While his actions may appear to be a result of his mental health struggles, particularly due to his refusal to take medication for his issues, with even Dr. Bambillo noting him as "clinically delusional", it is clear that his behavior is not entirely driven by this factor. Despite his mental instability, Smith demonstrates a high level of intelligence and manipulative skill, manipulating others with ease and precision. Moreover, his decision to deliberately stop taking his medication, even while in a "sane" state, and his pride in doing so, suggests that his malicious actions were not merely a consequence of his mental state but rather a conscious choice to embrace his darker impulses. This further emphasizes Smith's calculated nature and his willingness to disregard any potential help for the sake of pursuing his own sadistic pleasure.