Healthcare serial killers

August 24, 2007



This week, my latest book will be released. It’s called Inside the Minds of Healthcare Serial Killers, which pretty much explains the content. Many people think these cases are all alike, but that’s not the case. Whenever I give my undergraduate students a choice about whether I should talk about doctors and nurses who intentionally kill patients (HCSKs) or some other type of killer, they inevitably pick anything else. Like them, few people realize is just how unusual some of these killers are. They’re not mercy killers, although most claim to be. They generally have other motives, and they’re among the few types of serial killer for whom we can actually do a fairly accurate risk assessment. In retrospect, the red flags were all there.

Among the strangest is Dr. Michael Swango, who pled guilty to several counts of murder in 2000, although we may never know how many people he actually killed. Now here’s a guy who, during medical school and an internship, avidly collected stories about car accidents, deliberately poisoned coworkers, and openly admired Henry Lee Lucas, who he believed had wandered the country killing without consequence. Ted Bundy and Jim Jones were among Swango’s heroes, as was James Huberty, who slaughtered customers at a McDonald’s in 1984. Swango one told a female paramedic he’d like to plunge a hatchet into her head and revealed a violent fantasy to colleagues: he wanted to rush to the scene of an accident involving a school bus and a truck filled with gasoline. Another bus would slam into the truck, causing an explosion and sending kids flying. Nothing excited him more, except perhaps to tell families of patients that their loved one was dead. For him, that was truly erotic.

A few people saw the warning signs, but not most of Swango’s superiors. They kept ignoring the problems and when Swango finally managed to work on patients, a number of them died. He wasn’t called Double-O Swango for nothing – he had a license to kill.

Like many HCSKs, Swango succeeded by moving on from one establishment to another, and even going overseas. It was in Zimbabwe that one of the most bizarre stories emerged about him, as recorded in James Stewart’s excellent true crime narrative, Blind Eye. (It was also in Zimbabwe where his killing career was finally stopped.) He rented a room in a house that provided meals and every morning demanded the same breakfast: two eggs, four slices of toast, and a kilogram of fried bacon. Time passed and one day a servant went into Swango’s room. On a closet shelf she found dozens of neatly wrapped bacon sandwiches piled on top of one another, and in a drawer there were more. He hadn’t been eating all this bacon and bread, he’d been hoarding it – without refrigeration. Bizarre, but fascinating, and very likely related to his desire to kill.

The cases of HCSKs seem to have increased over the past decade and each one has its own peculiar stamp. Although it was my editor who suggested the book, I found that it was certainly a subject worthy of analysis – disturbing as well – and my hope is that what emerged from my study will help make our healthcare facilities safer. At the very least, someone who poisons associates and fantasizes about dead children won’t just be ignored or encouraged to go work elsewhere.



Psychopath vs. Sociopath

July 16, 2007

I’m often asked about the difference between a psychopath and sociopath, and it’s difficult to respond because the answer is complex. Many people mistakenly believe the two terms are interchangeable, which is no surprise since both politics and religion have influenced the long evolution of the concept of psychopathy. Thus, I want to discuss why we haven’t designated a single label for a certain type of personality disorder.


It was Theophrastus, a student of Aristotle, who first described this type of person, referring to him as the Unscrupulous Man. He was a liar, cheat, and con artist, without compunction about harming others for his gain. Thus, something was morally wrong with him. (Female psychopaths had not yet come into the picture.)


While psychopathy was the first personality disorder that psychiatry formally recognized in the nineteenth century, it wasn’t easy to crystallize a workable concept for analysis or research. Pinel, a French psychiatrist, used a phrase during the early 1800s that translated as “mania without madness.” He described impulsive people whose actions had negative consequences for themselves as well as others, yet they were fully aware of what they were doing. It seemed a mystery.


In America, Benjamin Rush designated the same behavior as moral derangement and observed that such people develop socially disruptive behavior early in life. In his opinion, they were bad not ill. An English physician, calling it moral insanity, viewed psychopathy as an emotional disorder: These people had criminal tendencies that were not deterred by the idea of punishment.


