The voice that only one person could hear

On January 24, 2023, Lindsay Clancy, a 32-year-old registered nurse living in Duxbury, Massachusetts, killed her three children. Cora was five, Dawson was three and Callan was eight months old. Clancy strangled them with exercise bands in the basement of the family home while her husband, Patrick, was out collecting takeout food from a restaurant and a laxative from a pharmacy.

She then went upstairs to the master bedroom, locked the door and used a kitchen carving knife to cut both her own wrists and several areas of her neck. The bloodstained knife was later found on a bedside table.

Although there was a lot of blood splashed around the bedroom, she apparently failed to sever a major artery in either her arms or neck. Some first responders described the wounds as superficial and said they were no longer actively bleeding, while more detailed medical evidence described multiple superficial lacerations together with some deeper wounds.

Clancy then jumped out of a second-floor window and landed on the frozen ground in the backyard. The fall shattered vertebrae and damaged her spinal cord, leaving her permanently paralyzed below the waist and wheelchair-bound

Her husband Patrick returned with the fast food only to find the bedroom locked, so he  unlocked the door with a spare key, and found blood around the room and the window open. He then ran downstairs and outside and found his wife lying on the ground,  seriously injured. She told him that she had tried to kill herself. When he asked where the children were, she directed him to the basement, where he found all three unresponsive and called 911 for an ambulance.

There has never been much dispute about who killed the children. The question at Clancy’s recent trial was whether she committed deliberate murder or was she so severely mentally ill that she could not appreciate the wrongfulness of what she was doing?

(The law on criminal insanity in Massachusetts differs from most states, but I will not discuss that issue here.)

The defense argued that she was suffering from postpartum, or puerperal, psychosis and obeying a male voice that commanded her to kill the children and then herself, while the prosecution argued that she was depressed and anxious but still understood her actions and deliberately arranged for her husband to leave the house so that she could kill the children and then herself.

After more than five weeks of testimony and approximately 38 hours of deliberation, the jury could not reach a unanimous verdict. The judge declared a mistrial on September 4. According to the defense, the jury stood 11 to one in favor of finding Clancy not criminally responsible, although jury deliberations are not normally disclosed officially. Prosecutors must now decide whether to set up a new trial with a new jury.

The case is particularly difficult because nobody doubts that postpartum psychosis is real. It is a rare but well-recognized psychiatric condition that can include hallucinations, delusions, paranoia, severe confusion and dangerously impaired judgment. In its most serious form, it can place the lives of both mother and child at risk.

Clancy had also been experiencing serious psychological problems in the  months since the birth of her youngest. She repeatedly sought professional help, was hospitalized and was prescribed or tried numerous medications. These included different antidepressants, drugs for anxiety and sleep, and Seroquel (quetiapine), the only drug in the assortment normally classified as an antipsychotic.

Apparently there were 13 drugs, although some reports said that she also took Benadryl, which would actually bring the numer up to 14.

Reports that she was given 13 (or 14) psychiatric medications can be misleading if they suggest that she swallowed all of them together. Nevertheless, she unquestionably passed through a complicated and frequently changing series of prescriptions during the months before the deaths.

Her family described insomnia, anxiety, depression, paranoia and fears about harming herself or the children. This was not the type of case in which a completely undocumented mental illness was first mentioned by a lawyer on the courthouse steps.

Nevertheless, the central claim remains impossible to prove: Did Lindsay Clancy really hear a male voice telling her to kill her children?

People who hear voices do not carry recording devices inside their heads. There is no blood test, brain scan or laboratory examination that can establish that a particular hallucination occurred at a particular moment. Psychiatrists can examine the patient’s history, behaviour, consistency and surrounding symptoms, but ultimately the voice exists only in the account of the person who says she heard it and cannot be heard by anyone else.

That difficulty becomes especially important after criminal conduct. A genuine command hallucination may explain otherwise incomprehensible behaviour, but a fabricated command hallucination can provide an equally convenient explanation for it.

This does not mean that Clancy invented the voice. It means that nobody else can know with 100% certainty whether she invented it or not.

There were reasons for the jury to take the claim seriously. Clancy described the voice relatively soon after the killings while she was still hospitalized, including in conversations with a hospital chaplain. Witnesses had observed a substantial psychiatric deterioration before the deaths, and she had already expressed fears that she might harm the children.

There were also reasons for caution. None of her treating professionals had documented complaints of auditory hallucinations or hearing voices before the killings, despite her numerous contacts with mental-health services. The alleged voice apparently arrived during the period in which she killed the children and disappeared afterwards.

Her descriptions of its message also varied. In one account, the voice said that she and the children would not be safe unless she obeyed. In another, it told her to kill the children so that she could then kill herself.

The sequence of her suicide attempt is also important. Self-cutting is commonly encountered in psychiatric facilities. It is usually not fatal and may occur for several different reasons, including emotional release, self-punishment, communication of distress or an actual wish to die.

