from being the victim of crime. In Part One, I will present her story. In Part Two tomorrow, I will discuss the case and talk about the after effects of incest and rape. This is a real story, although details have been changed and identifying features altered to protect confidentiality.

Elizabeth was a young girl of three when her stepfather began molesting her. She doesn't remember much about those early years, but has vague memories of being scared at night and not wanting to be left alone with her stepfather. Her mother told her that she was frequently treated for urinary tract infections when she was little.

At the age of five, Elizabeth remembers her stepfather calling to her from the garage, "Come help me fix your brother's bike." She was both excited and uneasy. Excited that her stepfather was asking for her help and uneasy that she would be alone with him, away from the eyes of her mother. "Come on, we'll go for ice cream afterwards." It was the first time she remembers her stepfather putting his fingers inside of her and more. It wouldn't be the last.

The abuse happened until she was thirteen. It stopped when her mother and stepfather divorced and her mother and she moved out of town. She never told her mother or a teacher or her best friend. Her stepfather told her not to tell or he'd kill her mother. She believed him and kept her mouth shut.

Elizabeth got good grades in school, was in Girl Scouts, and sang in the church choir. No one ever asked her if there was anything wrong. No doctor ever questioned her urinary tract infections. Her mother never wondered why Elizabeth tried to avoid being alone in the house with her stepfather.

In high school, Elizabeth started getting in trouble. She started hanging out with the "cool" kids and would meet up with her friends to smoke pot before school started. Drinking and other drugs followed and her grades began to slip. Drinking and drugging were an everyday occurrence and sex with any boy who showed her some attention was not uncommon.

Elizabeth's mother couldn't understand why her daughter was acting so out of character. She had been a sweet child and always willing to do any chore that was asked of her. She never complained and seemed to get along with everybody. Although Elizabeth never seemed very popular or had friends over to the house, her mother thought it was just because she was shy and liked spending time with her mother. She considered them to be very close.

In college, things seemed to turn around. She was able to get a scholarship to a small college out of town. Elizabeth decided it was time to turn her life around and put the past behind her. She made great grades and some good friends. No more drugs or alcohol and no more promiscuity. She was determined to go to law school and make something of herself. She wasn't going to be a victim to what happened to her as a child.

In law school, Elizabeth was studying late one night in the law library. Constitutional law was her most difficult and most interesting class. She wanted to do well in the hopes of getting a prestigious clerkship.

"I wanted my mom to be proud of me again. I know I had let her down when I was in high school. I was a really bad kid and caused her lots of grief," she told me on her first visit to my office. "I was raped that night. I caused her grief again."

Elizabeth was referred to me three months after she was attacked and sexually assaulted by a man who accosted her as she walked across the semi-dark campus. She didn't recognize the man and was unable to recall any distinguishing features. She just remembered his voice telling her not to scream or he would kill her. She thinks he had a knife but was too frightened to check. When he finished he told Elizabeth not to move for an hour or he would come back for her. She lay there for what seemed like forever before she found the nerve to walk home. She did not report the assault to the police.

"I was just in the wrong place at the wrong time," she said. "It was stupid of me to be walking alone that night. I was just asking for trouble, at least he didn't try to kill me. It could have been a lot worse."

Elizabeth had taken a leave of absence from law school and moved back home to be with her mother. She had not told the school about the assault, only saying that she was ill and would need to take some time off.

In my office I saw a woman severely depressed. She wouldn't look me in the eye, sat on my couch wringing her hands, and couldn't stop crying. She had lost twenty-five pounds in the last three months and was close to being hospitalized for the effects of malnutrition. Elizabeth kept repeating over and over again, "It's all my fault, it's always been my fault."

Please share your thoughts and feelings about Elizabeth and how you might go about helping her. In Part II tomorrow, I'll post my thoughts and relate how Elizabeth is doing.

Tweet

Group Think

by Lucy Puryear, M.D.

It is no longer 1984, but George Orwell was on to something when he penned his classic and prescient novel. Published in 1949, Orwell wrote of an eerie world where individualism was rejected and universal group adherence was mandated. Although the fear that 1984 would resemble "1984" the novel did not come true, many of his concepts are relevant to our culture today.

I would like to talk about group behavior and crime. In 1979, social psychologist Irving Janis coined the phrase "groupthink." He defined groupthink as "a mode of thinking that people engage in when they are deeply involved in a cohesive in-group, when the members' striving for unanimity override their motivation to realistically appraise alternative courses of action."

I am proposing that groupthink contributed to the financial crisis that we are facing today and allowed white collar criminals like Bernie Madoff and Sir Allen Stanford (pictured left) to swindle large numbers of intelligent investors. Those of us on the sidelines can't imagine how so many were taken in by unrealistic promises of over-the-top financial returns. But I'm certain if I saw the fortunes many of my friends were making I would want to join the party. When Madoff's funds consistently beat the market while others didn't, common sense would demand questions be asked. But no one wants to tell the Emperor he's naked, especially if they're serving caviar and champagne at the party.

