The ‘maternal homicide-suicide complex’ may be predicted and prevented. Three D-signals – gory Dreams, Delusional thoughts, Depressive affect – are consistently present beforehand…
MOTHERS WHO MURDER THEIR CHILDREN
three ‘D’-signals that could lead to prevention of this tragedy
1 gory Dreams . 2 Delusional thoughts . 3 Depressive affect
William Hogg MD
In recent years young mothers killing their children have all too frequently grabbed media headlines. People generally are dumbfounded and perplexed by such tragedies. Others are very angered. In the USA there often is legal and public clamor for the death sentence. Most defense lawyers intuit that the perpetrators must be mentally ill. But, little do even doctors know that these child killings may be predicted and possibly headed off.
In the early 1960’s a young woman was taken by police to a huge nearby mental hospital, Toronto’s notorious old 999 Queen Street. It was Christmas-time. Just twenty minutes before, she had slit the throats of her three young children in the bathtub. On examination by both the hospital superintendent and his chief psychiatric resident she was found free of any mental illness. She was returned to the police. The police got what they wanted, less help for the woman than evidence against their prisoner. She was charged with capital murder and taken to the equally notorious Don Jail. The next morning, sitting, wailing, on the concrete floor, she set herself on fire. She was then returned to the hospital where she remained for many months and on through her trial.
A couple of years before, while still a PG student, I helped care for a nurse who had hung her three children from a beam in the basement of their home. This horrifying case prompted me to review the instances of murdering mothers in Toronto and environs in the preceding 60 or so years (from 1900 on).
THE STUDY 
There were twenty-two cases. The charts in every instance were disinterred and each was poured over and meticulously cross-indexed and subjected to a careful statistical frequency analysis for any constantly repeating patterns or common symptoms and signs. No retrospective control group was set up. Incidentally, the case records done at the turn of the century (twentieth) were every bit as detailed as the more recent ones (early 1960s)—if anything, probably better written. It was not possible to get lawyers’ records, but the court proceedings were dug out.
All the women were of an age—around thirty. Many had a pre-tragedy history of what would pass for depression in 2000 or 1900. But, it was not always clear-cut until later, when events were reconstructed. In more recent years some had sought professional help within the preceding couple of months. It was received by a few but some were put off. The women didn’t press for help or understanding. After the fact this was recognized as depressive apathy.
After the murders, attempts had been made to discover their earlier prevailing thoughts. Specifically, these were that “the world is a terrible place, the children would be better off dead.” Several had voiced these ideas to a friend, their spouse, or a doctor, but were not taken seriously and dismissed. Surprisingly, many of the listeners agreed in passing that “life can be miserable.” Later, after the killings, many of the women expressed that they thought that they were “doing them a favor killing them, by helping them out of this cruel world, they wont have to face it.” In long term retrospect this can be recognized as delusional thinking. In only a couple of cases were the children seen by their mothers as monstrous or evil, as Satan, etc. That is, the majority were killed out of an excess of love and concern. These sad women kill the most-loved persons in their lives.
In a significant number of cases the women’s dreams in the weeks before the murders were gory and violent, vividly colored, and were of members of the family getting maimed, dismembered, or killed in terrible accidents. (You must remember that dreams were important to psychiatrists in the first half of the twentieth century!)
Many of the women’s lives, pre-murder, had become progressively pressed and pressured. They felt burdened by too much to do and especially in caring for more than one child, often the youngest being less than a year old. They had all seriously planned to kill themselves right after killing the children, in order to join them, but it virtually never happens right at the time—only much later. (One sad woman I personally knew, a cousin in-law, killed herself five years later while still in mental hospital. During visits she constantly expressed perplexity that she couldn’t kill herself along with her child.)
The women’s actions at the time of the murders are relevant. The murders usually take place in the morning, on a final impulse when no one is around. The children are killed with a homely method, ready to hand: a rope, a hammer or even a hatchet, the butcher knife in the bath—rarely by forcible drowning. The child most likely to run or put up a struggle is done away with first. Thus, the killings are not only gruesome and often bloody but seem brutal and coldly callused. The lives of more than one child are usually taken. Right afterwards there is no attempt to conceal the killings, no attempt to hide, run, or escape custody, no attempt to clean or tidy up. The woman immediately tells someone, anyone. She may wander outside and tell a neighbor, or phone her husband at work, or personally call the police.
