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Read the Notes – Don’t Write the Notes
Two rather opposing forces have perhaps by chance come together in day-to-day mental health practice, making an odd but powerful alliance.
There was a time when psychoanalytic theory was an important current in mainstream psychiatry in the UK. The Royal College of Psychiatrists still has a Faculty of Medical Psychotherapy and psychoanalytically minded junior psychiatrists can still be picked out in generic mental health teams but, as they approach seniority, they tend to split off into more protected specialist services working with personality or eating disorders, for example. It is true that a big inner London mental health Trust recently had as its chief executive a psychoanalytically trained psychiatrist but he moved on after a few years without leaving a trace. Social workers (almost exclusively women, it has to be said), too, in their fleeting golden age of the 1960s and 1970s, topped up or maybe legitimised their innate sternness with a psychotherapy training.
A key tenet of such training was that the analytic session should, as Wilfred Bion neatly put it, consist of neither memory nor desire. That is to say, the analyst or therapist should approach the prescribed fifty minutes with a mind emptied of history and intention so that the patient’s associations are spontaneous and pure. However, an approach which is logically consistent with a treatment based on free association, projection and transference in vivo in which the therapeutic work is done in the moment has been borrowed by hard-pressed, or rather oppressed, mental health professionals looking for corners to cut.
A failure to understand the merits of knowing a history combined with a resistance to doing the unexciting trawling that this involves tends to be rationalised with statements such as we want to get to know X first or we want to hear it from Y himself. While it is much less time-consuming it is also cognitively or intellectually less demanding to focus on getting to know X than it is simultaneously to combine a knowledge of the history and an understanding of the complexity of his difficulties with an alert openness to him in the room.
The key to effective clinical work with patients is to see the individual but recognise the type. Staff who tend towards seeing the individual will find it much harder to encapsulate the essence of the problem and to be effective clinically whereas those who are more interested in type will have problems with engagement and trust, which will also get in the way of real therapeutic progress. The first group risk being overwhelmed, the second being experienced as cold or remote.
A failure to track back through the history and seek out reliable, sympathetic informants arises partly out of a lack of interest, a rare commodity in mental health services, but it is also a by-product or side-effect of institutional defensiveness borne out of an essentially paranoid stance. This requires staff, in particular ward staff, to document relentlessly the minutiae of a patient’s behaviour, the quantity of data collated about a person being mistaken for the quality of interaction.
The purpose of this bureaucratic approach to so-called clinical care, in which key, defining biographical information is often missing, is to prepare for criticism and insure the organisation against blame when things go wrong. Knowing and understanding the patient, without which real treatment is impossible, comes a poor second to loading, or rather overloading, the recording system with data which can later be used as chaff to confuse the radar of investigation. Most damaging of all is that it promotes a narrowing down of how the patient is seen with an emphasis on illness and pathology instead of widening the focus to take into account the unique complexity which brings the patient to the ward or service. This can be seen in the schizophrenia tariff in which early in his career he is described as “having psychotic symptoms”. This later becomes “he has schizophrenia” and then “he is schizophrenic”, with the endgame being “he is a schizophrenic”.
Underlying the move from a clinical imperative to a bureaucratic one is an unconscious deference to the machine. This requires that staff, unaware that they are being softened up for their replacement by artificial intelligence (AI), become interchangeable conduits for a certain kind of information which is no longer a route to understanding but an end in itself. Interactive relationships, subjectivity and agency, deemed dangerous, subversive and unpredictable in a world of machine-thinking, are soon to join CDs, Tippex and the fax-machine in the skip of history. Their redundancy has already begun.
Did Nathan Matthews’ brain do it?
(“Free will is a necessary fiction”)
So how capacitous was Nathan Matthews in his brutal killing of his step-sister Becky Watts? To what extent was his responsibility diminished, perhaps by changes or deficits in his brain?
