There has been much criticism of our current mental health system here in the United States and assignment of blame in the Lindsay Clancy case. As a clinician who has worked in and been part of that system both directly and indirectly, from both within and without it, for the past fifty years, I offer some reflections on what works and what doesn't work in such cases, and why.
How was Lindsay Clancy Treated by her Providers?
Ms. Clancy was a professional nurse and fairly high functioning member of society prior to the insidious decline of her mental health that led to strangling her three young children and then trying to kill herself. What triggered this horrific chain of events and why didn't she receive sufficient mental health support to prevent this evil deed from happening? Was this, as some assert, an abysmal failure of the mental health system as it currently exists here in America? Did Ms. Clancy never receive the level of psychiatric treatment clinically called for by the reported severity of her symptoms? Is this a common occurrence with other patients as well? Patients who simply "slip through the cracks" of a broken system? Was she somehow discriminated against because of her gender, as some allege? What, in retrospect, should her treatment have been? And why was it not provided? The benefit of 20-20 hindsight is a key factor here but nevertheless begs the question of why the mental health professionals Clancy consulted failed to recognize the severe risks that her concerning symptomatology posed. Or, if they did, why wasn't more done to try to prevent this tragedy from happening?
What Actually Went Wrong?
Following the birth of her third child, Ms. Clancy felt more anxious and overwhelmed, reportedly consulted two different psychiatrists, was diagnosed with an anxiety disorder, and promptly prescribed numerous psychiatric medications to mitigate her symptoms. To begin with, this begs the question of whether she was properly diagnosed at that time. In this sense, I disagree with fellow PT blogger Dr. Helen Marlo regarding the importance of preliminary psychiatric diagnosis which, in my view, is absolutely essential.
Correctly and quickly diagnosing such conditions is a crucial starting point for both effective pharmacological and psychological therapy. For example, diagnosing and treating an anxiety or adjustment disorder is very different from diagnosing and treating a bipolar, major depressive, borderline, or psychotic disorder. One challenge to diagnosing patients properly is that, because psychiatric symptoms, unlike objective signs (see my prior post) are subjective phenomena, unless one specifically asks about them, the person may not voluntarily report suicidal or homicidal ideation, hallucinations, or paranoia, etc. due to shame, fear of being judged, hospitalized, or perceived as being "crazy." And, even when directly asked, may deny having such symptoms. Were Ms. Clancy's symptoms never fully reported to the clinicians she consulted or merely missed, minimized, or overlooked by them? Were their diagnostic skills lacking? Or, was the potential dangerousness or her symptoms grossly underestimated?
The Underlying Philosophy of Mental Health Treatment Today
These are complex questions without easy answers. But I will attempt to address some of them here. Though we are speaking about the American mental health system in general, this case raises universal questions regarding the state of mental health care today. Modern psychiatry, psychology, and other mental health disciplines stand, whether they acknowledge it or not, upon certain fundamental philosophical beliefs regarding the nature of the human condition, the root causes of psychiatric symptoms and aberrant human behavior, the sources of human evil, violence, cruelty, and suffering, and the most effective and appropriate approaches for addressing these matters.
Indeed, the entire edifice of our mental health treatment system in this country is constructed upon these preconceived philosophical foundations which directly and indirectly, consciously and unconsciously, inform and influence how we conceptualize and treat mental health issues. So, we could say that what happened to Ms. Clancy and, unfortunately, happens to so many others seeking psychiatric or psychological assistance today, can be attributed to a fallacious philosophy underlying the mental health system. But how so?
The predominant philosophical misconception of mainstream psychiatric and psychological treatment today is that since so-called mental disorders are presumed to be primarily neurobiological phenomena, their main treatment must be biological or biochemical. Moreover, that pharmacological intervention is both faster, cheaper, and more efficacious than psychotherapy in alleviating the patient's symptoms and suffering, and that this is the only purpose of treatment. (See my prior posts.) Additionally, that CBT, DBT, and other brief or short-term therapies are superior to more open-ended approaches such as psychodynamic, existential, or humanistic therapies. CBT (cognitive-behavioral therapy) or DBT (dialectical behavior therapy) might be better for addressing and mitigating certain specific symptoms or behaviors but not others.
And brief therapy can be sufficient in some cases, but certainly not all, or even most. When critical treatment decisions are made on the basis of dogmatic clinical philosophy, not to mention financial considerations, the consequences will be predictably disastrous.
Moreover, most seasoned psychiatrists, clinical psychologists, and other mental health professionals recognize, at least to some extent, the inherent dangers of certain archetypal kinds of symptom patterns, as well as the congenital human capacity for evil or destructive behavior toward self or others, and take aggressive steps to mitigate these dangers whenever possible, whether that involves voluntary or involuntary hospitalization, more intensive outpatient treatment, etc. Why did this not happen here?
For instance, in December, 2022, Ms. Clancy eventually sought outpatient psychiatric treatment at the Women and Infants Hospital Center for Women's Behavioral Health, a clinical setting specializing in perinatal and postpartum care and presumably sensitive and highly attuned to women's mental health issues in particular, but was supposedly told there that she was not suffering from postpartum depression, let alone postpartum psychosis. Yet, according to her husband, she expressed suicidal ideation and thoughts of harming her children to him at that time. So, this catastrophic failure of the system is not necessarily about gender, but, rather, about clinical naivete, i.e., the refusal or failure to take seriously the risks of her alarming symptomatology and the potentiality for evil or destructive, violent behavior.
Psychiatry Essential Reads
Denial of the very real human capacity for evil is an exceedingly dangerous defense mechanism in mental health professionals. Failure or refusal to foresee and attempt to prevent the possible worse scenarios or outcomes in such cases, can itself be catastrophic. The unwillingness to acknowledge the patient's human capacity for evil curtails the clinician's ability to intervene aggressively and prophylactically when needed.
Could This Act Have Been Deterred?
Had Clancy been admitted to an intensive treatment program or been urged to continue to attend ongoing psychotherapy sessions, she could have been much more closely monitored for any changes in or exacerbation of her fragile psychiatric condition. Here I concur completely with my colleague Dr. Marlo's point regarding the necessity and benefits of psychodynamic or other more intensive longer-term outpatient therapies in such cases and that being in a more open-ended therapy on at least a weekly basis could have potentially reduced the chances of this appalling crime occurring.
However, having said that, the sad reality is that even when patients suffering from severe and dangerous symptoms such as command hallucinations, paranoid delusions, suicidal or homicidal ideation, and profound depression or anxiety are regularly seeing a psychotherapist or psychiatrist, the outcome is not always good.