The actual term, psychopath, first showed up in Germany, during the latter part of the 19th century, but it also covered certain biological disorders, and by the early part of the twentieth century, “constitutional psychopathic inferiority” had become a catchall term for most mental and physical defects. Then brain damage and physiological conditions were placed in another medical category. The next step was to remove ‘constitutional’ from the classification, which still left the unworkably broad ‘psychopathic personality.’ For the percentage of people not psychotic or psychoneurotic who nevertheless caused distress in the community, the most common designation was psychopath.


More psychiatrists worked out ways to refine the concept, but it wasn’t until 1941 that the notion of a psychopath was ably crystallized. Hervey Cleckley published The Mask of Sanity, in which he offered 16 distinct criteria for diagnosis, including hot-headed, manipulative, irresponsible, self-centered, shallow, lacking in empathy or anxiety, and likely to commit more types of crimes than other offenders. They are also more violent, more likely to recidivate, and less likely to respond to treatment.


Now, what about the sociopath? As the concept of psychopathy continued to evolve, the emphasis on assessment in psychiatric circles moved away from traits and toward specific behaviors. To reflect this, some older concepts were renamed. In 1952, in the psychiatric nomenclature, the word ‘psychopath’ was officially replaced with ‘sociopathic personality,’ and both terms were often used interchangeably under the heading of ‘personality disorder.’ Then with the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) in 1968, ‘sociopathic personality’ yielded to ‘personality disorder, antisocial type.’ Such people were impulsive, guiltless, selfish, callous, and unable to learn from experience.


Twelve years later, the DSM-III introduced a list of explicit criteria for psychopaths, but calling it Antisocial Personality Disorder (ASPD). The criteria emphasized the violation of social norms rather than personality traits. However, many researchers were dissatisfied with this new approach because it had no utility.


During the seventies, some researchers ignored the DSM and devised better diagnostic assessments for the traditional notion of a psychopath, as Cleckley had viewed it. Robert Hare and his colleagues in Canada devised the Psychopathy Checklist (PCL-R), with 20 items covering both traits and behaviors. Yet most mental health professionals in the U.S. stuck with the DSM, as if ASPD meant the same thing. But it didn’t. ASPD is a broader category, inclusive of people who would not qualify on the PCL-R as psychopaths, and while some psychopaths might also be diagnosable as ASPD, it would not apply to all people diagnosable as psychopaths. Thus, the terms refer to overlapping but nevertheless different categories of people. (Try saying all of that five times, fast.)


Researchers who followed the traditional idea viewed psychopathy as a disorder characterized by such traits as lack of remorse or empathy, shallow emotions, manipulativeness, lying, egocentricity, glibness, low frustration tolerance, episodic relationships, parasitic lifestyle, and the persistent violation of social norms. According to Hare, “Psychopathy is one of the best validated constructs in the realm of psychopathology.”


Without getting the complex politics surrounding the different diagnostic systems, people who were unaware of the need for precision and accuracy for research and assessment adopted a preference for using either ‘psychopath’ or ‘sociopath’ and came up with their own workable definitions. In other words, things got a little sloppy. I’ve even seen writers use the term ‘sociopath’ but rely on the criteria specific to psychopathy. However, ‘sociopath’ has a different connotation for people who recognize the PCL-R as the best diagnostic assessment.


Which brings me back to the original question: the difference between a psychopath and sociopath. If you subscribe to the Hare criteria for a psychopath, then you see the conning, manipulative narcissistic liar and user as a psychopath, as long as he or she is completely lacking in remorse or empathy. The sociopath, however, is capable of guilt, caring, building relationships, etc., but only within a certain context. He or she will have loyalties to a specific group but not to society at large. They care nothing for social norms and will break them with impunity, if it serves their purpose. So, on the surface, they look just like psychopaths. However, they might genuinely feel remorse over harming someone within their group or family. They will have a moral code of behavior specific to that context: they might not lie, exploit, or manipulate within the group. Thus, they exhibit psychopathic behaviors in certain contexts but not all.


See? I warned you the answer was complex. Does it really matter? In a practical sense, yes. The PCL-R has been proven to be the best predictor of recidivism in criminal populations, and the best predictor of future criminal diversity and brutality. For those who are working with (or writing about) this type of person, grasping their motivational construct can be crucial to understanding what they’re all about…and what they might do in the future.  As far as I know, there is no equivalent diagnostic tool for a sociopath.