It takes a charismatic, talented individual to conceive of and pull off a massive fraud on the scale of Stanford's and Madoff's. But without individuals following, the Ponzi scheme never would have worked. It was only when there were no more investors left with money that the plan fell apart. But we weren't immune to the bandwagon.

The stock market is a prime example of groupthink. We think the economy is doing well and we invest as we see stock prices rising. We think the economy is doing a nosedive and we panic, pulling our money out and stopping our spending. None of really knows what the economy will or won't do, but the group dynamic says we're in really bad shape here whether or not we personally are.

The dominant message from the politicians is restoring consumer confidence. Meaning, if we believe things will get better, we will reinvest and re-spend and the stock market will go up. The stock market often has less to do with real data and more about how people feel. And right now we're all feeling bad.

It is not just financial malfeasance that is made possible by groupthink. Large crimes against

humanity require people to function with a singular group mentality rather than with individual judgement. Why did so many Germans, otherwise good people, tolerate the Holocaust and the torture and slaughter of millions? How is it possible that Jim Jones in Ghana convinced hundreds to drink purple Kool-Aid? David Koresh? Marshall Applewhite (shown right)? All of these men became cult leaders, convincing numbers of usually bright, well-meaning people to follow them, even to their deaths.

Groupthink is frightening and we are all susceptible to it. It takes a unique individual to stand up to the mob and risk being ridiculed, excluded, or worse. Remember what it was like to be a teenage girl, listening to others make fun of your best friend, but deciding to go along so that you could be a part of the cool crowd and not be ostracized from the clique? As the examples above prove, people will choose death over losing their place in the group and being left behind. Most frightening of all, as we become more and more enveloped by groupthink, we begin to think of those thoughts and ideas as our own and lose our ability to think for ourselves.

People are not responsible for the choices criminals make, but in certain situations it takes our cooperation (unconscious though it may be) to become victims. Those charismatic, narcissistic, antisocial individuals know a lot about groupthink, and how to use it to their advantage.

Tweet

Sex Education in Schools: Private Lessons

by Lucy Puryear, M.D.

It seems to me that there are more and more reports in the news of female teachers having sexual relationships with their male students. We're all very aware of male teachers taking advantage of their female students. When that happens most of us are not surprised; older men and younger women are a dyad familiar throughout the ages. The man is attracted to the girl's youth and adoration; she is attracted to his power and the prestige of being the chosen one.

Male teachers and their students are a ubiquitous story. One of my good friends in high school married our physics teacher twenty years her senior, one week after graduation. We were all fascinated, jealous, and grossed out. My English teacher once asked me to sit on his lap; I declined. My Spanish teacher got down on his knees after class and told me I was beautiful. I was 15. He must have been 40. I laughed and quickly walked out of the room. But were I more vulnerable or insecure or confused, maybe I would have pursued a special relationship with him. I'm sure I'm not the only ones with stories.

In those days we didn't consider these men sex offenders, though we should have. We just considered them weird teachers to stay away from. I made sure to never be alone in the room with either teacher again. Today male teachers taking sexual advantage of their young students are tried and punished. It is not tolerated.

But I don't remember stories of any female teachers taking advantage of male students. Was it going on and we just didn't know about it? Were the guys too proud or too ashamed to tell? And a 35-year-old female teacher marrying an 18-year-old kid was taboo. Okay for men, but no way for women.

The times have changed. Either more women are taking advantage of their male students or we are more aware that any teacher sexually engaged with any student is a sexual assault, whether consensual or not. Mary Kay Letourneau (pictured above with student Vili Fualaau) opened the door into the world of female teachers having relationships with their male students. She was sentenced twice for having a sexual relationship with Fualaau, starting when he was twelve.

Our very our Women In Crime Ink contributor Kathryn Scardino recently defended a Spring teacher who was accused of giving oral sex t0 two football players. According to the Houston Chronicle, Shannon Hrozek (pictured right) was given ten years of deferred adjudication, and agreed to surrender her teacher's license. Reading the comments of the public in response to this case was enlightening. Many applauded the two young men for getting serviced. Others pointed out that were this a male teacher with a female student the sentence would have been much more grave. We would be looking at a registered sex offender as opposed to a teacher who might have done two young men a "favor."

It is assumed that males are not harmed by having sex with an older woman, whereas young girls must be forced and taken advantage of. It is hard for many to imagine that a young boy could have sex unwillingly. But let me be perfectly clear: Any time there is a differential in power between two people, potential coercion exists. This is true for a doctor and patient, lawyer and client, pastor and parishioner, reporter and source, and teacher and student. Any time there is an inequality in a relationship the relationship cannot, by definition, be consensual.

It is the responsibility of the doctor, lawyer, pastor, reporter, and teacher to err on the side of restraint—even if the other party is "asking for it," professing love, or seems to not be harmed. It doesn't matter if the student, or patient, or client walks in to the room naked, begging to be taken. It is ethically and often legally required for the person in power to say no. Teachers need to be reminded of the power they hold in a child's eye and what a privilege it is to be given this power. A young boy assaulted by his teacher has been abused, even if others think him lucky.

