Sunday, July 29, 2012

Why Does Norway Want Breivik to Be Insane?

Anders Breivik bombed downtown Oslo and went about methodically murdering 77 people and injuring many more.  In his recent trial that came to a close last month he calmly described how he did it and discussed with detached curiosity the victims' various reactions or lack of reactions to his attacks.  Throughout, he taunted family members, survivors and the world with what can only be described as a psychopathic sneer.

sociopathic killer photo from trial
A sneer, micro or macro, is the universal expression of contempt

Is he insane?  This was the central question the recent trial revolved around.  Prosecutors want him to be insane, even though they now admit their doubt on the subject.  Prosecutor, Svein Holden, is quoted by the BBC as stating, "We are not convinced or certain that Breivik is insane but we are in doubt."  And yet, they continue to argue he should not be imprisoned but should instead be committed to a psychiatric institution.

Here, insane is more or less defined as psychotic.  Is he psychotic (insane) or psychopathic (sane but very very bad)?  That is the question.  Technically the defense is on a fool's mission to explain his actions as justified, but that is beyond absurd.  One wonders if the defense attorneys have undergone cognitive deficiency testing themselves--if not, perhaps they should.  While there is little if any evidence of actual psychosis there is a strong desire to place Breivik in that category, or maybe more to the point, to place him outside the categories of normal or sane.

Other than the fact that Norway has one of the most lenient and forgiving criminal justice systems on the planet, I know too little of that place and culture to fully understand their reasoning.  I can only surmise it gives some comfort to hold a belief that a man capable of doing what Breivik did cannot be normal or sane.  In a lay sense, what Breivik did makes him, by definition, insane.  This creates a safe psychological boundary between him and us.

It is an understandable sentiment, I'm sure.  But what does it say about a criminal justice system where prosecutors are not motivated by truth but by the outcome that makes them the most comfortable?

Can a man like Breivik be helped by psychiatric care?  If he were in fact psychotic, there are drugs that may (or may not) help.  Add some cognitive-behavioral whatnot and sometimes we see improvement, even dramatic improvement at times.  Conversely, if he is a straight up psychopath (as is likely the case), there is very little help possible if we want to be honest about it.

The Norwegian prosecutors fail to recognize the collateral impact of their strategy is to add more fear and stigma to the actual insane, the 1% or so of the world's population with a form of psychosis at some point in their lives.  Granted there have been plenty of psychotic shooters and killers over the years, and we may very well have experienced another one in Colorado just this month, but the vast majority of people with psychotic experiences, 1% of the world's population, are as non-violent as anyone else.  Some psychotic individuals can be dangerous, but lets not pin everything too horrific to comprehend on them just to make us feel a little more removed from the human potential for evil.

Saturday, July 7, 2012

They Want Us to Believe

There is a ubiquitous use of tense in mental health treatment, and curiously, it highlights an interesting contrast with the evangelists of multiple personalities.

In working with people on the more severe end of the spectrum of mental health disease (or "disease" in quotations if you prefer) we usually find that we cannot directly challenge beliefs we believe are delusive without threatening to lose the relationship, the precious rapport, that is often our only hope of helping, and yet we don't want to reinforce the delusion just in order to maintain rapport as that would also be counterproductive, so we try to ease our way through the dilemma with a little play of tense.  The client speaks in the indicative, "I have an implant in my neck that Richard Nixon speaks to me though." It is a solid fact.  Meanwhile, we clinicians reflect in the subjunctive, "You believe . . .", "You said . . .", or you might even risk a "I believe you believe . . ."  We leave it in an open and conjectural mood to show understanding, and thereby avoiding conflict, but without reinforcing.

Changes in tense are also important in the strictly professional side of mental health when we take our professionally sanctioned beliefs and apply them in the real world.  The ultimate document of professional belief, the Diagnostic and Statistical Manual, The DSM, is written entirely in the indicative tense.  Every mental health diagnosis is a fact and every criterion of every diagnosis is a fact.  These facts are immutable immobile objects with crisp edges.  The DSM is seemingly free from conjecture or uncertainty, much less fantasy and make believe.  Here we find ourselves in another dilemma because most clinicians (and researchers too I would guess) do not believe the diagnostic categories handed down from on high are factual at all.  Most of us handle these interesting but crude objects with healthy skepticism.  They are all works in progress that may or may not hold up long enough for the next edition.  The clients we work with are individual people who do not always so easily fit these models.  We are well aware they are just that, models.  Is Schizophrenia really a single disease entity or several that happen to look similar?  No one really knows for the time being.  So, we think and talk about these things in the subjunctive manner even though Medicaid forces us to write out our final diagnoses in the indicative.

three faces of eve as flying saucer UFO
It has recently struck me, however, when it comes to therapists who are wont to diagnose and promote Dissociative Identity Disorder (or Multiple Personality Disorder), the above outlined patterns do not hold.

Firstly, there is no distance between the belief of the clinician and the belief of the client.  They become fused in a shared belief.  A shared fantasy.  A shared dramatic enactment.  Between clinician and client, the belief system is spoken of in the indicative.  Changes of mood are distinct personages inhabiting a single body.  The clinician pronounces it.  The client reflects it and gradually comes to act it and be it.  The reality that DID becomes depends on the indicative mood.  The clinician and client must truly believe and always speak of it in the most confident and unwavering language.  Any doubt may cause the mirage to waver and blow away in the wind.  The clinician is on stage also, enacting the role of professional therapist, but it is an "as if" that only looks like therapy.  In fact, it is therapy in reverse, rather than curing or ameliorating, with this therapy the symptoms of the client strangely increase in strength and definition over time and eventually become cemented facts.

Secondly, there is no healthy skepticism on the part of the clinician in the professional realm.  Always these therapists use the same indicative tense used in the DSM whenever discussing their one cherished true diagnosis of DID.  They are believers who want us to believe in it too.  To convince themselves and us, they don't use the language of belief, they use the language of hard facts.  There are no maybes or uncertainties.  The facts of DID are proven and true.  Professionals who doubt run the risk of being called closed-minded or ignorant of the facts, or finally when we fail to align we are told we are invalidating toward their clients--spoken as if it is the worst possible insult.  It always strikes me that the selfsame therapists who want so hard to believe in the fact of DID are often the most doubtful of just about any other diagnosis in the DSM.  I have been told by a straight faced bearded therapist that many cases of Schizophrenia are actually DID.  There are many many people out there with mood fluctuations who have DID and don't even know it.  Or so I'm told.  I suppose the right therapist can skillfully draw out the symptoms and turn annoying mood fluctuations into a disabling condition and Medicaid will reward the therapist for many years to come.

It may be no coincidence the only other people I have experienced such a hard sell from, miraculously turning uncertainties into facts, are car salesmen and preachers.  I can't say that I've ever knowingly been part of a cult, but I imagine cult leaders also are inclined toward an indicative mood.