Junior Psychopaths

How did he come to your attention? How do these kids end up with CAMHS rather than in a YOI? Who decides that and how?

Just a personal interest here.

By the way, a book you and others might like: -

Kirk, S. A., Kutchins, H. & Rowe, D. (1999) Making Us Crazy: DSM - The Psychiatric Bible and the Creation of Mental Disorders New York: Constable

I’m an ICD-10 man myself, rather than DSM, so to say someone’s got F91.3 Oppositional defiant disorder they need :
“Conduct disorder, usually occurring in younger children, primarily characterized by markedly defiant, disobedient, disruptive behaviour that does not include delinquent acts or the more extreme forms of aggressive or dissocial behaviour. The disorder requires that the overall criteria for F91.- be met; even severely mischievous or naughty behaviour is not in itself sufficient for diagnosis. Caution should be employed before using this category, especially with older children, because clinically significant conduct disorder will usually be accompanied by dissocial or aggressive behaviour that goes beyond mere defiance, disobedience, or disruptiveness.”

“The disorder requires that the overall criteria for F91″ means :
Disorders characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct. Such behaviour should amount to major violations of age-appropriate social expectations; it should therefore be more severe than ordinary childish mischief or adolescent rebelliousness and should imply an enduring pattern of behaviour (six months or longer). Features of conduct disorder can also be symptomatic of other psychiatric conditions, in which case the underlying diagnosis should be preferred.

Examples of the behaviours on which the diagnosis is based include excessive levels of fighting or bullying, cruelty to other people or animals, severe destructiveness to property, fire-setting, stealing, repeated lying, truancy from school and running away from home, unusually frequent and severe temper tantrums, and disobedience. Any one of these behaviours, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.”

It’s got age, duration (specifically of the behavioural repetoire, not just of challenging behaviour) and indicators of intensity. This gives it more nosological status as a diagnostic entity rather than just a description of behaviour, to my mind.

Eschew that American frippery

“Eschew that American frippery” - is that the same as calling it Yank Wank? Throw them both away and give everyone Tazars.

In discussion on the YOI/CAMHS point; I’m having another of my epiphanies - that there is very little differnce in the admission criteria to either when it comes to behavioural/conduct stuff and I’m beginning to wonder if all offenders (youth/adult) should not first go thru a ‘health’ screening process in which amenability to treatment is assessed (along with other components like HCR20; PAI; etc), followed by a ‘treatment’ package and designed risk/probation outcomes and actions.

And those who don’t pass the amenability test can sit in jail until they do.
I wonder how many would continue to offend if given a jail term of “indefinite; depending on engagement and response to treatment”?

I’m beginning to wonder if all offenders (youth/adult) should not first go thru a ‘health’ screening process in which amenability to treatment is assessed (along with other components like HCR20; PAI; etc), followed by a ‘treatment’ package and designed risk/probation outcomes and actions.

Cue the collapse of CAMHS under the weight of work and expectation. Oh, I can just see it now - an overcrowded YOI and an overworked CAMHS ping-ponging a young crim back and forward as they play the game of “he’s your responsibility”.

This also pathologises criminal behaviour allowing the thieving, murdering, assaulting adults some of these young offenders become to claim “it’s my chemical imbalance, guv”.

Having seen many inappropriate cases being wrongly placed in or not in health care, I think there’s more need to do the job properly and prevent wasted spent time in health and ‘wrongly’ incarcerated individuals who ought receive treatment, respectively. However, if you want to take it up a level of thinking; we incarcerate both criminals and mentally ill offenders because of morality and social control - not because it’s the best thing to do for/with them.
I see the overall hypothetical scheme requiring lots more ‘clinical’ input but with aim to much less offending and thus jail time.
As for pathologising; we already get plenty of malingerers or mis-diagnosed admissions. And to some degree, is criminality not an imbalance of one thing or another already, particularly in psychopathic or recidivist offending, be that chemical, structural, moral reasoning, or whatever?

However, if you want to take it up a level of thinking; we incarcerate both criminals and mentally ill offenders because of morality and social control - not because it’s the best thing to do for/with them.

I disagree. Incarcerating rapists, murderers and paedophile is entirely the best thing to do with them. But even if I didn’t think that, morality and social control are vital to the functioning of any human society, and that’s a good enough reason to shove rapists, murderers and paedophiles in prison and for detaining people with mental health problems who are a risk to themselves and others.

