Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XXXIV

Suffering Souls: The Search for the Roots of Psychopathy
John Seabrook, The New Yorker- 11/10/2008

The Western New Mexico Correctional Facility sits in high-desert country about seventy miles west of Albuquerque. Grants, a former uranium boomtown that depends heavily on prison work, is a few miles down the road. There’s a glassed-in room at the top of the prison tower, with louvred windows and, on the ceiling, a big crank that operates a searchlight. In a box on the floor are some tear-gas shells that can be fired down into the yard should there be a riot. Below is the prison complex—a series of low six-sided buildings, divided by high hurricane fences topped with razor wire that glitters fiercely in the desert sun. To the east is the snow-covered peak of Mt. Taylor, the highest in the region; to the west, the Zuni Mountains are visible in the blue distance.
      One bright morning last April, Dr. Kent Kiehl strode across the parking lot to the entrance, saying, “I guarantee that by the time we reach the gate the entire inmate population will know I’m here.” Kiehl—the Doc, as the inmates call him—was dressed in a blue blazer and a yellow tie. He is tall, broad-shouldered, and barrel-chested, with neat brown hair and small ears; he looks more like a college football player, which was his first ambition, than like a cognitive neuroscientist. But when he speaks, in an unexpectedly high-pitched voice, he becomes that know-it-all kid in school who intimidated you with his combination of superior knowledge and bluster.
     At thirty-eight, Kiehl is one of the world’s leading younger investigators in psychopathy, the condition of moral emptiness that affects between fifteen to twenty-five per cent of the North American prison population, and is believed by some psychologists to exist in one per cent of the general adult male population. (Female psychopaths are thought to be much rarer.) Psychopaths don’t exhibit the manias, hysterias, and neuroses that are present in other types of mental illness. Their main defect, what psychologists call “severe emotional detachment”—a total lack of empathy and remorse—is concealed, and harder to describe than the symptoms of schizophrenia or bipolar disorder. This absence of easily readable signs has led to debate among mental-health practitioners about what qualifies as psychopathy and how to diagnose it. Psychopathy isn’t identified as a disorder in the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s canon; instead, a more general term, “antisocial personality disorder,” known as A.P.D., covers the condition.
     There is also little consensus among researchers about what causes psychopathy. Considerable evidence, including several large-scale studies of twins, points toward a genetic component. Yet psychopaths are more likely to come from neglectful families than from loving, nurturing ones. Psychopathy could be dimensional, like high blood pressure, or it might be categorical, like leukemia. Researchers argue over whether tests used to measure it should focus on behavior or attempt to incorporate personality traits—like deceitfulness, glibness, and lack of remorse—as well. The only point on which everyone agrees is that psychopathy is extremely difficult to treat. And for some researchers the word “psychopath” has been tainted by its long and seamy relationship with criminality and popular culture, which began with true-crime pulps and continues today in TV shows like CBS’s “Criminal Minds” and in the work of authors like Thomas Harris and Patricia Cornwell. The word is so loaded with baleful connotations that it tends to empurple any surrounding prose.
     Kiehl is frustrated by the lack of respect shown to psychopathy by the mental-health establishment. “Think about it,” he told me. “Crime is a trillion-dollar-a-year problem. The average psychopath will be convicted of four violent crimes by the age of forty. And yet hardly anyone is funding research into the science. Schizophrenia, which causes much less crime, has a hundred times more research money devoted to it.” I asked why, and Kiehl said, “Because schizophrenics are seen as victims, and psychopaths are seen as predators. The former we feel empathy for, the latter we lock up.”