(First posted on “In Cold Blog”)

Powerful Writing

June 4, 2007

The movie, Instinct, is about Dr. Powell, an anthropologist imprisoned for murdering some men after they’ve killed the band of gorillas that had befriended him.  A young psychiatrist, Dr. Theo Calder, is trying to learn how this violence arose so he can get Powell out of prison.   In one scene, he tries to prevent Powell from ending a session early and claims that he is the one in charge.   He will decide when it’s over.   Powell deftly overpowers him, locking him into a life-and-death grip, and demonstrates that if he chose to he could kill him in an instant.   While holding Calder in this crushing arm-lock, Powell urges him to use his free hand and a crayon to write down on a tablet what he has lost in that moment…or else.

Calder quickly scribbles the word, “Control.”

“No.”   Wrong answer.  Powell applies more pressure but gives him another chance.

“My freedom,” he writes, struggling to breathe, his eyes streaming with tears.


 One more chance, Powell tells him, and if he doesn’t get it right, his life is over.  “What have I taken from you?” Powell demands to know.

With a red crayon, Calder slowly spells out, “My illusions.”

That’s the right answer, and Powell lets go.  All along the young psychiatrist had believed that because he was outside the prison and was the one who could help Powell, he was in control.  In fact, he wasn’t, and he realizes from this lesson that much about what he believed he controlled in other areas of his life were illusory as well.  Now, he was enlightened.

That’s like writing.  We are Calder and the writing process is Powell.  In many ways, we think we’re in control.  We’re confident, we have something outlined, and we believe that this is the way it will turn out, more or less, in the final product—exactly as we envisioned, because we are the ones in control.

Yet when writing is truly imaginative, when a writer lives in it and uses it as a medium of human experience, what’s really in control is what writer Colin Wilson calls “Faculty X.” 

* It’s that sudden inspiration at the edge of consciousness that makes a story work in an unexpected way

* It’s that annoying tug of some notion that we resist in order to stay focused but which, when we stop resisting, turns out to be much better than what we had planned

* It’s that unbidden image that floats into a daydream that we never would have thought of outside the trance

* It’s when you have an interesting problem and rather than panic you allow something within yourself that is not within your mental control to solve it.

Your imagination and inner creativity can take you places that you’ve never known, but to get the best effect you must let go of the illusion, like Calder, and let it have its way.  That means you must trust something you can’t clearly grasp.

Wilson says that Faculty X is the ability to dissociate and put yourself out of your here-and-now thinking and move completely into your fantasy so that it becomes just as real.  It’s getting in touch with the part of you that is not controlled by your rational brain—a part that you rational brain does not even know.  I would add that, while it’s all of that, it’s also the ability to allow that fantasy its own manifestation, even if you can’t see where it’s going.  It’s letting yourself learn from a teacher who remains always behind you and who knows best what you need.

Going out in Faith

            In the story by Antoine De St. Exupery, The Little Prince, a pilot is stranded in the desert with a defunct plane.  He meets a little man who claims to be the prince of a different planet who has recently journeyed to Earth.  The prince relates to the pilot many startling observations from his journey and as he talks, time passes and the pilot grows increasingly afraid that he will run out of food and water before he can fix the plane.  The prince is unfazed.  All they need do, he says, is walk out into the desert and find a well.  

The pilot thinks the prince is a little nuts.  If they don’t know precisely where this well is and how far away, they could die before they ever reach it—if it’s there at all.  No, it’s better to remain with the plane, he believes, something he knows well enough to feel that he can make it work.  He trusts to that.  It’s familiar.  He’s in control.

But the prince insists.  He has complete faith that the well is there and that taking the risk is their only salvation.  They must go.

Finally, begrudgingly, only when he realizes that he is no closer to getting this plane off the ground, the pilot agrees to leave what he knows and walk into the unknown.  They trudge across the desert for some time and see no well.  The pilot’s initial doubts eventually become serious concerns.  They should never have left the plane!  He believes he could have fixed it by now, and it’s too late to turn back.   They could never get back there before they die from thirst.  But just when he feels sure they have made a fatal miscalculation, the prince discovers the well and all is saved. 

