by Kerry Daynes
Throughout the test Travis scratched his head and pursed his lips while drawing in breath sharply, like a contestant on a game show whose answer might win him a million pounds. He assured me that he wanted to do his level best, while also doing all he could to let me know this was an ordeal for him. At the end he had a score of 57; given that the average score of your man-in-the-street is 100, this put him in the extremely low range and flagged up the possibility of a marked learning disability. But a low IQ score can be an indicator of many things.
The way that the Wechsler test is organized means it becomes progressively more demanding until a person’s ability to answer correctly reaches a threshold. Typically, right answers tail or drop off abruptly as the tasks get harder. But Travis’s answers were patchy and inconsistent. He got some of the easy questions wrong but – just when I thought we could move on to the next section of the test – he got the really tough ones right. It wasn’t so much the final score, but the pattern in how he’d reached that score that made me wonder whether he might be malingering.
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‘Malingering’ – the deliberate faking of physical or, in this case, psychiatric problems – is generally something you’re more likely to come across in a personal injury compensation claim than in a forensic hospital. But malingering does have a special kind of allure to some of my more slippery customers, specifically those accused of serious crimes.
In English law, ‘insanity’ is a defence to any and all criminal charges. The defence can come in two forms: where the defendant claims he was insane at the time of the crime, or where the defendant asserts he is insane at the time of trial. The legal definitions and understandings of what ‘insanity’ might look like have morphed and mutated over centuries, in line with our understanding of the mind and human experience. In the 18th century, a person had to demonstrate the qualities of a ‘wild beast or infant’ to be considered insane. Since the late 19th century, courts have been concerned with ‘diseases of the mind’ and how these might impact a person’s capacity to appreciate the effects of their actions.
There have been some notorious and well-publicized cases of malingering. American serial killers such as Ted Bundy and Kenneth Bianchi claiming murderous alter egos have penetrated the public psyche, and this may go some way to explaining why the public at large and juries in particular tend to take a cynical view of those claiming insanity as a defence – and perhaps is why it is used so rarely with any success in courts. In the UK, Soham murderer Ian Huntley is perhaps the most high-profile example of a malingerer. In the immediate days following the disappearance of the two girls he would eventually be charged with killing, Huntley gave lucid interviews to the press and actively participated in the neighbourhood’s attempts to locate the girls. But when he was finally arrested and confronted with key evidence, he began staring into space, dribbling and being unresponsive. Police referred him to the high-secure Rampton Hospital for an urgent assessment of his mental state. Dr Christopher Clark, the consultant forensic psychiatrist who led the team, later said in court: ‘Although Mr Huntley made clear attempts to appear insane, I have no doubt that the man currently, and at the time of the murders, was both physically and mentally sound and therefore, if he is found guilty, carried out the murders totally aware of his actions.’
Why does an offender malinger? Much of the appeal, especially to someone who has committed a crime of the magnitude of Huntley’s, lies in the obvious fact that they don’t have to find answers to some ignominious questions. Being considered legally insane, on the surface, may also offer an attractive option for someone seeking to evade the rigours of the law and a custodial sentence.
Except it’s not that attractive because, ever since Parliament passed the Trial of Lunatics Act 1883, being deemed mad, as opposed to bad, tends to lead to a lengthy detention and treatment in a secure psychiatric institution. In the days of the asylum, that ‘treatment’ was likely to include beatings, being plunged into cold baths, straitjackets and even lobotomy. Today, there is a common perception that a modern-day secure hospital is the lesser of two evils, maybe even the soft option. It’s undeniable that overt torture is now frowned upon and hospitals offer a more pleasant environment than prison, with an en-suite bedroom and less of the violence that exists in prisons. But they are still detention, and by no means a Club Med experience.
There’s also often an assumption that admission to a secure hospital will be shorter than a prison sentence, but the truth is that people can end up staying far beyond what might have been the end of their prison term, because leaving depends on a person persuading a psychiatrist and/or Mental Health Tribunal that they have made a recovery – a nebulous concept at the best of times. A defendant deemed ‘insane’ can also be made subject to a hospital order with restrictions, under Sections 37 and 41 of the Mental Health Act, meaning they may be detained indefinitely, potentially forever, unless the Secretary of State for Justice decides that they can leave. Malingerers, be careful what you wish for.
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So here was Travis with his unusual IQ test results, his coin-in-the-hand red flags and his silky backgammon skills. The other factor that piqued my interest was how he behaved in front of the consultant psychiatrist, Dr Webb, a man who at this hospital occupied the status of demigod, with a well-groomed mullet and a penchant for power dressing. It didn’t seem to take Travis long to work out that the real authority didn’t lie with me. As soon as he was around Dr Webb his mental state seemed to undergo a miraculous transformation and he became a textbook madman.
This was most pronounced in our weekly ward round meetings. As in any psychiatric hospital, the senior staff team in a secure unit come together for their ward rounds. These have nothing to do with physically walking around a ward in the way a doctor might in a hospital; they are resolutely static group meetings, which take place in an office, around a big table. They’re usually led by the consultant psychiatrist, with an occupational therapist, a social worker, senior nurses and, at that time on the ward, me, the trainee psychologist.