     In January of 2007, Kiehl arranged to have a portable functional magnetic-resonance-imaging scanner brought into Western—the first fMRI ever installed in a prison. So far, he has recruited hundreds of volunteers from among the inmates. The data from these scans, Kiehl hopes, will confirm his theory, published in Psychiatry Research, in 2006, that psychopathy is caused by a defect in what he calls “the paralimbic system,” a network of brain regions, stretching from the orbital frontal cortex to the posterior cingulate cortex, that are involved in processing emotion, inhibition, and attentional control. His dream is to confound the received wisdom by helping to discover a treatment for psychopathy. “If you could target the brain region involved, then maybe you could find a drug that treats that region,” he told me. “If you could treat just five per cent of them, that would be a Nobel Prize right there.”
     The four hundred and six prisoners in the Western New Mexico facility are serving sentences ranging from a year to life without parole. New Mexico uses a classification system that assigns each inmate a number from one to six, with six being reserved for the most violent offenders; Western has inmates of all levels up to five. Although not all psychopaths are violent, Kiehl told me, the majority are fours, fives, and sixes.
     Unlike most academic psychopathy researchers, Kiehl has spent many hours in the company of his subjects. When he meets colleagues at conferences, he told me, “they always ask, ‘What are they like?’ These are guys who have spent twenty years studying psychopaths and never met one.” Although the number of psychopaths who are not in prisons is thought to exceed the number who are—if the one-per-cent figure is correct, there are more than a million psychopaths at large in the United States alone—they are much harder to identify in the outside world. Some are “successful psychopaths,” holding down good jobs in many types of industries. It is generally only if they commit a crime and enter the criminal-justice system that they become available for research.
     In the conference room where Western’s warden, Anthony Romero, greeted Kiehl, there was a framed tableau of illegal items confiscated from inmates, including handmade shivs and crude tattooing devices. Romero explained that Kiehl was using the scanner not only to study psychopathy but also to measure the level of craving in the brains of substance abusers as they go through a treatment program, also run by Kiehl, which is funded by the National Institute on Drug Abuse. The volunteer rate among the inmates is more than ninety per cent (although some are too muscle-bound to fit inside the scanning tube). As a “collateral benefit,” Kiehl throws in a free clinical examination of their brains. (He has discovered previously undetected tumors in about five per cent of the volunteers.) In addition to the pay they receive for their time (a dollar an hour, Western’s standard rate for prison labor), inmates get pictures of their brains that they can post in their cells. “There’s a lot of joking among the prisoners about who’s got the biggest brain,” Romero said.
     The scanner was housed in a tractor-trailer parked behind the prison’s I.D. center. We followed a correctional officer through an internal courtyard to the rehab wing, which consisted of a large common area surrounded by two-man cells. The prisoners were standing at attention outside their cells, some holding mops and brooms. I entered a vacant cell and saw the occupant’s brain, a grainy black-and-white image on a piece of a paper, its edges curling, tacked up over the desk.
     Then we walked through the common room and out a door at the other end, passing under a large poster with lines that read, “I am here because there is no refuge, finally, from myself.” The officer led us along a corridor of offices in which students from the University of New Mexico, where Kiehl is on the faculty, conduct psychopathy interviews and also counsel participants in the drug-treatment program. Carla Harenski, one of Kiehl’s postdocs, was interviewing a beefy guy with a tattoo on his neck. Her office, like those of all the researchers in the lab, is equipped with a button she can press to call for help if an interview gets out of hand.
