Susan Hatters Friedman, MD: The Force is with Her

The Early Years

Susan Hatters was born in Pittsburgh, Pennsylvania, and raised in Monroeville, an eastern suburb. Her father, the first in his family to go to college, earned a PhD in chemical engineering and worked in Pittsburgh's steel industry. Her mother worked in child welfare, then was the primary caregiver in the home, and later worked for the Internal Revenue Service.

Generations of her forebearers lived in Pennsylvania. Her paternal grandparents and family lived on Grandview Avenue on Mt. Washington, and the family got together every Sunday afternoon for dinner, after which her grandfather might have played his accordion or electric guitar. Today this area is known for its century-old incline, historic architecture, and sweeping views. Her great-grandfather and great uncle were lieutenants in the Pittsburgh police. Her grandfather worked as an air conditioner and heating repair mechanic at the Pittsburgh airport. In those times, the airports shut down at night and rented out space. Her grandfather's inspiration thus varied from magicians and their secrets to jet planes. Susan was enthralled by his stories of buried treasures and vacations organized with the purpose of excavating plane ruins from detailed maps he constructed.

Susan's maternal grandparents opened her mind to different cultures and experiences. Her grandfather served in the Pacific theater of World War II. Her grandmother, an elementary school principal, was an early role model. She was a woman with a meaningful career who encouraged Susan to pursue the same. Her grandfather was a successful salesman at Sears Department store as measured by his unsurpassed ability to sell outdoor furniture in the Pennsylvania winter. They planned a trip to Europe with Susan as a teenager and spent hours recounting her grandmother's sabbatical spent visiting schools in Japan.

The family relocated to Brecksville, Ohio, in 1985. The move was made after a merger of steel companies. Susan had never been to Ohio and equated it with a move to “the West.” She felt more a kindred spirit with her friends in Monroeville who were multicultural in comparison. She acclimated by immersing herself in her musical interests and traveling to summer music camps where she felt more at home meeting students from across the region. Her adoration for music flows from her family's musical talent. Her father was a vocalist and trumpeter. Her grandfather encouraged her love for music, which she would continue to perform through her training and career. (For example, Susan would be the sole musician in the Omri Yavin play, Here Comes Dad, during her forensic fellowship, and would find herself racing back from testifying in Columbus for opening night.) At the age of 10 she learned the clarinet, followed by the saxophone at 11. As well as her high school band and jazz orchestra, Susan performed in the Cleveland Youth Wind Symphony, and the Ohio Jazz Orchestra for Youth, where she met Paul Ferguson, who would become her music mentor. In what has come to epitomize, in my mind, true Susan fashion, she received a standing ovation for her junior high school saxophone solo performance but did not have her glasses on to appreciate the reverence.

Susan excelled in high school in both academics and as a musician. She and her mother visited the Ivy League schools with a world of aspirations, a journey serenaded by George Michael's Freedom, the tape cassette in the car radio jammed and unable to be expunged. Initially captivated by Massachusetts Institute of Technology, where she was accepted, she chose to stay in Cleveland at Case Western Reserve where she was awarded the Presidential Scholarship. She was a National Merit Scholar, Dean's Scholar, Phi Beta Kappa Honor Society inductee, and graduated summa cum laude. She studied music, history, and chemistry and vacillated between which one “would make sense career-wise.” Her interest in history derived from her fascination with people, culture, and society. She saw history as a foray into different lives, reading diaries, journals, and memoirs to find the voices of history, which would lead to later forensic writing about the Salem witch trials and the Spanish Inquisition.^13–14 She arrived at medicine after careful deliberation, knowing she could still pursue her musical interests on the side. She had not been interested in biology in high school but by college had an interest in medical school, tempered by her pragmatic self. She was accepted to the new primary care track at Case Western, an accelerated program for students interested in pediatrics, family medicine, and internal medicine.