And to some degree, is criminality not an imbalance of one thing or another already, particularly in psychopathic or recidivist offending, be that chemical, structural, moral reasoning, or whatever?

Possibly, but that argument could also be made for extreme promiscuity, alcohol abuse, crack smoking and the actions of well know negligent father and malodorous pain in the ass, Brian Haw, none of which should be the remit of mental health services.

Which supports my hypothesis to a certain amount that we should incarcerate, screen and treat or detain, as befits the screening.

I’m not suggesting we abandon our moral reason or social control, but that we organise it better.

Consider, rapists may be released within 3 years imprisonment or 5 years of treatment with indefinite ‘follow up’. sex offender registers have gone some way to striking a balance with the social control of the mentally ill offender, but the two distinct agencies are essentially providing the same services - in distinctly different formats. Why not amalgamate and optimise?

You said: -

I’m beginning to wonder if all offenders (youth/adult) should not first go thru a ‘health’ screening process in which amenability to treatment is assessed (along with other components like HCR20; PAI; etc), followed by a ‘treatment’ package and designed risk/probation outcomes and actions.

Assuming there is something to be treated. For a large number of crims, the “treatment” is removal from society as the “symptoms” of their “disorder” are lawlessness, violence and/or murder.

You believe no-one has the ability to travel the road to Damascus?

Two young children; beaten regularly, poor socio-economic upbringing, etc etc; the causative factors of so many cases seen incarcerated in either hospital or prison.
Those children become adolescents who develop a dependence on drugs as a way of coping with the stress of childhood memories and perhaps can’t see much future in their life beyond the next govt cheque.

One becomes psychotic because the stress of childhood memories and the effect of the drugs is too overwhelming.
One becomes violent because the stress of childhood memories and the need to obtain drugs is too overwhelming.

Which one deserves treatment?
Which one deserves to be imprisoned?
Which one is most likely to respond to intervention?
Which one is more likely to have a relapse?

Is the violent one any less likely to improve then the psychotic one?
Does the violent one deserve ‘lesser’ sympathy because they didn’t become mentally unwell?

Lawlessness, violence and/or murder are still symptoms; but is the aetiology that different?
Doesn’t a lot of todays forensic mental health look at more than just ‘psychotic processes’?
Perhaps these symptoms of non-psychoses are not of classic mental illness. But they do represent an ‘abnormal’ and socially unacceptable situation. How is that so different to the MHA purpose, other than [perhaps] an absence of an Axis I diagnosis?

Which one deserves treatment?

The one with an actual illness

Which one deserves to be imprisoned?

The criminal one

Which one is most likely to respond to intervention?

Depends what you mean by intervention. Incarceration is an intervention.

Which one is more likely to have a relapse?

Well, as only one of them is ill, then only one of them can be said to have a relapse.

Is the violent one any less likely to improve then the psychotic one?

Impossible to say

Does the violent one deserve ‘lesser’ sympathy because they didn’t become mentally unwell?

I’d rather reserve my sympathy for the violent one’s victims. A bad childhood is no excuse for being a violent arse.

Lawlessness, violence and/or murder are still symptoms

No they aren’t. I was being facetious.

The use of medicalised semantics to describe them does not distinguish between them so easily for me.

“Treatment” is but a medical semantic meaning “to bring about positive change by design”
“Imprisoned” is but the social variance of “Detained”
Incarceration, in itself, is as good an intervention as admitting to a unit where the staff do nothing.
“Relapse” is the medicalised word for “recidivism”

Becoming “a violent arse” as a result of a psychological and physiological addiction is no less a medical problem than becoming violent thru psychotic experiences or beliefs. Both are caused, in this case, by illicit drug use.

I never could see the world so black and white.
I never could judge between one and another in such calculated fashion.

To me they are but two of the same kind.
Lawlessness is an outcome as much as mental illness is an outcome of the same origin.
Certain choices are made - post-event and possibly prodromal (tho the continuum of ‘life’ is nothing but a set of ’symptoms’; yet morbidly they present quite differently - for the sake of perhaps a single DNA strand.

Why is it ‘patients’ are to be treated unconditionally with positive regard, yet ‘prisoners’ are to be condemned as “violent arses”?

Mr Ian, to me there is a clear difference between violence as a result of psychotic experiences and violence as a result of an enjoyment of violence for its own sake. To me, there is a clear difference between Peter Sutcliffe’s God-mandated mission to clean the streets of prostitutes and Ted Bundy’s sadistic sexual violation and murder of young college girls. To me, there is a clear difference between a dementing older woman distractedly removing something from a shop and an aggressive little street-rat nicking booze at the point of a knife from a local off-licence.

