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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From Brother to Brother - Part 1

by Stacy Dittrich

I remember the night all too well. December 26, 2007, my husband Richard and I slept peacefully after a long, festive Christmas Day. We were glad to see the year coming to an end. I was still a deputy with the Richland County Sheriff’s Office and Rich was a Mansfield police officer. We had endured one of those dark years in our profession, the kind that law enforcement agencies throughout history ultimately face. Our departments had been plagued with officer-involved shootings and deaths, all of which were scrutinized by the media. It was a year most of us went to work on edge, wondering if “today was our day.”

Last Christmas was a peaceful holiday—thoughts of work put aside as our daughters were always first priority—and we looked upon 2008 with high hopes. However, if we were ever to imagine how this year would end, we wouldn’t have believed it.

It was approximately 5:00 a.m. the day after Christmas when our phones began to ring: our house phone, and both of our cell phones—repeatedly, which is never a good sign in a household with two police officers. Rich and I were awakened and alerted to the fact that something was wrong—very wrong.

Unable to reach the various numbers that showed on our phones, I began to become extremely concerned about my father. A Mansfield Police Lieutenant, my father supervised Rich on the night shift. Since Rich usually takes Christmas off to spend with the family I was racking my brain trying to remember if my father was on his days off or not. Although it had seemed like several minutes, only seconds had passed when Rich opened his cell phone and read out loud a text that had just come in: MANSFIELD POLICE OFFICER BRIAN EVANS WAS JUST SHOT AND KILLED BY HIS BROTHER. (Evans pictured above.)

Standing in our kitchen in shock, Rich continued to read that Brian’s wife, Trina, had also been shot. I immediately fell apart. I had known the couple for a long time; their 10-year-old daughter Tess was a friend of my daughter’s, and the text didn’t reveal whether Trina was alive or not. The thought of this little girl losing both her parents was too much to handle at that moment. Rich, who had worked side by side with Brian nightly, was also overcome with grief. Regardless, the incessant phone ringing began again, and we began to learn the horrific events that had occurred leaving two innocent people dead, and two shot.

Late Christmas night, Brian, a few friends, and his brother, Larry—a corrections officer at a nearby prison—decided to take in a movie. For reasons that can only be defined as premeditated, Larry excused himself from the theatre and walked out, leaving the rest of the men scratching their heads. Brian and Larry had a good relationship so no one could figure out why he did this. Unknowingly, Larry had taken Brian’s truck from the movie theatre and drove it home. Becoming concerned, Brian called Larry’s wife, Carol, and asked her to pick him up and drive him to their home to find Larry. Brian also called Trina, who was with his sister, Kimberly, and told them to start looking for Larry—something was wrong.

As Brian and Carol drove to Larry’s home, they were unaware that he had already ambushed, and shot his neighbor, 44-year-old Robert Houseman, in the head—killing him instantly.

After spending an enjoyable Christmas with his parents and two young daughters, the well-liked and quiet Houseman was definitely in the wrong place at the wrong time. As he put his keys in his front door to enter, Larry Evans approached Houseman from the darkness, leaving his body to lie on the front porch of the duplex they shared (pictured above).

Brian spotted the body immediately upon pulling into Larry’s driveway. Clearly sensing the danger, Brian ordered Carol to leave the area for her own safety. Brian, a highly trained SWAT member, was also certified in the area of crisis intervention. Emerging from the darkness carrying a high-powered assault rifle, Larry Evans gunned down his own brother in cold blood, before shooting at his own wife who was fleeing for her life.

Mansfield Police Chief Phil Messer summarized Brian’s courage well:

“The fact that this was his brother makes the events even more tragic; however, it cannot be disputed his act to intervene instead of leaving in the vehicle with Carol Evans clearly saved her life and demonstrated his commitment to our oath. Yes, there may be a few among us who would have confronted such a situation in the same manner as Brian—the everyday heroes we read about from time to time—but there are those we expect to respond; our police officers and firefighters, what we call our hometown heroes.”

Brian’s body lay several feet from Houseman’s as Trina and Kimberly made their way to the home. Lying in wait, Larry opened fire on Trina and Kimberly as they pulled in, striking Trina in the right shoulder and Kimberly in the chest. Reacting instantly, Trina threw her car in reverse and sped away for safety. As she called for help, her main priority was getting a message to Brian—to warn him not to come to the house. Unfortunately, she was unaware that Brian had arrived first.

What followed was a stand-off between Larry Evans and my fellow officers at the Richland County Sheriff’s Department and Mansfield Police. Over thirty rounds from various weapons were fired at officers, weapons that—according to Carol Evans, who never reported the incident—were being stockpiled over the course of several days. Carol Evans, who now supports her husband, also has her sister, Debbie Spurlock on her side.

“Larry’s a good, good person. Everyone needs to know that,” Spurlock stressed about the barbaric monster that brutally killed two people and shot two others.

In no less than a cowardly fashion, Larry (pictured left) stripped his clothes off and surrendered to authorities, naked with his hands held high, knowing he wouldn’t be shot. In the aftermath of the brutal slayings, Evans was indicted on 19 counts of murder and attempted murder of Brian Evans, Robert Houseman, Trina Evans, Kimberly Evans, and countless law enforcement officers. His bond was set at one million dollars. Prosecutors are seeking the death penalty.

The trial of Larry Evans began—and ended—this week. Trina Evans courageously filed a motion to continue the trial, contending the findings of the psychiatrists were grossly inaccurate; the motion was denied.

This is only part one of an incredibly tragic story that has taken an astonishing turn of events. With the insanity plea thrown into the mix, the trial has already sparked outrage within the community, and numerous protests have already begun in downtown Mansfield. Was Larry Evans completely under the reign of a psychotic breakdown, or were the killings calculated by an intelligent, cold-blooded killer who knows the inner workings of the criminal justice system?

There is a growing, and all-too-realistic fear that Larry Evans may be out on our streets one day soon. While incarcerated, Larry has sworn to finish the job he started—a job that includes killing Trina and Kimberly.

On Tuesday, September 2, a three-judge panel (two, actually, since the third fell asleep) deliberated for only ten minutes after listening only to the testimony of one witness, a psychiatrist for the defense. The judges returned an appalling, and shocking, verdict of not-guilty by reason of insanity. A potential mass murderer may be on our streets in less than two years, as Larry Evans attempted to shoot and kill upwards of 15 people that night. At the announcement of the verdict, the courtroom erupted, stunning the victims, including Trina Evans (pictured above).

The second part of this story will focus on what went wrong during the trial, and how a historic lack of injustice could possibly be rectified. To hear Trina Evans' own thoughts on the verdict, listen here. WCI's Susan Murphy-Milano wrote her own blog on the tragedy when it occurred in December.

As for Trina and Tess Evans (pictured left with Brian), they are slowly picking up the pieces and holding their breaths.

Note: I will be discussing the case again on War On Crime radio with host, Levi Page, Sunday, Sept. 7th, at 10pm EDT: www.thewaroncrime.blogspot.com

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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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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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