A QUALITATIVE EXPLORATION INTO THE
SUBJECTIVE EXPERIENCES OF HEALTHCARE
SERIAL KILLERS
Chapter 1: Introduction and Present Study
Serial homicide claims a significant number of lives annually (Hickey,
2009). In the aftermath of these crimes, devastation ensues for the families of these
victims. Yet, the effects of serial homicide extend beyond the victims and their
families, leaving the wider community devastated from the brutality of these
crimes. According to the Federal Bureau of Investigation (FBI), serial homicide is
the “unlawful killing of two or more people in separate events” (Federal Bureau of
Investigation [FBI], 2008, p. 9). It is a unique phenomenon due to the often-brutal
nature of the crimes, how it is orchestrated, and the atypical motivations of a serial
killer (Skrapec, 1997). Many researchers agree that serial killers are (1) primarily
motivated by psychological gratification (Adjorlolo & Chan, 2014; Reid, 2017) (2)
may engage in brutal acts of violence (e.g., torture) to prolong the murders of their
victims and (3) select specific victims in the community that meet their “ideal
victim type” (Ressler et al., 1988).
Research suggests that vulnerable groups in society (e.g., sex workers) are
likely to be targeted by serial killers (Egger, 1985; Lee & Reid, 2018). According
to Egger, serial homicide victims are typically “vagrants, prostitutes, migrant
workers, homosexuals, missing children, and single and often elderly women” or
other socially powerless groups who belong to a lower socioeconomic class
(Egger, 1985, p. 9). In addition to Egger’s list, many missing and murdered
Indigenous women, who receive little police attention, continue to be victims of
serial homicide (O’Reilly & Fleming, 2016). Serial killers may wear a veneer of
normalcy and can easily blend in with a regular crowd of people, which makes
them even more dangerous (Skrapec, 1997). Psychopathic serial killers are social
chameleons and know how to garner trust in potential victims prior to murdering
them (Hare, 1993; LaBrode, 2007). It can be reasonably argued that serial
homicide should receive more academic attention due to a serial killer’s ability to
appear unsuspecting and the unsettling trend of marginalized groups being their
primary targets.
Further academic research on serial homicide could contribute to a better
scientific understanding of this crime and its perpetrators. Research on serial
homicide has focused on seeking patterns in characteristics of the offenders and
their victims (e.g., social and psychological factors) (e.g., Ressler et al., 1988),
police investigative failures (O’Reilly-Fleming, 1992; LePard et al., 2015; O’Reilly
& Fleming, 2016) and crime scene analysis (e.g., Keppel & Walter, 1999). Extant
research has revealed potentially significant factors that may contribute to the
development of serial killers and the continuation of serial murder for extended
periods of time. However, qualitative inquiry of serial homicide is an area that
remains largely unexplored (Beasley, 2004; Henson & Olson, 2010). Yet, studying
serial homicide through a qualitative lens can provide richer details about serial
killers in their motivation and how they murder repeatedly.
This study aims to explore the perspectives of an underexplored subtype of
serial homicide termed healthcare serial killers (HCSK) using qualitative methods
to broaden the knowledge of serial homicide in its totality. The present study also
aims to examine the subjective experiences of HCSKs within the theoretical
framework of neutralization theory (or techniques of neutralization), which posits
that individuals use verbal justifications called neutralizations to mitigate the
severity and their guilt in committing their deviant actions (Sykes & Matza, 1957).
The purpose is to shed light on neutralization techniques that HCSKs may use
justify their motivations for committing serial homicide. Insights from such
research has the potential to be employed by law enforcement and academia to
identify potential perpetrators and to prevent and halt these crimes in the future.
The methodology to be utilized in the current study will be described in detail
following the literature review and the section on current theories of serial
homicide.
Chapter 2: Literature Review
The Significance of Serial Homicide Research
There are several points that demonstrate the importance of studying serial
homicide academically. Firstly, it has been noted that serial homicide is currently
lacking research attention (Culhane et al., 2011; Reid, 2017). Reid has suggested
that serial homicide has received little academic attention since the 21st century.
According to Reid, it has primarily been a law enforcement area of study with the
FBI being the greatest contributor of research within this field (e.g., Ressler et al.,
1988). Law enforcement agencies have created typologies of serial killers and their
crime scenes as guides for law enforcement personnel working in homicide cases
(Douglas et al., 1992; Hazelwood & Douglas, 1980; Keppel & Walter, 1999). One
notable example is the FBI's dichotic Organized/Disorganized typology of serial
sexual homicide, which categorizes serial killers as either being Organized
(methodical/planned) or Disorganized (frenzied/unplanned) killers based on
evidence from their crime scenes and methods used to assault victims (Douglas et
al., 1992; Hazelwood & Douglas, 1980).
Law enforcement research has also provided an understanding of how serial
sex killers (SSK) develop by investigating the psychosocial stressors that are
common among them (Burgess et al., 1986). Burgess et al., a team of academics
and FBI agents, developed the motivational model, which posits that an SSK
develops through a trajectory of five interacting stages. They proposed that people
who commit sexual homicide are likely to experience childhood trauma followed
by increased isolation, violent fantasies, and antisocial behaviours, which lead up
to the commission of sexual homicide.
Despite the contributions of the FBI and law enforcement agencies, research
has shown there may be some empirical issues with law enforcement models of
serial homicide (Bennell et al., 2019; Canter et al., 2004; Kerr & Beech, 2016).
Canter et al. (2004) evaluated 100 crime scenes and found that few crimes matched
the Disorganized subtype, suggesting that this model may lack the ability to
classify all cases of serial homicide. Similarly, Kerr and Beech (2016) discovered
that not all sexual homicide offenders in their study had gone through the same
developmental trajectory as proposed in Burgess et al.'s (1986) motivational model.
The empirical drawbacks of these models render it necessary that serial homicide
receives further academic attention. This will allow researchers to test and improve
the empirical validity of existing serial homicide models and to uncover new
findings that could elucidate this phenomenon.
Secondly, academics have argued that serial homicide is a rare phenomenon
and that its prevalence rates are low (Skrapec, 2001b; Schlesinger, 2001). This
notion of serial homicide being a rare crime may strengthen the argument that it
may not require as much research attention. Despite this notion, further research of
this crime should not be dismissed since cases do continue to occur with the recent
discovery of serial killers Bruce McArthur and Elizabeth Wettlaufer who both
murdered in Ontario (Lancaster, 2018; McQuigge, 2019). Further research of this
crime may even help prevent and halt future occurrences of serial homicide as
shown in the following example.
University of Toronto researcher Sasha Reid, reported her suspicions of a
potential serial killer in Toronto’s Church and Wellesley gay community to local
police (Vendeville, 2018). She reviewed information from her databases and
discovered a pattern of similar men going missing from this area (Vendeville,
2018). Ultimately, the disappearance of Andrew Kinsman, a prominent member of
the gay community, led to the arrest of Bruce McArthur (Flanagan, 2018). In
addition to Reid, members of the general public had long suspected there was a
serial killer lurking in the Church and Wellesley area (Lagerquist, 2018). Although
Reid’s work correctly identified some characteristics of McArthur (Lagerquist,
2018), ongoing academic research in serial homicide may have the potential to
track down serial homicide offenders and prevent further occurrences
Although serial homicide may be a relatively rare phenomenon (Keatley et
al., 2018; Schlesinger, 2001; Skrapec, 2001b), a disproportionate number of serial
killer victims belong to powerless groups in society (Egger, 1985; Lee & Reid,
2018). Bruce McArthur targeted gay men who came from cultures where
homosexuality is heavily stigmatized, and people struggling with substance abuse
and poverty (McQuigge, 2019). Similarly, Elizabeth Wettlaufer targeted elderly
residents in a nursing home setting who were vulnerable and unable to fight back
(Lancaster, 2018). Egger (2003) posits that marginalized individuals are primarily
targeted as serial homicide victims because society perceives them to be “less
dead”, meaning they are impure, flawed, and offer no value to society (Egger,
2003; Vronsky, 2004). According to this theory, groups such as prostitutes,
Indigenous people, the homeless, and gay people are considered as social pariahs,
and their removal from society via serial homicide cleanses the community as a
whole. Further academic research in serial homicide could help elucidate the
motives and actions of serial killers, which could help prevent vulnerable
populations from being victimized and pushed into the margins further.
Thirdly, there are conceptualization issues in serial homicide due to media
influence and definitional inconsistencies, which academic research can resolve
(Hodgkinson et al., 2017, Reid, 2017; Skrapec, 2001b). Hodgkinson et al. (2017)
has stated that the media has overwhelmingly focused on sexually motivated
murders perpetrated by white males. They argue that this has perpetuated the myth
that serial killers can only be the sexually deranged lunatic who preys on young
women for sexual gratification. This perpetuation narrows the conceptualization of
serial homicide by dismissing cases where the serial killer may be female (e.g.,
Keeney & Heide, 1994) , not white (e.g., Maury Troy Travis) (Hickey, 2009), and
not kill out of sexual motivation (e.g., serial killers who murder in healthcare
settings) (Ramsland, 2007).
In addition, several academics have differed in their definitions of serial
homicide in terms of motivation, the relationship between victim and perpetrator,
and the number of victims per case (e.g., Egger, 1985; Fox & Levin, 1998; Holmes
& Holmes, 1998). This opens the potential of different serial homicide definitions
being used in different studies, which makes it difficult for scientists to confidently
compare results and draw conclusions. Further academic research can both clarify
the common myths concerning serial killers and resolve definitional inconsistences
in the literature to provide a more accurate and whole understanding of serial
homicide.
Overall, the aforementioned points suggest that the study of serial homicide
warrants more research attention. Due to empirical drawbacks with current models,
the impact of serial homicide on marginalized groups and conceptualization issues
caused by the media and definitional inconsistencies, it is necessary that academics
continue to study serial homicide to resolve these issues within the literature. It is
also important to continue developing new research studies in serial homicide to
resolve the following literature gaps.
Literature Gaps
Quantitative over Qualitative Inquiry
Serial homicide literature has primarily consisted of studies investigating the
descriptive characteristics of serial killers, relying on quantitative methods to
assess which characteristics are common (Henson & Olson, 2010; Skrapec, 2001a).
For instance, the Organized/Disorganized typology, based on interviews with
investigators and crime scene reports, was developed to understand the social,
psychological and behavioural characteristics of lust murderers (Hazelwood &
Douglas, 1980). Furthermore, serial homicide research has relied on traditional
methods, such as clinical tools and pathological models (e.g., psychopathy) to
explain the psychology and behaviours of serial killers (LaBrode, 2007; Skrapec,
2001a). This information may be useful for law enforcement personnel aiming to
apprehend these killers or clinicians treating serial killers with mental illnesses.
However, Skrapec (1997, 2001a) has argued that focusing too intently on
descriptions and clinical diagnoses of serial killers prevents researchers from
gaining a deeper understanding about motivations.
Currently, there is a paucity of research that has investigated the perspective
of serial killers and how they make sense of their own crimes (Henson & Olson,
2010; James & Gossett, 2018; Skrapec, 2001a). Henson and Olson have stated that
qualitative inquiry in the study of serial homicide is advantageous because
understanding how serial killers ascribe meaning to their crimes can provide a
deeper understanding of why they murder. Albeit scarce, existing research
investigating the subjective experiences of serial killers has revealed deeper insight
into the minds of these killers and sexual homicide offenders (James & Gossett,
2018, Kerr & Beech, 2016; Skrapec, 1997; Skrapec, 2001a).
An early study by Skrapec (1997) investigated the act of serial homicide as a
subjective experience. Specifically, Skrapec interviewed five serial killers and
analyzed their accounts using empirical phenomenology, a qualitative method that
“takes and describes the human experience of lived phenomena, and through
collaboration and intersubjective validation, seeks to reveal their fundamental
structure in terms of meaning” (Sixsmith & Sixsmith, 1987, p. 315).
In Skrapec’s (1997) research, she found that these serial killers felt (1) a high sense
of entitlement and blamed others for their actions (e.g., the victims) (2)
empowerment and control in killing others, and (3) vitality followed by a sense of
release after murdering (albeit shortlived), all of which pertained to their
motivation of killing repeatedly. Her research showed that these killers knew the
wrongness of their actions, but the moral repercussions of their crimes had no
significant meaning to them. The results of this study shed light on the feelings that
serial killers experienced as they killed, how they perceived their victims, and
provided a deeper understanding of the subjective experience of multiple murder.
Since then, other research using qualitative methods have expanded on how
serial killers makes sense of their crimes through their own narratives. Firstly,
when recounting their crimes, serial killers manage their identities by (1)
portraying themselves as normal (2) acknowledging barriers that impact their
normalcy (e.g., biological and psychological barriers such as “demonic
possession”), and (3) representing themselves as “vigilantes” to justify their
murders (Henson & Olson, 2010). Serial killers have also mitigate their crimes
primarily by (1) denying their victim by blaming them for their own demise and (2)
denying the responsibility of their actions by claiming memory loss, portraying
their partner-in-crime as the mastermind, or blatantly denying they were ever
involved (James & Gossett, 2018).
Qualitative research on the accounts of sexual homicide offenders (including
SSKs) by Kerr and Beech (2016) showed that their motivations of sexual homicide
stem from (1) seeking revenge from experiencing sexual abuse (2) homicidal
impulses (3) significant events causing an emotional reaction and (4) feelings of
loneliness. This study demonstrated that there was no single pathway within the
lives of these sex killers that led them to their circumstances, and that the
motivations of killing varied between killers to some extent.
Consistent with what was found in Skrapec’s (1997) research, subsequent
qualitative studies (e.g., Henson & Olson, 2010; James & Gossett, 2018) have
shown a consistent trend of serial killers deflecting blame from themselves by
blaming their victims, people in their lives, or other external circumstances of
which they feel they have no control. James and Gossett’s work, on the self-serving
accounts of serial killers, theorizes that deflection helps prolong the serial killer’s
crimes, because undermining the severity of their actions helps them justify their
murders and continue them. Skrapec’s work showed that killers deflected blame so
strongly that they viewed themselves as the greatest victims and sought to gain
control, which motivated them to murder. Kerr and Beech (2016) found that
experience of murder as an impulsive act was a theme most common in serial
sexual murderers. These varied implications demonstrate the high complexity of
the developmental and motivational trajectories that lead one to commit serial
homicide and sexual homicide.
Overall, qualitative research on the subjective accounts of serial killers have
provided insights in understanding the experience of serial murder from their point
of view. Skrapec (1997) claims that traditional clinical tools (e.g., diagnostic tests)
cannot provide such insights, which are important for understanding the underlying
emotional experiences of serial killers and what drives them to choose specific
victims and murder them repetitively. Ultimately, more work needs to be done to
clarify the rationale of victim selection and why these murderers continue to kill
until their apprehension or death. Implications from such research would be useful
in piecing together the etiological roots of serial homicide by clarifying (1) how it
happens and (2) why it happens to prevent future occurrences. Furthermore,
understanding how serial killers reflect on their crimes can lead to insights on
whether they felt their crimes were justified by creating rationalizations to reduce
personal responsibility. A theoretical framework titled Techniques of
Neutralization notably explores how individuals who commit socially deviant acts
verbally justify their criminal actions to reduce personal feelings of responsibility
and guilt (Bryant et al., 2018; Minor, 1981; Sykes & Matza, 1957). Qualitative
research has explored how serial killers reduce personal feelings of guilt using
justifications that align with techniques of neutralization (i.e., James & Gossett,
2018). The following section will explore the application of Techniques of
Neutralization to the deviant accounts of serial homicide and how this may reveal
insights into how serial killers articulate and reflect on their emotions, role and
responsibilities in their crimes.
Techniques of Neutralization
As stated in the previous section, existing studies which have qualitatively
explored the deviant accounts of serial killers has shed light on how they perceive
their crimes and how they reason with their crimes. However, as they reflect on
their actions and verbalize their experiences, serial killers may try to justify their
actions and neutralize the extremity of their actions (Henson & Olson, 2010; James
& Gossett 2018).
The use of neutralization techniques by serial killers to mitigate their acts of
committing serial homicide has been investigated by James and Gossett (2018).
James and Gossett framed the accounts of violent and sexually motivated serial
killers, using Sykes and Matza’s (1957) theoretical framework, techniques of
neutralization. Sykes and Matza proposed there are five different neutralization
techniques that criminals may use to lessen the severity of their actions which are
(1) the denial of responsibility (i.e., denying personal accountability of actions),
(2) the denial of injury (i.e., denying anyone was harmed from actions), (3) the
denial of the victim (i.e., claiming victim was at fault for own criminal actions), (4)
the condemnation of the condemners (i.e., claiming that detractors are unjust) and
(5) the appeal to higher loyalties (i.e., claiming actions were committed out of
personal loyalty to another individual or entity) (Sykes & Matza, 1957). Through
techniques of neutralization, individuals neutralize the seriousness of their crimes
and the harm they may have inflicted on others because of their deviant acts
(Bryant et al., 2018).
James and Gossett (2018) evaluated what violent serial killers say to reduce
their culpability in their murders and protect their self-identity. Their study
suggested that serial killers did in fact rationalize their crimes in ways that fit
within Sykes and Matza’s techniques of neutralizations. Techniques that were most
used by serial killers were (1) the denial of victim (i.e., blaming victims for their
own demise) followed by (2) the denial of responsibility (i.e., claiming memory
loss, blaming co-perpetrators, or not admitting to the crime), and (3) condemnation
of the condemners (i.e., criticizing law enforcement for their incompetence). The
techniques that were used least frequently by their sample of offenders were (1) the
appeal to higher loyalties (by three offenders) and (2) denial of injury (by one
offender).
Since Sykes and Matza (1957), techniques of neutralizations have been
revised with the addition of newly added neutralization techniques (Bryant et al.,
2018; Minor, 1981). Minor argued that certain techniques may have been
overlooked in Sykes and Matza’s original set of neutralization techniques. As a
result, Minor discussed the inclusion of the defense of necessity (i.e., rationalizing
that certain actions are necessary to pursue despite its moral repercussions) and
metaphor of the ledger (i.e., counterbalancing inherently bad actions by claiming to
have also engaged in good acts in life). Similarly, Bryant et al. (2018) proposed
that two neutralization techniques outside of Sykes and Matza’s (1957) initial set
accounted for their sample of genocide offenders which were victimization (i.e.,
claiming to have suffered or been persecuted to some degree) and appeals to good
character (i.e., highlighting own good deeds and admirable character traits)
(Bryant et al., 2018, p. 593). The application of neutralization techniques to the
accounts of deviant offenders may help shed light on how individuals mentally
prepare themselves as they engage in deviant actions, which have helped in
reducing personal feelings of guilt, neutralize the harmful effects of their actions,
and aid in their continual engagement in criminal behaviour (Kaptein & van
Helvoort, 2019).
Overall, an exploration of the subjective psychological experiences of serial
killers is necessary for a nuanced and detailed understanding of (1) what motivates
serial killers to murder repeatedly and (2) the specific meanings that victims hold
for the perpetrators of serial homicide (Skrapec, 1997). However, framing the
subjective experiences of serial killers within the theoretical framework of the
techniques of neutralization may provide a clearer understanding of how serial
killers contemplate on these experiences in terms of their own perceived culpability
and whether they try to redeem themselves and their actions through verbal
justifications. As such, the theoretical application of techniques of neutralization to
the accounts of non-sexually motivated healthcare serial murderers is worth
exploring to clarify the experiences of this subtype of serial homicide.
Healthcare Serial Murder
To date, serial killer typologies and developmental models have primarily
been based on sexually-motivated serial killers, which has limited the current
knowledge of the non-sexually motivated subtypes (e.g., Burgess et al., 1986;
Douglas et al., 1992; Keppel & Walter, 1999; Warren et al., 1996). An
understudied subtype of serial homicide is healthcare serial homicide, also known
as “clinicide” or “carer-assisted serial killing” (Lubaszka & Shon, 2013, p. 65).
Ramsland (2007) states that health care serial killers (HCSK) “may be any type of
employees in the healthcare system who use their position to murder at least two
patients in two separate incidents” but are psychologically capable of claiming
more lives than two (p. xii).
Despite the limited research, Lubaszka et al. (2014) conducted research on
the pre- and post-offence behaviours of health care serial killers (HCSK) and
discovered that their process of selecting and murdering victims was comparable to
the criminal steps of confidence ‘con’ men (e.g., fraudsters). Their research
suggested that a working typology of HCSKs may be necessary as these types of
killers may be easier to prevent than the ‘traditional’ serial killer who murders for
sexual gratification. They also suggested it would be beneficial to conduct in-depth
interviews with HCSKs in the future research of these murderers, which could
provide more information about these killers and their crimes. Such data would
also be useful to understand their perceptions on what led them to commit such
acts in the first place, which can provide a better understanding of serial murder
etiology.
Overall, the subjective experiences of serial killers have not been explored
greatly within academia. Yet, studies that have investigated the perspective of the
killers have revealed that there is more to their crimes than just madness (e.g.,
Skrapec, 1997). Existing research on the accounts of SSKs has demonstrated that it
is difficult to deduce their developmental and motivational trajectories into a single
model. Therefore, the process of how a serial killer chooses to murder repeatedly is
complex and still unclear.
As discussed earlier, serial sexual homicide has been the primary focus of
research attention within serial homicide research. Yet, HCSKs who are non-
sexually motivated may be worth investigating since they have received
considerably less attention, but their crimes may be the most preventable form of
serial homicide (e.g., Lubaszka et al., 2014). Furthermore, Lubaszka and Shon
(2013) have suggested that the profession that produces the most serial killers are
healthcare professionals (p. 66), which necessitates further investigation into
healthcare serial homicide. There continues to be a lack of insight in the
motivations of HCSKs and how they experience their crimes. Therefore, an in-
depth examination of the personal accounts of HCSKs it may be worth exploring to
better understand the crimes perpetrated by this subtype.
Based on existing research, this study proposes that it is worth examining
what HCSKs perceive as their motivation of killing repeatedly, their perceptions on
what drove them to start killing, what their victims mean to them, and their lives
before they were murderers as Skrapec (1997) had previously explored within
serial sex killers (SSK). An in-depth analysis of the personal accounts of HCSKs
can provide richer details about their subjective experience of committing serial
murder in a healthcare setting. This study aims to enrich and inform about the
psychological processes of HCSKs in the following questions: (1) How do
healthcare serial killers experience murdering repeatedly? (2) What are their
perceptions of their victims and of themselves? (3) What emotions do they
experience upon committing serial homicide and (4) How do healthcare serial
killers describe their motivations to commit serial homicide?
Any implications can shed light bring further knowledge about HCSK, an
area of serial homicide that has been neglected in all disciplines. Such implications
can then be compared to what has been discovered about SSKs that touch upon the
criteria above can help draw out similarities of all serial killers well as differences
between subtypes, which may help pinpoint the motivational and developmental
similarities across all serial killers. Skrapec (1997) discussed the idea that many
people have been angry enough to fantasize harming someone who has angered
them, but only very few cross over into the path of becoming serial killers. It would
be interesting to analyze how serial killers describe emotions to understand how
they perceive and feel emotions (e.g., “rage”, “sadness”, “love”) in comparison to
the non-serial killing population.
Analyzing the inner most feelings of rage in a serial killer can bring
academics and law enforcement closer to understanding when “rage” becomes
deadly. A novel research area would be to investigate under-explored subtypes of
serial homicide (e.g., HCSK) to provide a richer picture on who serial killers are,
what are their motivations in murdering others and what feelings they experience,
which should gauge a richer understanding of serial murder etiology.
Chapter 3: Current Theories of Serial Homicide
Theories of serial homicide have been developed, explored and challenged
by multiple disciplines such as (but not limited to) law enforcement (e.g., Douglas
et al., 1992; Hazelwood & Douglas, 1980; Keppel & Walter, 1999; Ressler et al.,
1988), psychology (Carlisle, 1993; Culhane et al., 2011; Hickey, 1997, 2009;
LaBrode, 2007; Schlesinger, 2000), sociology (DeFronzo et al., 2007; Hodgkinson
et al., 2017; Williams, 2017); anthropology (Leyton, 1986), history (Jenkins, 1996;
O’Reilly-Fleming, 1996), and biology (Blair, 2003; Gao et al., 2009; Mills &
Raine, 1995; Raine, 2013). Although each discipline differs in its approach to
elucidate serial homicide, they all have a common goal of providing a strong
comprehensive theory explaining why serial homicide occurs and ways to prevent
it. Given the qualitative psychological approach of the current study, the primary
theories that will be presented in this section will revolve around the prominent
psychological, psychosocial and social identity theories proposed by researchers
and investigators.