            We crave knowledge about the right direction.  We want to know exactly how our writing will turn out.  We seek to have a sense of progress and clear orientation.   But it’s better to trust things we don’t know.

            Trust is living inside the language so that you can invite others to enjoy the fullest experience.   They’re not just reading a story told in words, they’re coming inside a world.  There’s a moral responsibility attached to that and writers know its burden.   But they also know that they can’t do it any other way and still achieve a comprehensive exploration and expression of their imagination. 

            When you stop trying to control and instead immerse and allow, you will see and feel more.  Like Calder, you are forced to see and feel more.   Writing can grab you and lock you in a life-and-death hold until you admit that something more than your well-organized vision is at stake.  There’s a beating heart with a life of its own, and you need to find it.

            When I write, I trust that there is a center to the work, a hot spot from which everything else radiates, even though when I first begin I don’t know what it is.  I only sense it.  I know it’s there, but I don’t have a handle on it.   Sometimes early in a project I think I know and I believe I have control over it, but along the way somewhere, the work throws me to the desk to make sure I’m aware that I’m not the one in control.  Something that happens when I come together with the work is where the truly creative process goes on.

            I learned this by writing biographies.  To tell the story of a life, I needed to understand the person’s central dynamic, their beating heart, and I did that only with full immersion in both their life story and in the manner of language in which it had to be told.

            Then I learned this same thing by writing a novel.  I had written a short outline, sold it, and then faced having to finish it.   But the outline was my attempt to control the story, and the story had its own ideas.  At many points, I did not know where it was going and eventually the deadline was drawing near.   I didn’t know what to do.  Where was it going?  My saving grace was to go for walks, and that’s where I found the beating heart.   Whenever I went out while writing, a plot twist would pop into my head and as I walked, it worked itself out to the point where I was nearly running back home to get it on the page.  This went on for 300 pages, and when the second novel sold, I had learned to trust that the same process that had happened for me with nonfiction was there for me with fiction, too.   It was fun, if nerve-wracking at times.

            Finally, I was faced with co-writing a book.  The book was my idea but it was the other person’s material.  He was a former FBI agent from the Behavioral Science Unit.  He did not know what to do, but I convinced him that I did.  I was the “prince” telling him there was a “well” out there in the desert and we would find it.  I’d never written with someone else before, so I knew I was going to have to learn how as I went along. 

Now the trust factor was really a test.  I was going into the desert with material I didn’t even know and I couldn’t be sure that the beating heart would be there.  And we worked for over a year before I found the point where the book came together.  It was on the very last day at the very last hour before we had to be done, but it did happen.

            Here’s how:  The process was for Gregg McCrary to go over his cases with me and we picked those that would illustrate what he most wanted to get across.   We talked for two long days to see if we even had a book, and at the end of the second day, I saw it.  His approach to profiling and investigative analysis was through a martial arts perspective, so that was to be the context.  He explained how he used mental discipline to prepare himself for the bad guys.  His notion, from Shorenji Kempo, was to use the aggressor’s energy against him:

“When confronted, you’re taught to empty your mind of all preconceptions and to center yourself.  This allows you to correctly read a potential attack and, without hesitation, employ the proper defense.  Rather than attack back, you blend with the opponent’s attack and use his own momentum against him.  Although your instinct when pushed is to push back, instead you pull.  It’s analogous to when someone prepares to push open a door that he thinks will be difficult, and just as he starts to force it, you pull it open from the other side.  Because the opponent meets no resistance, he falls forward.”

            So we went along, building ten chapters with separate cases and mentioning the martial arts applications here and there.  It was a theme but it was not yet the beating heart.  I went over and over the material and couldn’t see how to pull out that hot spot around which the book contents would radiate.  We finished the first draft and then got to the draft we were going to turn in, and still it wasn’t there.  We sent it for editorial suggestions and did our revisions, and it still wasn’t there.

            By this time I’d read and reread this material so many times I knew it by heart.  We were on the final round, the copy-edited manuscript.  After that, the only changes we could make would be minor.  We were right up against the deadline.  I had to get this manuscript ready to mail the next day.  Gregg and I got on the phone and went over any last-minute changes.  It was nearly done, so I gave up and decided, OK, it was just going to be a book that would not have that center.  I wasn’t happy but did not know how to fix it.  To take a break, I went out for a walk.

