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'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.

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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.

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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.

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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.

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Mothers Who Kill

by Lucy Puryear, M.D.

I can imagine few things more horrific than a mother killing her own child. Mothers are warm, kind, nurturing people who would rather die than have anything happen to one of their precious children. But as we know all too well mothers do kill, and unfortunately it's all too frequent.

There are mothers who kill because they want revenge against their boyfriends or because they are desperate to keep the man they love. These women, like Susan Smith, the mother who drowned her two children in the lake while they were asleep in their car seats, are criminals. Although women like Smith (pictured right) may have many mitigating circumstances that make them feel desperate and alone, all of them have alternative choices besides killing.

There are some women who, feeling trapped in an untenable situation, decides that the only way out is suicide. But before they do this, they take the lives of their children. This sounds illogical to you and me, but consider the tragic case in Texas where a mother hung her four children before hanging herself. She was a 25-year-old Mexican immigrant, who had a restraining order against her common-law husband for domestic violence. She was working at Wendy's in order to support herself and her family. She was depressed, financially in crisis, and away from her extended family.

It is believed that this was an example of altruistic filicide, motivated by a mother's love and her belief that her children's deaths were better than leaving them in this world without a mother. Were this woman to have lived she would have been tried for murder, but is she the same type of criminal as the examples above?

Today is the seventh anniversary of the Yates children's death at their mother's hand on June 20, 2001. She was tried, convicted, and sentenced to life in prison with the option of parole after 40 years. Due to non-factual testimony by Dr. Park Dietz, the State's highly paid expert, Andrea Yates was given a new trial five years after her original conviction. This time the jury found her not-guilty by reason of insanity. She was sent to a maximum security state psychiatric facility in Vernon, Texas. She was no longer a criminal.

What few realize is that Ms. Yates remains under the jurisdiction of the courts. Although no longer in maximum security, she will remain in a state hospital until a judge determines that she is no longer a danger to herself or others. Even if she were well this is unlikely to happen.

So why rehash the Andrea Yates case? Yes, I testified that she was psychotic at the time of the drownings (hearing voices speaking to her from the TV, believing that she was invaded by Satan and that he was trying to ruin her children through her and send them to hell) but I've had many arguments with others who believe that although mentally ill, she was responsible for the killings and should be punished. I'm not going to continue to try to change the minds of others about this particular case.

I do want to talk about postpartum psychiatric disorders, which are real and treatable. In the case of postpartum psychosis, if recognized and treated, mother's and children's lives can be saved. Andrea Yates is not an isolated case. There were two more incidences reported in Texas within a few years after the Yates tragedy. Those are just the cases that made the news and only in Texas. These were also women who heard God or Satan speaking to them and believed killing their children would somehow save them or save the world. Putting these women in jail or executing them will not stop maternal filicide from happening.

It is estimated that between 1 and 2 women per 1000 deliveries will develop postpartum psychosis. This is a psychiatric emergency. The psychotic thoughts revolve around the baby and often include thoughts of harming the child and themselves. The only way to treat these disorders is through prompt diagnosis and medical treatment. A mother who is psychotic should never be left alone with her child.

Criminologists and forensic psychiatrists are desperate to understand why people commit crimes and how to prevent them from doing so. Many criminals have been so damaged in childhood that changing their character and behavior is impossible. But postpartum psychosis and infanticide is preventable.

Andrea's treating psychiatrist took her off her anitpsychotic medication two weeks prior to the drownings. She was seen by him two days before the drownings. Although mute and catatonic he sent her home. She had been hospitalized twice, and despite medical records that doccumented she was still paranoid and ill, she was released. It is not noted in the records that at any time anyone asked her if she had thoughts of harming her children.

On June 4-7, 2008, Houston was host to the 22nd annual conference of Postpartum Support International. Supported by the Yates Children's Memorial Fund (YCMF) of Mental Health America of Greater Houston (MHA) and Texas Children's Hospital, over 300 attendees heard lectures about about postpartum psychiatric disorders, their recognition and treatment. The more we educate health care providers, mothers, and those who love them the more lives will be saved. The more we talk the more mothers will feel safe to speak out loud the confusing feelings they are experiencing. The more we destigmatize postpartum psychiatric disorders and make it safe to ask for help, the fewer tragedies will end up on the front page of the newspaper.

