Monday, October 12, 2009

Update

Sorry that I haven't had any posts lately. I've been busy with my new family, including my son, Mark Yates, who is about 1-1/2 years old now. He is such a blessing.

I also started law school this fall. My goals are (1) to improve the way in which our society responds to crime, particularly for mentally ill defendants, and (2) to improve our health care system, particularly for mentally ill patients.

I was able to visit Andrea this summer, and she is doing well, all things considered. She is in a state hospital, and she has been medically stable for five years.

Monday, June 16, 2008

Book Review: "First, Break All The Rules"

Overall rating: 3.5 out of 4 stars

(Note: Most of the posts on this site cover mental health, legal, media, forgiveness, and spiritual topics.  This book doesn't really address any of these, but I did read it, and it is a good book, so here is a short review.)

This book was written in 1999 by Marcus Buckingham and Curt Coffman of The Gallup Organization.  It is basically some conclusions from extensive research on what the best managers do, including:
  • Understand that each person has special talents (recurring patterns of thoughts, feelings, and behaviors) that can not be taught
  • Help people recognize and develop their talents
  • Select and place people based on their talents
  • Define the right outcomes (describe excellence) and allow people to achieve those outcomes in their own way
  • Measure performance against outcomes
  • Expect the best from people
  • Complement or support missing talents
The book also includes some guidelines for customer satisfaction that I find to be very interesting.  The customer satisfaction hierarchy is:
  1. Accuracy
  2. Availability (there when needed)
  3. Partnership (we are in it together)
  4. Advice
These build advocate customers who are very loyal.

It is also important that a company provide a framework for personal growth and management by creating heroes in every role, defining measured levels of performance, and having overlapping pay bands.

One important thing that I learned from this book is that it is better to build on strengths than it is to shore up weaknesses.  How can we ever excel if we spend our time developing our weaknesses rather than our talents?  Why struggle with something that we are not good at when there is someone else with the exact talents needed who could do it instead?

Here is a simple example: I am better with numbers than I am with words, and I occasionally work with engineers who do not speak English.  Should I take the time to learn their language?  No!  Instead, I should focus on enhancing my technical knowledge (my talent) and rely on an interpreter who is better with words (his talent).

How should we spend our time?  How can we be happy in our work?  How should we work together in an interdependent community?  How can we achieve excellence?  To me, this book helps answer these questions by encouraging us all to focus on developing and using our talents.

Monday, January 21, 2008

Book Review: "Infanticide; Psychosocial and Legal Perspectives on Mothers Who Kill"

Overall rating: 4 out of 4 stars

This book, edited by Margaret G. Spinelli, M.D., is an amazing compilation of chapters by some leading experts on postpartum disorders, infanticide, and the law. Although the chapters were written by a variety of experts, the book flows reasonably well. The book is intended to help save the lives of children by revealing what is already known about infanticide and providing a framework for future research on the subject.