Tweet

It Doesn't Get Crazier Than This

by Lucy Puryear, M.D.

In 2004 Andre Thomas killed his wife and children, cut their hearts out, put the hearts in his pocket, and walked outside. He then went home, put them in a plastic bag and threw them out. He stabbed himself three times in the chest and then walked into a police station to report his crime. What a horrible, heinous crime. He was understandably tried for capital murder. On the surface this looks easy--he turned himself in to the police and confessed his crime. He only needed to plead guilty and await his sentence. But while awaiting his trial in his solitary cell, he pulled his own eye out and ate it. Yes it's true, he plucked his own eye out and ate it, right there in his cell.

I have never evaluated Mr. Thomas, but according to newspaper reports he has a diagnosis of schizophrenia. His behavior now at least starts to make some sense. He suffers from delusions and altered reality. Maybe he hears voices. He reportedly believed that his family was possessed by the devil. Killing them was saving the world from evil. I couldn't find any report as to why he plucked his eye out. The prosecution suggested it was a ploy to appear insane. You've got to be kidding me.

I agree people try to fake mental illness to escape some form of punishment. I personally was duped by a fellow who showed up in the psych ward claiming to be a wolf. It took me about 30 minutes to figure out that his story was bogus and he was trying to find a warm place to stay for the night. He laughed when I told him that his diagnosis was that he was full of "s--t." He was quickly discharged.

Non-mentally ill people do not pluck their own eyes out for some secondary gain. People with schizophrenia, when seriously ill, have been known to mutilate themselves in an attempt to cut off offending body parts, or kill themselves. I have personally witnessed one case of a man who cut off his own penis (fairly rare, but does happen), a man who cut off his arm with a circular saw, and a woman who slit her own throat. These persons had delusional "reasons" for doing these things and were "crazy" enough to be able to carry it out. I would propose that it would be close to impossible for any of us to pull out our eye voluntarily unless we were hallucinating on LSD or mushrooms. We would be temporarily "crazy."

In 2004 a judge declared Mr. Thomas competent to stand trial. He was found guilty and sentenced to death. While awaiting his sentence to be carried out, Andre Thomas last month plucked out his other eye and ate it. Yes really, he ate his other eye and is now blind.

The terrific blog, Grits For Breakfast, posted on this story on January 9, 2009. The comments were amazing. Although there were several who were sympathetic with Mr. Thomas's mental health issues, many more suggested that he should be executed to put him out of his misery. Well that's one way to deal with the mentally ill in prison-- kill them.

To those of you who would suggest that I am soft on crime, consider this novel idea. How about we make mental health treatment available in the community to those who need it. Had Mr. Thomas been adequately treated and monitored he never would have killed his family or plucked out his eye. Three people would be alive today and an enormous amount of money would be saved keeping him out of the prison system. That's not soft on crime, that's preventing crime.

There are so many problems here. How do you find someone competent to stand trial who is so severely mentally ill? The standard for competency is not very stringent. You have to understand the charges against you and be able to participate in your own defense. Those are easily met standards. How do lawyers and judges who may know next to nothing about mental illness evaluate the mental state of a defendant? By the time a defendant appears in court they have usually been medicated and no longer display obviously bizarre and crazy behavior. Someone who is no longer psychotic will often try to make logical sense out of the crime they committed and will say that they knew at the time that what they were doing was wrong.

There may be one way to make some sense out of the issue of the mentally ill who commit crimes. Several communities have Mental Health Courts. These courts are in place for those defendants who have histories of mental illness before committing a crime, or committed a crime while mentally ill. The lawyers, judges, and others assigned to these courts have special training in mental illness and are equipped to knowledgeably handle these defendants. Instead of the revolving door from prison to back on the streets where psychiatric care is lacking, then back in prison when another crime is committed, these persons can be put into a system where follow-up is mandatory and resources are available. Another example of not being soft on crime, but preventing crime.

Harris County, Texas will soon have it's own mental health court. Judge Jan Krocker's 184th District Court will hear felony cases of defendants diagnosed with schizophrenia, bipolar disorder and severe depression on a full-time basis. What a great idea: stop crime by making sure the revolving door is closed for those with mental illness. The perfect liberal and conservative agenda all rolled into one. Unfortunately for Mr. Andre Thomas and for his family it's too late in coming.

Tweet

Get Ready for the New Year

by Lucy Puryear, M.D.

I am writing this from the front porch of a cottage in beautiful Santa Rosa Beach, Florida. We've been fortunate to have three days of gorgeous sunny weather. I've ridden bikes, walked the beach, been kayaking on a lake, and rested. Rest is not something I ever get enough of and it's a luxury. It's been easy to put the anxieties and traumas of 2008 aside and just be in the moment.

I must admit I am dreading the ten-hour car ride back home to Houston with four children and luggage crammed into two back seats. Fortunately we left the exuberant black lab at home with good-natured friends. We hope they are still good natured—and still our friends—when we retrieve her. And I am praying that the good time we all had in Shangri-la will make our drive home a little kinder and gentler than the trip here.

