Aetiology of Forensic Psychopathology

Aetiology is “the study of the causes of disease.” (Reber and Reber, 2001)

The concept originates in a medical model that looks predominantly at biological factors, for example the genetic basis of bipolar disorder. This is broadened within the psychiatric model to include aspects of the environment, which would include psychological or social factors. There is a risk when employing the medical model of attributing the cause of a mood disorder to biology, rather than recognizing biological factors as contributing to an individual’s affective experience, alongside environmental factors. (Bartlett, 2010)

Spitzer and Wilson (1975) explored whether psychiatric disorders can justifiably be referred to as physiological dysfunction, and concluded that they cannot. Their reasons were: 1) that the aetiology of psychiatric disorders is never fully understood, and they are typically multi-factorial; 2) that features of psychiatric disorders are often part and parcel of normal experience, unlike, for example, ‘coughs’ or ‘heart pain’; 3) that there would need to be a demonstrable physical change in the individual – in fact that there are instances where this is the case, as well as more recent research into genetic pre-disposing factors in personality disorder (Tobena, 2000), and; 4) that physiological dysfunction should proceed independently of environmental influences, which is not the case.

It is important to note that Caspi et al (2014), and Patalay et al (2015) have recently elucidated a general factor for psychopathology (p-factor) in psychiatric disorders onto which all aetiological factors load. Higher p scores have been associated with greater life impairment, greater familiarity, poorer developmental histories and more compromised early brain function. The authors propose that the p-factor explains the challenges of identifying common aetiological factors associated with any specific psychiatric disorders.

In terms of the relationship between psychopathology and offending behavior, the psychodynamic perspective presents with another useful way of thinking:

“At times, the criminal act is the expression of more severe psychopathology; it is secretive, completely encapsulated and split from the rest of the patient’s personality, which acts as a defence against a psychotic illness (Hopper, 1991). On the other hand, it can be a calculated act associated with professional, careerist criminality. The forensic psychotherapist can help to clarify these difficult diagnostic issues. ” (Welldon, 2011: 174)

Welldon (2011) reminds us further on that patients with severe psychopathology have experienced profound instability and inconsistency at crucial junctures in their early lives in which both their psychological and physiological survival were in jeopardy. These experiences have effectively disrupted processes of individuation and separation through undermining the basic trust towards primary caregivers that most people are able to depend on.

This paper will examine the work carried out so far to identify the aetiologies of common forensic psychopathology that manifest specific offending behaviours, considering physiological and environmental factors, and including psychodynamic perspectives.

Violent crimes

Despite the media’s portrayal of mentally ill individuals as the common perpetrators of violent crimes, most individuals with mental illness are not violent, although there is a small but significant association. (Yakeley, 2010)

It is worth bearing in mind Estela Welldon’s (2015) observations, that the common public response to violence is rarely scrutinised as it appears on the surface to be logical and pragmatic. Projection and splitting are usually at play, and as a result perpetrators are labelled ‘bad’, with those looking on defending their ‘goodness’ in contrast, which is an example of Melanie Klein’s (1946) ‘projective identification’. As this approach to understanding the dynamics of violence is often viewed as condoning the criminal act, psychodynamic approaches can be vilified, and as a result the forensic psychotherapist has the invidious task both of trying to help their patient, whilst working through some of the painful problems that wider society contends with.

If we turn to research studies, this is what we find.

Violence in individuals with mental disorder has been correlated with a range of maladjusted behavior during early childhood, which in turn are associated with aetiological factors. (Burke, 2010)

Such maladjusted behaviours include attention and concentration problems, recurrent failure in academic settings, and truancy and expulsion from school (Harris, et al 1993), anti-social behavior at an early age (such as chronic alcohol/substance abuse, and aggressiveness) (Farrington, 2001), impulsive, reckless behavior during adolescence, problems with peer group relationships, and hostility towards authority (Melton et al, 1997).

The aetiological factors associated with these maladaptive behaviors are sexual and physical abuse and neglect (Ferguson and Lynskey, 1997; Weiler and Widom, 1996; Widom, 1989), separation from parents at an early age (under 16 years), parental rejection, low parental involvement, cruel and inconsistent parenting (Muetzell, 1995), parental alcoholism (Moffitt, 1987; Rydelius, 1994; Virkkunen et al 1996) and violence within the family (Blomhoff et al, 1990; Fitch and Papantonio 1983; Johnston 1988; Ryan, 1989).

Burke (2010) stresses that whilst these factors may not directly cause violent behavior, they may “structure potential violence” (41) and they may shape triggers to future violence. Glasser (1996) noted that an individual diagnosed with schizophrenia does not commit a homicidal act as a result of psychological malfunctioning. As Doctor (2008: 2) avers “even the most apparently insane violence has a meaning in the mind of the person who commits it. There is a need to be aware of this meaning and to learn from it in an attempt to prevent further violence.”

