Tag: psychiatry

PsychiatryPsychologySexual Abuse

Psychiatry: Religion, Power, and Sexual Assault

on June 15, 2022

Religious communities are one of many places which provide people a sense of belonging. Connecting with fellow congregants with like-minded beliefs brings comfort and safety. However, religious institutions are not exempt from exploiting, coercing, and manipulating devotees into unsavory demands. Experts.com Member and Psychiatry Expert, Dr. Mark I. Levy, MD, DLFAPA, shares insight about abuse, power, and institutional betrayal within religious groups.

Although abuse occurs in every religious institution and denomination, the most recent scandal involves the Southern Baptist Convention. According to AP News, the Southern Baptist Convention’s Executive Committee, along with other high-profile members, currently have a chance to acknowledge a scathing report regarding their lack of action toward allegations of sexual assault. For over two decades, survivors and involved members of the church received unsatisfactory responses to abuse, which included, “resistance, stonewalling, and even outright hostility from some within EC.” An investigation has been conducted and a report was released on Sunday, May 22nd, 2022.

After seven months, a lengthy 400-page report has now been published. It mentioned, “for many years, a few senior EC leaders, along with outside counsel, largely controlled the EC’s response to these reports of abuse…and were singularly focused on avoiding liability for the SBC.” This list was made public days after the investigative report’s release, which was the SBC’s effort to encourage national churches to be “proactive” in defending the vulnerable (FOX News). Ed Litton, Southern Baptist Convention’s President, stated he was “grieved to my core” for the survivors and urged churchgoers to “prepare to change the denomination’s culture and implement reforms,” (AP News). He also vowed to address the failures and the report’s findings during their 2022 national meeting in Anaheim, California on June 14th and 15th, 2022. While the body of the Convention will meet in Anaheim, several high-ranking Executive Committee members will not be attending, as they have relinquished their roles in the church.

The Southern Baptist Convention is not the only denomination to be accused or charged with sexual assault. A recent study by the University of Alberta was released in 2019 detailing patterns of sexual assault in religious and ideological groups. This includes the Catholic Church, Protestants, the Branch Davidians, Fundamentalist Latter-Day Saints, Hindu ashrams, and various cults. Along with academic studies, documentaries such as Leah Remini: Scientology and the Aftermath (Netflix), The Vow (HBO Max), and Keep Sweet: Pray and Obey (Netflix) also expose the coercive abuse that occurs in these groups.

Experts.com Member, Dr. Mark I. Levy, MD, DLFAPA, provides his contributions on the matter. When asked about grooming minors and sexual assault against adults within religious groups, Dr. Levy presents a thought-provoking paradox. He states:

“When humans identify with codes of ethics, which all religions espouse, they put themselves at risk of their own fallible humanity. In general, there’s always this perceived idealization of the role of the person in a morally heightened position and the fact that life is imperfect.”

The discrepancy between the revered status of religious leaders, along with the virtuous sermons they preach, and the egregiously immoral acts committed, is the shock value associated with deplorable situations like the ongoing Southern Baptist Convention scandal. Sexual assault and rape are heinous crimes altogether, but the inconsistency also explains why religious sexual assault contentions make more news headlines than workplace, university, or random abuse cases.

Dr. Levy provides four reasons why sexual abuse continues in religious groups:

  • Authority: The sexual abuse against minors and adults in religious environments has more of an emphasis on a person’s position of authority rather than the ideology itself. “Authority is a critical component to this because a person has to be in a role of trust and respect, which increases the chance of being able to abuse minors. It disarms them when the person is recognized as the leader because they are more prone to trust and believe them.” In communities like churches, repeat abusers in authoritative roles are not quick and brash in pursuing their ulterior motives. Due to their constant access to believers, they meticulously and strategically develop a seemingly benign relationship with their victims to ultimately exploit them at a given opportunity.
  • Power: If authority is the vehicle for abusers, then power, granted by their authority, is the fuel that perpetuates these atrocities. “Sexual abuse is always about power. Sexual abuse of children, which clearly uses that, is also about the sexual gratification of the adult abuser’s needs. They’re peculiar because the sexual interest is focused on minors because of the abuser’s own psychopathology.” Defenders may say it is justified by culture, tradition, and love, but it is illegal under the law because children are not mature enough to give consent.
  • Structure of the Group: “There are particular problems with institutions dominated by men, which are virtually all major religions. One wonders if the leaders of the Catholic Church were female…, whether there would be the same sexual abuse scandal.” This is not to say that women cannot abuse others. However, sometimes the camaraderie within fraternal groups is based on a “boys will be boys” mentality, which tends to excuse abusive behaviors and disregard the damage done to victims.
  • Structure of Belief System: “I think that sometimes within religious belief systems where sin is a prominent concept and confession of sins leads to forgiveness, the psychological damage done, and not to mention the legality of the sin, is often overlooked because it is forgiven in a religious concept.” To reverse this, victims subject themselves to acts they would not do otherwise to avoid sin, reach salvation, or to meet the expectations of the congregation. When church leaders manipulate ideology for their own selfish satisfaction, they violate their congregant’s spiritual, moral, and physical vulnerabilities.

As stated above, offenders in authoritative positions like priests or teachers are typically repeating abusers. Repeat abusers generally commit certain behaviors that allude to deviant motives. Specifically, regarding the adult sexual assault of minors, Dr. Levy has named a few warning signs that can potentially mitigate further abusive situations when identified. These include solely befriending single moms, children having an “adult friend,” overstepping boundaries (children sitting on laps or being invited out to dinner alone), and becoming an “adopted uncle” of the family. Some of these behaviors may not directly indicate the person is an abuser, but all four certainly pose a concern.

If you or someone you know needs support, call 1-800-656-4673 or visit https://www.rainn.org/resources.

Criminal JusticeExpert WitnessForensic PsychiatryUncategorized

Coerced Suicide: Forensic Psychiatry Expert Witness Details Murder by Proxy

on November 5, 2019

Last week the news exploded with the story of Alexander Urtula’s suicide. The story garnered attention because of the allegedly outrageous actions of Mr. Urtula’s ex-girlfriend, Inyoung You, who is accused of psychologically manipulating Urtula and pushing him to kill himself.

Reports from the Boston Globe outlined the accusations against Inyoung You, a 21-year old former Boston College student and South Korean national, who badgered her ex-boyfriend into committing suicide.

In an editorial article calling for a coerced-suicide law in Massachusetts, the Boston Globe stated “According to prosecutors, You psychologically and physically abused her boyfriend, Alexander Urtula, over an 18-month relationship, and repeatedly urged him to kill himself. The two exchanged 75,000 text messages, which Suffolk County District Attorney Rachael Rollins said showed You’s ‘complete and total control over Mr. Urtula both mentally and emotionally.’”

Readers may recall a similar incident, out of Massachusetts, which made headlines back in 2017 when Michelle Carter was tried for involuntary manslaughter for the death of her boyfriend, Conrad Roy. You can read more about that case in this Washington Post piece.

These two cases from the same state, with strikingly similar fact patterns, ending in the suicide death of two young men has made the state consider a law about coerced-suicide. An issue, I might add, my lay mind never would have considered necessary.

The reason Massachusetts is considered a coerced-suicide law is pretty straight-forward. Michelle Carter was prosecuted and convicted of involuntary manslaughter. Inyoung You, is now being charged with the same crime. However, the punishment for involuntary manslaughter in Massachusetts, carries a punishment of up to 20 years. Whereas a proposed law, Conrad’s Law (named after Michelle Carter’s victim), would make punishment for coerced-suicide a 5 year maximum sentence.

To me this makes sense. If you do not actually cause the death (i.e. pull the trigger or pilot the automobile) then you should not face the same criminal liability as someone who did cause loss of life. With that said, you need to be punished for being a truly terrible person and manipulating someone to take their own life.

Now, I do have difficulty with words being used to convict someone of a crime. The ACLU had difficulty with this too when they criticized the Michelle Carter case. They felt it would chill free speech. I understand that concern, so I needed to dig into the psychological manipulation and coercion aspect a bit deeper.