As I think back on 2008 with some perspective I can see it's been a hard year. We've all suffered from the economic roller coaster, though I am grateful that I am one of those that have been least affected by the chaos. I have never been rich, so I haven't had much to lose. I am not retiring tomorrow so hopefully my 401K will have a chance to rebound. I have a good career and I am my own boss so I know I won't be fired as the company downsizes. It is difficult though to watch parents or neighbors or friends suffer with the uncertainty and fear about their financial futures.

Houston was hit by Hurricane Ike, and I realized a VERY little bit what those of New Orleans must have struggled with after Katrina. I was only without power for eight days but those eight days felt like a ring of hell. I can't even imagine what it must feel like to have lost your home (though some of my friends and patients did) or loved ones. Houston is still struggling to recover normalcy and Galveston will never be the same.

I know that many of us feel disoriented and confused by these times. I hear it from patients in my office every day. Our houses used to be worth more than we bought them for, and we could imagine buying something bigger and better when we decided to sell. Vacation plans were extravagant and credit seemed endless. If I wanted to go on a biking trip to Italy, then I could put it on a credit card and know that there was more where that came from. Having more and more seemed to be the goal and we could all feel good that we were prospering. Then the sense of endless attainment fell apart and the rules changed.

As I face into 2009, what do I see? I see hope. There is hope that with a new administration real change will happen. Common sense will prevail and we will scale back to a more reasonable economic climate. Poor Barack Obama. Whether you voted for him or not, you have to feel compassion for the man who is taking over our country at one of the worst of times, and feel hopeful that he can accomplish even some of the changes he envisions.

I feel hopeful that the stock market will recover, and my retirement fund will regain some of what it lost. I am hopeful that eventually falling housing prices will allow those who could never own a home to enter the market. And I truly hope that the middle class will prosper and we will be a country with a middle class again; not just a country of the rich and the poor.

And then I have those dreams I've had for a long time. Dreams that there will be no poverty, child abuse, domestic violence, or mothers who kill their children because of treatable mental illness. I wish for the abolition of the death penalty, and a change in our penal system from one of harsh punishment to a focus on rehabilitation. I hope that everyone who wants a job can find one, and that children are loved and cared for by their parents.

Yep, you have now pegged me as a liberal, soft-hearted, fool. Some of you may be thinking worse of me. But in the job I do, sitting with those who have suffered loss, trauma, and pain, I have to believe that good things can arise from hard times. And it is our humanity that allows us to take hardship and learn from it to make our lives better, more fulfilled, and more human. Without that belief and that hope, we should all give up and go home because none of us are fortunate enough to be spared pain.

So I am looking forward to 2009 with hope for better things to come. I am grateful to be part of this great group of intelligent and accomplished women who write for this blog. Although we don't always agree with each other (I'm waiting for my anti death penalty comment to take some heat), we all like and respect each others' knowledge and accomplishments. How much fun it is to be included.

As I shut this down for the night and get ready to post, I wish all of our bloggers and readers many blessings and good things for the new year. Please wish for me safe travels, quiet children, limited bathroom stops, and a dog who is welcome back at our friends' house.

Peace.

Tweet

It's An Outrage

by Lucy Puryear, M.D.

"Woman Who Cut Off Baby's Arms to be Released," Houston Chronicle, November 7, 2008. Dee Schlosser was arrested in Dallas, in November of 2004 for cutting off her daughter Maggie's arms, resulting in her death. In the aftermath of the Andrea Yates case in Texas, several women have been found not guilty by reason of insanity after killing their children. All of these women, including Schlosser, were psychotic at the time of the killings. Schlosser believed that by cutting off her daughter's arms she was making a more perfect offering to God. The police came to her home and found her soaked in blood humming along to a hymn.

Schlosser was sent to a state mental hospital where she received treatment and continued to be under the jurisdiction of the court. According to law, persons found NGRI (not guilty by reason of insanity) must remain in a state mental hospital indefinitely until it is determined by their psychiatrist that they are no longer a danger to themselves or others and can be maintained in outpatient treatment. Schlosser will be released into the community where she will be mandated to meet with a psychiatrist weekly. She will no longer be allowed to have contact with her other two children, and may not be in close proximity to any other children. It is unknown where she will live when released. She will remain under the jurisdiction of the court permanently and will be forced to return to the hospital if she again becomes dangerous.

Understandably the prosecutors of Collin County are unhappy with her release and wish the laws were different. Understandably the citizens of Dallas are unhappy that she may released into their community. Understandably there may be some renewed talk about having the laws changed. Maybe Dee Schlosser should have been committed to a state psychiatric facility for the rest of her life? It is an outrage that a mother who killed her children is free to walk the streets.

I am going to ask you to believe that Dee Schlosser should be released and be free to live what ever kind of life she is able to piece together for herself. She is no longer psychotic, she is on medication, she will be monitored by a psychiatrist to make sure that she remains well. So why should she remain in the hospital; just so our sensibilities are appeased? That's a waste of money. Her being in the hospital does not protect you or your children. Dee Schlosser has no intention of coming to your house to cut off the arms of your child.

