Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis

by Montross, Christine

  “See yourself what?” I asked gently. She glanced up at me, and I could see that her eyes had reddened and filled with tears. Her right thumbnail was digging deeply into her left index finger’s nail bed. There was a small, bright spot of blood. She took a deep breath and looked straight into my eyes.

  “Drowning him. Or taking a knife,” she said, still quiet but now firm. “Slitting his throat.” Her gaze stayed on me. My stomach turned; I hoped my face did not betray the way I felt.

  Over the years of my training, I have learned the potency of the first words I say to patients after they tell me their central concern. Even the most psychotic patients can retain the human capacity for gauging their listener’s response. Often it’s a test. A delusional patient may tentatively reveal that the same black van has been behind him in different cities, morning and night, to see whether his fears are dismissed or taken seriously. A pedophile may explicitly describe his fantasies to see how easily you can be shocked, or scared away and led off course. Regardless of the literal content that is disclosed, it seems to me that in such situations the real question these patients are asking is almost always the same: How well can you tolerate my suffering? How well can you sit with the pain?

  Nothing about Anna made me feel as if she were trying to shock me. In fact, to the contrary, she seemed as if she had summoned up enough courage to tell me the truth and now was terrified about what I might think of her and of the horrific vision she had conjured. I imagined that if Anna were to tell her family members about these thoughts, they would immediately and appropriately shift their concern to the child. My own thoughts reflexively ran toward him, too. However, it was my job as Anna’s psychiatrist to focus on how these visions were affecting her. Still, I was better able to do so because Anna was on a locked ward and thus posed no immediate threat to her son.

  Her eyes remained on me. I weighed my response. My gut told me that I could empathize with Anna, with how frightening and disturbing it must be for her to have those thoughts. And yet offering that kind of opening might close her down in the event that I was wrong. If I said, as I felt inclined to do, “That must be very difficult for you,” and in fact part of her shame lay in the fact that she was not feeling disturbed by the thoughts, then my assumption would only compound that shame and diminish the likelihood of her telling me how she truly felt.

  “What has that been like for you?” I finally asked. She looked at me with incredulity.

  “What do you think it’s been like for me? It’s absolute hell! I’m constantly feeling afraid that I might hurt him. And then, I mean, what kind of a mother . . . ?” And here she trailed off once again, tears slipping down her cheeks into the pursed corners of her lips.

  “Have you been able to talk with other people about this?” I asked her, sensing from her question that the degree of shame might have prevented her from sharing her fears with anyone who could potentially be a support to her.

  “Not in so many words,” she replied. “I think my mother-in-law is convinced that I didn’t really want to be a parent. I’m always asking her to come by and watch the baby, to take him out whenever I’m alone with him. I always make it sound like something urgent has come up, but”—and here she allowed herself a small, self-aware smile—“there are only so many things I can invent that require me to run an errand by myself or be at home alone. She has to be catching on that something is up. I even try to rotate. Sometimes I call my sister, but she’s so busy with her own three kids that I feel guilty. I mean, I can’t even handle one—how can I ask her to take care of her family and my baby, too?”

  Anna’s desperation and shame were unmistakable. Yet I still didn’t have a clear picture of what she was experiencing when these images came into her mind. I picked up her pale pink hospital chart from the rolling rack beside my chair and quickly paged through it. When I came to the doctor’s notes from Anna’s evaluation the night before in the emergency room, I took a moment to read through them.

  “This is a thirty-four-year-old married female who self-presents seeking help for what she describes as ‘the urge to kill my son,’” the emergency psychiatrist’s intake form read. “The patient is also having thoughts of killing herself.”

  As Anna gingerly continued to talk with me, she eventually elaborated upon what I had found in the chart, though she did not look at me as she spoke. For the last six or seven days, she said, she’d had visions of drowning or stabbing her son, accompanied by voices telling her to see what it would feel like to hold the child underwater. These voices and visions were now coming many times a day, sometimes even multiple times an hour.

  I knew I would meet daily with Anna while she was hospitalized and that I would need many sessions with her to more fully understand what she was going through and in what context these symptoms were occurring. Still, in this first meeting, I went through a relatively standardized set of questions and topics to try to learn more about her: Had she ever been to a psychiatric hospital before? (No.) To her knowledge, did anyone in her family have any kind of mental illness? (There was an uncle who’d been depressed and another one who drank too much.) Was there ever a time that she had felt that drugs or alcohol were a problem for her? (She got pretty drunk a few years ago on New Year’s Eve, she said. Did that count, if it was only once? No, I said. Then no, she said.) Eventually, with the basic initial questions covered, I returned to the issue at hand.

  “I can hear how upsetting these last days have been for you,” I began. Then, gently, “How likely do you think it is that you might actually hurt your son?”

  Anna closed her eyes, then opened them and refocused on the corner of the room beyond my chair, where the gray-painted cinder-block walls joined each other and met the floor.

  “I don’t want to hurt him,” Anna said, beginning to cry. “I’m just so afraid I might get worn down and give in.”

