Dawn’s nursing notes reflected her own continued apprehension: “Patient reports that son and mother-in-law were here for visiting hours. Patient reports that she had homicidal feelings toward her son. Reports voices were telling her to see what it would feel like to stab him. Reports she couldn’t wait for the visit to end. This writer suggested patient tell her mother-in-law not to visit with the son. The patient watched football the rest of the afternoon.”
I sat down and talked with Anna again. “I’d like to talk some more about exactly what you’re seeing and hearing when you have these thoughts,” I told her. She nervously nodded her assent. For the first two days, I had treated Anna’s symptoms somewhat as I would have treated a trauma victim’s flashbacks. The prevailing psychological theories in trauma treatment historically endorsed repeated and detailed retelling of the trauma story by the victim, with the thought that the repetition would dilute the potency of the experience and eventually bring peace and healing. More recently (due in part to research that was conducted in the aftermath of the September 11 terrorist attacks), we have come to understand that retelling the story in a detailed way may in fact be akin to reexperiencing—and thereby deepening the damaging effect of—the trauma. Because I had understood how distressing it was for Anna to experience these visions and suggestions, I had resisted asking her to go over them with me again in detail. Yet Anna’s symptoms had not improved in the slightest, despite the fact that I had been giving her an antipsychotic medication for two days now. I was starting to worry that I was missing something.
“Well,” she began, “it’s almost always the same. I’m doing something normal, like laundry or brushing my teeth, and all of a sudden I see this horrible sequence, like a movie in my mind. I’m hurting my son. I . . . I . . . I kill him, either with a knife or by holding him underwater. I never see myself in that moment, only his body and what I’ve done to it. While I see this, there’s a voice—almost like a voice-over—saying, ‘Try it. Try it. Just see what it feels like.’”
“Then what happens?” I asked.
“Then I see myself bending over his body, so sad at what I’ve done.” She grew quiet. “It’s so awful to talk about. It’s like I’m a monster.”
“Is there ever anything after that?” I asked.
“Sometimes,” she replied. I stayed silent to allow her to continue. “Sometimes I see myself in jail because of what I’ve done.”
“Do you ever actually think that you are doing it?” I asked her. “Are you ever unsure as to whether what you’re seeing is happening or whether it’s only in your mind?”
“Oh, I know it’s in my mind,” Anna replied. “I’m just so scared that one day my mind will overpower my heart, you know? And that I’ll act out this film that has played in my head over and over again.”
“How often does it play?” I asked.
“I don’t know.” She paused to think. “Maybe once an hour. Maybe more. It’s been happening less since I’ve been in here, but when I’m around my son, it’s going all the time.”
As Anna was describing this personalized horror film looping endlessly in her mind, I began wondering whether these were true visions and voices in the form of command hallucinations or whether they were in fact obsessive thoughts. The difference is a critical one. Obsessions are involuntary, upsetting, persistent thoughts that cannot be reasoned away. Hallucinations are false sensory perceptions. In other words, was she imagining this scenario over and over or was she actually, physically seeing it?
This was not an issue of mere semantics; my working diagnosis would dictate Anna’s treatment, a course of action that, if I were wrong, could have catastrophic consequences. My two potential categories of diagnosis—psychotic versus obsessive-compulsive—called for opposite forms of treatment. If Anna was indeed having command hallucinations to kill her child, the risk that she could fall into Resnick’s category of psychotic filicide was a real one, and she should be kept away from her child in order to keep him safe. If, however, this troubling film in her mind was obsessive and not psychotic, then the treatment would call for her to spend more time with her son in increasingly distressing and anxiety-provoking settings. This would allow her to see that she would not harm him, no matter how strong her fears of doing so might be.
There were risks associated with either course of action. If I wrongly diagnosed Anna as psychotic and made her visits with her son fewer, further between, and more heavily supervised, I would be reinforcing her belief that she could not safely spend time with him. I would also rob Anna’s son of a critical relationship with a mother who was loving, albeit afraid. If, however, I incorrectly diagnosed Anna as obsessive and implemented a treatment plan in which she would spend unsupervised time with her son, I could be placing this much-loved toddler in a position of real peril.