Many of you would say she should be in jail, or even executed for what she did. That would solve the problem. She did something bad and she should be punished. Does it matter that her brain was malfunctioning? That the blood flow to certain areas of the brain were increased where they shouldn't have been and decreased to other parts? Was this happening to her because she chose to be crazy or decided that hearing voices and was a good idea?

Let me ask you to fantasize for a moment. What if you had a hundred and four degree fever and you became delirious. You were hearing someone walking into your room in the middle of the night and when you looked up you saw a masked man carrying a gun. You reached for your gun on the bedside table and shot. Only later when your illness was treated were you aware that you had shot your husband. Death penalty? Think that's not possible? Hallucinations happen all the time with high fevers and brain infections. Your brain is malfunctioning.

Let's speculate again. You are driving in your car and have a heart attack. You swerve off the road and plow into a group of people standing on the corner of the street. A mother and her young child are killed. Death penalty? Clearly you didn't do this on purpose. Your heart was malfunctioning and caused behavior that was out of your control. Let me go a little further. What if you knew you were at risk for heart disease but declined diet and exercise and didn't take your heart medication because you didn't like the side effects. Death penalty? Surely you knew you were at risk for a heart attack. In fact you doctor warned you on numerous occasions. The fact that you had a heart attack isn't all that surprising. Are you responsible for those deaths?

Mental illness is a brain disorder. The symptoms are behavioral, and often the symptoms are horrific. No one wishes to be mentally ill, anymore than someone asks to have diabetes or heart disease or meningitis. And untreated the symptoms of mental illness can be deadly, just like any other medical illness. Not just for yourself, but as I described above, for others. Why do we treat the mentally ill as criminals?

Dee Schlosser will never live a care free life. She must live with the knowledge and memory of killing her child. She will no longer be able to care for or have contact with her other children, and her marriage ended in divorce. What kind of life will she have? Can you imagine waking up every day to that horror? As a matter of fact, most mothers who have killed their children eventually end up killing themselves.

Let me let you in on a secret. Every single one of you reading this has a mental illness, has a family member with a mental illness, or knows someone who has one. And if you don't know someone who does that's simply because they don't talk about it. The stigma of mental illness is so great that we can't face admitting that we are all affected. This is not unlike epilepsy in earlier times. Until the cause of and treatment for epilepsy was discovered family members were hidden in asylums, attics, and weren't allowed to marry into good families. That is where mental illness is today.

Dee Schlosser deserves to be released if she is no longer suffering from her symptoms. She is medicated and no longer poses any danger to anyone. Don't worry, if you feel the need for her to be punished she already has been. She will continue to suffer every day of her life no matter where she is living. She needs our prayers. And we need to pray that some day we can find the cause of and a cure for mental illness so that no one kills their child because they're sick.

Tweet

Is Casey Anthony Another Susan Smith?

by Lucy Puryear, M.D.

I am often asked by the media to comment on cases where mothers have harmed or killed their children. I frequently am called by attorneys asking for help in their cases where a mother has killed her child.

Because of my work in the Andrea Yates case it is hoped that I may be able to offer some psychiatric defense for other defendants. If the alleged murderer was suffering from psychosis then a verdict of Not Guilty by reason of insanity may be successful. Many attorneys wrongfully assume (or hope against hope) that if the mother they represent has killed her child then she must be "crazy." I am sure she is "crazy" in some form, but not always in a way that mitigates her responsibility for the crime.

It is impossible for me to forget the case of Susan Smith. It was October of 1994, and I was a second-year resident in psychiatry at Ben Taub Hospital in Houston. I was learning how to diagnose psychiatric illness and treat psychiatric emergencies. We were also being trained in detecting whether someone was fabricating or exaggerating their illness for some secondary gain. It was not at all unusual to interview persons who were trying to get prescription medications from naive young doctors, or who wanted to be admitted to the hospital for a warm bed and three free meals.

But as I watched Susan Smith on television tearful and begging for the lives of her children, I felt tremendous sorrow and grief for her. I could only imagine how devastating it would be if I had been accosted and my children kidnapped. Her grief felt in sharp contrast to the drug addict trying to convince me they were terribly anxious and needed me to prescribe Valium. I knew one women was in real pain, and the other just trying to manipulate me.

The nation and I were shocked to learn that while Susan Smith sobbed, her children were strapped in to their car seats, at the bottom of a lake. The person responsible for their deaths? Their mother.

In the Casey Anthony case we have a mother who allegedly killed her child, stored her daughter's body in the trunk of the car, and then began to party. Only when questioned did she report that her daughter had been missing for some time.

Unlike Susan Smith, we never saw her on television begging for her child's return. We did see her at the disco and at Target, acting as if life couldn't be better. Even if she didn't murder her cute-as-a-button daughter, why is she acting so blase about the fact that her daughter is missing? Unexplainable.