There are many things that stand out to me in this book. Here are some of them:
  • The US legal system has a long way to go to catch up with the rest of the world in response to infanticide. The US laws are inconsistent; depending on where she lives in the US, a woman who commits infanticide could be given hospitalization, probation, a short prison sentence, and lengthy prison sentence, or the death penalty. That just isn't fair. Consider Andrea's case. We resided in Harris county, Texas, which has sent more people to death row than any other county (and 48 states!) in the US. The DA in Andrea's case, Chuck Rosenthal, treated Andrea exactly as he would have treated a serial killer (i.e., charged her with capital murder, sought the death penalty, and spent about $1M to prosecute her) in spite of the fact that Andrea has hundreds of pages of medical records that indicate she suffered from a severe postpartum illness. If Andrea had taken the lives of our children in almost any other state in the US, she would have received more civil treatment. In fact, in England and in many other countries around the world, Andrea would have been charged with manslaughter and given probation and medical treatment.
  • Women are at much greater risk of developing mental disorders after having a child. Throughout the life of a woman, her highest risk for psychiatric disorders and hospital admissions occurs during the first three months after childbirth. The risk of developing psychosis during the first 30 days after giving birth to a child is over 20 times greater than the two year period preceding the birth. The risk for developing a psychiatric disorder is highest during the first week, declines fairly sharply to the first month, and then continues to slowly decline during the months that follow.
  • The symptoms of postpartum psychosis (PPP) are different than other psychoses. Women who suffer from PPP tend to appear disorganized and confused. This may be due to the lack of sleep associated with pregnancy and childbirth. A couple of other symptoms are suspiciousness and self-neglect. Andrea had all of these. She did not sleep well. She seemed restless and fidgety. She did not take care of herself. Also, the book points out that PPP patients should also be considered bipolar. Andrea's family has a history of bipolar illness, and bipolar is a genetic disorder. It is clear to me that Andrea suffered from PPP.
  • Neonaticide is the killing of a newborn child. The mothers of these children are generally young mothers who tend to deny their pregnancies. Oftentimes, their denial is caused by a strong contradiction between their own beliefs (e.g., "Good girls don't get pregnant before marriage") and being pregnant. Curiously, their denial can be so severe that their bodies do not appear pregnant and their family and friends (and sometimes even doctors!) participate. In many cases, when the baby is finally born, the mother can not face the reality of having a child, and she enters a dissociative state during which she takes the life of her baby, either through a deliberate act or through neglect.
  • Our insanity laws in the US require that the accused suffer from a recognized mental disease or defect. Unfortunately, the "gold standard" for defining mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM), does not recognize postpartum disorders. Instead, there are other disorders (e.g., "Major Depressive Disorder with Psychotic Features") that are designated as having "postpartum onset" if they occur within 30 days after giving birth. There are a couple of problems with this. First, PPP and neonaticide have unique symptoms that are not included in the other disorders. Second, postpartum symptoms can start beyond 30 days after giving birth. This leaves a defense attorney with the difficult task of mapping his defendant's symptoms to recognized disorders with slightly different symptoms in order to prove that she was insane.
  • The American Academy of Psychiatry and the Law (APPL) has written guidelines for the evaluation of mentally ill defendants entitled, "Practice Guidelines for Forensic Psychiatric Evaluation of Defendants Raising the Insanity Defense." I am going to add a review of this as a future topic for this blog. One thing that disturbs me about our legal system is how two "experts" can look at the same facts and draw completely different conclusions. Also, I believe that there are "hired guns" within our legal system who have a lot of credentials and purposely offer testimony that favors their employer (either the defense or the prosecution). Of course, most defendants can not afford their testimony. Having guidelines such as these could help remedy these problems.
  • There is a chapter in this book on attachment theory. I had never heard of this before, and I find it fascinating. Basically, a baby will develop an attachment style that mimics his mother's attachment style. The book lists four attachment styles for the child and three attachment styles for the mother. A "secure" mother will have a "secure" baby. I am not completely clear on the other mappings. However, it is clear that any underlying attachment problems that the mother has are passed on to her child. Some therapists rely on mother-child interaction to identify their attachment styles, to work through underlying issues, and to practice appropriate behaviors. This is actually a treatment for both the mother and the child. Sadly, it is very difficult (if not impossible) for a woman who suffers from a postpartum disorder to form a secure bond with her child.
  • Andrea's case occurred just before this book was completed. In many respects, Andrea's case reaffirmed many things that Dr. Spinelli had already planned for her book. In her conclusion, she mapped the circumstances of Andrea's case to some risk factors that were described in the book. Some of them are true, and some of them are not. In particular, she stated that I offered "poor partner support" which is simply not true. It is true that we had a more traditional lifestyle. What is not written is that I worked hard to provide for my family, I worked hard around the house, I helped care for our children, and I diligently sought medical treatment for Andrea. In 2000, I suggested to her that she could work half time and I could work half time; her response was, "I am a mother now." The item listed after "poor partner support" in the book is "isolation". I would say that this is true. We had some friends, but not a lot of friends. We also did not belong to a church which I now regret. If Dr. Spinelli combined these two items into a single item entitled, "poor support system", then I would agree with that. While Andrea was sick, my Mother and I formed most of her support system, and we were not enough. Both of us were completely exhausted. After the book was published and Dr. Spinelli learned more about the case, she called me and apologized for some things that she had said about me which I appreciated.
At the end of her book, Dr. Spinelli writes that the goal of saving lives is attainable. She encourages us to not turn away from these mothers and their families, but rather to learn from them so that we can prevent future such tragedies. I agree wholeheartedly.

