The Anatomy of Violence

by Adrian Raine

  When Judge Mattison rendered his judgment, his reference point was a change to the constitution of Oregon two years earlier, which had placed the rationale of punishment away from reforming the individual and toward both the protection of society and also personal responsibility. In this context he argued:

  To me, this was a clear statement that the protection of society in general was to be of more importance than the possible reformation or rehabilitation of any individual defendant.… [M]y focus must be much broader than the possible reformation or rehabilitation of Mr. Kinkel.6

  On November 10, 1998, he sentenced Kip to 111 years in prison without the possibility of parole. Kinkel became the first juvenile to serve a life sentence in the state of Oregon. He could never be free again.

  We now move into the future. We pluck the same Kip from 1993 and skip him forty years ahead in time to 2039. He is now a ten-year-old schoolboy, five years before the fateful killings. A new school screening program has identified him as a potential killer. He obtains residential state-of-the-art treatment that successfully tackles the neurodevelopmental factors placing him at risk for future violence. He is later released and lives out a normal life as a crime-free citizen and functional father. Bill and Faith become doting grandparents, two other children live out their lives instead of dying a harrowing death, and twenty-five more people are no longer life-scarred victims of deadly assault.

  That’s a future I will suggest to you in this final chapter—Lombroso’s legacy. Stopping crime before it starts with advanced prediction and treatment efforts. Addressing, with modern technologies and scientific techniques, this grave public-health problem that kills so many globally. Can we improve our approach to crime prevention to create a society that is both more civilized and safer, where a belief in actual rehabilitation trumps the retributive instinct that dominates our justice system today? I believe we can. But before that happens, we need to take a fresh look at the causes of the violence that infect our society and cultivate a more compassionate perspective, not just for the victims, but also for the perpetrators who live on.

  FROM SHADOWS TO SUNSHINE—VIOLENT CRIME AS A CLINICAL DISORDER

  I’d first like to share something personal with you—my sister. Roma was like a mother to me. The years have passed since I last saw her, but my memories of her are clearly etched in my mind. I remember her perching me on the countertop in the kitchen and putting on my socks and shoes. Or the day she sat on the sofa in the living room with me on her lap in my new trousers. She fussed over me like a mother hen. I remember the soft touch of her hand as she walked me down the street early one evening as the sun was fading, stretching out our elongated shadows into the remains of the day. I remember her holding me in her arms and telling me how lovely I was. I could feel her caring, her warmth, and her tenderness. Roma to me always looked so special, so serene, so beautiful. Right now I can see her beautiful face, her gorgeous dark curly hair, and her understanding eyes.

  Roma left school at sixteen and worked for a while in Binns, the main department store in Darlington, our hometown in the northeast of England. She was a natural-born caregiver who always wanted to help people—just as she cared for me. So she became a nurse at Darlington Memorial Hospital. What happened to my sister next, when she was just eighteen, is narrated by her nursing colleague and friend Clare Fitzgibbon, who won the Macmillan Gold Medal for nursing.

  Clare recounts in her book Sunshine and Shadows her time being a nurse working on the ward with Roma. Her close friend had become pale and tired, and had continuous sore throats. Roma eventually collapsed on duty and was taken to an infectious-disease unit on the edge of town. Clare was wondering one day what was wrong with Roma when the ward sister told her to quickly prepare a side room on the Florence Nightingale Ward. A new leukemia patient was being admitted.

  The pale patient was being wheeled along the corridor and through the swing doors on a trolley with a blood-transfusion bottle rocking precariously on a short pole. Clare was in shock to see that the new cancer patient was Roma.

  She nursed Roma through her final days, surprised at how quickly her dear friend had faded. As she recounts in her book, a very moving narrative on caring for cancer victims:

  her dark Italian eyes seemed to have taken over her face, her clear, pale skin was now ashen, framed by her dark, beautiful hair.… Roma looked straight at me. “I’m dying” she said simply, clutching my hand. Blood was trickling down both her nostrils. “Please tell them I love them” she gasped, “my mother, my father,” again she gasped for air, “all my family,” she managed a half smile, her face now colourless, “and you.” … Tears were streaming down my face. “And we all love you too” I got out, as she died in my arms.7

  The bright sunlight of my sister’s radiant life was overshadowed by a particularly acute form of leukemia. On September 18, Roma’s life was snuffed out—perhaps mercifully—in just two weeks,8 although that’s painfully long compared with the victims of most acts of violence. We all miss her, just as Clare does to this day.

  I have reflected a great deal on Roma, and her death has profoundly affected my thinking. The other cancer that bloodies the lives of so many more people—violence—is to me as much medical as the sickness that killed my sister. For me, Roma’s death is a metaphor for how I think we need to treat violence. It requires more compassion, less retribution, and a new clinical perspective that I want to move you toward considering.