What are the possible reasons a mother could kill her child? From a psychiatric point of view, I think there's something seriously wrong with someone who murders her own child. It doesn't mean I think they shouldn't be punished, but I also think that a diagnosis of some type can be made. Let's start with the "easier to make the connection" psychiatric disorders:

1. Psychosis: A person hears voices telling them to harm their child or has a delusion that makes them believe their child needs to be saved from evil or their child is evil and the world needs to be saved. This was true in the Andrea Yates case; she believed her children were being taken over by Satan, and in order to save them from hell she had to send them to heaven while they were still innocent enough for God to take them. This can happen to women who become psychotic for the first time after delivery, or in patients who have previous diagnoses of schizophrenia or bipolar disorder. This can be prevented with appropriate psychiatric intervention and medication. Mothers can be treated and children do not have to die.

2. Depression: A mother can become so severely depressed that she wants to kill herself but feels that her children would suffer without a mother. She kills the children before she attempts to kill herself. Sometimes she is unsuccessful at taking her own life and must face the emotional and legal consequences of her choice. This can happen in severe postpartum depression or in cases where a mother is depressed due to financial or marital stresses. She believes she is protecting her children from being left behind to suffer. Depression can also be identified and treated and lives saved.

3. Borderline Personality Disorder: This is a complicated diagnosis and varies in severity from individual to individual. The characteristics of this diagnosis are mood lability with terrible feelings of depression, loneliness, emptiness, and despair. This mood symptoms are often accompanied by substance abuse, risk-taking behavior, and suicidal thoughts with less serious attempts. These attempts are often seen as cries for help. Persons with BPD form intense chaotic relationships which are often passionately good early on and then become disappointing and passionately bad later on. This disorder usually occurs in people who have histories of childhood abuse, abandonment, parents with disorder, or other chaotic, "not safe," inconsistent attachments to caretakers. Borderline Personality Disorder is hard to treat. The treatment consists of long-term psychotherapy and medication.

Although I have not personally interviewed Susan Smith, this is most likely her diagnosis. She was raised by a violent alcoholic father who later committed suicide when her mother divorced him. Her mother remarried a man who molested Susan for many years without reprisal. Susan began to engage in relationships with married men while she was in high school and was in the middle of a divorce and rejected by her lover when she released the parking brake in her car and watched her children drown. She knew what she was doing was wrong, but at that moment was feeling such despair and hopelessness that it felt like a way to make life less complicated. She also believed that without her two children her boyfriend might take her back. She was terrified to be alone without a man in her life to allow her to feel complete.

4. Narcissitic Personality Disorder: This is an unfortunately common personality disorder that often does not cause the person who has it much discomfort. Persons with this type of character have little regard for needs or feelings of others, but use others to meet their own needs and desires. Often those with this type of disorder are successful in their business or careers and can appear outgoing and charismatic, but they draw people to them for their own personal gain. If a loved one or colleague stops being useful to them then they can be easily disposed of without much pain. If there are problems in their lives, they are blamed on the inadequacies of others. Narcissistic individuals have a hard time taking personal responsibility. The causes for this disorder are not entirely clear, but often there is a childhood history of being highly adulated by parents, not made to take responsibility for mistakes with parents often helping to cover-up or fix problems, and having things given without having to learn the value of hard work and disappointment.

I don't know Casey Anthony's history, but her behavior certainly fits one who has little regard for others, is primarily interested in her own welfare and happiness, and will go to great lengths to escape consequences or punishment. Susan Smith confessed to what she had done and felt remorse. Casey Anthony continues to lie and deceive.

5. Antisocial Personality Disorder: These are the people who fill our jails. People without conscience, morality, or the ability to live within societal norms. I can give too many examples of this. . . . Mothers who drown their kids to get back at cheating boyfriends . . . Mothers who leave their kids alone to go hang out at the crack house . . . Mothers who abuse and torture their children for . . . enjoyment. At the moment there is no treatment for this disorder. Therapy as an adult doesn't work. Early childhood intervention is most likely the key. There has been one study published that links those in jail to having had mothers who had postpartum depression. By the time someone reaches jail it is mostly too late.

Mothers will continue to kill their children. Jail may most certainly be appropriate for some individuals, but it is not a deterrent to other mothers. Fortunately there are some causes of maternal filicide that are very treatable with proper screening, identification, and treatment.

The Mother's Act in Congress failed but will be brought out again for another vote. This law would require more money be earmarked for the recognition of, treatment for, and research of postpartum psychiatric disorders. (If only it been part of the "pork" in the bailout, like the Parity bill which mandates insurance companies pay equally for psychiatric illnesses.)

Early childhood intervention to prevent child abuse, neglect, ensure quality education and day care, and support for single mothers could go a long way towards decreasing the incidence of antisocial personality disorders. Susan Smith could have benefited from intensive therapy and intervention by someone to stop the abuse by her stepfather. We have the means and the knowledge to stop some of these heinous crimes.

Casey Anthony? There was a book written in 1954 called The Bad Seed. A good read.

Tweet

Upholding Legal Rights of Mentally Ill Defendants

by Lucy Puryear, M.D.