Patients who survive sometimes often say that they intended suicide, but the statement alone does not establish the degree of intent present at the time,and anyone who researched methods of suicide would easily find out that self cutting was not a very effective method of committing suicide.

Clancy was a highly trained registered nurse. If she had calmly planned to die by cutting her wrists or neck, she would presumably have known that death required damage to major blood vessels. Yet she used a carving knife to make numerous cuts without severing a single artery and then resorted to jumping out of an upstairs window from about 20 feet.

That does not look much like a carefully calculated suicide method. It looks more like an improvised and escalating sequence: cutting first, discovering or fearing that it had not worked, and then choosing the window.

But that observation also cuts in two directions.

The defense could say that this chaotic progression is consistent with a woman in an acutely psychotic or dissociated state, acting under a command without rationally planning how to carry it out. The shattered spine, exposure on the frozen ground and dangerously low body temperature certainly make it difficult to dismiss the entire episode as theatrical self-injury.

The prosecution could answer that an unplanned suicide attempt after the killings does not prove that the killings themselves were unplanned or psychotic. A person might deliberately commit murder and then panic, despair or attempt suicide after confronting what she had done.

Indeed, the prosecution eventually clarified that it was not arguing that Clancy’s suicide attempt was wholly fabricated. Its position was that the cutting methods she initially chose were unlikely to achieve death. The defense pointed to the subsequent window jump as compelling evidence that she genuinely intended to die.

Both propositions may be true. The cutting may have been medically ineffective, while the overall sequence represented a genuine and increasingly desperate suicide attempt.

The expert witnesses predictably reached different conclusions about her mental condition. A defense psychiatrist believed that Clancy was psychotic and acting under a command hallucination. Prosecution experts believed that she was suffering from depression and anxiety but retained the ability to distinguish right from wrong. One noted that the alleged voice appeared without the broader delusional system often accompanying command hallucinations.

However, there is another important factor, which is that Clancy’s professional background adds a whole new layer.

She held a bachelor’s degree in biology, completed an accelerated nursing degree and passed the national licensing examination for registered nurses. She then worked for approximately nine years as a labor-and-delivery nurse at Massachusetts General Hospital.

She was not a psychiatrist, psychiatric nurse practitioner or certified nurse-midwife. But it would be difficult to believe that an experienced labor-and-delivery nurse knew nothing about postpartum psychosis.

Psychiatry and maternal-newborn care are substantial parts of nursing education and licensing examinations. Puerperal psychosis appears in ordinary nursing and obstetric textbooks. A nurse working for years among women giving birth would also hear about it from doctors, nurses and coworkers, even if she rarely encountered a florid case herself.

Charlie Larga has decades of experience in hospital management and risk management. One lesson from that experience is that professional knowledge does not make people immune to mental illness. Doctors can become delusional, nurses can become addicted to drugs, and psychologists can fail to recognize that they are falling in love with patients.

Another lesson, however, is that professional knowledge can work in two directions. It may help someone recognize symptoms and seek treatment, but it can also provide the vocabulary needed to describe, exaggerate or fabricate them.

Clancy would have known that thoughts of harming herself or her children were a psychiatric emergency. She would also have known that hallucinations and delusions could be evidence of psychosis. Her training therefore supports the prosecution’s argument that she was unusually capable of communicating clearly with her treatment providers.

At the same time, the defense can argue that her repeated efforts to obtain treatment show that even a knowledgeable nurse could not navigate an increasingly fragmented course of illness and medication.

The big mistake is to treat either interpretation as self-evident.

It is possible that Clancy was a gravely ill woman who sought help but descended into a brief psychosis that destroyed her family. It is also possible that she was seriously depressed but nevertheless deliberately killed her children and later attached a psychiatric explanation to what she had done. Depression, anxiety, self-injury and even a genuine suicide attempt can all exist without eliminating criminal responsibility.

Patrick Clancy’s continued sympathy for his former wife does not answer the legal question either. He lost all three of his children and has chosen to understand their deaths through the framework of mental illness. That position deserves respect, but it is neither medical evidence nor a verdict.

Whatever eventually happens, Lindsay Clancy is unlikely simply to return to ordinary life. A first-degree murder conviction could mean life in prison. Conviction of a lesser offence could still mean many years of imprisonment. A finding that she was not criminally responsible could lead to confinement in a secure psychiatric institution, with release dependent upon repeated findings that she no longer presents a danger.

Given the deaths of three small children and the severity of the illness asserted by her defense, psychiatric confinement, treatment and supervision could also continue for years.

One form of confinement would be punishment and the other treatment, but neither outcome amounts to walking free.

The jury’s deadlock may therefore reflect more than indecision. It may also reflect the honest limit of what courts, psychiatrists and ordinary citizens can determine about a voice that, if it existed at all, was heard by one person alone.