Future Topics

This post contains future topics for the blog. If you have any suggestions for other topics, then please let me know.
  • Review of the American Academy of Psychiatry and the Law (APPL) "Practice Guidelines for Forensic Psychiatric Evaluation of Defendants Raising the Insanity Defense."
  • FAQ: Why do you support Andrea?
  • FAQ: Why did you divorce Andrea?
  • FAQ: How is Andrea doing? (with her permission)
  • FAQ: What role did the Woroniecki's influence have on the tragedy?
  • Steffi K. case (Germany)
  • Review of 2002 trial transcript
  • Review of 2002 report of Dr. Dietz to the state

Sunday, December 9, 2007

Common Myths

This post contains common myths about Andrea's case and our lives. I'll continue to update the post over time.

Myth: I didn't change diapers. Source: Mrs. Kennedy, Andrea's mother. I found the following text here: "Andrea Yates' mother, Karin Kennedy, said her son-in-law told her after the birth of their fourth child that he had never changed a diaper." Andrea was a stay-at-home mother, and she did change most of the diapers. However, I also changed many diapers, starting with Noah. After Noah was born, Andrea returned to work for two weeks. During that time, I stayed home to take care of Noah in the morning, and Andrea's mother came over to take care of Noah in the afternoon. I was the only one home with Noah. Who did Andrea's mother think was changing his diapers at that time? It was me! Through the years, I changed hundreds of diapers. Also, I think I changed the messiest diaper. Early one morning, Andrea was swimming and Luke started to stir. I discovered that he was covered from head to toe in brown "goo". His diaper had leaked. What a mess! Not only did I change his diaper, I gave him a bath and washed his clothes!

Myth: I ignored Debbie Holmes' pleadings to seek medical treatment for Andrea. Source: Debbie Holmes, Andrea's friend. An anonymous reader referred me to this link that contains the following text: "Andrea Yates' best friend also took the stand Thursday and described how she repeatedly begged Russell Yates to get his wife help. ... Holmes testified that she called Russell Yates three times, sobbing and begging him to get help for Andrea Yates." This leaves the impression that Debbie was continually begging me to get help for Andrea, that I was ignoring her pleas, and that I didn't seek medical help for Andrea. These are simply not true. On May 3, 2001, while my mother and children were home, Andrea inexplicably filled our family bathtub with water. On that same day, Debbie visited our house and Andrea avoided her. Debbie called me later that day and suggested that we take Andrea to see a doctor. She wasn't hysterical. She wasn't pleading. She simply made an observation and a suggestion. I completely agreed with Debbie. In fact, we already had an appointment scheduled with Dr. Saeed for the very next day. At that appointment, Dr. Saeed admitted Andrea to Devereux for the second time. To the best of my recollection, that is the only time that Debbie ever offered any suggestions regarding Andrea's medical care. In fact, during the three months leading up to the tragedy, Debbie was not around much. She brought 2-3 meals to us, she went to the park 2-3 times with my mother and our children, and she visited Andrea in the hospital once. I know that Debbie cares about Andrea and that she was very hurt by the tragedy. However, I was really surprised that she had so many negative things to say after the tragedy given her limited knowledge of, and involvement in, Andrea's care.

