DIAGNOSING AFTER THE FACT IS A TRICKY BUSINESS.

That has not deterred keyboard warriors from commenting on the recent mistrial, in Massachusetts, of Lindsay Clancy.  I recommend psychiatrist Sally Satel's "Here's What the Jury Should Have Found," in The (Not Detroit) Free Press.  Professor Satel is a skeptic of the therapeutic approach to everything (aw well as being sister by a different mother to longtime libertarian Virginia Postrel) and her essay will reward careful study.  The abstract observes, "I believe psychosis drove this mother to kill her children. The jury deadlocked and the judge declared a mistrial. If she is retried, she should not be found criminally responsible."

Therapeutic practice has led to a therapeutic culture in which ever more subtle explanations of people behaving badly has spilled over into explaining away, or enabling, people behaving badly.  Charges and counter-charges focusing on that popular therapeutic culture interfere with clinical understanding of psychosis, which, the professor argues, is real, if rare, and thus difficult to diagnose.  If anything, the professor makes a strong case to keep the research enterprise distinct from the policy environment.

There might have been warning signs, had clinicians noticed.

Clancy’s clinicians should have known that she had experienced boundless energy, racing thoughts, obsessive cleaning, and feelings of elation—a manic state—in the weeks after her son Dawson was born in 2019. Talking to her husband or parents or ob-gyn at the time could provide such data if the patient is not forthcoming. Importantly, a history of postpartum activation or mania is a risk for full-blown postpartum psychosis after the birth of subsequent children.

Clancy’s pharmacological treatment also came in for intense scrutiny by the defense. In all, she received mental-health care from at least six clinicians, who prescribed a total of 13 drugs, including antidepressants, antipsychotics, mood stabilizers, and benzodiazepines (drugs in the Valium family).

Some of these medications exacerbated her already serious condition. Clancy’s first antidepressant, Zoloft, which she tried in the fall of 2022, triggered racing thoughts and a two-day period of no sleep—another suggestion of a bipolar disposition. Also, Zoloft’s strong activating effect on her suggests a potential for bipolar disorder.

None of which will bring her three children back, nor make her future life any better.  Sometimes bad experience can only make future postpartum psychoses (which Professor Satel argues are rare) have better outcomes.

That is, unless People In Authority over-correct.

Hindsight is clear-eyed, and I am a bit hesitant to criticize her clinicians, who truly seemed to want to help. That said, someone in charge needed to know if Clancy’s condition was resistant to the medications (her illness just was not responding) and if her medications caused intolerable side effects. This is difficult to do without knowledge of all the treatments she received; after all, clinicians need to know whether it might have been time to move to lithium or even electroshock. Escalating treatment is warranted because, if postpartum psychosis is treated well, the patient has an excellent chance of getting better.

My last point about prognosis is important because some experts are now worried that the media coverage, as well as civil malpractice actions filed by Clancy and her husband, are making clinicians reluctant to treat high-risk patients. They need to keep in mind, however, that the vast majority of women with postpartum psychosis do not commit filicide like Lindsay Clancy, and that, as I indicated, not only is postpartum psychosis rare, the response to treatment is usually good.

There are also things legal practitioners could learn, according to Jed Rubenfeld, who asserts, "The Law Is Inadequate to Judge Lindsay Clancy." Why? "Massachusetts law only allows for bad options when ruling on an insanity defense. The one sensible solution, voluntary manslaughter, is off the table."

So it often is with jury deliberations.  In Wisconsin, for example, if a jury finds a defendant to have acted in self-defense, that precludes any murder or manslaughter conviction.  In Massachusetts, apparently the holdout juror admitted to some doubt that the defendant acted deliberately.  Granting her insanity was a thought too far.

That's the stuff of future law review articles.

Massachusetts law is weird when it comes to cases in which the defendant pleads insanity. In most of the country—and in federal prosecutions as well—when criminal defendants plead insanity, it’s up to them to prove it. But in Massachusetts, the state has to prove that Clancy was not insane, and it must do so beyond a reasonable doubt.

Think about that: If there’s any reasonable doubt about her sanity, Clancy must be acquitted. And how could there not be reasonable doubt about Clancy’s sanity? The psychiatric “experts” who are testifying sharply disagree about it. All across the country, Americans sharply disagree about it.

Indeed. Professor Satel.

Psychosis is alien and its all-consuming power is difficult to grasp. I can see why some people turn to punishment as the resolution of an unfathomable crime and as justice for the children.

I’d hoped the jury would unanimously blame the ravages of a terrible illness, rather than the woman at the center of this tragedy. In the end, it was stymied.

Three lives have been ended and many others have been irreparably damaged. Yet some good might come from this highly publicized trial.

In other states, "voluntary manslaughter" might be a compromise between murder in the first degree and (temporary?) insanity, but in the Commonwealth of Massachusetts, notes Professor Rubenfeld, that crime arises in events such as a bar fight gone wrong.

Someday, perhaps, we’ll finally unlock the mysteries of the human brain and heart. But until that day, the best the law can do in a case like Clancy’s is an uncomprehending compromise. Voluntary manslaughter would have been the right such compromise, but sadly, the jury doesn’t know that.

And so the research enterprise, the patient beavering away at ever more challenging anomalies not easily covered under a bright line rule, goes on.