Lucky for me, I have access to an incredible database filled with expert witnesses and consultants. Turns out I didn’t have to look far, because one of my members, Dr. Sanjay Adhia was already sharing about the subject matter on social media. So we coordinated a little question and answer on the topic.

Forensic Psychiatry Expert Witness Dr. Sanjay Adhia:

Dr. Sanjay Adhia is triple-Board-Certified in Psychiatry Forensic Psychiatry and Brain Injury Medicine. In addition to forensic/expert witness practice, Dr. Adhia serves as the Assistant Professor of Psychiatry at University of Texas Health and Science Center and a Psychiatry Consultant at The Institute for Rehabilitation and Research (TIRR) Memorial Hermann in Houston. He treats those with brain and spinal cord injury who have complicating psychiatric disorders along with general psychiatry and addiction psychiatry patients.

His forensic practice focuses on the psychiatric impact of personal injury, abuse, competency, violence, intoxication and complicating mental illness. He is experienced at assisting attorneys in medical malpractice and wrongful death claims. He also performs occupational and other Independent Medical Exams. In addition, Dr. Adhia works with Physicians for Human Rights and DAYA Houston to assess victims of kidnapping and false imprisonment, human trafficking, undue influence, physical and sexual abuse and rape. Learn more about Dr. Adhia’s practice by visiting his webiste: www.forensicpsychiatrynow.com.

Let’s get to the nitty-gritty. I provided questions and Dr. Adhia provided some outstanding answers regarding coercion.

NR: According to the article from the Boston Globe, coerced-suicide has not been defined by law. Does forensic psychiatry have a definition? If not, can you describe how you would define “coerced suicide?”

Dr. Adhia: As far as I know, there is no formalized definition of “coerced suicide” for forensic psychiatrists. With coerced suicide, there could be an element of undue influence which is defined as “influence by which a person is induced to act otherwise than by their own free will or without adequate attention to the consequences”[1]. I believe “coerced suicide” should be distinguished from “assisted suicide”.

NR: Can you describe what one may be going through when considering suicide?

Dr. Adhia: Suicidal ideations are generally accompanied by severe distress.  Suicide is seen as a solution to the distress and may be perceived as the best if not only solution. It may start with fleeting thoughts without intent to more frequent thoughts with intent. One may then consider various methods of suicide and develop a plan. There could be several suicide attempts before a completed suicide.  Of course, there are instances when a catastrophic stressor or coercion may lead to an impulsive suicide without a preceding history.

From the media account, Mr. Urtula was described as having depression. One of the potential symptoms of Major Depressive Disorder (MDD) are suicidal ideations.  Additionally, victims of abuse can have suicidal ideations without necessarily having depression.

With additional information, we may be able to determine if Mr. Urtula had suicidality brewing for months or if he was suddenly coerced to jump without any preceding suicidal intent.

NR: This is now the second high-profile case involving young women encouraging a boyfriend to end his own life. Would this qualify as a form of domestic abuse according to psychiatrists?

Yes. However, I would expect there be other forms of abuse present preceding the coerced suicide. The literature often refers to domestic abuse as Intimate Partner Violence (IPV). According to the Centers for Disease Control and Prevention[2], there are four types of IPV:

  1. Physical violence
  2. Sexual violence
  3. Stalking
  4. Psychological aggression

Coerced Suicide would be consistent with psychological aggression which is defined by the CDC as “use of verbal and non-verbal communication with the intent to harm another person mentally or emotionally and/or to exert control over another person”. According to prosecutors, Mr. Urtula endured both physical and psychological abuse. The fact that he was located at the parking garage may represent stalking.

Of note, Intimate Partner Violence in of itself, absent suicide coercion, can lead to unintended suicide.[3]

NR: Would coercion in a suicide case (involuntary manslaughter) be similar to the coercion involved in an “undue influence” matter? Are the power dynamics similar?

Dr. Adhia: Coercion is one of the tactics involved in undue influence. Undue influence constitutes controlling others by utilizing the dominance or authority in a relationship, taking advantage of a vulnerability and by employing certain tactics.[4] These tactics include controlling necessaries in life, using or withholding affection, intimidation and coercion. Coercion is the act of threatening to compel an act.