Extreme examples, I’ll grant you, and of course there is that vast sludgy grey area called “personality disorder”.
However, to me, you seem to be pathologising criminal behaviour, as if it were only that tiny smidegon different from mental illness. This, in my opinion, is just not so and does a disservice to people with mental illness and - to some extent - criminals as well.

There is the element of choice to consider. Someone with psychosis may not make a real, rational, informed choice to - say - strip off naked and walk down the street. Not so the violent crim who decides that today is a good day for rolling a few queers in the local park. You seem to be keen to remove that element of choice from the criminal’s behaviour. Having a bad childhood and using drugs does not make you into a mindless crimbot. If you remove that element of choice from the crim, then you effectively argue against any chance of the person taking responsibility and feeling remorse for their crimes - important elements of a criminal’s rehabilitation, I’m sure you’d agree.

Years ago, we may have explained criminal behaviour as the result of demon possession or an imbalance of the humours. Nowadays, we have psychiatry to identify those demons for us, so our explanations for aberrant behaviour are couched in the language of the mental healthcare professional. We further stigmatise people with mental health problems, though, if we lump them in with armed robbers and serial kilers.

I disagree. Violence does not result from psychotic processes; it results in mental illness from the same process of violent crimbots: where moral reasoning is compromised and where the ‘threats’ outweigh the ‘consequences’.
Even if a psychotic person sees the devil and hears commands to kill or be damned forever - the comparison of the drug addicted individual who feels compelled by physiological and psychological need to breach the same boundary, for me, is no different.

Granted, the mindless beating of a vagrant in the park is a crime not really worthy of trying to ‘justify’ - but there is a personality type that would do that and a personality type that would not. Is this, in itself, not pathologising?
I do not suggest anyone with a pathology for criminogenic behaviour has an excuse or attributable blame shifting option - society still requires and demands safety, and rightly so.

Your argument also somewhat undermines all the prison programmes that are 80% similar to those run in secure mental health environments where ‘criminogenic’ behaviours are addressed. Do you suggest prisons should simply incarcerate and not seek to make change thru self improvement programmes?

I would suggest we already provide treatment to both sets of persons; what varies are the setting and the indiosyncrasies of those medicated going before the MHRT and those often also medicated but going before the parole board.

As my previous post on this topic argued some weeks ago; we incarcerate the mentally ill far longer than their criminal counterparts and give them far more complex hoops to jump thru with an increasingly more complex and expansive legal framework by which we contain them.
This reality does not support the argument that prisoners are mindless violent thugs, less worthy, and mentally ill people ought be sympathised with.

Couple of things: -

I didn’t say psychosis caused violence, but that violence may be a response to psychotic symptoms. To my mind, there is every difference between someone who is violent in response to psychotic symptoms and someone who is violent because they are intoxicated. There is no mitigation in law for you being smashed out of your gourd, and rightly so in my opinion. Otherwise, drunk drivers who injured people would never be prosecuted.

Do you suggest prisons should simply incarcerate and not seek to make change thru self improvement programmes?

Quite the opposite. It’s my belief that criminals should be made to face their personal responsibility for their crimes, a concept that is significantly weakened by adopting an “illness” model of criminal behaviour.

I’m going to take a risk and throw a “service user” perspective into the debate:

1. First off, I’ve always felt that if those in the world of medicine stray into the world of morality (as psychiatry has done since it started) then they need to tread very very very carefully indeed. So I’m glad to see such issues being intensely debated.

2. I’ve had a fair old spread of diagnoses chucked at me over the years. I have one criminal conviction (possession of 0.92g cannabis resin in 1980). The criminal conviction is “spent”: with the diagnoses I’m not so fortunate, they’re on record forever.

