Meghan
I’m being followed.
The certainty of it hits me as I step onto the subway car and feel everyone’s eyes on me. For a moment I chalk it up to my bright orange winter hat with the cryptic phrase “Wear Orange” on it. But as I look around the subway, I catch more strangers’ eyes, our glances meeting for a second before they look away, back down to their phones, earbuds in their ears. My eyes begin to dart around the subway car, making contact with more and more sets of eyes before they quickly shift their gaze. My heart pounds: I’m not just being watched. The phones in their hands and the earbuds in their ears, they’re taking direction and communicating my moves. I’m being surveilled.
I get off the subway to switch lines, walk quickly, glancing over my shoulder repeatedly, and take off my orange hat to blend in with the other commuters. Trying to lose whoever might be following me. My brain pays acute attention to every little detail, searching for clues and moving faster as the minutes pass.
I head to the end of the platform and into the last car of the train and find a seat. At the end of the car, a disheveled man is yelling, ranting about the government and war. The revelations start coming. He’s a defector. He used to be very powerful. Now he’s marginalized, no one would believe a ranting homeless man, but he speaks the truth.
I listen intently, trying to piece it all together. Terrified what his rants, the surveillance, and the feeling that they’d all been talking about me earlier at the office is all adding up to.
Uncertain what to do, I continue in forward motion. I reach the Delancey and Essex stop on the F train and walk through the Lower East Side. I make my way through the crowded Friday night streets toward the hotel bar to meet my friend, Janie, visiting from Los Angeles, half-hoping that an old friend and a glass of wine will make it all better. I pass more men on the sidewalk begging with signs and cups, covered by sleeping bags and boxes.
The men know the truth. They won’t bow down and accept what’s going on. They’ve been cast aside by the city government because of it, desperately trying to coax people who pass by into listening or feeding them.
Revelations coming quickly and heart racing, I make my way into the dimly lit hotel bar and make out my friend’s smiling face at one of the bar tables. A wave of relief washes over me. I feel safe. For a moment, my heart rate slows. Then, just as quickly, two unfamiliar faces seated beside her catch my eye. Fear fills my body. This is not an innocuous happy hour. It’s a recruitment event. A ploy to lure me in.
It’s as if my skin has suddenly shrunken down three sizes and my heart might pop out of my chest at any moment. But I act natural, hide the tightening going on in my body, what I’m coming to know. I focus on getting a drink and food. Meanwhile, my brain scans my day, my memory, trying to connect details quickly enough to figure it out, to find a way out, all while trying to fit in at the hip Lower East Side bar.
More and more people arrive, former coworkers from my years at the New York City Department of Education. They’re people I’ve spent stressful long nights at work with, cleaning hundreds of thousands of lines of student data and endlessly polishing communications to go out to thousands of teachers, and happy hours and laughs to balance the stress of serving 1.1 million kids in the pressure cooker of New York City. These are people I love and respect.
Instead of feeling excited, each new familiar face that walks in is a signal of how deep the scheme runs. The past few years of my life have all been a sham. Our relationships formed under false pretense. The long con. All leading to this very moment. They’re gathered together for the sole purpose of my recruitment.
I sip my drink and manage to give a few semicoherent greetings while my mind continues to work at warp speed in the background, trying to figure out exactly what kind of scheme they’re targeting me for and whether I’m already implicated, given my years working for the city government.
Drink in hand, I walk back over to my friend in from LA, who I’m now certain is leading the recruitment effort. They’ve been gathered here under her invitation.
“Who’s watching June and Millie?” Janie asks.
“Colin,” I say. And at that moment, a fear I’ve never felt before fills my body. She’s threatening me, threatening to hurt my babies. She knows the recruitment effort is failing, letting me know the stakes.
I come up with the first plausible excuse to leave I can think of, I don’t feel well, and walk-run through the streets of the Lower East Side back to my apartment. I pick up my pace and cross the street at odd times, trying to lose whoever’s tailing me.
The five-block trek to my apartment feels like miles, as if I’ll never get to my children. I glance over my shoulder again and again, trying to spot the people following me, checking to see if I’ve lost them. Meanwhile, I worry that I’m too late, that my legs can’t carry me fast enough for my girls to still be alive when I walk in. Breathless, I put my key in the lock of our apartment door, turn it, and throw the door open. Colin looks up from feeding Millie and June, surprised to see me. “Why are you home?”
