by Kerry Daynes
Rosenhan’s experiment has been widely reported the world over. While the original study is now a bit dated, it does still serve as a useful reminder, not only of the arbitrary nature of diagnosis, but also of the way we describe and interpret behaviour though the filter of our expectations. If you’re considered mad, all your behaviour is construed as madness. (Likewise, if you are considered bad, all your behaviour is construed as bad.)
*
Dr Webb diagnosed Travis with ‘schizoaffective disorder’, a hybrid diagnostic label describing a combination of psychotic symptoms, such as hallucinations or delusions, plus extreme highs and lows of mood. He was prescribed antipsychotic medication, not that he ever took it – because almost as soon as Travis’s diagnosis was decided, he escaped.
In any kind of secure institution the windows can only ever be partially opened, as much to stop people trying to throw themselves out as to prevent them escaping. But when staff went into Travis’s room one summer morning, they found he had circumvented this problem by simply removing the entire window frame, using an electric screwdriver. Subsequent investigations revealed that Travis had been having an affair with a nurse who worked night shifts at the hospital over the summer. She had brought the screwdriver in for him, along with a mobile phone so that they could talk to each other and plan his escape. This explained his ‘diurnal variation in mood’ and all those suspicious early nights: he had been texting his girlfriend and practising with his power tools in his room every evening (not a euphemism).
Travis was found three days later, hiding out at the nurse’s house just a few miles down the road – it struck me as an unambitious escape plan, but each to their own. He didn’t come back to the hospital, because in the short time that he had been missing the prosecution case against him had been dropped. This wasn’t unusual; criminal cases collapse all the time. With no charges against him and – now presenting with nothing other than absolute mental clarity – he was free to go. Fortune favours the bold.
Travis never came back and, after a day or two of monumental staff gossip, he was forgotten about. But I’ve always remembered him. He taught me to see the people I work with as more than merely prisoners or patients, and that sanity is a spectrum, each of us differentiated by a matter of degrees. During ward rounds, while we had all been earnestly wringing our hands about what diagnostic label to give him, each of us projecting our own versions of the people we wanted to be seen as, Travis had arguably been the sanest person in the room.
The whole experience also reminded me that while faking it can be a useful strategy, at least in the short term, in the end honesty is the best policy. Discovering Travis’s truth, and knowing that my early suspicions about him had been right all along, helped me begin to feel that I could trust my own judgement. Instead of pretending, it was a step towards truly becoming the psychologist I wanted to be.
CHAPTER 5
WITCHDOCTORS AND BRAINWASHERS
I suppose it is tempting, if the only tool you have is a
hammer, to treat everything as if it were a nail.
Abraham Maslow, Towards a Psychology of Being
‘I reject your schizophrenia! I reject your schizophrenia!’
Marcus’s deep, throaty voice boomed out from behind his door with all the force of a priest performing an exorcism. He was shouting his protests to a nurse, who was crouched down on her tiptoes, wobbling slightly as she talked to him from the other side.
I was one of three psychologists and four assistants at this secure hospital. For a place that was supposed to transform minds, it didn’t exactly scream mindfulness. It was a 1960s concrete monolith, hidden way out in the sticks, down lanes and through fields, and had aged about as beautifully as the rolling hand towel contraptions, long since broken, in the staff toilets.
Beds and other furniture in secure hospital bedrooms are fixed firmly to the ground. As well as limiting the opportunities for feng shui, it means people can’t blockade themselves into their rooms. But Marcus had created his own human barricade, wedging his long and slender body behind the door. As I shifted up a gear into a half-run, along the corridor towards the commotion, it occurred to me that he must have been straining every sinew he had to keep that door closed. Although his efforts were in vain; in secure hospitals, the doors are hung on hinges that open both ways.
Incoherent speech echoed around the corridor, then with clarity he shouted, ‘I killed my brother! I killed him!’
This wasn’t a delusion. He was right, he had. Marcus had stabbed his older brother Raymond twice in the back, lacerating his right lung and causing a fatal tension pneumothorax. It had happened outside the gates to the park, in the middle of the day, as Marcus’s four-year-old daughter, still strapped into her booster seat, watched from the back of Raymond’s car.
I slowed up as I got closer to the commotion, not wanting to interfere. Nurses are highly skilled and well experienced at dealing with this sort of situation and they wouldn’t normally want me sticking my oar in. But it was late evening – I’d stayed on after my usual nine to five to finish writing a report – and staff numbers at this hour were lower than during the day, so I stood nearby just in case.
The nurse was holding one of those little paper cups that looks a bit like a mini-muffin case, with pills in it. Behind her a male nursing assistant must have been anticipating trouble, as he was standing in the classic de-escalation pose: one arm loosely across his body and the other hand under his chin like The Thinker. The idea is that you look concerned and attentive, but your hands are in a convenient position if you need to spring into action – either through fending off an attack while protecting your face and torso, or taking hold of someone’s arm or head in a physical restraint.