Andrea Yates was not a woman destined to be a killer. She came from a good family, was highly educated, and loved her children enormously. It could have happened to you or me or to any other woman who delivered a baby. Society let her down. Doctors let her down. Our criminal justice system initially let her down.

We can't stop every mother from taking the life of her child. There are those who do so that we can find no explanation for why they made that choice. And those mother's should be punished. There are many who say that Andrea Yates got away with murder, that she should be punished and suffer for what she did. She does, every day when she opens her eyes and remembers Noah, John, Paul, Luke, and Mary, and remembers how they died.

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Free Will: Too Much of A Good Thing?

by Lucy Puryear, M.D.

As a teenager I struggled with authority. Yeah, me and every other adolescent who's walked this earth. I balked against anyone telling me what to do, when to do it, or what I ought to think about it. It's my body, my hair, my education . . . so leave me the hell alone. I swore when I had my own children I would never repeat the "sins" of my parents.

And then of course I had my own kids and I knew they needed guidance and gentle influence, and sometimes even some not so popular rules. "No, you can't stay up until two on a school night, no you can't go to a party where there are no parents, no you may not speak to me that way. . . ." And their response to me is the same one I gave my parents: "I can't wait until I'm eighteen and you can't tell me what to do anymore."

What you realize as an adult is that it's not so simple. There are not automatically unrestricted freedoms that come with adulthood. There are still rules, and expectations, and societal norms, and even laws that must be followed. And as I tell my children, "No, you don't have to do what I say, but there are consequences to not doing so." If you break my household rules you may get grounded or lose your allowance. If you break societal laws you may do jail time or worse.

The dilemma comes in our society where the government was founded on individual rights of free speech, freedom of religion, the right to bear arms (rights currently being hotly debated), versus the needs of the larger group to be protected from someone's individual rights. Is it okay for you to threaten me with bodily harm as an expression of your right to free speech? Is it okay not to wear a helmet when you ride your motorcycle, if after you squash your brain on the highway, my tax dollars are used to take care of you?

Nowhere is the tension between freedom of religion--an individual's right to choose--and societal laws and norms greater than in the case of the polygamists in Eldorado, Texas. (Women and children after being removed from the compound pictured below.)

So what's so wrong with polygamy? If a woman chooses to be one of five wives, shouldn't she have that right? Not my choice to do so but then no one is asking me to. I assume the FLDS church is just fine with my decision to stay away from them. They're not knocking on my door trying to recruit me as wife number six. So why don't we just leave them alone to practice their religion in peace?

I can think of a lot of religious practices that seem very strange to me. How about taking communion on a Sunday and believing that it is truly the body and blood of Christ? (I actually do believe in that as a practicing Episcopalian, but I'm also willing to admit others might think that practice quite odd and non-sensical.) How about the Jewish practice of circumcision, which is a religious ritual but practiced now by Jews and non-Jews alike? You don't think cutting the foreskin off of a baby's penis a little barbaric?

Where do we draw the line between free will and the safety and well-being of others? The FLDS group from Eldorado believes that they are upholding God's prophetic vision for them to live their lives in plural relationships. The United States has laws that make polygamy illegal. However these groups have been practicing polygamy for decades and mostly have been left alone to practice their religion. But this case hinges on the well-being and protection of minor children. And that's where the issue of free will becomes very important.

We do not believe that children under the age of eighteen (a somewhat arbitrary cut off) have the right to free will. I think mostly because we think they're not mature enough or wise enough to exercise their rights using good judgement. And that's often true. Ask any child whether they thought going to school was a good idea and you'd get many who'd opt for the "only if I feel like it and there weren't any tests" track. So as a society we have chosen to subsume the rights of the child under the rights of the parents. And in the Eldorado case the parents have chosen to allow their underage young girls to be married to much older men and to participate in sexual activity, often against their will. Most of society calls this child abuse, and this is why the children were removed from the compound. Child abuse trumped the right to practice your religion without obstruction from the government.

It will be interesting to see how this case turns out. I think many will be surprised to see that most of the women and children will be allowed to return to the compound. It could be a worse fate for some of these children to be taken away from their mothers and sent to foster care. That can't be the answer for what's in the best interest of these children. And it may be astonishing to many that if given the choice, most of the women would choose to take their children and return to what they consider a safe and nurturing home.

