“I just threw him in the lake and expected him to die. . . My only regret is that he lived.”
So said my patient recently. I wondered if this was yet a further test for a relatively new psychiatrist at this prison. I had been tested by other prisoners. Would I believe what they said— whether it was truthful or not? Would I be horrified? Would I prescribe a medication that might be abusable or divertible? Would I shake their hand if extended to me?
However, this test seemed like something more, for I felt chills for the first time. This must be the moment of truth I was expecting—and dreading—since I first visited the prison some months ago. So, I wondered. . . what sort of danger was he describing?
A. Gang retribution?
B. A symptom of Antisocial Personality Disorder?
D. All of the above?
E. None of the above?
F. Some of the above?
If I was ever to help this patient, I assumed that I would have to find the right answer. But did I really want to try? Did I have to? After all, as Ronald Pies, MD has noted, most psychiatrists don’t want to venture into the currents of evil.1 There must be good reasons why they don’t. I felt trapped, yet it was too late to just walk away from this man and this facility as much as I wanted to at that moment.
It would be easy to determine whether the act of throwing someone in a lake and expecting him to drown was an act of gang retribution (option A). Even if the prisoner did not want to talk about gang affiliations, I could simply check the details of the criminal records and sentencing.
I’m sure I could figure out whether Antisocial Personality Disorder (option B) applied in this patient’s case.
But evil (option C)? How could I decide whether such behavior was a manifestation of evil—a word not mentioned once in DSM-IV? What did I, as a psychiatrist, know about evil? One of our expert forensic psychiatrists, Michael Stone, MD, claims that psychiatrists don’t know more about evil than anyone else.2
I knew evil was an emotionally charged word, often with religious associations. The concept of evil varies considerably from one cultural group to another and from individual to individual. For clinical purposes, I came up with a working definition. Evil is unacceptable, destructive behavior, exhibited without remorse and without a more general moral framework, which cannot be explained solely by psychopathology.
Until I began part-time work in a prison, my exposure to evil was generally indirect. I had worked extensively with refugees who had PTSD—including survivors of the Holocaust and of the Balkan conflict in the former Yugoslavia. The acts they described seemed evil to me, yet they were also culturally sanctioned by those in power and accepted by many of the citizens. The worst to me personally was hearing of how grandchildren were tortured in front of their grandparents in Yugoslavia. Yes, I was a new grandparent at the time.
As a prison psychiatrist, I knew I would not be exposed to all possible evil inside. I would not see those without an identified mental illness. Prisoners themselves seem to feel that child molesters are the most evil. This reminded me of the hierarchy of evil that Google had tried to operationalize by developing a 15 item “evil scale.” Google’s corporate motto, “Don’t be evil,” could then encompass evil ranging from apathy all the way to torture.
Armed with this background and definition of evil, I thought I might be able to answer the test question with more clinical information. Here are the details of the case. (The specifics have been modified to protect the prisoner's privacy.)
I had already seen Mr X several times before I sat through the session with him that gave me the chills. At our initial evaluation, his records indicated a variety of diagnostic possibilities and an array of medication trials initiated by a number of clinicians. He admitted that he hadn’t been very compliant with any of the treatment regimen. Mr X wasn’t sure whether he wanted—or needed—medication.
He told me he was preoccupied with “necrophilic” thoughts. At first, he did not want to describe these thoughts in any detail. Over the next few weeks, he tried another trial of lithium and bupropion and, for the first time, he took propranolol. He also saw a psychotherapist, but decided that he didn’t want to explore his thoughts further because he “didn’t want to do anything to cause me to not feel like myself.” On the one hand, I was comfortable with this lack of progress. Leave well enough alone, I thought. On the other hand, the mention of “necrophilic” thoughts made me very uneasy. If there was something attractive to him about dead bodies, was he more dangerous that I had supposed?
Mr X had stopped taking his medications for 6 weeks by the time I saw him on the day he gave me chills. I asked if his necrophilic thoughts were any different without medications than with them. He quickly brushed aside a direct answer and instead shared more about his fantasies. He told me he thought his crime was almost a fulfillment of a fantasy—that he was bound to hurt or kill someone. After a long pause, in his usual charming, dramatic, and school-boy manner, he told me he’d been at a party. All of a sudden, as if in a trance, he intervened in a quarrel. He described slugging a stranger, knocking him out, dragging him away, putting him in the trunk of his car, and then dumping him in the lake. Mr X did not seem worried that he would do something like this again, but he was worried that he’d get into more trouble if he did.
I suggested that it might help me to understand him better if he shared more about his upbringing.
He reported that his parents divorced when he was 3. He was raised by his mother, who had intercourse in the presence of all her children. Occasionally she would beat him with a dog chain. He went to special education classes and had been in and out of psychiatric treatment since he was 6 years old. By the time he was 10, he was shooting birds and small animals and hiding them when they were killed. Later, for a while, self-cutting made him feel better because it reduced the unbearable tension he felt inside. Religion was of no help. Mr X was a loner.
I was reminded of the Old Testament story of Jacob wrestling with what might be angels. It felt like Mr X was wrestling with something devilish. I consulted my colleagues. I received some notes of caution. Could I end up in Mr X’s necrophilic fantasies and be at risk some day? What treatment could possibly succeed after years and years of failure? Would Mr X be willing to try a longer-acting medication, such as intramuscular antipsychotics, for a possible bipolar component? Or was I grasping at straws?
I wonder whether doing prison work is akin to opening a Pandora’s Box of concentrated evil. No wonder my predecessor decided just to ask the prisoners about their sleep habits—nothing else—and prescribe accordingly!
Some psychiatrists with whom I had spoken before I began my prison work recommended that I see patients first without looking at their criminal records (so as not to bias my clinical assessment). Ultimately, I decided to review any relevant criminal history before I saw a patient. I wanted to understand why that person was in prison (and the data about the prisoner’s criminal behavior is usually accurate). Most often, the evil-seeming behavior seems intertwined with whatever psychopathology may be present.
Therefore, pending more information, my answer to the test question is option F. My patient may be describing some antisocial traits, some evil, and perhaps more. If this answer is indeed correct, then (as psychiatrists), it may be worth looking into our souls to try to address any treatable psychopathology that may be aiding and abetting the evil.
“A Zen master, when asked where he would go after he died, replied, 'To hell, for that's where help is needed the most."
--- Rashi Philip Kapleau
1. Pies R. Psychiatry and the heart of darkness. Psychiatric Times. 2009;26:104.
2. Stone M. A Forensic Psychiatrist Illuminates the Darker Side of Humanity. American Psychiatric Publishing, Inc, 2008.