In football you need to set aside the goals to analyse your team’s performance effectively and usefully. Focus on outcome prevents a full and accurate understanding of its antecedents. Bracketing off the fact of the 130 deaths in Paris on 13th November 2015 at the hands of sadistic psychopath gangsters in order to try to understand the metamorphosis of a benign religion into a patriarchal perversion shouldn’t be seen as an apologia or an insult to the dead and their mourners. Similarly, putting to one side the heinous butchery by Matthews of his step-sister is not to dilute it or to be callous towards the trauma and suffering of those close to her.
Matthews described himself as a “metrosexual Neanderthal”, an interesting and maybe perceptive oxymoron. His mother remarked: “he’s a different person, he’s not the child I remember bringing up……I find it hard looking at the monster he’s turned into…..he’s totally different from the child I brought up”, a cri de coeur which is a striking echo of the bafflement of the parents of young men brainwashed by distant mullahs. Seven years before the homicide he was seen in the Territorial Army, of which he was a member for some time, as “a good team player and a likeable, popular soldier”.
The late teens and early twenties are a peak time for the emergence of serious mental illness (most often schizophrenia) in young men and while the vast majority do not, as Matthews did not, develop the symptoms of formal full-blown mental disorder, it is clear that many young adults are destabilised by a kind of transitional upheaval which can be seen as psychological, cultural or even organic, depending partly on your particular politics of the mind. Often this is managed by them with alcohol and/or drugs, chosen because of their immediate efficacy and reliability, or the seeking out of danger which is in some ways a mirroring of or metaphor for the turmoil within. Because of an ego searching for a signal or structuring which will restore stability, a minority are exposed or vulnerable either to indoctrination (which has the aim of colonising identity) or to less florid or disruptive disorders than psychotic illness. That is to say, the psyche at this age or stage adopts defensive manoeuvres in order to prevent or forestall disintegration or collapse.
More significant than Matthews’ change of personality (“going downhill and becoming increasingly paranoid”, as his grandmother put it) and the changes of facial expression or demeanour that tend to accompany this, was his extreme hoarding and the retreat to his bed-space that often goes with it. While the roots of this behaviour may date back to the late teens or early twenties, it doesn’t tend to become problematic or obtrusive until middle-age. In Matthews’ case, however, it was established and significant.
There is a theory, exported from the USA so it must be viewed with caution, that hoarding, along with the fibromyalgia that he was also said to suffer from, is associated with organic damage or at least changes in the brain; in particular in the case of hoarding, in the interior ventromedial and cingulate cortices. A genetic disposition is thought to lie behind these while a companion theory is that they are the sequelae of profound traumatic loss or a history of forced sexual activity. These areas in the brain are said to deal also with weighing up conflicting information and relative significance or importance. When a cousin of Matthews’ victim says “he is beyond human, he is an animal” and his mother that “what has happened wasn’t ment [sic] to”, this could be seen as intuitively pointing to a lack of intentionality in his actions and an inability to take in the enormity of them, the latter a characteristic of terrorist gunmen with whom psychologically he has a lot in common.
Matthews’ hoarding and cognitive and intellectual shortcomings also have something in common with what are called the negative symptoms of schizophrenia where there is a retreat to a small island of solipsism in a sea of grossly impaired functioning and interaction. As with terrorists, his murderous dysfunctionality took him right up to the door of madness without ever managing to get in. For both, the unconscious is trapped in a dilemma, with the choice only of going mad or going killing.
A further clue to the essential impulse which took Matthews to murder and his fellow-travellers in Paris to slaughter lies in criminologist Dr Jane Monckton Smith’s observation that he had an ability “to behave completely normally after doing something completely abhorrent”, which differs maybe only in degree from the capacity we all have to bracket off cleanly and immediately our sexual activities from our mundane, non-sexual world. The fact that Matthews could potter off to a DIY store to buy a chain-saw soon after the murder with the apparent insouciance which terrorists also display post hoc can be seen to suggest that in certain forms of killing the death instinct has hitched itself to the sexual instinct, la petite mort thus becoming la grande mort. Maybe.
