Reasons Count

As a fourth-year psychiatry resident many years ago, I encountered a patient on the psychiatric emergency service whom I have never forgotten, because my experience with him jelled a distinction about the importance of explaining violence. Brought in involuntarily by the police for being “dangerous,” he was a fearsome visage: six feet four, shaven head, angular jaw, the triangular build of an athlete, a history of paranoid schizophrenia and violence. I’ll call him Mr. Big. His court order papers explained that he had threatened to kill his brother-in-law.

Mr. Big’s story, in brief, was that he was a veteran on disability, and that he had purchased, some years ago, a small home using his wits and savings from his pension. Although he admitted that he could be, and had been, violent off his medications, he explained that he had been taking his medicines reliably for two years and had never had any trouble over that period—until now. His brother-in-law, according to Mr. Big, had moved in and appropriated his home while the patient was away on a trip to see a friend, and now refused to leave, to the chagrin of both the patient and his sister. Mr. Big had threatened to kill the brother-in-law in indignation with the in-law’s behavior. The brother-in-law never called or appeared. The sister, it turns out, corroborated the story, and after an examination revealed only minimal idiosyncrasies of thought and affect, the patient was referred for legal counseling, released, and the family was warned. We all hoped that justice could be found peacefully.

Wilson and Adshead emphasize in their thoughtful discussion of violence and psychiatric symptoms that the explanation for the violent act is crucial to assessing its pertinence to mental disorder. What was elegant in Mr. Big’s case was that the motivation for threats of violence was proximate, morally comprehensible, corroborated by at least one other, insightful, and most of all, clear-cut. Although these features for distinguishing violence due to normative motivation versus violence due to mental disorder are addressed by Wilson and Adshead, they would agree that, unfortunately, these tools of proximity, comprehensibility, ordinariness of motivation, insight, and corroboration are often absent, unobtainable, or inadequate.

But these considerations are helpful in ruling out violence as symptom, which is the lesson Mr. Big taught me—reasons count. Wilson and Adshead go on to critically consider the features that may be positive identifications for violence as symptom. With “deplorability,” they identify a feature of the violence that exceeds what I have termed “normative motivation,” which defies our empathic ability to understand the perpetrator’s point of view. However, deplorable events are perpetrated by soldiers and police in their socially approved work, so even deplorability has limits in its utility. Indeed, social psychologists’ research has shown, as Susan Fiske and colleagues put it, “Virtually anyone can be aggressive if sufficiently provoked, stressed, disgruntled, or hot” (Fiske et al. 2004, 1482). Also, like “normative” motivation, deplorability is culture—and politically—relative, another limit to its utility.

Even with complex causality, the INUS approach of Mackie’s offers a way to link symptoms to a more complex causal network while admitting that the social components of the causal network may exhibit particular moral and pragmatic interests. For medicine, the INUS approach is sensible and coherent with biomedicine’s intellectual culture of multifactorial causation of disease. However, criminal culpability in law is usually a dichotomous decision; any taint of choice links the offender to the whole culpability package (Sadler 2002).

The conclusion one is left with is that no failsafe tools permit us to distinguish violence provoked by mental disorder versus normatively motivated violence. I tend to agree that, for some cases, we will never be able to broker the distinction between disordered violence versus nondisordered violence. My pessimism is based on the technical limitations of parsing mental life retrospectively in a way that will always allow for the kind of clear-cut distinction described in the case of Mr. Big (Sadler 2002). That is, how, after the...