It is worth referring to the proposed “Conrad’s Law” which indicates coerced suicide involves “substantial control or undue influence over the victim, or to have manipulated their behavior through fraud or deceit”.[5]

NR: Some stories I’ve read, indicate Inyoung You had “complete and total control” over Mr. Urtula. How would a person find themselves under complete and total control of a significant other?

Dr. Adhia: To understand how Ms. You would achieve such control; one can look at the cycle of IPV[6] which consists of:

  1. Tension Building Phase
  2. Acute Battering Episode
  3. The Honeymoon Phase

In the first phase, the victim attempts to appease the perpetrator in hopes of avoiding abuse. It may feel as if the victim is walking on eggshells. Eventually the tension will build and phase two will occur with the abuse. Afterwards, there will be a honeymoon phase where the abuser will convince the victim to stay in the relationship. The abuser could promise an end to the abuse. Many of the victims have been are conditioned to be highly dependent on the abuser. They may be convinced they will be unable to obtain love and happiness without the abuser. This may help explain why Mr. Urtula did not leave Ms. You and how she was able to gain control of him.

According to the CNN article, Ms. You threatened self-harm to manipulate Mr. Urtula in order to control and isolate him. She sent him over 47,000 texts and commanded him to end his life.  The abuse escalated just prior to the suicide. She tracked the location of Mr. You and was at the scene of the parking garage where he jumped to his death.

In Mr. Urtula’s case, it is likely he was rendered particularly vulnerable due to depression. Some of the symptoms of depression include fatigue, indecisiveness, decreased concentration along with feelings of worthlessness, helplessness and hopelessness.

With the interplay of Depression accompanied by the tactics and dynamics of IPV, one can get a sense of how Ms. You could achieve “complete and total control” over Mr. Urtula.

NR: Anything additional you feel like you need to add to this story… Please do so.

Dr. Adhia: The hope is someone with suicidal ideations in a relationship would have a supportive partner who will encourage their loved one to seek help. In extreme cases, a partner can call 911 and involuntary treatment in a psychiatric hospital can be sought. There are unfortunate instances when the partner does not recognize the signs of suicide or does not know help is available.  In Mr. Urtula’s case, it appears his partner literally pushed him off the parking garage.

The mass suicide in Jonestown by devotees of Jim Jones could be considered a mass coercion. Jim Jones had his followers practice drinking the Kool Aid. Having the children drink the Kool Aid first served to coerce the parents to follow course.

The Urtula and the Conrad case reminds us both males and females can be victims of Intimate Partner Violence. It is worth noting that the dynamics could be more complicated if there are children involved and the victim is financially dependent on the perpetrator.

If a victim is danger of imminent violence or suicide, call 911 to obtain immediate assistance. Other phone numbers can be found https://ncadv.org/resources.

Special thanks to Dr. Sanjay Adhia for taking the time to help educate us about this unfortunate matter of coerced-suicide. Please share this article with those who need to read it. Please take care of those around you. Let’s all try to be a little nicer to each other.

[1] Lexico Definition https://www.lexico.com/en/definition/undue_influence

[2] Preventing Intimate Partner Violence https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html

[3] Intimate Partner Violence – A Pathway to Suicide By Tony Salvatore https://leb.fbi.gov/articles/featured-articles/intimate-partner-violence-a-pathway-to-suicide

[4] Defining Undue Influence Mary Joy Quinn (October 15, 2018) https://www.americanbar.org/groups/law_aging/publications/bifocal/vol_35/issue_3_feb2014/defining_undue_influence/

[5] Bill calls for coercion to be a crime https://www.sentinelandenterprise.com/2019/07/25/bill-calls-for-coercion-to-be-a-crime/

[6] The Cycle of Domestic Abuse https://www.domesticviolenceroundtable.org/domestic-violence-cycle.html

Criminal JusticeCriminal LawForensic Psychiatry

Date Rape Drugs: Expert Comments on Unreliable Tests, Harming Prosecutions

on March 4, 2019

A few weeks back, BuzzFeedNews wrote an in-depth article on the unreliability of date rape drug testing and how the tests harm investigations and often prevent prosecutions.