All mental health staff get training in the physical management of violence and aggression. Although these days the laying of hands on a patient is considered very much the last resort and the emphasis is firmly on de-escalation – calming the waters to avoid violence and confrontation. Orwell would be proud of the linguistic shift that has taken place to describe these techniques; what used to be known as ‘control and restraint’ is now referred to as ‘care and responsibility’.
Whatever you call it, asking hard-working and undervalued hospital staff to wrestle with someone who may or may not be acting in a rational or predictable way puts most of them in an impossible position. It’s no less undignified for the person being wrestled, who, already in a state of agitation, can find themselves being restrained by up to four members of staff, an experience which for anyone can be frightening and claustrophobic.
(Thankfully, I’ve only had to use my C&R training once; as soon as I took hold of the patient’s arm, he flung himself to the floor, his arms curled in at the elbows and wrists. He was clearly an old hand at this manoeuvre. He had been in hospital for over ten years and he told me later that being restrained was the only time other human beings ever touched him.)
I didn’t know the nurse crouched behind the door. She was part of the night team so our paths had not crossed before. She looked formidable, a no-nonsense matron at a boarding school. She was talking to him in a firm, uncomfortably patronizing tone.
‘You were very poorly at the time,’ she said, trying to persuade him to take his medication.
His response was a jumble of words and phrases: ‘Don’t recapture then violence brainwashers…children crying halos around my head.’
This was a ‘word salad’. The term has most recently been associated with Donald Trump’s more incoherent public statements, but the phrase actually originated in psychiatry, where it is used to describe a common feature of severe psychosis. Word salad is a bit like predictive text, as it conjures seemingly random and unconnected vocabulary straight out of someone’s mind and sends it out of their mouths in no immediately obvious order. Although it can sound nonsensical to the listener, if you think of the words as a sort of unconventional poetry or riddle you realize that there is meaning in there, if you have
the time and the patience to crack the code.
While Marcus wasn’t making any real sense to me or to anyone else on the ward, it was clear that he had something important to say. And what he did manage to communicate that evening was his intense, gut-wrenching grief. He became more lucid and in a gravelly, cracked voice, he roared: ‘I’m not sick. YOU are the ones that are sick in the head!’ His distress was now audibly escalating. ‘I killed my brother! Because of you!’
The nurse replied, ‘No Marcus, it was because you have an illness and that’s why I want to give you this medication. It will help you feel better.’
‘Get out of my house. I reject your schizophrenia.’ He was getting louder and more forceful as this fruitless exchange developed. Although they were speaking the same language, they may as well have been from different planets. Marcus was getting angry because he felt he wasn’t being heard, while the well-meaning but old-school nurse seemed oblivious.
The nursing assistant and I exchanged glances, a little voltage of mutual understanding passing between us, and I let him know I was going to step in. I gave the nurse a wave and pushed my hand downwards in the air, to signal she needed to take it down a notch. But she didn’t know who I was and seemed to look through me. She ploughed on regardless.
I sensed that the situation was escalating and felt like it was time to intervene. I stepped forward. ‘Marcus, it’s Kerry.’
He shouted back, ‘Witchdoctor! Witchdoctors and brainwashers.’
The nurse looked at me and opened her mouth, as if to shut the conversation down. Before she had a chance to intervene, I tried my luck.
‘Marcus, I can hear that you are feeling really frustrated. Tell me about what’s happening.’
Everything went quiet.
‘I killed my brother,’ Marcus said.
‘Yes, yes you did, you killed your brother.’
The nurse stood up and took a step back, her lips pursed so tightly they had almost disappeared. I suggested, as tactfully as I could, that she could perhaps give us some time to talk and maybe pop back in 15 minutes.
And then I sat with Marcus for a bit, listening to him speak. The door was ajar, and I sat opposite him, saying very little but attempting to make sense of what he had to tell me. Sometimes you just have to sit with a person, validate what they are feeling and not be afraid of their pain and grief. Marcus had done something dreadful and irreversible. The kind of thing that can’t simply be blithely explained or medicated away.
After Marcus had offloaded for a while, the nurse returned and silently passed him some tablets and a glass of water before departing. I didn’t see her again until I left that night, and when I said goodbye she didn’t reply.
*
On the day he killed his brother, Marcus believed that Raymond was possessed by demons.
Marcus had been haunted by graphic visions of Raymond beating him for weeks. These fleeting but vivid images were agonizing for Marcus and, in his state of mind, he believed that they had been deliberately placed inside his head to punish him. Malevolent voices in his head claimed that they had a hold over Raymond, that they were torturing him and it was all Marcus’s fault. In among the battle noise and chaos in his mind, only one clear thought emerged: he had to kill his sibling.
After his arrest, Marcus had been diagnosed with ‘schizophrenia’. Schizophrenia is, like so many of our diagnoses, a catch-all term for a plethora of altered states. This includes everything from hallucinations (seeing, hearing, feeling or smelling things), delusions (believing paranoid or extraordinary things) and muddled thinking to difficulties concentrating or a lack of emotion and drive.
