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.

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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.

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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.

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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.

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Desperate Times Lead To Desperate Measures . . . Or Is It Just a Poor Excuse for Murder?

by Robin Sax

As the financial times and the economy continue down a very slippery slope, people are becoming more panicked than ever. Just last week I was at the airport and overhead a businessman calming his wife on the phone, explaining to her that “we’re almost there, it’s going to turn around.”

I have spoken to parents who have dutifully opened college savings plans 18 years ago, only to be stressed about how they are going to pay for their kids’ college education. The money’s just about gone, and people have lost their homes, their jobs, and their life savings. And then there are those who have lost their minds.
In the last two weeks alone, stories of desperation have made headlines throughout the country. In Los Angeles, there was the case of 45-year-old Karthik Rajaram, a guy who appeared to live the “picture-perfect life” with all the accoutrements of a successful life: a beautiful home, a career, a family, luxury cars. When he lost his job as a financial advisor, he pulled a gun on his 39-year old wife, his three sons (ages 7, 12, and 19), his 69-year-old mother-in-law, and then himself. He left a suicide note saying that his financial troubles had led him to conclude that this was his only option. All he left behind were his possessions, which are now packaged by crime-scene tape (above).

Meanwhile, in Ohio, a 90-year-old woman attempted suicide after facing eviction from her home of 38 years. In despair, she actually shot and wounded herself.

Just a few weeks ago, my post was about the bigger picture of how economy and crime went together like peas and carrots. I looked at the presidential candidate platforms for guidance, understanding, and hope. But neither John McCain nor Barack Obama inspired me or gave me answers to who was going to fix this mess. However, I was certain of and continue to know that our economy has a direct correlation to our crime rate.

I am not alone in my opinion. Richard Rosenfeld a sociologist at the University of Missouri – St. Louis said, “Every recession since the late ’50s has been associated with an increase in crime and in particular, property crimes and robbery, which would be most responsible to changes in economic conditions.” He does point out, however, that “there is typically a year lag between the economic change and crime rates.”

But as the economy continues to plunge and homes continue to foreclose, do we face increased risk of murder and suicide? Can economically hard times really lead someone to kill? I look to my colleagues—profiler Pat Brown and psychiatrist Dr. Lucy Puryear for answers. While fascinated with why people can do the things they do, as a prosecutor I know the answers are not necessarily elements of a crime that I must prove.

For example, in a murder case, I need to show that a defendant had the specific intent to kill, but I don’t have to prove motive, even if I know there is one.

As a human being, an American, and a prosecutor, I feel it is my obligation to understand how the conditions in our country can trigger this type of desperation. Is it what others suggest—a poor excuse to kill? According to Rich Paul, a vice-president of Virginia-based Value Options, Inc., which handles mental health referrals, calls about stress-related foreclosures and financial hardships have gone up 200% in California in the last year. Rates of depression increase as the economy worsens. Stress and depression are one thing. . . . Murder is another.

Since the economy affects everyone, we all need to understand how it works and come to grips with it. And perhaps, even more important, we all need to know that there are options, help, and resources for everyone in these most difficult and stressful times.

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