Susan began medical school at Case Western Reserve in August 1995. The medical school curriculum had shifted to favor small group learning experiences. It was in this intimate setting that she met her husband, Josh Friedman, an MD–PhD student. Josh had just returned from spending a year working in Kenya. He was well-suited to be cast as the expert witness superhero in a medical parody of the O.J. Simpson case directed by Susan and the small group. They married during their second year of medical school. Susan points out that her introduction to AAPL began with Josh. Andrew Watson, MD, an early member of AAPL and GAP, Professor of Law and Psychiatry at the University of Michigan and recipient of the Isaac Ray and Seymour Pollack awards, was part of Josh's family, and, during college, Josh had enjoyed many dinners with Andy and his wife Joyce. Susan was well suited to the Friedman family. Everyone knew exactly what she meant when she spoke about her interests in child murder, insanity, and the like. Josh's grandfather, Lt. William Bedwell, had performed competency to stand trial evaluations during the Nuremberg war trials. The likelihood of marrying into a family of historical forensic psychiatrists seems suspect, but Susan declares she fell in love with Josh well before she learned of his forensic pedigree.

Although the perspective varies depending on the storyteller, Josh's early career as a pediatric hospitalist led to an interest in child abuse and his position today as a child abuse pediatric specialist at both Cleveland Clinic and MetroHealth, the local county hospital. Susan maintains that her interests in child murder had no bearing on Josh's subspeciality. I suggest that her persuasive channeling may have had a role. Their work is complementary, including collaborating in authorship and presentations.^15,–,17

Susan and Josh have raised two children, Troy and Elise. Troy studied both biology and Japanese. Biology led to his internship as a SCUBA diver at an aquarium, and he was a teaching assistant in Japanese, prior to working in the Japan Exchange and Teaching (JET) Program in Tottori, Japan. Elise is studying philosophy at Birkbeck, University of London, after completing her diploma at University of the Arts London, and spends her spare time designing jewelry and entrepreneuring the recently launched online London Delicatessen.¹⁸

Early Career and Mentorship

Susan's interest in psychiatry was discovered during her primary care track rotations in medical school. She planned a career in family medicine but found herself most interested in the mental health concerns of her patients. Susan and Josh enrolled in Dr. Resnick's law school course during their second year of medical school. In response to Dr. Resnick's inquiry about why students selected the course, Susan stated, “I'm here because I love reading mysteries and this seemed like an interesting class.” Dr. Resnick replied that the course was rigorous and suggested that her time might be better spent reading a Stephen King novel. Josh answered Dr. Resnick next, fawningly stating he was interested in a career in forensic psychiatry. But it was Susan who found herself awestruck that “forensic psychiatry was actually a job.”

During her fourth year of medical school, Susan met Miriam “Mim” Rosenthal, a psychiatrist working within obstetrics, who would mentor Susan over the course of the next two decades. Dr. Rosenthal introduced Susan to maternal mental health, which would become one of Susan's areas of expertise. All of us who know Susan, also “know” Mim because Susan frequently references her, a testament to gratitude for a beloved mentor.

Surrounded by the extraordinary mentorship offered by Drs. Rosenthal and Resnick, coupled with her revelation that her interests in history, mystery novels, and mental health could all be entwined with a career in forensic psychiatry, she decided to pursue psychiatry at Case Western. It was during her psychiatry residency that she learned to become a researcher. Susan jokes that she never imagined a research career which she had conceptualized as killing mice or sifting through national databanks. She explains, “I became interested in research when I realized you could explore data to answer burning questions in our field. I research things I see clinically that I'm wondering or passionate about … those things that bug me or don't make sense encourage me to explore.”

During her fourth year of residency, she was the academic Chief Resident and completed a forensic elective with the forensic fellows, where this story began. She was also working at that time with Dr. Rosenthal to start a community psychiatry program for pregnant and postpartum women.¹⁹ After her residency, with the mentorship of Dr. Rosenthal, Susan completed a fellowship in women's mental health where she honed her skills in academic writing and research. She began the Case Western Forensic Psychiatry Fellowship in 2004. For those of us who keep track, Susan is Fellow Number 50. Dr. Resnick described Susan as “an uncommon combination of warmth, intelligence, intellectual curiosity and determination” and explained “well before her fellowship she managed to attend a law school course, initiate research projects, and attend the Andrea Yates trial.”

Following her fellowship, Susan took a position at Northcoast Behavioral Healthcare, a forensic hospital affiliated with the fellowship, while developing a maternal mental health program. Susan, with Dr. Rosenthal's mentorship, led the Neonatal Intensive Care Unit Psychiatry Program at Rainbow Babies and Children's Hospital, working with parents of critically ill infants and staff.²⁰ This was pioneering work as many facilities do not offer an integrated approach to maternal mental health. Dr. Steve Noffsinger, Case Western Forensic Psychiatry Fellowship Director, described Susan as “clearly enamored with forensic psychiatry and from the start it was obvious that she had a bright future ahead of her.”