It is one of the profession’s most broad and diversely applied labels and has expanded and altered further and wider over time. Unfortunately ‘schizophrenia’ has now become a derogatory and often insulting moniker that leaves little room for nuance or individuality under its gloomy and heavy-duty stamp. It is a condition that everyone thinks they understand, a common trope and easy punchline in popular culture. You are never alone with schizophrenia, so the old joke goes. Or as Billy Connolly put it: ‘Roses are red, violets are blue, I’m a schizophrenic and so am I.’
The common understanding of schizophrenia means Norman Bates, Jekyll and Hyde, the Mad Hatter. Calling someone a ‘schizo’ is now shorthand for someone who loses their temper easily, or appears to be like a different person when they are enraged. But that’s not schizophrenia, that’s being angry.
It has also come to be associated with dangerous, violent or criminal behaviour; horror films are full of apparently psychotic axe-wielding maniacs. A 2012 study of the representation of schizophrenia in Hollywood looked at 40 films featuring characters with that diagnosis released between 1990 and 2010. It found that over 80 per cent of them displayed violent behaviour and nearly a third committed homicides.
And it’s not just the fictional world – violent crime is the most frequent and pervasive theme in coverage of schizophrenia stories in the news.
But the stereotypes fall down when you consider that 1 per cent of the world’s population has been given a diagnosis of schizophrenia, giving us around 51 million schizophrenic people worldwide. If all of these people were violently assaulting and killing others we’d be stepping over the corpses in the street.
In fact, there are between 50 and 70 cases of homicide a year in the UK involving those, like Marcus, who have a severe mental health problem at the time of killing. Of course, this is still far too many and preventing these tragedies should be a concern for everyone. But most of the over 220,000 people in the UK with a diagnosis of schizophrenia live unremarkable, peaceful lives. They are ordinary people in your street, your office and your local pub, posing no threat or danger to anyone. But their stories don’t sell newspapers, so you, like me, only come into contact with the horror stories.
So what makes some people with a diagnosis of schizophrenia pose a risk while others don’t? Research tells us that the answer lies in the many other factors that make up human existence. The risk of violent behaviour is typically linked to other circumstances, problems or issues which are not necessarily directly connected to someone’s mental ill-health. In particular this includes substance misuse but also a fundamental lack of personal and/or professional support and a previous history of violence, either as the victim or the perpetrator. However, contrary to the media headlines, the rate of violence in those who have been diagnosed with schizophrenia, while marginally above the rate in those who haven’t, is still too slight to be able to predict with any precision.
*
This was just after the turn of the millennium, and there was a steadily increasing demand for beds in secure hospitals. One look at the NHS England balance sheets at the time told you the story: early intervention, community and mental health crisis services were not receiving nearly the same level of funding and investment as secure services. In fact expenditure on medium-and high-secure mental health services made up around one-fifth of all public spending on adult mental health care at the time. The money was being spent on detention rather than prevention, the horses had bolted long before any doors were being locked.
And whereas I had once been almost the only forensic psychologist in the village, more and more forensic psychologists were moving into secure hospitals, many from the prison service, from where they brought a certain philosophy and model of intervention with them.
The fashion was (and still is) for treatment programmes tightly packaged into step-by-step manuals and delivered to patients in groups: Sex Offender Treatment Group, Fire-setters Group, Anger Management Group, and so on. Each combines a series of educational and CBT-based sessions aimed at teaching participants the new attitudes, values, beliefs and patterns of behaviour they will need as reformed citizens. Delivered with dogmatic methodology, these programmes are administered by psychologists – but also often by other staff, in truth by anyone with a manual and a few days’ training. It is psychological practice industrialized �
�� with your programme sheets, scripts and questionnaires in front of you, you write reports using templates, you rate engagement on a scale, you tick boxes to show rigid procedure has been adhered to. It’s prescriptive for everyone involved – patients were never in straitjackets, but it increasingly felt as though you, the psychologist, were.
I am an advocate of cognitive behavioural therapy and other derived therapies for treating a whole range of problems, such as phobias and mood issues. But their effectiveness in preventing reoffending in the long term is still up for debate – no matter how fervent somebody’s professed changes in attitudes and beliefs in the artificial environment of a prison or secure hospital, whether it will have the desired effect on their behaviour many years into the future when they are in the real world isn’t clear. While my feelings about the usefulness of these one-size-fits-all group sessions were conflicted at best, I was left feeling certain that they trained many patients to become skilled at saying what they thought their Stepford psychologist wanted to hear.
Not Marcus though. His frequent refrain of ‘I reject your schizophrenia’ was becoming the soundtrack to an impasse at his every ward round. Meetings that usually culminated in Marcus pointing at us – the senior staff – and calling us ‘witchdoctors and brainwashers’.
Despite being prescribed large doses of antipsychotic medication, which he always grudgingly accepted, he continued to be tormented by voices. He could often be overheard having intense, irate discussions while alone in his bedroom. His risk assessment made for hair-raising and pessimistic reading, describing him as ‘paranoid, treatment resistant and lacking insight’.