There will be much argument over whether or not these women from Eldorado are acting freely. They have been raised in this environment and some would say "brainwashed" to believe that they are subservient to men and that it is their duty to practice plural marriage. Most of all of us have been "brainwashed" by the way we are raised. I'm an Episcopalian, my next door neighbor is a republican, my best friend was raised to believe in astrology and the power of crystals. But I would say we have free will because we have the freedom to choose whether or not we want to continue the practices of our parents. They may be disappointed or even angry if we choose to vote for a democrat, but we won't be banned from contact with the family.

Adults should be allowed to practice whatever religion, or be in whatever relationship configuration they choose, as long as minor children are not abused, coerced, or denied the right to choose another lifestyle in adulthood. When someone who does not have the right to exercise their own free will is hurt, the law needs to intervene. This is true for children, the elderly, and those with serious and persistent mental illnesses. Thirteen-year-old little girls should not be having intimate relationships with men. That is not religious freedom. That is child abuse.

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Do You Believe in Evil?

by Lucy Puryear, M.D.

My last post referenced the case of Joshua Mauldin, a 20-year-old man found guilty of putting his two-month-old daughter in a microwave for ten seconds. The defense was hoping he would be found not guilty by reason of insanity. That plea was rejected by the jury and he was sentenced to twenty-five years in prison.

In reality, less than 1% of defendants use the insanity defense, and of those who do, less than 20% are successful. That is a good thing. We want people who do bad things to be punished. We most certainly want them put in an environment where the chance that they will re-offend is limited. We also don't want lawyers and their clients to abuse the insanity defense and make it less effective for those who are truly and severely mentally ill.

So if Mr. Mauldin wasn't insane, what was he? And was he fully responsible for the crime he committed? I know I have just raised the hackles of several of our contributors, but hear me out. How do we explain what causes people to commit heinous acts of violence against others? In Mr. Mauldin's case, the defense tried to claim that he had a long history of mental illness and at the time of the crime was unaware of what he was doing. The jury didn't buy that explanation.

But Joshua Mauldin did have some form of mental illness as testified to by both the defense and the prosecution experts. Was he adequately treated? Did he have appropriate follow-up to assure that he was on the proper medication and that he had been taking it as prescribed? Was he depressed? Psychotic? Not an excuse, but a factor? The legal system even allows for mitigating factors to be considered when deciding upon a sentence. Rage, passion, mental illness, poverty, and abuse are acknowledged as possibly contributing to the perpetration of a crime.

As I psychiatrist I often try to understand why people do the things they do . . . hopefully so they can stop making bad decisions that hurt themselves or others. When someone commits a violent crime it's often not that hard to understand why. A psychotic person hears Satan's voice telling him to kill. A pedophile was sexually abused as a young child by a close family member. A teenager panics when she delivers a baby she's told no one about. These explanations help us to make sense out of how someone can do some things so awful to others and give us some hope that we might be able to prevent future tragedies. We can make sure there is access to psychiatric care, we can work to identify children who are being abused and get them help, and we can set up laws that allow mothers to turn over infants to hospitals or fire stations (Baby Moses Law).

But I must admit, after I count up the mentally ill . . . and the abused . . . and the neglected . . . and the disenfranchised . . . how do I account for those who, despite fairly reasonable upbringings, inflict terrifying and horrific acts against innocent others? I want to find some brain disorder, some chemical imbalance that makes sense of this for me. I don't believe people are born to commit atrocities. And yet . . .

There are some whose eyes you look into and see darkness. Despite my best efforts I can't find a way to make human contact--find that piece of them that connects to others. Often these people are good at "pretending" to be human. They have studied others and can mimic appropriate reactions or responses. But inside there is no true capacity to know or care what another thinks or feels. In his novel No Country for Old Men, Cormac McCarthy depicts a character, played by Javier Bardem in the film adaptation (pictured above), who kills and makes sport of it. He enjoys the chase and the terror that his victims experience as he flips a coin to decide whether they live or die. It gives you chills as you watch this inhuman human, kill.

Medical science is trying to find the cause and hopefully the "cure" for people without a conscience. At the moment there is no medication nor therapy that has been very effective. It is hard for me not to want to find a reason for the horror: brain damage at birth, poor nutrition, maternal deprivation? It is hard for me as a healer not to want to heal. And yet I must acknowledge I am helpless. And maybe there is just such a thing as evil.

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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.

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