Philosophy, Psychiatry and Psychopathy

Personal Identity in Mental Disorder

Christopher Heginbotham

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9781138721999
• eBook ISBN: 9781351759533
• Edition: 1
• Topic: Philosophy
• Subtopic: Philosophy History & Theory

First published in 2000, Philosophy, Psychiatry and Psychopathy was highly topical in tackling the interface of applied philosophy and psychiatry at a time when government and clinicians were giving careful consideration to new forms of treatment for people with psychopathic disorder.

The book brings together contributions from lawyers, philosophers, psychiatrists and clinical managers to explore the inter-related conceptual and political implications of Psychopathy.

Philosophy, Psychiatry and Psychopathy will appeal to those with an interest in the history and development of theories and research relating to philosophy and psychiatry.

1 Philosophy, Psychiatry and Personal Identity

Clinics, Concepts and Philosophy of Psychopathy

CHRISTOPHER HEGINBOTHAM

This book arose out of a conference organised by the Society for Applied Philosophy in 1997 to explore conceptual issues at the interface of philosophy, psychiatry, psycho-analysis, and law. Conference participants brought a wealth of experience and insights across the whole field of mental disorder, but the main elements of participants’ papers and the ensuing discussion focused on the problems of personal identity and disordered personality, with specific attention to psychopathic personality disorder. A number of the papers collected here deal with the construction of personal identity and identification, but the depth of analysis of personality disorder at the conference was somewhat unexpected, and suggested that the focus of this book should be on psychopathy.

Psychopathic personality disorder (sometimes called psychopathy, or severe personality disorder, or sociopathy) is a clinical and social presentation which has challenged philosophers, psychiatrists, psychologists and lawyers for many years. There is no single definition of psychopathy nor a common understanding of the aetiology, taxonomy and genealogy of psychopathy. Working criteria have been established (Hare, 1980) and an expanding literature testifies to the burgeoning interest in psychopathic personality disorder. One reason why psychopathy has been under-researched is that for many years medicine (psychiatry) has considered persons with psychopathy to be untreatable and therefore to be outside the normal realm of psychiatric intervention. The 1980s and 1990s, however, have witnessed significant progress in the development of psychological therapies, notably but not exclusively cognitive behaviour therapy and forensic psychotherapy, and these clinical interventions have begun to demonstrate real success in the treatment of conditions hitherto considered refractory.

The emergence of therapeutic modalities relevant to psychopathic personality disorder (PPD) has occurred in parallel with at least two other important developments. The first is an increasing concern amongst politicians and the general public about mentally disordered offenders, many of whom are perceived to have some form of ‘unbeatable’ mental health problem. During the 1990s in the UK alone there have been over 50 major inquiries (either sitting or finalised) into homicides by mentally disordered people, many of which have identified offenders as having some form of psychopathic or sociopathic disorder. The disorders presenting in these cases were perceived to be of such a nature and degree that the statutory psychiatric services were unable or unwilling to provide treatment. The Mental Health Act 1983 (England and Wales) - and associated Acts for Scotland and Northern Ireland - allows the civil detention of people with mental disorder only when there is some form of ‘medical’ treatment available for the disorder. The courts have steadily widened the meaning of the terms ‘medical’ and ‘treatment’ to include a wide range of medical, psychological and nursing treatment and care, but there remains a strong prejudice within psychiatry that PPD is unbeatable.

Acceptance of the un-treatability of PPD has a long history, but the screw was tightened further by the 1970s debate on treatability as a test for compulsory admission to hospital. Publications such as ‘A Human Condition’ (Gostin 1975) took a human rights perspective in proposing that no person should be detained involuntarily unless there was a treatment available for his or her condition. The subsequent 20 years have seen a steady change in abitudes towards treatability, partly as a result of the emergence of new therapies, partly as a reaction to homicides and other serious incidents perpetrated by people with mental disorder, and partly from the recognition that there is a specbum of behaviour and disorder and that a few patients are ‘truly refractory’. Developments in forensic psychotherapy, the work of the Portman Clinic with sex offenders, pioneering work with violent prisoners, and the work of therapeutic communities such as the Cassel Hospital and the Henderson Clinic, are just a few examples which point to the relevance of providing therapeutic opportunities for such individuals.