• • •
My own daughter is seven weeks old when I first take her to our family’s Michigan lake cottage. She is a lovely pudge of a baby with a few soft threads of hair, deep cobalt eyes, and a new smile that thrills me whenever it breaks across her face. The May lake is freezing cold, and Deborah and I are wearing jeans and sweaters. But I (who always leap from the car and run down the dock every time I arrive and lift the clear water to my lips the very last moment right before I leave) am determined to introduce my baby to the lake and it to her.
I put her in shorts and a little shirt, slip my hands beneath her armpits, and dip her tiny toes into the green water. A kind of baptism. Her face grows stern and perplexed, as if to ask, What is this sudden shock of chill? She pulls her thick, bowed legs up to her belly. I dip her again, then once more, all the while singing gleeful nonsense to her. Smiling broadly, Deborah snaps pictures. Half a moment later, our baby girl threatens to cry, and I concede, cradling her to me and pulling the base of my sweater up around her diapered bottom, her blanched and dripping legs.
That evening my mother pulls the cover off the old motorboat and we decide to take a sunset ride. I swaddle our baby in a beach towel. As I step into the boat with her in my arms, my father holds tight to my elbow, protective, steadying us until I sit down on the bench seat in the bow. My mother walks the boat out to a depth where we can start it without having the prop dig in the sand. Evening’s slant of light turns the lake’s surface reflective—a metallic, mirrored gray. If I lean a bit over the boat’s edge, my head and shoulders cast a shadow that lets me peer into the water, its clarity giving an unobscured view of the sandy lake bottom with its occasional rock, clamshell, furrowed path left by a freshwater snail.
Eventually my mother clambers aboard, revs the motor, and buzzes us around the lake’s periphery. With the engine’s hum, our baby sleeps soundly; the warmth of her little body against me seeps across my abdomen—the place where she has so recently been inside. In the big end of the lake, the sun begins to dip beneath the tree line, and my mother cuts the motor. We drift to a stop. The water beneath the boat is more than two hundred feet deep, and so even in brightest daytime it is dark and bottomless-appearing. In this half-light of dusk, the water is impenetrably black.
I stand up in the boat’s gently rocking bow to take it all in—the quiet, the soft breeze, the sky beginning to burst into a reckless orange glow. As I do, a flash. No other way to describe it. A sure knowledge that if I were to drop my baby overboard, she would sink like a stone and be gone. Fear rises in me, a heartbeat pounding in my throat as I clutch her to me and sit back down. Still, the uncertainty will not relent. Can I keep this small being safe? Can I hold her tightly enough to thwart the peril just beyond the boat’s edge? The world; this holy lake; we parents and grandparents of this child, capable swimmers who would instinctively risk our own lives to save her—suddenly none of it steadies or offers protection. There are only my untrustworthy arms, this fragile infant, and these encircling, fathomless depths.
The image of her falling from me is not a wish or an intent. It is a fear. But the fea
r is such a terrible one that it feels as though thinking it might make it so. Between the thought (I could drop my baby overboard) and the rational, instinctive reassurance (But she is safe, and I would never do that) must be a sliver of a second. What if, during that split second, some motor impulse were to act on the fearsome thought? Some senseless, wild, physical reflex of obedience—unmanaged by reason or love?
I am not by nature an anxious soul. Beyond a ride or two in careening airplanes or the moments in which I received news of serious diagnoses in loved ones, I have never before felt this degree of unremitting fear that makes me tremble, unable to breathe adequately. Never from just a thought, never without real, justifiable external cause. Never since. Back on land, the moment passes. It never returns with that degree of intensity, but similar scenarios resurrect the fear, even if its return is more muted. On a ferry ride from Vancouver to Nanaimo when our daughter is nearly one, I hold her close to me as we look over the rail at the vast expanse of mountains and sea. My heart skips, and I have to step back five feet, then ten from the railing. A year and a half later: At the height of the London Eye, safely encapsulated in our glassy pod, I hold our six-month-old son snugly in a sling. As the space opens beneath our feet, again the catastrophic—and impossible—flash that I might drop him.