Myth: Dr. Saeed prescribed 24/7 monitoring for Andrea. This is completely false, and I am not sure where this myth was started. It may have been part of Dr. Saeed's trial testimony. The fact is that Dr. Saeed diagnosed Andrea as depressed (not psychotic), and he treated her accordingly. Also, he never asked Andrea whether or not she had homicidal thoughts, and he never mentioned the possibility that she could pose a danger to herself or to our children. He knew that my mother was helping out some during the day. I hope that that was not part of his decision to not readmit Andrea on June 18, 2001, when she had obviously declined. An important point to consider is that a family can not protect itself from a psychotic person. Andrea could have just as easily burned our house down or poisoned us. There are many similar cases in which a mother killed her children while adult family members were home. A psychotic person belongs in a hospital. Period.

Friday, December 7, 2007

FAQ: Why did you keep having children?

I have gotten this question a lot from people, and it is a fair question given what has been reported in the media.

Let me start by clarifying a couple of things. First, many people picture Andrea as a helpless woman who slowly deteriorated through the years as a result of being overwhelmed with more and more children. This is simply not true. Andrea is a very smart, conscientious person. She was valedictorian of her high school class, she was captain of her high school swim team, and she practiced as a registered nurse at MD Anderson Cancer Center for eight years.

Before we married, Andrea decided that she would stop working as a nurse when our first child was born, and we decided that we would have as many children as we were blessed to receive. When Noah was born, Andrea left nursing to become a stay-at-home mother. She absolutely enjoyed her role as a mother. Of course, things were busy with five children. At the same time, we were all very happy.

Also, Andrea only exhibited signs of depression after our last two children were born. She seemed very much herself after our first three children were born. In fact, I did not notice any changes in her appearance or functioning, and no one ever mentioned to me that she seemed depressed in any way. Andrea has told me several times that she felt fine after Noah, John, and Paul were born.

After Luke (our fourth child) was born in 1999, Andrea became very depressed. The depression started a month after Luke was born, and it gradually worsened over three months, until Andrea tried to commit suicide and needed to be hospitalized - twice. During this time, she slowly changed from a vibrant woman to a catatonic zombie. This was not a subtle change. She was a different person.

While she was sick, Andrea would only respond in 1-2 word statements. She walked around nervously. She seemed disorganized and confused. She scratched her head. Her leg shook uncontrollably. She carried Luke around on her hip and would not feed him even when he cried. She was unkempt. She would stare blankly into space for extended periods. At her sickest, she would not eat or drink, and she could barely walk.

Andrea was hospitalized in an intensive-care psychiatric unit. One day, I spent two hours pleading with her to start taking an antipsychotic medication that her doctor, Dr. Starbranch, had prescribed. Andrea said less than 10 words the entire visit. She was a zombie. After our visit, I spoke with Dr. Starbranch about Andrea's condition. Dr. Starbranch decided that it was an emergency situation and decided to give Andrea an injection.

The injection was a cocktail that included, among other things, Haldol, a very powerful antipsychotic medication, and Ativan, an anti-anxiety medication.

After Andrea received the injection, an amazing thing happened. Within 24 hours, she was on her feet. She was walking. She was talking. She was eating. To this day, I am utterly amazed by how much and how quickly she improved! It took a while to find a medication that worked for Andrea. Her family and I had started to lose hope that she would ever be herself again. Then suddenly, within one day, she was mostly back! There was hope!

After the injection, Dr. Starbranch continued to give Andrea Haldol. She also started to give her Wellbutrin, an antidepressant with some mood-stabilizing effects. Andrea did very well on both medications and recovered quickly. Dr. Starbranch discontinued the Haldol after Andrea had been stable for a couple of months. Andrea discontinued the Wellbutrin herself. For all of 2000, Andrea seemed well.

This had been an exhausting experience. Finally, things started to seem normal again.

Andrea and I discussed the possibility of having more children. We both love children, and we would have loved to have more.

Some of the biggest challenges in 1999 were: recognizing the symptoms of Andrea's depression, seeking prompt treatment, and determining which medications worked for her. Dr. Starbranch and her staff told us that if we had more children, then there would be a 50 percent chance that Andrea would become depressed again, and that if she did become depressed again, then she would have the same symptoms and require the same treatment.

