Family Murder: Pathologies of Love and Hate

Dr. Laura Roberts (00:10):

Hi, I'm Dr. Laura Roberts, editor-in-chief for the books portfolio of the American Psychiatric Association. Welcome to the APA Books podcast.

Dr. Laura Roberts (00:30):

Welcome to Unbound. Today, we're going to be speaking with Susan Hatters Friedman. Dr. Friedman is the inaugural appointment to the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in the Department of Psychiatry, and it looks like she is the entire university all rolled into one person. She has professor appointment in reproductive biology, pediatrics, and is an adjunct professor of law at Case Western Reserve. She's also the director in the Division of Forensic Psychiatry at University Hospitals Cleveland Medical Center.

Dr. Laura Roberts (01:09):

She does a lot for our profession. She is a deputy editor for the Journal of American Academy of Psychiatry and the Law. She's served as the vice president of the American Academy of Psychiatry and the Law, chair of Law and Psychiatry Committee for the Group for the Advancement of Psychiatry. We're going to come back to that in just a minute, but has done so much to serve our field.

Dr. Laura Roberts (01:31):

Dr. Hatters Friedman, who, with her permission, I'm going to call Susan, is the person who put together, with a GAP committee, a book called Family Murder: Pathologies of Love and Hate. This is a phenomenal book, and we're going to talk about it. It just won an award, the 2020 Manfred Guttmacher Award from APA and AAPL. It's quite an unusual book. I'm very excited to speak with Susan today about it. Welcome, Susan.

Dr. Susan Hatters Friedman (02:10):

Thank you. I'm excited to be here.

Dr. Laura Roberts (02:11):

Yeah. Thank you so much. I have to tell you, you receive proposals for books at the American Psychiatric Association's publishing group, and when we got this proposal, it was on family murder, and I was really concerned that it be done in a very rigorous, thoughtful, non-sensational way. I also had a deep, because of my own experiences elsewhere and during my training in New Mexico, a sense of how important family murder and murder of members of families are. So I was intrigued by the book, but was so concerned that it be done beautifully and thoughtfully and in a way that helped advance the field. What I want to tell you is, you did it. This is a-

Dr. Susan Hatters Friedman (03:06):

Thank you.

Dr. Laura Roberts (03:07):

... beautiful book. Could you tell our listeners, of all the things that one could write about, how is it that your group and you arrived at this extraordinary and really very important project in psychiatry?

Dr. Susan Hatters Friedman (03:24):

Sure, thanks. The Group for Advancement of Psychiatry is broken up into committees, and our committee is the Committee on Psychiatry and the Law. I'll just say a little bit about what we do at GAP, is that we have meetings twice a year for a couple days, and what we do is we talk about the current issues facing our field and how we can be of educational service, as well as serving as a think tank for psychiatry at GAP.

Dr. Susan Hatters Friedman (03:59):

One of the topics that our group kept coming back to is family murder and the cases that we've seen, but also thinking about prevention. Through our discussions with other members of the committee, all of whom are authors of chapters in the book, we have had various expertise within different specific types of family murder.

Dr. Susan Hatters Friedman (04:28):

For example, Dr. Phillip Resnick is on the committee and has done a lot of the early work in describing filicide, and actually coined the term neonaticide, for murder of the child in the first day of life. Peter Ashe, another member of the committee, is a child and adolescent forensic psychiatrist and had done work in a similar sphere. With the different clinical and forensic work that the various members of the committee have, we really were talking a lot about family murder and thinking that it would be an important project for us to tackle and bring our clinical and forensic knowledge to.

Dr. Susan Hatters Friedman (05:11):

Personally, for me, I've been quite interested in maternal mental health clinically. One of the things I think about a lot as I'm seeing pregnant and postpartum women is safety in the home, so both suicide and violence, violence either toward the mother or perpetrated by the mother, and the prevention of that. We see horrible cases in the news of parents who have killed their children, for example. That is something that I have in my mind as I'm doing my clinical work that had led me, dating back to residency, to have interest in increasing our research knowledge about the characteristics of mothers and parents who kill their children. It's been a personal interest of mine within the forensic arena, but also within my clinical work for my whole career.