Psychological Theories of Serial Murder: Positivism and the Clinical
Approach
Arguably, psychological theories of serial homicide, proposed by
investigators and psychologists, have traditionally been positivistic by exploring
which specific characteristics define the psychological makeup of a serial killer
(e.g., LaBrode, 2007). These theories have primarily explored psychopathology to
shed light on the psychological profile and triggers of serial killers. Such research
has been reliant on clinical and typological approaches by providing diagnoses or
developing classification systems to clarify the behaviours of serial killers (e.g.,
Douglas et al., 1992; LaBrode, 2007). Law enforcement and academics have
investigated personality characteristics of serial killers, by theorizing that serial
killers could be profiled and their personalities and behaviours can be elucidated
from evidence found at their crime scenes (Burgess et al., 1986; Douglas et al.,
1992; Keppel & Walter, 1999; Ressler et al., 1988). This has resulted in several
typological frameworks, which have primarily been used as guides for law
enforcement personnel (e.g., Douglas et al., 1992).
Hazelwood and Douglas (1980), of the FBI, first presented their
classification system of lust murderers, which they argued as being either (1)
Organized methodical murderers who plan each of their sexual homicides
thoroughly and attempt to conceal their actions and (2)
Disorganized murderers who murder sporadically with little-to-no planning before
and after the murders. Their typology was based on investigative reports of the
crimes, interviews with law enforcement personnel and a literature review of
violent crimes. However, research has suggested that the behaviours and
psychology of serial killers is not so clear-cut and that all cases of serial sexual
homicide cannot be categorized into a single dichotomy (Canter et al., 2004;
Skrapec, 1997). Yet, this typology was primitive in its attempt to describe the
motives, personality, and methods of serial sexual murderers and has been
referenced in future guides to aid investigative units dealing with potential serial
homicide cases (e.g., Douglas et al., 1992).
Examples of typological frameworks following Hazelwood and Douglas’s
(1980) lust murderer typology include motivational typologies developed by
Holmes et al. (1988), Dietz (1986), Fox and Levin (1998) and Keppel and Walter
(1999). All the mentioned typologies discuss factors such as (1) serial killer
motivation (2) crime scene behaviour of serial killers, (3) methods of murder
and/or (4) modus operandi (MO). The general theory based on the findings of these
typologies in terms of the motivation and psychology of serial killers appears to be
the following:
1. Serial killers may either be externally (e.g., financial gain) or internally
motivated (e.g., psychological gratification)
2. External motivators of committing serial homicide may include: (1)
financial profit or (2) being commanded to kill by a higher power due to
a psychotic break
3. Psychological motivations leading to the commission of serial homicide
may include: (1) a need for power to control victims (predicated by
sadistic fantasies), (2) experiencing thrill/excitement from murders, (3)
feelings of anger or revenge (e.g., towards victim, from childhood abuse),
(4) murdering out of duty or personal mission, or (5) sexual gratification
4. Psychological gratification may either be derived from the killing process
(e.g., humiliation or torture) or the act of killing itself
5. Each murder committed by a serial killer may involve a ritualistic act or
the killer may leave a signature (i.e., a unique characteristic) that is not
consequential to the murder
6. Some subtypes experience violent and/or sexual fantasies, which the
killers try to fulfill by committing sexual assaultive acts leading up to
homicide. (Dietz, 1986; Fox & Levin, 1998; Holmes et al., 1988; Keppel
& Walter, 1999)
Evidently, the literature has covered a vast amount of motives of serial
killers which may include both intrinsic (psychological) or extrinsic (e.g.,
monetary/material) reasons. However, it should be noted that some researchers
believe that serial homicide is committed primarily due to psychological
motivation (Egger, 1985; Reid, 2017). Some typologies have even recognized that
healthcare serial murderers belong to a distinct subtype in their typology,
indicating that it should be studied distinctly from other types (e.g., Dietz, 1986).
The vast number of motives that have been posited by typological research
highlights the complex nature of serial homicide. Overall, typologies may offer
some utility for (1) law enforcement personnel who may be examining crime
scenes of severely violent crimes and (2) adding descriptive knowledge of serial
homicide in the literature through providing a compilation of motives and
descriptive characteristics of the criminal. However, it may not bring us closer to a
deeper etiological understanding of the experiences of the killer, which is vital to
truly understanding their motivations (Skrapec, 1997).
Through a positivistic paradigm, psychological research of serial homicide
has also been reliant on defining the psychology of serial killers through using
clinical terminology (e.g., Hare, 1993). The most widely recognized diagnoses that
have been applied to the behaviour and psychology of serial killers are
psychopathy and antisocial personality disorder (ASPD) (FBI, 2008; Fox & Levin,
1998; LaBrode, 2007). Psychopathy is a personality disorder that is characterized
by severely dysfunctional interpersonal, emotional, antisocial and lifestyle
characteristics that include (but are not limited to): (1) lack of remorse, (2) lack of
empathy, (2) impulsivity, (3) manipulative or conning behaviour, (4) aggression,
(5) irresponsibility and (6) poor behavioural controls (Hare, 1993, 1996, 2008). It
is strongly associated with criminality and its prevalence is 15 to 25 percent higher
in incarcerated populations than the general population (Hare, 1996).
ASPD and psychopathy have been used interchangeably with each other,
which is incorrect (Labrode, 2007). Instead, ASPD has been considered the clinical
extension of psychopathy (Hare & Neumann, 2008). According to Hare and
Neumann, ASPD was later developed and listed as a clinical disorder in the
Diagnostic and Statistics Manual (DSM) since formerly, there lacked a valid and
accepted measurement of psychopathy (Hare & Neumann, 2008). Although there
is some overlap between ASPD and psychopathy, they are widely recognized as
separate diagnoses, with ASPD representing more of criminal behaviour and
socially deviant factors associated with psychopathy (e.g., irresponsibility, defying
social norms) instead of emotional dysfunction (e.g., shallow affect, lack of
empathy) (Hare & Neumann, 2008; Wall et al., 2015). Furthermore, psychopathy
has been widely studied in forensic populations, while ASPD is described as less
severe in its behavioural and affective traits (Paris, 2015).
The DSM-V briefly describes ASPD as a “pervasive pattern of disregard for,
and violation of, the rights of others that begins in childhood or early adolescence
and continues into childhood” (DSM, 2015, p. 659). The diagnostic criteria of
ASPD includes (but are not limited to): (1) Blatant disregard for social norms and
engaging in unlawful behaviour, (2) deceitfulness through repeated lying and
conning, (3) impulsivity or lack of planning ahead, (4) aggressiveness through
repeatedly engaging in fights or assaults, (5) lack of regard for the safety of self or
others, (6) irresponsibility and (7) lack of remorse.
Serial killers have often been used as case studies to illustrate the
psychopathic personality (Hare, 1993). Furthermore, serial homicide researchers
have described serial killers as suffering from antisocial personality disorders such
as psychopathy (Fox & Levin, 1998; Sears, 1991). Potential causes and significant
factors contributing psychopathic behaviour and violent crime has been studied
extensively by neurobiologists, who have investigated the association of specific
patterns of brain activity to antisocial behaviour or emotional deficits in violent
offenders (e.g., Mills & Raine, 1995; Gao et al., 2009). The associations that have
been identified between violent and/or psychopathic behaviour and brain anatomy
has been the following: (1) poor decision making, low impulse control and high
aggression with structural deficits in the prefrontal cortex and (2) dysfunctional
emotional and interpersonal traits (e.g., lack of empathy, poor moral reasoning,
manipulativeness, emotion recognition) and poor fear conditioning with deficits in
the amygdala-hippocampal region of the brain (Blair, 2003; Gao et al., 2009; Yang
et al., 2010)
Evidently, psychopathy has served as a conceptual framework used to
explain the psychology and behaviours of serial killers. Recent research has
theorized that serial homicide may be a separate pathological disorder known as
Homicidal Pattern Disorder, which requires that an individual must (1) victimize
strangers with full knowledge of the legal consequences (2).murder out of internal
(e.g., psychological gratification) instead of external (e.g., monetary) motivation
(3) experience high tension (prior to the murder) that needs to be released and (4)
suffer from a cluster B personality disorder from the DSM (e.g., antisocial,
histrionic, borderline, narcissism) (Vronsky, 2004).
Overall, some psychological theories approach serial homicide through
pathologizing the crime. The indication is that certain psychological theories
maintain that the etiology serial homicide may be best explained by considering it a
clinical disorder. Potentially, these theories may also maintain that serial homicide
can be prevented through treatment if it is regarded as a psychological disorder.
Some serial killers have described themselves and their crimes in the context of
mental health (e.g., Henson & Olson, 2010). It would be beneficial to examine
whether specific serial killer subtypes (e.g., HCSK) perceive their crimes and
behaviours through a clinical lens and diagnose their own misdeeds.
Psychosocial Development: Attachment, Fantasy, and Compulsions
Another theoretical approach that researchers have taken is focusing on the
motivations of serial killers through a psychosocial developmental lens. A
prominent theory of how one develops into a serial killer is the theory that adverse
childhood experiences during development is critical and often leads to the
development of negative thoughts and specialized fantasies
(Arrigo & Purcell, 2001; Burgess et al., 1986; Hickey, 1997, 2009; Keppel &
Walter, 1999). Specifically, several psychosocial models of serial homicide
theorize that there are specific critical experiences that affect childhood
development and socialization. Such experiences may include (1) poor attachment
to a parental figure from a lack of guidance and nurture, (2) experiencing (or
witnessing) sexual, psychological and/or physical abuse, (3) rejection and (4)
negative familial events (e.g., divorce, death in the family) (Burgess et al., 1986;
Hickey, 2009).
It is argued by several models that traumatic and maladaptive experiences in
the developing child can either (1) instill a low sense of self-esteem in the child, (2)
begin to shape a child’s thinking patterns in a specific maladaptive way or (3) push
the child into a dissociative state where they suppress their trauma (Arrigo &
Purcell, 2001; Burgess et al., 1986; Hickey, 1997, 2009). According to these
models, traumatic experiences eventually lead the child or adolescent to develop
and live within violent and/or sexual fantasies that he or she has created.
These models (i.e., Arrigo & Purcell, 2001; Burgess et al., 1986; Hickey, 1997;
Ressler et al. 1988) tend to emphasize more of the environmental triggers that
affect the psychological state of serial homicide offenders rather than genetic
predispositions.
Fantasy is an important concept in serial homicide (Carlisle, 1993). Several
theories have discussed what budding serial killers gain from their internalized
fantasy worlds. According to several theories, fantasies may serve as (1) a
protective psychological barrier from negative feelings and experiences (e.g.,
social isolation, childhood rejection, trauma, abuse, etc.), (2) a transitional stage
that allows them to prepare and try out some of their deviant behaviours (e.g.,
stalking) and (3) an alternate world for budding offenders, to live vicariously in a
position of power to dominate others, compensating their lack of control over their
real life. (Carlisle, 1993; Hickey, 1997; MacCulloch et al., 1983).
Important considerations regarding fantasies and motivation are that they
highlight motivators such as comfort and control. Fantasies may be used as a safety
blanket and provide an escapism for the severely abused and troubled child or
adolescent, thus providing them comfort (e.g., Hickey, 1997). Secondly, fantasy
may serve as a coping mechanism for abused and budding serial killers to reclaim
control of their lives. Serial killers in childhood may fantasies to protect themselves
from their painful reality by vicariously living in a world where they are the
domineer rather than the dominated (e.g., Hickey, 1997). In their fantasies, serial
killers are in control of their own lives and the lives of others (Carlisle, 1993).
Control is an important psychological theme and has been cited as a
motivational factor of serial killers in several typologies (e.g., Keppel & Walter,
1999; Hickey, 2009). According to Ressler et al. (1988), control extends beyond
physically restraining the victim and involves verbal tactics. SSKs in their study
wanted to control their victims’ behaviours through guiding them on how to react
during the sexual assault. Evidently, serial killers wanting to be in control is an
important psychological mechanism. Understanding how control is experienced
and processed in the mind of a serial killer can be clarified further through (1)
qualitative inquiry into serial killers’ experiences of control and (2) also
investigating non-sexually motivated subtypes of serial killers who may cite
control as a motivational reward.
Fantasies are recognized as being catalytic towards pushing a troubled
individual into being a full-blown serial homicide offender. Yetanother debilitating
factor that is often discussed is the precipitating event which causes an individual
to finally break and commit homicide (Ressler et al., 1988). Precipitating events
are particularly stressful and primarily revolve around interpersonal (i.e., marital
conflicts, divorce, parental conflict, death of significant person), financial (i.e.,
employment issues, money problems), legal and familial events (i.e., birth of child)
(Arrigo & Purcell, 2001; Ressler et al., 1988). Ressler et al. also cited substance
use as a factor that contributes to or precedes the murder. These additional factors
demonstrate the intricacies of the psychosocial trajectories leading to serial
homicide. Further investigation into the role of fantasy, control and many other
factors should be explored through the perspective of the killers to clarify what
these factors mean to them.
Lastly, another psychological component that has been investigated
thoroughly in the literature is the compulsive nature of serial homicide. It is widely
understood in the literature that serial killers distinctly possess uncontrollable urges
to murder repeatedly (e.g., Hickey, 2009). The compulsive need to murder can be
found in several definitions, which state that serial killers resume their regular life
but eventually give in to their compulsions to murder again (e.g., Egger, 1985). As
an effort to highlight the compulsive nature of serial homicide, some scholars have
argued for definitional revisions, arguing that the term ‘serial’ does not accurately
depict the psychological mechanisms of a serial killer (e.g. Reid, 2017;
Schlesinger, 2008). Schlesinger has argued that focusing on the ‘serial’ aspect of
serial homicide through assessing victim count obscures the more important
elements that are integral to serial homicide, such as compulsivity.
The argument is that serial killers who have been apprehended early are
fundamentally the same as serial killers who may have murdered many more
victims (Schlesinger, 2008). Overall, from a psychological point of view, focusing
less on the victim count of serial killers may allow researchers to concentrate on
more important elements of serial homicide such as homicidal compulsions.
Clearly, compulsions in serial homicide are important since it is a crucial
element in the psychology of serial killers. However, Schlesinger (2008) has
argued that knowledge of the compulsions of serial killers is oblique and far more
difficult to understand and explain. Neurobiological research states that
characteristics of poor impulse control and hyper aggression, all of which are
common in serial killers, are linked to lower gray matter volume in the prefrontal
cortex (Gao et al., 2009). This provides a biological basis of compulsions in serial
homicide but does not help elucidate the process of how one is compelled to
murder again and again. A vicarious understanding of how serial killers experience
compulsions to kill through qualitative inquiry may provide richer details and
nuances of their compulsions. It may even help researchers understand how serial
killers feel about or react to their compulsions (i.e., whether they have ever felt
frustrated by their compulsions or done things to try to stop the compulsions).
Overall, psychological theorists taking on a positivistic approach have
argued that (1) the behaviours and psychology of serial killers can be understood
from their crime scenes and through a clinical lens and (2) there is a specific
psychosocial developmental trajectory that children and adolescents go through
which predicts future serial homicide offending. However, it could be argued that
framing the etiology of serial homicide through clinical or typological frameworks
may be too deterministic and inflexible. The positivistic approach may in fact
impede on the ability to further delve into the deeper and more complex
psychological processes experienced by serial killers (Kerr & Beech, 2016;
Skrapec, 1997, 2001a).
Skrapec (1997) has argued that simply using descriptors may result in an
explanation of serial homicide that is oversimplified and may prevent researchers
from understanding the complex psychological processes involved in serial
homicide. It may not be enough to simply label someone as having a lack of
remorse or empathy. An in-depth qualitative examination of a serial killer
discussing their lack of remorse or empathy may provide the literature a
comprehensive understanding of what it truly feels like (for a serial killer) to
experience a lack of remorse or guilt. Such accounts may bring researchers closer
to understand their motivations, emotions, and cognitive processes more fully.
Socio-Cultural Theories of Serial Homicide: Social Class and Self-Identity
Researchers have advocated for the study of the socio-cultural factors of
serial homicide, an area that has not been widely studied (Hodgkinson et al., 2017).
Hodgkinson et al. has argued that the study of serial homicide has been too
individualistic in its approach by using labels and diagnoses to describe the
behaviours of a subset of offenders (e.g., the diagnosis of a psychopathic
personality disorder). The argument is that investigating serial homicide through a
clinical and pathological lens (1) provides only a limited understanding and is
limited to only a few cases and (2) has created myths that serial killers can only be
white, male, and sexuallymotivated. Hodgkinson et al. called for a socio-cultural
approach that also tries to factor in how cultural and social aspects contribute to
acts of serial killing. Hodgkinson et al. (2017) stated the following: “Within
capitalist cultures, which maintain high social incentive for status and power serial
killing may perhaps be viewed as one way to ‘cheat the system’ and reap rewards
that social conformity to conventional standards of morality and normality often do
not yield.” (p. 288).
The effects of specific social and cultural aspects that may facilitate the
commission of serial homicide may provide a more rounded and holistic
understanding of serial homicide. Furthermore, investigating how certain socio-
cultural aspects influence serial killers and their crimes by examining how they see
themselves in the world may bring researchers closer to the etiology of serial
homicide. Although limited, some researchers have attempted to understand serial
killers in how they see themselves in a wider social context through social class
and selfidentity theories (Henson & Olson, 2010; Leyton, 1986).
Hunting Humans, written by Leyton (1986), proposes an interesting theory
between class conflict and serial homicide based on Ted Bundy, a notorious SSK.
Leyton framed serial killers as social outcasts who are frustrated by their own
social class to the point of homicidal rage. It should be noted that the perspective of
crime as being a by-product of social inequality (i.e. conflict theory of crime) is
rooted in the writings of Karl Marx (Brown et al., 2010). As Brown et al. explains,
Marx proposed that social inequality is prevalent in all societies grounded in a
division between the rich elites (i.e. the bourgeosie) and the working class who are
forced to work for them (i.e. the proletariats). As a result, the conflict perspective
of crime arose, proposing that (1) there are groups in society who are in conflict
with one another due to opposing values and power differentials and (2) society
and its laws support the interests of those who have the most power (Brown et al.,
2010).
Leyton’s (1986) theory of serial homicide reflects the fundamentals of
conflict theory. Leyton theorized that Bundy’s crimes may have been a by-product
of two factors: (1) his illegitimacy from being born out of wedlock and (2) the
deterioration of his relationship with a high-status woman. According to Leyton,
the discovery of Bundy’s illegitimacy from being born out of wedlock left him
feeling like he was on lower end of the ‘social class’ totem pole. Furthermore, his
relationship ended with his rich elitist girlfriend which the closest thing he had to
being affiliated with the higher status. Leyton stated Bundy’s breakup left him
feeling dejected further from the higher class he wished to join. Inevitably, Leyton
theorized that these experiences led Bundy to release his frustration and murder
other (presumably) rich, white females who resembled the ex-girlfriend who made
him feel like a social outcast.
Feelings of inferiority in a capitalist world is an intriguing approach on why
an individual may act out in perverse and aggressive ways. If class conflict and
social pressures are influential to serial homicide as Leyton suggested, the effects
of class conflict on serial homicide could potentially be clarified further by asking
how serial killers feel about their position in society. Leyton’s theory also
demonstrates that self-perception of serial killers and examining their reflections of
themselves in the eyes of others is significant in understanding their motives and
triggers. Current studies by Henson and Olson (2010) and James and Gossett
(2018) have theorized in their respective studies that serial killers may find it
psychologically easier to continue their crimes by making rationalizations for their
actions.
James and Gossett (2018) theorized that serial killers mitigate their feelings
of guilt, selfblame and protect their own self-image by deflecting the responsibility
of their crimes to others such as (1) the authorities (e.g., law enforcement), (2) co-
perpetrators or (3) their murdered victims but not themselves. Henson and Olson
(2010) theorized that serial killers manage and fight back against their stigmatized
serial killer identities either by (1) emphasizing that genetic and psychological
barriers and past traumas have prevented them from being “normal” and (2)
distancing themselves from their identities by trying to portray themselves as
normal. These killers also tried to reason that instead of being cold heartless killers,
they were vigilantes of justice (Henson & Olson, 2010). These theories (i.e.,
Henson & Olson, 2010; James & Gossett, 2018) suggest that serial killers
understand the social drawback or stigmas that are associated with being serial
killers. Therefore, they may try to protect their image, their feelings, and their
crimes through reconstructing their identity.
Current studies on self-reflections of serial killers may provide a glimpse
into (1) how they view themselves in relation to the world and other social groups
and (2) how these selfperceptions relate to their murderous behaviours.
Investigating socio-cultural aspects that facilitate serial homicide can help
researchers focus on the problematic aspects of social structures in respective
societies. However, understanding the impact that social structures (i.e., class
inequality, social identities) have on serial homicide occurrences may be best
understood through exploring how serial killers view their position in society.
Overall, psychological and socio-cultural theories of serial homicide each
provide micro and macro explanations by positing that (1) serial killers can be
categorized into subtypes based on individual characteristics (e.g., personality
characteristics, crime scene behaviours, clinical diagnoses) and (2) the motives of
serial killers can be understood by their culture and the social position they hold in
their world, respectively. However, many of these theories base their theoretical
findings on cases of serial sexual homicide. A subtype which lacks an
understanding are non-sexually motivated serial killers such as HCSKs who
murder in healthcare facilities. Exploring the subjective experiences and self-
reflections of HCSKs will not only provide more of an experiential and nuanced
understanding of the psychological processes of serial killers. It will also provide
more knowledge of HCSKs in the literature which is currently in its primitive stage
(Lubaszka et al., 2014)
Considering what theories have been proposed in the literature, there are
several inquiries to consider when analyzing the deviant accounts of HCSKs.
Within the psychological paradigm, it is understood that serial killers seek control
and possess uncontrollable compulsions to murder repeatedly. But how do serial
killers perceive the concepts of ‘control’ and ‘compulsions’ with respect to their
crimes and themselves? How would serial killers make sense of their compulsions
as they are experiencing them? Have these killers ever experienced feelings of
wishing that the compulsions would stop?
Furthermore, the literature has suggested that serial killers may try to
mitigate the social impact of being a serial killer by (1) blaming others for their
crimes or (2) hiding their true selves by projecting a positive, normal law abiding
image to the world (Henson & Olson, 2010; James & Gossett, 2018). Considering
what has been identified in the current literature, how do HCSKs perceive and deal
with being labelled as convicted serial killers by the world? Will HCSKs justify
their actions by claiming that psychological, biological or social characteristics are
to blame for their own crimes? Will they reason that their lack of proper parental
guidance has contributed to what they have become now? These are just several
inquiries to consider. The following section will address the research questions of
the current study that may hopefully shed light on the inquiries above.
Chapter 4: Methodology
Methodology
As previously discussed, the purpose of this study is to delve into the
psychological processes of healthcare serial killers through examining their
personal accounts detailing their lives and murders within the theoretical
framework of techniques of neutralization (Bryant et al., 2018; Minor, 1981; Sykes
& Matza, 1957). This study hopes to shed light on the following research
questions:
(1) How do serial killers create justifications (if applicable) and reflect on the
following?
a. The experience of murdering repeatedly?
b. Their perceptions of their victims and of themselves?
c. Their motivational reasons of committing serial homicide
d. Emotional experiences upon committing serial homicide
(2) How do the experiences and justifications of murder compare between
healthcare serial killers and their sexually motivated counterparts?
The research questions for this study are concerned with the subjective
experiences of HCSKs and potential neutralizing statements verbalized by them
based on their thoughts, perceptions, and emotions. Exploring the types of
neutralization techniques that HCSKs may use can clarify (1) how they mentally
justify their crimes and (2) whether neutralizations may psychologically help them
continue their murders. As such, the overall objective is to develop a psychological
understanding of HCSKs, which has traditionally been reliant on quantitative
inquiry (Henwood & Pidgeon, 1992). However, the research questions posed in
this study deem it appropriate that qualitative methods be used.