Reading the article angered me. I became frustrated over the additional harm done to victims from a lack of national testing standards. My gut feeling was our lack of national or even statewide standards and capabilities, results in victims being re-victimized after a rape.

As with many other blog posts, it forced me to dig a little deeper and communicate with experts to see who was available to comment on this topic, to continue the discussion. Hopefully, by continuing the discussion we might shine more light on the problem and bring it one step closer to a solution.

Without reliable testing standards, how do we preserve evidence for a future prosecution? Even worse, how do we even know if the victim was drugged? If we do not set a standard, how will medical facilities know which drugs to test for during a DFSA screening? Furthermore, we need a comprehensive testing protocol to determine the standard of care when drug-assisted rape is suspected.

Normally, I provide my “two-cents” on a subject before diving into the Q&A with an expert witness. With this subject, I want to hear directly from the medical professional, and I’m sure the readers feel the same.

Forensic Psychiatry Expert Witness Sanjay Adhia

Dr. Sanjay Adhia is triple-board-certified in psychiatry, brain injury medicine and forensic psychiatry. In addition to forensic/expert witness practice, Dr. Adhia is medical director of PACE Mental Health Clinic in the Houston area.  His forensic practice focuses on the psychiatric impact of personal injury, abuse, competency, violence, and complicating mental illness. Dr. Adhia evaluates and treats psychiatric injury and disability in victims and alleged abusers. Dr. Adhia is among one of the few forensic psychiatrists who is board-certified in Brain Injury Medicine. To learn more about his forensic psychiatry practice, visit: https://www.forensicpsychiatrynow.com/.

Nick: You have written about the issue of date rape drugs in this article  (also found directly on Dr. Adhia’s website: https://www.forensicpsychiatrynow.com/date-rape-drugs) in the past. What are some drugs commonly used in date rape assaults?

Dr. Adhia: Common characteristics of many drugs used in Drug Facilitated Sexual Assaults (DFSAs) include the ability to incapacitate a victim and to cause anterograde amnesia (inability to recall the assault).

There are quite a few drugs commonly used in DFSAs. The most common and readily available drug is alcohol. Sedatives that are used by perpetrators include Ambien. Benzodiazepines, a class of medications used to treat anxiety, are often employed in DFSAs.  They include Valium, Xanax, Ativan and Rohypnol (“Roofies”). Gamma-hydroxybutyrate (GHB), a recreational drug with stimulating and sedating properties, is preferred by some perpetrators as it leaves the body quite rapidly. Ketamine (an anesthetic), Ecstasy (MDMA) and Soma (muscle relaxant) are additional examples of date rape drugs.

Nick: According to the BuzzFeedNews article, there are no national standards with regards to drug testing for date rape drugs. Do you have any recommendations for testing standards?

Dr. Adhia: I would recommend national standards. These standards could establish certification requirements for labs, lab staff and physicians who interpret the tests. For, example there are physicians who are certified to be an MRO (Medical Review Officer). They have expertise in interpreting drug tests.  The standards should include time-specific criteria for the various samples to be tested (blood, urine or hair). There should be a list of drugs that are required to be tested. Recently, I was involved in a case where the sample was destroyed after a year and GHB was not included in the testing battery. The standards should establish reliable methodology and concentration cut-offs for each tested substance. Ideally, there should not be any false-negatives or false-positives. Confounding factors could be considered in national standards.

Nick: In the past, I only ever heard it referred to as “date rape.” I understand it is now called Drug-Facilitated Sexual Assault (DFSA). Is there a national committee working to create standards for addressing DFSA cases?

Dr. Adhia:

A National Protocol for Sexual Assault Medical Forensic Examinations, 2nd Edition was published by the Department of Justice Office of Violence Against Woman. It includes a section on drug and alcohol testing. (Refer to https://www.ncjrs.gov/pdffiles1/ovw/241903.pdf page 107).

