“But does psychological sophistication override a sense that some actions are just plain bad? How much of human behaviour, in the end, can one understand?”
Joe Cinques Consolations, Helen Garner
Writing in Joe Cinques Consolations, Australian author Helen Garner presses us to ask whether psychological understanding of human behaviour is sufficient to overcome our intuition that some actions are simply bad. This question lies at the heart of forensic psychiatry and has broader application for general psychiatrists as we seek to navigate the path between morality and psychology. The critical discussion that follows examines Garner’s question through different lenses, and concludes that the dichotomy she offers is a false one: a person’s behaviour can be both bad and understandable.
Some actions are just plain bad
Throughout history, humans have been preoccupied with questions or right and wrong. From Biblical imagery of heaven and hell, through to this week’s debate about two young women with COVID-19 who lied about their travel, people are eager to label others as ”good or bad”, “right or wrong”. This moralistic approach to human behaviour has been a strong thread in the history of psychiatry: from the burning of witches, to the use of cold baths and beatings as punishment in asylums, people with mental illness were frequently considered to be “social deviants or moral misfits” deserving of punishment for their transgressions (Lieberman, Shrinks). It was not until Philippe Pinel – at the urging of his friend and former patient Jean-Baptiste Pussin – removed the shackles from patients at Salpetriere in 1800 that we entered an era of more humane “moral treatment”.
From a legal and ethical perspective, the consequence of labelling behaviour as “bad” rather than “mad” is that punishment can follow. The touted aims of punishment are several: (a) deterrence (dissuading this person specifically, and other people generally, from doing the bad thing again), (b) incapacitation (physically preventing this person from doing the bad thing eg through incarceration), (c) retribution (giving the wronged party a sense that justice has been done), and (d) rehabilitation (changing this person’s future behaviour). In order to distinguish between “mad” and “bad” behaviour, lawyers and forensic psychiatrists look to the twin limbs of the M’Naghten rule: (1) did the person know the nature and quality of what they were doing? and (2) were they capable of understanding that it was wrong? If the answer to both questions is “yes”, the person is unable to plead insanity as a defence, and the court can conclude that their conduct was – to use Garner’s phrase – “just plain bad”.
Most human behaviour is understandable
This binary approach to “good and bad”, is at odds with modern psychiatric practice. Research shows that a complex array of biological, social, and psychological factors influence a person’s behaviour. From a biological perspective, studies of twins adopted by different families show that about 50% of the variance in antisocial behaviour is explained by genetic factors. Recent research into transcranial magnetic stimulation has found that focusing a magnetic stimulus on a part of the brain known as the salience network can improve impulse control, which in turn reduces unwelcome behaviours such as gambling. From a psychological perspective, poor attachment as an infant and adverse childhood experiences are associated with higher rates of antisocial behaviour, which may include criminal offending. From a social perspective, nearly 50% of young people under youth justice supervision are aboriginal though they make up only 5% of the youth population overall (AIHW). These appalling figures cannot be separated from the devastating effects of colonisation on connection with land, language, and customs among indigenous peoples.
Under a recovery model, consumer activists urge mental health practitioners to reframe the question: “Don’t ask what’s wrong with me, ask what happened to me” (Eleanor Longden, The Voices in my Head). This approach seeks to understand the background behind the behaviour. For example, someone who lashes out against clinicians during a medical procedure may be re-experiencing an earlier trauma. In this situation, offering calm clear explanations, and asking for consent before beginning the procedure, is far more person-centred than the punitive use of physical restraint or seclusion. Under the CHIME model (Leamy 2011), connectedness, hope, identify, meaning and empowerment are key elements of recovery: none of these are served well by labelling someone as “simply bad”.
Actions can be both bad and understandable
In my clinical experience, actions can be both understandable and bad. By way of example, a clinical interview with a man accused of murdering his wife yielded a rich biopsychosocial formulation. His childhood upbringing, personality structure, and recent stressors all contributed to his violence against his wife and child. In one sense, it was possible to understand the background behind the behaviour. At the same time, he knew what he was doing and he knew that it was wrong. As such, it was appropriate that he face the consequences of those actions. Given that a key aim of punishment is rehabilitation, it was possible for me to both see the behaviour as bad, and to seek to understand it, in order to protect other women and children in future. A rich understanding of bad behaviour is helpful at both an individual level, in informing rehabilitation, and at a social level in advocating for reform to address the drivers of antisocial conduct.
In the end, Helen Garner offers us a false dichotomy. It is possible for “psychological sophistication” and a belief that “some actions are just plain bad” to co-occur: we need not choose between one or the other. Some actions are clearly bad: the wilful taking of innocent human life is perhaps the clearest example. Yet, in describing such behaviour, psychiatrists need not feel trapped by binary religious notions of saints and sinners, nor by binary legal notions of sane or insane. Instead, we can use research evidence, biopsychosocial formulations, and person-focused models of recovery to create rich and three dimensional understandings of human behaviour. In turn, we can use these formulations to say “this behaviour is bad, and here is how we can support this person, and others like them, to find a better path in life”