Historically, psychology has adopted a “natural science” approach to
researching phenomena (Charmaz & Henwood, 2010). Charmaz and Henwood
describe this approach as positivistic, objective and discovering causal
relationships between variables through controlled experimental studies (Charmaz
& Henwood, 2010; Henwood & Pidgeon, 1992). Kubrin et al., (2009) describe
positivism as a philosophical position that human behaviour is determined,
meaning one’s actions are out of their own control. In addition, Charmaz and
Henwood (2010) explain that the natural science paradigm takes on a quantitative
approach in research, which traditionally involves statistical analysis to measure
human behaviour. Henwood and Pidgeon (1992) explain that quantification, “the
standardization, measurement, and number”, is significant within the natural
science paradigm (p. 98). Under this paradigm, concepts under study are tangible,
meaning they can be observed, manipulated, and tested to generate results that are
generalizable and replicable (Henwood & Pidgeon, 1992, p. 98).
However, over focus and over-reliance on patterns has been argued to be
rigid and may not provide a fuller, holistic understanding of the psychological
processes that people experience (Charmaz & Henwood, 2010). For instance,
researchers have long discussed the adverse impact of childhood trauma that is
commonly experienced among serial killers (e.g., Hickey, 2009; Ressler et al.,
1988). This common finding demonstrates that this experience may hold some sort
of significance as a child develops into a serial killer in adulthood.
However, simply knowing that this pattern exists among serial killers does
not fully reveal what childhood trauma means to the serial killers who have
experienced these hardships. A way to fully understand may be through a rich
examination of the accounts of serial killers and analyzing their explanations of
how traumatic events may have led to their murderous crimes. This latter approach
is called the naturalistic (or interpretative) paradigm, an approach that has directly
critiqued the position that only the natural scientific approach can extrapolate root
causes of human behaviour (Henwood & Pidgeon, 1992).
According to Henwood and Pidgeon (1992), the naturalistic or interpretative
paradigm studies perspectives of reality from the participants’ point of view and
focuses on description rather than causal explanations. It focuses on the how rather
than why. The goal of this current research project is not to conduct an
experimental study and test hypotheses to make generalizations about serial killers.
Instead, this thesis project is interested in deriving rich details about psychological
processes and homicidal experiences of HCSKs to better understand how they
reflect on their crimes and justify them. Therefore, the use of qualitative methods
to understand the psychology of serial killers is dependent upon the research
questions posed in this study.
Grounded Theory
Grounded theory (GT) is a method used to study empirical processes, and it
has been advocated for studying psychological processes (Rennie et al., 1988).
This method is flexible and involves (1) gathering and comparing data, (2)
developing interpretations about the data through codes and (3) considering all
potential theories of the data (Charmaz & Henwood, 2010). This method is
comparative, meaning that researchers remain interacted with their data and ideas
about the data (Charmaz, 2015). There are several key characteristics in grounded
theory. Firstly, data collection and analysis occur simultaneously, and secondly, the
analytic codes that researchers develop are strictly from the data and not from
preconceptions and apriori hypotheses (Charmaz, 2015). This method involves
theory construction by evaluating the concepts that emerge from the data, meaning
it fits within a naturalistic paradigm (Henwood & Pidgeon, 1992).
The concept of theory construction is important since this current study aims
to build a theory of how HCSKs in the current study reflect on their crimes, and
justify their actions based on emergent patterns found within their criminal
accounts. Charmaz (2015) has noted that one of the highlights of GT qualitative
studies is its ability to makes sense of human behaviour. By using the GT method
on the self-serving accounts of HCSKs, this study can investigate patterns in the
feelings, thoughts, and perceptions of HCSKs to build a theory of their
psychological processes that may pre-empt their murderous behaviours.
General guidelines for grounded theory involve two coding methods of the
data. At the early stages of grounded theory, researchers start with more flexibility
in developing codes from the data, but later these codes are grouped further or
linked together to build a richer theoretical understanding of the data (Henwood &
Pidgeon, 1992). The first coding method is initial coding, where the researcher
collects and codes the data by explaining “what is happening in the data” (Charmaz
& Henwood, 2010, p. 244). Initial coding is done with a line-by-line coding style,
where the researcher develops a code for each line in their data (Charmaz, 2015).
Charmaz describes the second coding method as focused coding, which is more
conceptual and makes sense of initial codes that were created from observations of
the data. According to Charmaz and Henwood (2010), focused coding entails
gathering, examining, and comparing the most prominent or common initial codes
and data integration.
A GT approach to serial homicide has been conducted by Hickey (1997)
who collected data from 399 solved cases of serial homicide between 1800 to 1995
using the GT method. Most recently, Sharma’s (2018) thesis work examined
detailed accounts of serial killers throughout their life to develop theories about the
life events that may have led them to serial murder. These accounts came from
secondary sources such as interviews with the offenders, biographical novels of
killers, trial transcripts, and accounts from the offenders’ friends and family.
Sharma’s study used GT draw out similarities and differences in the significant life
events of three serial killers.
Firstly, Sharma (2018) conducted initial coding, which allowed the
researcher to compare the developmental patterns of each of the offenders and
make sense of the offender’s perspective. During the initial coding stage, Sharma
also used In Vivo codes to represent significant phrases spoken by the offender.
Secondly, Sharma conducted focused coding by (1) grouping together the most
significant or frequently occurring codes reflecting the data and (2) finding
potential links between categories to further develop theoretical understandings
about the development of SSKs. Although this study contained limitations such as
the inability to follow up and probe with the offenders, several factors emerged
from the data and deeper theoretical insights were made based on the factors
presented. For instance, this study discovered that many of the factors (e.g.,
loneliness, stress/trauma, power/control, low self-esteem) were interrelated with
each other, demonstrating the complexity of the developmental patterns of serial
homicide. These results reflect what was found in Reid et al.’s (2019) study on
SSKs, who concluded that serial homicide cannot fit within a single developmental
model.
Qualitative inquiry into serial homicide may provide more richer details into
the lives of serial killers. It may help direct researchers towards asking the right
questions to serial killers to clarify the psychological processes that transcend these
offenders from fantasizers to murderers (Skrapec, 1997). The flexibility of GT and
the support of its use in understanding psychological phenomena (e.g., Rennie et
al., 1988) renders it a useful method for my own proposed research questions.
Rennie et al. have stated that the objective of a grounded theory approach is to
generate a new theory that is linked to real experiences of people. Charmaz (2015)
has also suggested that grounded theory can be applied to psychological studies
and may be used to study individual processes such as “motivation, personal
experience, emotions, identity, attraction, prejudice and interpersonal cooperation
and conflict” (p. 59). The objective of this current thesis project is to conduct a
theoretical analysis on the accounts of HCSKs to understand how they may justify
their crimes using techniques of neutralization when discussing (1) their motivation
to kill and (2) their emotional experiences upon committing serial murder (e.g.,
Bryant et al., 2018). Grounded theory may be a viable method for looking into the
cognitive and emotional processes of this serial killer subtype.
Serial killers are unique because of their compulsion to murder repeatedly.
Therefore, approaching a population through a naturalistic paradigm can account
for any unique experiences and reflections they may have about the world, their
victims and themselves, different from those who are non-serial murderers.
Similarly, such an approach can show similarities that they may share with the
general population, to further understand their explanations of what they believe
led them astray into a murderous rampage.
A critique of using qualitative methods is that one cannot guarantee the
validity of the account (Sixsmith & Sixsmith, 1987). This can be perceived as
problematic when considering how serial killers may describe their roles in the
murder event, by trying to give off a better impression of themselves through
embellishing their accounts with false events or omitting details altogether.
However, Skrapec (1997) argues that upon gathering data for qualitative analysis, a
researcher should not concern itself with the facts of the case. The primary goal of
studying the subjective experiences is not to study the facts of the crimes
committed by serial killers. Instead, the goal of an in-depth examination of the
accounts of serial killers is to bring attention to the thoughts, emotions, and
perspectives of the killers, which can provide an understanding of how they make
sense of and rationalize their actions.
Chapter 5: Procedure
Procedure
This study utilized GT to explore the subjective experiences of five HCSKs.
To retain a homogeneous sample, it is important that both healthcare serial murder
and serial murder in general are established. There are several definitions of serial
homicide that are present in the literature (e.g., FBI, 2008; Fox & Levin, 1998;
Holmes & Holmes, 1998; Skrapec, 2001b). Definitional inconsistencies and the
broad criteria of the most current definitions has been viewed as a gap in the
literature and has remained an area of debate (Lubaszka & Shon, 2013; Reid, 2017;
Skrapec, 2001b). Specific criteria of serial homicide under debate include the
minimum threshold and motivation (e.g., Dietz, 1986). Definitions of specific
serial homicide subtypes have been provided by researchers, such as the sexually
motivated serial killers have within studies conducted by the FBI (Ressler et al.,
1988). HCSKs have not been studied as widely as SSKs, but Ramsland (2007) is
one researcher who has presented a definition of healthcare serial homicide, which
she defined as belonging to the following criteria
(1) Must be an employee in the healthcare system (not only limited to
doctors)
(2) Must use their position to commit murder
(3) Must murder at least two patients in two separate incidents
(4) Has the psychological capacity to kill more than two people (Ramsland,
2007, p. xii).
Previous literature has operationalized HCSKs with Ramsland’s definition
(e.g., Lubaszka & Shon, 2013). Therefore, any HCSKs who meet these criteria
were included within this study. Furthermore, this research explored North
American HCSKs who operated within the past two decades since first, this
increases the likelihood that these offenders had killed in environments with
similar norms and mores. Secondly, it also ensures homogeneity within the studied
sample.
Sampled Offenders
The five cases that meet the criteria of Ramsland’s HCSK definition are the
following individuals along a brief description of each of their crimes. Each of
these HCSKs were identified in a preliminary search:
Elizabeth Wettlaufer. A female registered nurse in Woodstock, Ontario
who was 49 at the time of her arrest in October 2016 (Miller & Westoll, 2016). She
pled guilty to first-degree murder of eight patients, seven of whom were her
patients at Caressant Care, a long-term care home (Contenta & Siekierska, 2016).
Her method of murder was injecting insulin in her victims, whose ages ranged
between 75 to 96 years of age (Goffin & Dolski, 2016).
Charles Cullen. A 43-year-old male registered nurse who, in 2003, had
confessed to murdering between 30 to 40 patients in ten different hospitals between
1987 to 2003 (Ramsland,
2007; Yorker et al., 2006). Charles Cullen’s method of murder was administering
lethal doses of digoxin, a heart medication, to his patients (Ramsland, 2007). He
was charged in December 2003 and given to 11 life sentences for murder (Yorker
et al., 2006).
Donald Harvey. A 35-year old male who was employed as a nurse’s aide in
a healthcare institution called Drake Memorial Hospital (Ramsland, 2007). In
1987, he murdered at least 23 patients by injecting them with various deadly
substances such as cyanide, arsenic and insulin and “petroleum-based cleaners”
(Ramsland, 2007, p. 82; Yorker et al., 2006). He was arrested that same year and
pled guilty to 24 counts of murder, although claimed to have murdered over 70
people (Yorker et al., 2006). According to sources (e.g., Yorker et al., 2006), he
was given three life sentences.
Orville Lynn Majors. A male practical nurse, who began murdering
patients in the Intensive Care Unit (ICU) in 1993 when he was 32 (Yorker et al.,
2006). While employed at Vermillion County in 1993, the death toll at Vermillion
County Hospital had nearly quadrupled within a year (Ramsland, 2007). According
to Ramsland, his method of murder was injecting patients with lethal doses of
potassium chloride and epinephrine. He was subsequently charged in 1997 with six
counts of first-degree murder, convicted in 1999, and sentenced to life in prison
(Ramsland, 2007; Yorker et al., 2006).
Efren Saldivar. A male respiratory therapist who worked night shifts at the
Glendale Adventist Medical Center located in southern California (Ramsland,
2007). He murdered patients by injecting them with lethal doses of either Pavulon
or morphine in 1989 and 1998 when he was 19 and 28 years old, respectively
(Yorker et al., 2006). According to Ramsland (2007) he provided various accounts
to law enforcement, first stating that he murdered between 40 and 50 patients, but
later claiming that he had lost count after the 60th victim. He pled guilty to six
murders and was subsequently sentenced to six life sentences plus 15 years
(Yorker et al., 2006).
Data Collection and Analysis
Similar to previous research (e.g., Reid et al., 2019; Sharma, 2018),
interview data was gathered from secondary sources in which the killer discussed
his or her thoughts, feelings, motivations, and general experiences upon
committing serial homicide. Personal accounts were evaluated in the form of
diaries, interviews (with the media, law enforcement), quotes from various articles.
Since this project is strictly interested in investigating the ways that HCSKs defend
their actions through exploring their subjective experiences of serial homicide,
secondhand accounts from family, friends, or acquaintances of the offender were
not included for analysis. A minimum of one interview per offender were analyzed.
There were challenges in finding more than one interview source for each
HCSK as this is an understudied population who are not interviewed as frequently
as their sexually deviant counterparts. However, in a preliminary search, the five
sampled offenders were discovered and selected using the following two
procedural steps, similar to Field and Pearson’s (2010) data collection stage.
Firstly, a list of HCSKs was compiled from (1) googling the search term
“North American healthcare serial killers”, (2) Yorker et al.’s (2006) article
containing the names of North America HCSKs and (3) books containing
information on HCSKs (e.g., Ramsland, 2007). Secondly, the names of HCSKs
from North America were entered in the Google search and the LexisNexis
academic database to locate any first-hand accounts (i.e., interview data), which
were saved in individual folders created for each killer. Such search entries
included [name of killer] + transcript OR interview OR interview transcript OR
quotes OR interrogation OR confession OR diaries/journals. Links with video- or
audio-recorded interviews were bookmarked and viewed for analysis (see
Appendix A). Because this is a qualitative study, up to five North American
HCSKs with available first-hand accounts were initially included in the sample.
The rationale of choosing five offenders was due to the flexibility of the GT
method, where a minimum sample size has not been specified (see Charmaz,
2015).
Interview transcripts of Charles Cullen, Donald Harvey, Efren Saldivar,
Orville Lynn Majors were retrieved from LexisNexis Academia, which were news
transcripts. Elizabeth Wettlaufer’s interview was conducted by the Ontario
Provincial Police (OPP) but the data was retrieved from YouTube via CBC News’
YouTube account (CBC News, 2017). A separate transcript of Elizabeth
Wettlaufer’s interrogation by the OPP was retrieved from a Google search of
“Elizabeth Wettlaufer interview”. Interviews with Charles Cullen and Donald
Harvey were conducted by CBS News’ 60 Minutes segment and interviews of
Efren Saldivar and Orville Lynn Majors were conducted by ABC’s segment 20/20.
A video-recorded copy of Cullen’s interview was also found and retrieved from
YouTube. Across all killers, the time span of when these interviews occurred was
between 1988 to 2013 (see Appendix A). Although both Orville Lynn Majors and
Efren Saldivar provided interviews to the media, they did not confess or admit to
killing their patients. They provided little details about their murders by denying
them altogether which made their sources unviable for analysis. As a result, both
Majors and Saldivar were excluded from the final sample in this study. All killers
murdered in the United States except for Elizabeth Wettlaufer, who murdered
patients in Woodstock, Ontario, Canada.
The accounts of HCSKs were pasted in a separate word document by killer.
The transcripts of each killer were coded according to the guidelines of grounded
theory. Firstly, initial coding was conducted using line-by-line coding to denote
what was happening in the data in terms of (1) emotions, thoughts, and motivations
of HCSKs, and (2) their perceptions of their victims. Charmaz (2008) states that
initial coding (also known as open coding) allows researchers to closely interrogate
and read the data. This phase is extremely important since it helped with
familiarization of the accounts of HCSKs to fully understand what the data was
suggesting. In Vivo codes were also applied to quotes made by the HCSK
offenders. According to King (2008), In Vivo coding is applied to short phrases or
words in the data, specifically terms used by participants in the study. Charmaz
(2008) states that In Vivo codes allow researchers to gain insight into the
participants’ meanings from their words and their actions. Sharma (2018) used In
Vivo codes on “special terms” stated by the offenders, which were significantly
meaningful (p. 28). Since this thesis project is concerned with the subjective
experiences of HCSKs, In Vivo codes allowed for a better understanding the
perceptions and experiences of HCSKs from their point of view.
After the initial coding stage, focused coding was conducted. As stated
earlier, focused coding allows researchers to “sort and synthesize large amounts of
data” (Charmaz, 2008, p. 164). In this study, the initial codes generated from the
accounts of each killer were colour coordinated into broad themes of who or what
they were discussing at the time (e.g., the crime, their victims, their emotions, their
relationships etc.). Further synthesis of the broader and the most frequent codes
were conducted to highlight a common theme and trend that was occurring in the
data. Furthermore, these common themes were later compared to other sections of
the data to generate specific and prominent themes and to develop a theory on the
subjective experiences of HCSKs within this sample.
Charmaz (2008) also explains that grounding theorists closely inspect their
focused codes to examine which of these codes are best at clarifying or interpreting
a phenomenon. Sharma (2018) used focused coding by grouping the line-by-line
(initial) codes that were most frequent from the data to compare and explain larger
sections of the data. Similarly, this study is interested in looking for common
themes in the subjective experiences of HCSKs to elucidate how they reflect on
their experiences and rationalize committing serial homicide. Focused coding was
used to group together theoretical codes on differences and similarities between the
motivations, emotions, and perceptions of HCSKs to theorize what drives them to
kill repeatedly and in excess.
Throughout the GT coding process, memo writing took place at both the
initial and focused coding stage to interact with the data as it was being collected to
gain a better understanding about what was occurring in the data. Memo writing
also helped with the development of larger themes, concepts, comparisons between
the data and theories about the subjective experiences of HCSKs. These memos
were later reviewed, compared with one another, and contributed to the analysis of
the subjective experiences of HCSKs.
As common themes emerged from the data of each HCSK offender, they
were analyzed within the theoretical lens of neutralization theory (Sykes & Matza,
1957). Direct quotes from each offender was included as examples to highlight
prominent themes relating to their subjective experiences and perceptions of their
crimes, victims, and themselves. These quotes were then examined and compared
with neutralization techniques that have been identified in the works of Bryant et
al. (2018), Minor (1981) and Sykes and Matza (1957). The application of
neutralization theory to the subjective experiences of HCSKs in the current study
was to investigate whether they use specific verbalizations to justify their crimes
and reconcile their own feelings of guilt and responsibility in committing murder.
Chapter 6: Results
This study investigated the subjective experiences of HCSKs using
qualitative psychological methods. Specifically, GT was used to evaluate how
three HCSKs experience committing serial homicide. Specifically, their emotional
experiences, motivations of murder, and their perceptions of their victims and own
identities as killers were analyzed from their personal accounts using GT. The
subjective experiences of HCSKs were also examined within the theoretical
framework of neutralization theory to better clarify how they understand and
justify their own actions and whether their verbalizations aided in their prolonged
murders (Bryant et al., 2018; Minor, 1981; Sykes & Matza, 1957). Comparisons
between the experiences of HCSKs and those of violent and/or sexually-motivated
serial killers (from other studies) will be examined in the next section. As stated by
Charmaz (2015), grounded theory is distinct in its use to study meaning, thoughts
and perceptions, and its approach of both collecting data and performing analyses
simultaneously. The process of data collection and analyses began by first
reviewing the media and interrogation transcripts of the three sampled killers in
this study: Elizabeth Wettlaufer, Donald Harvey, and Charles Cullen.
The data was studied closely to become more familiarized with the meaning
within the killers’ words. Video-recorded data that aligned with the transcripts
were also studied to further understand the killers’ experiences of their murders.
Audio- or video-recorded copies of the transcripts were limited and found for two
killers, Elizabeth Wettlaufer and Charles Cullen. As the data was being collected
and studied, it was also being analyzed closely by first using lineby-line initial
coding to describe what was occurring in the data. After the initial coding stage,
focused coding was conducted, which was a two-stage process. First, initial codes
for each killer were grouped into larger broader categories. As an example, the
initial codes of Donald Harvey were coded into the following larger categories:
“crime”, “victims”, “emotions”, “motivation”, “self”, “mental health”, “life
events”, “investigators”. Second, after these codes were broadly categorized,
similar initial codes from these broader themes were grouped together and
developed into a single focused code/theme. The codes and themes of each killer
were compared to evaluate both similar and different trends happening in this
study’s sample of killers. In the categories of “self”, “victims”, “crime”,
“motivations”, and “emotions”, several prominent themes and sub-themes were
drawn from the three HCSKs listed in Appendix B.
Direct quotes from the accounts of the three HCSKs that highlighted specific
themes and subthemes were examined further in the context of neutralization
theory (e.g. Sykes & Matza, 1957). The accounts of HCSK offenders in the current
study were compared with the techniques of neutralization identified in the
literature (e.g., Bryant et al., 2018) to examine whether HCSKs use specific
neutralization techniques to defend their actions and to reduce their own
accountability and guilt in their crimes.
Results identified in the current study will be separated into two sections.
Common themes related to subjective experiences of the HCSK population will be
discussed in the first section and separated into five major categories: self-identity,
victims, motivations, crime, and emotions. Firstly, themes under self-identity will
revolve around how HCSKs perceive and explain themselves, their social identities
and how fit in with the world in which they reside. Secondly, victim-related themes
(i.e., how HCSK offenders perceive and feel about their victims), will be
elaborated. Thirdly, motivational themes will follow, which will shed light on what
the offenders perceived were the motivational factors to their crimes. Fourthly,
crimerelated themes will be discussed, which will go in-depth into major findings
relating to how HCSKs perceive and reflect on their crimes. And lastly, themes
relating to emotional experiences will be presented, specifically how HCSKs
describe their emotional experiences of their crimes and of themselves pre- and
post-murder.
The second section will compare findings in the current study to themes that
have been identified in (1) other qualitative studies of serial killers and (2)
anecdotal accounts of violent and/or sexually motivated serial killers. These
comparisons will be sectioned into two parts. The first part will present the
commonalities between common experiences and justifications in the current study
and those in the literature and accounts of violent serial killers or SSKs.
Conversely, the second part of this section will present dissimilarities between the
current study’s findings and what has been identified in the qualitative literature on
violent and/or sexually motivated serial homicide.
Themes Relating to Self-Identity
The current study aimed to clarify how HCSKs perceived and reflected on
their selfidentities. As a result, this study explored themes relating to how HCSKs
described their experiences of living in their own respective worlds. This study
discovered that each HCSK shared common experiences and perceptions of how
they viewed themselves. Firstly, the most common theme identified in the self-
reflections of HCSKs was internal conflict from their actions. They either
perceived their actions as both immoral yet moralistic and/or dealt with religious
conflict. The second theme identified relating to self-identity was HCSKs
perceiving themselves as being misunderstood and victimized by others. Thirdly,
HCSKs perceived themselves in dual identities and experienced conflict by
viewing themselves as both a saviour and a serial killer. HCSKs also reflected on
how their own identities fit within the world they reside. Therefore, a fourth self-
identity theme was identified, in which HCSKs wanted to be viewed not by their
dark predatory crimes, but as normal citizens like everybody else. An analysis of
these themes in the context of techniques of neutralization will be further detailed
below.
Feeling Internally Conflicted
All killers in this study experienced internal conflict when reflecting on their
behaviours and their crimes. However, the types of conflicts varied between
offenders and related to morality and religious experiences. As a result, two
subthemes, dealing with moral conflicts and dealing with religious conflicts were
identified and will be elaborated in-depth in the following sub-sections.
Dealing with Moral Conflicts. Donald Harvey, Elizabeth Wettlaufer and
Charles Cullen all felt morally conflicted about their actions and their own role of
their crimes. All killers acknowledged that there was a wrongness in what they had
done but also perceived their crimes as something that had to be done for the
greater good. Donald Harvey expressed no guilt for what he had done, by stating “I
once never had any guilt” (CBS News, 1991, p. 1). However, he verbally
acknowledged that killing his victims was wrong on some moral level by
expressing “Well, I didn’t have the right to take any of their lives away…” (Roth,
1993b, p. 4). Yet, Harvey also described his killings as an act of setting his victims
free by claiming he was “…releasing them from that bondage that would hold them
down.” (Roth, 1993b, p. 3). Evidently, he perceived his crimes in two ways which
conflict with one another. First, he recognized that he is a killer and a criminal and
that what he did was wrong. Yet, he perceived a sense of morality in what he did
since he expressed needing to set his victims free from a long life of suffering.