Dr. Laura Roberts (06:08):

Yeah. Honestly, it's such a forbidden topic, and yet, as you were saying, greater understanding of this area in general, and then in particular, in looking at young families and maternal mental health, it'd be wonderful if we could do more to prevent these horrific outcomes. Maybe you have some thoughts that our listeners would be very interested in, I'm sure, on prevention efforts in working with mothers who are at risk for poor outcomes.

Dr. Susan Hatters Friedman (06:43):

Sure. Prevention is one of the big focuses of the book. One of the points that we're trying to come across with in the book, as well, is that even the same act can have various different motives. And for the various different motives, we need to think differently about prevention.

Dr. Susan Hatters Friedman (07:04):

If we take the example of a mother who's killed her child, that could have happened for very different reasons. Commonly, it's a case of fatal maltreatment, where there's been chronic abuse or chronic neglect and the child ends up dying. I know these are horrible things to be thinking about and talking about, but they're really important in our role in prevention. The mother has killed the child in that manner. You can imagine that what we're thinking about, prevention, is going to be really different than if the acutely psychotic mother kills her child because of delusional thinking.

Dr. Susan Hatters Friedman (07:43):

In each of the types of murder that we talk about in the book, be it intimate partner homicide, be it siblicide, be it infanticide, what we're really asking readers to think about is that there are these different motives, and then that leads to different prevention strategies. For example, I think that the Andrea Yates case is well-known from the national news. She had been acutely unwell, acutely psychotic, when she killed her children in the early 2000s. Prevention on a case like that is going to be really different than the chronic child abuse prevention cases.

Dr. Susan Hatters Friedman (08:23):

When we think about parents with mental illness who ended up killing their child, what we want to think about is, could there be more services available to people prior to this awful outcome? Are we identifying mental illness in mothers and in fathers? Are we getting them the treatment that they need, and are we giving them the social support that they need through various social service entities?

Dr. Susan Hatters Friedman (08:54):

It even cuts back to the stigma around postpartum mental illness. Women are told this is supposed to be the happiest time of their life, and within a lot of subcultures in America, it's embarrassing to have depression during this time. Or even if you do acknowledge it yourself, your family members are saying, "No, you don't need medication. No, you don't need to see a shrink." So it even starts with stigma, but then it's identification of which parents have a postpartum depression, have postpartum psychosis, and then from there, getting the proper treatment and the social supports in place.

Dr. Susan Hatters Friedman (09:32):

It's also about asking our patients about their parenting, about their relationships. I think sometimes that can be difficult within a quick med check or with the rapid pace that we have in psychiatry sometimes. But I think it's so important to consider the patient's home life when we're seeing them, and not just the symptoms that they're presenting with.

Dr. Laura Roberts (09:58):

As I said in the very beginning, it's such an important issue, completely, really, neglected in the scholarly literature. Obviously, there's lovely work in the forensic psychiatry space, but in terms of the broader literature, that was the opportunity I felt that we had. I want to thank you and your committee and GAP overall, with whom we have really a wonderful relationship here at the publishing house. This idea that we could bring greater knowledge to the field as a whole, and perhaps even to other areas adjacent to psychiatry, that would really benefit from understanding more about family murder as a stigmatized topic. I think we just have not done enough.

Dr. Laura Roberts (10:43):

Part of what is so valuable about this book is the scholarship. It's very rigorous. It's not sensationalized in any way, which of course we were really vigilant for, but clearly you all had been very vigilant for. It's a very, very serious treatment, very systematic and scholarly, of a very serious and neglected societal issue.