By police report and other people’s memory, the women are all lucid and seemingly normal when first seen after the killings. There is no denial, little crying (or what would be expected as part of remorse). Thus, the women are strongly declared as cold-hearted—and normal. Normal at this point! Often they are examined within the hour. They were found free of mental illness, even by specialists. Being declared as “normal,” immediate mental help is rare. They are quickly booked and charged with murder. Within 24 hours, however, most of the women break down with overt illness—psychotic depression—and may belatedly attempt suicide. This suicidal attempt is very serious but bizarre. The time between the killings and this breakdown is a true lucid interval. They were psychotically depressed all along. It is as if the act of killing had temporarily shocked them out of killing themselves too.
There are two lessons to learn, one diagnostic and the other preventive:
First, virtually all of these tragic women are psychotically depressed. They have a lucid interval of normality right after the killings (lasting up to 24 hours) that causes them to be seen as OK by police and doctors. They are jailed rather than hospitalized and, while there, may make a bizarre or very serious suicide attempt. Such may result in hospitalization or some kind of suicide watch in jail. Diagnostically, I call this whole sequence the maternal homicide-suicide complex.
Second, recognition of this complex beforehand can lead to prevention of violence. Most important in this respect are gory dreams and depression before the killings, along with delusional-like wishes that the children be dead and free of life’s tribulations. The two biggest obstacles to prevention are not being aware of the homicide-suicide complex and not taking the woman’s usually vaguely-put intentions seriously. It sounds “just too horrible, and anyway, this nice lady wouldn’t/couldn’t do such a thing.” They could and will! Ask about dreams and if they are gory, preferably hospitalize.
To tie up the case of the woman who cut her children’s throats in the bathtub…
Several months after the killings I was approached by her young defense lawyer (a friend of mine) about his client. She was now fit to stand trial. It was going to be a capital murder trial, his first. (In those days people were hung for less in Canada.) And he had no defense for her. She was declared sane at the time of the killings and both the hospital superintendent and resident, high-level expert witnesses, were subpoenaed to court by the prosecution to testify against her to that effect. (Which they did.) My friend, naturally, had never heard of my incubating notion of a homicide-suicide complex. I explained it to him, particularly the lucid interval, and agreed to help him in court.
I went to the hospital, read her chart, and interviewed her. Amazingly, she had been seen at that very hospital about six weeks before the killings—with depression—given one of the old-fashioned tricyclic antidepressants, and put on a waiting list until after Christmas. In the meantime—tragedy.
Trying very hard not to lead her, I cautiously probed about any recent gory dreams. She had had them and I believed she was being honest. In fact she was not at all avid to help develop any defense. She was now tormented about the fate of her children and didn’t really care all that much about what was happening to her. But she was fit to face the law and stand trial.
In court my lawyer friend asked to be allowed to present the nature of the homicide-suicide complex. The judge, despite the expert witnesses to the contrary, accepted the proposition that she had in fact been quite mad at the time of the killings, and that her apparent normality was a shock-induced “entirely spurious” lucid interval. He responded by declaring her not guilty by virtue of insanity. He sentenced her, as a Lieutenant Governor’s Warrant, to a good forensic hospital from which she was released as ‘well’ in about six month’s time. I don’t know what became of her, but I presume she pursued a life of tormented sadness.
With all the publicity over the years about murdering mothers, even though no one seemed to be making knowledgeable comments over TV, I still could hardly believe that some knowledge of the homicide-suicide complex, as I understood it, did not exist. Therefore, an abbreviated review of the general psychiatric and criminology literature was done in December 2003. Textbooks old and new were perused for references to the keywords homicide, murder and suicide in connection with depressed mothers killing their children.