In ward rounds each patient is discussed; their behaviour, mood, relationships with others and pretty much everything else analysed by the team. Medication and therapy are considered, as is any supervised leave they might get from the ward and, if it’s on the cards, plans for their discharge. This overall package is called the Care Programme Approach. Patients are often invited to join meetings at the end, so they can discuss their care plans and ask permission for changes like home visits, leave or adjustments in medication.
Walking into a room full of people who you know have just been talking about you is a daunting prospect for anyone, so I always felt for them coming in. Most of us take for granted that we are the experts on our own lives and dispositions. But in this instance the patients have to defer to a team of professionals debating the inner workings of their mind and determining what is right for them. The patients often tried really hard in these meetings to mask the difficulties they were having. For many it was their only chance to see Dr Webb, who they knew wore the most important trousers and, as the only trained medical doctor in the room, prescribed their medication.
As with every team I’ve ever worked on, in this hospital the staff were a colourful group with no shortage of idiosyncrasies. The passive-aggressive social worker wore socks with ‘fuck off’ written on them, and would surreptitiously lift his trousers up at the ankles in meetings, covertly flashing the expletives on his hosiery when anyone was particularly annoying him. The occupational therapist was fastidiously hygienic, and would pass around the antibacterial gel before every meeting and wipe door handles and light switches before using them.
Privately, in fact so privately that it was only in my head, I called my supervisor Dr Renton (as in, Rent-an-opinion). He ran his own medico-legal psychology practice on the side and was proud of his growing popularity among certain lawyers who could rely upon him to identify a severe mental health issue in any or all of their clients. He would never k
nowingly pass up an opportunity for self-aggrandizement and had once called in sick to the hospital so that he could appear on morning television to discuss a local crime story that had attracted media interest. One of his patients came into the ward round that morning and said he’d seen Dr Renton on the television. Dr Webb, with an all-knowing sigh, made some notes. Then, looking over his glasses at the patient, said, ‘Do you ever feel that the television is talking to you? Or about you? Is it broadcasting your thoughts?’ It took more than a few reassurances from the occupational therapist and myself to convince Dr Webb that the exasperated patient had not been hallucinating.
There was always a certain amount of peacocking going on between Dr Renton and Dr Webb, the pair of them locked in a constant battle for status and recognition. But Renton could never quite compete with Webb who, as a psychiatrist, was always going to be higher up in the pecking order. He drove an Aston Martin V8 Vantage Le Mans – the kind of sports car that was surely compensating for something – and would sometimes let the patients sit in it long enough for a visiting relative to take a photograph.
This clinical team were not only my colleagues but a prize collection of the many strange quirks and foibles that can be found in a group of human beings at any one time, even those who are supposedly sane and functioning normally. Whatever normal is. Because, as human rights advocate Paula Caplan points out: ‘normality is not “real” like a table…[it] is what psychologists call a “construct”. This means that there is no clear, real thing to which the normality label necessarily corresponds.’
One ward round morning Travis came in as usual. He was tidy and fresh as always, and sat down in the designated patient chair. The rest of us – circling the table with serious faces, like members of the Jedi Council – shuffled our papers while we waited for Dr Webb to look up from his notes and start the meeting.
Eventually he cleared his throat, welcomed Travis and asked if he knew everyone sitting round the table (he did, he had seen us all every day for the last six weeks). Travis looked around the room and said, ‘I don’t know.’ So we went through the motions, each of us formally introducing ourselves, and Travis nodded his head and made occasional twitches and small bounces in his seat – behaviour I had never seen him exhibit before in any of the one-on-one sessions I’d had with him.
Dr Webb started to ask Travis about how he had been feeling that week, but before he had finished the sentence Travis pushed his chair back and hid his face in his hands, a picture of despondency, and then started shaking his head violently from side to side. At one point he looked to the left and jumped slightly out of his chair, as if he had been startled, all the while remaining silent.
‘Are you being bothered by any voices or unusual experiences?’ Dr Webb asked him. Travis repeated the question back to him, wide-eyed, as if he was having a minor religious experience. ‘Bothered by hearing voices?’ Then his voice lowered very slightly, and he said, ‘Yes voices…really bad voices.’
Dr Webb picked up his Mont Blanc – a sure sign that something significant was coming – and Travis shifted upright in his chair (as did the rest of us in the room), like a child hoping to get a second helping of pudding.
Now waving the pen around like a small wand, Dr Webb explained to Travis that his solicitor had requested information regarding his fitness to stand trial. He launched into a well-worn, monotone speech I’d heard him deliver a few times by then: ‘Fitness to plead is governed by the Criminal Procedures (Insanity and Unfitness to Plead) Act 1991. That means that we must assess whether or not you understand the charges against you.’ Dr Webb raised his voice and spoke slowly for the last four words, presumably in case Travis was now also deaf and couldn’t hear him.