With these words, my heart drops. He’s not asking why I’ve come home, but why I didn’t join. He’s in on it.
I scan Colin’s face and see fear. I suddenly realize that he’s not just aware of the recruitment effort, that he himself is already implicated in the scheme. He needed me to join. If I don’t, we’ll both be killed. I know too much now. They can’t spare my life and risk exposing what I know, the cult running the entire city.
I don’t hint at what I now know. I’m not sure where his ultimate loyalties will lie. Instead, I begin to silently and frantically assess my options. How deeply he’s involved. Whether it’s possible to get us all out alive and free or if he’s in too deep and instead escaping our 750-square-foot apartment with two babies unnoticed in the middle of the night in December is the only way to save me and my girls.
Once the girls are in bed, I sit on the couch next to him, staring at the TV. My body writhes below the surface, trying my best to pretend nothing’s wrong, while my mind turns over how to save us. I feel time start to slip away.
Colin answers a knock at the door. He brings me sushi delivery and an opened beer. I leave it untouched. It must be poisoned. I sit on the couch, thoughts racing until the TV starts to threaten me. Somehow, it’s the face and voice of my uncle saying from the screen, “If she thinks she’s getting out of this alive, she’s wrong.”
I can’t sit next to him and play it cool any longer. Worried I’ll break and reveal all I’m putting together before I know what to do, I get up. “I’m tired. Let’s go to bed,” I say and move into our bedroom just feet away.
I lie awake all night but get up to open the windows and look in on the girls repeatedly. Remembering how my sister had said years ago that a simple crack of the windows could prevent death from carbon monoxide poisoning, I continue to open the windows, trying to release the poisonous gas that must be coming from the newly rattling fridge so that it doesn’t kill my kids.
“Jesus, Meg. It’s freezing. Close the windows,” Colin says.
I watch for the rise of their bellies and then lay down, turning over details, trying to figure out what’s going on and whether we can get out alive.
When morning comes, I’m no closer to escape or salvation. Colin goes down to get the mail and comes back with a book and an U.S. Weekly magazine. He tosses the book on the counter and the phrase “Required reading” on the jacket jumps to my attention. It’s the first book of the cult brainwashing. He then hands me the magazine. “Why don’t you relax?”
I take the magazine as if it holds answers and head to our bedroom, spinning on the newest detail: required reading delivered to our door. As I turn the pages, words jump out. It’s as if they aren’t two dimensional and instead are making their way to the center of my attention themselves, for me. As I continue to flip, I notice that the words are about me, speaking to me. I pause on the section “Loose Talk,” a collection of things celebrities have said. Their quotes float freely, decontextualized.“It was a huge mistake.”
“I had no idea how painful it would be.”
They’re threats, warning me I must comply. The lengths they’ve gone to, how deep it goes. I’m surrounded. I nearly throw the magazine across the room and jump from the bed and quickly enter the living room.
My time is running out. I can feel everything getting heavier, less room to move, to negotiate. Getting out of this now seems impossible. Instead, I must join, comply, show my allegiance to whatever I’m up against. But I have to figure out how, quickly.
I grab my iPhone and look at my e-mail, searching for some insight that might save me. The inbox in my personal Gmail loads with new messages. I realize they’re coming from somewhere powerful. Not the banal power of advertisements and consumerism but something larger, offering me chances to prove my loyalty by showing what I’m willing to put on the line.
One of the e-mails is about buying property. There were so many messages about real estate. I need to buy something. It’s a money-laundering operation. I frantically scroll, searching the e-mail for links or phone numbers to call as time continues to run out. A login button. Progress. I must get into the system and start buying. I don’t have the millions of dollars apartments are selling for, but it doesn’t matter. It’s all a front. I just need to prove I’m willing to participate in this type of scheme, like the bankers selling bad mortgages. I type in my go-to password. It doesn’t work. I retype it in case I made a mistake. Still no luck. With each lost second, I feel the pressure get heavier, knowing if I can’t deliver, I’ll be dead soon. And so will my babies.