But if we take the focus back behind mind, behaviour and then instinct to speculation about grey matter itself, there is a wealth of recent research which suggests that a wide range of human activity and expression is traceable to particular, precise hotspots in the brain. For example, it is claimed that a belief that something is sacred is processed by different neural system from those which give rise to a belief that something is mundane or trivial; and other parts of the brain, also associated with reward, become active when beliefs are disavowed or disowned. This raises the interesting possibility that those with brains which are overdeveloped in the area which deals with the sacred (and perhaps immutable) and under-developed in the area which loosens attachment to certain beliefs are likely to be resistant or even impervious to persuasion, conversion and de-indoctrination or de-radicalisation. And if it is true and aetiologically significant that those with right-wing views have a more pronounced amygdala than those with left-wing or socialist views, this could be seen to account for the fact that it is extremely rare for politicians to cross the floor of the House of Commons – and, for that matter, for any political or even moral debate to end with one participant conceding that the other was right all along.
The lexicon of research which points to, at the very least, a significant link between physical phenomena or changes in the brain and behaviour is growing exponentially. An inability to plan among many teenagers is said to derive from their immature prefrontal cortex. Using alcohol (and, by extension, cannabis as well, I guess) during puberty is reported to change the reward system in the brain permanently, thereby leading to an inclination towards addiction. “Defective” pathways in the brain, perhaps established at a similar stage, are believed to be connected to an irresistible desire to smoke. The pattern-making part of the brain is said to be overdeveloped in excessive gamblers because they tend to imagine patterns in random outcomes of the gaming machine or roulette-wheel. Some brains (clumsily characterised as “female”) are tuned to interpersonal contact and empathy while others (“male” ones) are geared up to be concerned primarily with system and structure.
In the area of mental disorder, it has been known for a while that the children of older fathers are more likely to develop schizophrenia. Similarly, factors in utero which determine relative digit size are also believed to be closely associated with depression. What is invariably called “lack of insight”, that is the conviction among those who suffer from schizophrenia that they are not ill, may in fact be identical to anosognosia, which is the physical incapacity of some patients who have suffered brain damage, perhaps through stroke, to understand that they are ill. So-called conduct disorder is said to be linked to inactivity in the part of the brain which deals with empathy (see above). MRI scanning suggests that a predisposition to a sexual attraction to children may be a function of faulty wiring in the brain which directs sexual impulses towards them instead of nurturing ones. Those with such interests are three times more likely to be left-handed or ambidextrous than the general population, and tend to be significantly shorter than other criminals, characteristics which are determined early in pregnancy. Conditions in utero, in particular low thyroid levels, are also believed to be implicated in the development of low IQ.
Williams-Buren syndrome is a rare neurodevelopmental disorder which includes some interesting and common symptoms. In addition to the heart defects and unusual facial features which are characteristic of the condition, sufferers tend to be hyper-verbal, anxious (with phobias, often of wasps, dogs and thunderstorms) and particularly good at reading intention, emotion and mental states in others. They favour music as a regulator of their anxiety. They are very friendly to strangers but less good at deeper interaction with others, leading them to be gregarious but also quite lonely or emotionally isolated. They tend to come across as kind but inwardly mask hostile or antagonistic feelings (see Freud, who was a neurologist before he was an analyst, on “reaction formation”). While the physical features of the condition are precise but rare, the apparently psychological ones are fairly common and tend to go together in particular personality types – and occupations, for that matter. It is not unreasonable or illogical to extrapolate from this that such psychological characteristics are actually the product of a mild form of neurodevelopmental pathology.