Dr. Susan Hatters Friedman (11:07):

Thank you. We do start each chapter with a case, something that's moved the author of the chapter, moved various members of the committee. We talked as a committee about which cases we would use for different chapters, and they're not used for any... They're used to illustrate the type of family murder and some of the characteristics that we commonly see in the murders. They may be cases that the reader remembers from the news and have stuck with the reader as well, but the purpose of using them is to illustrate and also...

Dr. Susan Hatters Friedman (11:47):

One of the points throughout the book is to show the humanity of people who end up engaging in these awful acts of murder within the family, because the motive may be related to mental health, but it may be related to not being able to deal with stressors that are insurmountable. It may be related to other motives for murder, like anger, jealousy, greed, et cetera. Those are feelings that any of us living in a family may have experienced, and so just really seeing the humanity of people who end up committing these offenses as well.

Dr. Laura Roberts (12:27):

Let's talk maybe about some of those cases. You talked with us previously about how the Susan Smith case was particularly compelling to you. There was some piece of humanity there that mattered to you. Do you want to tell us about that particular case?

Dr. Susan Hatters Friedman (12:45):

Sure. I'm happy to. Susan Smith, that case really stuck with me personally. It was in the early '90s, when I was a young mother, as was Susan Smith. It was a national news story that I think a lot of people in the country were following. She had drowned her two young sons by driving her car into a lake with them strapped in the backseat in their car seats. However, it was not reported that way initially. Instead, there was a national manhunt.

Dr. Susan Hatters Friedman (13:19):

She had told the police she was carjacked by a Black man, so there were racial overtones as well. You could see her on the evening news tearfully pleading for this Black kidnapper to release her two kids. He could keep the car that he had stolen with them in the backseat. It was over a week before the police had a confession from Ms. Smith about what had actually happened, that she had actually driven the car into the lake with the boys inside and killed them.

Dr. Susan Hatters Friedman (13:52):

During that time, I think a lot of... I don't think my experience was unique. I think a lot of people were concerned about this, and thinking about what would you do in that situation, et cetera. Then suddenly it turned from her being this woman who this horrible carjacking had happened to, to her having killed her children. For me, as well, with a young child and with the same first name, Susan, it was a story that really stuck with me. That was long before I was a forensic psychiatrist that it stuck with me.

Dr. Susan Hatters Friedman (14:31):

A chance to look back at these cases and think about them that the book provided those of us as authors, but also the readers, I think is important. Susan Smith's case would be one type of child murder by the mother. Then the Andrea Yates case, for example, that we had mentioned earlier, different motive put forward in court and different preventative factors, perhaps, as well.

Dr. Laura Roberts (15:00):

Who do you hope will be reading this book? I've commented on how I think the general psychiatry audience and psychologists, obviously, people in forensic areas in general, I think would benefit from this. Is that your intended audience? What are you hoping people will gain from reading the book?

Dr. Susan Hatters Friedman (15:21):

Sure. Yeah, the intended audience is general psychiatrists, forensic psychiatrists, psychologists, also those in the social service arena to see some of the bigger-picture issues across the different types of family murder, and then also attorneys and judges. In the book, we follow not only the case, not only the characteristics before the case, but then unique legal issues relevant to that specific sort of case, insanity evaluations, for example, or the risk of reoffending, et cetera. I think, as we talked about earlier, the big-picture things that we are trying to get across in the book are that this is something psychiatrists, mental health professionals, the law needs to be thinking about so that we can think about prevention, that there are various different reasons why each of these types of murders happen.

Dr. Susan Hatters Friedman (16:20):

For example, something that I learned much more about as we were writing the book was intimate partner homicide in the elderly. The way that the media often portrays it is that it's an altruistic, loving husband who kills his wife, who maybe has medical problems. It's presented as a sort of euthanasia.