Charles Cullen acknowledged being sorry for killing his patients, replying “yes,”
when asked if he was sorry (Kroft & Simon, 2013, p. 17). In an interview by CBS
correspondents Kroft and Simon (2013), Cullen expressed knowing that “Yes, [he]
did” understand his actions were entirely wrong while he was killing and
afterwards while reflecting on what he did (Kroft & Simon, 2013, p. 17). However,
in the same interview, he also framed his killings as something that had to be done
by describing that “… it felt like I needed to do something. And I did.” (Kroft &
Simon, p. 7). He framed these killings as a mandatory task, as if only he had to be
the one to carry out his crimes. Furthermore, Cullen stated “…I thought I was
helping” by putting his patients out of their suffering (Kroft & Simon, 2013, p. 6).
By Cullen’s admissions, it could be argued that there are two polarizing
moral perceptions in how Cullen viewed his own killings. First, he may have
viewed his crimes as morally reprehensible by verbally expressing his guilt and
regret of how wrong it was for him to kill these victims by his own accord. Yet, he
may have also tried to justify that his crimes were moral duty that only he could
carry out. He had to end the suffering and viewed ending his patients’ lives as the
only way they could be free from their suffering. Overall, it is arguable that Cullen
felt a sense of responsibility in caring for his victims. However, he perceived his
duties not as nursing these victims back to health. Instead, his role in bettering his
victims’ situation was to terminate their lives to cease their suffering.
Elizabeth Wettlaufer also perceived her crimes in two different ways. In her
interview with the OPP (2016), she perceived her crimes as an act of betrayal. She
betrayed her victims and their families through her killings. She expressed feeling
extremely horrible when speaking to her victims’ families, acknowledging that she
had betrayed their trust by killing their loved ones. However, she also rationalized
that on some level, she carried out her crimes because some of her victims either
begged for death by claiming a victim told her “I wanna die, I wanna die…”
(Ontario Provincial Police [OPP] 2016, p. 51) or might have deserved it to some
degree because they were allegedly unkind (OPP, 2016, p. 38). From a moralistic
viewpoint, Wettlaufer may have rationalized that killing her patients was right on
the part of her victims, who she claimed were verbal about their suffering. In
addition, Wettlaufer went into detail about the sexual abuse that was inflicted upon
her by some of her victims, claiming that one victim “would say inappropriate
things and he did touch [her] inappropriately once” and “he would grab the nurses
uh breasts and buttocks” (OPP, 2016, p. 29). Although she reasoned that her
victims’ behaviour was not why she selected them, she did reflect and wonder
whether her victims’ unkind
behaviour was a reason she targeted them (OPP, 2016, p. 37).
By these separate perceptions, Wettlaufer may have experienced a moral
conflict in her actions. On one end, her actions were wrong, and she committed the
ultimate betrayal as a nurse by murdering her patients and ruining the lives of her
victims’ families. On the other end, she was moral in her actions by (1) doing her
victims a favour by giving them what (she claimed) they wanted: death or (2)
fighting back against them for (her claims of) their sexual abuse. The subjective
experiences and perceptions above among these killers demonstrate that these
HCSKs have all experienced a moral dilemma from their actions. They have both
transgressed morally by taking the lives of others. Yet, they also perceived their
actions as being done with good (moral) intentions by either ending the suffering of
their patients or getting retribution against abuse.
These findings are comparable to two neutralization techniques in the
literature, denial of victim (Sykes & Matza, 1957) and defense of necessity (Bryant
et al., 2018). Firstly, HCSKs in the current study who have reflected on their
actions appear to minimize the harm their actions have caused their victims. They
do so either through justifying that their patients were suffering by claiming that
“the people weren’t suffering anymore” after they were killed (Kroft & Simon,
2013, p. 6). They also neutralized their crimes by alleging the patients provoked
them with their disrespectful behaviour, stating “I wondered if that’s a portion of
how I chose him” (OPP, 2016, p. 37). Through these justifications, HCSKs denied
their patients were victims in their deaths. This finding can be aligned with the
theory that serial killers manage their self-image as the ‘bad men’ and minimize the
impact of their crimes by using tactics such as (1) denying the people they
murdered as being victims and (2) perceiving themselves as vigilantes (James &
Gossett, 2018).
Secondly, as stated earlier, Charles Cullen expressed “… it felt like I needed
to do something…” in explaining why he killed his patients (Kroft & Simon, 2013,
p. 7). Donald Harvey rationalized that his actions were necessary to “release [the
victims] from that bondage…” (Roth, 1993b, p. 3). In her statements above,
Elizabeth Wettlaufer disputed whether her crimes were truly wrong by suggesting
she might have been justified in murdering her patients because they were
allegedly unkind and vulgar (e.g., OPP, 2016, p. 29; OPP, 2016, p. 37). These
statements from both offenders are examples of the neutralization technique
defense of necessity (Bryant et al., 2018). Each offender defended their crimes by
suggesting they were obligatory and challenging the notion that their crimes were
truly inhumane and deviant. Using this neutralization technique may have helped
HCSKs protect themselves from feelings of disgrace and guilt by framing their
murders as necessary. However, it should be noted that HCSKs in the study also
made statements that support they perceived their crimes on the other end of the
moral spectrum, recognizing the immorality and unlawfulness of what they have
done. This finding falls outside of the social theories proposed by some of the
literature (e.g., James & Gossett, 2018). These findings may demonstrate that
HCSKs may find it more difficult to rationalize their crimes as necessary and
experience extreme internal conflict when doing so.
Dealing with Religious Conflict. Religious conflict was not a common
theme, but was a major conflict experienced by Elizabeth Wettlaufer. She
perceived and framed religion and God’s role in her life in two polarizing ways.
First, Wettlaufer implicated God as the motivation to her killings. She expressed
that God had summoned her to kill for His own purpose, claiming that “… this
might be the person that God wants” (OPP, 2016, p. 31). She explained further that
God was the one who (1) perceived the victims as suffering (i.e., “I thought now
this must be God because this man is not enjoying his life at all”) and (2) ignited
the red “surging” feelings and urges in her to lethally inject her victims (OPP,
2016, p. 88). She framed herself as God’s pawn, expressing that she was being
used by God to kill because she claimed He communicated to her “…this is how
you work for me” (OPP, 2016, p. 61). Yet, she also perceived God as a reason to
stop the killings. She claimed to reach out to the church, read her bible, and prayed
to God to help her stop her urges of wanting to kill any more patients (OPP, 2016,
p. 64). She also acknowledged that religious intervention helped attenuate her
murderous urges (OPP, 2016, p. 65). By reaching out to the church, she expressed
feeling that her strong faith and involvement with God was helping her stop the
killings. These admissions appear to be contradictory and demonstrates the extreme
conflict she experienced from God’s influence on her killings.
Other religious conflicts within Wettlaufer was when she questioned whether
her actions came from God. She did this by bringing up the possibility that the
devil was summoning her and blaming the devil for her actions (OPP, 2016, p. 31).
Elizabeth Wettlaufer also expressed denial, confusion and doubt that her
murderous urges could even come from God (OPP, 2016, p. 93). Elizabeth
Wettlaufer’s conflict towards religion and God also extended to her personal
feelings and relationship to God. On one hand, she perceived God as her saviour
and a solution to end her murders. If she sought out God, everything would be
okay, and her killings would cease. Yet when she continued with the killings, she
expressed resentment towards God by stating that He had failed her (OPP, 2016, p.
69).
Elizabeth Wettlaufer’s justification of God controlling her and commanding
her to murder her patients is closely related to two of Sykes and Matza’s (1957)
neutralization technique (1) the appeal to higher loyalties and (2) the denial of
responsibility. Elizabeth Wettlaufer portrayed herself as a devout follower of God.
She claimed her crimes were committed to fulfill His cause by stating “I honestly
believed at the time that God wanted me to do it (e.g., commit murder)” and “…
part of me thought it might be God that purpose through my life” (OPP, 2016, p.
20). According to techniques of neutralization, Wettlaufer may be conflicted
between her social obligations of not committing homicide and her loyalty to her
religion. Firstly, by claiming that her actions were committed out of loyalty to God,
Wettlaufer appealed to higher loyalties and reduced personal culpability. Secondly,
she neutralized the severity of her actions by denying responsibility when claimed
that God had complete control over her actions. By verbalizing that “there was
always the red surging that I identified as God telling me this is the one” (OPP,
2016, p. 61), she neutralized her negative feelings from committing her crimes by
refusing to take accountability for her own actions.
Yet, the current study demonstrated that Wettlaufer’s perception of being a
follower of God appears to be more complicated and contradictory. On one hand,
Wettlaufer portrayed herself as a devout follower of God who did as what He
commanded by killing his chosen victims. Yet she also portrays her religiosity
positively, advocating that her deep association with her religion had helped her
stop the crimes and to become a better person overall. Yet again, she shunned God
and perceived Him as responsible for her crimes when religion and God were not
able to stop her urges. Evidently, the perception of religious intervention appears to
be more complex in the current study. However, Wettlaufer’s experiences match
those of the serial killers examined in the literature (i.e., Henson & Olson).
However, Elizabeth Wettlaufer also mitigated personal responsibility by pointing
out what God made her do, and what God could not do for her (i.e., stopping her
urges).
Feeling Misunderstood and Victimized
Feeling misunderstood or victimized was a common theme identified in the
accounts of Donald Harvey and Elizabeth Wettlaufer. Each of these two killers
experienced feeling victimized and misunderstood from either being (1) betrayed
by their confidantes, (2) abused by others and/or (3) exploited by professional
experts. Donald Harvey experienced feeling victimized by several people in his
life. Firstly, he described being abused by both a family neighbour and a neighbour
in his childhood. Donald Harvey did not go into detail about the type of abuse he
endured although the interviewer confirmed Harvey was sexually abused (Roth,
1993a). However, in his accounts, he felt the deterioration of his psychological
state and eventual path to murder were partially linked to his traumatic childhood
experiences. In addition, Harvey gave off the impression that he does not respect
the “so-called experts”, who he believes profits from him and other serial killers.
This is evident in the way he criticized and downgraded the expertise of
psychologists. He did this by stating how easy it is to be an expert of serial killers
and that reaching expert-level knowledge of the subject has been dumbed down to
writing books about the topic (Roth, 1993a).
Donald Harvey arguably gives off the impression of being resentful,
misunderstood and betrayed by psychologists. He may have experienced
resentment from feeling how it is unethical that psychologists use serial murder for
their own personal gain. By his criticisms of the experts, he may have felt they do
not truly understand him. Instead, to him, they are opportunists who make a big
spectacle of the serial homicide phenomenon rather than try to understand the
crime and its perpetrators.
Elizabeth Wettlaufer described being a betrayer to her victims and their
families by taking their lives. Yet, she also expressed feelings of betrayal from
support groups and friends when they divulged her secrets to the authorities. There
is a sense of resentment in the way she framed her words. She stated she confessed
to someone who she thought was a friend instead of calling this individual her
friend (OPP, 2016, p. 93). Furthermore, she previously viewed the individual (to
whom she confessed her crimes) as being a support and resource for her mental
health issues. However, she later perceived this individual as not a friend, but
someone who went behind her back by going to the authorities and revealing her
trusted secrets (OPP, 2016, p. 96). Although these admissions could be interpreted
as Wettlaufer feeling betrayed against friends, she stated that she understood that
this friend was trying to do the right thing by turning her in (OPP, 2016, p. 96).
Wettlaufer also made several admissions about her lonely life and how she lives an
isolated life but does not cope well in isolation (OPP, 2016, p. 107). Overall,
Wettlaufer expressed feelings of betrayal and loneliness from having no one
around her. Although she felt betrayed by those close to her, she also expressed
that her apprehension was necessary.
Elizabeth Wettlaufer and Donald Harvey’s justification of feeling
misunderstood and being the victim closely aligns with the victimization
neutralization technique identified in Bryant et al.’s (2018) study. Elizabeth
Wettlaufer stated, “I told um someone who I thought was a friend … who turned
around and called the police to make sure that it had really been dealt with” (OPP,
2016, p. 96). It is arguable she felt betrayed because she stated she thought her
support advocate was her friend, yet he was not because he had divulged her
secrets to the authorities.
Donald Harvey expressed feeling misunderstood by indicating, “You know,
everyone that ever sees someone that kills a lot of people, they all become experts.
If one psychologist sees a serial killer, then suddenly he can write a book and he’s
got all the answers. And he may never see another one again”, critiquing whether
psychologists really understood him or others like him (Roth, 1993a, p. 2). Donald
Harvey also discussed his victimization through the abuse he endured in childhood
by stating that he was “abused by the uncle and the neighbour”, claiming this
experience partially contributed to his development into a serial killer (Roth,
1993a, p. 1). According to Bryant et al., (2018), individuals using neutralization
techniques of victimization will justify their actions by claiming that they are
victims who have been persecuted. This may help them neutralize their feelings of
guilt, ease their conscience and provide them excuses to commit serial homicide,
because they too have suffered in their lives. The statements above by Elizabeth
Wettlaufer and Donald Harvey suggest they may be trying to neutralize the
brutality of their actions by portraying themselves as victims through being (1)
betrayed by close confidantes, (2) abused by others in childhood and (3)
misunderstood by so-called experts who only care about profiting off of their lives
to write books.
Furthermore, self-victimization in the current study is comparable to
minimization tactics that serial killers have used to protect their self-image and
destigmatize their crimes (James and Gossett, 2018). The literature has suggested
that serial killers protect their emotions from guilt using neutralizations tactics such
as (1) portraying themselves as the true victims and (2) attributing their actions to
their past (traumatic) experiences (James & Gossett, 2018). As the current
literature suggests, several HCSKs in the current study (1) framed their identities
and crimes as a product of their traumatic experiences and (2) claiming to be
treated as fodder for books.
Being a Serial Killer Versus Being a Saviour
A common theme in all accounts was each killer struggling between two
identities: being a serial killer versus being a saviour. Donald Harvey perceived
himself as both a hardened convicted criminal and a destroyer of lives but also a
liberator. Donald Harvey did not hesitate to discuss his criminal history in his
statement “I committed 37 aggravated murders, seven attempted aggravated
murders and one felonious assault.” (Roth, 1993b, p. 1). Furthermore, he described
his crimes as destruction of everything in his path (CBS News, 1991). However,
despite his acceptance of his criminal status, Harvey rationalized that his killings
were an act of liberation. He described his victims as being tied down until they
were dead, potentially viewing them as living without freedom and dignity (Roth,
1993b). Instead of leaving them alive and confined to a life of what he perceived as
undignified suffering, he justified that he liberated his victims by setting them free
into death. By these admissions, he is a criminal for what he did and destroyed
many lives. Yet, he is also someone who was releasing them from that bondage”
that limited his victims to a life of prolonged solitude, pain and eventual death
(Roth, 1993b, p. 3).
Charles Cullen’s accounts also demonstrated that he too struggled with dual
identities between being a saviour and serial killer. During his interview with 60
minutes, when asked if he was a serial killer, Cullen evaded the question by first
stating that his identity of a serial killer ”depends upon a person’s definition”
(Kroft & Simon, 2013, p. 1). He followed up with this comment and admitted that
he was a serial killer if the definition is “more than one and it’s a pattern…” (Kroft
& Simon, p. 1). However, Cullen also expressed that he thought he was helping his
victims by what he was doing. By these explanations, Cullen seemed to express
two separate perspectives from what he has done. He admitted to being a serial
killer, although it was a challenge for him to accept it immediately. Yet, he also
perceived his actions as an ‘act of help’ and thought he was alleviating their
suffering through death.
Elizabeth Wettlaufer also discussed her identities in two polarizing ways. On
one hand, she stated that (1) she will be perceived as a monster when her crimes
are exposed and that (2) she was someone who did a terrible thing by taking
innocent lives (OPP, 2016, p. 108). Yet, she perceived her identity as one where
she saved and cared for her victims and their families. She perceived her role as
carrying the burden of her victims’ families, so they did not have to suffer while
their loved ones were dying (OPP, 2016, p. 12). She perceived herself as an
alleviator of other people’s stress by taking on the demanding task of caring for
their terminally ill loved ones. And finally, she perceived herself as saving the
victims who pleaded for death.
By these accounts, HCSKs framed themselves and their actions through
vigilantism by claiming they want to put an end to injustice on their own terms.
The statements made by HCSKs in the current study may be examples of the
neutralization technique appeals to good character (Bryant et al., 2018). Elizabeth
Wettlaufer highlighted her favourable character attribute as a selfless caregiver,
claiming that caring for palliative patients was “… just an opportunity to give the
family a rest” (OPP, 2016, p. 12). Furthermore, Donald Harvey and Charles Cullen
suggested the killings were committed for morally good reasons, making assertions
such as “I was releasing them from that bondage that would hold them down till
they died” (Roth, 1993b, p. 2) and “… I thought I was helping them” (Kroft &
Simon, 2013, p. 6). By verbalizing there were redeemable aspects of their crimes
and themselves, HCSKs in the current study may be trying to justify that their
killings were not as reprehensible as they seemed to deal with their actions
Being Us Instead of Being Them
Another common theme within this sample of HCSKs also related to how
the killer perceived their own social identities and how they wanted others to
perceive them. All HCSKs attempted to retain a sense of normalcy, either by (1)
not immediately accepting their identity as a serial killer, (2) emphasizing they are
just like everybody else, (3) trying to live a ‘normal’ life and/or (4) rejecting the
label of mental illness. Through these experiences, it is arguable that they perceive
their identities as socially unacceptable and are experiencing stigma. As a result,
they rejected these identities by portraying themselves as belonging with the rest of
“us” instead of being one of “them”.
Charles Cullen was hesitant in admitting he was a serial killer. When asked
whether he considered himself to be a serial killer, he replied that it depended on
the definition, evading the interviewer’s yes-or-no question. After some line of
questioning, he eventually conceded and accepted that what he had done falls
under the definition of serial homicide (Kroft & Simon, 2013). It could be argued
Cullen’s hesitation and evasion of being asked if he is a serial killer may be due to
shame or the stigma of adopting the ‘serial killer’ identity. The acceptance of this
serial killer identity has placed him out of the “us” category with the non-killer and
noncriminalized population and into the “them” category, the undesired, inhumane
individuals who committed deviant acts.
While Charles Cullen expressed hesitation in admitting his serial killer
identity, Donald Harvey did not reject his identity as a criminal and fully accepted
that what he had done was murder. Yet, he arguably experienced some conflict in
his perceptions of his self-image and social identity and tried to claim normalcy.
The following observations were made to support the claim above. Firstly, he
stated that because of the abuse he endured in his childhood, “it messed [him] up
mentally” (Roth, 1993a, p. 1). In addition, he also claimed that he was a defective
person by expressing “I think I was like a bad car” (Roth, 1993b, p. 3). By these
admissions, he may have perceived himself to be a killer and different from others,
primarily due to the adversities he experienced in the past. Despite his claims of
being defective and mentally disturbed he also attempted to reject the identity of a
mentally-ill individual, refusing to accept that he is “sick” and expressing
adamance that he is like everybody else (CBS News, 1991).
Harvey further tried to push the narrative that he is like everyone else by
portraying himself through other social familial roles. He described himself to be
the same person he has always been despite his murders. He did so by describing
himself as a brother, a son, and a member of a family just like most others (CBS
News, 1991). Through these perceptions, he is further emphasizing the need to be
recognized as being like the rest of us. Harvey may have experienced conflict when
associating himself with mental illness. On one hand, he admitted that there is
something wrong with him inside and maintained that his messed-up nature caused
him to kill. Yet he rejected the mentally-ill label entirely, which may indicate that
he perceived mental illness labels as undesirable, stigmatizing and wanted to avoid
being associated with it. Overall, he recognized that in part, he may not relate to
many others because he is a criminal, feels psychologically disturbed, and ended
up killing multiple people. Yet he tried to compensate and retain his normalcy by
rejecting mental illness and arguing that he has a family just like everyone else.
Overall, Harvey contradicted himself in terms of whether he is a “normal” person
yet tried to portray to others that is like everyone else. In this sense, he may not be
like us, but he wants to be recognized as one of us.
Unlike Donald Harvey and Charles Cullen, who both arguably tried to retain
their normalcy and social status as being one of “us”, Elizabeth Wettlaufer
perceived herself to be psychologically troubled. Elizabeth Wettlaufer was
transparent about her mental health struggles by revealing her diagnoses with
Borderline Personality Disorder (BPD) and substance abuse issues (OPP, 2016, p.
15; OPP, 2016, p. 19). She was explicit in stating that she ”wasn’t in [her] right
mind” (OPP, 2016, p. 93), reasoning that she committed her crimes because there
was something psychologically wrong with her. By these admissions, it appears
that Wettlaufer accepted the social label of mental illness and did not reject the
idea that she may be different from others. She embraced the idea of receiving
professional mental help and had the opinion that mental help would have
benefitted her sooner and could have prevented her from killing her patients (OPP,
2016, p. 54). Furthermore, as stated earlier, Wettlaufer acknowledged and
understood that as soon as her crimes would be made public, the world would
perceive her as a monster. However, Wettlaufer did discuss the troubles of dealing
with what she had done and expressed wanting to live a life that did not involve
murder (OPP, 2016, p. 53). This may indicate her desire of wanting stability and to
lead a normal life like everybody else.
HCSKs in the current study who tried to project an image of normalcy may
be using the neutralization technique appeal to good character (Bryant et al.,
2018). They expressed dismay and denial at being labelled as a serial killer or
pathologically sick individuals, perceiving these labels as socially reprehensible.
They dissociated themselves from these deviant identities to avoid being social
pariahs and emphasized their socially acceptable identities (e.g., familial status).
For instance, when Donald Harvey was asked whether he regarded himself as a
“sick person”, he provided the following statement “No-- I’m the same person I
was on the street except for the killing part. I’m still—I’m still someone’s brother,
someone’s son, I’m still the same…” (CBS News, 1991, p. 2). Elizabeth Wettlaufer
expressed that she “didn’t wanna do it anymore” when she referred to the killings,
trying to justify that she was someone with good intentions (OPP, 2016, p. 52).
These statements suggest that HCSKs in the current study may be using the
appeals to good character neutralization technique to further distance themselves
from their criminal actions and reduce their guilt , which was done by highlighting
their (1) socially favourable identities or (2) desire to act out in socially acceptable
ways.
Victims
Recurrent themes relating to HCSKs’ perceptions of their self-identity were
presented in the previous section. Along with self-identities, this study also
investigated how HCSKs justified their actions by exploring how they felt about
their victims in terms of (1) their relationships to the victims, (2) why the victims
were selected (3) and how they perceived the impact of their crimes to their
victims. Several victim-related themes were identified. The first theme identified
and presented below is HCSKs justified their victims’ deaths as being quick and
painless. The second victim-related theme was HCSKs perceiving their victims as
suffering more in life than in death. And thirdly, the final victim-related theme that
was identified was HCSKs reflecting on how personal the victim selection process
was during the murders. The process of choosing who to kill varied across
offenders which may have depended on (1) their interactions with their
victims/patients (2) and how they perceived the health of their victims. Each of
these themes will be discussed in-depth below and will be examined by comparing
the offenders’ direct accounts to techniques of neutralization (Bryant et al., 2018;
Minor, 1981; Sykes & Matza 1957).
Perceiving Victims’ Deaths as Quick and Painless
All three killers in this sample perceived their victims’ deaths as quick and
painless, stating their victims did not suffer for long. Donald Harvey described the
deaths of his victims as being incredibly quick, stating that “it was only for maybe
two seconds and then it was over with,” for one of his victims (Roth, 1993b, p. 2).
By this account, it could be argued that Harvey was trying to mitigate his killings
by justifying that his victim’s death was quick and painless. In his interview with
Roth (1993b), Harvey’s justifications extended beyond the victims by discussing
how he was looking out for the best interests of his victim’s wife. He justified his
actions by stating “I waited until she come [sic] back before I killed him becausee I
didn’t want to mess up her vacation by having her husband die” (Roth, 1993b, p.
2). By these admissions, the following could be argued: (1) Donald Harvey
perceived himself as considerate for murdering at an appropriate time that would
not ruin the plans of the victim’s family and (2) he justified his killings by trying to
find a kernel of positivity within the murder event.
