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What does it mean to be “crazy?” I’ve spent much of the past few days stewing on the story of Lindsay Clancy. For context, she is a mother who, in the throes of postpartum something-or-other, whacked her three kids. Killing your own offspring is, on its face, an unambiguous evil. Only the most fanatical (and likely also psychotic) of anti-natalists would suggest otherwise. Clancy has not been characterized as an unambiguous evil. The exact nature of her mental illness is still at issue in the trial, but many figures have converged on the idea that Clancy was not of sound mind and thus is not culpable the way you or I would be. I suspect that no matter what her sentence is, a vocal chorus of mental health advocates will decry it as excessive. I sympathize here — having worked with the severely and persistently mentally ill, living with acute psychosis is hardly living at all.
I think this case is an interesting segue into something I’ve noticed more and more about how we adjudicate moral harms in the public sphere. I’d like to soapbox for a moment. Cool? Thanks. The experience of harm, at least colloquially, is limited to two parties: the offender and the victim. These people experience the qualia of the situation with their own eyes, ears, limbic systems, pain receptors, and memory banks. Unless we were physically present, the rest of us schmucks don’t have that privilege. We can only experience the event through language. We describe what happened. We ideate on the nature of the harms, the observed damages, and the more latent impacts. Most importantly, we construct a theory of mind for those involved. We daydream about what they might have been thinking, or, in cases like Clancy’s, if they could think at all. Bluntly, we want to know if we should treat them harshly or if there are, say, intervening factors that reduce their culpability. All of this is mediated by language.
Many of these intervening factors can be modeled on a spectrum. Someone can be more or less psychotic, more or less cognitively impaired, more or less ignorant to their situation. For the sake of discussion, let’s assume that Clancy experienced severe psychotic symptoms. In this case, minimal gymnastics are required to describe her nature as such. Clancy is psychotic → therefore she didn’t know what she was doing → therefore she’s off the hook. Thus, it is written. However, how should we treat someone who was a little less psychotic? How about a little less than that? What if they had psychotic symptoms, but they were subclinical or didn’t neatly fit diagnostic criteria? This is where language fails us. Human qualities may be modeled on a spectrum, but language is discrete. And so, the spectrums get “sticky,” and the labels gain outsized importance. A line must be drawn. The person must be sorted.
These sticky spectrums exist for a variety of traits. If you’re “just” poorly socialized and have a blind spot for a particular social norm, you’re expected to do better. If you’re diagnosed neurodivergent, it’s more tolerable to break the norm because you “can’t control it.” If you’ve had a few drinks and crack skulls in a bar fight but are otherwise a normal chap, you’re probably on the hook for assault. However, if you’re a person in the throes of capital-A alcoholism, you can break into a family’s home, sleep on their child’s bed, and avoid charges because you’re burdened by a sickening disease. If your IQ is 70, you can be sentenced to death. If your IQ is 69, you’re much too intellectually disabled for that to be fair. In each of these cases, the mental states at the time of the offense are similar if not near-identical, and yet resulting judgments vary based on how we categorize the offender’s nature. We don’t adjudicate based on “sort-ofs” and “somewhats.” In common parlance, either you’re an alcoholic or not. Either you’re intellectually disabled or not. Either you’re culpable or not. This strikes me as unfair.
I suppose I’m advocating for the spectrums to be less sticky, or for words to have less of a gravitational pull. Clancy will likely receive a modified sentence based on her state of mind. Yet, what ought we to do with people in the midst of mild, manageable psychosis who may still yet have impaired judgment? Maybe they don’t get away with a full insanity defense, but their sentence could be modified accordingly. This is why I oppose mandatory minimum sentencing. The job of the court — and the court of public opinion for lesser matters — is not just to determine what happened, but to determine the appropriate consequence. The question is whether or not this is a utopian suggestion. Is human nature too punitive to implement this mindset at scale? Are we interested in justice or just blood?
Relevant Scott: The Categories Were Made For Man, Not Man For The Categories
I started a comment and then remembered you might be one of the people with an actual medical background so I won't perseverate and will ignore some of the misunderstandings of people below.
What's your read on the actual dx? I've been trying my best to avoid the details but the case is now everywhere so might as well try and dig in.
I've also spotted an interesting culture war element, even in medicine (and even among my friends who work in mental health) nearly all of the women don't think she did it (they blame the husband). Most of the men? Think she did it (and with most of those also thinking it wasn't psychosis).
The only exception I've run into was a forensic psychologist.
Perhaps something to chew on.