Dr. Susan Hatters Friedman (16:44):

When we looked more at the data and more about cases, that is one type of intimate partner homicide in the elderly; however, there are many other cases where there's been a longstanding history of intimate partner violence. There's maybe an additional stressor, such as a planned move out of the home. There's likely guns involved. In many cases of intimate partner homicide by the elderly, it's actually the end result of intimate partner violence throughout the relationship. Understanding that we may have preconceived notions from what we read about in the news or hear about on the news, and that may not actually be the whole picture of these cases.

Dr. Susan Hatters Friedman (17:33):

Yeah, for me, the big purpose is really bringing this to psychiatrists and those in the legal arena that this is something we need to be thinking about in our evaluations and in our treatment as part of prevention, but also being aware there's not a one-size-fits-all prevention for all types of family murders. It's depending on the perpetrator-victim relationship and depending on whether there's mental illness present or stressors present, et cetera.

Dr. Laura Roberts (18:05):

Well, so here we are in the middle of a time in our country and in our world where everybody is feeling extraordinary stresses, and everyone is feeling vulnerable in a way that I'm not sure I've seen in my lifetime. I wonder if you have thoughts about whether families are under such greater strain and stress, duress, economic challenges, relationship challenges, social isolation, and then families being isolated, if you have greater concern about these issues at this time.

Dr. Susan Hatters Friedman (18:40):

Yes, we do. That's actually something we were talking about on our committee's Zoom call a couple months ago about, actually, having greater concerns about family murder in the time of COVID. It's the risk factors that you were just talking about. All of us are feeling incredibly stressed about the virus, about finances, about losing jobs, and then people are in their homes. Now they're coming out more, depending on where they live; but with schools being canceled and a lot of work from home, there's a lot of chance for arguments to get bigger.

Dr. Susan Hatters Friedman (19:20):

I know also that in the community of women who are victims of intimate partner violence, for example, they're suddenly pretty much 24/7 behind locked doors with their abuser. This is a difficult time also in the child abuse arena. Child abuse pediatricians are talking about concerns about child abuse potentially going up significantly related to the same thing, being at home all the time, increase of the other risk factors and stressors too. Then this isolation, the social distancing turning into significant isolation. These are all things of concern.

Dr. Laura Roberts (20:06):

Let me just talk about one last thing before we have to close. Honestly, I could talk with you... It's just such a rich discussion, and thank you so much.

Dr. Susan Hatters Friedman (20:16):

Thank you.

Dr. Laura Roberts (20:17):

It's the issue of secondary trauma. Here we are talking about hard things. Some of the listeners may find this to be difficult and may evoke patient stories that were difficult. I know as we're talking, I'm remembering people I have taken care of, and the sense of helplessness. I don't know about you, I'm assuming you do have intrusive thoughts of horrible things that I've learned in the course of my clinical care of patients, not without compassion for the people, but it does leave an imprint on us. I don't know if you have thoughts for our listeners about dealing with your own responses to these hard human experiences and how you sit with them, work through them, and any guidance you would have for our listeners about these hard issues.

Dr. Susan Hatters Friedman (21:13):

Sure. Thanks for asking. That's a really important question. I noticed for myself early on some reactions. Even when I was a resident going through to do the research I did then, going through all the coroner records of families who had been murdered was difficult to read sometimes.

Dr. Susan Hatters Friedman (21:34):

For me, one thing I did was try to really keep separate my home life with my lovely kids and my husband from the horrible things that I was reading about, trying to keep that separate. The other really important thing to do is have compassion for ourselves and to check in with ourselves about how we're feeling about things, not to try and ignore them. For me, another thing I do is talk with my colleagues when I've had a particularly upsetting case, talk it through about how I'm feeling about it.

Dr. Susan Hatters Friedman (22:10):

Certainly, if you're treating someone and hearing these things, either when you're treating them in a correctional facility or afterwards, or if you are treating them and hearing these things and making decisions about risk and hospitalization, or notifying child protective service, et cetera, as psychiatrists, we're still humans and we're still going to have feelings about it. We need to be thinking about our countertransference. Certainly, for example, seeing patients in a correctional setting who have committed a family murder, we could certainly develop countertransference about that. I think that the healthiest thing to do is to be able to recognize that and then talk it through, either with colleagues or seeing someone yourself if necessary. But yeah, I think that even for seasoned forensic psychiatrists, some of these cases can be difficult to focus on.