Elizabeth Wettlaufer displayed some conflicting reports about the nature of
her victims’ deaths. Firstly, Wettlaufer described her victims as dying peacefully as
if there was no suffering when they did pass (OPP, 2016, p. 54). Although
Wettlaufer expressed the imagery of her victims dying peacefully, she also used
vivid terms to describe her victims’ death, stating they would get “diaphoretic red”
and “… they’d lose consciousness they’d shake” after being injected (OPP, 2016,
p. 48). These two admissions are contradictory and demonstrates that Wettlaufer
may have perceived her victims’ death as both peaceful yet unpleasant.
The statements above made by Donald Harvey and Elizabeth Wettlaufer can
fit within the neutralization technique, denial of injury (Sykes & Matza, 1957). As
discussed earlier, previous literature (e.g., James & Gossett, 2018) has shown that
serial killers will (1) explicitly deny the victim status of those they have murdered
and (2) claim they are the true victims. However, serial killers in previous studies
generally do not deny the injury they have inflicted upon their victims (James &
Gossett, 2018). The current study on HCSKs corroborates with some of the
theoretical insights found in the previous literature. Specifically, HCSKs denied the
victim status of their patients’ by undermining the severity of their deaths.
However, HCSKs refuted that their victims were harmed, which is an inconsistent
perceptual theme from what has been identified in the literature (James & Gossett,
2018). Another observation that can be made from Donald Harvey’s accounts
above, which is that he may have been appealing to good character by justifying
that the timing of his victim’s murder was convenient for his immediate family
(Bryant et al., 2018). Ultimately, making such a statement may helped Donald
Harvey downplay the brutality of his actions and accept them.
Perceiving Victims as Suffering Alive
All three killers in this sample perceived their victims as suffering alive.
Elizabeth Wettlaufer stated that her victims begged her and the staff for death
(OPP, 2016, p. 51; OPP, 2016, p. 66). She also stated that some of her victims
would reject help from her and the other nurses. At some point, Wettlaufer even
displaced her perception of victims’ suffering onto God, stating that God perceived
one of her victims as not “not enjoying life at all” (OPP, 2016, p. 88). Overall,
Wettlaufer stated that she perceived her victims as suffering in life. Her admissions
could also be interpreted as Wettlaufer rationalizing what she did by displacing the
responsibility of her actions to her victims or God. Despite these rationalizations,
Wettlaufer described that some of her patients tried to defend themselves by
struggling or trying to scratch her (OPP, 2016, p. 61).
Donald Harvey was also argued that his victims were suffering in life,
implying that they were being deprived of their freedom by stating that they were
in “bondage” (Roth, 1993b, p. 3). Like Elizabeth Wettlaufer, Donald Harvey also
rationalized that he killed his victims because he perceived them to be suffering in
life. He transitioned them over into death to free them from a life of confinement.
While Charles Cullen did not explicitly state feeling like his victims were suffering
alive, he stated that he felt like he was helping his victims by killing them. It could
be argued that Cullen also rationalized and perceived that his victims’ lives as
unpleasant, so he helped them by killing them (Kroft & Simon, 2013).
As covered in the previous section, HCSKs denied inflicting pain and harm
to their victims, and rationalized their victims were suffering while being alive.
Donald Harvey claimed. I was releasing them from that bondage that would hold
them down till they died” suggesting their victims lacked freedom and dignity
while they were alive (Roth, 1993b, p. 2). Additionally, Charles Cullen rationalized
that he thought that “people weren’t suffering anymore” (Kroft & Simon, 2013, p.
6). And lastly, Elizabeth Wettlaufer attributed blame to her victims by claiming her
victim “seemed to be waiting to die” (OPP, 2016, p. 44). By these direct accounts,
HCSKs in the current study may be using the neutralization technique denial of
victim by claiming that their victims either (1) desired death or (2) regained their
freedom when they were put to death. By denying their patients as being victims,
HCSKs were able to reconcile that killing their patients was necessary, rendering it
easier for the offenders to come to terms with their murders and continue them.
Reflecting on Whether Victim Selection Was Personal
The current study identified a gradation between how personal victim
selection was to the killer within this sample of HCSKs. Killers in this sample
either regarded the victims as nothing more than a number count and objects or
described their victims through their names and personality. Donald Harvey was
not emotionally charged when discussing his victims. He did not mention their
appearances, their personalities, or even their names. Instead, Harvey emphasized
the number of victims he claimed. He made a comparison of his victim count to a
stamp collection in his statement “Well, if you have a stamp collection, you know
approximately how many stamps you have, right?” (Roth, 1993b, p. 1). Several
inferences can be made from Harvey’s perception of his victims. Firstly, Harvey
may have made this comparison between his victims to a collection as an
expression of pride. Donald Harvey may have been proudly bragging about how
many victims he killed down to the very number, just as an individual would brag
about how many stamps he or she has collected. Secondly, he may be objectifying
his victims, perceiving them not as humans with feelings, but inanimate objects
who cannot fight back. He went into lucid details about looking his victims in the
eyes and watching them die yet reduced his victims down to numbers and objects
(Roth, 1993b).
Charles Cullen did not compare his victims to objects or numbers as Donald
Harvey did. However, he did not go into detail about who his victims were and
expressed uncertainty of how many he had killed in his nursing career by only
providing estimates of his victim count (Kroft & Simon, 2013). Furthermore,
Cullen denied that his selection of victims was personal, meaning that his
decisions of who to kill was not based on his own feelings towards this victim
(Kroft & Simon, 2013). However, he framed the act of killing his victims as a
being personal because it “felt like [he] needed to do something” (Kroft & Simon,
2013, p. 7). It was personal because he expressed “I thought I was helping…” and
that the killings were something that he personally had to do (Kroft & Simon,
2013, p. 6). Overall, it appears that Cullen felt no personal emotional attachment to
his victims but felt strongly towards the act of killing his victims.
Unlike Donald Harvey and Charles Cullen, Elizabeth Wettlaufer was very
descriptive about her victims and went into detail about their personalities, likes,
dislikes, even recalling the things her victims mentioned to her and the way she
used to nurse them (e.g., OPP, 2016, p. 57). She expressed knowing her victims on
a personal level from nursing them, unlike her male HCSK counterparts who also
nursed their own victims. She described her victims using both positive and
negative characteristics and mainly spoke disparagingly of her male victims. She
perceived her male victims as aggressors and sexual abusers yet perceived her
female victims as suffering and burdened from life (OPP, 2016, p. 29; OPP, 2016,
p. 44).
There appears to be a conflict between whether victim selection was based
off personal emotional reasons. Elizabeth Wettlaufer placed a stronger emphasis on
religious intervention being the reason why she continuously murdered victims
(e.g, OPP, 2016, p. 61). Despite this explanation, Wettlaufer doubted and
questioned herself as to whether her victims were selected because she claimed
they were abusive or pleaded for death (e.g., OPP, 2016, p. 37). If the personalities
of her victims were a factor in their demise, it could be argued that her murder
streak may have been affected by her emotions and perceptions of her victims.
Another indication of her strong personal investment in her victims is her
perception of her victims being the “chosen ones: (OPP, 2016, p. 38). She
described this as a strong motivating factor of why they were selected.
Evidently, there are clear differences in how each killer regarded their
victims personally. Based on the data, Donald Harvey perceived his victims as
nothing more than an inanimate object such as a collection of stamps. Each of his
victims represented one stamp within his personal collection of stamps. However,
Charles Cullen did not express feeling emotionally influenced by his decision of
who to kill. Although he claimed not to feel any sort of personal vendetta against
his victims, the act of murdering these victims was personal for him. He felt that it
needed to be done, and that he was the one that had to do it. Elizabeth Wettlaufer
placed a higher emphasis on religion and God being the main reasons of why she
killed. However, she expressed wonder and doubt as to whether she would have
murdered her victims if they were (allegedly) not abusive or crude towards her and
the staff.
Charles Cullen replied with “No, no” when asked whether killing his victims
was personal (Kroft & Simon, 2013, p. 6). However, he expressed feeling that the
act of killing was a personal duty that he had to carry out by stating “… I needed to
do something. And I—I did.” (Kroft & Simon, 2013), suggestive of the
neutralization technique the defense of necessity (Minor, 1981). Charles Cullen
legitimized his crimes by clarifying that it was a necessary act that had to be done,
which may have helped him mentally justify that his repeated murders were
acceptable. Elizabeth Wettlaufer’s affirmation of God perceiving specific victims
as the chosen ones aligns with the neutralizing technique, denial of responsibility
(Sykes & Matza, 1957). She expressed that specific victims were chosen by God,
not her, distancing herself from being the main culprit that chose who lived or died.
In addition, although she claimed that victims were not killed out of feelings of
resentment towards them, she claimed a victim was unkind and reflected,
“I wondered if that’s a portion of how I chose him” (OPP, 2016, p. 37). Elizabeth
Wettlaufer’s statement suggests that she used the neutralizing technique denial of
victim (Sykes & Matza, 1957). By denying the victim by claiming her victim was
unkind, she neutralized feelings of guilt from committing murder.
Motivational Themes: Psychological, Situational Factors and Personal
Motivation
This study was interested in elucidating whether HCSKs use neutralization
techniques (e.g., Bryant et al., 2018) to justify their crimes when describing their
motivations of committing serial murder. Theoretical research in psychology and
law enforcement investigating the motivations of serial homicide has
overwhelmingly discussed how serial killers use violent (and often sexual)
fantasies to cope with negative emotions from experiencing poor attachment and
traumatic events (Hickey, 2009; Ressler et al., 1988). As described earlier, fantasy
may be a way to for traumatized children and adolescents to reclaim control, where
they can envision themselves as dominating others in antisocial ways (Burgess et
al., 1986).
Most studies agree that violent fantasies are catalytic and compels the
offender to engage in deviant behaviours that lead up to homicide (e.g., Hickey,
1997; MacCulloch et al., 1983). As discussed in previous sections, psychosocial
studies have also investigated significant factors such as (1) precipitating events as
triggers that also propels a budding offender to engage in serial homicide and the
(2) compulsive and addictive element in serial killing (Schlesinger, 2008).
Considering these widely-studied topics of serial homicide, the current study also
identified motivational factors from the killer’s accounts, which will be separated
into three broad themes: (1) psychological motivation, (2) situational factors, and
(3) personal motivation. Subthemes in each of the aforementioned themes will be
addressed in the order previously listed.
Psychological Motivation: Being in Control Versus Losing Control and
Experiencing
Psychological Disturbances
Two major themes relating to psychological motivational factors were
identified in the current study. Firstly, a recurrent theme of HCSKs in this study is
that they experienced control, but in two polarizing ways. While all killers in this
study experienced an overwhelming compulsion to murder repeatedly during the
crimes, HCSKs either (1) expressed disdain and experienced loss of autonomy
from losing control or (2) derived psychological pleasure from being in control. A
second recurrent theme related to psychological motivation is that HCSKs justified
their crimes by stating they experienced psychological disturbances during the
murders. This was primarily in the form of (1) stress or (2) the experience of deep
psychological problems. These will be discussed in depth in the following section.
Being in Control Versus Losing Control. All HCSKs in this study
expressed the fact that they lost control with respect to murdering their victims.
Once the killings started, each killer expressed that they had difficulties stopping
their murder streak. However, there are some differences in how each killer
perceived the concept of ‘control’ and their own self-control.
Both Elizabeth Wettlaufer and Charles Cullen felt that their actions were
beyond their control. Charles Cullen stated, “I don’t know if I would’ve stopped”,
not knowing whether he would have been able to stop the murders despite claiming
to feel bad about the killings (Kroft & Simon, 2013, p. 17). Elizabeth Wettlaufer
expressed feeling extremely ashamed about not being able to halt her urges of
killing patients by stating “I felt horrible I felt angry at myself, I felt like I had
failed myself…” (OPP, 2016, p. 69). Both Elizabeth Wettlaufer and Charles Cullen
expressed feeling like they had no autonomy in their choices. In their minds, they
could not control their urges and lacked self-control.
Donald Harvey’s concept of self-control somewhat differed from the other
two HCSK’s. Donald Harvey expressed ‘control’ as being one of the motivations
of murdering his victims (CBS News, 1991). He enjoyed being in control by
having the option of choosing who lives and dies. He perceived ‘control’ as a
psychological reward from committing the murders in his statement “I’m a control
freak. I just like to—the control. That is your reward” (CBS News, 1991, p. 1).
Elizabeth Wettlaufer and Charles Cullen did not express enjoyment in having
control over their patients’ lives. Similar to the other two HCSKs, Donald stated
that once he started killing people, he could not stop (CBS News, 1991). Yet,
unlike the other two HCSKs, he also perceived himself as being in control. His
level of control extended beyond his victims’ families to his own fate. He stated the
following in response to his murder case:
“If they come up with one piece of evidence, then John Powell - before they
had anything on me at Drake or not - then John Powell would have become
a death penalty case anyway. So it was like the Price Is Right, you've got
door number one, door number two, door number three and I chose door
number one.” (Roth, 1993b, p. 3).
When he selected door number one, he was referencing that he chose “life” instead
of the death sentence. By this admission, he made the conscious choice of pleading
guilty so that he could have a chance at life, therefore felt he had control over his
own fate.
HCSKs in the current study claimed to experience homicidal compulsions
that were uncontrollable. They each claimed they lacked the ability to control their
urges to murder, which can be paralleled with the neutralization technique denial of
responsibility (Sykes & Matza, 1957). As stated previously, Charles Cullen
claimed to be apologetic for his actions but admitted, “…But like I said, I don’t
know if I would’ve stopped.” (Kroft & Simon, 2013, p. 17). Donald Harvey also
indicated that he lacked the ability to control himself by stating “Once I killed the
first one, and the second one, I don’t think I --- there was any stopping” (CBS
News, 1991, p. 1). And lastly, Elizabeth Wettlaufer continuously pointed out that
her urges to kill arose from a red surging feeling, claiming “I started to get the
feeling that surge again” that could not be controlled because of God’s power
(OPP, 2016, p. 73). These statements made by HCSKs in the current study is
suggestive of them neutralizing their culpability by reframing their level of
responsibility. By convincing themselves and others that God or their unrelenting
psychological urges were to blame for their crimes, HCSKs were able to reduce
personal feelings of guilt and perceive themselves as unaccountable for their
actions.
Experiencing Psychological Disturbances. All three killers in this sample
indicated that they experienced psychological disturbances around the time of their
murders. They had perceived their psychological state as playing a major role in
their murders in two ways: (1) feeling overwhelmed/stress and (2) feeling
psychologically damaged inside. These psychological experiences will be
elaborated below.
Feeling Overwhelmed/Stressed. Experiencing overwhelming stress was a
common theme, occurring in both Charles Cullen and Elizabeth Wettlaufer’s
accounts. Charles Cullen expressed extreme stress in his accounts by stating, “I felt
overwhelmed at the time…” during the commission of the murders. Elizabeth
Wettlaufer described multiple stressors in her life while her murders were
occurring, which came from personal, interpersonal, and environmental
circumstances. Firstly, Wettlaufer described feeling stressed from overworking
herself to be the ‘perfect nurse’ and ‘perfect person’ in her statement, “I was
always putting this pressure on myself to be a really good nurse and to do
everything perfectly” (OPP, 2016, p. 16). This stressor also ties in with her
environmental stressor of working at an overwhelmingly stressful work
environment which required her to do many things at the same time and having to
do them perfectly (OPP, 2016, p. 90). Elizabeth Wettlaufer also described feeling
that her job stress was influential to her addiction problems (OPP, 2016, p. 16).
In addition, Elizabeth Wettlaufer expressed several stressors in her
interpersonal relationships such as her divorce from her ex-husband (OPP, 2016, p.
31). She discussed how her divorce was catalytic to her crimes and her mental
health struggles by stating “When my ex and I broke up in 2007 I was already
taking the medication for my borderline personality disorder… and I was so angry
and it was like a voice said inside me I’ll use you don’t worry about it” (OPP,
2016, p. 19). The statements above can be argued as HCSKs using victimization as
a neutralization technique to justify their actions (Bryant et al., 2017). HCSKs in
the current study may have been trying to shift blame of their crimes to the
different stressors in their lives to feel less guilty and more as individuals who have
also suffered.
Feeling Psychologically Damaged Inside. All three killers in this sample
expressed feeling that there was something internally wrong with them. Donald
Harvey was conflicted in his perception of his own mental state. He was very
adamant about being like everyone else. He perceived himself (and expressed to
others) as being normal and the same person he has always been (CBS News,
1991). Despite his protests of being in the majority, Harvey also expressed feeling
that there was something “messed up in [him] mentally” and partially attributed
his “messed up” state to the abuse he endured in his childhood (Roth, 1993a, p. 2).
However, unlike Wettlaufer, he never explicitly blamed his mental state as being
the reason why he began killing his patients. Instead, he blamed those that abused
him for the unravelling of his actions. Donald Harvey may have not wanted to
admit that there was something fundamentally wrong with him that made him kill.
Instead, he may have wanted to place some responsibility of his actions onto those
who hurt him in the past.
Elizabeth Wettlaufer also attributed the motivation of her crimes to her
psychological state. Elizabeth Wettlaufer went into detail about how a red surge
feeling would arise and influence her to inject her patients (OPP, 2016, p. 66). She
claimed that this continuous red surging feeling within her was summoned by God
(OPP, 2016, p. 57). She also described feeling laughter in her gut before and during
the killings which was influential in her decision to kill
(OPP, 2016, p. 45). She reflected on this feeling from God and perceived it to be
psychological. This religious motivational factor was later clarified by Wettlaufer
as untrue and manifested due to mental health issues (OPP, 2016, p. 93).
Donald Harvey was vague in his description of his perceived psychological
issues. Yet, the other two HCSKs in this sample clarified their mental health
problems by labelling it with a specific psychological or psychiatric disorder.
Charles Cullen was clear in stating that he had been suicidal his entire life by
disclosing “I tried to kill myself throughout my life...” (Kroft & Simon, 2013, p. 7).
As cited earlier, Wettlaufer described her substance abuse issues and “taking
medication for Borderline Personality Disorder” (OPP, 2016, p. 19).
These findings demonstrate that HCSKs have tried to make sense their
actions and themselves using diagnostic criteria (i.e., suicidal ideation, personality
disorders, substance abuse, perceived break with reality, inner psychological
turmoil). Similarly, past qualitative studies of serial homicide have revealed that
serial killers blame genetic predispositions and psychological issues for their
deviant behaviours, similar to what HCSKs have done in the current study (Henson
& Olson, 2010).
These parallels confirm that HCSKs may attribute their motivations to
committing serial homicide to characteristics that are beyond their own control.
These verbal justifications can be related to two neutralization techniques,
victimization and denial of responsibility (Bryant et al., 2017; Sykes & Matza,
1957). The use of both neutralization techniques is evident in (1) Donald
Harvey’s claims of childhood abuse influencing him to becoming a serial killer, (2)
Charles Cullen’s disclosure of his suicide attempts and (3) Elizabeth Wettlaufer’s
discussing the impact that her mental health issues (i.e., BPD) played on her crimes
by claiming that she felt “so angry and it was like a voice inside me I’ll use you
don’t worry about it” (OPP, 2016, p. 19). Their justifications may have helped
them (1) perceive themselves as the true victims due to their traumatic past and
psychological distress and (2) feel less accountable and more vindicated in their
actions.
Situational Facilitators: Coping Poorly at Place of Employment
HCSK offenders in the current study framed their motivations around
situations that had been occurring in their life during the murders. The primary
theme that was identified in terms of situational motivation was dealing with issues
at the workplace. Two killers in this sample, Elizabeth Wettlaufer and Charles
Cullen, expressed poor coping skills at their place of employment. The theme of
job stress is frequent in Wettlaufer’s interrogation. Elizabeth Wettlaufer perceived
her job as difficult, extremely stressful and taxing to her mental health in her
statement “… it’s a hard job any nurse will tell ya… then they would add different
things like oh you have to do this and that… (OPP, 2016, p. 16). She also discussed
feeling very frustrated whenever she went to work (OPP, 2016, p. 90). She felt like
her job was a burden and expressed the overwhelming task of having to take on
many patients at once (OPP, 2016, p. 16). Elizabeth Wettlaufer also expressed
extreme pressure to do her job perfectly in her statement “just always feeling like I
had to be the best possible person an very very stressful job giving medications to
thirty-two people…” (OPP, 2016, p. 16). Therefore, she may have perceived the
‘perfect nurse’ identity as stressful and damaging to her own imperfect identity.
Although Cullen did not go into detail about his reflections of his workplace, he
briefly stated that he found it extremely challenging to work in a burn unit and
expressed “… there was a lot of pain, a lot of suffering. And I didn’t cope with that
as well as I thought I would.” (Kroft & Simon, 2013, p. 4).
Elizabeth Wettlaufer and Charles Cullen both revealed they coped poorly at
their places of employment. Elizabeth Wettlaufer specifically detailed how her
workplace affected her own self-perceptions and emotions negatively by (1)
experiencing immense pressure in perfecting her nursing role and (2) perceiving
her workplace as burdensome and overwhelming. Furthermore, she stated “I
definitely think that stress played into it maybe made me made my mind more
susceptible” to committing the killings (OPP, 2016, p. 62). Statements by Elizabeth
Wettlaufer and Charles Cullen are examples of them neutralizing their guilt
through victimization and denial of responsibility (Bryant et al., 2017; Sykes &
Matza, 1957). Both offenders asserted that their workplace was detrimental to their
mental health which ultimately helped them justify that they were killed because
they were vulnerable.
Personal Motivation: Perceiving Crime as a Duty
The current study also identified motivational themes that were personal to
the offenders. HCSK offenders in this study perceived their crime as a personal
obligation. All killers in this sample perceived their crimes as a duty that had to be
done, but each killer differed in the type of duty they felt they had to serve.
Elizabeth Wettlaufer’s duty was a mix of both religious and moral. The subtheme
of moral duty was present in Wettlaufer’s account when described her female
victims as suffering and injected them so their suffering would end. For example,
this is evident in her statements “he would just say it sometime that he just wanted
to go” (OPP, 2016, p. 87). Elizabeth Wettlaufer typically described her male
victims as sexual aggressors through her statement “… he was another one who
liked to grab asses” (OPP, 2016, p. 40). As stated previously, shepondered on
whether she had killed another victim for his crude personality traits (e.g., OPP,
2016, p. 40). However, Wettlaufer explicitly claimed that she did not choose her
victims because of any altercations between her and them (OPP, 2016, p. 94).
Elizabeth Wettlaufer perceived that her crimes revolved around a religious duty by
claiming that her actions reflected what God wanted, and that she was His pawn in
the killings (OPP, 2016, p. 31).
Donald Harvey and Charles Cullen did not describe any religious
intervention in their crimes. Instead, they described their killings as serving only a
moral duty. Donald Harvey described his victims as being in ”bondage”, meaning
they were restricted of their freedom and determined that his killings were an act of
breaking his victims free from a prolonged life of slowly dying (Roth, 1993b).
Charles Cullen stated that he thought he was helping his victims by killing them
with the powerful drug, Digoxin (Kroft & Simon, 2013). Although he stated it was
difficult to “think about things that were going through [his] mind at the time”, he
felt obligated to act as he did by injecting his victims (Kroft & Simon, p. 6).
HCSKs in the current study consistently perceived their crimes as an
imperative task they had to carry out. Their claims of terminating ailing patients
out of a religious or personal moral code are examples of them using the
neutralization technique defense of necessity (Minor, 1981). Donald Harvey
expressed, “The freedom that I felt and I looked at it that I was releasing them from
that bondage…” (Roth, 1993b, p. 2). Furthermore, Charles Cullen justified his
actions were necessary by stating “… I thought I was helping” (Kroft & Simon,
2013, p. 6). And lastly, Elizabeth Wettlaufer pointed out the crude things that some
of her patients did by stating “[the victim] did touch me inappropriately once”
(OPP, 2016, p. 29) or was adamant that victims pleaded to her “…. Why can’t you
help me die?” (OPP, 2016, p. 66). These statements accusing victims of either
being sexual aggressors or sufferers pleading for death can also be viewed as
examples of denying the victim (Sykes & Matza, 1957). However, overall, the
statements by HCSKs in the current study provided them a way to view their
killings as obligatory. Their justifications of committing their crimes to fulfill a
religious or ethical obligation may have helped them defend the necessity of their
actions and feel less culpable from committing them.
