Lessons Learned from a Mother

Today, I met a child killer.

On an early spring morning in the resident didactics room, ten psychiatrists-in-training sit around a long rectangular table headed by forensic psychiatrist Dr. Martinez. A round-faced, clean-shaven man with welcoming eyes and graying hair, Dr. Martinez lectures about prisons, crime, and death with the soft-spoken familiarity of a favorite uncle recounting a weekend trip to the family lake house. His overview of the specific qualifications for this defense will be followed, we are told, by an hour with a past patient who was deemed not guilty by reason of insanity (NGRI) for the crime she committed: two counts of filicide.

We are told to familiarize ourselves with her case beforehand as a sort of trigger warning. Dr. Martinez distributes a brief written biography prepared by our visitor for the following week. The biography summarizes why she will visit; Mary, a 20-something woman, delivers a child. Weeks afterward, she experiences symptoms of racing thoughts, insomnia, and feelings of wanting to abandon her child in a parking lot, and she is subsequently diagnosed with severe postpartum depression. No formal treatment is mentioned. Several years later, Mary and her husband decide to have another child. Given what transpired after their first child, the young family prepares for a potential repeat mood disturbance. This time, however, things spin more rapidly out of control, and Mary finds herself hospitalized in a psychiatric ward mere days after delivering. She is discharged after a short stay, and she is then quickly re-admitted. This happens four times over the next three months. Three days after her last discharge, Mary drugs and suffocates her two children, a four-year-old and a three-month-old.

“Four months and three months.” “Drugs and suffocates.” A chill creeps through me. “Suffocates.” Not an impersonal, premeditated overdose, but the skin-to-skin, intimate violence of pressing down on the grooves of a face, stifling a faint rhythmic breath.

On the day of her visit, before she arrives, an uneasy silence hangs in the room. People shuffle papers, squirm in chairs, and stare out the window. My left nostril and upper lip twitch as a bricolage cliché of a schizophrenia-spectrum patient swirls into my imagination. The image in my head is not flattering, and admittedly, unfair; a callous stereotype of a disheveled, wild-haired, disorganized woman with sneakers caked in mud and stained with grass.

The handle turns. I whiten my knuckles under the table. I glimpse the skinny metal stub of a cane, a thin pale ankle, then a woman, maybe somewhere in her late forties, thin but not frail, dressed in creased khaki cotton pants, pressed white collared shirt peeking out from under a forest green knitted cardigan. A gold pendant dangles from her neck. Beneath a neatly trimmed, silver-black bob, hazel eyes blink behind a pair of rectangular, wire-framed eyeglasses. She sits down next to Dr. Martinez and surveys the room with smooth, owlish movements. She lingers, intentionally, it seems, on our faces, as we make eye contact and quickly look away. She introduces herself, then asks each of us our names and career interests. We comply and fall quiet.

She tells us about her children. Her older child's babbles and endearing, annoying habits. The messes she made opening the fridge door and dumping food on the floor. After every infraction, her matter-of-fact explanations made with a cocked head that melted her mother's heart.

She recounts the birth of her second child, the “little cute wee thing” he was. Amid the schmaltzy descriptions, her voice catches. “I did a horrible thing.”

Mary tells us she never thought about “mental issues” before her first child. Going through postpartum depression after her first child was “the most frightful, debilitating experience” she had ever had. For her second pregnancy, she was proactive, but still her mood teetered on the blues, slipped into depression, then free-fell into full-blown psychosis. Psychosis, a mind state in which thoughts can unspool from an otherwise tightly wound and organized system into a jumbled pile, unrelated pieces mish-mashed together and rendered incomprehensible.

Mary describes the unprompted barrage of thoughts that would storm her mind, assaulting her constantly in indestructible loops: you're worthless, you should die, your life is in danger, you're a waste, you're a terrible mother. At first, she could distance herself from the intrusive thoughts, but they folded into an inner voice, blurred with her own consciousness, whispering to her, startling her like the snap of a twig heard alone in the woods. She wasn't sure if she was thinking or listening or talking, where they ended and she began. She soon found herself within the sterile, padded walls of a psychiatric ward.

