Though Murder Has No Tongue (35 page)

According to the American Academy of Psychiatry and the Law, forensic psychiatry is “a medical subspecialty that includes research and clinical practice in the many areas in which psychiatry is applied to legal issues.”
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Forensic psychiatry can be further subdivided into many different areas. These include criminal (competency to stand trial and NGRI evaluations), civil (psychiatric malpractice, disability evaluations), and treatment (in a forensic hospital, in correctional institutions). This is not a complete list, and it is a simplistic one. Many forensic psychiatrists and psychologists wear multiple hats. For example, I used to work on an inpatient forensic unit at a state mental hospital. All of my patients were either NGRI or incompetent to stand trial. My job involved providing clinical care, writing reports for the court, testifying, and supervising forensic psychiatry trainees.

Individuals were practicing forensic psychiatry long before it was recognized as a unique field. However, the American Academy of Psychiatry and the Law was not founded until 1969. In 1992, the American Board of Psychiatry and Neurology established a Committee on Certification of Added Qualifications in Forensic Psychiatry, which made forensic psychiatry a specific subfield of the discipline. To sit for the board's examination provided by this committee and receive credentials as a board-certified forensic psychiatrist, an individual must complete a year-long forensic fellowship after four years of general adult psychiatry training. After passing the initial certification test, a maintenance-of-certification examination must be passed every ten years to maintain credentials. Board certification in forensic psychiatry is not a requirement for the practice of forensic psychiatry, however: many psychiatrists perform forensic evaluations and act as expert witnesses without specialized training. Having forensic credentials, however, may give a psychiatrist more credibility as an expert in the eyes of juries and servants of the court.

As I've already indicated, the reality of criminal forensic psychiatry
is
a little different from as-seen-on-TV. Most of us psychiatrists are not part of police interrogations or victim interviews during the investigation of a crime, although I am sure that there are some who work very directly with law enforcement. Our involvement with the criminal justice system usually begins after a suspect has been charged. A court might order a defendant to undergo an evaluation by a psychiatrist or psychologist for many reasons. If there are any concerns that the defendant's ability to understand court-related information or participate in his or her own defense is impaired by a mental condition, the court may order a Competence to Stand Trial evaluation. A Sanity at the Time of the Act evaluation is ordered when a defendant's mental status at the time of the alleged offense(s) may have affected his or her criminal responsibility. If a defendant has already been found guilty of the charges, the court could
order a mitigation of penalty evaluation or request psychiatric recommendations for treatment. If a defendant is found not guilty by reason of insanity and is hospitalized, the court requires periodic evaluations to justify the need for continued hospitalization. A series of evaluations are also required before one of these patients can be discharged from the hospital.

In the 1930s, “insanity” meant something different than it does today. Essentially, it was used as a synonym for “mentally ill.” At his inquests of lunacy, Gaylord Sundheim was said to be “insane” and in need of hospitalization. Today, “insane” is a specific legal finding: when someone is insane or not guilty by reason of insanity, under the applicable state insanity statute, a defendant has been found criminally non-responsible for his or her crime. In Ohio, “A person is ‘Not Guilty by Reason of Insanity' if he proves that
at the time
of the commission of the offense, the person
did not know, as a result of severe mental disease or defect,
the
wrongfulness
of the person's acts.”
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Sanity statutes vary from state to state, and if the examiner applies the wrong one, her evaluation and final conclusions will be wrong, and her opinion will get torn apart on cross-examination. The insanity defense is rarely used and rarely successful. All persons found insane are mentally ill or mentally retarded, but not all defendants with mental illness are insane.

In an NGRI evaluation, once the evaluator understands the applicable law, the data collection and review begin. In a given case, this data can include clinical interview(s) with defendant; interviews of victims, witnesses, involved law enforcement, and attorneys; the defendant's medical and psychiatric records; and review of the prosecutor's case file.
Who
and
what
the psychiatric expert has access to may be determined by which side, prosecution or defense, hired him in accordance with the laws of evidence. Some states, Ohio among them, have designated forensic centers or court clinics. Evaluators who work for court psychiatric clinics are neutral, in the sense that they are not hired by either side. Regardless of whether the evaluator is employed by a neutral organization or was employed by the prosecution or defense, their final opinion should be based on an unbiased assessment of the data.