Conklin’s textbook of Criminology made no reference to murdering mothers. Two older British psychiatric textbooks, Clinical Psychiatry, by W. Mayer-Gross, and Guide to Psychiatry, by Myre Sim, confined all references to homicide to a section on legalities and the McNaghten Rule of evidence. Henderson and Gillespie’s Textbook of Psychiatry, also British, made no reference to homicide. Nor do the American texts by Gregory (Biological and Social Psychiatry) and by Noyes and Kolb (Modern Clinical Psychiatry). Freedman and Kaplan’s old Modern Synopsis of Psychiatry, now out of print, barely mentions suicide in depression let alone homicide; homicide in general was linked with schizophrenia, not depression. Their Comprehensive Textbook of Psychiatry goes no further. The multi-volume American Handbook of Psychiatry does not list homicide in its index. A loose-leafed, constantly updated American textbook, Psychiatry, had nine lines on “obsessions of infanticide” in connection with postpartum depression. No connection between child homicide and maternal depression and suicide was found in the American Psychiatric Association’s Diagnostic and Statistical Manual, DSM-1V-TR.
Thus, in all the major American and British textbooks of psychiatry and one book on criminology no mention was made of predictable maternal child homicide and personal suicide. This was supported by a selective tour of the internet on December 11, 2003. Apparently, no one else has observed and documented the maternal homicide-suicide complex. (I probably should have published this article while still in PG work.)
Three more case examples
I think, but will never really know, that I have personally prevented at least five of these tragedies in some fifty years of practice. Here are three representative cases:
A 1966 case: One of the four children of a 31 year old mother was referred by the school to the public health Children’s Clinic for treatment of a behavior disorder. The mother, who attended alone without her husband, was harried and clinically depressed. She had recently had her last child. On direct questioning she acknowledged repetitive and frightening dreams in which her family was mutilated in a car accident. She volunteered that life was unrewarding, she felt trapped, and “what with all the turmoil now in the world the children would be better off dead too.” These were offhand, inappropriately bland, remarks. She was not intense or tearful. However, with obvious relief, she readily accepted the idea of hospitalization, where she spent the next three months. In the meantime the original child patient was also treated. The family was followed intermittently for the next five years. All continued well.
That was the first case I encountered in practice. It had a ring of the documented Toronto murdering mothers. But being unsure, I placed her in hospital as simply suicidal and looked after her myself. She later confided in clear words that she had been planning to kill her children and then herself.
A 1975 case with unexpected tragic outcome: A 29 year old profoundly depressed and agitated mother of three young children was brought to my general medical practice office by her sister with whom she was staying. This was the first and only time she was seen by me. She was unkempt, disheveled, unwashed and withdrawn. The patient’s husband had recently abandoned the family. She now fantasized and dreamed of his gory death and mumbled to the effect that the children and herself would be better off that way too. There was “nothing left in life.” The head of a regional psychiatric unit was contacted by phone and referral for emergency admission was reluctantly accepted. The patient was promptly certified and sent off immediately, 20 miles by ambulance. A few days later she hung herself from a toilet stall on the ward. The children were subsequently made Crown wards and placed in separate foster homes.
This was the first in-house suicide of a fairly new psychiatric unit. I was not on its staff. At the inquest, to which I was not invited, I was publicly chastised for not getting the patient to hospital early enough! When I read this in the newspaper, I protested to both the paper and the coroner. The paper retracted and the coroner promised to correct his report. The reason this is mentioned is to warn people who predict something horrible—that comes to pass. Be prepared to be vilified and also assertively defend yourself.