Dr. Susan Hatters Friedman (23:09):

Sorry, did you want more?

Dr. Laura RobertsLaura Roberts (23:11):

Well, I was just going to say, well, you talked a little bit about keeping it separate, keeping your professional life and your family life separate. How do you do that? You're carrying it around. You're you, and you're carrying it around with you. Just to help people think about how to partition in a healthy way. You've alluded to just suppressing or distancing oneself from it could be constructive, creating a sense of separation.

Dr. Susan Hatters Friedman (23:42):

Yes.

Dr. Laura Roberts (23:43):

But it could accumulate and be more worrisome. I do worry about compassion fatigue and burnout and emotional exhaustion. The work that we do is different, and these are serious threats to our on well-being, but also our ability to be present and effective in the care of the next patiewnt, right?

Dr. Susan Hatters Friedman (24:07):

Yes, absolutely. I think recognizing in ourselves, like we talked about with supervisors back when we were residents, recognizing in ourselves when we're angry at a patient or feeling hateful toward a patient, that's important to recognize. It doesn't mean that we're a bad doctor. It means that we're experiencing countertransference, and then working through that with colleagues. I think those of us who are in academic medicine are so lucky with a lot of colleagues around to discuss these issues. I think it would be harder in private practice, in particular.

Dr. Susan Hatters Friedman (24:45):

One of the things that I think is great during the fellowship year in forensics, if it's a program with several fellows, is the fellows hear about each other's cases in supervision and able to digest some of the things that we hear in supervision together about cases. Then what we found is myself and other fellows years later still going back to their classmates or other fellows to talk through some of the stressful parts of hearing these things and being the treater or being the evaluator in these cases.

Dr. Laura Roberts (25:22):

As you're talking, I'm thinking about the function that professional organizations serve in our lives as we mature and go through our own professional developmental path. It sounds like with your GAP committee, for example, you are telling stories and hearing one another and helping meaning-making or sense-making of these hard human experiences. One of the products is this hard but beautiful book.

Dr. Susan Hatters Friedman (25:56):

Thank you.

Dr. Laura Roberts (25:57):

Yeah. I would just think about APA and other organizations. We may not be in supervision anymore, but we have colleagues we can turn to and reflect on some of these experiences.

Dr. Susan Hatters Friedman (26:11):

Exactly.

Dr. Laura Roberts (26:12):

Well, I want to thank you, Susan, for bringing forward such an extraordinary book. I want to thank your committee and I want to thank GAP for the partnership and collaboration around this book. You're so articulate and so thoughtful. I really hope that we'll see another book from you in the future.

Dr. Laura Roberts (26:35):

I think it would be really, really wonderful, because this idea of deepening our sense of humanity in the forensic cases, in particular, in the field of forensic psychiatry, is just such a lovely and thoughtful observation. I think it's something... Many psychiatry programs don't have a forensic fellowship, for example, may or may not. The general training may or may not cover a lot in these areas, and so I worry that we're bringing up psychiatrists who don't have that experience and exposure that people who engage in violence or hateful, hard things have happened, that there's a human process that led to that moment. I think your book does a great job with that, but I do hope you'll keep sharing your insights and the work of the committee and your own work.

Dr. Susan Hatters Friedman (27:33):

Thank you so much. It's been such a pleasure to work on this book, and to work with you on this book.

Speaker 3 (27:51):

Our original music is by Willa Roberts. Our executive producer, Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing, John McDuffie, publisher. Be sure to visit psychiatryonline.org/podcast to join the conversation, access show notes, and discover new content. Subscribe to us on your favorite podcast platform. Thank you.