  “Give in?” I asked.

  “To the voices, to that urge.” She paused, but I could tell she had something more to say. She took a few breaths, bit her bottom lip, and looked up at me. “I’m not the kind of person to commit suicide,” she said. “I don’t want to, and religiously, I believe it’s wrong.”

  “Okay,” I said, waiting to hear where she would go next.

  “And it’s not like I’ve been planning how I would kill myself or anything. It’s just . . .” Her crying turned to sobs. “I don’t know how much more of this I can stand.”

  Once I finished my initial meeting with Anna, I returned to the nurses’ station to write in her chart. Immediately the unit staff circled me and talked over one another: Was I sure she had told me everything? Did I realize she wanted to see how it felt to drown her baby? Did I think she was trying to get attention, or was she really that screwed up? They made their collective opinion clear: They had seen all kinds of patients working on a psych ward, but Anna was dangerous and her symptoms were particularly galling.

  Eventually Dawn, the formidable and unflappable nurse in charge of the unit, made her way toward me, and the circle dispersed. Only one day earlier, I had seen Dawn march down the hallway addressing multiple patients’ problematic symptoms quickly and effectively without slowing or missing a step. “Kevin, pull up your pants,” she said to a patient who commonly masturbated in public. “Susan”—and here she addressed a woman who was admitted time and again for cutting and burning herself—“by hitting the wall, you’re telling us you don’t think you’re safe to go out on the walk with the rest of the group.” Dawn was a real veteran, and despite my medical degree she clearly outranked me in clinical experience. When she had something to say to me, I listened.

  “That Anna freaks me out,” she said quietly, leaning over the desk beside me. “I hope you’re not thinking of sending her back home with her kid. I’d hate to be the one with that hanging over my conscience.”

  I hated it, too. But I also knew that it is more common than one might think for m
others to have thoughts of killing their children. A 2008 article in Comprehensive Psychiatry revealed that in a study of mothers of children under the age of three, 7 percent of nondepressed mothers had thoughts of harming their children. In the group of mothers suffering from depression, that number shot up to 41 percent. In a sample of mothers whose infants were colicky, 70 percent experienced “explicit aggressive fantasies” about harming their babies. Twenty-six percent of the mothers reported that during episodes of colic they’d had thoughts of killing their children.

  Despite my knowledge that many women have these thoughts and few actually act on them, listening to Anna raised in me a mix of emotions, not the least of which was fear about her eventual day of discharge.

  • • •

  On June 20, 2001, Andrea Yates called 911. She told the police that she had killed her five children, ages six months to seven years. When the police arrived at her house, she led them to the bodies of her children, whom she had taken one by one to the bathtub and drowned. Despite years of inpatient and outpatient psychiatric treatment—and indeed an appointment with her psychiatrist to which she had gone with her husband only two days before the murders—Andrea Yates succumbed to a series of delusions about herself and her children. A retrospective 2009 article in the journal Psychiatric Times reports, “Ms. Yates experienced both depression and psychosis. She believed that her house was bugged, television cameras were monitoring her home, and that Satan was literally within her. She became convinced that her children were not righteous and would ultimately burn in hell. She believed that she needed to kill her children before [they reached] the age of accountability [in order] to save their souls.” The extent of her delusional belief system was obviously not clear to her psychiatric providers at the time, or to anyone else who might have been able to intervene and thereby save the lives of the five children. How, then, could I possibly reach a point with Anna at which I would feel confident sending her home to be with her son?

  Without a scientific test to determine whether Anna might be a danger to her son, I needed to better understand her symptoms, so I could determine a more precise diagnosis and treat her accordingly. I needed to talk in depth with her and with her family members to get a clearer picture of what Anna’s life had been like recently. I needed to establish and be a supportive relationship for her. Most important, I needed to determine whether Anna fit the profile of someone who might murder her child.

  We do not know much about women who kill their children. Forty years ago there was almost nothing on the topic in the scientific literature. In 1969 the American forensic psychiatrist Phillip Resnick conducted the first review of the world’s literature on child murder. Resnick scoured reports from 1751 to 1969 and found only 155 published cases. (The small number of historically published cases was not an indicator of the infrequency of the killing of children but more likely a testament to how irregularly such incidents were documented. We now have far more data. In fact, the U.S. Department of Justice estimates that, on average, 256 American children were killed by their mothers every year from 1976 to 1994, or one child every thirty-four hours.)

  In an attempt to better understand the motives that could lead a mother to kill her child, Resnick proposed a means of categorizing these cases. He first divided them based upon the age of the child and in doing so designated 24 of the cases as “neonaticides,” or killings of children less than twenty-four hours old. The remainder of the cases, in which the children who died were more than one day old, he called “filicides.” To further underscore the relational factors that distinguish the two, he writes, “One is the killing of an unwanted neonate within the first few hours of life. The other is the murder of a child after its role in the family has been more fully established.”

