More on the Here & Now

APART FROM A MORE RECENT CONTRACT with a local mental health service, the last post I held as a psychologist in the NHS was at a nationally-acclaimed medium-secure unit. This is a psychiatric hospital where patients are compulsorily detained under the Mental Health Act because they present a serious danger to others and possibly themselves. The
patients were all men (initially there were a few women) mainly in their 20s and 30s. Most had a history of violent offending and polysubstance abuse or dependence. The most common diagnosis was paranoid schizophrenia, often related to their use of drugs.
What had gone wrong in these people’s lives to bring them to this place? There were common themes in their personal histories – unstable family lives, absent fathers (often with criminal records), impoverished neighbourhoods, years spent in care, failure at secondary school, association with similar peers, early alcohol and cannabis use, and so on. In fact this is a story common to many prison inmates. So the answer to my question seems to be that the problem lies in their early upbringing (‘nurture’). If however you are, say, a geneticist or a neuroscientist, you may be keen for your specialism to explain where the problems lie (‘nature’) and what the
solutions might be. Perhaps the genes that predispose people to criminal activity also make them low achievers,
irresponsible parents, poor breadwinners, etc., and they pass on all of these attributes to their offspring.
I must declare that I am more favourably disposed to environmental accounts of criminality, partly as a result of my professional experience and the research evidence, partly for irrational reasons – I find those who espouse genetic theories tend to be unpleasant, mainly male, ‘we’re cleverer than you’ academics, whose pronouncements seem to be far removed from the realities faced by those directly involved, one way or another, with offenders (calm down – Ed.).
However, what are often neglected in discourses on the causal factors behind much of human behaviour are the powerful influences of the immediate social environment in which people find themselves. Amongst these influences are the expectations implicitly and explicitly fostered by that environment concerning one’s behaviour, attitudes, beliefs and values.
In the case of the secure hospital the majority of newly
arrived patients would have been well socialised into the
toxic environment of prison life: trusting no one, forever ‘watching your back’, betraying no weaknesses, always getting your own back, never ‘grassing’, and so on. Their mental state on admission could be quite severe; some would be in an acute psychotic state and be confined to their room, occasionally under constant observation from one or more nurses. Over the ensuing weeks these patients would improve remarkably, owing to their medication, lack of access to drugs and alcohol, and increasing familiarisation with their new environment. But over the longer term another transformation would take place. Adherence to the prison ethos would fade into the background as the patients gradually adopted in significant, though admittedly not complete, measure the values and conduct promoted by their new community. These included mutual respect and consideration at all times;
deprecation of any form of physical or verbal abuse such as racist or sexist remarks, even in response to the same; the reporting of any intimidation or bullying by others; and strict adherence to house rules such as restrictions on what patients could have in their rooms or could exchange with each other. These expectations applied equally for staff and patients and were enforced with zero tolerance, with serious consequences for any transgressions. Importantly, unlike a prison, the construction of the unit and the visiting arrangements made the importing of drugs very difficult. (Remarkably, in time the unit successfully adopted a blanket no-smoking policy.) To witness at first hand the changes that came about in the personalities of these people was indeed heart-warming.
Unfortunately, the environment to which the patients would return in time (usually with an intermediate step such as a low secure unit or open psychiatric ward) would mostly likely not be one that fostered the same attitudes and
behaviour that prevailed on the unit. Though post-discharge re-offending is lower for medium secure units than for prisons, especially for the first two years, all too often the discharged patients would struggle to maintain their improvement. For many their mental state would deteriorate and they would resume taking drugs and/ or drinking to excess. Saddest of all would be the occasional news of the death of a discharged patient, usually through inadvertent drug overdose or suicide. Still, I am certain that the unit had, and continues to have, many lasting achievements to its credit.
Many examples of the significant influence of the
here-and-now environment are encountered in clinical practice. Speech and language therapists will tell you that the methods they teach their clients can work wonders in the session but this is not replicated in their clients’ everyday lives. ‘I feel a lot better when I am here, but it doesn’t last long when I get out there’ depressed patients may tell their therapist. Nocturnally incontinent children may have dry beds during a spell in hospital. The rituals of the obsessive-compulsive patients may cease on admission to the psychiatric ward (but may reappear when the ward starts to feel like ‘home’). More striking than these examples is the report that only 5% of heroin-addicted US soldiers retained their addiction once they returned home from Vietnam in the 1970s (compared with what then was the usual post-discharge relapse rate of 90% for addicts treated in clinics)1.
There is now growing concern in the UK about the mental health of children. Psychiatrists and psychologists are busy investigating what is wrong with the children – inventing tests, studying their brain scans and their genetic makeup,
creating disease labels, and devising treatments – and no doubt personally benefiting from this industry. To ask what is wrong with the environment in which the children are growing up and what can be done about that implies political solutions that those who have power seem reluctant to consider.