            Because I deeply immerse in my writing, my walks are always like films of the books—they play out visually the entire time I’m walking.

            About fifteen minutes into this walk, one scene from the book unfolded in my mind and there it was.  The epiphany!  I knew where the hotspot was.  I ran back home, typed it up to include in this last draft, and emailed it to Gregg.  He called right away and said, “I wouldn’t change a word.”

            The “moment” was this:  In all of his investigations, he generally consults from the sidelines and does not get face to face with a killer.  His mental preparation is devoted to “reading” the criminal behavior, not actually sparring with a killer.  But there is one case in the book in which he must put that martial arts into action, and do it fast.  He was in court in
Austria and the serial killer, Jack Unterweger, was defending himself.  He had killed eleven women in three countries and because he was a bestselling writer and popular journalist, he believed he could charm the jury as he had charmed everyone else.  However, he was not prepared for a behavioral analysis from the FBI that clearly linked him to all eleven crimes and throughout McCrary’s testimony, Jack directed his lawyers to cross-examine him.  But he watched like a hawk.  At some point, he apparently decided that he needed to say something to McCrary.  It was not allowed, but he got up and crossed the room anyway.   No one stopped him, and now McCrary had to consider what to do.  

“The judges ordered a morning break around 10:30.  We all stood as the jury was dismissed and then I bent over to collect my notes and place them into my briefcase.  I didn’t know until I looked up that Jack had come out of his chair and was walking with purpose right over to me.  The police officers and his attorneys ordered him to stop, but he wasn’t listening to them.  This was Jack, after all; the one who would introduce himself to the local police before he murdered; the one who would interview unwitting investigators about the progress of their investigation into his murders; the one who charmed and manipulated the Viennese literati into springing him from prison.  Of course he would approach me without any hesitation.  He was even smiling.

“I shouldn’t have been surprised, but I was.  And yet this was the moment for which I had trained for so many years, the moment when I was to assess without thinking the type of energy my opponent directed toward me, and use it against him.  I quickly centered myself and waited until he was within two feet of me, where he stopped.  In broken but understandable English, he said, ‘The first murder was not a sexual homicide.’ 

“I realized he was referring to the 1974 killing of Margaret Shaefer.  He was correcting me, but I knew that he was also attempting to charm me.  His was a manipulative energy, and he knew I was a strong witness against him.  Thinking fast, I replied, ‘Is that right?’  Then with the force of his own cunning, I added, ‘But the others were?’ 

“At that point, his attorneys and a police officer grabbed Jack and pulled him back toward his seat, but I saw the light in his eyes.  He shook his head, smiled and responded, ‘A clever question.’  I sensed that he appreciated my wit, but he’d sidestepped the small verbal trap that I had laid for him.  Yet in that brief moment, we had been caught in a zone of two minds engaged in silent combat.  I would never forget it.”

Jack was convicted.

McCrary’s experience with the Shorenji Kempo moment was like my experience with creativity.   You prepare and prepare and you know your stuff so well, and you can’t predict the moment when all of that preparation will pay off, but you can just immerse and trust the process so that when it’s needed it will flow forth.  His martial arts, like my walking, was the conduit for the creative process to rush in and save the moment.

And I love that.  It’s scary, because you really need it to happen and maybe some day it won’t, but the exciting part is to trust that it will happen, and then when it does, the rush you get (and the results) are so far beyond what you could have created under more controlled conditions. 

            There’s an organicity to writing.  You live it when you trust it and immerse in it, and it repays you with character, idea, and plot that already thrives within you.  The body is the conduit and you need to find the way to let what’s inside flow forth, then boldly go seek the well that is there, even if you can’t see how far away it is.  Once you lose your illusions about how much in control you are of language and story, and admit that there is a power that you don’t mentally grasp, you can let that power amaze you.

            A poet recently said to me that she understood all this but had a hard time knowing what to trust.  I said, “It’s not what to trust, it’s that you trust.”  The “what” will emerge as a result. 