3. I believe that the number of instances where an illness genuinely impinges on moral responsibility is far, far smaller than is generally perceived. We live in a world where too much is being medicalised. We live in a world where “I want” becomes “I need”, where “I need” becomes “I have a right to” and where “I have a right to” becomes “I can justify any behaviour in order to get what I want”. Maybe this is due to commercial pressures, maybe there is a general fall in moral standards, but to medicalise it is to legitimise it, and the result of this is that the concept of “responsibility” (now being bastardised on planet earth) slips into further decline.

beakie:
A response to psychotic processes, in my mind, is no greater an excuse for breaching moral codes than “real perceptions”.
“I am hungry cos the voices tell me so” is no better an excuse than “I am actually hungry” if both persons then go on to kill someone for a loaf of bread. They are both equally culpable of over reacting.
Similarly, for the deluded person who genuinely fears for their life, such as someone paranoiac to the point of belief that the man pointing an umbrella in your direction is actuially about to stab you with it; they have the same rights to ’self-preservation’ in their moral reasoning as those believed sane in the same yet more real situation of someone with a lethal hand held weapon in front of them.
I have no problem accepting that moral ground, as equally as I accept they further require to be detained to assess the intensity of such delusions and likelihood of the same re-occurring. Just as a court of law would remand the perpetrator of the second offence scenario to determine it’s likely reoccurence.

The illusion of ‘caring’ for someone by incarcerating them does not work for me. However, I am quite happy to accept that they are incarcerated for breaching moral codes; just as for the criminal.
The belief is that we can change the psychotic processes and this reduces the likelihood of future occurrences; however, I believe the ‘defence’ of mental illness still requires proof that the behaviour was ‘reasonable’ given the perceived circumstances. Of course, there are many additional attributable factors; stress; illicit drug use at the time; poor physical health; etc that are considered - but these must apply equally to those with or without mental health defence, as they are not the “illness” itself.
It is these further attributable mitigating factors that I believe you are saying are not ‘treatable’ yet mental health allows them, and the criminal system does not.
I believe, it is these further mitigating factors that can be just as important to “treat” in criminal people as they are in “mentally ill” people and thus reduce their propensity for recidivism/relapse.

Jan:
You’re sense of risk is my sense of a calming influence.

In regards #3 and furthering your point (to anyone):
Is it a case that we are (or, “I am” - as advocating my corner) perhaps seeking to be far too ‘understanding’ for all; or is it the case that we have become far too ‘understanding’ towards those who plead ‘mental health defence’?

Or is it the case that mental health defence comes with an opportunity to wipe out all other risk increasing behaviours by simply attending the presenting “illness” alone? (Which, incidentally. is the model I currently have to work under - and am very not-happy about).

To take just one point from your answer: -

The illusion of ‘caring’ for someone by incarcerating them does not work for me.

In the context, you seem to be talking about detention in hospital. I would have to disagree very strongly that detention in hospital can’t be a caring action. In cases where the outside world is just too threatening and terrifying for the person, or where they are likely to kill themselves, or where they have neglected themselves to the point of near-starvation or dehydration, or where their continued presence in a situation presents a risk of them hurting other people detention seems entirely a caring action. I cannot see any alternative that would be “more caring”.

And this point also: -

It is these further attributable mitigating factors that I believe you are saying are not ‘treatable’.

I don’t know how you have deduced this from my argument as they are all treatable. However, treatable does not mean ‘can be put forward as mitigation’. If I get steaming drunk and beat you up because you remind me of a work colleague who’s getting on my tits, I am still totally culpable for my actions, as well I should be. My stress and alcohol use can be treated, but they should not be taken as any mitigation for my actions whatsoever. Otherwise, you end up with a perverse incentive for crims to claim they were pissed or drugged or just a wee bit uptight when they robbed that bank or smashed that old woman’s face in with a brick, or raped that woman in an alleyway.

“If I get steaming drunk and beat you up because you remind me of a work colleague who’s getting on my tits, I am still totally culpable for my actions,”
On which we would agree.
I further believe that a person deluded by mental illness who commits the same actions, for the same beliefs, is therefore equally as culpable and to the same degree.
If that person took amphetamine to cope with the negative feelings of being a survivor which caused a delusional psychotic experience that then caused them to think I was a work colleague who got on their tits - we agree they remain culpable - but under mental health or criminal law? And, if mental health, then why?

“I would have to disagree very strongly that detention in hospital can’t be a caring action”
Assuming by ‘caring’ you mean “providing an intervention designed to bring about relief” then we can also agree. Whether it is a caring action or not is down to the service.
But do you consider that incarceration in prison has to be done without ‘caring’?

I further believe that a person deluded by mental illness who commits the same actions, for the same beliefs, is therefore equally as culpable and to the same degree.

Well, it would depend. If they’re being pissed off with you was because they identified you as the man who they believed put the camera in their head and the tape-recorder in their spinal column, then I don’t think there’d be an equivalence.

But do you consider that incarceration in prison has to be done without ‘caring’?