Resistance to the idea that conditions or phenomena in the brain may possibly determine or cause behaviour is widespread and rarely weakened by the emergence of research which indicates that they do. This is partly because beliefs about cause are influenced by beliefs about, and especially investment in, solutions. So, politicians are likely to believe that legislation, policy, the economy, power relations, information, education and so on are the factors which have the greatest influence on behaviour because this is their territory and currency. Therapists, counsellors and social workers tend to appear automatically opposed to biological explanations for the problems they are employed to tackle and instead attach greatest importance to the role of environment, intrapsychic factors or an interplay of the two. That said, it does happen that old-timers in the helping business are eventually swayed by cumulative empirical evidence to believe that genes and the physical brain rather than the froth of family dynamics or life events determine illness, disorder or whatever deviations from the norm should properly be called. Seeing distinct and discrete conditions such as depression or schizophrenia repeat themselves down and across generations is, whatever your political or occupational orientation, persuasive.
All of this may seem like yet another reworking of a tired nature-nurture dualism (which most of the time is politically rather than technically driven). Philosophically, things have moved on and it is generally agreed we need to be less linear and binary on the one hand, and more systemic and dynamic on the other. Equally, the study of epigenetics has taught the layman that, while the environment (in its broadest sense) does not alter genes themselves, it does cause genes to express themselves in particular ways. This looks like a healthy dissolution or synthesis maybe of the nature-nurture impasse which it would be perverse to resist.
Whatever. The confluence of a number of different currents is creating a mainstream of thought which will be hard, if not impossible, to resist. Where mind and brain have been coterminous (i.e. mind cannot extend beyond the boundaries of brain), it seems clear that eventually they will be held to be all but synonymous (i.e. actions which once were seen as the product of the mind at work will be seen as the unmediated fallout from events or phenomena in the brain). Thus states of mind will simply be states of brain.
While resisting the inevitable may have many benefits (as resisting the inevitability of death clearly has), considering its implications with the aim of mitigating or even pre-empting them may have more. If what we do is merely what our brains do, in volition, capacity and responsibility will in time come to be seen as the quaint artefacts of an innocent age. The assumption and validity of mens rea will wither in direct proportion to the expansion of the diagnostic manual of mental disorder. As highly elastic constructs such as Asperger’s Syndrome, attention deficit hyperactivity disorder and personality disorder turn more people into patients, their application will gradually confer absolution on alleged sufferers. Blame and punishment will become vestiges of a cruel and abusive past. Treatment, eventually in the form of physical manipulation of the brain, will replace incarceration which will remain only for refuseniks and renegades. In divesting themselves of agency, so-called sufferers will unwittingly also cede power to the State, its criminal justice system being eventually administered not by prison and probation officers but by medics and marketised treatment centres.
While this movement may have to mark time for a generation or so while the will to blame and the hunger for vengeance or retribution play themselves out, it is almost certain to gather an almost irresistible force, not least because medical intervention will be so much cheaper than years of detention and all the infrastructure needed to underpin it – and it will put an end to tiresome recidivism with the easy promise of increased security for all. In fact, chemical castration for persistent sexual offenders can be enforced in a number of European countries and American states, and, where it isn’t enforceable, offenders themselves may agree to it or even seek it out.
In the fearful New World of the generation after next, successors of Nathan Matthews will be seen as victims themselves – of the faulty wiring in their brains or a glitch in their DNA. The effectiveness of, no doubt, instant, painless physical treatments will then be used as an argument for pre hoc, preventive intervention in childhood, in utero or even earlier, along the lines of the elimination of unarguably genetic disorders which is being mooted now.
The only way to dig philosophical heels in against the momentum of this dystopian current is to see free will as a necessary fiction, as a quaint confection with no supporting objective evidence for its existence. If free will is assumed, perhaps as an article of faith, meaning that there is a small but sufficient corner of the ego which is impervious to disorder or pathology, then there will always remain an onus on the disordered or pathological to find means to head off their offending and pre-empt their crime. Nathan Matthews was fully guilty because the consequences of the alternative would be intolerable. Individual responsibility must remain, as must guilt and blame, without which, in the long run, there is no freedom.