Wednesday 27 February 2008


An argument made by a patient's mother to me (who couldn't grasp what her son said his schizophrenia was about) went like this :

If I was to stand next to you at a bus stop, point out some random person across the street who was wearing red and say, "They have to die. They have to die!" you'd be wary. If I then said, "Go and stab them! Go on, now, quickly, go and stab them!" you'd probably pull out your mobile 'phone and call the police who'd want a chat about why I was making threats to kill, which they take seriously.

Presumably you'd also ignore me, rather than stabbing up some poor soul simply because I told you to.

The mother's point was that this is what her son experiences; he has auditory hallucinations both giving comment and imperative commands. Crucially, he doesn't have delusional beliefs or delusional perception (and in fact I'm unsure how robust the diagnosis of schizophrenia is since he just hears voices). She just couldn't see why it was any different hearing them as voices compared to hearing her say something he'd normally find ridiculous and discount. She felt he should be able to treat the voices just the same way he'd treat some random meaningless stranger, "who's chirping away with rubbish!"

I don't wholly agree with her, but she got me thinking. Without delusions or cognitive distortions, as a capacitated adult (passing the MCA 2005 test), is he totally responsible for all he does? She believes he is. Courts consistently have not.


Disillusioned said...

Very interesting - and scary....

Is a diabetic, in the state of hypomania, fully responsible for his / her actions (since, without the hypomania, he/she would presumably be able to recognise that abusive behaviour is wrong)?

Maybe it comes down to whether you "believe" that mental illness is a "real" illness or not?

Having said that I am not familiar with what features provide a distinction between what might crudely be stated as "mad" or "bad".

Jan said...

So where, exactly, does Pt X believe these voices come from? It's a very interesting scenario, but my own feeling is that the question above is pivotal. If they are the voice of some omnipotent being, who in the pt's belief system must be obeyed, or if they're from the local scrote who eggs all and sundry on to commit felonies then the question of responsibility may be a bit clearer. Part of the equation is missing.

The Shrink said...

Jan, he did recognise that they came from within himself, somehow. He had no delusions or paranoia or grandiosity at all.

Shrink Wrapped said...

Personally, I would take a cognitive approach to this - its not what happens to you but how you interpret it that matters.

I really like Romme and Escher's work and an understanding of what voices me and how people understand and construct their experience of voice hearing. It has a lot of implications for how we work voice hearing in mental health services

Like your patient's mum says - if her son doesn't do what the voices tell him, does it matter? Is he dangerous? What implication does his or other people's interpretation of his voices have for his mental health and well-being? Is it a neuro-cognitive oddity or a sign that the man is dangerous or mad? How the voices are interpreted will probably determine how much distress (or indeed, enjoyment) the person feels about them.

Anonymous said...

"ooohh I love these questions" said Ian bouncing up and down with his hand in the air waiting for teacher to hear the voices in his head saying "pick me sir, pick me!!"

I recall a similar debate on Mr Man's Wife's page few weeks back. We debated the issues of why some people with 'madness' are violent and some are not. Essentially, my self-extrapolated theory (possibly shared with Mr Kellogs too as we pondered the question together over a bowl of his finest crunchy flakes of corn wondering what to call them...) .. moral reasoning is a key issue. We all have one and ours are all different within the same continuums but they form the intrinsic protective factor against doing all sorts of amoral/immoral acts, depending on how we were dragged up.
Hearing voices telling you to do something is perhaps, at the least, like peer pressure egging you on. Not being able to escape it can be a little aggravating but as long as his moral reasoning remains generally intact, then he's not going to harm anyone, right?
Thing is, mum could be right - if he can rationalise his "voices" to be what they are, then does he have cause to hurt anyone? Presumably he understands right from wrong - and even if the voices tell him stuff - does he have to believe it or act on it? Having a mental illness does not make you non compus mentis if you are aware of that illness - losing insight or rationality does.
If he loses the 'rationality' which would mean giving credence to the voices - and ergo became 'deluded' - then he increases his likelihood of acting compliantly with them, even against his original intrinsic protective factor - as the voices counter his own moral reasoning.
However, even if he retains full insight into the voices, there still remains an issue:
Baumeister did some work on ego-depletion and how our will-power is a measurable energy that depletes as we use it and replenishes when we rest or gain positive "ego boosts"/rewards.
Hearing voices or suffering peer pressure all day and night and in such intense or violent manner - even for someone who isn't really a nasty piece of work (ie has a moderate sense of morals) - without rest and without positive ego boosts -may sooner or later the suffer too far an ego depletion and the will/energy to resist is gone.
Consider how it is after a hard working week yet that one person has been an arse all week with you. You've forced yourself to be socially polite all week til eventually - back - camel - straw - you just let rip into them - that's ego depletion.
So although the 'voices' may be integral to the ego depletion - loss of will power in itself is a normal neurophysiological event. I would suggest then that the absence of delusional beliefs, and the presence of full insight - he might get away with "extreme provocation"?

Jan said...

But wouldn't "extreme provocation" need, by definition, to have been instigated by a third party? In this case there is no external influence, or even the delusion of external influence.

Anonymous said...

No idea Jan, it would depend on how the courts view internalised provocation - I consider 'pain' (not externally caused) to be a mitigator in certain cases tho doubt it would extend to a defence for manslaughter.
Perhaps 'under duress' is the term - but with insight as to the aeitology of the provocation, 'mens rea' (the knowing what you did was wrong) would not be negated and I believe any offence caused would be a criminal matter not MH.

Jan said...

I think that's where I'd end up too.