I throw my phone down, grab my laptop, and frantically try to reset the password. I feel them closing in on me, as if the oxygen is disappearing from the room. My hands shake and my brain races as I type. I try to settle everything enough to focus and complete the task at hand. It’s the only way to show my allegiance and save our lives.
Unable to crack the password and sensing the sand nearly gone from the hourglass, I call the number in the e-mail. I tell the man who answers, nearly breathless, that I want to buy the two-million-dollar apartment on the second floor.
Colin is suddenly there, grabbing the phone from my hand. “I’m sorry there was a miscommunication,” he says and hangs up the phone. He turns to me and yells, incredulous, “What are you doing? You called Terry?”
His words hit me right in the heart. He hates Terry, our landlord. He hates how Terry smokes in front of the entrance to our building. He hates how Terry makes snide remarks when we leave our bikes in the hall for a second when we forget something, a binky, snacks, for our bike ride. Calling Terry is clearly not how I’m supposed to show my loyalty. I feel guilty for even thinking he could be the answer.
I’ve failed at finding a way to prove my loyalty to them. I refocus on getting to the girls. I wait until Colin comes out of the bedroom and head for the bedroom door.
“Meg, stop!” he yells.
I ignore his words and move toward the door. He firmly plants himself between me and the door and uses the full weight of his body to prevent me from getting any closer. He moves side to side as I push against him and attempt to get around him. He’s so much bigger than me. It’s clear that pushing alone won’t get me through the bedroom door. Time is running out. I pull back my right arm and launch my fist forward with all the strength that I have. My fist lands twice on his cheek, with June and Millie just on the other side of the door. He grabs his face but doesn’t let me gain any ground. I’m still on the wrong side of the door.
The piercing ding of the elevator at the end of the hall sounds each time the doors open on our floor. With each ding I know their arrival, the people coming to kill me, is imminent. Each person and car that passes our apartment is a signal that they’re keeping a close eye. Time is nearly up. Low on options, an idea hits: the roof. Show I’d be willing to jump, prove my commitment to them.
“I need to go to the roof,” I tell Colin as I move toward the front door of our apartment, desperate to get to the other side.
Colin races toward me, locking the door in front of me. I plead with him as I try to unlatch the deadbolt and open the door.
“I just need to go for a run,” I say, switching tactics, hoping this will be met with more sympathy. He continues blocking the door. We get into another scuffle. Our bodies push against each other and into the rattling fridge, knocking the girls’ Christmas art onto the floor and spreading red glitter all over the off-white tiles.
As we wrestle, it’s clear that I’m not going to get through the front door. He’s too much bigger. Instead, I refocus on the now unguarded bedroom door and run toward it, trying to get to the girls. I’m sure that they’ll be dead soon, suffocated from the gas being released from the fridge. Killing them off is all part of the ploy to get me into the cult: a painful initiation. With nothing to care about, I’ll willingly pledge my allegiance.
Colin’s quicker. He beats me to the door, goes through it, and slams it behind him, positioning himself on our bedroom floor, wedged between the black dresser and the door, holding the door shut with his feet as I push as hard as I can from the other side.
It becomes a race, back and forth, from door to door. Heart racing, body shaking, sensing everything slipping away. And he’s quicker and stronger every time. I’m no closer to the roof, no closer to the girls.
The elevator dings. Time’s up.
The apartment door opens, and they hold me down, handcuff me, strap me to a gurney, and wheel me away while I scream. My children left behind, suffocating in the closet.
Not long after, everything cuts to black.
I don’t think I’d believe it if I hadn’t felt it. How one can go from a rationally thinking mind, clicking on all cylinders to totally deluded and a threat to yourself and your family, in my case, in a number of hours and minutes.
Looking back, I hadn’t felt like myself a month after returning to work from maternity leave. I was anxious and a bit sad. But mired in our responsibilities, working parents with two small children in the city, finding time to pause enough to figure out why felt like a luxury we didn’t have. Eventually, not feeling like myself became the new normal. And it all looked pretty good on paper: big job, beautiful family. Until I went from having it all to nearly losing everything.
To move from the shell of myself that emerged from Bellevue Psychiatric Hospital, December 19, 2015, ashamed, riddled with posttraumatic stress disorder (PTSD), and lacking any sense of self-worth, to the version of me now would require peeling back the layers. To reckon with what had caused me to not feel like myself, with why I’d just kept going anyway.