No, and I don’t think anything I’ve said has suggested that. But for me, personally, the ‘caring’ would be directed at the culprit’s victims and wider society than the person themselves who, to be perfectly frank and honest with you, I don’t give much of a damn about

And this would be the ‘grey’ area that I think is often avoided in the criminal justice system -
When in a life threatening situation, we can go so far as to defend murder for anyone.
But what is the understandable response (or defensible reasoning) for something like the delusions you example?
(Not that having one avoids the need for detained treatment) I would argue that even if you did believe I had done that to you, then it would not ‘justify’ you assaulting or killing me any more than if it were true. The principle I suggest is that the presence of mental health issues (including psychoses) does not obviate the moral responsibility nor does it compromise the individual’s moral reasoning - in essence I guess I am debating the concept of “mens rea” & “actus rea” and whether the person with psychoses has any defence for acting outside what, even under un-real circumstances, might be considered unreasonable or over-reactive.

And stating you don’t really give a damn of what happens to those incarcerated in prison might be construed as suggesting you believe they can rot without intervention or care.
The victim’s needs are taken as a given. I think there is a general consensus that victims deserve such compassion.
However, I cannot switch my reasoning from accepting mentally disordered offenders have understandable ‘reason’ to offend and criminals are just wankers.

I do believe however that there are those persons who are morally capable yet choose to care more about themselves than they do the next person, to the point of offending against them. The presence or absence of mental illness is irrelevant. It is the nature of underlying personality that makes their offending morally aberrant.

I would argue that even if you did believe I had done that to you, then it would not ‘justify’ you assaulting or killing me any more than if it were true

Who said anything about it “justifying” the crime? It doesn’t justify it, it sets it in a context wherein your powers of reasoning were not as they might have been. This is not about justification but mitigation.

The principle I suggest is that the presence of mental health issues (including psychoses) does not obviate the moral responsibility nor does it compromise the individual’s moral reasoning

I think you’re onto a sticky wicket if you try and argue that someone who thinks the Martians are stealing his thoughts through telescopes in the sky is just as capable of moral reasoning as someone whose mind is not clouded by such psychotic phenomena. Moral responsibility is another thing: yes, the person has done the act, they are ultimately responsible for it. But mitigation of that responsibility on the grounds of mental disorder has a long tradition in law, and for good reason.

And stating you don’t really give a damn of what happens to those incarcerated in prison might be construed as suggesting you believe they can rot without intervention or care.

Speaking as a human being with human emotions like anger and disgust and not as a mental health professional (or whatever I am nowadays) - yep, that’s about the size of it. I really could not give two hoots what happens to a child rapist or an armed robber or a serial murderer once they get behind bars. As long as they are kept away from potential victims for a very very long time, if not indefinitely, I’m perfectly unconcerned if their every waking moment is a living hell. I reserve any sympathy or empathy for the unfortunate victims of their behaviour.

Oops, pressed submit too soon

The victim’s needs are taken as a given

Sadly, I don’t believe this actually to be the case. Victims are incredibly badly served by our justice system.

However, I cannot switch my reasoning from accepting mentally disordered offenders have understandable ‘reason’ to offend and criminals are just wankers.

Again, who said anything about “understandable reasons”?

Understandable reasons is my reference to how people with mental health defence are morally absolved by the presence of a psychotic illness. In some cases this may be valid but I think the current process jumps that stage of the process.

ie
Person A & Person B are both hungry.
Person A asks to do odd jobs for money to buy a meal.
Person B steals one.
Morally, person B is wrong.

Pt A & Pt B hear voices telling them the staff are all Martians, stealing their oxygen and they’re going to die.
Pt A becomes distressed and withdraws from society.
Pt B becomes distressed and assaults staff.
Morally, pt B is wrong.

There are clearly those who do not fit this theory; I’ve nursed some who really do not believe what they did was wrong - most famously for me; a guy who stabbed a Queens Guard in the leg because he believed it was a test of honour that the Guardsman was in agreement with. His moral reasoning was undoubtedly compromised.
However, I think the determination of the ability for moral reasoning can not tested by the mere presence or not of a mental illness. I believe there are issues of personality and moral reasoning that persuade the person to behave the way they do, just as Person A behaves differently to Person B.

The testing of someone’s moral reasoning ability is most frequently assessed in levels of psychopathy and not mental illness, tho psychopathic traits can exist in someone who is also mentally ill - or not.

Victims are badly served. And we both agree that they are more deserving of any care.