Experiences and Perceptions of Crime
This study was concerned with how HCSKs perceived their crimes both pre-
and postmurder. With respect to criminal behaviour of serial killers, much of the
literature has focused on the crime scene characteristics of serial killers to build a
typology of their methods and motives (e.g., Douglas et al., 1992; Warren et al.,
1996). Such information has served as guides for law enforcement personnel
working on violent crimes. However, these typologies have been useful references
to understand how serial killers physically commit their crimes and the skills they
employ to catch victims, murder them, and conceal the evidence after the murders.
However, the current study aims to delve deeper into criminal actions of serial
killers by (1) delving into the processes of how HCSKs experience committing
serial homicide repeatedly and (2) exploring how they justify their actions.
As discussed earlier, this study investigated not only if HCSK offenders
experience uncontrollable urges to murder repeatedly, but any other outstanding
thoughts or reflections they may have such as whether they have attempted to
justify or redeem themselves by verbally repenting or expressing the desire to stop
the crimes. Two themes have been identified that relate to how HCSKs reflect on
their crimes. The first theme that will be discussed is HCSKs reflecting on whether
they wanted to be apprehended or not, which varied between offenders. The second
following crime-related theme is HCSKs perceiving external factors as partially to
blame for their crimes. This second theme contains several subthemes that indicate
specific external factors that HCSKs assigned blame to, which are (1) the
authorities, (2) lack of security/surveillance and (3) (experiencing) trauma/abuse.
These two themes will be presented below in the sequential order listed above and
framed within techniques of neutralization (Bryant et al., 2018; Minor, 1981; Sykes
& Matza, 1957).
Wanting to be Apprehended Versus Carrying on Crimes
All killers within this sample were apprehended and eventually convicted.
However, each killer reflected on their apprehension differently in terms of
whether they wanted to be caught. Donald Harvey spoke with regret when
discussing his mistakes that led him to being discovered and arrested. He discussed
how he selected the wrong method to kill his patient. In his recollection of events,
he stated “I should have went the other way instead of—I should have injected it
into an I.V. instead of giving it to him in his gastric tube, and that was my
downfall”, expressing regret in how he administered the poison through his
victim’s gastric tube instead of injecting it (Roth, 1993b, p. 3). Overall, Harvey’s
subjective experiences are regret and fully understanding that he was sloppy in his
final murder. Donald Harvey’s regret of making a blatant error leading to his arrest
could be interpreted as Harvey wanting to continue his killings. Because he made
mistakes in his crimes, he was eventually convicted of murder and is no longer
free to kill.
Charles Cullen expressed actions and feelings that both indicated wanting to
be apprehended but also wanting to avoid detection (Kroft & Simon, 2013).
Charles Cullen recognized that he took steps in avoiding apprehension by stating
“… I mean, I continued. But I was also—I was also careful. I was also—deny it
any time anybody would have asked me” (Kroft & Simon, 2013, p, 10). Charles
Cullen’s meticulosity can be perceived as him not wanting to be caught for his
crimes. Yet, he expressed feeling some resentment towards authorities who he
claimed knew what he had done but did not approach his situation more seriously.
In his statements “… I was caught at Saint Barnabas, and I was caught at St.
Luke’s… There’s no reason that I should’ve been able a practicing nurse after
that.” (Kroft & Simon, 2013, p. 9), he expressed disbelief that he was ever able to
resume nursing despite his actions being revealed in two different hospitals. By
these admissions, Cullen potentially experienced resentment which may suggest
that he did want to be caught. Charles Cullen may have also made these statements
to deflect the responsibility of his crimes to other people. Overall, Cullen may have
dealt with confusion and conflicting feelings on whether he wanted to be
apprehended for his crimes.
Elizabeth Wettlaufer also made admissions that could either be perceived as
her wanting to be apprehended or to avoid apprehension during the commission of
her crimes. She stated, “I would just try to stay away from it”, indicating that she
avoided the crime scene as much as possible after killing a patient (OPP, 2016, p.
47). She also admitted that she would have falsified reports of her deceased
(murdered) victims if given the chance in her statement “I wouldn’t have click that
one if I had given him an insulin…”, which is another indicated that she
consciously tried toavoid detection (OPP, 2016, p. 39). By these actions, she may
have tried to draw less attention to herself, which would suggest that she did not
want to be caught. However, Elizabeth Wettlaufer made admissions which may
support the idea that she wanted to be apprehended. She claimed to have confessed
to multiple people such as a pastor, close friends and a support worker at the
Centre of Addiction and Mental Health (CAMH) (e.g., OPP, 2016, p. 26).
Furthermore, unlike the other HCSKs in the sample, she explicitly discussed how
much she wanted to not harm any more victims in her statement “… I didn’t want
to nurse anymore I didn’t want to hurt anybody anymore…” (OPP, 2016, p. 20).
Although she expressed feeling betrayed when her close confidante at CAMH
alerted her to the police, Wettlaufer expressed feeling relieved after being
discovered and confessing (OPP, 2016, p. 92).
According to Charles Cullen’s statement above, he claimed that he should
have been apprehended sooner which may indicate he desired being apprehended
sooner. He also argued that his actions were not taken seriously because of his
ability to continue nursing despite being a suspect at two different institutions.
However, his statement may be both examples of two neutralization techniques,
condemnation of the condemners and denial of responsibility. He condemned
healthcare staff for his continued killing career by their lack of punitive measures
when he was a suspect by his statement “They said if you resign, we’ll give you
references. And I decided to go with that” (Kroft & Simon, 2013, p. 9). Overall,
Charles Cullen may have expressed his concerns to neutralize his own feelings of
guilt and accountability by blaming healthcare administrators who failed to (1)
escalate his case to the authorities and (2) revoke his license to practice.
Elizabeth Wettlaufer’s statement above indicated her claims of wanting to
stop committing homicide. She also confirmed with investigators, “yes, that’s
right”, when asked whether the potential of working with children influenced her
choice to cease her serial killing (OPP, 2016, p. 94). Overall, her statements may
be suggestive of her trying to weaken her emotional guilt and tarnished image as a
serial killer through the neutralization technique appealing to good character
(Bryant et al., 2018). In her statements above, she may be trying to neutralize her
own guilt of being a murderer by highlighting her redemption of wanting to change
for the better. Therefore, she may have been trying to justify that (1) she is
inherently a good person with morals and (2) she is not a brutal and ruthless killer
as one may assume because she has the desire to cease the killings.
Blaming the External Factors for Continual Crimes
All three killers stated that some external factor facilitated the commission of
their crimes. They did so by either claiming (1) to not being apprehended sooner by
the authorities (2) to have easy accessibility of drugs, and/or (3) past trauma
influenced their killing behaviours.
These subthemes will be addressed below.
The Authorities. In his interview with Kroft and Simon (2013), Charles
Cullen described the hospital administrators as being completely aware of his
crimes. He expressed feeling that he should have been stopped sooner after
claiming to be caught twice for his role in his patients’ deaths. When he was
discovered, he suggested that the investigation was flawed, feeling that his license
should have been revoked. He makes further suggestions about how the hospital
forced him to quietly resign to avoid any legal ramifications against their
institution for allowing him to work. He also expressed feeling perplexed that he
could work while he was under suspicion. In describing his experience of being
caught, he frames his continual crimes as not his responsibility. Charles Cullen did
not state anything to the effect of “I should have stopped this sooner”, but instead
blamed the administrators for not stopping him by his statements “At Saint
Barnabas, they could’ve had my license investigated and probably revoked at that
point in time” (Kroft & Simon, 2013, p. 4), and “I think they had a strong
suspicion” (about his murders) (Kroft & Simon, 2013, p. 8). These statements
suggest that Cullen insisted external sources were to blame for his continual
killings. Yet, he also expressed not feeling that he was under suspicion until after
he was dismissed from work, contradicting his other suggestion of the hospital
knowing what he was doing all along (Kroft & Simon, 2013).
Charles Cullen deflecting blame of his crimes from himself to the authorities
can be paralleled with the neutralization technique condemnation of the
condemners (Sykes & Matza, 1957). His justifications can also be compared with
the themes that were identified in James and Gossett’s (2018) study. James and
Gossett’s sample of serial killers condemned the condemners by blaming law
enforcement for not catching them sooner, just as Cullen also implicitly blamed
authority figures for their shoddy investigation of his crimes by stating “I think
they had a strong suspicion” followed by “There’s no reason that I should’ve been
a practicing nurse after that” (Kroft & Simon, 2013, p. 9). Furthermore, similar to
the subjects in James and Gossett’s study, Cullen also delved into the ulterior
motives of the authority figures to further deflect blame from himself. Charles
Cullen expressed feeling that the healthcare administrators were aware of his
crimes but cared more about protecting themselves from community backlash and
potential legal ramifications. Overall, James and Gossett (2018) and Sykes and
Matza (1957) would have argued that Cullen placed blame on the administrators to
protect his image and his feelings from culpability in the crimes.
Lack of Security/Surveillance. Charles Cullen and Elizabeth Wettlaufer’s
accounts contained a theme of how healthcare institutions lacked security and
regulations, which made it easier for them to carry out their crimes. They described
how there was either (1) an easy accessibility of drugs/medications and/or (2) the
lack of technological surveillance during their crimes. Charles Cullen extended his
feelings of external blame from authorities to how healthcare institutions made it
easy for him to murder by discussing drug accessibility.
Charles Cullen and Elizabeth Wettlaufer both share the theme of feeling that
drug accessibility was easy and taking advantage of the hospital’s lack of
surveillance. Charles Cullen makes comments such as not being traced when he
obtained the drug “dig”, a slang term for the heart medication, Digoxin (Kroft &
Simon, 2013, p. 5). Charles Cullen described how it was easy to obtain dig by
stating “I wouldn’t go for Dig. I would go under Tylenol or another medication that
would be in the same drawer” (Kroft & Simon, 2013, p. 6). (Kroft & Simon, 2013).
Despite claiming not to purposefully seek out dig, Cullen experienced enjoyment
of using dig by stating how he chose it because of its powerful effect on the heart.
Elizabeth Wettlaufer also described how insulin, her drug choice, was not tracked
at one of the homes where she worked (OPP, 2016, p. 84). Furthermore, Wettlaufer
perceived the ease of obtaining medication from the medication room by stating
“um yeah it was fairly easy to take meds from there” (OPP, 2016, p. 59). She also
described the lack of security in her work by confirming that there were no
cameras in the medication room in one of her workplaces (OPP, 2016, p. 58).
Elizabeth Wettlaufer also expressed some knowledge of how powerful insulin is
lethally in combining two types of insulin (i.e., short and long acting drugs) by
stating “I didn’t know for sure but I figured it would be much stronger than just
short acting” (OPP, 2016, p. 51).
Both Elizabeth Wettlaufer and Charles Cullen claimed to not purposefully
seek out finding lethal drugs to murder patients. Therefore, they framed drug
accessibility as something that was made easy based on the placement of the drugs,
made possible by the healthcare institutions where they worked. By these
admissions, it could be argued that their denial of seeking out the drugs is a way to
suggest that their killings were not premeditated. Yet, both expressed knowing how
powerful their drugs of choice were, therefore having pre-emptive knowledge of
the lethality of injecting these medications into patients.
Charles Cullen and Elizabeth Wettlaufer’s justifications about (1) not
intentionally seeking out drugs and (2) lack of security/surveillance in the hospitals
and (3) the lack of regulation in distribution and obtainment of medical equipment
(i.e., drugs) is consistent with the neutralizationtechnique denial of responsibility.
The statements above by Elizabeth Wettlaufer and Charles Cullen suggests they
placed the onus of their crimes on those in upper level management (i.e., healthcare
administrators) who failed at maintaining safety precautions for their patients.
Their justifications allowed HCSKs them to deflect the responsibility of their
victims’ deaths from themselves and onto the poor safety regulations that made
their crimes possible. Ultimately, the use of denial of responsibility as a
neutralization technique may have provided Elizabeth Wettlaufer and Charles
Cullen an excuse to continue their crimes because it is easy and not their fault.
Trauma/Abuse. Two offenders, Elizabeth Wettlaufer and Donald Harvey,
discussed experiencing abuse and described how their abuse affected them. Donald
Harvey discussed experiencing abuse in the past. He also felt that to some degree,
others were to blame for the path that led him to commit healthcare serial
homicide. He did so by attributing his psychological trauma to his abusers who
harmed him in his childhood. Furthermore, he claimed to have been abused by
people close to him such as an unrevealed family member and a neighbour (Roth,
1993a). He may not only perceive himself to be the victim of his family’s abuse
but may also perceive his murdered patients as victims of his family’s abuse.
Elizabeth Wettlaufer described having a very close and tight-knit
relationship with her parents and family (OPP, 2016, p. 106). However, the theme
of sexual and physical abuse was prevalent in her accounts of her crime. She
described experiencing physical and sexual abuse by some of her victims. She
claimed that some of her male victims would make lewd remarks towards her, grab
her breasts and buttocks, and would do the same to the rest of the nursing staff
(OPP, 2016, p. 29). Elizabeth Wettlaufer also described that many of her patients
and victims were unkind to her (OPP, 2016, p. 38). She was contradictory to how
these negative interactions with her victims and abuse affected her subsequent acts
of killing. She claimed that these experiences were not the reason she chose to
murder her patients. Yet she also commented on wondering whether she chose to
kill her victims because of their alleged cruelty towards her (OPP, 2016, p. 38).
Another glaring observation in Wettlaufer’s accounts is her perception that being
assaulted by patients is integral to her profession. In addition, she recalled being
told by her supervisor that if a patient assaults the nurse, the onus is on the nurse
(OPP, 2016, p. 94). These admissions could be interpreted as Wettlaufer feeling
that physical abuse is normal and being hit is her fault instead of the attacker.
Donald Harvey directed some blame of his crimes to his former experiences of
being abused as a child.
Donald Harvey and Elizabeth Wettlaufer’s accounts of experiencing abuse
can also fit within the neutralization technique of victimization (Bryant et al.,
2018). Donald Harvey directed some blame of his crimes to his former experiences
of being abused as a child stating “I think [the abuse] contributed 20 percent to me
being a serial killer. I think there was something probably messed up in me
mentally, or it messed me up mentally. (Roth, 1993a, p. 1). , Elizabeth Wettlaufer’s
recollection of experiences of abuse during adulthood by claiming to be sexually
and physically abused by many of her patients-turned-victims (primarily male)
(OPP, 2016, p. 37; OPP, 2016, p. 40). . Charles Cullen and Elizabeth Wettlaufer
may be expressing these claims to lessen their personal feelings of guilt by
reiterating that they are the victims because their murders were retribution for the
abuse they endured in childhood or adulthood.
Overall, HCSKs in the current study shared similar experiences and
perceptions of crime by expressing (1) both the desire and fear of being caught for
their crimes and (2) displacing blame of their continual crimes onto shoddy
investigations, ineffective healthcare regulations, and/or past traumatic
experiences. Within these themes, HCSKs experienced their crimes through a
sense of preparedness through discussing their MO. They demonstrated a clear
understanding of how to manipulate the regulations of their workplaces and used
this knowledge to murder their patients repeatedly without detection. However,
HCSKs reflected on their crime by expressing disdain and resentment against
authority figures such as healthcare administrators and investigators (i.e., Charles
Cullen), who they felt should have stopped the problems sooner. HCSKs reflected
on the causes of their crime and claimed that ineffective investigations, loose
hospital regulations, and/or experiencing childhood abuse provided them the
foundation to murder without being detected.
Emotional Experiences
Themes in this final section of the first part of the current study relate to how
HCSKs articulated their emotional experiences upon committing serial homicide.
Common theories and explanations as to why serial killers can murder many
victims without appearing to experience emotional inhibitions (i.e., guilt, fear) has
been covered extensively by neurobiological, psychological, and law enforcement
research (Culhane et al., 2011; Hare, 1993; Keppel & Walter, 1999; Raine, 2013).
The current study takes these theories into consideration but aims to delve deeper
in its exploration of HCSKs’ emotional experience and how they rationalize their
feelings.
This study aims to not only seek whether HCSKs experience specific
emotions, but what these emotional experience means to the killer and whether
they use emotional expressions to defend themselves and justify their murders. In
other words, how would an HCSK perceive or reflect on their feelings of guilt if
they were to express this emotional experience. This study identified several
themes relating to HCSKs’ emotional experiences. The experience of remorse, or
lack thereof, was the first theme identified and explored in the accounts of HCSKs.
The acceptance of guilt was the second theme identified, which reveals how
HCSKs perceive the concept of guilt and how they apply it to themselves. The
third emotion-related theme is HCSKs’ experience of two polarizing feelings pre-
and post- murder. HCSKs experienced polarizing feelings, which were (1) anger to
elation and/or (2) stress to relief, both of which are subthemes of the third theme.
And lastly, negative self-feelings was the final emotion-related theme identified.
The aforementioned themes will be elaborated in-depth below in the sequence
listed above.
Feeling Remorse
There was a common theme in each killer describing how remorseful they
felt about committing murder, which differed between each killer. Donald
Harvey’s accounts support the idea that he was remorseless about killing his
patients. However, both Elizabeth Wettlaufer and Charles Cullen described feeling
more remorse than Donald Harvey, with Wettlaufer expressing more intensity in
her remorse.
Donald Harvey expressed feeling absolutely no remorse for his actions in his
statement “I never once had any guilt; never once shed any tears” (CBS News,
1991, p. 1). Donald Harvey’s lack of remorse could be interpreted as him not
feeling emotionally affected or regretful from killing his patients. However, when
discussing his own adversities in his life, Harvey immediately portrayed himself as
a victim. For instance, he suggested that he was a product of his own environment
and that he in part became a killer and was “messed up” due to his sexually abusive
childhood (Roth, 1993a, p. 1). Donald Harvey was clearly more emotionally
affected by what happened to him than what he did to his patients. He perceived
himself to be the victim and expressed only feeling sorry for himself in his
accounts. By Harvey’s accounts, remorse was not a feeling he could experience or
perceive within himself towards his victims.
Charles Cullen conceded with “Yes, I did” when asked if he understood
what he did was wrong and that he knew it was wrong during and after the killings
(Kroft & Simon, 2013, p. 17). However, Cullen was somewhat evasive since he
avoided going into detail about his feelings and emotional state during the murders.
When he was asked about how he felt during the killings, he could not describe
how he felt and stated the difficulty in “going back in time and thinking about what
things were going through [his] mind…” (Kroft & Simon, 2013, p. 6) . Charles
Cullen replied affirmatively when asked if he was sorry, and followed up by stating
that he did not know if he could stop despite feeling sorry (Kroft & Simon, 2013).
His avoidance and lack of detail in his accounts could be interpreted as an attempt
to detach emotionally from the crimes or to avoid facing his feelings about what it
did.
On multiple occasions, Wettlaufer was very expressive about feeling guilty
and remorseful for what she did. She stated that speaking to her victims’ families
made her feel “crappy” and “horrible” (OPP, 2016, p. 35). Her feelings extended
beyond guilt, and she described feeling “guilt”, “shame” and “anger” in what she
did to her victims (OPP, 2016, p. 71). She also expressed that apologizing to her
victims and their families will never make things right again in her statement, “I’m
sorry isn’t enough” (OPP, 2016, p. 54). Unlike other killers, Wettlaufer expressed
wanting to rectify the situation by dedicating herself for study for (1) medical
interventions for budding serial killers and (2) clearer answers that will contribute
to the prevention of healthcare serial homicide (OPP, 2016, p. 99). Elizabeth
Wettlaufer was the only killer to verbally express wanting to make things right and
create something positive out of the terrible things she did. Arguably, her
expression of remorse was redemption; to try to right the wrongs that she did from
killing patients.
The findings above demonstrate that feelings of remorse differed across
offenders. Harvey did not only admit that he lacked empathy and guilt for his
victims, but also was adamant about being the victim which can be argued as him
neutralizing his guilt through victimization (Bryant et al., 2018). Charles Cullen
claimed to feel sorry for what he had done. Elizabeth Wettlaufer claimed to
experience the most remorse of all the HCSKs in the current study, expressing the
desire that “maybe somebody can study [her] and come up with answers and new
medications so this doesn’t happen again” (OPP, 2016, p. 99). Charles Cullen and
Elizabeth Wettlaufer’s expressions of contrition may be examples of them
appealing to good character to neutralize their own sadistic and inhumane qualities
as murderers (Bryant et al., 2018). By expressing remorse, they may have been
trying to justify that they are not ruthless murderers because they do experience
guilt and empathy for those who have suffered from their actions.
Accepting Guilt
All three killers in this sample accepted they were guilty people, irrespective
of whether they felt remorse for their actions. As stated earlier, Donald Harvey did
not emotionally feel bad or remorseful for what he had done. Although he stated he
did not feel guilt, Harvey made admissions that he was a guilty man by stating “I
didn’t have a right to take any of their lives away but I did…” (Roth, 1993b, p. 4).
There may be two different dimensions of guilt that Harvey experienced. Firstly,
Harvey did not harbour any emotional guilt for what he did. Yet, he admitted to
killing 37 patients and conceded that from a logical standpoint, what he did was
morally wrong (Roth, 1993b).
In Charles Cullen’s accounts, accepting guilt appears to be very difficult for
Cullen. Charles Cullen verbally acknowledged being sorry for what he did to his
victims, even only when he was questioned about his feelings. However, he did not
immediately accept his own guilt and described his feelings about ‘guilt’: “I think
that I had a lot of trouble accepting that word for a long time”. (Kroft & Simon,
2013, p. 3). He spoke in the same evasive manner when he was confronted about
whether he was a serial killer by avoiding the question and replying with “I—I
mean, I—I guess it depends on the definition.” (Kroft & Simon, 2013, p. 3).
Overall, although he did admit he was guilty, his feelings towards admitting he is
guilty of murder was complicated and difficult for him.
Elizabeth Wettlaufer was very descriptive in her admission of guilt. She
claimed to have confessed to multiple people about her crimes such as a pastor and
close confidantes. She also admitted knowing that God summoning her to kill was
not real, which could be perceived as her admitting that her actions came from her,
not God. Furthermore, Wettlaufer revealed her guilt further by acknowledging that
“absolutely” innocent victims were affected by her actions and that she was ready
to face the repercussions of her crimes (OPP, 2016, p. 108).
All three HCSKs verbally accepted being guilty of their crimes. However,
each HCSK perceived and processed the outcomes of their crimes differently.
Charles Cullen blatantly stated that what he did was wrong yet found it difficult to
implicate himself as a guilty man, which may be indicative of him using appeals to
good character as a neutralizing technique (Bryant et al., 2017). Charles Cullen did
eventually concede verbally that he was a guilty man. However, he may have been
trying to preserve any decency left in his self-identity that had been tarnished from
being a convicted murderer by not being transparent about his guilt.
Experiencing Polarizing Feelings During and After the Murders
Although all killers in this sample experienced negative emotions during the
time of the murders, only Donald Harvey and Elizabeth Wettlaufer experienced
polarizing emotions about their murders. Charles Cullen’s own descriptions of his
emotional state were not discussed in detail. However, Cullen briefly described
having suicidal feelings rather than experiencing anger (Kroft & Simon, 20
From Anger to Elation. Feelings of anger were commonly experienced
within this HCSK sample. Both Elizabeth Wettlaufer and Donald Harvey stated
that emotionally, they were either angry or unhappy during the time of the murders.
Elizabeth Wettlaufer stated that she experienced anger at the time of the murders,
although she mentioned that she did not feel anger towards her victims (OPP, 2016,
p. 71; OPP, 2016, p. 81). Donald Harvey described his murders as destructive in
his statement “I was like Sherman going through Atlanta – destroy everything in
my path” (CBS News, 1991, p. 1). To CBS News, Harvey also stated “When I was
unhappy, I killed people…”, linking his murderous acts to his feelings of
unhappiness (CBS News, 1991, p. 1). Yet, Harvey described feeling a rush and
elation from his killings (Roth, 1993b). He also stated that he experienced pleasure
in controlling his victims (CBS News, 1991). One could argue that based on this
description, he experienced an uplift from killing others. These two separate
accounts demonstrate that Harvey experienced polarizing emotional states in
relation to the murders.
From Stress to Relief. Two out of three killers, Elizabeth Wettlaufer and
Charles Cullen expressed feeling stressed during the murders. Although Donald
Harvey did not explicitly mention he was stressed during the murders, he and
Elizabeth Wettlaufer both described feelings of relief and elation from committing
the murders in their statements “The pleasure I got was control” (CBS News, 1991,
p. 2) and experiencing “a release of pressure” post murder (OPP, 2016, p. 37).
