Many thanks to all those who read my article on the machinations of the NHS regarding mental health services. I always read the comments to my articles and am grateful to my commentators.
Whilst looking through, I read a very interesting spoof which was asking me for protocols on serial killers being kept safe in the community and I felt the need to go pick up on this, in terms of general mental health as well as serial killers; even though it was meant as a very good bit of satire (I hope)!
Current wisdom says we should all be aware of our mental state and our “emotional temperature” at all times and adjust as necessary to return it to equilibrium. Unfortunately, most people take this to mean if we find ourselves experiencing what is called negative thoughts and emotions, the onus is on us to get rid of them as soon as possible.
As a result, I have decided to give you a snapshot of some of problems we treat in the mental health services at various levels and the theory that treatment is based on, so that hopefully, those of you who don’t know can be better informed.
The trouble with mental health is that people get it mixed up with real life and the trouble with serial killers and psychopaths is that people confuse them with those who have a serious mental health condition. The two can coexist, but hardly ever.
To take mental health in general. When we are infants, we do not have much going for us apart from the will to survive and without proper care, that survival is quickly extinguished. However, as we grow to adulthood and if our upbringing has been adequate, we develop skills to care for ourselves. We learn to overcome obstacles and develop the will to make the most of whatever talents we may have and to generate our own friendships, companions, and way of living. Lots of things can go wrong in this developmental phase, which is why the way children are dealt with is so important in society.
The overall phase itself is split into several sections with their own milestones, and goes from birth to twenty-five, which is the time when full frontal lobe development has taken place and is the last part of brain development. This final phase is called achieving maturation. That is a long time; even longer if you count development in the womb. Maturation is when the person has developed executive control over their emotions and this ability to control is located in well-developed frontal lobes.
The idea that “a little child shall lead you” is a recipe for disaster. Children really are not wired in sufficiently for that to ever be possible, no matter how academically bright they may be. You are asking them to perform the impossible. They can give an opinion and contribute up to the level of their current development if asked, but to encourage them to take the responsibility for planning and executing complex abstractions will not end well.
Unfortunately, modern society in its current form is not conducive to attaining maturity and a lot of people who come for treatment have the developed ability of somewhere between fourteen and eighteen. This is not necessarily their fault, but it does mean that they lack the complete complement of skills to negotiate a fully adult life and manage their emotional experiences.
Please bear in mind that I am not talking about intelligence here, but the ability to manage emotional states and solve interpersonal and external problems.
Even those who attain more sophisticated and well-developed skills can indeed become ill through exceptional events such as trauma and complex bereavement amongst other exceptional life circumstances; but both indicators have now become so abused, they seem to apply daily to about three quarters of the population in situations you would ordinarily expect an adult to manage.
I make this distinction because lack of complex social skills and emotional incontinence seems to be rife now and so it is not surprising that many more people present with depression and anxiety-based problems than did in the past. If you really want to see some protocols for dealing with common mental health problems as agreed through NICE, please type in “Talking Therapies Manual” to your browser and you can read what is currently recommended for these kinds of everyday mental health issues as well as the recommendations for assessment and treatment. This is freely available to the public.
So, what about Harold Shipman et al, and how does this fit in with serious mental illness if at all. The people cited in the comment that started this article would not be classed as having a serious mental health problem, but an “active” personality disorder. The DSM and the ICD classify a personality disorder as a group of characteristics laid down in infancy and early childhood that remain fixed and unchanging throughout life to the detriment of the person and or/other people. How they get expressed and whether some disorders include violence or murder as part of that expression depends on circumstances and other characteristics.
Years ago, we used to keep an eye on children who exhibited characteristics of developing the psychopathic triangle; which was fire setting, bed wetting and animal torture. If this was part of an ongoing everyday pattern for the child, they were referred to child psychiatry for a fuller assessment and treatment. It is possible to help someone at a very young age to manage these characteristics if enough work is done, but with this kind of problem, the child must believe there is something in it for them or they would see no reason to cooperate.
It was considered too harsh to label children in this way in the eighties and so now it is not possible to formally diagnose them before adulthood; the rationale being that children can change, even when ongoing disturbing indicators are present.
For adults displaying signs of psychopathy, the main indicator is not having developed true empathy at even the most basic level and feeling justified in removing anyone or thing in the way of the pursuit of their goals, which means no conscience or remorse, meaning treatment is almost never successful. Psychopathy in particular manifests in a range of behaviours and the psychopathic killer is still very rare. The best con men would score highly on the Hare checklist for this condition for instance, as would many captains of industry amongst other elites. Such people have been able to use their lack of empathy and conscience to get to the top of their profession, whereas someone able to have feelings of guilt or sorrow might hesitate before talking certain steps. If you are interested in knowing more, Robert Hare, who compiled the original checklist has written a very interesting book for the public called “Without Conscience”, based on twenty-five years of research.
Non-violent psychopaths are often very proud of their “skill”. Having not developed emotional responses past anger and irritation, they are immune to manipulation and feel no remorse when they do something wrong, or cause harm to another. If required, psychopaths can fake an emotional response, but it always seems a bit off to others who have developed the normal range of emotions.
In terms of classification, personality disorders have their own taxonomy and are split into two groups. Those focussed on self, such as borderline personality disorder and schizoaffective disorder and those focussed on the world, such as narcissism and psychopathy. The former cause most harm to the person who has them and the latter most harm to society.
The difference between personality disorders and serious mental health illness is that in the latter, the person has been to all intents and purposes developing as expected and that the symptoms have appeared as something unusual. For instance, it is mainly between the ages of seventeen to twenty-five, that schizophrenia usually emerges. Bipolar is also an adult illness, despite Americans diagnosing children as young as four with the problem and prescribing medication.
Most psychopathic killers are very difficult to apprehend, because they have no remorse or even fear and will just forget about it afterwards; making catching them out in a lie extremely difficult for those investigating. Most paranoid schizophrenics, or paranoid psychotics kill because some inner voice or optical illusion is instructing them, often against their will. Paranoid Schizophrenics are often angry that you can’t see or hear what they do, as they believe you would understand what they did if you could. This demonstrates that people with psychotic illnesses do worry about how the world labels them in a way that just wouldn’t occur to psychopaths. When on medication and free from delusions, the relief at being free from such an unpleasant mental state is profound. However, the side effects can be very severe and often lead to patients stopping their meds in the hope that when the side effects go away, the delusions wont come back.
So, in response to my commenter, it is extremely difficult to know if someone has personality problems that are likely to result in a tragedy, but it is possible to know if someone has a serious mental illness that could. Forming a focus group of psychopaths to develop treatment protocols is a fast way to the end of humanity so I think I’ll pass that on that one! Besides, I know of no treatment currently on offer that works.
For the former, arming yourself on what to look out for is the best defence and for the latter, proper mental health services to treat people with these illnesses is essential.