  Although Resnick went on to publish a paper the following year that reviewed what was known about murders of newborns, this first seminal paper focused only on the 131 documented filicides. It was called “Child Murder by Parents: A Psychiatric Review of Filicide,” and despite the four decades that have passed since its publication in the American Journal of Psychiatry, Resnick’s classification by apparent motive—the first taxonomy of any kind for these unthinkable acts—remains highly utilized today.

  The article established five categories of filicide: accidental, spouse revenge, unwanted child, acutely psychotic, and altruistic.

  Accidental murders of children arise not from homicidal intent but rather from abuse or neglect of a child that inadvertently results in the child’s death. A pediatrician colleague shared with me one such case she had recently seen in which a mother became drunk and fell asleep on top of her baby while wearing a down coat. She awoke to find the baby not breathing and without a pulse.

  Resnick defined spouse-revenge cases as those in which parents deliberately kill their children in order to make their spouses suffer. The mythic Greek character Medea, who kills her two sons to avenge the infidelity of her husband, is the prototypical example within this category. Resnick found this type of filicide to be the least common, and subsequent research has supported that finding. Nonetheless, this motive is not a simply mythological one and might have been at play in the 2010 case of Theresa Riggi, who admitted to having stabbed to death her eight-year-old twin sons and their five-year-old sister in the midst of a custody battle with the children’s father.

  Murders of unwanted children are more commonly infanticides, as was the case with Melissa Drexler, the highly publicized American “Prom Mom” who, in 1997, had concealed her pregnancy, gave birth to a baby in the bathroom at her high-school prom, disposed of the infant in the bathroom trash can, and rejoined her friends on the dance floor. However, this motive was also suspected in the equally high-profile case of Susan Smith, who buckled her one- and three-year-old sons into the backseat of her car and let it roll into a lake, where the boys drowned. Smith first achieved infamy because of the racism implied by the fact that she initially claimed “a black man” had taken her children in a carjacking. Later she was held in even greater derision when court proceedings revealed that one week prior to the incident Smith’s boyfriend had written her a letter saying that he liked Smith but did not believe he was suited to raising children.

  Acutely psychotic infanticides occur when parents are hallucinating, delusional, or delirious and act out of the fear or anger brought about by their psychotic symptoms. In these situations, Resnick writes, an emotional impulse “is translated into a violent action.” A mother in this instance might push her son out the window, believing him to be an agent of Satan who intends to kill her. Alternatively, these crimes may be the result of confused, involuntary actions that occur during seizures, as when Resnick tells of an “epileptic mother who placed her baby on the fire and the kettle in her cradle.” In either scenario these are women whose minds are in the throes of a severely distorted reality.

  Finally, and most interestingly, mothers who commit altruistic filicide believe that their actions are compassionate and driven by love. They kill in an attempt to alleviate their children’s suffering—be it real or imagined, present or future. A range of mothers fall within this category; for example, the mother of a neurologically devastated child who smothered him to put an end to his unceasing seizures, as well as the fifty-year-old paranoid widow who believed that an imaginary slavery ring was attempting to take her eleven-year-old daughter and so murdered her to save her from that fate. In testifying on Andrea Yates’s behalf at her jury trial, Resnick applied this category of altruistic filicide to Yates. In the midst of Yates’s psychosis, Resnick argued, her motivation for the murders was altruistic. Yates believed she was saving her children from a lifetime of hellfire and damnation by killing them before they were of an age to be held accountable for their sinful natures. This classification of altruistic filicide would also include mothers who are planning their own suicides and who kill their children so as not to abandon them, or to save them from the grief of their moth
ers’ deaths. This filicide-suicide subgroup is not insignificant. It represented an enormous 42 percent of the women in Resnick’s study population, a finding reinforced by the fact that we know approximately 5 percent of mothers who commit suicide also kill their young children.

  My task, therefore, was to try to determine how likely Anna was to fall into one of these categories. In talking more with her over the days of her hospitalization, I was able to rule out certain of Resnick’s groups, even as Anna’s disturbing visions continued. Her son was not an unwanted child, Anna and her husband had been excited to become pregnant, and she continued to say she found joy and meaning in her identity as a mother. Anna’s marriage had its share of marital discord, which had been exacerbated by her husband’s inability to understand this sudden shift in his wife’s mental health, but there was no evidence of the kind of conflict that would lead her to kill her son out of spousal revenge. The child was not neglected or abused. The family confirmed that he had always been healthy, apart from some mild asthma, and I had seen him toddle around the unit one afternoon during visiting hours, chubby and beaming. More important, as Anna and I began to speak to her family members about her symptoms and treatment, every one of them attested to how well loved and well treated the boy was.

  My central question, then, was whether Anna was psychotic and, if so, whether her psychosis could be deeply entrenched enough to have tragic consequences. Were the “visions and voices” she experienced in fact visual and auditory hallucinations that were commanding her to commit acts of violence against her son? Was she able to stay in touch with reality enough to know she should not harm him? Or, as was true for Andrea Yates, was there some secretly held delusional framework within Anna’s mind that had led her to believe that killing her son would somehow be an altruistic act of love and kindness?