Why we should dig up Houdini

May 13, 2007

In April, forensic experts announced their intention to examine the exhumed remains of escape artist, Harry Houdini.  They hope to determine whether the renowned showman was poisoned after his last performance on October 24, 1926, killing him on Halloween.  Some people say leave the dead in peace, but if scientific methods unavailable back then can solve a mystery that still commands attention, why not use them?

Houdini was 52 and in excellent physical condition when a young man responded to his challenge to punch him in the stomach, hitting him before he was ready.  He suffered the effects the following day and ended up in Detroit’s Grace Hospital.  Apparently his appendix had ruptured, causing fatal peritonitis, although no autopsy confirmed this diagnosis (and the death certificate placed the appendix on the wrong side).  Despite his risk-taking career, his sudden demise shocked the world.  Houdini was buried in Machpelah Cemetery in Queens, New York, and now, more than eight decades later, his grandnephew, George Hardeen, seeks the truth.  He initiated the exhumation, but some critics claim it’s a publicity stunt for a book.

A recent biography, The Secret Life of Houdini, published last year by William Kalush and Larry Sloman, revisited rumors that Houdini was murdered and detailed suspicious circumstances surrounding his death.  Their chief suspects were members of a group called the Spiritualists, because Houdini had devoted himself to debunking their séances.  He even offered a cash prize for proof of their claims, which was never collected.  Not surprisingly, say the authors, Houdini received several anonymous death threats.  It makes for enticing, albeit controversial, reading.

Still, it seems unlikely that a team comprised of busy and prominent professionals would engage in this venture just to sell someone’s book.  Heading the team is James E Starrs, professor of law and forensic science at the George Washington University, who has organized twenty exhumations, including those of Jesse James and Albert DeSalvo, the so-called Boston Strangler.  Also on board are forensic pathologist Michael Baden, anthropologist William Bass III (founder of the “Body Farm” in Tennessee), and toxicologist Bruce Goldberger, president of the American Academy of Forensic Sciences. 

With other scientists and technicians, they intend to analyze the fingernails, bones, hair, and any remaining soft tissue for signs of lethal poisoning.  Detectable metal-based poisons might still be evident, says Starrs, which justifies the project.  He adds that decisions to do an exhumation are never simple, but “some notable people die surrounded by legends and half-truths, making it legitimate to exhume their remains in an age where science can supply answers to the cause and manner of death, especially if the person in question has historical significance.”  Houdini seems a viable candidate.

Besides the potential state of the remains, other factors motivate the dig.  Starrs thought that Kalush and Sloman had pinpointed items of “an extraordinarily suspicious nature.” First, Houdini apparently suffered from ptomaine poisoning of unknown origin a few weeks before he died.  Second, a doctor had injected Houdini with an “experimental serum,” and no one knows what it was.  Third, the death threats. 

“Houdini was an enemy of the Spiritualists,” Starrs notes, “and according to this biography, one of the other anti-Spiritualists traveling the same terrain as Houdini also died under mysterious circumstances.”

In fact, the biography includes a letter written two years before Houdini died, in which Spiritualist devotee Arthur Conan Doyle (once Houdini’s friend) hinted that a “payday” was coming and Houdini would “get his just desserts very exactly meted out.”  Conan Doyle apparently meant that angry spirits would do the deed, but who knows?

A surprising presence at last week’s press conference was Anna Thurlow, the great-granddaughter of the medium, “Margery,” whose husband, Le Roi Crandon, was one of spiritualism’s most ardent proponents.  She fully supports the exhumation, even if it means learning that Houdini was indeed a victim of foul play.

But there’s another question about this death investigation: would Houdini have approved?  Before he died, he vowed that if there was an afterlife, he’d return; he gave his wife a secret code by which to identify him and ensure that no one feigned contact.  Despite a decade of attempts, no medium ever duplicated his code.  Given his emphasis on evidence, it seems likely that the Great Houdini would have appreciated this science-based – and attention-getting – approach.

Blog rookie

May 12, 2007

kath-w-stiff-2.jpgI’ve written 30 books.  I’m currently at work on 3 more.  I write about the dead, whether vampires, ghosts, corpses or victims of violence.  I don’t know why; I don’t try to solve my own mystery.  That’s what keeps me writing.