Lydia Kellett
Dr Mark Freestone is a senior lecturer in the Centre of Psychology, Queen Mary University of London. He originally trained as sociologist and has worked in prisons and forensic mental health for over 15 years as a researcher and a clinician, including in category A prisons that house some of the UKs most notorious and high-risk criminals. He has also worked at high-security special hospitals as part of the Dangerous and Severe Personality Disorder Programme, which piloted new interventions for men and women in the UK with a diagnosis of psychopathy or severe personality disorder. He was a consultant to series one and two of BBC America’s Killing You and is an editor of the Journal for Forensic Psychiatry and Psychology and currently an advisor to NHS England in services for Men and Women with a diagnosis of severe personality disorder. He has published several academic articles on personality disorder, psychopathy and violence risk. And as if that wasn’t enough, Mark is publishing his first book called ‘Making a Psychopath’, which is a funny, devastating, at time quite graphic, articulate but very readable account of seven of the most dangerous minds that Mark has encountered over the last 15 years of his work in prisons. One key aim of his book he says, “is to help humanise psychopaths” and help the reader understand why it is so difficult for these men and women to form the kinds of social and emotional relationships we all take for granted. So, Mark, welcome, thank you so much for coming. We’re delighted to have you. First of all, please can you help us understand what is the clinical diagnosis of a psychopath? What are some of the clinically recognised psychopathic traits and tendencies and how are these measured?
Dr Mark Freestone
I mean essentially a Psychopath is someone who lacks the ability to reason emotionally in the same way that most of us do or most of us would take for granted. In terms that are pretty, I suppose trendy in psychology and psychotherapy at the moment , a psychopath lacks the ability to mentalise. That means that they can’t recognise emotions in themselves or in other people and can’t understand where those emotions come from. Now, that applies in two ways. Literally, if you present a psychopath with a picture of somebody else expressing an emotion, it could be fear, sadness then they can’t recognise that there’s an emotion being expressed at all and certainly can’t put a name to it until the expression becomes almost comically distorted. So, anger would have to be sort of full-blown facial morph and they are unable to think of the consequences of what would happen if somebody was expressing an emotion. So, a corollary of that because it’s the same area of the brain that things about emotional reasoning and moral reasoning and risk and reward, they’re not very good at making decisions about what is beneficial for them and why? Psychopathy is forever attached to something called, we call colloquially a psychopath test. So, this is the psychopathy checklist revised, created by Dr Robert Hare in 1993 now, hasn’t changed much since then, perhaps it should do and it is a checklist that is administered by clinicians, so, that’s usually psychologists or psychiatrists but technically anyone who’s been trained to do it can do it. So, John Robertson very famously, the British comic writer, undertook the training and went ahead and started diagnosing people in his family and in the street with varying degrees of psychopathy. That… it’s a checklist, as I said, of 20 questions but you’ve got to have 30 points and each of those items that I put up is worth potentially one… you can have a score of one or two. So, you need about 15 traits. In the community, most people have none or one. So, you get one point. So, if you have 30 points in total, you would be classed as a clinical psychopath, which means you’d have the full, a full psychopathic disorder.
Lydia Kellett
Can you talk us through the anatomy of the brain of a psychopath? Is it different from the brain in a non-psychopath and if it is, how is it different?
Dr Mark Freestone
I suppose the key, there’s two key areas of the brain that are different in a psychopath as far as we know. There may be others but this is where research has been focused. The first area is the amygdala. And we think that the amygdala is responsible for emotional processing right and it has complex links to the pre-frontal and orbital frontal cortex. In a psychopath, emotional processing is poor because their amygdala is a) smaller, it just has smaller volume, b) it shows less activation and thirdly, we think there’s actually structural differences in the amygdala so it doesn’t quite have the same properties. It is very difficult to test out these areas of the brain. But when you use contrast tomography or PET scans on a psychopath’s brain, the actual patterns of activation in the amygdala are different as well. The amygdala is linked to other areas of the brain, the pre-frontal and orbital frontal cortex which is the area at the front of the brain here. So it’s not just the individual parts of the brain, it’s also the link between them that’s really important. And of course, we know that the orbital frontal and pre-frontal cortex are involved in moral reasoning and decision making as well.
Lydia Kellett
And so the anatomy of the brain, as you show in these slide, is it that somebody is born with these defects or can you develop these defects? Can you develop the changes in the anatomy of the brain through various circumstances?