Overcoming the deep seated prejudice against treatment for people with PPD has been a long and up hill struggle. The gradual acceptance of psychotherapeutic understanding and techniques has been one element of these changing attitudes. Another has been the recognition of the damaging effects of childhood physical and sexual abuse. Pioneering and innovative work such as de Zulueta’s ‘From Pain to Violence’ (1993) have begun to change the perception of many clinicians to the therapeutic possibilities which might be available. A recognition and an understanding of the developmental processes which lead to PPD are a first step in developing intervention strategies as well as providing a focus on primary, secondary and tertiary prevention.

We should not assume, however, that PPD is a single disorder with a straightforward aetiology. Not only does the extent of the disorder, as manifest through antisocial behaviour, fall on a long spectrum from ‘normal’ social behaviour to that which is wholly aberrant, but there may be, as with many other mental disorders, a number of different disease entities bound up in present ways of describing PPD. Defining the various elements of PPD is a complex and demanding task. One approach to showing the difference between PPD and other forms of deviance is to consider offending behaviour by paedophiles, which is distinct from but often confused with the behaviour of those with PPD. Paedophilia is an example which may suffice to demonstrate a first step in unpicking the complex aetiology and presentation often conflated as PPD.

Paedophilia is perceived understandably by the majority of members of society as a severely aberrant, unattractive and unwanted form of personality The ‘folk’ perception of paedophilia has a number of intertwining strands. These comprise, as a minimum, (a) that paedophiles are dangerous criminals whose behaviour must be stopped more or less at any cost; (b) that if such people cannot see the error of their ways they are either mad, or bad, or both, and (c) in any event custodial care should be provided to ensure that they cannot re-offend. If we analyse the nature of sex offending, especially paedophilia, we can see some very significant differences from those features which we find in PPD (Carson and Heginbotham, Chapter 9).

It turns out in practice that the distinction between PPD and paedophilia is simple and clear cut. More challenging is the possible distinction between primary and secondary psychopathy (Mealey 1997) and whether a primary and secondary characteristics sometimes are combined in the single individual. Similarly Blair (1998) has suggested that individuals with aggressive antisocial tendencies tend to come from environments in which violence against others is a way of acquiring status. If the individual has an emotional deficit that tends to psychopathy, then his or her behaviour is likely to be particularly dangerous. In Blair’s view, the person will lack a mechanism that would tend to inhibit antisocial behaviour in other people. Blair proposed (1993) a model for the development of morality which implies a specific cause for psychopathy. He suggested that in individuals whose behaviour is socially responsible there may be a ‘violence inhibition mechanism’ (VIM), a cognitive mechanism which is activated by non-verbal signs of distress and initiates a withdrawal response. Psychopaths lack this VIM and thus the distress cues which reduce aggressive behaviour in the majority of individuals cause no affect in those with psychopathic disorder.

The papers collected in this publication seek to address some of these challenging issues. The interest of contributors is in the clinical and philosophical manifestations of psychopathy as a mental disorder, rather than in psychopathy as a sociopathic trait. It has been suggested that in it’s sociopathic manifestation, psychopathic tendencies, if intelligently used by their ‘owner’, may be of great value in business or commerce (Mealey 1997). Primary psychopaths act intentionally in an antisocial manner having reached a certain level of cognitive development at which they are able to distinguish emotions of the self from the emotions of others. On this basis, primary psychopaths are not incapable of empathy with others but rather choose intentionally not to empathise. This suggests a ‘bad’ rather than ‘mad’ model of behaviour.