Internationally, the United Nations has published “Guidelines for the forensic analysis of drugs facilitating sexual assault and other criminal acts.”

Nick: In your forensic psychiatry practice, how do you go about treating those suffering the aftermath of DFSA? For example, victims often cannot remember the attack, so what approaches are used? With what issues are victims likely to suffer after DFSA (i.e. depression, anxiety)?

Dr. Adhia: Drug-induced amnesia is not protective of PTSD and other disorders that can occur after a DFSA. For example, some of Bill Cosby’s DFSA victims reported symptoms indicative of PTSD in their victim-impact statements. Many of his victims had life-long effects such as a reduced ability to trust men and form relationships, panic attacks, and nightmares. In DFSAs, there can be a sense of shame and self-blame. A victim could be at increased risk for substance abuse or suicide.

The treatment for PTSD and other co-occurring disorders such as depression or anxiety disorders include medications and counselling. Two medications often used in PTSD include anti-depressants and a blood pressure medication that helps reduce the nightmares. Occasionally, mood-stabilizers and anti-psychotic medications are used to target associated symptoms such as irritability.  Counselling includes individual and group psychotherapy.

Nick: Any other comments on concerns you wish to share about this crime…

Dr. Adhia: With increasing awareness, the hope is victims act promptly to preserve evidence for prosecution. Many of these drugs will exit the body in under three days or less. A victim can save his or her urine in a clean and closed container and refrigerate it promptly. A rape kit should be performed as soon as possible. The National Sexual Assault Hotline can be called at 800.656.HOPE to find a medical center for a sexual assault forensic exam with urine and blood testing for drugs.

Prompt treatment of the medical and psychiatric sequelae of DFSA is critical. A victim should be monitored and treated for any drug toxicity. There have been unfortunate cases of overdose such as with Tammy Homolka who choked on her vomit after being drugged with halothane in the course of a DFSA committed by her sister, Karla Homolka and Paul Bernardo. Emergency birth control and STD treatment is often indicated after sexual assaults.

Victims should be evaluated and treated for psychiatric disorders soon after the assault. The hotline number above can be contacted to provide referrals.

 

Again, the National Sexual Assault Hotline phone number is: 800.656.HOPE. The hotline is maintained by RAINN (Rape, Abuse & Incest National Network). They also have live chat options available on their home page: https://www.rainn.org.

 

 

Criminal LawExpert WitnessForensic Psychiatry

Golden State Killer, Part 2: Forensic Psychiatry and the Rapist and Serial Killer

on May 14, 2018

As readers of Part 1 are aware, I’m following this case closely due to the connection to our local community. If you are anything like me, you wonder how someone could allegedly commit so many heinous crimes? Then, after a decade of committing dozens of rapes and multiple murders, the suspect ends his reign of terror (at least as far as we know).

What We Know:

From 1976 to 1986, a violent criminal struck fear throughout the State of California. Twelve murders, 45 or more rapes, and more than 100 hundred residential burglaries are attributed to one man. Authorities have indicated the suspect was meticulous in the planning of his crimes, which started as burglaries and escalated into violent offenses.

The crime spree spanned Northern and Southern California, including Sacramento, San Joaquin, Orange, Ventura, and Contra Costa Counties. The suspect was known by many names, such as Visalia Ransacker, Diamond Knot Killer, Original Night Stalker, East Area Rapist, and more recently the Golden State Killer. It wasn’t until a couple of years ago that DNA evidence connected the dots of all the crimes and detectives realized the crimes were committed by the same individual.

An arrest was made in late April. After using an innovative investigative technique (submitting a DNA profile to a free online ancestry database), detectives identified James Joseph DeAngelo, Jr., a former police officer and mechanic living in Citrus Heights, California.

What Makes Someone Commit Such Crimes?

Violent crimes are difficult for most of us to understand. Certainly we’ve all had emotional moments that could have resulted in a terrible decision had we lost self-control or been otherwise unbalanced. Although I don’t condone violence, I’ll admit reading about crimes where the violent result was understandable. Not acceptable, but understandable. For example, a parent acting violently towards someone who harmed his or her child is the type of violent behavior I can understand.