A 1990 case: An elderly and tired patient anxiously reported that her 35 year old daughter had become very depressed after the birth of her first baby. She was disorganized at home. She was unsettling both grandparents with hints of killing herself and the baby. She thought the baby boy was Satan and refused to feed or care for it. The author paid an unsolicited emergency home visit during which the new mother confirmed what her mother had said and further revealed recent gruesome and dismembering dreams involving her husband (a distant man, preoccupied with his business). The patient was considered suicidally depressed and potentially homicidal. The options were firmly pointed out to all: Children’s Aid protection for the baby and hospitalization for the mother or a 24 hour home suicide watch by the husband while the grandparents temporarily took the baby to their home. Given this Hobson’s choice, the latter alternative was taken. (Amazingly, there was no resentment over this arbitrary approach. In fact, the whole family was extremely grateful.) The patient was placed on antidepressant medication. Crisis oriented individual therapy was provided every second day along with weekly and ad hoc extended family therapy sessions at home (including grandparents at first as well as husband). In less than a month the mother was free of delusions and depression and able to begin, with help, some of the care of the baby. She had no more children. Over the next 10 years this mother became both doting and competent, ably conferring with pediatricians and teachers, etc., about a very gifted and active son, “who I almost killed … were it not for you (helping me).”
This was the last case I saw before retiring. Politically engendered cost restraints on hospitals had long since resulted in a policy of very early discharge. Hospitals were no longer a protective haven for psychiatric patients. More innovative home treatment was called for. This sort of management, once started however, requires that the doctor be on 24 hour call, just in case. If a case comes up just before vacation time, the risk of hospitalization and a dangerous early discharge by an uninformed or skeptical alternate doctor, must be weighed against canceling or postponing the vacation.
the most important findings in the maternal homicide-suicide complex are:
1. Before the murders there is prior depression with delusional thoughts and vivid and grim or gory dreams. This 3-D triad of signals—Depression, Delusions, Dreams—is pathognomonic of the maternal homicide-suicide complex. Its recognition is predictive and, if acted upon by the alert clinician, potentially preventive of the children’s homicide.
2. The killings of the most-loved ones are brutal. A handy, homely method is used. It all seems coldly planned and ruthlessly executed. (Police will lock onto these things in order to get a conviction.) But there is no attempt to escape or cover up. In the mother’s demented mind, the children are genuinely loved; these are mercy killings to her at the time.
3. A lucid interval, lasting some 24 hours, begins immediately after the killings. It thwarts a serious plan to kill her own self too. I surmise that the act of killing literally ‘shocks’ the woman out of depression into temporary ‘normality.’ Experienced psychiatrists are fooled. The woman may be jailed instead of hospitalized during this interval. (The notion of a lucid interval appeals to judges and may enable an ‘insane at the time’ type of determination.)
4. The depression returns, usually the next day. It is overtly much more severe than that preceding the killings for obvious reasons—silent grief over the deed, sudden realization of the horror. Suicidal propensity may come and go for many years.
5. While too late for the children, a late correct diagnosis of the homicide-suicide complex is better than nothing. It may help in the woman’s legal defense.
The homicide-suicide complex and its predictive 3-D triad might be added to the forensic psychiatric lexicon. All depressed young mothers between 25 and 35, harried and with several young children, should be asked about recent gory dreams involving any loved ones, family or friends, and about delusional thoughts to the effect that it would be merciful if the children were dead. These dreams and thoughts must be very carefully elicited, avoiding any prompting or suggestion; they likely wont be volunteered. If the 3-D triad is present it is very serious and portentous. The family needs to be informed and the children protected, or the woman hospitalized. Saving the children by killing them is her major delusional obsession; she wants to suicide right after—“to join them”—but usually cannot, until long after.
I do not see how evidence-based clinical research could ever be carried out on mothers with postpartum depression displaying the 3-D triad. The tough question is: How could a clinician with any conscience ever set up a double-blind controlled study? Epidemiological research through public health units is, however, possible.
The great mass of human beings are not acutely selfish. After the age of about thirty they abandon individual ambition—in many cases, indeed, they almost abandon the sense of being individuals at all—and live chiefly for others, or are simply smothered under drudgery. But there is also the minority of gifted, willful people who are determined to live their own lives to the end… George Orwell. Why I Write (1961), Collected Essays.
 Nowadays and for many years, LGW’s in Ontario rarely ever get released. Despite fancy review boards, no one wants to assume risk, and a patient can remain locked up interminably. In the mid eighties, after twenty years of incarceration, even though healthy and with grounds privileges for fifteen of them, a patient in a final act of desperation committed suicide by hanging from a tree limb in the hospital park.