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A fascination with violence

Yale Medicine Magazine, 2007 - Spring


Dorothy Lewis has spent her career trying to understand serial killers such as John Allen Muhammad and Ted Bundy. Her theory—that all violent offenders share three traits—was once considered outrageous but now influences Supreme Court decisions.

Dorothy Otnow Lewis, M.D. ’63, HS ’70, a clinical professor in the Child Study Center, recalls her childhood in New York City during World War II as painful and awkward. As children were choosing up sides for a game, she remembers praying, “Please God, let me be picked second to last, not last.” The little girl who was the object of so much teasing at school would once again see her prayers go unanswered.

At home, things were not always easy. She was tangled in an ambiguous relationship with her older sister, who liked to hide in dark closets, jump out and scream, “The green witch will get you!” But at other times, she helped Dorothy with her French homework, keeping her a week ahead of her classmates. A serious, often sad, child, Dorothy was urged by her mother to be more social: “shorten your skirts; be a butterfly.” But young Dorothy never felt much like a butterfly. She felt like an outsider, and she credits that feeling of isolation with her lifelong interest in society’s pariahs.

Her interest began in kindergarten, when a precocious desire to understand how a human being could be so cruel led her to try to figure out Adolf Hitler. After all, she was horrified when she watched her uncle slaughter a chicken on their farm in New Jersey. In Lewis ’ memoir, Guilty by Reason of Insanity: A Psychiatrist Explores the Minds of Killers, she recalls stories of the Nazi dictator hanging over her childhood as “a source of fascination and fear.” She was the only student in her elementary school “who did not rejoice upon hearing of Hitler’s suicide. Now I could never know what made him tick. … I was convinced, even as a child, that Hitler could not have been born that way. Something had to have happened to him. No one could be born that way. I still believe that.”

Lewis has spent her career as a psychiatrist studying murderers and searching for scientific explanations for their behavior. Her work would take her away from her family as she flew to reform schools and prisons around the country to research cases or testify for the defense. It would put her in the company of such notorious murderers as Mark David Chapman, who shot John Lennon; serial killers Ted Bundy and Arthur Shawcross; and in 2005, John Allen Muhammad, the so-called “Beltway Sniper,” who examined her fingers and told her she should drink more water. Lewis’ work would place her on the stand as a defense witness where prosecutors would do their best to discredit her. It would even put her at odds with the mainstream of her profession as she challenged conventional theories that attribute violent behavior to socioeconomic deprivation and lax discipline.

Her findings, based on psychiatric and neurological evaluations coupled with reviews of medical records, have appeared in such publications as the American Journal of Psychiatry and the Journal of the American Academy of Child and Adolescent Psychiatry. Three elements, she has found, occur consistently in the most violent offenders: brain dysfunction, child abuse and psychotic thinking, particularly paranoia. When all three occur simultaneously, Lewis believes, they become primary ingredients in a recipe for violence.

Her theories, once considered outrageous, influenced Supreme Court rulings on capital punishment in 1988 and 2005. The outsider has become the expert and even something of a butterfly. “She’s very petite, very feminine. The last person in the world you’d expect to be doing this work,” said Jonathan H. Pincus, M.D., HS ’64, her longtime collaborator, now chief of neurology at the Veterans Administration Medical Center and a member of the Center for the Brain Basis of Cognition at Georgetown University in Washington, D.C.

In concentrating on violence, Lewis chose, to put it mildly, the road less traveled. Her husband, Melvin Lewis, M.D., HS ’59, professor emeritus and senior research scientist in the Yale Child Study Center, frequently ribs her, “Dorothy, with two basic drives why did you have to choose violence?” She has no regrets. “Violence is probably the single most important public health issue anywhere in the world,” Lewis said.

A murder with no reason

She is a master at separating the lurid side of her work from her family life. On a snowy afternoon last winter in her comfortable Tudor home in New Haven, a boom box flooded the house with Mozart. Lewis sat on the sofa thumbing through case records.