How do we reconcile vengeful, “loss of control,” or “heat of passion,” violence with violence that seems to be done for pleasure? Why does an offender experience joy from inflicting pain and fear upon a victim? What causes a person to lead a life of rape and murder?

There are so many questions on this topic. Does a lack of understanding make us more fearful? Does the human condition require a rational explanation for irrational acts we cannot fathom?

A little information before we continue:

For this portion of our series on the Golden State Killer, I sought input from a forensic psychiatry expert witness. Part 3 of this series will include input from one or more forensic psychologists.

It is important for readers to understand the difference between psychiatry and psychology. Allow me to differentiate between the two. For any psychologists and psychiatrists reading this post, I apologize for the very simplified descriptions of your professions, but we’ve had lawyers contact us looking for an expert, unaware of the distinction.

A psychiatrist is a medical doctor (MD, DO) capable of prescribing medications to address mental, emotional, and behavioral disorders. They generally focus on diagnosis and treatment. A psychologist is not a medical doctor. Psychology-based doctoral degrees are usually Ph.D or Psy.D. They generally are unable to prescribe medication and focus more on helping patients to effectively cope with mental, emotional, or behavioral disorders via psychotherapy (non-medical treatment). Again, this is an oversimplification of two highly complex professions.

Today, we will be addressing the Golden State Killer with some input from Experts.com member and forensic psychiatry expert, Dr. Stephen M. Raffle.

Stephen M. Raffle, MD – Forensic Psychiatry Expert Witness:

Dr. Stephen Raffle is double board-certified in Psychiatry and Forensic Psychiatry. He has over 40 years of experience as a clinical and forensic psychiatrist offering his expert opinion in federal and state jurisdictions nationwide. Dr. Raffle has conducted over 5,000 psychiatric assessments in his career and was a professor of psychiatry at UCSF Medical Center for 20 years. You can learn more about Dr. Raffle by visiting his website: psychiatristexpertwitness.com.

Nick: Are there common psychological attributes among serial killers?

Dr. Raffle: A common feature is a lack of empathy with victims. Most serial killers ​(with few exceptions) understand they are committing a crime because they take care not to be caught. Antisocial Personality Disorder and Borderline Personality Disorder commonly are present. Sadomasochism is also a common feature. Depending on the shared characteristics of the victims, the serial killer may have problems with impotence, paranoia, or sexual perversions which cannot otherwise be satisfied. Paranoid Schizophrenia is a common psychiatric disorder but not universal. A diagnosis of paranoid schizophrenia, in and of itself, does not necessarily justify a finding of insanity, because “insanity” is a legal construct, not a psychiatric diagnosis.

Nick: If so, what types of psychological attributes are common among serial killers?

Dr. Raffle: Refer to my response in No. 1 above. In addition, the psychiatric disorders, as diagnostic entities, may include:  ​Sadomasochistic Personality Disorder, Necrophilia, Paranoid Schizophrenia, Borderline Personality Disorder, Antisocial Personality Disorder, or other psychotic disorders.

Nick: Does a serial rapist or serial killer experience joy or pleasure from tormenting and harming their victims?

Dr. Raffle: Yes.​

Nick: If so, why is it they experience joy or pleasure from inflicting pain or committing murder?

Dr. Raffle: In each instance, the torture is combined with sexual arousal (which is commonly not acknowledged by the perpetrator), leading to an emotional discharge, often overtly sexual in nature​ upon the death of the victim. Following the murder, serial killers have recurrent fantasies about various aspects of the ritual associated with the killing, which brings satisfaction. Over time, the recurrent fantasies become progressively less satisfying, (i.e., “old news”) resulting in a need for new fantasy material. Hence, the serial nature of the murders.

Nick: Can forensic psychiatry explain how one becomes a serial killer? Or, what causes one to become a serial killer?