Dr Mark Freestone
So, if you have a child who has experienced very high degrees of neglect, they will show reduced white matter and reduced grey matter, right down to the limbic system as well. So, if somebody’s experienced high degrees of neglect, they will probably have reduced volume and activation in their amygdala and even some of the parts of the limbic system that control movement. So, there’s a study by Bruce Perry, who’s a psychiatrist in the United States, that shows that you know, kids at the ages of 14, 15 who’ve been very heavily abused can actually have reduced motor skills because their development has been so retarded by the experiences that they’ve had. But he also shows that with exposure to a sort of good enough, caring environment and fresh air and conversation, it’s surprising how plastic you know, a young man or woman’s brain is in terms of getting those things back. So, we know that while the environment can cause those same structural problems, in most people they can recover if they are caught earlier enough. The problem we have with psychopathy in particular, is that there’s some evidence that some lack of structure in the amygdala can actually be genetically inherited. We call this something called, it’s called callous unemotional traits. So, even children who are quite young, sort of 9, 10, 11, 12 you can genetically inherit these callous unemotional traits and they are very, very linked to the central point development of psychopathy. But of course, only about 40% of kids with those traits will develop anything like clinical psychopathy. So, it’s not clearly a case of, you have these genes and you’re a psychopath. It’s much more nuanced than that.
Lydia Kellett
And is it possible to reverse the damage done to a drain that’s a consequence of trauma or some kind of experience?
Dr Mark Freestone
That’s a good question. A first response might be, ‘Well is it necessarily damage?’ because a psychopath’s brain changes we think partly as a result of genetic inherited genetic traits sure but also as a result of the environment around them. Now it could be a very adaptive response. For example, if somebody’s very heavily abused or neglected, to be very, very sensitive and very easily sort of traumatised is, is going to make it much, much, much harder for that person to live a normal life and there is a lot of psychodynamic theory that suggests well, psychopathy is a defence against these kind of awful situations which would then lead us into the question of, ‘Well, okay if it’s a defence can you change it? Can you recover from it?’ Just throwing people into CBT and just hoping for the best isn’t going to work ever, ever and I think that’s largely what’s been done before. If we think about what exactly affects psychopaths, what’s wrong with them, it’s something to do with the way that they process emotions that we think is linked to their environment growing up. So, something like mentalisation-based therapy where we try and reintroduce those mentalisation ideas, try and almost push people to recognise emotions in themselves and even talk about them, even when it’s difficult and they’re uncomfortable. If it’s more targeted at the exact deficit, behavioural, cognitive deficits that psychopaths have I think that’s much more promising and I think it’s probably more hopeful than we’ve been for a long time.
Lydia Kellett
So, I have two questions on this. The first is the Netherlands-based system. You speak in your book about your trip over in 2005 and they’ve taken quite a different view to the ones we have in the UK. It’s much more community-based in nature, it’s therapeutic. And actually the in-patients have jobs, they run the cafes they run the restaurants etcetera. How helpful do you feel that that is in terms of an environment for rehabilitation? And secondly, do you feel that that could be translated to our population of psychopaths?
Dr Mark Freestone
So, the big difference between us and the Netherlands is that the Netherlands don’t have this obsession with treatment, right. So, for them, they use the term Risk Management. Once you make that distinction, you know that you’re not trying to treat, you’re trying to manage somebody throughout their, the rest of their lifespan, so that they don’t re-offend. Now, it’s efficient to manage people out of hospital, right? So, the Van der Herten Clinic, the intention is to provide care that’s efficient and that means involving people in their own care which is a fantastic idea, get them to take some ownership for it, some responsibility and it doesn’t infantilise in the way that parts of the British system do. Not only that but you can be economically active. If you’re a psychopath you’re oriented in time and place, you don’t have psychotic breaks, you might have a very low temper threshold or you might be you know, inherently given to manipulating the system, sure. But if your system is well enough set up that should be something that people can deal with. So you can provide people with employment. You can provide them with a full pathway, right the way from the point of sentencing to the point of absolute discharge. And if there’s you know, hiccups along the way you can go back up the system. You can go back down the system and I think the key point in relation to the Netherlands that we don’t have in the UK is that all of that is managed by a single point of contact. It’s usually the clinic. And we don’t have that joined-up thinking in the UK, it’s just a system of referrals you know, so, if I have a problem with my chest pains and I get referred to a specialist and he may refer me to someone else. I’m going to get referred to Outpatients. And that doesn’t work terribly well for physical illnesses but it’s dreadful for a psychopath who’s experienced this kind of chaotic engagement throughout their entire life. So, that cross talk isn’t there yet at the point where we could say, ‘This is a system we could deliver in the UK’ but I think it’s the only answer and I just wish we’d started on this process 10, 15 years ago.