Her records are full of drawings and writing samples from the murderers she has examined. There are sketches that they made of their own disjointed conceptions of their brains as well as scenes of sexual abuse they remembered from childhood. Lewis often saw as much in the style of their works as in the substance. “See. Here! And here again!” She tapped the pages wherever she saw marked changes in handwriting—clues that the writer may periodically dissociate.

Until 1984, when she recognized her first case of dissociative identity disorder (DID), she questioned the phenomenon ’s very existence. It is still regarded with skepticism by some psychiatrists.

Once known as multiple personality disorder, DID is marked by two or more personalities coexisting in the same patient. While DID has been listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders since 1994, the diagnosis remains controversial—some psychiatrists believe it is the product of therapist suggestion. Nevertheless, Lewis is now asked to lecture about did internationally—evidence, in her view, that the profession is giving the diagnosis more credence.

As she pored over records of Lee Anne Jameson, the first juvenile murderer Lewis ever evaluated, a small boy bounded into the room and asked, “Grandma, do you have any batteries?” Her grandson, Noah, held up an action figure. Lewis looked up from the book and grinned. She asked him a bit about his day, then directed him to the batteries. When Noah left the room, she returned to the Jameson case without missing a beat.

Lee Anne (a pseudonym to protect the girl ’s identity) was 13 when she killed her best friend with a paring knife while waiting for a school bus. No one, least of all Lee Anne, could say why. Lewis got involved in the case because she was running a clinic in New Haven’s juvenile court at that time. Observing “normal” children in a preschool as a child psychiatry fellow at Yale didn’t interest her; she convinced the faculty that her evenings with her daughter, Gillian, then four, gave her ample opportunity to observe normal child development. She got permission to observe at the juvenile court in New Haven. After witnessing the severe psychopathology in children and families coming through the court and the lack of services available to them, she received a grant from the state of Connecticut in 1971 to open the first court clinic in the state. With psychologist David A. Balla, Ph.D., a research associate at the Child Study Center, she published Delinquency and Psychopathology in 1976. The book was based on their work with children in the clinic.

One of the first cases Lewis encountered was that of Lee Anne. The girl ’s medical history was telling. She had made more than 30 visits to Yale-New Haven Hospital. While pregnant with Lee Anne, her mother suffered from syphilis and untreated hypothyroidism, conditions that limited Lee Anne’s intelligence. During a difficult delivery, the soft bones of the baby’s cranium had been squeezed together and her clavicle broken. The ensuing years saw a string of emergency room visits—cuts, burns, stomach pains and numerous accidents and injuries. Lee Anne was dismissed as a manipulative attention-seeker. No one paid attention to a medical student’s note: “she stared off into space and could not be aroused for several seconds. … Get EEG.” Lewis suspected a neurologic problem and consulted Pincus, then also a faculty member at Yale. Pincus found some signs of neurologic problems and ordered an EEG, but it was normal. Nevertheless, Lee Anne’s symptoms were consistent with complex partial seizures. She also was paranoid and sometimes heard voices that told her what to do.

Lee Anne displayed the three traits that Lewis and Pincus would see again and again in murderers: brain injury, psychosis and a history of abuse. Their combined testimony was less conclusive than Lewis would have liked. But it was enough to get Lee Anne sent to a treatment center; it was also the start of a partnership that would alter the careers of both doctors, who often see things very differently.

For example, Lewis has long been at odds with the conventional wisdom and often puts more trust in her own observations than in the literature. Pincus, however, has a deep respect for the literature. And when they began their second collaboration, in 1977, Pincus observed that the study was “a waste of time.” Lewis was studying the neuropsychiatric characteristics of youths in Long Lane School in Middletown, then Connecticut’s detention facility for violent juveniles. The state wanted detailed information about the children who would be housed in a proposed secure wing. Pincus did not believe that violence and neuropathology were linked—he opened one of the classic texts on crime and psychiatric disorders and read a list of factors not associated with criminal behavior, including such impairments as schizophrenia and brain damage. Pincus finally agreed to participate in the study after Lewis explained that her grant included a stipend for a neurologist—he needed the extra income. What he found was staggering. He told Lewis that he had never seen so many neurologically impaired children in one place.