Comment as you wish! I welcome more discussion even if you think it's redundant. I have education in the issues at hand, though I do not currently work in a diagnostic capacity with psychotic populations. I'd describe more, but I am overly protective of my online footprint and anonymity is why I enjoy participating here.
I haven't read about Clancy extensively, so my comments are tentative and open to correction. Generally speaking, psychotic diagnoses are a shitshow. Presentations vary wildly within the same diagnosis and treatment is a blunt instrument, to put it nicely. The defense claims she experienced some form of bipolar disorder with accompanying post-partum depression. From what I have read, her presentation aligns more with depression with psychotic features, but again, these categories are extremely fuzzy.
Notes taken from her psychiatrist indicate she was experiencing what are commonly called "command hallucinations," or voices that tell you to do things. It seems trivial to us mentally sound folks to resist voices - just say no - but it's not merely a voice. These hallucinations are often experienced like a form of possession, where the voice is accompanied by a loss of control or feeling of being "overridden." I once worked with a man who attempted to strangle me while crying and saying, "I'm so sorry, I don't want to do this." I believe him. He warned me when he was about to lunge so I could avoid it. I knew him well and in his right state of mind, he was a kind and gentle person. During his worst moments, he believed he was possessed by a pagan god. There was nothing we could do to talk him out of it, the only thing that worked were very strong doses of rescue medication (usually benzodiazepines). It is entirely possible that Clancy had similar experiences. It's hard to say. Much of the commentary around her mental health has focused on the depression, suicidality, and sleep disturbances that she experienced, rather than the psychosis. I am surprised the defense has taken this approach.
The other point I'd like to make is that the day-to-day experience of psychosis varies incredibly. I've worked with patients who have had fantastic weeks and consistent upward progress. These good periods can create a false sense of security and normalcy and often result in medication adherence wavering. Naturally, the progress comes to a swift halt (or even regression) in these cases. Even worse, sometimes downturns occur for no apparent reason despite consistent treatment. Here, there is little that can be done other than providing rescue medication, hoping the episode passes, and tweaking the prescription. Even within a single day, presentations can change dramatically. As such, the claim that she could wake up in the morning, take her kids to school, and come home to kill them does seem psycho-medically plausible.
Ultimately, it's hard to diagnose her remotely or evaluate the validity of the expert claims. I am very interested in her presentation these days. She appears to be able to sit in the courtroom with minimal difficulty and is evidently not experiencing these symptoms anymore. Perhaps she's just better at concealing them. I wonder what changed - was it time, or a new treatment?
I've written this and am only now seeing you are a physician. Apologies if some of these observations are elementary to you.
I'm quite interested in the differential, even if the information to really figure it out isn't available (and it wouldn't be appropriate anyway).
The impression I got is that she didn't endorse any CAH before or after the killings until meeting with someone hired by her defense. If this is true....yikes.
While patients lie about and minimize AH all the time it's usually noticeable enough, especially in someone getting enhanced scrutiny (for instance after murdering their children).
I'm therefore not sure I buy that she has some form of postpartum psychosis or unmasked BP w/PF, especially given the blatant doctor shopping, help seeking/unseeking behavior, and odd regimens (which can of course stem from poor clinical care but usually involves some element of questionable patient decision making).
If you toss out primary psychotic pathology it rapidly gets really interesting (and this dovetails into your original post). The observed behaviors are demonstrably abhorrent. Do you need to automatically catch a diagnosis as a result?
DSM personality pathology requires persistence and pervasiveness, I haven't heard any evidence to establish that. Is this instead Cluster-B adjacent coping mechanisms in the setting of some other process such as anxiety, depression, or abusive behavior from the accused of being personality disordered himself husband?
I don't think laymen should really be weighing in on criminality and legal proceedings for psychosis because that gets thorny pretty quickly (aka what is Anosognosia anyway?), but I think it's pretty mainstream and reasonable to treat DSM personality pathology (especially BPD and ASPD) as criminality instead of insanity. Likewise terrible stuff that doesn't quite fit into a diagnostic box.
Although if psychosis was present - it's easy to underestimate the danger in first episode psychosis, without proper practice managing symptoms things can go off the rails very fast.
Uh-oh. In my experience CAH tend to be quite persistent and well-documented, since they are public enemy no. 1 when it comes to patient safety.
I think this is the only scenario that I could really accept - if the killings happened in her first episode of psychosis, prior to treatment. It's going to come down to how thorough her psychiatrists were in documenting the progression and severity of her symptoms, so they can generate a rough timeline of her illness. I think we will probably never know these details and can only hope the court does its due diligence.
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