• • •
Thinking about Anna, I felt the memories of these thoughts resurface. I remembered the boat’s edge, the glint of evening on the black lake, and I remembered having felt the steep pitch of fear. But as I remembered those moments, I felt only reflective. Analytical. Calm and secure. I did not feel the fear. I only recalled it.
I wonder whether the difference in these situations between someone like me, who happens to be wired on the less nervous side of things, and someone like Anna, who had told me that she had been an anxious person well before she was a mother, is attributable in large part to the persistence of the fear. I was rattled—deeply, but briefly—by isolated thoughts that I could be responsible for the deaths of my children. Anna’s violent thoughts might have been of this exact nature. Worst-case imaginings. Devastating what-ifs. And yet, unlike mine, her mind held fast to what was meant to be fleeting. She was unable to let the images go. She became haunted by the thoughts, reliving not only their content but also the terror they fueled. Anna began to believe that she was bound to carry them out if she were not somehow prevented from doing so.
It was not a coincidence that some of my most anxious moments occurred when I was a new mother. In a blog piece for Scientific American, the primatologist Eric Michael Johnson points out that the stress hormone cortisol increases in animals (humans included) during pregnancy and in the postpartum period. This underscores what any parent knows: that new motherhood is a stressful time. But it also means that our bodies are operating at a heightened level of vigilance. Johnson argues that increased anxiety in mothers is evolutionarily beneficial. “Natural selection,” he explains, “has provided mothers with an early warning system, one that can alert them to danger before others are even aware of the risk.”
Whether it was cortisol, or breast-feeding, or any number of other aspects of my physical and hormonal tumult, there is no question in my mind that I have never felt more like an animal than I did in my early postpartum days. I wanted to comfort my infant daughter so fully that her cry was physically painful to me. The smallest signal of her unease would send me rising from much-needed sleep, hoisting my birth-wounded body out of bed and lifting her to me to nurse. Going to her was arduous, but it was nothing compared to the discomfort I felt from her small cry.
The eeriest and most powerful example of primitive postpartum instincts I have ever observed came from Deborah, a mere eight hours after she delivered our son. Worn out from nineteen hours of labor without a wink of sleep, Deborah was finally sleeping soundly in the hospital bed. I was napping fitfully on an awkward recliner beside her when her voice awakened me.
“Christine!” she called urgently. Still primed from the excitement and fear and helplessness of Deborah’s labor, I felt a surge of adrenaline rush through my body. I leaped up to her, catastrophizing. Was she bleeding? Was she in pain? Was she safe? “That’s our son,” she said.
“What?” I asked, confused. Our baby boy had been taken to the nursery for routine testing more than an hour earlier. I had no idea what she meant.
“That’s him. He’s crying. Can you go to him?” Faintly, above the hum of the fan in our window, I heard a baby’s cry.
“Sweetheart,” I said, “get some sleep. There are a million babies on this floor. Half of them are in the nursery. I’m sure it’s not our baby.”
And here she grew more urgent—angry, even. “It’s our son,” she insisted. Her tired eyes brimmed with tears. She could not yet get out of bed as her body recovered from the delivery. “Go to him.” As any nonbirthing parent will likely understand, when my partner had endured hours of pain and the associated rigors of childbirth to bring us a child, I would have been inclined to do anything she asked of me. Still, as I padded down the long hallway to the nursery, I thought that this request—and the prospect that Deborah had identified the distant cry as our child’s—was ridiculous. After all, our son had cried for a minute at most when he was born. In the subsequent hours in which we held him, wept over him, kissed every centimeter of his perfect form, we had heard nothing more from him than sleepy snuffles.