Elizabeth Wettlaufer and Charles Cullen reported feeling extremely overwhelmed
at the time of the killings. Their primary stressor came from their place of
employment. Elizabeth Wettlaufer experienced extreme frustration from her place
of employment in her statement “yep I was frustrated with my job I was I had a
huge um, huge workload” (OPP, 2016,
p. 90). Wettlaufer stated that killing provided her a release of pressure and relief
(OPP, 2016, p. 37). Charles Cullen did not go into detail about how he felt right
after committing the murders. However, Cullen also stated feeling overwhelmed
during the time of the murders and coped poorly when he worked at the burn unit,
which may have contributed to eventually killing his victims (Kroft & Simon,
2013).
Donald Harvey did not describe feeling stressed prior to his crimes but
vaguely stated that he was unhappy prior to the murders. However, along with
Wettlaufer, committing serial homicide shifted his mood and helped relieve his
feelings of unhappiness. The findings within this theme may suggest HCSKs in the
current study used victimization as a neutralization technique (Bryant et al., 2018).
They may have been justifying their murders by claiming to experience emotional
turmoil prior to the murders. This is evident in statements such as
“afterwards I did feel a release and relief… like a release of pressure” (OPP, 2016,
p. 37), “I was unhappy” (CBS News, 1991, p. 1) and “I felt overwhelmed at the
time” (Kroft & Simon, 2013, p. 7). HCSKs in the current study may have used
these statements to victimize themselves as experience extreme stress and
unhappiness to reduce feelings of guilt and accountability in their actions.
Feeling Negatively about Self
All three HCSKs expressed negative feelings about themselves. Although
Donald Harvey tried to express that he was a normal family man like most other
men, he perceived himself as a defective person. Donald Harvey compared himself
to a “bad car” and being the “lemon” (Roth, 1993b, p. 4). He evaluated himself on
a scale of ‘good’ and ‘bad’ and associated himself with the latter. These comments
can be interpreted as Harvey having a negative self-image.
Charles Cullen was direct about feeling negatively about himself. He
discussed disliking himself, having feelings of unworthiness and suicidal feelings
throughout his life (Kroft & Simon, 2013). Charles Cullen may have a very low
opinion of himself based on these accounts, which supports the theme of negative
self-imagery. Elizabeth Wettlaufer also made comments that suggest she viewed
herself negatively. She expressed feeling incompetent by making comments about
always trying to be the ‘perfect nurse’ (OPP, 2016, p. 16). She experienced stress
and perceived herself as a failure from not being able to be perfect. Her negative
selfimage extends beyond feelings of inadequacy. Further Cullen and Harvey, she
also experienced feelings of unworthiness and feeling bad. However, unlike other
murderers, her negative selfreflections included shame, embarrassment, and feeling
stupid (e.g., OPP, 2016, p. 22).
The current study on HCSKs revealed that low self-esteem, through negative
self-talk, was a common in the accounts of each HCSK. Serial killers did not
explicitly link their homicidal urges to their feelings of low self-esteem. However,
their accounts indicated that their negative self-affect had caused a great deal of
stress and unhappiness for some HCSKs, which are emotional triggers that were
identified pre-crime for these offenders. Statements such as “I never really liked
being who I was. Because I didn’t think I was worthy of anything” (Kroft &
Simon, 2013, p. 7) and “I think I was like a bad car” (Roth, 1993b, p. 4) made by
Charles Cullen and Donald Harvey, respectively, may be examples of them using
victimization as a neutralization technique to justify their actions (Bryant et al.,
2018). To reduce personal feelings of culpability, they may have tried to express
they are also victims from struggling with negative self-concepts.
Overview of Shared Similarities Within HCSKs
This current study investigated how HCSKs subjectively experience living
as murderers based on their account of their crimes using GT. The results of this
study suggest that HCSKs in the current study share some similarities in their
thoughts, perceptions of and emotional experiences from their crimes and justified
their actions using neutralization techniques (Bryant et al., 2018; Minor, 1981;
Sykes & Matza, 1957). Firstly, the killers in the current study experienced similar
feelings and perceptions of their own identity and how they think society perceives
their identity. Each killer experienced internal conflict from their crimes and
struggled with whether their actions were justifiable from a moralistic or religious
standpoint. They ultimately neutralized the severity of their actions by (1) denying
the victim (i.e., claiming they did not suffer or were disrespectful) and (2)
defending the necessity (i.e., stating they put their patients out of their misery), (3)
appealing to higher loyalities (i.e., committing crime due to loyal obligation to
God) and (4) denying responsibility (i.e., expressing less accountability due to
being controlled by God’s powerful force).
Similarly, they struggled with their dual identities as both ruthless serial
killers and saviours of their ailing patients. Each of these killers used victimization
as a neutralization technique to reduce personal feelings of guilt and responsibility
in their killings (Bryant et al., 2018). This is evident when they expressed feeling
victimized, misunderstood, or betrayed either by family, friends, or psychologists
who they felt tried to profit from their crimes instead of understanding who they
really are. Lastly, these killers expressed wanting to be like the rest of us and less
like them by not fully embracing the serial killer status or aligning their lifestyles
and values with societal expectations. By these expressions, they were using the
neutralization technique appeal to good character to portray themselves in a
favourable light despite their crimes (Bryant et al., 2018).
Secondly, this sample of HCSKs perceived their victims as suffering while
they were alive, rationalizing that keeping them alive would have only subjected
them to a long and insufferable life. This justification of killing their patients out of
mercy aligns with the neutralization technique denial of injury (Sykes & Matza,
1957). These killers also mitigated the severity of their crimes by rationalizing that
their victims’ deaths were as quick, painless, and convenient as possible for all
people involved, which are examples of the neutralization technique denial of
victim (Sykes & Matza, 1957). The degree to how personal the murders were to the
killers varied between impersonal (i.e., objectifying the victim) to very personal
(i.e., retribution for being abused by patients). Claims of male patients behaving
inappropriately towards the perpetrator and the nursing staff were examples of
denying the victim, to justify the killings were committed on individuals who were
not entirely innocent (Sykes & Matza, 1957).
Thirdly, three themes relating to motivation were identified: psychological,
situational, and personal. HCSKs in the current study stated they experienced high
levels of stress and psychological disturbances in the form of personality disorders,
childhood trauma, or suicidal ideation, which may have been to neutralize their
accountability through using denial of responsibility as a neutralization technique
(Sykes & Matza, 1957).. Situational precipitating events such as work-related
stress and issues with interpersonal relationships (i.e., divorce) were also identified
as motivational reasons by HCSKs in the current study. These were examples of
HCSKs using neutralizations by claiming that their extenuating circumstances
contributed to their killings to feel less accountable for their actions. And finally,
each of these killers asserted that their crimes were committed out of personal
morals (i.e., duty, religion, to end suffering), therefore using the defense of
necessity as a neutralization technique to portray their killings as justifiable and
well-intentioned rather than cruel and unjust, (Minor, 1981).
Fourthly, crime-related themes revealed that two killers in the current study
reflected on whether they wanted to be apprehended for their murders HCSKs
either expressed frustration at not being apprehended sooner and blamed the
authorities for their lack of punitive measures against their actions, which may be
justifications that fall under both denial of responsibility and condemnation of the
condemners (Sykes & Matza, 1957). Furthermore, HCSKs who expressed the
desire to cease the killings may have been expressing these sentiments to neutralize
their own guilt as murderers through appeals to good character (Bryant et al.,
2018).
The majority of HCSKs in this study experienced conflict between wanting
to be caught and wanting to avoid apprehension. Donald Harvey was the only killer
in the study to express regret from making sloppy mistakes during his final murder
which led to his apprehension. Furthermore, each killer reflected on their crimes by
blaming them on several factors. They perceived the authorities and healthcare
personnel as being culpable for the murders due to lack of intervention. Their
assertions of the authorities being the true culprits of the crimes due to their lack of
intervention and implementation of safety measures, they mitigated their own guilt
and involvement through condemnation of the condemners (Sykes & Matza, 1957).
Two killers in this sample discussed experiencing abuse as a contributing factor to
their crimes, therefore using the neutralization technique denial of responsibility by
claiming their abusers were the ones who influenced their dissent into serial killers
(Sykes & Matza, 1957).
Lastly, the subjects in the current study experienced a myriad of emotions
which were often polarizing. HCSKs in the current study stated that they
experienced emotional turmoil prior to the crimes, specifically stress and general
unhappiness. They also perceived their own lives in a negative light and spoke
poorly of themselves by expressing shame, suicidal ideation, or perceiving
themselves as bad and defective. Their verbalizations of experiencing unhappiness,
stress, and negative self-affect may be a form of victimization to cancel out their
feelings of guilt from killing patients (Bryant et al., 2018).
HCSKs in this sample also reflected on how remorseful they felt about their
killings, which varied between killers. Donald Harvey expressed feeling no
remorse for killing his victims and justified that he was the victim, corresponds
with Bryant et al.’s (2018) neutralization technique victimization. The other two
HCSK offenders stated they were remorseful for what they had done. Their claims
of repenting may be a pattern of appealing to good character to justify they were
not inhumane because they were capable of contrition. And lastly, although all
killers in the current study acknowledged they were guilty of perpetrating their
crimes, Charles Cullen admitted he was hesitant in accepting his guilt and
association with being a serial killer. His initial resistance of accepting his guilt of
being a serial killer may have been an attempt in restoring his tarnished image by
using Bryant et al.’s (2018) neutralization technique appealing to good character.
Overall, this study identified common subjective experiences and justifications of
murder in the accounts of HCSKs, which has provided a vicarious understanding
of their (1) perceptions of their victims and of themselves, (2) experiences as a
serial killer, (3) motivational reasons of their killings and (4) emotional
experiences from their crimes. Such insights are useful for healthcare serial
homicide literature. However, comparisons into how the experiences of HCSKs
compare to those of their violent and/or sexually motivated counterparts may
provide a more rounded understanding of serial homicide. Comparisons between
the subjective experiences of HCSKs and SSKs will be detailed in the next section.
Chapter 7: Results II
Comparative Differences and Similarities Between HCSKs and Violent Serial
Killers
Qualitative research into serial homicide has rarely explored how the non-
violent and non-sexually motivated killers experience serial killing. The purpose of
this study was to address this gap by (1) identifying common themes in the
psychological experiences of HCSKs and (2) examining how they justify their
actions using neutralization techniques. Another purpose of this study is to identify
similarities and differences between the subjective experiences of HCSKs and
violent serial killers who may be sexually motivated. The importance of comparing
these two subtypes of serial homicide is that firstly, it may help support any
universal similarities in the experiences of sexually violent and non-sexually
motivated killers. Such information could provide a better understanding of serial
homicide in its totality.
Secondly, identifying differences in the experiences of HCSKs and violent
and/or sexually motivated serial killers (i.e., SSKs) is equally important since it
will allow for a better understanding of which experiences are unique to each serial
killer subtype. For the purposes of this analysis, killers are considered SSKs if they
have murdered two or more victims in separate events, which is the standard
definition presented by the FBI (2008). Secondly, they are considered sexual
homicide offenders if their crimes fit within the criteria of Ressler et al.’s (1988)
definition of sexual homicide. Ressler et al. states that a homicide is considered
sexual if it meets any of the following criteria:
1) victim attire or lack of attire
2) exposure of the sexual parts of the victim’s body
3) sexual positioning of the victim’s body
4) insertion of foreign objects into the victim’s body cavities
5) evidence of sexual intercourse (oral, anal, vaginal) and
5) evidence of substitute sexual activity, interest, or sadistic fantasy (p. xiii).
Based on the definitions above, the accounts of two violent serial killers,
Richard Ramirez and Aileen Wuornos, will be examined in the following sections.
Given the small sample of three HCSKs in the current study, two violent serial
killers were selected. Richard Ramirez was an SSK who was convicted of thirteen
murders that took place between 1984 and 1985 in the suburbs of Los Angeles and
San Francisco, California (Carlo, 2006). Ramirez was known for breaking into his
victims’ houses at night, where he brutally raped and murdered his victims and
mutilated their bodies (Carlo, 2006).
Richard Ramirez has statements that reveal his subjective experiences of his
crimes which is why his statements were included for study (Carlo, 2006; Hye
Nuv, 2018). Aileen Wuornos was not an SSK but lured in seven male victims by
prostituting herself to her victims and then murdering them violently by firearm
(Arrigo & Griffin, 2004). An analysis of her account will be included to
demonstrate that “feeling misunderstood” is a theme that is commonly experienced
across different types of serial killers.
Shared Similarities Between HCSKs and Violent and/or Sexually Motivated
Serial Killers
There were several similarities and differences in the perceptions and
subjective experiences between HCSKs and SSKs when they reflected on how they
justified their crimes, victims and own identities. There were five thematic
similarities identified in the psychological experiences of HCSKs in this study and
violent and/or sexually motivated serial killers from the current literature and their
own statements. The following six themes will be discussed in the following order:
(1) feelings of being misunderstood, (2) blaming the authorities, (3) denying the
victim, (4) seeking control versus losing control, and (5) precipitating events.
Feelings of Being Misunderstood. Feeling misunderstood and betrayed by
others was a common theme within HCSKs in the current study. However, this
theme is also present when reviewing the accounts of two violent serial killers:
Aileen Wuornos and Richard Ramirez. Donald Harvey experienced feelings of
betrayal and being misunderstood by others through expressing his disgust at
psychologists who he felt were not there to help him or understand him, but instead
were profiting from his crimes (Roth, 1993a, 1993b). Similarly, Richard Ramirez
expressed similar sentiments when he spoke out at court after being convicted of
thirteen counts of first-degree murder. In court, Ramirez stated the following:
“I don’t even know why I’m wasting my breath, but what the hell. You
maggots make me sick. You don’t understand me, you are not expected to.
You are uncapable of it. I am beyond your experience. I am beyond good
and evil. Legions of the night (unintelligible)… Repeat not the errors of the
night prowler and show no mercy. I will be avenged. Lucifer dwells within
us all.” (Hye Nuv, 2018, 0:06).
Based on this account, Ramirez expressed his disgust at the public and the courts,
who he felt were not worthy of his time. He emphasized that not only do they not
understand him, but also that they are incapable of understanding him. Richard
Ramirez’s speech to the court can be paralleled to Donald Harvey’s disgust
towards psychologists and justice system, who he discredited as non-experts.
Instead, he viewed them as opportunists who did not understand him or treat him
humanely.
Similarly, Aileen Wuornos also expressed similar sentiments to Donald
Harvey in her final interview before her execution (Broomfield & Churchill, 2003).
During her interview with Nick Broomfield, Wuornos expressed feeling used and
wronged by the justice system and the entertainment world. Her feelings about the
cruelty of the criminal justice system and the entertainment industry is evident in
the following quote: “You sabotaged my ass society. And the cops and the system,
a raped woman got executed. It was used for books and movies and shit”
(Broomfield & Churchill, 2003; 1:20:45). She displayed distrust and reluctance to
the interviewer when she told him, “I’m not giving you book and movie info, I’m
giving info for investigations and stuff and that’s it” (Broomfield & Churchill,
2003, 1:21:37). By these comments, it is evident that Wuornos experienced pain
and resentment and felt she had been objectified by a world who failed to
recognize her humanity. Wuornos was particularly vocal about being wronged and
used for fodder for entertainment purposes, instead of being helped, heard, and
saved. Wuornos’s experience is comparable to Donald Harvey’s perception of
psychologists, who he felt only cared about profit. Overall, Donald Harvey,
Richard Ramirez and Aileen Wuornos claimed they either felt misunderstood and
or used for profit by others. In the context of neutralization techniques, one could
argue that HCSKs in the current study and violent serial killers Aileen Wuornos
and Richard Ramirez may both be using victimization to neutralize their actions.
Blaming the Authorities. HCSKs in this study had perceived that the
authorities (i.e., investigators, healthcare administration) had also been responsible
for the murders due to their negligence (e.g., lack of surveillance) and lack of
thoroughly investigating their cases. Charles Cullen blamed the hospital staff, who
he claimed knew about the killings but did not escalate his activities further to
avoid legal ramifications (Kroft & Simon, 2013). Elizabeth Wettlaufer perceived
that it was very easy to obtain the insulin to kill her patients. She did so by pointing
out the structural flaws of the hospitals where she worked such as a lack of
surveillance and lack of tracing on insulin supplies (OPP, 2016, p. 58).
There is a parallel between the theme of blaming the authorities in this
current study to themes identified in James and Gossett’s (2018) study on the
neutralization techniques most frequently used by serial killers based on the
theoretical underpinnings of Sykes and Matza (1957). James and Gossett’s (2018)
sample of killers also blamed the authorities for the prolongation of their own
crimes through “condemnation the condemners”. This was a common technique
used by serial killers who blamed law enforcement in James and Gossett’s study.
Blaming law enforcement or higher authorities has also been identified in the
accounts of Aileen Wuornos, who was adamant that law enforcement knew she
was a budding serial killer. According to Wuornos, law enforcement had set her up
to be a serial killer by stating the following: “Let them know that I know the cops
knew who I was before Richard Mallory died. I left prints everywhere and they
covered it up. They let me kill the rest of those guys to turn me into a serial killer”
(Broomfield & Churchill, 2003, 1:14:18). Wuornos expressed her adamance and
outrage when being questioned by the interviewer, pleading to him, “And I’m
telling you because the cops let me keep killing them Nick! Don’t you get it?”
(Broomfield & Churchill, 2003, 1:19:45). Overall, findings from both James and
Gossett’s (2018) qualitative study on violent serial killers and Aileen Wuornos’
verbal accounts are comparable to how HCSKs in the current study blamed the
legal authorities and hospital administrators for the facilitation and prolongation of
their killings.
Denying the Victim. One HCSK in the current study, Elizabeth Wettlaufer,
expressed feeling that some of her victims made her profession difficult and
reasoned that these victims died because they were asking for it. Elizabeth
Wettlaufer described several of her victims negatively, particularly her male
victims whom she claimed were sexually abusive. She also pondered on whether
her victims’ rudeness was critical in selecting them to die (OPP, 2016, p. 38).
However, Wettlaufer also contradicted herself at times by confessing that her
victims were innocent people (OPP, 2016, p. 88; OPP, 2016, p. 108).
The theme of blaming the victim is one that is common in James and
Gossett’s (2018) study on neutralization techniques used by violent SSKs. James
and Gossett discovered that the denial of victim was the most frequently used
neutralization technique in their sample of killers. In other words, their subjects
were most likely to rationalize that (1) their victims were no good or (2) argue that
if their victims had not fought back and complied, they would still be alive. James
and Gossett posited that by denying the victim, the serial killers were able to view
themselves as the true victims. Arguably, Wettlaufer may have used a similar
technique to the subjects in James and Gossett’s study. She may have tried to
rationalize that she was the true victim by denigrating her male victims as mean,
abusive and perverted.
Differences Between HCSKs and Violent and/or Sexually Motivated Serial
Killers
Conversely, there were differences in how SSKs and HCSKs experienced
serial homicide and justified their crimes. There were two crucial differences
identified in this study between HSCKs and SSKs. These two differences were (1)
denying victims were suffering, (2) experiencing fantasies, which will be
elaborated below.
Denial of Injury. First, both HCSKs and SSKs differed in how they
perceived the pain and suffering they had caused their victims in their deaths. In
the current study, HCSKs tended to deny that their victims were suffering in any
way when they were killed by them. Contrarily, James and Gossett (2018) found
that their sample of violent killers were less likely to deny their victims were
injured. As stated earlier, James and Gossett used Sykes and Matza’s (1957)
techniques of neutralization to frame how serial killers neutralize the severity of
their crimes.
Overall, James and Gossett’s results showed that serial killers in their study were
less likely to denial of injury in their victims. In their study, there was only one
instance in which a killer denied the victim was in pain when they were killed. The
sole case in their study was Dennis Nielsen, an SSK who told his dead victim that
he was not hurting at all. James and Gossett’s study demonstrated that more likely
than not, these killers did not deny the injury they inflicted on their victims.
Contrarily, in this study, denial of injury was commonly used by HCSKs,
who denied that their victims suffered greatly by their actions. HCSKs often
described how their victims died a quick and painless death from their injections.
Donald Harvey emphasized how it took only two seconds for his victims to die,
implying that it was a quick death that did not involve much suffering (Roth,
1993b). He also described himself as freeing his victims. Elizabeth Wettlaufer
perceived her victims as dying peacefully (OPP, 2016, p. 54). However, although
there was an instance where she contradicted herself by describing her victims
having convulsions and turning red after injecting them. Charles Cullen stated that
he thought he was helping his victims by killing them and putting them out of their
misery.
Overall, these comparisons suggest violent and/or sexually motivated serial
killers may not share the same perceptions of their victim’s demise as HCSKs.
HCSKs in the current study perceived their victims’ death as painless and freedom
from a life of undignified suffering. However, violent and sexually motivated serial
killers do not deny the pain they have caused their victims. As James and Gossett
(2018) explain, it would be difficult for a sexually sadistic serial killer who has
tortured and sexually assaulted their victims to deny they have caused them harm.
HCSKs in this sample did not use brutally violent means to murder their victims,
instead using medical instruments (i.e., injection by needle) to kill their victims,
just as a doctor or nurse would do to a patient in need of their medication. Different
methods used between HCSKs and violent sexual killers may help explain why
perception of injury to the victim differs between each subgroup.
Experiencing Fantasies. No HCSKs in the current study claimed to have
violent or sexual fantasies prior to or around the times of their killings. Yet, the
development and experience of violent and sexual fantasies has been identified in
several theories and models of serial homicide (Arrigo & Purcell, 2001; Burgess et
al., 1986; Hickey, 1997, 2009; Ressler et al., 1988). MacCulloch et al. (1983)
studied the association between sadistic sexual fantasies and subsequent criminal
behaviour in psychiatric patients diagnosed with psychopathy. In their study,
psychopaths practiced their violent sexual fantasies by trying out parts of their
fantasies such as stalking, terrorizing their victims using threats or violence, and
ultimately, murdering their victims. The concept of a personal fantasy world is an
important one that is rooted in childhood development and is considered a crucial
experience that leads one to commit serial homicide (Burgess et al., 1986; Carlisle,
1993; Hickey, 2009).
Carlisle (1993) suggested that deep-seated feelings of emptiness and sadness
will lead to excessive daydreaming and fantasies in a child. Carlisle stated all that
exists within these sexually violent fantasies (fueled by anger and emptiness) begin
to take control over an individual’s reality, leading them to crave acting out their
fantasies in real-life. Hickey’s (1997) trauma-control model of serial homicide
suggests that environmental factors such as traumatizations (e.g., especially
rejection) are influential in indicating whether an individual will become a serial
killer, more than predispositional factors (e.g., biological factors). These
traumatizations instill low self-esteem, social rejection, and feelings of
worthlessness in a developing child or adolescent.
In Hickey’s (1997) model, children create fantasies which serve as an
escapism for these abused children and help them take control of their lives and
cope with trauma that was not properly addressed (i.e., therapy). Hickey also adds
that fantasies progressively become more violent with substance use, pornography,
and being situations that reinforce trauma (e.g., rejection), and these fantasies fuel
the impulse to commit homicide. Burgess et al.’s (1986) motivational model
compliments the trauma-control model in terms of its take on the relationship
between early childhood and adolescent trauma and the subsequent formation of
violent and sexual fantasies. In Burgess et al.’s model, a child’s exposure to trauma
(e.g., witnessing or being a victim of sexual or physical abuse), improper
socialization and development due to failing to properly attach to a parent or
guardian leads to the development of patterned behaviours and thoughts that are
negative and antisocial. Ultimately, their thoughts develop into specialized
fantasies that are used to compensate feelings of isolation.
Keppel and Walter’s (1999) typological model on signature killers
categorizes SSKs into four types of murderers, two types of whom experience
fantasies: the power-reassurance (PR) and anger-excitation (AE) killers. They
describe the PR killer as one who seeks reassurance from his victims of his sexual
prowess. The PR rape murderer is acting out a fantasy where he achieves feelings
of adequacy in a sexual conquest. However, when rejected, this killer is driven by
homicidal rage and seeks control over the victim, leading to overkill. The AE killer
is sadistic receives gratification through hurting, dominating, and humiliating his
victim. Inflicting pain and using torture revitalizes specific fantasies that are
generated by the AE killer and the cycle repeats.