Dr. Raffle: The prediction of violence in a specific individual is difficult, given the extremely rare occurrence of serial killers. Certain risk factors are identifiable for predisposing an individual to violence; however, the constellation of symptoms, behaviors, life experiences and genetic makeup makes it impossible to identify serial killers before the fact or even to explain how one “becomes a serial killer.” That said, a propensity toward violence most commonly occurs in individuals who have a prior history of violence, premeditated violence, paranoia, a strong impulse for revenge, drug and/or alcohol abuse, Antisocial Personality Disorder, Borderline Personality Disorder, the experience of repeated childhood sexual abuse and/or physical abuse, obsessional thinking, unresolved gender identity issues, sadomasochism, and conflicts about dominance/submission. The causes to become a serial killer commonly include prior sexual fantasies, coupled with torture ending in murder. The shift from fantasy to reality may occur following a personal crisis and need for greater satisfaction than is provided by the fantasy. Once the taboo of murder is breached, the serial killer is freer to convert subsequent emotional needs into murderous actions. Most serial killers have a ritualistic aspect to their killing which reflects their unconscious needs and conflicts, such as killing prostitutes, homosexuals, homeless people, or other such categories. The commonality of the victims usually is based on childhood experiences, parental attitudes, and psychosexual conflicts.

Nick: Are there common childhood development (characteristics or circumstances) issues among serial killers?

Dr. Raffle: The most common childhood development characteristics and circumstances include parental neglect, inconsistent parental behaviors, resulting in excessive, unpredictable punishment​ unrelated to wrongdoing, physical or sexual abuse by a parent or close relative, extreme religious beliefs, isolative behaviors as a child, poor impulse control, conduct disorder during childhood, victimization of various sorts during childhood, to name several.

Nick: News reports indicate the Golden State Killer was active between 1976 and 1986. Is it likely he stopped committing these crimes?

Dr. Raffle: On a probability basis, he didn’t stop committing his crimes after 1986. The nature of his fantasies may have changed over time such that subsequent murders were dissimilar enough from the earlier murders that they don’t share enough commonality to identify him as the perpetrator.

Nick: Is it uncommon for a serial killer to stop committing crimes?

Dr. Raffle: It is common for a serial killer to continue committing crimes.

Nick: Are there items you think the public should know about forensic psychiatry, as it relates to the Golden State Killer, that I have not covered in the above questions?

Dr. Raffle:

a) Serial murder is an extremely uncommon occurrence. It is extremely difficult to prospectively predict a particular person will become a serial killer, irrespective of the forensic psychiatrist’s ability.

b) The ritualistic behaviors of a serial killer do not define insanity or even suggest it​. Serial killers as a group are cunning individuals who seek not to be caught, who do not confess, and who obtain considerable self-satisfaction at the expense of their victims.

c) Serial killers as a group do not understand the intrinsic causes of their behavior and are extremely unlikely to be cured of their obsessional murdering. As the practice of psychiatry now exists, it is unreasonable to expect successful treatment of a serial killer.

d) The FBI Behavioral Studies Unit has interviewed and analyzed all of the serial killers who have been brought to justice. Certain statistical profiles exist which assist law enforcement to “profile” a serial killer based upon the victim type and associated rituals. Roy Hazelwood headed the unit for approximately 20 years and probably knows more about serial murderers than anyone else. His work has been instrumental in creating “profilers.”

e) The psychological makeup of serial killers is different from mass murderers. Serial killers who kill by sniping random people or cars are psychologically more similar to the mass murderer than the serial killer because they usually snipe more than one person during a shooting episode.

f) Contract killers are not serial killers. The mentality of a paid assassin is essentially that of an antisocial ​person who does not empathize with his victims and is therefore comfortable earning his or her living killing others. The obsessional quality or ritualistic behavior of the serial killer is not shared with the assassin. Their only common ground is they have killed more than once. The difference is the assassin is told whom to kill and is paid for it; whereas the serial murderer chooses his victims and engages in other behaviors in addition to a murder which satisfies unconscious needs. Conceptually, as serial murderers go, the assassin is “professional” and the serial murderer is a “hobbyist.”

Stay Tuned:

A huge thank you to Dr. Raffle for his very thorough insight into the mind of the Golden State Killer. Next week we’ll be bringing you more insights on the psychological nature of this perpetrator with input from some of our forensic psychology expert witnesses.