     In order to distinguish psychopaths from non-psychopaths among the Western volunteers, Kiehl and his students use the revised version of the Psychopathy Checklist, or PCL-R, a twenty-item diagnostic instrument created by Robert Hare, a Canadian psychologist, based on his long experience in working with psychopaths in prisons. Kiehl was taught to use the checklist by Hare himself, under whom he earned his doctorate, at the University of British Columbia. Researchers interview an inmate for up to three hours, and compare the inmate’s statements against what is known of his record and his personal history. The interviewer “scores” the subject on each of the twenty items—parasitic life style, pathological lying, conning, proneness to boredom, shallow emotions, lack of empathy, poor impulse control, promiscuity, irresponsibility, record of juvenile delinquency, and criminal versatility, among other tendencies—with zero, one, or two, depending on how pronounced that trait is. Most researchers agree that anyone who scores thirty or higher on the PCL-R is considered to be a psychopath. Kiehl says, “Someone who scores a thirty-five, a thirty-six, they are just different. You say to yourself, ‘Aha, here you are. You are why I do this.’ ”
     Harenski recently interviewed a Western inmate who scored a 38.9. “He had killed his girlfriend because he thought she was cheating on him,” she told me. “He was so charming about telling it that I found it hard not to fall into laughing along in surprise, even when he was describing awful things.” Harenski, who is thirty, did not experience the involuntary skin-crawling sensation that, according to a survey conducted by the psychologists Reid and M. J. Meloy, one in three mental-health and criminal-justice professionals report feeling on interviewing a psychopath; in their paper on the subject, Meloy and Meloy speculate that this reaction may be an ancient intraspecies predator-response system. “I was just excited,” Harenski continued. “I was saying to myself, ‘Wow. I found a real one.’ ”
     At the end of the hall, a door led outside to the trailer. Inside, there was a small sitting area; computer screens and hard drives were built into a large console in the center, and the fMRI scanning tube was at the back. Its surfaces were made of molded white plastic. Harenski’s husband, Keith, the chief MRI technician in Kiehl’s lab, sat in front of the computer, monitoring a scan in progress. The screen showed what the inmate inside the scanner was seeing. All that was visible of him was his feet, covered with dirty white athletic socks, which protruded from the mouth of the tube.
     Kiehl and the researchers in his lab have designed two tests—or tasks, as the researchers call them—one word-based and the other image-based. Kiehl said he had avoided complicated moral problems, such as the classic trolley dilemma, in which the subject is asked to choose whether to cause one person’s death in order to save the lives of others in the path of a runaway trolley, because psychopaths might not understand the problem or wouldn’t answer seriously. “You try to minimize their opportunities for messing with you,” he said. The same tasks are performed by control groups, one of non-psychopathic inmates and another of non-inmates with intelligence-test scores and educational backgrounds similar to those of the inmates.
     The word-based task was under way. The inmate was being shown a series of words and phrases, and was supposed to rate each as morally offensive or not. There were three kinds of phrases: some were intended as obvious moral violations, like “having sex with your mother”; some were ambiguous, like “abortion”; and some were morally neutral, like “listening to others.” The computer software captured not only the inmate’s response but also the speed with which he made his judgment. The imaging technology recorded which part of the brain was involved in making the decision and how active the neurons there were.
     Neurons in the brain consume oxygen when they are “firing,” and the oxygen is replenished by iron-laden hemoglobin cells in the blood. The scanner’s magnet temporarily aligns these iron molecules in the hemoglobin cells, while the imaging technology captures a rapid series of “slices”—tiny cross-sections of the brain. The magnet is superconductive, which means it operates at very cold temperatures (minus two hundred and sixty-nine degrees Celsius). The machine has a helium cooling system, but if the system fails the magnet will “quench.” Quenches are an MRI technician’s worst fear; a new magnet costs about two million dollars.
     The inmate wore a helmet with a head coil for receiving magnetic data and, on the inside, a screen on which words were projected. A sensor measured “skin conductance”—palm sweat. During the functional imaging scans, there was a series of high-pitched beeps, then a loud drilling sound. And during the brain-anatomy scans the machine made a low, rapid thumping, like a metal heartbeat. As the inmate’s brain was scanned, he crossed his feet at the ankles and then uncrossed them. His toes wiggled.
     Psychopaths are as old as Cain, and they are believed to exist in all cultures, although they are more prevalent in individualistic societies in the West. The Yupik Eskimos use the term kunlangeta to describe a man who repeatedly lies, cheats, steals, and takes sexual advantage of women, according to a 1976 study by Jane M. Murphy, an anthropologist then at Harvard University. She asked an Eskimo what the group would typically do with a kunlangeta, and he replied, “Somebody would have pushed him off the ice when nobody else was looking.”
