The Disappointing False Dichotomies Behind 'Crazy, Not Insane'

The HBO documentary promotes public misunderstanding of criminality and DID.

Posted Nov 30, 2020

HBO recently released the documentary Crazy, Not Insane featuring long-time forensic psychiatrist Dr. Dorothy Otnow Lewis and her theories of the origins of criminal behavior. This issue is a deep and fascinating topic for most people because it gets to the core of what constitutes good and evil, and whether people are always culpable for their behavior, especially when it is grievously harmful such as murder and rape. The fascination with these core questions about human nature and behavior is also probably why there is a huge cottage industry for crime-related entertainment.

Forensic psychiatry is a subspecialty in the field often focusing on criminology and the application of scientific and clinical expertise to legal contexts. The competency to stand trial is one issue that forensic psychiatrists often evaluate, as part of prior legal precedents in the United States that affect punishment depending on the ability to distinguish between right and wrong when committing a criminal act. These professionals often weigh in on the famous “not guilty by reason of insanity” defense for criminal offenders. It remains a centuries-long philosophical and scientific debate over nature versus nurture when regarding people’s culpability for their behaviors, and whether people deserve to be labeled as “evil” or criminal when they kill or harm others, or whether there is more complexity to what leads to crimes. Psychiatrists still struggle amongst themselves to quantify and understand biological determinism versus situational influences when diagnosing and treating their patients. Sometimes this debate causes artificial dichotomies within the field’s practitioners, who tend to align their views one way or another for various skewed reasons, including oversimplification, ease of research, self-promotion, financial incentives, and more.

Sadly to me, Dr. Lewis, despite her supposed years of expertise and prestigious affiliations, does not demonstrate a deep awareness of the complexity of psychiatric nosology or forensic diagnosis in this film. The movie tries to paint her as some sort of misunderstood “pioneer” who is ahead of her peers in understanding criminality, but this portrayal is questionable. The documentary focuses on Dr. Lewis’ background and her own psychological theories of criminal behavior stemming from her past clinical experience. Her main premise is that most murderers, including serial killers, suffer from childhood trauma, abuse, and neglect, which in turn causes many of them to develop the controversial diagnosis of dissociative identity disorder or DID (formerly known as multiple personality disorder). She views the murderous and violent parts of these people as a split identity they possess as a sort of defense mechanism and questions their true culpability in their crimes as a result. While she agrees most serial killers are a danger to society and must be locked away to protect people from their uncontrollable impulses, she strongly feels the death penalty is cruel and unjust for their behavior, even likening it to burning innocent, misunderstood people accused of witchcraft at the stake.

The film features several clips of interviews illustrating her point of view, but to my own professional eye, these clips often sow more doubt than support for her claims. She discusses one murderer who had visible abnormalities on potentially key brain regions on neuroimaging. There is a compelling argument for considering the contributions of pre-existing neurobiology to criminal behavior, with a significant body of research to date indicating genetic trends in antisocial behavior and differences in neuroimaging and serotonin modulation in studies of criminals. But she doesn’t seem to incorporate those crucial biological findings much and focuses more on her clinical interview where she seems adamant that he is exhibiting different personalities at different moments. During another interview with a man who stabbed his partner, she seems oddly naïve, almost trying to become buddies with the rather dramatic patient, who seems extremely suggestible to her whims that he may be exhibiting different personalities. She notes another patient on death row who committed a crime while a teenager is psychotic and hallucinating before her eyes and shifting between personalities … when to me he just seems cognitively slowed and willing to tell her what she wants to hear and did not appear to be actively hallucinating. She (and a neurologist colleague she partners with) seem all too eager to dismiss other realistic possibilities like secondary gain through an insanity defense, or the frequently manipulative and lying nature of people with severe antisocial personality traits. Overall, she comes across as ready to shoehorn all these people into her core theory re: DID, even Ted Bundy, her star interview and the movie’s climax.

Her explanation of Bundy, well known to be one of the most prolific and cunning serial killers of all time, as someone who suffered from childhood abuse and DID seems strained when she argues that his different signatures in letters to his wife and use of different nicknames indicate various split personalities.

At other times her theories seem contradictory and incoherent. She discusses neurobiological contributions to these criminals’ behavior which would seem to argue that their behavior is ingrained to some extent (and perhaps not totally their fault in that sense) but then in turn argues that criminals are “not born but made.” She mentions a chilling anecdote where Bundy apparently threatened a relative with a set of kitchen knives at age 3, an age where one might argue he could not have learned that behavior from anyone. She insists Bundy’s grandfather was abusive, but various family members contradict that story.

While there is no doubt to me that childhood abuse and trauma can contribute to criminal behavior, with the learning of maladaptive violence and anger, it cannot be the sole cause either, given that so many victims of abuse and trauma also never become serial killers or even necessarily mean or aggressive people. Also, such trauma and its links to DID are also rare and unique; it isn’t a given that everyone with trauma develops anything as extreme as DID, which itself remains a hotly debated diagnosis, although most psychiatrists agree dissociative behavior (not necessarily discrete personalities) can be a common defense mechanism and form of avoidance against traumatic memories. It is certainly a leap to say that DID is linked to most serial killers and murderers. If anything, their high frequency of antisocial personality traits posits they would be more likely to feign such personalities, either for actual gain, or just for its own sake. For someone who has interviewed and worked with so many criminals, Dr. Lewis’ seems curiously naïve about the frequency and broadness of these severe manipulative behaviors, which I and most psychiatrists have encountered very routinely in these populations.

She also seems unaware of high comorbidities of unstable personality structure in criminals, leading to histrionic and borderline traits as well, which can be mistaken for supposed DID. These other personality types have traits of unstable self-image and self-esteem, which are indeed tied often to trauma or insecure attachment as children and can lead to mood swings and identity disturbance. But they do not necessarily lead to frank DID. These individuals also tend to be highly suggestible to outside influences and “feeding symptoms” in order to gain various forms of attention, both consciously and unconsciously.

Unfortunately, with this very public platform, Dr. Lewis will spread her oversimplified message of the origins of severely criminal behavior as all tragic, misunderstood victims of DID. While I completely agree with her thoughts that a person’s upbringing contributes to their psychological makeup, she splits this factor off into a falsely simplistic relationship between upbringing and behavior: that serial killers all have a particularly horrible upbringing and then inevitably become people with DID. She briefly mentions but doesn’t coherently integrate the possibility of concomitant genetic or neurobiological factors (which also argue against pure culpability of these killers for their actions). She doesn't help assert or clarify that there is a spectrum to the contributions of both biology and environment in these individuals, as well as the types of behavior they engage in. While her core message of compassion for the complexity leading to these killers’ behavior and the moral questionability of the death penalty is a reasonable one, her method of gaining attention for this message may lead to more misunderstanding and confusion about the origins of the criminality she has devoted her career to studying.