Their collaboration continued when Lewis joined the faculty of New York University (NYU) in 1979 as a professor of psychiatry. She made the move because her Yale appointment as a clinical professor carried no salary. She also maintained a small private practice in addition to her academic work. But when Melvin Lewis was diagnosed with angina, she faced the possibility of becoming the sole breadwinner for a family that now included two children.

“I wanted to work in New Haven, and Yale was the obvious place to begin my job search,” Dorothy Lewis wrote in her memoir. “Yale was not interested. Yale had never in its history given a tenured faculty position in psychiatry to a woman psychiatrist; maybe once to a pediatrician, once to an epidemiologist; never to a woman psychiatrist. Yale was not about to break tradition for me.” After receiving offers from Columbia, Cornell and NYU, Lewis joined the faculty at NYU, because it had an inpatient adolescent unit and offered access to Bellevue Hospital’s prison ward. Lewis secured funding to study prisoners and again convinced Pincus to become the project neurologist.

An interview four years later on the CBS Morning News brought her to the attention of a Florida public defender. The lawyer saw Lewis’ interview with Diane Sawyer on the subject of children who kill, and thought that the children she described sounded a lot like two of his clients on death row. He asked Lewis and Pincus to come to Starke, Fla., to evaluate his entire death row clientele. The only place to eat was a greasy spoon with an electric sign outside flashing “Burn Bundy Burn,” a reference to the serial killer Ted Bundy, due to be executed. Bundy was not on their list of convicts to examine, though Lewis would end up interviewing him many times before his execution in 1989.

Lucky Larson (not his real name) was on their list. Larson was sentenced to die for two separate murders in which he ’d hacked victims to death in the course of robberies. The death row inmate’s demeanor was remarkably cheerful. Larson explained that he’d adopted an optimistic attitude after a serious car accident he’d had years before the murders. Larson’s smile was lopsided, as was his gait. Tests revealed several brain injuries. An MRI showed that his frontal lobes had been injured and could not perform their usual job of controlling impulses emanating from the deeper, more primitive parts of the brain.

Meanwhile Lewis was probing Larson’s history for evidence of abuse. Interviews revealed nothing. He had no memory of maltreatment of any kind. Displaying a characteristic of many brain-damaged individuals, he would go off on verbal tangents and then ask, “Where’d I go? What was the question?”

When Larson ’s brother, Frank, was arrested for molesting his own children, the defense team got important clues about Lucky’s upbringing. Where, Lewis wondered, had Frank learned such behavior? A private investigator working for Lucky Larson’s lawyers found social service records documenting that Lucky’s mother had begun sexually abusing Lucky when he was six years old. His father, jealous of the relationship, was violent toward the boy. Once Lucky scrambled up a tree to escape his enraged father. The man took an axe and chopped down the tree with Lucky in it.

Larson won a new sentencing hearing, but the jury again condemned him to death. On death row, he talked almost constantly —happy chatter about very little. He would try to snap his fingers—even though his neurological problems made the task impossible—to illustrate how little it all mattered. “The only comfort we could find,” Lewis wrote, “was in our knowledge that the very lesions that separated Lucky’s frontal lobes from the rest of his brain and caused him to act so ferociously also protected him from appreciating the reality of his situation and kept him in perpetual good spirits.”

A scientific explanation for violence

Over the past 25 years Lewis and Pincus have evaluated more than 100 juvenile and adult capital defendants. They are often asked to testify for the defense during the sentencing phase. That atmosphere is emotionally charged, and the scrutiny they receive can be intense.

One of her best-known adversaries is forensic psychiatrist Park Dietz, M.D., M.P.H., Ph.D. Dietz testified for the prosecution in the case of the New York serial killer Arthur Shawcross, for whom Lewis was a defense witness. In addition to being a frequent prosecution expert witness, Dietz also runs Threat Assessment Group, a firm that advises employers on the risk of stalking, product tampering and other forms of violence in their workplace.