     The condition was first described clinically in 1801, by the French surgeon Philippe Pinel. He called it “mania without delirium.” In the early nineteenth century, the American surgeon Benjamin Rush wrote about a type of “moral derangement” in which the sufferer was neither delusional nor psychotic but nevertheless engaged in profoundly antisocial behavior, including horrifying acts of violence. Rush noted that the condition appeared early in life. The term “moral insanity” became popular in the mid-nineteenth century, and was widely used in the U.S. and in England to describe incorrigible criminals. The word “psychopath” (literally, “suffering soul”) was coined in Germany in the eighteen-eighties. By the nineteen-twenties, “constitutional psychopathic inferiority” had become the catchall phrase psychiatrists used for a general mixture of violent and antisocial characteristics found in irredeemable criminals, who appeared to lack a conscience.
     In the late nineteen-thirties, an American psychiatrist named Hervey Cleckley began collecting data on a certain kind of patient he encountered in the course of his work in a psychiatric hospital in Augusta, Georgia. These people were from varied social and family backgrounds. Some were poor, but others were sons of Augusta’s most prosperous and respected families. Cleckley set about sharpening the vague construct of constitutional psychopathic inferiority, and distinguishing it from other forms of mental illness. He eventually isolated sixteen traits exhibited by patients he called “primary” psychopaths; these included being charming and intelligent, unreliable, dishonest, irresponsible, self-centered, emotionally shallow, and lacking in empathy and insight.
     “Beauty and ugliness, except in a very superficial sense, goodness, evil, love, horror, and humor have no actual meaning, no power to move him,” Cleckley wrote of the psychopath in his 1941 book, “The Mask of Sanity,” which became the foundation of the modern science. The psychopath talks “entertainingly,” Cleckley explained, and is “brilliant and charming,” but nonetheless “carries disaster lightly in each hand.” Cleckley emphasized his subjects’ deceptive, predatory nature, writing that the psychopath is capable of “concealing behind a perfect mimicry of normal emotion, fine intelligence, and social responsibility a grossly disabled and irresponsible personality.” This mimicry allows psychopaths to function, and even thrive, in normal society. Indeed, as Cleckley also argued, the individualistic, winner-take-all aspect of American culture nurtures psychopathy.

The above text covers the first three pages of this ten page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.

Good Grief: Is There a Better Way to Be Bereaved?
Meghan O'Rourke, New Yorker- 2/1/2010

One autumn day in 1964, Elisabeth Kübler-Ross, a Swiss-born psychiatrist, was working in her garden and fretting about a lecture she had to give. Earlier that week, a mentor of hers, who taught psychiatry at the University of Colorado School of Medicine, had asked her to speak to a large group of medical students on a topic of her choice. Kübler-Ross was nervous about public speaking, and couldn’t think of a subject that would hold the students’ attention. But, as she raked fallen leaves, her thoughts turned to death: Many of her plants, she reflected, would probably die in the coming frost. Her own father had died in the fall, three years earlier, at home in Switzerland, peaceful and aware of what was taking place. Kübler-Ross had found her topic. She would talk about how American doctors—who, in her experience, were skittish around seriously ill patients—should approach death and dying.
      Kübler-Ross prepared a two-part lecture. The first part looked at how various cultures approach death. For the second, she brought a dying patient to class to talk with the students. Asking around at the hospital, she found Linda, a sixteen-year-old girl with incurable leukemia. Linda’s mother had just taken out an ad in a local newspaper asking readers to send Linda get-well and sweet-sixteen cards. Linda was disgusted by the pretense that her health would improve. She agreed to visit the class, where she spoke openly about how she felt. The students, Kübler-Ross observed, were rapt but nervous. They avoided dealing with the source of their discomfort—the shock of seeing an articulate, lovely young woman on the verge of death—by asking an abundance of clinical questions about her symptoms.