Travis was staring straight ahead, over my shoulder, with a gormless expression on his face so drama-school perfect I had to mentally doff my cap to him for his exemplary rendering of what was once referred to as a ‘lunatic’, but I also noticed the capillaries in his ears turning pink. This was an indication of his blood pressure rising – and a sign that he was understanding a great deal more about the turn in the conversation than he was hoping we’d realize.
Dr Webb continued: ‘And we must assess whether you understand the effect of a guilty or not guilty plea, and can instruct your legal counsel, follow evidence or challenge a juror.’ Travis continued to stare past me, blinking rapidly and nodding ever so slightly with each point. Dr Webb, raising his voice again, said, ‘So, Travis, can you tell me what you understand about having to go back to court soon?’
Dr Webb had lobbed the ball and now we all slowly turned our heads to see Travis’s return. Travis stared at Dr Webb for a few seconds, picked up a piece of paper from the table in front of him, put a corner of it in his mouth and began to slowly chew it.
Sometimes after ward rounds, on the walk back to my shared office, I would look across the enclosed garden to what, in those less health-conscious times, was the ward’s designated smoking area. I’d often see the patient we’d just been talking to go and sit on a bench in the furthest corner of the grounds to smoke. As soon as they thought they were alone and no longer being observed, they’d start to animate: nodding, gesturing, talking back to their voices. Sometimes you could see the relief on their faces, now they could finally let go. They tried so hard to maintain a veneer of sanity in the ward round.
After Travis had eaten the paper and been steered out of the meeting by a nursing assistant, I mentioned my concerns about the inconsistencies in his psychometric scores and the possibility of malingering. Travis was reporting a pretty diverse array of symptoms too – didn’t it strike my colleagues as suspicious? But my comments passed with very little acknowledgement or discussion from the rest of the team. In fact it was like I hadn’t said anything at all. And perhaps, because I was so keen to maintain my own outward image of the competent psychologist, I didn’t challenge it in the way I would today, when I know that I am a competent psychologist. I decided that perhaps I was missing something obvious that my more experienced colleagues were seeing.
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If I was honest, getting to the bottom of Travis and his apparent contradiction presented me with an opportunity to prove myself in this new role. Doing long hours at the hospital and finishing my master’s in the evening, I was spending most of my life at work. I have no doubt that I came across as officious and superior, when in fact I was over-compensating for the fact that I was struggling quite considerably with anxiety.
After falling over at Sheffield railway station I’d continued to have attacks of severe vertigo and sickness, and had been diagnosed with Ménière’s disease – a degenerative illness of the inner ear, which would eventually leave me deaf in my right ear and affect my sense of balance for good. I was learning to spot the warning signs of an attack (ringing, buzzing, humming and pain in my ears, distorted hearing, feeling off balance and like a balloon was being blown up inside my head). But the possibility of suddenly becoming dizzy and maybe dropping down here in my new role, where I was really trying to do my best professional psychologist pose, was angst provoking in itself. I couldn’t tell where the anxiety ended and the Ménière’s began.
If I felt an attack coming on at work, I wobbled off the ward to my office so that no one could see me breaking out in a hot sweat or trying to breathe my way through a panic attack. I would keep my head very still and walk very slowly, trying not to topple over. It probably added to the affected air I was already projecting, but I didn’t want to get found out. Instead, I put all my energy into maintaining my own veneer, pretending I had everything under control. Had I been my own patient, I might even have suspected I was hiding something myself.
It became apparent that not diagnosing Travis with something would not be an option. Stark raving normal doesn’t appear in any of the diagnostic manuals available to psychologists, despite the fact they contain an ever-expanding list of disorders (there are over 300 of them in the DSM alone right now, each one voted for inclusion by a com
mittee of the world’s most powerful psychiatrists, a large proportion of whom have interests in the pharmaceutical industry). Other members of the team reported that Travis had been seen ‘wearing headphones and dark glasses’, as if they were solely the proclivities of someone plagued by hallucinations and not something most people do when they want to listen to music in the summertime. Another colleague reported that Travis had a ‘diurnal variation in mood’ which meant he lived by daylight hours, went to bed early and wasn’t that communicative with staff when they did their hourly checks in the evenings. It didn’t sound that unusual to me – I don’t like talking to people who wake me up in the middle of the night either – but as I was beginning to understand, within the context of a psychiatric ward the most banal behaviours can appear unbalanced; the lines between normal experience and ‘symptoms’ can become almost impossible to make out.
Which begs the question: how reliable is any psychiatric diagnosis? This was the subject of a classic experiment, conducted by the American psychologist David Rosenhan in 1973. Rosenhan sent eight ordinary people to psychiatric hospitals and told them to complain of hearing a voice – a classic diagnostic criterion of ‘schizophrenia’. All eight were admitted by doctors into hospitals, and although none of them displayed any further odd behaviours or even mentioned the voice again, the majority of them received a diagnosis of a mental illness and were prescribed medication. Famously, a staff member documented evidence of one of the pseudo-patients ‘engaging in writing behaviour’. Putting pen to paper had become suspicious and loaded. Luckily for the stooges, after about three weeks most of them were declared to be in remission and discharged.