On June 19, 2008, the Supreme Court of the U.S. issued a decision in which it held that a higher standard must be used to determine defendants' competence to represent themselves in criminal cases than the test used to determine the accuseds' competence to stand trial. Plainly speaking, this means that while a mentally ill defendant can be found competent to stand trial it does not necessarily follow that they can competently represent themselves as their own counsel.

Fundamentally this could be viewed as a negative decision for the mentally ill. One of our constitutional rights is self-representation in court. We are allowed to tell our story the way we want it told and to plead our case in a manner that we believe is in our own best interest. Now most of us would do a pretty terrible job of maneuvering ourselves through a court case, but sometimes taking your lawyers advice doesn't turn out as you'd hoped. I have heard defendants ask, "Why didn't my lawyer do this, or why didn't they say that?" Sometimes juries will express, "Why didn't we hear from the defendant, I want to hear his version of the story." Not speaking for yourself is not always the right decision.

It becomes very complicated in a case where the defendant is floridly psychotic (hearing voices, speaking in gibberish). Nothing useful will come from that defendant trying to conduct his own trial. The court process becomes derailed and nothing good is accomplished for either the defense or the prosecution. Often the defendant by his very mental state convicts himself with little effort by the prosecution.

But does it make sense to allow someone to be competent to stand trial and yet too ill to represent themselves? Most courtrooms are all too ready to allow a mentally ill defendant to be tried. Recently the Supreme Court of the United States said yes in the Indiana v. Edwards decision. (Facts of the case excerpted from the NAMI newsletter.)

In July 1999, Ahmad Edwards was discovered trying to steal a pair of shoes from an Indiana department store. After being discovered, he fired a gun at a store security officer and wounded a bystander. He was charged with attempted murder, battery with a deadly weapon, criminal recklessness and theft. He was diagnosed with schizophrenia and subsequently found incompetent to stand trial and was committed to a state psychiatric hospital for further evaluation and treatment. His competency and mental status fluctuated over the course of five years and he was not found competent to proceed to trial until July 2004.

In June 2005, Edwards stood trial. He asked to represent himself but the trial court rejected this request and the jury found him guilty of criminal recklessness and theft but failed to reach a verdict on the charges of attempted murder and battery. The State decided to retry him on the attempted murder and battery charges and he was retried in December 2005. The trial court again found that he was competent to stand trial but not competent to represent himself.

Despite being represented by counsel at his retrial, the jury convicted him on both counts. Edwards appealed, arguing that he had been wrongfully deprived of his constitutional right to represent himself. The case eventually reached the Supreme Court, which addressed the legal question of whether the standard for allowing defendants to represent themselves at trial should be higher than the standard for finding defendants competent to stand trial.

The Court decided that there was a higher standard for representing yourself than the standard for competency. To be found competent to stand trial you must be able to consult with your attorney with a "reasonable degree of rational understanding." This means in general that you are able to know what you have been charged with, be able to consult in formulating your own defense, and be able to explain the nature of the pleas involved. (In an interesting aside, Andrea Yates was found competent to stand trial although she initially wanted to plead guilty so that she would be executed by the state which was the only entity who could kill Satan inside of her. She understood the plea but her psychosis was unable to initially allow her to follow her lawyer's advice.)

The Edwards decision states that to be competent to represent yourself you must have the ability for "organization of defense, making motions, arguing points of law . . . questioning witnesses and addressing the court and jury." The court is stating that those that are mentally ill may be well enough be found competent but still not be able to represent themselves. While this may appear to be taking away the rights from persons with a disability it may be ultimately in their best legal defense. The Court also comments on the humaneness of the decision, "A right of self-representation at trial will not affirm the dignity of a defendant who lacks the mental capacity to conduct his defense without the assistance of counsel," Justice Stephen G. Breyer wrote. "To the contrary, given that defendant's uncertain mental state, the spectacle that could well result from his self-representation at trial is at least as likely to prove humiliating as ennobling."

The United States has long struggled with the treatment of the mentally ill. From locking them up in sanitariums for years to locking them up in jails. No one knows quite what to do with the mentally ill defendant who, although it may be obvious that they've committed a crime, it's also obvious that they are seriously disturbed. In Houston alone it is estimated that some 50% of the inmates in the juvenile justice system are seriously and chronically mentally ill. Jail is not a great treatment for a psychiatric disorder.

Texas in particular has struggled with the death penalty and the mentally ill criminal. We have had a history of executing those with known, documented, and profound psychotic illness. This is an embarrassment for our state and a terrible example for respecting human rights. This ruling by the United States Supreme Court is a very small step forward in assuring that those who commit crimes and are suffering from mental illness have both their rights protected and receive fair trails. What to do with a mentally ill defendant after conviction is the topic of another blog. I look forward to sharing my thoughts on a very complicated issue.

Tweet

Split Personality? The Stripper and The Soccer Mom.

by Lucy Puryear, M.D.