Wanderlust and the Abroad Experience

A couple years after fellowship, Susan began to think about a family experience overseas. She wanted a cultural experience while her children were still young. Dr. Resnick advised her that if she was going to do this, she should explore working with international leaders in the field. She did just that. In 2007 after we presented together at the World Psychiatric Association in Melbourne, she went to Auckland to meet with Dr. Sandy Simpson. It was the visit to New Zealand, although brief, and her discussions with Simpson that captivated Susan. She remarked, “I fell in love with New Zealand. It is a place where culture is seeped into everything. I didn't know anyone there but upon my departure, after a week's visit, I was already longing to return.”

One year later, Susan and her family moved to Auckland. Josh completed a child protection fellowship and Susan worked at the Mason Clinic, the largest forensic service in New Zealand. The plan was to return to the Cleveland after one year so their son, Troy, could finish his senior year in the States. They stayed 14 months during which Susan made lifelong mentorships and friendships. As experienced by many of us, Susan is a connector of people. Dr. Simpson, now Chair in Forensic Psychiatry, Centre for Addiction and Mental Health and University of Toronto, remarked: She makes links with people, encourages others, mentors younger [colleagues] and supports contemporaries in generous and creative ways. When she made the bold move to New Zealand, a move that is not easy for many coming from a very different social and professional culture, she thrived. It was always clear that she was open, respectful, and fascinated by new experiences, places, people, and culture.

Between 2010 and 2012 Susan returned to her previously held positions at Northcoast and in maternal mental health settings at Case. From 2010, Susan served as the mental health editor for the Journal of Immigrant and Minority Health. By then, her wanderlust had transformed into the pursuit for cultural proficiency. Susan had experienced the importance of culture in psychiatry and wanted to “live life another way.” In 2012, she accepted a position at the University of Auckland Medical and Health Sciences as Associate Professor in the Department of Psychological Medicine where she remained until 2018. In the course of those years, she navigated relationships across disciplines, weaving her interests in forensics, perinatal psychiatry, culture, and academics. She has written prolifically about this work.^21,–,27 To her Kiwi colleagues, Susan was a leader and a scholar but, most importantly, a fascinating, fun colleague. Dr. Himadri Seth, New Zealand Director of Advanced Training in Forensic Psychiatry, remarks: Her very high academic standards encouraged all of those under her tutelage to maintain those same standards. Her accomplishments are a reflection of her ability to work with experts in the field not only in North America but also other English-speaking nations. Susan's modest approach has allowed her to work with people of all backgrounds and personalities to ensure optimal teamwork.

The Return Home

It appeared that Susan had emigrated. She had returned to New Zealand in a way that appeared to be permanent. But in 2018, an opportunity she called her “dream job” pulled her 8,000 miles back to Cleveland. Susan became the inaugural Phillip J. Resnick Professor of Forensic Psychiatry and Adjunct Professor of Law at Case Western in 2018, followed by Professor of Reproductive Biology and Professor of Pediatrics. It might sound like a homecoming, but the truth is Susan never left. She maintained connections and academic responsibilities on both sides of the globe. She attended every AAPL, APA, and GAP meeting while overseas. She had given presentations in twelve countries. This transcontinental commitment speaks to Susan's ability to connect. Dr. Appel remarked, “she has an uncanny ability to recognize traits that will make people effective collaborators and takes the initiative to put them in touch with each other.” Many of us who have come to know Susan are products of what Dr. Katie Cerny, Case Western's General Psychiatry Program Director, coins “The Susan Effect.” Dr. Cerny describes: It is overwhelming to even contemplate the scope of The Susan Effect. Susan does many things well but one of her most admirable skills is how she elevates the careers of others. Although she is an extremely high achiever, Susan has always sought to empower others with education, share success, and pull others up the metaphorical academic career ladder with her.

The Susan Effect is evident simply by looking at the CVs of Susan's colleagues; there you will find dozens of collaborations with Susan, almost all initiated by her.