Only later, in putting a name to and learning more about what I’d experienced, postpartum psychosis, would I realize how lucky I was. How things could have ended very differently had any detail of that Friday and Saturday been slightly altered: had my husband returned from his work trip one day later, had he been slower to the door than I, had he let me out of his sight, had the police and the hospital staff not treated me like the threat I was to myself from the moment I was wheeled in until the moment I walked out.
And much later, I’d reflect on how luck wasn’t a strategy.
The weird thing about psychosis is that often the things that you think are happening are happening. Every detail is just a little off. Your brain is working, applying logic and thinking, but weaving it into an alternate reality. Each affirmation further feeds the paranoia. I could sense people were coming to take me away. I believed they were going to kill me. People did come to take me away. To put me in a mental institution. To try and get me better. It would take me a long time to realize the distinctions.
The delusions that I lived in that day, psychotic, mirrored reality but distorted, as if seen through a twisted fun house mirror. Similarly, in healing, lucid, I’d find shades of truth in the alternate reality my brain had constructed that December day. In the scheme running things, out to get me and my girls.
Peeling back the layers, I’d discover that much of what contributed to my postpartum psychosis was a lack of proactive support for mothers and families that left me in a precarious position during one of the most vulnerable periods of a woman’s life. There was no paid leave and a lack of understanding of the tender nature of the postpartum period in the workplace that led to unhealthy back-to-work-after-baby plans.1 There was inadequate education about and treatment of maternal mental health concerns generally and a lack of diagnostic status of postpartum psychosis specifically2 that led to limited research, investment, and study and thus insufficient awareness, support, and care in the physician and parent communities, and the stigma and fear around mental health3 that led to my husband’s battling me for hours before finally calling 911. There were unbalanced gender roles and norms leading to women taking on undue burdens at work and at a home.4 There were cultural expectations attached to having it all, without meaningful social safety nets to support it, and the glossy version of motherhood, Instagram-worthy, prevailing over honest dialogue about tradeoffs and difficulties.5 To name a few factors.
In unveiling this, there’d be echoes of truth in my delusions, knowing that, although a cult wasn’t closing in, there had been a certain setup at play. A lack of proactive and quality care for mothers and families through arguably the most precarious time in our lives.
And that the “luck” I experienced in making it out alive, and not having hurt anyone, was not something everyone could claim. That it was also connected to the body I lived in, the social class I belonged to.3 Nearly a decade later, after years of eye movement desensitization retraining (EMDR) therapy and now free of PTSD, it’s the underlying feeling that something’s terribly wrong that still rings true.
Susan
I’m both a forensic psychiatrist and a reproductive psychiatrist, spending different days of the week in different clinics across the course of my career. I was lucky to learn about maternal mental health from my pioneering mentor Miriam Rosenthal, MD, and forensic psychiatry from the inimitable Phillip Resnick, MD. When I began working in these two areas decades ago, I’d receive odd looks when describing the two parts of my work to others, and comments that the two were completely unrelated. In reality, forensic psychiatry and reproductive psychiatry are unfortunately often connected.
As I heard Meghan’s powerful story in my reproductive psychiatry clinic, I could easily imagine one of the two worst outcomes in our field leading to an intersection with forensic psychiatry. If any of the unthinkable tragedies had occurred because the strategy of “luck” didn’t work, if she had delusionally believed that she was saving her children from the cult by ending their lives, if she had attacked her husband to (delusionally) save herself, or if she had ended her own life because of the delusional pressures she was facing, I considered (wearing my forensic hat) that no one she had seen the night before at the work party would have considered it within the realm of possibility. Yet I understood the very real chance that, had her husband not recognized the urgent risk, tragedy would have ensued.