The clinical interview with the defendant must be thorough and free from leading questions. The purpose of the interview is to reconstruct the mental state of the defendant at the time of the act. Sanity is past-mental-state evaluation. The evaluator must always keep in mind that the person's present mental state can be vastly different from what it was at the time of the alleged acts.

Once the interviews are done and the paper records are reviewed, it is time to try and make sense of things. This is the truly fun and rewarding part of forensic psychiatry. It is a bit like a mind-challenge puzzle. Did the defendant have a severe mental disease at the time of the alleged act? Does the evidence
suggest knowledge of wrongfulness at the time of the act, or does it imply the defendant did not know what he or she was doing was wrong? Did the defendant have a rational motive for doing what he or she did (i.e., revenge or profit) or was there a non-reality-based (delusional) motivation?

What qualifies as a “severe mental disease?” Schizophrenia, major depressive disorder, and bipolar disorder are pretty universally recognized as severe psychiatric illnesses. For the purposes of an insanity defense, some psychiatric disorders are controversial. These include post-traumatic stress disorder and dissociative identity disorder (DID, more commonly known as multiple personality disorder). Disorders of substance use do not qualify as severe mental disorders for the purposes of insanity. For example, an individual high on cocaine who commits an assault cannot claim insanity even if he is determined to suffer from
The Diagnostic and Statistical Manual of Mental Disorders, Version IV-TR (DSM-IV)
diagnosable cocaine dependence. Keep this in mind for the discussion of Sundheim's alcohol and barbiturate use.

Just because a defendant carries a historical diagnosis of schizophrenia (or bipolar disorder or . . . ), he will not automatically be found insane for all criminal acts. It is entirely possible that his symptoms of mental illness were inactive or minor at the time of the alleged crime. The symptoms could also have been totally unrelated to the criminal acts. For example, if someone's schizophrenia causes him to believe his mother is trying to poison him and he goes out and kills the first person he sees, it does not follow that his act flowed from the delusional belief about his mother. However, if he had killed her because he genuinely believed it was the only way to preserve his own life, he
may
have a legitimate case for insanity. As a forensic psychiatrist, I ask myself: “If I accept the delusional belief or hallucination as being true in this mentally ill individual's reality, would that justify the offense committed?” A man's auditory hallucination that a woman he passed on the street called him “stupid” would not justify his killing her. However, if the man had a delusional belief that the woman was following him with the intent to kidnap and torture him for top-secret government information, this changes things a bit. If he further delusionally believed that this woman would torture his wife and children to get to him, well, you can see how this scenario
might
lead to a successful insanity defense, should he harm the woman.

Not guilty by reason of insanity is an affirmative defense. This means that the accused admits to doing the wrong act but is offering a justification for why she should not be held criminally responsible for it. Self-defense and duress are two other examples of affirmative defenses. If Gaylord Sundheim had admitted to being the torso killer during Eliot Ness's secret interrogation and we had some documentation of what was said during that meeting, it
would be possible to do a very rudimentary insanity analysis. How fascinating that would be!

“Was Gaylord Sundheim insane? A lunatic? A psychopath? Or just plain crazy?” As a psychiatrist, I try to stay away from words like “crazy” and “lunatic.” Those are nonspecific lay terms that only serve to foster stigma against the mentally ill. Before I suggest possible diagnoses for Sundheim, a few more definitions and explanations are called for. First, I will describe antisocial personality disorder and psychopathy.