Forensic fellows from Case Western describe her infectious enthusiasm and passion for teaching. Dr. Nina Ross, 2021 graduate of the fellowship, reflects, “Susan has a brilliant mind and a sharp sense of humor, but also never fails to incorporate her thoughtfulness and her deep sense of compassion into everything she does.” Susan has a reputation for being the “go to” person for publications. Dr. Ashley VanDercar, describes “the beauty of Susan's supervision style and type of mentoring is that she combines her professional experience and clarity of thinking with her personality and reassuring demeanor.” “She taught me to question every potential source of bias within systems and, perhaps most importantly, within myself,” remarks Dr. Katie Kruse, also a 2021 graduate.

True teachers enlighten all around them, not just their students. Dr. Ryan Hall, Assistant Professor at the University of Southern Florida, points out, “Susan can discuss the intricacies of a scientific research article in one minute and then totally, out of the blue, reference a Star Wars quote which illustrates her point.” Dr. Joy Stankowski, Chief Clinical Officer, Forensics at Northcoast, echoes this observation: “Over the twenty years that I have known Susan, she has always been interested in sharing her love for forensic psychiatry with others, as a colleague and a mentor.”

AAPL Contributions

Susan is a well-known face at AAPL having presented at the past 17 annual conferences, served in all positions of governance except for treasurer, published dozens of JAAPL articles, and been awarded most of the AAPL-sponsored awards. Former AAPL President, Dr. Rick Frierson, remarks, “If Susan agrees to do anything, you can rest assured it will be done on time and flawlessly. She is so reliable and takes pride in her work as an academic forensic psychiatrist.”

Susan and I are currently leading the development of the AAPL resource document for reproductive psychiatry in forensics. She, among others, worked on drafting the Cultural Factors in Forensic Evaluations section of the AAPL Practice Guideline for the Forensic Evaluation.²⁸ Her recent JAAPL editorials and writing have continued to focus on culture and gender.^29,–,32 She has always referred to AAPL as her academic home and shared her hospitality with newcomers, allowing for meaningful relationships and collaborations across North America. Dr. Charles Scott, former AAPL President, states, I have been most impressed by Susan's continued dedication to advancing the field of forensic psychiatry through her research, publications, and teaching. She has achieved so much without ever asking for acclaim or attention in return. She is always a woman of brilliance, yet never one of bravado.

It is often overlooked, but Susan has accomplished all of this in a very short period of time. Susan is one of the youngest AAPL members to have served in so many different roles in AAPL, including President. She is our seventh woman President.

Personal Growth

Susan outlines one of the guiding principles in her career, “to give back by teaching … to have a role in molding the next generation.” Her success is prefaced on a true work-life balance. Knowing Susan is to know her passion for learning new things and sharing the experience with others. Susan describes achieving this balance by establishing “boundaries and optimizing my time.” But spending time with Susan does not feel timed or measured. Instead it feels seamless from discussions about the bias in forensic psychiatry to the local jazz venue and the recent jewelry creations by her talented daughter. She has a longstanding interest in writing fiction, studying both playwriting with Gary Henderson in New Zealand and humor writing with the Second City. Susan's most recent educational pursuit is a Masters in crime fiction writing at the University of Cambridge. She recalls the morning she learned that Sophie Hannah, internationally bestselling writer of crime fiction,³³ would be the lead teacher at Cambridge. Susan shrieked in excitement prompting Josh to scurry in and ask if she was having a seizure. She has since published dozens of creative pieces, including in the well-regarded literary magazines Hobart, Eclectica, and JMWW.^34,–,36 Susan garnered a nomination for the Best of the Net for her fiction piece “Whydunit”.³⁷ Dr. Resnick was on to something with his Stephen King comment 25 years ago.

Future Vision

As she embarks on her leadership role as AAPL's 48th President she reflects, “my teaching and writing have often focused on cultural and gender bias and right now it's become more obvious these should remain at the forefront of our thinking.” She questions how we practice within a legal system with inherent problems, and how we find the truth and work in these spaces ethically. Susan aims to begin to answer these questions by doing what she does best, bringing people together, across continents, and employing a research-based approach to answer those things that “really bug us.”

As we look to the future of forensic psychiatry, in a world where the causalities of a pandemic remain unhealed and in a society where the pursuit of truth and science remain disparate, the role of our leaders is paramount. The promise of Dr. Hatters Friedman's leadership is vast. May her Force be with us.