In Meghan’s story, the most poignant detail to me, the one that has stuck with me the most for years, is the phrase “required reading” on her book’s dust jacket. An idea of reference, yes, but also somehow helping me make the connection that Meghan is an everyman, an everywoman, could be anyone. Intellect does not set one apart when the risk of postpartum psychosis exists. And it is the very intellect and cleverness on the part of the person who the psychosis victimizes that can prevent the needed help and care. Meghan did not share her thoughts and fears because it seemed that everyone was part of a plot against her. Many other mothers I’ve talked to have not shared their thoughts, because of knowing that showing one’s mental health symptoms in the postpartum can lead to calls to Child Protective Services, separation from one’s children. So, pretending to hold it together when these stakes are so high (and in some cases related to the stigmatization of maternal mental illness in our society), concealing symptoms to the outside world, leads mothers time and again to a lack of treatment seeking and can prevent proper care. During brief Emergency Room visits, mothers experiencing postpartum psychosis can appear asymptomatic, knowing what to say in response to internalized stigmatization and worries about custody. But there are devastating consequences for mothers and families if psychiatrists are not knowledgeable about postpartum psychosis and able to assess well enough to surface delusional thinking concealed because of fears.
Meghan’s ability to vividly describe her experience of her horrifying descent into psychosis, with reflection and insight, allows us a window as forensic psychiatrists that we don’t usually have, bringing this terrifying experience to life for us all. Postpartum psychosis is intertwined with significantly elevated risks of both suicide and infanticide. Meghan’s story brings that link to life in a way that regular lectures cannot: the meaning making of an intelligent woman figuring out the scheme and the cult from the information she was receiving; rapidly shifting changes in beliefs about who she could trust, her friend’s veiled threats to harm her babies and later her husband Colin’s reaction meaning that he was part of the plot and that they could both be killed.
Postpartum psychosis, although diagnosed since the time of Hippocrates, does not have status as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).2 This is also despite a genetic basis supported by research.6,7 This means, in turn, that psychiatry training tends to have limited exposure to the concept of postpartum psychosis.
I’ve seen cases where postpartum psychosis has been wrongfully diagnosed as postpartum depression and even malingering. On the other side, I’ve seen cases in which a significant medical problem from delivery is misinterpreted as postpartum psychosis before appropriate workup. And it is crucial both from a treatment perspective and for understanding the course of illness (as a forensic psychiatrist) that postpartum psychosis is not conflated with the very different disorder of postpartum depression. If doctors are not even well aware of postpartum psychosis, there is no way that new mothers or their partners or families could be.
The rapidity of symptom development in postpartum psychosis is a unique feature that brings organicity to mind. (It is also crucial that psychiatrists screen for various medical causes of the presentation, as detailed elsewhere.8,–,10) But the sudden onset may also lead the forensic psychiatrist to concerns about malingering. This is one reason why experience in reproductive psychiatry may be essential in some cases of infanticide. Indeed, the postpartum period is the time in any woman’s life when she is most likely to develop mental illness symptoms.11 Postpartum psychosis with its rapid onset and development, as well as its range of symptoms, including not only psychosis (as in its name) but also mood symptoms (such as dysphoric mania) and delirium-like symptoms, is “one of the most concerning of psychiatric disorders.”11
When Meghan came to see me, it was in the context of long-term healing, with a goal of prophylaxis of further episodes of postpartum psychosis with the next addition to her family. She had educated herself, learning everything there was to read about this entity that didn’t have its own name in America. In treatment, we checked in quite regularly to ensure that prevention was going well and that she was adjusting to the postpartum. Even without worries of developing another episode of postpartum psychosis, navigating early mothering, especially with now three young children at home, is stressful for anyone. In addition to medication, we talked a lot about early warning signs but also what normal was: normal thoughts and worries versus worrying about being psychotic. Meghan shared thoughts, such as seeing a heavy portable speaker, watching out for it: what if it dropped on the baby and then seeing images of herself hitting him with it. Or seeing a sharp corner of a table: what if the baby fell on it and then seeing images of her smacking him into it. It was only after Meghan’s experience with postpartum psychosis that she felt both safe enough and it important enough to share these types of thoughts with a doctor and her spouse, vigilant for the delusional thoughts that had overtaken her during postpartum psychosis. And in sharing these types of intrusive thoughts with me, and others, to see if she was okay, she found they went away. The postpartum is a time when we reproductive psychiatrists see not only postpartum depression very commonly but its twin, postpartum anxiety. Often the anxiety features worries that a mom has about her new baby, the person who she is most focused on. And if determining the difference between anxiety and psychosis can prove difficult for physicians as outside observers, much the more so for the person it is happening to. Yet open dialogue about thoughts can support women in moving through them or lead to proper treatment where necessary.