Antisocial personality disorder is one of several personality disorders described in the
DSM-IV.
A personality disorder is a pattern of behavior and emotions that differs from cultural norms and manifests in several areas: cognition, emotional response, interpersonal functioning, and impulse control. The pattern is evident in many different areas of the individual's life. It is an inflexible way of seeing and responding to the world that starts in early adulthood. Perhaps most important, the pattern causes distress or impairment to the individual.
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Notably for our assessment of Gaylord Sundheim, it cannot be due to the direct physiological effects of a substance or a medical condition.

The hallmarks of antisocial personality disorder are a disregard for and violation of the rights of others starting by age fifteen. The
DSM-IV
specifies that three or more of the following must be present to make the diagnosis: repeated breaking of the law, deceitfulness, impulsivity, aggression and fighting, recklessness, and remorseless irresponsibility.
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The individual must also be at least eighteen years old at the time of diagnosis. Evidence of childhood conduct disorder must also be present. Unfortunately, we know next to nothing about Sundheim's childhood.

What can we conclude about antisocial personality disorder and the Mad Butcher of Kingsbury Run? If we look at the acts of the torso killer, we can identify many of these traits. The killer certainly did not conform to social norms. Murder is definitely a violation of the law. Beheading numerous human beings is certainly aggressive and shows disregard for safety. I think we can also infer that the killer must have used deceitfulness to lure his victims and hide from the law. Mrs. Sundheim clearly felt her husband demonstrated consistent irresponsibility in his roles as husband and father. With the caveat that we don't know anything about childhood conduct problems, we have more than enough criteria to make the diagnosis of antisocial personality disorder.

Popular culture is filled with examples of “psycho killers,” but what exactly is a psychopath? The literature on psychopathy is complex and extensive. In some articles, psychopathy is said to be the old term for antisocial personality disorder. Many use the terms interchangeably. Still others consider
psychopathy to be a broader concept than antisocial personality disorder. Not all psychopaths are criminals and not all criminals are psychopaths. Dr. Robert D. Hare is a firm believer that antisocial personality disorder and psychopathy are not the same thing. He devised the
Psychopathy Checklist-Revised
(
PCL-R
), which has been used to evaluate psychopathy in research settings. Put very briefly, two main factors are assessed by the
PCL-R
: callous, selfish, remorseless use of others and chronically unstable and antisocial lifestyle. It is also very important to state that psychopathy is not the same thing as psychosis. Fictional examples of psychopaths include Hannibal Lector from
Silence of the Lambs
and Alex from
A Clockwork Orange.
Real-life killers like Jeffrey Dahmer, Ted Bundy, and John Wayne Gacy have been described as psychopaths. Because of the gruesome nature of his murders and the way some of the bodies were disposed of, many would be quick to label the torso killer as a psychopath. However, even if we could prove Gaylord Sundheim was the Mad Butcher, it would be irresponsible to label him a psychopath on such limited data.

So what can we conclude about Gaylord Sundheim and still be on reasonably firm footing? With the obvious caveat, once more, that I did not conduct a personal evaluation of Sundheim, the available evidence most strongly supports a diagnosis of chemical dependence. Specifically, Sundheim appears to have suffered from alcohol dependence. The
DSM-IV
diagnosis of this disorder requires a maladaptive pattern of alcohol use leading to impairment or distress in at least three of these areas within the same twelve-month span: tolerance; withdrawal; using alcohol in larger amounts or over a longer period than was intended; persistent desire or unsuccessful efforts to cut down or control alcohol use; giving up or reducing important activities because of alcohol use; and continued alcohol use despite knowledge of a persistent or recurrent physical or psychological problem likely to have been caused or exacerbated by alcohol.
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Divorce and probate court documents give ample evidence that Sundheim met several of these criteria. He was probated to City Hospital at least three times for “dipsomania.” Dipsomania is a historical term referring to a sudden and irresistible need to drink alcohol. Sundheim's drinking continued despite the development of peripheral neuritis (pain, loss of sensation) in his legs and feet. Most notably, he continued to drink despite the destruction of his marriage and neglect of his children.