There is no such thing as a "split personality." I know, most people think it describes someone who has schizophrenia or someone with multiple personalities. Really it's a meaningless term used mostly in the media to describe someone who's generically "crazy." But in the case of Mechele Linehan née Hughes, convicted killer, it may be a term that helps us understand how a seemingly loving doctor's wife and mother of a beautiful little girl could orchestrate the murder of an innocent man who loved her.

Mechele Hughes (pictured right) was a very popular young stripper at The Great Alaskan Bush Co. There she made the acquaintance of several men who became enamored of her and showered her with expensive gifts. She was good at her job. One of her admirers, Scott Hilke, asked her to marry him and she said yes. Another man began to shower her with attention and money and he eventually moved in with her. His name was Kent Lippink. He would be murdered with two bullets to his body and one to his face. He too was engaged to be married to Mechele Hughes.

John Carlin (pictured left) was the third man intimately involved and infatuated with Mechele Hughes. When Mechele's house needed repairs he invited Mechele and Kent Lippink (pictured together, right) to move in with him and his 16-year-old son, John Carlin, IV. Mechele was engaged to Scott Hilke who was now in Washington, engaged to (so he thought and told his family) Kent Lippink, and on occasion travelling to Europe with John Carlin. This was an odd family to say the least, with Mechele, the successful stripper, at the center of it all. And then Kent was found murdered.

Fast forward to today. Mechele is now Mechele Linehan. She married Colin Linehan, a doctor, in 1998, and they had a daughter in 1999. She had friends, volunteered, and according to her husband, is a wonderful wife and mother. She has also been tried, convicted, and sentenced to 99 years in prison for her role in the murder of her "fiance" Kent Lippink. John Carlin, Mechele's former suitor, has been convicted and sentenced to 99 years in prison for pulling the trigger and killing Kent. Both deny any involvement in his death and are filing appeals.

I don't know if they are guilty or not. Both juries believed so. I invite you to review the evidence for yourself; it's fascinating and certainly is incriminating. But what is more fascinating to me is how there seem to be two Mecheles.

There's the Michele who was a professional exotic dancer and could manipulate men to fall in love with her and shower her with money and gifts. This Mechele was even able to entice another man to kill for her. (Kent had a life insurance policy with Mechele as the beneficiary that he changed a few days prior to his death.)

Then there's the respectable, upstanding Mechele, married to a doctor, loved by her friends, a model citizen. Colin, her husband, insists that it is an impossibility that the woman he loves and knows better than anyone in the world is capable of murder. He is fighting to have her released. Her friends say they know it is ridiculous to think of her as a "femme fatale," manipulating men and plotting to have them murdered.

Who is Mechele Linehan? Could she be both dangerous and a wonderful and loving woman? Is it possible that her husband is right; the woman he knows is incapable of murder? Maybe he only knows one side of her, the side she allows him to see. How could he not know he was living with someone who could kill?

In psychological terms there is a phenomena called "vertical splitting." Imagine a vertical line drawn straight down the middle of your body, from the top of your head to your feet. This leaves you with two halves, split vertically, a right and a left side. The sides are both part of you, but because you are split in half, sometimes it's easy to ignore what your left side is doing. And because your two sides aren't fully integrated, it's easy to pretend that the left hand that just stole that apple isn't really you—at least it's not part of the right side of you, the side that would never imagine stealing anything.

People use this way of functioning psychologically everyday. An easy example is the pastor who speaks from the pulpit about the evils of homosexuality but is later caught in a clandestine homosexual affair. In the pulpit he is the man he believes he says he is; righteous, moral, and a zealous follower of the Bible.

But when his desires overtake him he is able to put aside the righteous man (split off that part of himself) and allow the other part of him to be fulfilled. He is able for a moment to not think of himself as the man in the pulpit while he is engaged in activity that is abhorrent in one area of his life, but is fulfilling in another. When he is back in the pulpit he is able to ignore or split off his previous actions. And isn't everyone shocked and surprised when they find out? How did we not know? How were we all so taken in?

This happens when people have affairs, but still believe they are good spouses in good marriages, or when people lie, steal, and cheat others (think of Enron), but still go to their kids' little league games and donate money to charity. And the common denominator is that people who are able to use vertical splitting are very engaging, charming, successful, and able to make the rest of us believe they are who we think they are, or who we need them to be. When they are committing adultery or stealing, or worse, they are able to shut out the other reality of their lives and not think about who they may hurting or disappointing. It's almost as if they can believe it never happened, they never did anything wrong, and they are outraged when caught and continue to deny bad behavior.

It is quite likely that Mechele committed this crime. And it is quite likely she will never admit it, never feel remorse for it, and will continue to believe that she had a good life that never should have been interrupted by a trial.

Her husband (above, with Mechele) will most likely never believe that the woman he so loves was capable of murder and he will continue to believe that she was wrongly convicted. Her daughter will suffer for the rest of her life missing her Mommy. Kent Lippink will never have his life back because he trusted and loved the wrong woman.

Who are these people? They live next door to you and me, we work with them, we go to church with them, and some of us, like Colin Linehan, are married to them.

Tweet