  As a psychology undergraduate in the 1970s I had been fascinated by the psychosomatic approach to illness—mind-over-body causation. Susan Sontag wrote provocatively twenty years after Roma’s death about how cancer—the paradigmatic disease for much of the twentieth century—was wrongfully viewed as something to be ashamed of, something to be covered up.9 The psychosomatic perspective on illness considered the person to have caused their own cancer. Their internal aberrant personality, hallmarked by inhibition and anger suppression, caused a somatic disease, and psychotherapy was offered as an alternative treatment. The person was responsible, not any outside agent.

  I believe we currently view the cause of violence in a similar way. Don’t you think some offenders are just plain evil? It’s the serial killer’s own internal demon that caused him to kill. Two world-leading academic clinical psychologists have in the past provoked me to consider that possibility—and it is indeed provocative. Perhaps there are no external biological or social causes—instead it’s evil. Could that really be?

  Perhaps. But my concern is that if we begin to think in that almost spiritual way, we have regressed to how crimes were explained in medieval days—by an evil spirit. Surely we have progressed further, scientifically and rationally? Cancer is not a punishment for our sins but a disease produced by external biological and social forces that can be treated. I would ask you to not only consider violence as a public-health problem, as a disease that affects our society—but also to think about it rationally and clinically, not inflected by ideas of sin and evil. I sense that that was the essence of Sontag’s point on the illness my sister died from—the same cancer that Sontag herself would die from—and it’s the same point I want to make to you about the nature of violence.

  Just as our perspectives on cancer have now radically changed, so too, I believe, are our perspectives on violence about to change. Like Clare, I’ve been on a ward with my own patients, being up close and personal with them for four years—working with them as a psychologist in top-security prisons and caring for them in therapy. For thirty-five years I’ve been trying to understand what causes their illness. We’ve given up on lifers in much the same way that doctors had to give up on my terminally ill sister, moving Clare Fitzgibbon to hatred for them when all they could say was, “It’s time you called the priest. We’ve done all we can.”10 It was seemingly time for Roma to confess her sins and take responsibility for causing her cancer. How in future years can we turn the dark shadows of prisons into sunshine? How can we cure this violent cancer?

 
Before moving into the future to provide an answer I need to explain my own perspective on violence further. Let’s drift back twenty years, to a book I wrote in 1993, six years before Kinkel’s conviction, called The Psychopathology of Crime: Criminal Behavior as a Clinical Disorder. I argued that repeated violent offending is a clinical disorder11 in just the same way that cancer, depression, and anxiety are viewed today. In viewing violence this way, I’m not referring to someone who loses his temper one day and slaps someone, but to the class of violent criminal offenders who repeatedly perpetrate significant criminal violence upon others. I would also include nonviolent criminal offenders—those who are recidivistically antisocial. I believe there are good grounds for this view.12

  Fundamental to this idea is the definition of clinical disorder as a “dysfunction.”13 Essentially, something is not working right in the individual. The DSM—the Diagnostic and Statistical Manual of Mental Disorders—is used by psychiatrists and clinical psychologists to diagnose all clinical disorders.14 It is a veritable bible for psychiatry. Let’s see how a revision proposed for the next edition, which represents 36,000 mental-health physician leaders, defines what a disorder is and how it fits recidivistic violence. The proposed definition in DSM-5 is as follows:

  A Mental Disorder is a health condition characterized by significant dysfunction in an individual’s cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning. Some disorders may not be diagnosable until they have caused clinically significant distress or impairment of performance.15

  Do violent offenders have abnormal functioning in terms of how they think, feel, and behave? Yes, they certainly do. Does this “dysfunction” have a biological basis? Is something not going right in their development? I have argued that crime germinates early in life from a neurodevelopmental and genetic base. I’ve suggested that there is a heck of a lot that is just not working right in violent offenders. They are also impaired in how they perform in life—whether at school, at home, or at work. Violence certainly causes distress to others, and the offender himself is frequently in a distressed state. Repeated violent offending is a clinical disorder.16

  In the field more broadly there are at least nine different criteria for judging whether a certain condition is a clinical disorder—such as statistical infrequency, deviation from the social norm, and deviation from ideal mental health.17 Recidivistic crime is relatively infrequent. It deviates from the social norm. And we know that offenders are not the picture of ideal mental health. Combine this with distress and suffering to others and self; impairments in social, occupational, behavioral, educational, and cognitive functioning; and the host of biological and brain impairments we have documented already, and the case is fairly complete. Of course, most individual criteria of what constitutes psychopathology have significant weaknesses, but when combined together they help describe a gestalt picture of psychopathology against which violent crime may be viewed. Recidivistic offending meets these criteria just as well as most disorders listed in the DSM, and, indeed, it fits better than some already listed.18

  What will be the critical turning point that will lead to this radical way of thinking? It will be the development of new treatments that conclusively stop violence in its tracks. Once that happens—once we can “treat” offenders successfully—retributive justice will seem archaic. We’ll witness a significant change in society’s perspective, driven particularly by how judges decide to deal with defendants in sentencing.