As I approached the nursery, the cry grew louder but still, to my ear, no less indistinct. I knocked on the door and entered, only to find a swaying nurse shushing our wailing son, who was protesting mightily after his heel had been pricked for a bilirubin test.
I took him from the nurse, swaddled him, and sang to him, and he settled. I wheeled his little plastic bassinet over to our room, where Deborah had fallen back asleep. I held our boy and sat down on her bedside, nudging her awake.
“You won’t believe this!” I crowed. “It was our son crying!”
She looked at me with incredulity. “That’s what I told you,” she said, reaching out to pull our baby toward her, and then, with him in the crook of her arm, sighed back into sleep.
• • •
If Anna’s thoughts were true obsessions, she was unlikely to harm her son. However, like many psychiatric symptoms, the manifestations of anxiety run a broad spectrum. And one of the things we do understand about mothers who kill their children is that before the murders they are often subjected to enormous amounts of stress.
According to Eric Michael Johnson, this effect may be demonstrated in part in nonhuman primates. He cites research by Dario Maestripieri on macaque monkeys. Maestripieri has shown that the increased cortisol levels in pregnancy are “directly related to protective behaviors that keep a mother’s infant from harm,” like when I rose from sleep to feed our hungry daughter or when Deborah sent me off to rescue our son from his blood test. Mothers who are vigilant about their infants’ risks and needs are more apt to have offspring that survive, thereby promoting this alertness via natural selection.
However, just as too little maternal cortisol might leave an infant in peril, too much maternal cortisol—brought about by prolonged periods of stress—carries with it its own dangers. Maestripieri explains, “A large body of evidence indicates that extremely high or chronically elevated cortisol levels due to stress can impair maternal motivation and result in maladaptive parenting behavior.” That is, mothers under too much strain may have difficulty as parents. Among Maestripieri’s macaques, mothers were sometimes noted to abuse their infants. Those episodes of abuse frequently followed periods of maternal social stress.
In her enthralling book Mother Nature, the anthropologist Sarah Blaffer Hrdy meticulously demonstrates that in many species—including humans—mothers kill their children much more routinely than we might imagine. Blaffer Hrdy suggests that animal mothers may eliminate their offspring in direct response to biological and social circumstances. There is, she wri
tes, plentiful biological evidence that mother “beetles, spiders, fish, birds, mice, ground squirrels, prairie dogs, wolves, bears, lions, tigers, hippopotami, and wild dogs [in] a range of conditions . . . cull their litters and abandon or cannibalize young.”
We may be able to follow—and perhaps even accept—the grim logic by which a mother bird allows an older sibling to nudge a weaker, younger fledgling out of the nest to eliminate competition for food or by which a California mouse kills its pups if it finds itself without a mate to help raise them. Still, even if we accept the logic of survival in those examples, it is difficult if not impossible for most of us to consider human mothers as capable of any similar action. And yet they are.
In his piece for Scientific American, Eric Michael Johnson raises this question: Since humans can consciously decide between right and wrong and can “design political systems that protect the least among us,” shouldn’t humans be better at protecting our children from maternal infanticide than, for example, “our distant monkey cousins”?
“The answer to this couldn’t be more clear,” Johnson writes. In fact, “humans are very different [from our monkey cousins]. . . . We’re much worse.” Blaffer Hrdy concurs. As it turns out, our human infanticidal actions are not unique among animals, but they are unique among primates. Infanticide “is widely documented among primates, both human and nonhuman,” she writes in Mother Nature. “But in other primates, the killer is almost always an unrelated individual, never the mother. Even when nonhuman primate females are implicated in infanticide, mothers don’t harm their own infants, they kill someone else’s. Only under the direst circumstances does a mother cease to care for her infant or actually abandon it. . . . It is not that unusual for a mother monkey to treat her baby roughly, to briefly drag it, or even punish it with a slap or threaten it with a toothy grimace—especially when she is trying to wean. But no wild monkey or ape mother has ever been observed to deliberately harm her own baby.”
Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis Page 16