On this argument, highly successful business people demonstrate at least an element of sociopathy; they are able to understand the effect of what they are doing on others but at the same time discount the moral or psychological harm that they are causing. From a game-theoretic perspective a small percentage of such individuals in society will be highly successful. Once the proportion reaches some index level, however, such individuals will begin meeting similar individuals too frequently, and, on average, their success rate will diminish. The evolutionary dynamics of primary psychopathy suggests that sociopathic behaviour will be stable whilst the numbers remain small.

Secondary psychopathy on the other hand describes those people whose development has been affected as a result of environment, nurture or abuse (or some other factor) and are unable to form appropriately empathetic relations with others. The development of an individual’s desire to engage in acceptable and normative behaviour appears to be reasonably consistent from an early age. There are however differing theories of moral development. Kohlberg (1964) suggested that moral development advances in parallel with reasoning ability and thus differences in moral understanding can be attributed to differences of intellectual or cognitive ability. Conversely, Blair (1995) suggests that amongst other elements of psychological structure, there is the ‘violence inhibition mechanism’ (discussed above) and this must be initiated or primed before the individual can achieve full moral development. Lack of this mechanism is crucial to the establishment of psychopathic disorder. Alternatively the ‘violence inhibition mechanism’ may not be developed adequately; and it is possible that cognitive abilities are impaired also leading to impaired moral reasoning.

An alternative approach to the aetiology of secondary psychopathy is provided by, amongst others, de Zulueta (1993), drawing heavily on psycho-analytic theory to describe the effects of childhood physical, sexual or psychological abuse. There may be a number of ways in which such abuse leads to psychopathic personality. From a Kleinian perspective it will lead the individual to identify him or herself with a bad object leading to damage or destruction of self esteem and thus to an undermining of empathy with others.

The difference between primary and secondary psychopathy may be explained in differences in developmental environment. If there is a violence inhibition mechanism (which we might suppose can be more or less active) it suggests that some people have an emotional deficit but are not nurtured in an environment which triggers overly aggressive behaviour. We might speculate that some of those people will channel their emotional deficit into higher status activities - such as aggressive business practices - and develop behaviours which are psychologically rather than physically violent. If this is true then a further difference emerges.

As we have seen, evolutionary dynamics (Colman and Wilson 1997) suggest that some small proportion of persons with psychopathy in the community is an evolutionary stable position, and will settle down at some small percentage of the population, typically to 2-4%. Evolutionary dynamics using game theory based on the well known ‘chicken’ (or hawk/dove) game provides a mechanism for determining the equilibrium level. A higher percentage and each person with psychopathic tendencies will meet other similar individuals too frequently; much less than 2% and there will be ‘opportunities’ for antisocial gain which are not taken up!

This theory also suggests that, for secondary psychopaths particularly, the relative gain for the antisocial person is much less than the potential loss to the other person in any interaction. The example given by Colman and Wilson is that a mugger may gain only a small amount from assaulting or even killing a passer-by, but that the consequences for the victim may be catastrophic. This might not be true however for the person who operates in a sophisticated and psychologically aggressive fashion. In this case the gain may be very significant at the expense of relatively low losses to many people - for example small shareholders on the stock exchange. There may thus be two quite different forms of psychopathy in practice although linked causally dependent on the level of deprivation in childhood and the extent to which this damages the violence inhibition mechanism (if such a mechanism exists).

A key element in any discussion of PPD is the notion of empathy. By empathy we mean the ability of individuals to understand the effect of their own actions on others. Empathy has been defined as ‘an affective response more appropriate to someone else’s situation than to ones own’ (Hoffman, 1987, p48). It is often assumed, perhaps wrongly, that having empathy or being able to empathise with others leads individuals to treat others as they would wish to be treated. As George Bernard Shaw once remarked - you “do not treat others as you would want to be treated, their tastes may not be the same”. Paradoxically primary psychopaths may be able to empathise, in the sense of understanding the affective response of the other person, but not feel that affective response personally.