  For that to happen, of course, we’ll need some really big breakthroughs. But even today there are signs of progress, many coming from advances in other medical disciplines. Let’s take a closer look at leukemia, as a current-day example of what could happen tomorrow with violence. Leukemia very likely results from a genetic mutation in DNA that produces protein abnormalities that make too many white blood cells. Normally these white cells are produced in the bone marrow and protect us from viruses. But the new white cells produced by the illness are immature, and they crowd out the healthy cells, dampening the immune system and reducing the number of red blood cells that provide oxygen. That results in anemia, pallor, and shortness of breath, as it did with Roma. The reduction in blood platelets, which normally aid clotting, resulted in Roma bleeding from almost every orifice in her body. The immune-system suppression results in unremitting infections, such as Roma’s repeated sore throat and infected tonsils, and eventually death.

  For one form of leukemia, called chronic myelogenous leukemia—CML—we have an understanding of its genetic basis. Genes on two chromosomes normally regulate white-blood-cell growth. In leukemia, the ends of these two chromosomes get switched around, with one getting shorter. This shortened chromosome is named after the city I currently work in—the Philadelphia chromosome—and was discovered in 1960, just three years after Roma’s death. It now contains a new hybrid gene that uses a molecule called ATP that activates other proteins and causes the cancerous growth that produces the excessive white blood cells. How can ATP be blocked? By using a drug called imatinib, sold under the name Gleevec.19

  Okay, you say, this is all fine and dandy for a cure for cancer, but crime and violence is only half genetic and it’s just not so clear-cut. Yet the reality is that while some cancers show heritability at a similar level to crime and violence, many cancers are not heritable, even though they have a biochemical genetic basis.20 So what’s happening here?

  Duing the time you read the paragraph on Roma’s death, hundreds of changes had taken place in your genome. Hundreds of thousands occur every day, but we have natural repair mechanisms that reverse this genetic damage.21 When these repair mechanisms go awry, mutations can result in gene abnormalities, producing defective proteins that in turn result in faulty physiological functioning and impaired health. What can cause some interruption to the natural correction that normally takes place? Think back to the concept of epigenetics that we discussed in chapter 8. Environmental experiences alter gene expression. That’s why many cancers have little or no heritability and yet they operate through genetic processes.

  For that reason I fundamentally believe that what we see today in cancer can happen tomorrow for violence. Mutations can be repaired with medication. The speed with which science made progress on the human genome project is just one example of the rapidity of change that is possible. I ground this prediction on what I have seen in the past thirty-five years of my research career on crime. I’ve seen how breakthroughs come first in physical clinical conditions and the development of new medicines—not infrequently from research on cancer. Those conceptual breakthroughs tend to filter down to other medical illnesses. Advances in medication get applied to psychiatric illness. Then from psychiatry there is invariably a trickle-down effect to violence and crime. Take cognitive-behavior therapy, pioneered by Tim Beck at the University of Pennsylvania. It was first developed for depression, and now it is one of the best and most used interventions for adolescent and adult antisocials alike.22 Take the application of medications for epilepsy, psychosis, and ADHD, which are being used today for aggressive children and adolescents. Very slowly—but very surely—I see it happening.

  Why am I sure this change will occur? Because the theoretical framework and science are in place right now, and because treating the physical causes will work more quickly and effectively than repairing the complicated social factors that also contribute to criminal behavior. Bad neighborhoods basically don’t change much over decades,23 and the cycle of poverty is equally resilient. You now know that the environment critically interacts with biological and genetic risk factors in shaping violence.24 You now know that there is a significant genetic basis to crime, aggression, and violence. You now know about epigenetics—that changing the environment changes gene expression. You know that current medications can attenuate aggression and violence. You know that a new generation of cancer medications has the capacity to reverse gene mutations.
We could have the capacity to change violent behavior more quickly through biological interventions.

  From a practical standpoint, can we stop the social causes of crime? John Laub and Rob Sampson are prominent criminologists who argue for the importance of the neighborhood in crime causation.25 Improving neighborhoods will help reduce crime, and we should certainly do more for that goal. They also persuasively argue that daily situational contexts and experiences can be turning points that either start or stop crime, whether it’s getting married, getting a job, or even joining the army. I believe they are right. Yet the problem remains that it’s going to be darn near impossible to control people’s daily social interactions and experiences. After all, our lives can turn on a dime, with a chance meeting. We won’t be able to predict and control these chance fluctuations. Not now—nor in thirty-five years’ time.

  Yet we also know that environmental and even chance events can promote genetic and biological alterations through the process of epigenetics. Can we control the physiological effects that give rise to basic cognitive, emotional, and behavioral risk factors that spawn violence? In theory we could, by developing drugs in the same way they are currently being developed to treat some forms of cancer. The future promise is that a new generation of medications can be developed to block the functioning of the faulty proteins that will be identified in the future as the genetic and biological bedrock for violence. We first need to identify which structural genetic mutations give rise to which specific faulty proteins that in turn give rise to the biological risk factors for violence. It will take time—a long time—but the theoretical potential is there if we have the courage and conviction to pursue that path. So far we have not.