Mothers with untreated postpartum psychosis have a significantly elevated risk of both suicide and infanticide as well as difficulty caring for their vulnerable infant because of their symptoms.8,–,13 There is also a strong intersection of filicide and suicide among mothers who kill, with 16 to 29 percent of mothers also committing suicide when they kill their child.12 Of course, mothers with postpartum psychosis may also kill because of motives of fatal maltreatment, unwanted child, or partner revenge, as may any other filicide offender. Although a careful analysis of motive in a mother who has killed is essential in cases of postpartum psychosis, as it is in any such parent,12,14 the motives of altruistic filicide and acutely psychotic filicide are much more understandable in cases of postpartum psychosis associated with infanticide than they are in many other situations.9,13,15,16 Although the diagnosis of malingering should absolutely be considered in the differential of postpartum psychosis with associated infanticide, forensic psychiatrists should be aware of the differences between the presentation of postpartum psychosis and schizophrenia, with different symptom clusters and rapidity.12 Collateral information may become even more important, and forensic evaluations should be completed as soon as possible because of rapidly shifting symptoms.12
Outside of inadequate parent and physician awareness of postpartum psychosis clinically, within the forensic arena, after serious offending, the lack of a diagnosis in the DSM is problematic for additional reasons.12 For example, the cognitive problems of postpartum psychosis are not fully appreciated in court and are not merely part of another psychotic disorder or mood disorder diagnosis, clumsily made.12 For many, the case of Andrea Yates comes to mind. Ms. Yates had killed her five children while in the throes of postpartum mental illness. She had even been warned by her psychiatrist regarding not having future pregnancies, because of the severity of her postpartum psychosis.17,18 I attended the Andrea Yates trial while in training with Phillip Resnick, MD, who was an expert witness in the case. Postpartum psychosis was not in the DSM, and Resnick diagnosed Ms. Yates with schizoaffective disorder.17 A legal finding of insanity is always predicated on a mental illness being present. Yet without postpartum psychosis being in the DSM, not only is there a burden for families clinically, there is a burden for courts, juries, and defendants.
Despite lack of diagnostic status, there have been efforts to better educate both physicians and the public about postpartum psychosis. It now features in a national reproductive psychiatry training series freely available online,19 and a recent podcast for psychiatrists seeks to educate about the condition and its risks.20 At the American Academy of Psychiatry and the Law (AAPL), the AAPL Reproductive Forensic Psychiatry Practice Resource Document includes guidance about the diagnosis and its attendant risks.21 Further, efforts organized by those with lived experience, for example, the creation of Pregnancy and Postpartum Psychosis Awareness Day,22 have begun to add more attention to postpartum psychosis and to network survivors and champion storytelling to center and build understanding of the lived experience. Designated task forces, for example Postpartum Support International’s Perinatal Psychosis Task Force,23 composed of individuals with lived and learned expertise, have helped link voices in research and practice to those with lived experience to advance understanding and build awareness of postpartum psychosis.
And, after a recent forensic case that made international news because of statements that a mother who allegedly killed her children was reportedly experiencing postpartum psychosis, increased media attention has focused on this very real but poorly understood condition.24 Meghan and I, both alone and together, sought to use the spike in interest to educate the public and psychiatrists about the condition, through media interviews and articles,25,–,27 and continue to give academic presentations together in various venues.
Conclusions
Stories have great power in the life of women and in the work of forensic psychiatrists. They teach us and help us empathically attempt to comprehend experiences of others. Meghan’s first-person account of her harrowing experience as a young mother with vulnerable children dependent on her, and the “luck” she had in getting help before tragedy ensued, is instructive. And yet, without a formal DSM diagnosis of postpartum psychosis and proper messaging, women and families are at risk of missed diagnoses and inadequate treatment. Further, in the forensic arena, when violence or homicide occur in cases of unrecognized or untreated postpartum psychosis, the ability to help the trier of fact understand can be limited for the same reason. When mothers are properly diagnosed with postpartum psychosis, the disorder is very treatable, morbidity can be prevented, and, over time with the proper supports, women like Meghan can even integrate and make meaning from the experience and posttraumatic growth can occur.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2024 American Academy of Psychiatry and the Law