Detailed and harsh in his criticism, Dietz has accused Lewis of interpreting “ambiguous symptoms” as psychosis. “I can’t escape the theory that Dr. Lewis has some position or a zealotry against the death penalty that influences her findings and judgment,” he said.

Lewis, however, insists that she takes no sides on the morality or politics of the death penalty. She offers objective testimony on the mental health of accused killers, most of whom hide their illnesses and childhood traumas because “they’d rather be killed than called crazy. … I just give you the facts. Then if you decide you want to kill him, you can kill him,” she said.

Of course, her strictly clinical explanation for murder does not answer traditional questions of right and wrong. Fox News commentator Bill O’Reilly once asked her in a 2002 interview, “But Dr. Lewis, what about evil?”

“Evil is not a scientific term,” Lewis answered. “It’s a religious term.”

In most cases, Lewis sees the defendant executed despite her testimony. But her work has changed the way the death penalty is applied nationally. Lewis ’ research on juveniles condemned to death in Texas became part of the record in a 1988 Supreme Court ruling that youths under the age of 16 could not be executed, and in a 2005 Supreme Court ruling that murderers cannot be executed for crimes they committed before the age of 18. (Justice Thurgood Marshall also cited her work in his 1991 dissent from a Supreme Court decision allowing the execution of the brain-damaged Ricky Ray Rector.) Her research cited in the 2005 case found the same three factors she had so often observed—a history of abuse along with psychiatric and neurological problems—and documented how little the courts had considered them.

Her most important contribution, according to Pincus, is establishing the link between child abuse and violent behavior. It would be easy to see how their work together might have made Pincus and Lewis anti-death penalty crusaders, but they avoid association with groups trying to ban capital punishment. Instead they have become zealous about preventing child abuse.

Preventing child abuse

Lewis has retired from NYU but remains a clinical professor in the Department of Psychiatry and in the Child Study Center at Yale. She continues to evaluate violent offenders, conduct research on violence, supervise trainees and see private patients. She is currently studying the moral implications of our knowledge about violence; the origins of the concept of the sociopath; and ethical issues surrounding the “lottery” of life that places some people at greater risk of becoming violent. She is also working with Jennifer S. Bard, J.D. ’87, M.P.H., professor of law at Texas Tech University (TTU) School of Law and adjunct associate professor of neuropsychiatry at the TTU School of Medicine, on a study of capital defendants who represent themselves. One of Lewis’ major interests continues to be the prevention of child abuse. Child abuse, says Lewis, acts in several ways. First, the abuse itself can cause brain damage that leads to a lack of control in individuals. It exposes children to an unhealthy model of behavior. “Children do as they see,” she said. The stress resulting from ongoing physical and verbal abuse changes the structure of the brain. And finally, she said, “Abuse engenders rage that is almost never expressed toward the perpetrator of the abuse. That rage is displaced onto others.

“I would give my right arm to get funding to do an early identification and prevention project,” she said. “We could identify kids early whose maladaptive behaviors reflect terrible violence at home.” The goal would be to offer support to parents—parenting education and mental health services—rather than remove children from the troubled home. But she believes that the program would be seen as intruding on families and therefore be a tough sell.

Lewis ’ childhood curiosity about humanity’s dark side launched her on a mission to understand the very people much of society would prefer to eliminate. Ted Bundy asked to see Lewis the day before his execution and even kissed her goodbye. “Everyone else wants to know what I did,” he explained. “You want to know why.”

If violence is the most serious public health problem in the world, Lewis sees understanding killers as the key to devising a cure. The closest that Lewis comes to condemning the death penalty has less do to with arguments about justice and compassion than a thirst for answers. “How is it,” she asks in her memoir, “that we pour millions of dollars into Bundy books and the like, but are nevertheless willing to sacrifice further knowledge about him and his ilk in the interest of doing away with them?”

At 69, and after decades of study, Dorothy Lewis is no less fascinated by our pariahs than she was at age five. YM