Given these things, Andrea and I decided to have more children. If Andrea did become depressed again, then we would quickly recognize her symptoms and take her to a doctor; and her doctor would give her the same medications that had worked before. Therefore, we (in hind sight naively) thought that her symptoms would not be severe, nor last for long, because she would be treated quickly and effectively.

Here is an analogy: Suppose you could receive a beautiful new car in exchange for enduring the flu for two weeks. Would you do it? A child is much more valuable than a car. Also, two weeks with the flu is worse than what we expected. We had no idea that having another child could lead to such a tragedy. To us, it was a good trade.

Now, about our conversations with Dr. Starbranch. It is true that Dr. Starbranch recommended that we not have any more children, because Andrea could become sick again. When we told her that we wanted to have more children, she said that she wanted to put Andrea on medications during and after the pregnancy, and Andrea refused, because she was concerned that the medications could harm the baby.

During the course of Andrea's treatment, Dr. Starbranch never explained to me that Andrea had been psychotic and was potentially harmful to our children. She did explain that Andrea was depressed and was potentially harmful to herself. This is a key point. Apparently, Dr. Starbranch also wrote a comment in Andrea's medical record that Andrea could become psychotic again if she had more children.

I suspect that Dr. Starbranch withheld this critical information from me, because she has a duty to Andrea to maintain doctor-patient confidentiality. At the same time, she had a duty to Andrea and me to warn us if our children could possibly be in danger. On the whole, I believe that she is a competent psychiatrist. However, if she did believe that our children could be in danger, then she should have explicitly warned us.

To be complete, during the course of Andrea's treatment and through a lot of discussion, Dr. Starbranch did mention to me that it is possible for a woman to become psychotic and harm her children. However, she never warned me that Andrea herself was psychotic, nor did she describe the symptoms of psychosis to me. I did not know that Andrea was psychotic and posed a threat to our children in 1999 and 2001 until after the tragedy.

So what mistakes did we make? What could we have done differently?

Well, first, I do believe that Andrea and I treated her illness too lightly. We believed that Andrea had a routine case of postpartum depression, while in fact, Andrea had a very severe case of postpartum psychosis. Similarly, we expected that if Andrea became depressed again, then the progression would be slow as in 1999. However, what took 2-3 months to develop in 1999 took 2-3 weeks to develop in 2001.

Second, we naively believed that any psychiatrist could treat Andrea effectively. Dr. Starbranch did treat Andrea effectively; Dr. Saeed did not. While Dr. Starbranch found a combination of medications that worked for Andrea and fought our insurance company to keep her in the hospital until she was well, Dr. Saeed gave Andrea medications that exacerbated her condition and discharged her while she was still the sickest patient in the hospital.

If we had known these things at the time, then I think we would have decided to count our blessings and stop having children. At the same time, I feel blessed to have known Mary for the short six months of her life. She was a beautiful little girl.

Sunday, October 7, 2007

Book Review: "When There Are No Words"

Overall rating: 3.5 out of 4 stars

In his book, Charlie Walton shares his personal experience with grief. The book is written to those who have recently suffered the loss of a loved one. It offers those who are grieving an idea of "what they are in for", some practical advice for grieving, and some encouragement to "make it" as Walton has done.

Although the book is short, Walton manages to cover a broad range of topics associated with grief. Some of the topics that I can relate to include: the presence of family and friends, grieving in your own way, inaccurate and uncaring media, our tendency to cast blame and treat false theories as facts, and the value of hugs!

Walton also touches on some other topics that are more thought-provoking: how to handle guilt, why we should not judge each other, and the role that memories play in our pain. His advice on these is simple and straightforward, although I would like to see more on each of these topics.

One thing that impresses me about the book is its easy style. It is very easy to read, and Walton has a knack for keeping things simple and relaxed. This is especially impressive given the subject matter of the book.

This is a very good book for those who have recently lost a loved one.