We may have to accept either (a) that some persons with PPD have empathy as defined but are able to use that empathy self interestedly knowing that the other person will be harmed in some way; or (b) our definition of empathy must be enhanced to emphasise not only the ‘affective response’ but to incorporate the idea that the person acts appropriately and normatively as a result of that affective response. In other words empathy is more than “an emotional response [or emotional reaction] to a representation of another’s internal state”,…. but incorporates an intention to act normatively in response to that emotional state. Psychopathic ‘empathy’ may be only partial or limited empathy such that the person understands the internal state of emotion generated in the other person but does not in turn have a fully developed emotional response to the other’s state.

Exploration of empathy is a crucial element to understanding PPD. In Chapter 2 Gwen Adshead describes the notion of empathy as affective resonance and the ability vicariously to introspect. She explores whether empathy can be dismantled and how empathy is acquired and developed in children. Attachment theory and failure of attachment and of parenting suggests that the establishment of empathy is a necessary factor in achieving ‘selfhood’. Empathy is also defined by Piers Benn in Chapter 3 in Strawson’s terms as ‘participant reactive attitudes’. PPD leads us to suspend participant attitudes under certain circumstances because we perceive psychopaths as lacking effective participant attention and are thus excluded from a rational web of public attitudes. But this leads to a further paradox. If persons with psychopathy have no moral sensitivity then surely society has the right to treat such people as outside the normal web of participant involvement and to be excluded and shut out of society completely. Yet we cannot say such persons are non-human, for they evidently are humans; but they appear to lack some element of what it means to be ‘truly’ or ‘fully’ human, in the sense of being an authentic and integrated member of the human community.

Primary psychopaths on the definitions provided here are bad, not mad, and are callously indifferent to the hurt of others even though they may understand what that hurt is. When the hurts and harms generated by such psychopaths reach some threshold of societal tolerance, society then has the right to exclude that person completely from social discourse. Conversely secondary psychopaths could be considered truly mentally ill - they have a mental disorder as a result of mental conditioning and are thus worthy of society’s care and concern. Secondary psychopaths are ‘genuinely’, authentically mad, (or at least, mentally ‘damaged’) unable to empathise, perhaps as a result of dysfunctional nurture, and thus have a right to all the resources that society can provide to enable them to overcome the disorder from which they are suffering.

Although Strawson’s concept of ‘participant reactive attitudes’ is helpful in widening our understanding of empathy, it may be insufficient or inappropriate in explaining the lack of prudential judgement in persons with secondary psychopathy. Primary psychopaths appear to have reasonably well developed cognitive abilities to make complex judgements about the reactions of others whilst discounting the hurt felt by others. Secondary psychopaths, on the other hand, whilst making good ‘street wise’ judgements of immediate necessity, are usually bad at making longer term judgements of their own best interests (Maher, 1990). On the Strawsonian view, moral responsibility need not imply the actual application of reactive attitudes. It only requires that the person be a candidate for such attitudes. It is thus essential to consider what participant reactive responses are generated in the person and the extent to which an individual is reactive and responsive to reasons.

It has been suggested recently that for an individual to be morally responsible for an action the person must have a mechanism that is reasons-responsive. (Fischer and Ravizza 1998). Such ‘reasons-responsiveness’ requires both an internalist and externalist conception of moral responsibility rather than the traditional exclusively internalist conception. There are two elements to this. First, the arrangement of an individ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Copyright Page
• Table of Contents
• List of Contributors
• 1 Philosophy, Psychiatry and Personal Identity: Clinics, Concepts and Philosophy of Psychopathy
• 2 Through a Glass Darkly: Ethical Dilemmas in the Treatment and Management of Psychopathic Disorder
• 3 Freedom, Resentment and the Psychopath
• 4 Disordered Minds, Diseased Brains and Real People
• 5 Mental Content and the Myth of Problems in Living
• 6 The Concept of Mental Injury
• 7 Dynamics as a Unifying Concept in Psychotherapeutic Psychiatry: An Annotation
• 8 Personal Identity and the Social Institution
• 9 Therapeutic Jurisprudence and Psychopathy: A Philosophical Exploration