If we are thinking less about the root causes, and more about the moment to moment dynamics that precede violent crimes, it is helpful to remember James Gilligan’s assertion that acts of violence, and this is especially true of those acts that appear irrational, are most often preceded by subjective feelings of humiliation. (Gilligan, 1996)

For more detail on the psychodynamics underpinning violent crimes, we have learnt from De Zulueta (2006) what some consider to be a nearly ineluctable process that takes place in between mental and physical pain and its development into physical violence. Where De Zulueta makes reference to individual situations, Meloy and Yakeley (2014) apply a similar approach to the context of group and social violence, including acts of genocide and terrorism.

Violence towards women

As with any other offending behavior explored here, there is a biological theory underpinning domestic violence against women, which points to men’s average greater size and physical strength. Dobash and Dobash (1992), and Koss et al (1994), note that this implies such incidents have different meanings and physical consequences for the victims. There are also powerful discourses that make aggression, and therefore violence, as naturally masculine behavior, as well a biological sub-plot, which connects levels of testosterone and aggression. (Hearn, 1998)

From a psychological perspective, a commonly attributed cause is problematic personality types, or personality disorders (Dobash et al 2000; Hearn, 1998; Koss et al, 1994), though this has been criticized as withdrawing the agency from such men, which also makes the possibly of them engaging in transformative change of themselves difficult. (Dobash et al, 2000)

Sexual offending

The prevalence of mental ill health amongst sexual offenders is low (10% or less) (Sahota and Chesterman, 1998b), although in the region of 30%-50% for personality disorders. (Ahlmeyer at al, 2003; Madsen et al, 2006) However, there is no causal relationship between mental ill health and sexual offending. Any relationship is complex, and needs to take into account aetiological and risk factors.

It is important to bear in mind that whilst the following characteristics have been observed in men who’ve committed sexual offences, they will not be present in all individuals who offend. (Houston, 2010)

As discussed above, early attempts to understand sexual offending began with a focus on biology, such as Goodman’s (1987) theory, which concentrated on hormonal and genetic factors. Elaborating on Marshall’s (1989) observations of an interaction between deficits in the capacity to have intimate relationships, and sexual offending, Marshall and Barbaree (1990) proposed a multifactor ‘integrated’ theory. The theory included genetic factors alongside the influence of the criticial adolescent developmental task in males of distinguishing between aggressive and sexual impulses, as they emanate from the same brain structures. They recognized that hormonal factors will render this task more challenging, especially in the context of unfavorable early development.

Hudson and Ward (1997) hypothesized that men who have sexually offended against children tend to have anxious, pre-occupied and fearful styles of attachment. Attachment theory is the psychological model of the dynamics of human relationships, learnt in early childhood, and articulated especially in times of stress. (Bowlby, 1971) Smallbone (2006) later developed an ‘attachment-theoretical revision’ of the ‘integrated’ theory.

The significance of negative early childhood experiences and their contribution to the development of maladaptive patterns of attachment in later sexual offending has been increasingly examined in the last two decades. Craissati et al (2002) found that the family history of sexual offenders involved high levels of disruption, neglect and violence, and Prentky et al (1989) found a relationship between inconsistency in caregivers, and familial sexual deviation and abuse, with severity of sexual aggression within a cohort of sentenced rapists.

Higher levels of physical abuse have been identified in the family lives of rapists than other sexual offenders (Marshall et al, 1991) or non-sexual offenders (Leonard, 1993). High rates (40%) have been found amongst convicted child abusers (Craisatti and McClurg, 1996).

A history of sexual abuse has consistently been found to be more common in sexual offenders than in either non-sexual offenders or non-offenders. In men who have sexually offended against children, the rates of victimization have been found to be between 46% and 51% (Craissati et al, 2002; Craisatti and McClurg, 1996; Houston and Scoales 2008).

Studies have also examined underlying beliefs and cognitive schema of sexual offenders, for example, the work on cognitive distortions by Abel et al (1989), and implicit theories that underpin these cognitive distortions amongst men who offend against children (Ward and Keenan, 1999), and amongst convicted rapists. (Polaschek and Ward, 2002)

There are various theories that bring these things together, such as Finkelhor’s (1984) model of sexual offending against children, Wolf’s (1985) model of the influence of early childhood adversity leading to sexually deviant interests, and Ward & Siegert’s (2002) aetiological theory of sexual offenders against children, and the heterogeneity amongst them. In addition, models of sexual aggression towards women have been constructed by Hall and Hirschmann (1991), which has been critically evaluated by Ward et al (2006), and Malamuth et al (1993).