The models and theories of SSKs above demonstrate that fantasies function
as following: (1) a maladaptive process that begins in childhood as a result of poor
attachment and traumatic events (i.e., abuse) and feelings of worthlessness, (2) a
coping mechanism to preserve one’s selfesteem and sense of control, (3) to live out
another identity and engage in acts in an imaginary world that could not done in
reality and (4) an experience that is catalytic in the commission of serial homicide
and is protected upon committing sexual murder.
In the current study, no HCSKs discussed experiencing an internal fantasy
world, contrary to what has been identified in the literature on SSKs. HCSKs in the
current study spoke of their crimes in a pragmatic manner by rationalizing that they
killed to save their victims from a life of agony. Elizabeth Wettlaufer spoke of
dealing with severe mental health issues at the time of her killings, stating that at
the time she thought she was being summoned by God to kill her patients (OPP,
2016, p. 85). The experience of fantasy appears to be ritualistic step that is
experienced more than once according to several models of serial homicide (e.g.,
Burgess et al., 1986; Hickey, 2009). Elizabeth Wettlaufer described her God-
intervening experiences as reality rather than a fantasy. However, Wettlaufer’s
recurrent experiences of divine intervention and the victims being the chosen ones
were ritualistic and occurred almost every time she injected an overdose of insulin
into her victims. However, HCSKs did not explicitly state they experienced
fantasies or tried out behaviours from an internalized fantasy world.
Chapter 8: Discussion
The purpose of this present study was to (1) explore the serial homicide
phenomenon through qualitative psychology, and (2) expand the knowledge of
healthcare serial homicide. To date, a qualitative exploration of serial homicide
through the perspective of the offenders has rarely been investigated (Henson &
Olson, 2010). Additionally, there is an overwhelming focus on violent serial killers
who murder out of sexual motivation, and such killers have now become the only
widely recognized representation of serial homicide (Hodgkinson et al., 2017). An
overwhelming focus on serial sexual homicide diverts research attention away
from the nonsexually motivated killers such as HCSKs, which is detrimental to
understanding serial homicide in its totality.
While HCSKs may not use brutal and sexually sadistic methods to murder
their victims, they may incur even greater societal harm given their ability to evade
detection and, as a result, accumulate more victims than their violent and sexually
motivated counterparts (Lubaszka et al., 2014). For example, Harold Shipman was
suspected to have claimed over 200 victims before finally being apprehended and
convicted (Yorker et al., 2006). Lubaska et al. (2014) have suggested that serial
killers are produced more in the healthcare industry than in any other profession.
The prolificity of serial homicide in healthcare settings renders it necessary to
clarify healthcare serial homicide in terms of the crime, the victims, and the
perpetrators.
Prior to this study, qualitative inquiry into the subjective psychological
experiences of healthcare serial murder had rarely been explored. This study has
revealed some insights into how three HCSKs psychologically experience and
justify their crimes which could help with (1) addressing the current literature gaps
and (2) exploring potential research directions to further elucidate healthcare serial
homicide. This study primarily investigated subjective experiences of
HCSKs using qualitative psychological methods (i.e., GT).
The results of this study identified similar trends in how three HCSKs
perceive themselves, their victims and experience serial homicide. This study also
discovered that HCSKs in the current study frequently justified their actions using
several techniques of neutralization (Bryant et al., 2018), which help them reduce
feelings of guilt, responsibility and accept their own criminal actions. Similar
experiences and justifications of criminal behaviour were also discovered in studies
conducted on violent serial killers. The most consistently identified psychological
mechanism that HCSKs in the current study experienced was inner conflict in how
they perceived their own identities and actions. HCSKs in this study tried to retain
a positive and socially acceptable image by, which indicates they used the
neutralization technique appealing to good character (Bryant et al., 2018). This
was evident when HCSKs either (1) talked about being a family member (2)
rejected being associated with mental illness, (3) avoided admitting they were
serial killers or (3) tried to lead as normal a life as possible during the killings.
However, HCSKs also recognized and acknowledged that indeed, there was
something deeply wrong with themselves internally. HCSKs may be experiencing
conflict and may be trying to rationalize and preserve positive self-affect by
claiming to be normal. HCSKs also struggled with internal conflict between
perceiving themselves as being ruthless serial killers and saviours who ended the
suffering of their ailing patients. Their identity conflict could be interpreted as
them trying to rationalize their killings as acts of liberation and justice for their
dying patients, therefore denying them as victims.
Previous literature on serial homicide have suggested that serial killers try to
minimize their own guilt and self-blame by deflecting responsibility of their crimes
from themselves and blaming others (James & Gossett, 2018). James and Gossett
theorized that minimizing personal responsibility allows serial killers to preserve a
positive self-image and reduce negative feelings (i.e., guilt) which helps them
continue their crimes. This current study identified that HCSKs similarly
experience conflict and attempted to reconcile their negative feelings using specific
justifications (i.e., techniques of neutralization) to condone their killing behaviours.
However, future research with a larger sample size could replicate the current study
to follow up on how HCSKs justify committing serial homicide. It would be
informative to investigate whether a larger sample of HCSKs use specific
rationalizations even or novel neutralization techniques as a crutch to mentally
support their urges and prolongate their crimes.
This study also identified differences within the HCSKs that are worth
exploring in future studies. For instance, there were differences between the
subjective experiences of male and female HCSKs in the current study. This study
identified that the male HCSKs (Charles Cullen and Donald Harvey) and female
HCSK (Elizabeth Wettlaufer) differed in their level of transparency when they
discussed their psychological disturbances or emotional experiences. Males in the
current study were either (1) less transparent in discussing their feelings and state
of mind or (2) hesitated or refused to admit that they were different from others.
Specifically, they perceived the label of “serial killer” or “mentally ill” as
undesirable. Elizabeth Wettlaufer, the single female HCSK in this study, was
descriptive about how she felt emotionally about herself and the crimes she
committed. She openly discussed her substance abuse issues and psychiatric
diagnosis of BPD.
However, these findings are minimal, relying on a relatively small sample
size. Furthermore, only one female HCSK was analyzed in the current study so it
would be faulty to conclude that there are definitive gender differences between
male and female HCSKs. Therefore, future research studies focusing on the
differences between male and female HCSKs would be beneficial to clarify gender
differences in serial homicide. Female serial killers are not as widely studied as
male serial killers (Keeney & Heide, 1994). Additionally, it should be noted that
the number of male and female HCSKs are almost equal, yet males are dominant in
serial homicide outside of the healthcare industry (Hickey, 2009; Lubaszka &
Shon, 2013). Investigating gender differences between male and female HCSKs in
the future may shed light on the experiences and motivational trajectories of female
serial killers since they are more prevalent in the healthcare industry. Future
gendered studies on HCSKs may also provide more insight to why female serial
killers are so much more prevalent in healthcare settings.
Similar and different experiences have been identified within HCSKs and
between HCSKs and violent and/or sexually motivated serial killers. However,
there continues to be missing gaps and gray areas in how HCSKs experience serial
homicide. As an example, serial homicide literature has consistently identified
fantasy as a catalytic driver that pushes an offender from their imaginary world to
committing real atrocities (i.e., rape, murder) (e.g., Ressler et al., 1988). Fantasy
was not identified as a theme in the accounts of HCSKs in the current study.
Although HCSKs did not discuss fantasy, it may be faulty to infer that HCSKs do
not experience fantasy and are therefore dissimilar to other serial killers who have
an internalized fantasy world (i.e., SSKs). The reason this may be a flawed
interpretation is that the current study’s data is limited in terms of quantity and that
this study utilized secondary data rather than first-hand accounts through
interviews. There may not be enough data to exclude fantasy as an experience not
found in the HCSK population. However, this issue can be addressed in future
studies through adjusting methodological gaps.
As stated earlier, this study relied on archival interview data to explore how
serial killers in the healthcare industry experience serial homicide. For feasibility
purposes, secondary data analysis had to be conducted to explore the research
questions of the current study. However, the use of secondary analysis may have
impeded on the ability to fully capture and analyze the subjective experiences of
HCSKs. With secondary data analysis, there is a lack of control in terms of
direction. Specifically, a researcher cannot ask questions, probe or follow up on
comments made by HCSKs in their respective interviews. Future studies would be
able to obtain richer and more detailed accounts from offenders through an
interview setting.
Lubaszka et al. (2014) also recommended that in-depth interviews would
enhance the knowledge of healthcare serial homicide. Kerr and Beech (2016)
conducted interviews with sexual homicide offenders and analyzed common
themes in their interviews to understand their motivations in committing sexual
homicide. They noted that scholars have called for a phenomenological-descriptive
approach in studying sexual homicide. They also stated that quantitative studies
may hinder understanding the motivations of sexual homicide. Similarly, Skrapec
(2001a) also advocated for a phenomenological approach to serial homicide.
Skrapec stated that literature on serial homicide has focused too intently on (1)
studying the pathology of the offender using traditional psychological tools (e.g.,
psychometric tests) and (2) using broad descriptions of the offenders, victims, and
crime scenes to clarify the serial homicide phenomenon.
According to Skrapec (2001a), neither of these approaches provide deeper
insight into the lived experiences of serial killers. She proposed the need to move
away from conventional methods and to use phenomenology by examining the way
killers describe their crimes, their lives, and the world around them. Future studies
that aim for a clearer understanding of how HCSKs process, experience, and
rationalize the act of serial homicide should consider conducting in-depth
interviews with HCSKs and using a phenomenological approach. These
methodological steps can allow researchers to (1) take control of the interview to
attain all the necessary details and (2) thoroughly conduct a structured analysis that
is precise, reliable, rich, and informative.
Studying the internal experiences of serial killers is essential to understand
the serial homicide phenomenon. However, the study of subjective experiences is
only one aspect of serial homicide. The exploration of a serial killer’s internal
world should be studied along with other factors of serial homicide. Firstly,
exploring the developmental trajectories of HCSKs in future studies would be
informative and add to the healthcare serial homicide literature. Exploring the
development of HCSKs can be achieved by investigating sources outside of the
offender’s account and looking into validated data sources from books, articles and
the accounts of the friends or family members of HCSKs. Reid et al. (2019)
investigated the developmental pathways of SSKs and concluded that a unified
developmental model of serial sexual homicide may never be possible given
developmental complexity and unique experiences of each individual SSK. They
also concluded that engaging in serial homicide may just be a way for SSKs to
cope with the instability in their psychopathology rooted in childhood. Applying a
lifecourse theory of crime to HCSKs to study their (1) development, (2) influential
life events and (3) risk and protective factors from conception to death would help
clarify the psychopathology and development of HCSKs (Farrington, 2010).
Secondly, looking into the structural factors that may facilitate the
commission of healthcare serial homicide (e.g., flaws in the system and regulations
of healthcare institutions) would help build a better understanding of how these
crimes occur for a lengthy period without detection. HCSKs in the current study
perceived a lack of security measures in their place of employment by lack of
surveillance and easy access to medications. Investigating the structural factors of
healthcare institutions in terms of its regulations and security are worth
investigating since knowledge of these factors are just as important to help prevent
future serial homicide occurrences.
Chapter 9: Limitations
Several themes were identified in the accounts of Elizabeth Wettlaufer,
Charles Cullen and Donald Cullen, which suggest that they may share experiences
that are unique to HCSKs. However, the killers within the current study also shared
similar perceptions of their own identities, emotions, and psychological
experiences to their sexually motivated counterparts.These similarities suggest that
there may be some universal similarities between HCSKs and SSKs.
Despite the findings above, several limitations within this study should be
addressed.Firstly, this study relied on a small sample size. GT does not specify a
minimum number of cases for analyses (Charmaz, 2015). Instead, GT emphasizes
on attaining theoretical saturation¸ which refers to gathering enough data to the
point where further data collection would no longer be productive to the already
observed themes or theoretical categories (Bloor & Wood, 2006; Charmaz, 2008).
It should be noted that theoretical sampling (i.e., collecting specific data to build
emerging theories from the data) is limitless in GT (Bloor & Wood, 2006;
Charmaz & Henwood, 2010). Although sampling is limitless, the current study
investigated the subjective experiences and accounts of only three HCSK
offenders. The lack of available data means that the results and analyses in the
current study are limited to the three offenders.
Issues that affected the current’s study sample size was that HCSKs do not
willingly confess their murders as often as violent sexually motivated serial killers,
as reflected in this study. For instance, convicted HCSKs such as Efren Saldivar
and Orville Lynn Majors provided interviews to major news outlets. However,
their accounts were limited because both denied being involved in their convicted
crimes (Jarriel et al., 1997; Vargas et al., 1998). It should be noted that Saldivar
initially confessed to murdering his patients but recanted his confession and
professed his innocence on an ABC News report covering his case (Vargas et al.,
1998). Overall, a small sample size and dataset for analyses means that one should
be cautioned to generalize about HCSKs based on findings in the current study.
Instead, results from this study could serve as a guide to devise a set of questions
for follow up research to explore any missing gaps of the psychological
experiences and developmental trajectories of HCSKs.
A second limitation in this study is the disproportionate amount of data
between each killer. Elizabeth Wettlaufer’s account was comparably larger and
more detailed than the accounts of Charles Cullen and Donald Harvey. Elizabeth
Wettlaufer’s police statement was over 111 pages long on a .pdf file. Charles
Cullen’s interview totaled 14 pages on a .doc file. And lastly, Donald Harvey’s
accounts came from three interviews, totalling 9 pages on .doc file. The
disproportionate amount of data between killers would mean that Wettlaufer’s
accounts has more substance and can be more deeply analyzed. Irrespective of the
large discrepancies of data between offenders, this study was able to properly
conduct a qualitative analysis and comparison of each offender’s experiences and
perceptions.
A third limitation found in this study is that the venue of where the
interviews took place differed between killers. Charles Cullen and Donald Harvey
both spoke to media personnel from
CBS News and/or ABC. However, Elizabeth Wettlaufer’s interview was an
interrogation, where she confessed all her crimes willingly to a law enforcement
officer who had the authority to arrest her. The power dynamic between
interviewer and killer may differ between a media context and a law enforcement
context.
The argument is that killers being interviewed by the media may feel less
pressured in an interview with a news reporter than with law enforcement
personnel who have authority to arrest them. News broadcasters are seeking out
these killers for ratings, so killers may have the upper hand and power to decline
commentary. Additionally, there is the possibility that killers being interviewed by
the media may attempt to respond in socially desirable ways. Maxfield and
Babbie (2014) discussed the problematic influence of ‘social desirability’ on self-
report questionnaires (SRQ) or face-to-face interviews. They stated that people will
filter their responses when being interviewed to make themselves look good.
Furthermore, the interviewer who is interviewing the participant can greatly affect
the types of responses being elicited. For instance, Ted Bundy who was
interviewed by a Christian pastor spoke in socially desirably ways that fit into the
pastor’s Christian narrative by pointing out the dangers of pornography on his
crimes (KingdomWorks Studios, 2018). Based on Ted Bundy’s example,people
who are being interviewed by a national broadcaster will try to present a more
socially acceptable image for a specific audience. With regards to the current
study, HCSKs may try to present themselves more favourably by glossing over
certain details about their crimes or may try to garner sympathy by also portraying
themselves as victims.
Overall, (1) the venue where the interview took place and (2) the interviewer
may affect how the killers discuss the crimes, which may affect the analyses of
their accounts. It should also be noted that Elizabeth Wettlaufer showed no such
resistance when she was interrogated by law enforcement. She was willing to talk
about her involvement in her crimes despite the power differential between herself
and the police officer who interviewed her. Regardless, these limitations (i.e.,
interview venue and interviewer) should be considered when evaluating the
experiences of HCSKs in the current study.
A fourth limitation to consider is timing, in terms of when the interview took
place after Charles Cullen and Donald Harvey were arrested and discovered to be
healthcare serial killers. Charles Cullen was interviewed in 2013 by CBS News,
eleven years after he was apprehended (Kroft & Simon, 2013). Donald Harvey was
interviewed in 1991 and 1993, four to six years after he was arrested and convicted
of murder (CBS News, 1991; Roth 1993a, 1993b). However, Wettlaufer confessed
to the killings before she was apprehended and willingly provided a police
statement detailing the crimes. The differences between each offender in terms of
the time gap from their conviction date to their interview date may affect (1) the
homogeneity of the data and (2) how each offender perceived or remembered their
offenses. As time goes on, serial homicide offenders who have had time to reflect
on their crimes may have different perceptions from when they were first
discovered as perpetrators.
Personal motivation depending on when the interview took place can affect
how an offender explains their motivation and experience of murder. As an
example, Ted Bundy’s accounts differed between interviews. Long after his
apprehension, Bundy’s accounts were published in a book titled Conversations
with a Killer (Michaud & Aynesworth, 2000) and Bundy spoke in-depth about the
details of his methods and fantasies to a couple of journalists. Yet, as discussed
earlier, in Bundy’s interview with a Christian pastor a day before his execution,
Bundy focused on pornography as a factor in his murders (KingdomWorks
Studios, 2018). Furthermore, Bundy was also willing to be interviewed to provide
information on the whereabouts of some of his victims to delay his execution
(Blanton & Crawford, 1989).
The study of subjective experiences (e.g., phenomenological-descriptive
research) does not focus on the truthfulness of the facts about the crime (Skrapec,
2001a). Yet, it could be argued that Bundy differing responses were largely based
on his personal motivation (i.e., delaying his execution). Therefore, the veracity of
the accounts of each offender in the current study should be considered. It is
uncertain whether the time gap between each offender’s arrest and date of the
interview skewed or changed how they perceived their crimes or serial killer
identity. None of the killers in the sample denied their crimes and fully admitted
they were the culprit in their series of murders. Out of the three offenders, Charles
Cullen was the most evasive when asked questions about his feelings and mindset
during his killings.
A fifth limitation is that this study used secondary data, which gives the
researcher little control over what information to extract. The information is
limited only to the data being presented, with no ability to follow-up with
questions. Arguably, the interviews conducted by ABC and CBS with Donald
Harvey and Charles Cullen, were not meant to be studied for academic purposes.
These media interviews conducted by investigative journalists were meant to
capture the interest of viewers for ratings by providing them a glimpse into the
motivations of HCSKs. The end goal of investigative journalists differs greatly
from qualitative researchers. The former aims capture a story that will garner more
attention from the public whereas qualitative researchers in academia are interested
in the gaining rich insight into the experiences of their subjects. Overall, a lack of
follow-up and delving further into experiences cannot be achieved through
secondary analysis of archival data. These are limitations of archival data, whereas
interviews provide more control and flexibility since a researcher would be able to
probe for detailed responses.
Lastly, there may be a gender bias within this sample. Elizabeth Wettlaufer
was the only female analyzed in the current study, therefore the current sample
lacked homogeneity in this aspect. The lack of homogeneity in gender across all
killers suggest that the sample may lack some uniformity. This study found that
male HCSKs in the currentstudy were either reluctant to admit being defined as a
serial killer or emphatically rejected any label associated with mental illness. Yet,
Wettlaufer, the sole female HCSK in the current study differed from the other two
males and was open about her mental health struggles and emotional turbulence
through her killing career. Based on this anecdotal observation, the literature would
suggest that male HCSKs may not want to appear as weak and helpless, instead
opting to preserve an ideal masculine figure who is strong, silent, and independent
(Wendt & Shafer, 2016). However, it should be noted that the current study had a
very small sample containing only one female HCSK and two male HCSKs
therefore gender differences cannot be established.
Chapter 10: Conclusion
Overall, this study has provided some clarity into the inner worlds of three
HCSKs, who within themselves struggled with (1) the moral repercussions of their
actions, (2) their own sense of belonging in the world they live and (3) battled
between being a serial killer and a saviour of their patients. HCSKs in the current
study also expressed being psychologically, situationally and personally motivated
to murder through (1) desiring control or being controlled (2) feeling
psychologically disturbed or stressed, (3) coping poorly from their workplace and
(4) perceiving their crimes as a personal duty. In addition, HCSKs in the current
study rationalized that their crimes were prolongated due to the negligence of their
employers and battled between the desire of being caught or being apprehended.
And lastly, HCSKs in the current study claimed to experience stress and claimed
that killing their patients provided them a sense of relief and/or elation from their
work-related stress and psychological disturbances.
HCSKs in the current study justified their actions and their crimes in ways
that parallel the techniques of neutralization (Sykes & Matza, 1957). Specific
neutralization techniques used by HCSKs in the current study were the following
(1) the defense of necessity (i.e., legitimization of crimes by claiming they
were to end the suffering of others)
(2) the denial of responsibility (i.e., killing due to uncontrollable
circumstances such as being controlled by God, homicidal compulsions
and/or stress)
(3) the denial of victim (i.e., claiming patients were sexual aggressors or
needed to be put out of their misery)
(4) condemnation of the condemners (i.e., blaming healthcare administrators
were for failing to prevent the crimes from occurring)
(5) the denial of injury (i.e., claiming the killings were quick, painless and
ended the victims’ suffering)
(6) the appeal to good character (i.e., emphasizing socially desirable
characteristics and rejecting being labeled as mentally disturbed or a
serial killer)
(7) victimization (i.e., claiming to feel betrayed and misunderstood by
others; feeling overworked and stressed; alleging they were abuse victims
in their childhood or as nurses)
(8) the appeal to higher loyalty (i.e., claiming to murder victims out of
loyalty to God)
Comparisons between HCSKs in this study and violent serial killers in the
literature also demonstrate that each have used similar neutralization techniques to
justify their crimes (Bryant et al., 2018). Specifically, each justified their crimes
through(1) victimization (i.e., feeling misunderstood and victimized by the
system), (2) blaming the authorities (i.e., ) and (3) denial of victim (i.e., blaming
victims’ deaths on their behaviours). HCSKs in the current study also showed
dissimilarities in how they experience, perceive and justify their crimes. Most
notably, HCSKs denied their victims were suffering while violent sexually
motivated killers could not excuse the pain they inflicted on their victims.
Furthermore, fantasy, which is often cited as an experience in models and theories
of SSKs, was not discussed as experience from HCSKs in the current study. Future
studies would benefit from investigating whether fantasy is present in the
experiences of HCSKs. It would be interesting to discover whether another study
would replicate the findings in the current study or provide evidence that fantasy is
present in the HCSK population.
By using a GT approach, this project aimed to expand on unfolding the
subjective experiences of three HCSKs. There are very few studies that have
investigated HCSKs, therefore knowledge about this serial killer subtype remains
limited. Regardless of this limitation, the implications from this project are
significant and impactful in several different ways. Firstly, revelations about the
motivations, emotions and perspectives of HCSKs will add to the literature of
serial homicide. The current knowledge of healthcare serial killing is limited.
However, an indepth analysis into the accounts of HCSKs may help expanded the
knowledge of their psychological processes.
Additionally, this study has provided some theoretical insight into what may
drives these types of murderers to kill repeatedly. Therefore, qualitative inquiry
into serial killers who murder in the healthcare industry may help clarify serial
murder etiology in terms of how each subtype (non-sexually motivated versus
sexually motivated) experiences serial murder similarly and differently. In
addition, findings from this study have helped open new lines of inquiry for future
studies. Studying the development of HCSKs and factors that help facilitate and
prolongate the commission of healthcare serial murder are areas that should be
investigated. As previously mentioned, healthcare serial killing may be the most
preventable form of serial murder (Lubaszka & Shon, 2013). Lubaszka et al.
(2014) also explained that HCSKs do not have to hunt for victims since they are
patients who are already easily accessible to them. Studying the healthcare system
and development of HCSKs may help clarify the etiology of healthcare serial
homicide and help with building preventative measures in medical institutions
against healthcare serial murder.
Insights into how HCSKs perceive their dual roles as doctors and serial
killers may be informative for researchers, hospital administrators and other
healthcare workers to understand warning signs of HCSKs operating in their
respective hospitals. Recognizing the issues in the system that help facilitate the
prolongation of healthcare serial killing can help with policy reform.
Understanding structural and organization issues in hospitals can help create new
regulations that could stop killers from manipulating the system. This study hopes
that future research will continue to study the subjective experiences of HCSKs to
provide a holistic understanding of serial homicide in its totality by (1) studying an
understudied subtype and (2) developing insights that could help with detecting
and preventing future HCSK occurrences.
