Preventing murder in the family with Dr. Susan Hatters Friedman

Susan Hatters Friedman, MD, joins Lorenzo Norris, MD, host of the MDedge Psychcast and editor in chief of MDedge Psychiatry, to talk about family murder.

Dr. Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry at Case Western Reserve University in Cleveland. She also is professor of pediatrics and reproductive biology, and adjunct professor of law at Case Western.

In addition, Dr. Hatters Friedman is editor of Family Murder: Pathologies of Love and Hate, which was written by the Group for the Advancement of Psychiatry's Committee on Psychiatry & Law.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Overview of family murder

• Family murder is defined as situations in which any member of a family kills another family member. It encompasses a wide scope of violence that includes intimate partner homicide; infanticide, including purposeful feticide; neonaticide (murder in first day of life); siblicide; and parricide (a child killing a parent).

• The book, Family Murder: Pathologies of Love and Hate, discusses the epidemiology and public health implications of family murder, various motivations, and pertinent psychiatric assessments, including risk assessments and sanity evaluations. It was written to prompt better screening and risk assessments, with the goal of prevention.

Motivating factors leading to murder

Phillip J. Resnick, MD, who also works in forensic psychiatry at Case Western, identified five main motives of parent-child violence.

1. Fatal maltreatment is the result of fatal neglect or abuse by a parent. This type of family murder is common and is most likely to be prevented, especially with intervention by Child Protective Services.
2. Altruistic murder occurs in three categories in which a parent wants to spare a child from perceived suffering:

• Psychotic parents with delusions about their children being harmed.
• Murder-suicide, such as when a severely depressed and suicidal parent kills their child to avoid leaving them without a parent after their suicide.
• Parents who kill a child with serious, chronic physical illness as a means of "saving" the child from a "worse" fate.

1. Acutely psychotic murder occurs in the context of serious mental illness such as schizophrenia, bipolar disorder, or postpartum psychosis. Preventing this type of murder means monitoring the content of delusions and hallucinations related to family members. The Andrea Yates murders are a prime example of this type of murder.
2. Unwanted child motive is most common in neonaticide cases. The child is considered a hindrance to something the parent wants, such as a relationship. To screen for this risk, physicians can ask whether the pregnancy was planned and observe the interaction between child and parent, especially during the first hours to days of life.
3. Partner revenge is rare but is most likely to occur in context of a custody battle, with one partner seeing murder as a means of revenge. Psychiatrists can observe interactions between partners and inquire about threats from partners.

Screening and preventing violence

• Psychiatrists can screen for violence by asking: "How are disagreements handled in your family?" This broad, neutral question elucidates family dynamics about partner violence, anger, and negative parental practices. It can generate information aimed at preventing fatal outcomes.
• Strong human emotions, such as anger, jealousy, and pride, combined with risk factors such as a history of violence and access to weapons, drive family murder.
• Psychoeducation about childhood development can decrease the risk of violence, especially in the fatal maltreatment category.

Addressing countertransference issues

• Family murder stimulates strong countertransference in response to the perpetrator. Working as a team can diffuse these emotions and allows a venue for processing.
• Building rapport with patients and recognizing their humanity by using phrases such as "When he died," rather than "When you killed him."

References

Family Murder: Pathologies of Love and Hate. Group for the Advancement of Psychiatry, 2018.

Hatters Friedman S. Filicide-suicide: Common factors in parents who kill their children and themselves. J Am Acad Psychiatry Law. 2005 Jan. 33(4):496-504.

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