This is Part 3 of a series on the controversial Lindsay Clancy case. Read Part 2 here.
The crucial question of whether Lindsay Clancy was or was not psychotic at the time of the crime was central to the recent mistrial. Apparently, 11 of the 12 jurors were convinced that she lacked criminal responsibility for her actions. But was this because they believed Clancy had been suffering from postpartum psychosis or only severe postpartum depression?
One of the primary problems with the differential diagnosis and conveying it to the jurors is related to the still extremely poor understanding, both in psychiatry and psychology and the general public, of the fundamental nature of psychosis. What is psychosis? What causes it? What is its significance? And who is really at risk for developing it?
What Is Psychosis?
Psychosis is a very broad category of mental disorder with a relatively vague definition. But most mental health professionals today would agree that psychosis basically consists of the presence of hallucinations and/or delusions, usually marked impairment that grossly interferes with social, occupational, or day-to-day functioning, and deficient “reality testing” or a so-called “break with reality.” Schizophrenia, which appears in approximately 0.5 percent to 1.5 percent of the population across cultures, is one classic form of psychosis. But there are several other kinds of psychotic disorders specified in the DSM 5-TR, including unspecified schizophrenia spectrum and other psychotic disorders, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, delusional disorder, shared psychotic disorder, substance-induced psychotic disorder, and psychotic disorder due to a general medical condition. In addition, psychosis may be experienced by sufferers of severe major depressive disorder, bipolar disorder, or borderline, paranoid, and schizotypal personality disorder when under stress. And although psychotic disorders such as schizophrenia are chronically debilitating, some, like delusional disorder, are less so as regards daily functioning. By definition, psychosis usually involves impaired insight, reality testing, and judgment, which is what makes it so crucial in lack of criminal responsibility or insanity defenses.
Conceptualizing Psychosis
Most psychiatrists and clinical psychologists today take an almost exclusively biological, medicalized view of psychosis, believing it to be a “broken brain” disease. A “mental illness.” A genetically inherited neurobiological abnormality. A fundamentally physiological phenomenon. But this is merely one still unproven theory of psychosis. Indeed, there may be somewhat different etiologies for different psychotic disorders, different courses of the illness, and different prognoses. The statistical fact is that multiple studies of identical twins have shown concordance rates (meaning the probability that both monozygotic twins will be schizophrenic) ranging from around 35 percent to 70 percent, indicating a significant (average of about 50 percent) but only partial, not total (or 100 percent), genetic basis for psychosis.
In my book Anger, Madness, and the Daimonic (1996), I present some alternative ways of conceptualizing psychosis (what we historically call madness) and discuss its close connection to repressed anger or rage in particular, and, more generally, a long-standing repression, dissociation, or denial of the daimonic (see May, 1969; Diamond, 1996, 2026). For example, the relatively rare phenomenon known as folie à deux, shared psychotic disorder, or induced delusional disorder in which one dependent person adopts the psychotic worldview of another more dominant individual, clearly illustrates the psychological rather than neurobiological causes of psychosis in certain cases. (Indeed, some studies have shown that schizophrenic patients have a significantly higher history of childhood trauma than the general population, which begs the question of whether their illness could be trauma-based.)
Another way of conceptualizing psychosis is that it is a stress-induced existential crisis involving an acute distortion of reality due to finding consensual reality as it is unacceptable or intolerable. (This linkage of psychosis with stress is supported by the classic diathesis-stress model, which posits an interaction between genetic predisposition and environmental stressors.) Psychosis can also be seen at least partly as an elaborately constructed and carefully maintained unconscious psychological defense mechanism guarding against intimacy and fending off existential reality so as to avoid being abandoned, rejected, disappointed, or otherwise retraumatized.
How one conceptualizes psychosis, or any other mental disorder, dictates and informs how we go about trying to treat that condition. (Only a few centuries ago, psychosis, madness, or insanity was believed to be caused by demonic possession, for which exorcism was considered the only remedy, and there are still those today who believe themselves to be possessed and seek out exorcism when conventional psychiatric treatment seems insufficient.) How we conceptualize psychosis also affects the capacity to understand the risks or vulnerabilities in particular individuals for becoming psychotic at some point in their lives. (For example, consider the DSM-5-TR proposed diagnosis of attenuated psychosis syndrome, previously psychosis risk syndrome in DSM-5, a condition defined by the presence of mild psychotic-like symptoms with relatively intact reality testing that, while not severe enough to be diagnosed as psychosis, can, in 15 percent to 35 percent of cases, be prodromal to developing a true psychotic disorder within several years.)
Indeed, even the great psychiatrist C.G. Jung, a pioneer in the psychotherapeutic treatment of psychosis, seems to have experienced some psychotic symptoms triggered by the psychosocial stressors of being excommunicated by Freud and the Freudians, precipitating a profound midlife crisis persisting for more than a decade. He conceptualized and characterized his own personal experience (Jung, 1961, 2009) as an encounter or “confrontation with the unconscious,” which he courageously and consciously elected to submit to, deeply explore, and document, and, as a result, was eventually transformed by this terrifying experience. (See my prior post.) Indeed, much of what he later came to call “analytical psychology” derived from this extraordinary, prolonged, perilous, and disorienting inner odyssey. Thus, from a Jungian perspective, psychosis is the consequence of being inundated, overwhelmed, overrun, or possessed by the unconscious and its complexes and, as a result, becoming confused between inner and outer reality.
Having said all that, I submit that no one, even the most “normal” person, is completely immune to experiencing psychosis or, at least, psychotic symptoms. Psychosis is a deeply disturbing and distressing state of mind that any of us can succumb to under the right or wrong circumstances. I understand that this is both a controversial and frightening assertion. We prefer to think of psychosis as something that happens only to other less fortunate, genetically vulnerable individuals. But this is not true. And if, as I suggest, we all possess the congenital capacity or potentiality for psychosis, transitory or otherwise, i.e., if psychosis is an archetypal human experience, would this indicate that we all carry within us the genetic predisposition for it? Is psychosis rooted in what Jung (1961) called an “archetype,” an “inherited structure of the psyche,” a pre-existing, innate, potential form or pattern of human behavior or experience present in every person?
Psychosis Essential Reads
Conclusion
Did Lindsay Clancy truly suffer from postpartum psychosis or merely severe postpartum depression without psychotic symptoms, both of which are triggered or exacerbated by the biopsychosocial stressors of giving birth? Was the defendant really experiencing auditory command hallucinations and paranoid delusions of thought broadcasting at or just prior to the commission of the crime? If so, she was, by any definition, psychotic and, in the eyes of the law, not sane or responsible. Or, more cynically, could Ms. Clancy have been malingering (something that occurs in an estimated 8 percent to 21 percent of forensic cases such as this) by intentionally mentioning those symptoms, perhaps drawing upon her professional experience as a registered labor and delivery nurse to manipulate others into believing she was psychotic at that time? On that key question, the jury is still out.