Lydia Kellett
From your perspective, what was it like working with psychopaths day in day out? What was the effect on your mental health, if at all, of your work?
Dr Mark Freestone
I think it’s a question of who gets under your skin. You talk to 10 clinicians, they’ll all have one patient that particularly you know, gets under their skin and kind of nibbles away at them. And it’s really difficult to work out why and the suspicion is that perhaps it’s more about you than it is about them and that’s difficult to accept. I tend to get particularly upset by patients who I start to feel sorry for. I think for other people it varies, so, it could be you know, some people who find very, very psychopathic, very primary psychopathic people very aggressive and dominant., very difficult. Other people find sex offenders very difficult and other people find anyone with offences against children very difficult to work with. So, what it is that’s sort of triggering that difficulty varies a lot.
Lydia Kellett
Yeah, absolutely. The other thing you say about working with psychopaths a lot of those who suffer with severe personality disorder, have this kind of hunger for identity. And clinicians often feel like they have to try and find out what that is so that that person can then look at themselves in the mirror, recognise themselves and then job done, move on. But often it’s not easy like that. A lot of the time you feel like failures. You haven’t helped the patient and everybody is no better off. That must be a very difficult experience from your perspective?
Dr Mark Freestone
Yeah. I mean, the way you expressed that is really interesting. Because actually with forensic mental health, what we’re trying to do is make sure they don’t come and offend again. But you get drawn into this you know, some of the men who would also be diagnosed with a borderline personality disorder as well as psychopathy. So, one of the examples in the book is a patient was discovered to have very serious kidney disorder, to the point where their kidney was going to fail within a couple of years. You know, everyone was like, ‘You need to have a transplant. We can arrange this. We’re a hospital. We have good links to the university hospital where the surgery could be done’. Everything’s arranged and two weeks before almost, I think it was slightly less than that, the patient decides he doesn’t want the kidney transplant. Now, this is such a massive middle finger to us as the hospital but also to his own life because he is going to be on dialysis for the rest of his life and he may well die at some point and all of this felt like it was just being done to sort of spite the system. Rather than with any thought to you know, this man’s quality of life or wellbeing or even ability to live beyond the very, very short-term. So, that level of identity dysfunction like, ‘Who am I? What do I want from my life? How can I be happy?’ for some of these men is so compromised that even the decision to continue with your life is really, really distorted and it makes you sort of like there’s no grand truth in this work. There isn’t a sort of position in which you can say, ‘This is the right thing to do’.
Lydia Kellett
Yeah absolutely and I guess this kind of goes back to a bigger umbrella point which is the kind of the definition of a psychopath lumps a shed load of characters, personalities, traits into a fairly clunky, probably out of date test. The book, I think, is really amazing. It just, it’s dispelling the myth that actually psychopaths are Machiavellian, globe-trotting, glamourous assassins and actually there’s a real human, there’s a real human sadness behind them.
Dr Mark Freestone
I’m really glad you took that way. There is a Machiavellian globe-trotter in there, just for your, for everyone’s delectation. I was sort of prompted to do this work after consulting on Killing Eve. I mean the challenge with a villain is to try and say, ‘Well, this isn’t just a person who’s defined by being a psychopath. They also have this sort of archaeology of life experiences and trauma and ideas and frustrations and desires’ and that’s the thing that we mustn’t forget, is that a psychopath is not completely defined by being a psychopath. It’s almost like a deficit that they may have sure and they can’t do things that other people have and in some cases because their psychopathy is so developed they can do things that we can’t, like commit horrible crimes with apparently no guilt or remorse. But no psychopath is defined entirely by their psychopathy. That’s a bit of a sort of cliché I guess that we need to challenge.
Lydia Kellett
Absolutely. So, that leaves me to say thank you so much Mark. We’ve really enjoyed having you and thank you very much for all your amazing insight.
Dr Mark Freestone
It’s been a pleasure. Thank you so much for having me.
Lydia Kellett
Thank you.
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