She describes her psychotic state of mind. There, the staff members, with their condescending glances, were having hushed conversations behind the nursing station, scheming to kill her. A plastic apple juice bottle on her tray had a needle prick on its underside, the injection site of a fatal toxin meant to end her life. She flung it across the room into a corner. She left to go to the bathroom and when she returned, it had vanished. The undercurrent to the entire experience was constant, unshakable, palpitating, wrenching, primal fear.

My mind flashes to the floridly psychotic patients I've newly admitted to the inpatient unit: hyper-aroused, suspicious, eyes glinting with desperation. Even two decades later, talking about it for the umpteenth time, Mary's voice tightens and she frequently needs to pause for water.

They gave her meds, she says, familiar names to us residents: haloperidol, benztropine, sertraline. The medications erased some of the thoughts and voices but simultaneously removed her life force, suspending her in a state like an old television with its rainbow bars, fixed, artificial, blank. She learned to dance the inpatient waltz with her psychiatry team. “No, I'm not hearing voices.” “No, I'm not seeing anything that's not there.” “No, I'm not going to harm myself or others.” Two days after discharge, she flushed her meds. The next afternoon, exasperated by another of her toddler's antics, she remembered a lesson from her mother: if you're feeling overwhelmed and out of control, just take a nap. A few hours later, her husband found his wife in an incommunicable state, and his children dead.

The denouement details her recovery: six years in a state psychiatric hospital over a hundred miles from her home, a medication regimen that didn't obliterate her mind, and an eventual slow re-integration into her community. She now maintains a “conditional release,” a set of parameters she has to follow to remain outside of the facility walls, including informing her case manager of any movement outside of county lines and never being alone with a child under the age of 12. Mary invites questions from the group. We just say “thank you.” Soon enough, the clock strikes the hour and we break off, back to our clinical responsibilities for the day.

Now months after the lecture, I find my thoughts lingering on this encounter. I've treated incarcerated and formerly convicted patients before, even known their crimes, but this was the first time the knowledge of the crime was paired with an intense, impassioned retelling of the story from the culprit's perspective. Mary put on no mask, made no attempt to whitewash the brutality of her actions. She was self-effacing, frank, and even affable. A few times, she had interjected recommendations to us future full-fledged psychiatrists with an out-of-character “Yo!” and I'd felt the corners of my mouth turning up, cracking against the self-imposed stoicism I had sworn to at the beginning of the lecture.

I had mischaracterized Mary based on snap judgements and lazy psychological heuristics derived from media-driven preconceptions of criminals and my own relatively limited exposure to psychiatry, unpleasantly revealing to me my own fallibility as both a physician and a person. My initial hostility violated the nonjudgmental regard I should have had toward her, and I was ashamed of my repulsion despite the context of her illness. Had she been my patient, I likely would have flown through the same gamut of questions, categorized and diagnosed her, and prescribed the same medications. It feels better to try and convince myself I would have seen something deeper that maybe would have prevented the deaths of those kids.

In the brisk current of a resident's workday, it's tempting to fly through the work and merrily head home to your “real life.” But being holed up in a dilapidated hospital was this woman's real life. Waking up from a psychotic fugue to two dead children was her real life. Mary's family's entire life course changed completely because of her illness, and her story reminds me of the fragility of all of our lives, how easily we can be derailed from the sense of security we take for granted.

I met a woman with a breath taking story, a story of fear and then unfathomable loss, and instead of dismissing her entirely based on her actions, I took the time to actually listen and focus on her humanity. This shift of focus is one of the many lessons Mary taught me, and I'm a better person for it.

• © 2020 American Academy of Psychiatry and the Law