      Soon afterward, as her biographer, Derek Gill, relates, Kübler-Ross took a job as an assistant professor of psychiatry at the University of Chicago. Four students from the Chicago Theological Seminary learned that she was interested in terminal illness and asked if she might help them study dying people’s needs. Kübler-Ross agreed to try. At Chicago’s Billings Hospital, she began a series of seminars, interviewing patients about what it felt like to die. The interviews took place in front of a one-way mirror, with students observing on the other side. This way, Kübler-Ross gave the patients some privacy while accommodating the growing number of students who wanted to watch.
      Many of Kübler-Ross’s peers at the hospital felt that the seminars were exploitative and cruel, ghoulishly forcing patients to contemplate their own deaths. At the time, doctors believed that people didn’t want or need to know how ill they were. They couched the truth in euphemisms, or told the bad news only to the family. Kübler-Ross saw this indirection as a form of cowardice that ran counter to the basic humanity a doctor owed his patients. Too many doctors bridled at even admitting that a patient was “terminal.” Death, she felt, had been exiled from medicine. Kübler-Ross began to work on a book outlining what she learned in her work with the dying. It came out in 1969, and, shortly afterward, Life published an article about one of her seminars. (“A gasp of shock jumped through the watchers,” the Life reporter wrote. “Eva’s bearing and beauty flew against the truth that the young woman was terribly ill.”) Kübler-Ross received stacks of mail from readers thanking her for starting a conversation about death. Angered by the article and its focus on death, the hospital administrators did not renew her contract. But it didn’t matter. Her book, “On Death and Dying,” became a best-seller. Soon, Kübler-Ross was lecturing at hospitals and universities across the country.
      Her argument was that patients often knew that they were dying, and preferred to have others acknowledge their situation: “The patient is in the process of losing everything and everybody he loves. If he is allowed to express his sorrow he will find a final acceptance much easier.” And she posited that the dying underwent five stages: denial, anger, bargaining, depression, and acceptance.
      The “stage theory,” as it came to be known, quickly created a paradigm for how Americans die. It eventually created a paradigm, too, for how Americans grieve: Kübler-Ross suggested that families went through the same stages as the patients. Decades later, she produced a follow-up to “On Death and Dying” called “On Grief and Grieving” (2005), explaining in detail how the stages apply to mourning. Today, Kübler-Ross’s theory is taken as the definitive account of how we grieve. It pervades pop culture—the opening episodes of this season’s “Grey’s Anatomy” were structured around the five stages—and it shapes our interactions with the bereaved. After my mother died, on Christmas of 2008, near-strangers urged me to learn about “the stages” I would be moving through.
      Perhaps the stage theory of grief caught on so quickly because it made loss sound controllable. The trouble is that it turns out largely to be a fiction, based more on anecdotal observation than empirical evidence. Though Kübler-Ross captured the range of emotions that mourners experience, new research suggests that grief and mourning don’t follow a checklist; they’re complicated and untidy processes, less like a progression of stages and more like an ongoing process—sometimes one that never fully ends. Perhaps the most enduring psychiatric idea about grief, for instance, is the idea that people need to “let go” in order to move on; yet studies have shown that some mourners hold on to a relationship with the deceased with no notable ill effects. (In China, mourners regularly speak to dead ancestors, and one study has shown that the bereaved there suffer less long-term distress than bereaved Americans do.) At the end of her life, Kübler-Ross herself recognized how far astray our understanding of grief had gone. In “On Grief and Grieving,” she insisted that the stages were “never meant to help tuck messy emotions into neat packages.” If her injunction went unheeded, perhaps it is because the messiness of grief is what makes us uncomfortable. Anyone who has experienced grief can testify that it is more complex than mere despondency. “No one ever told me that grief felt so like fear,” C. S. Lewis wrote in “A Grief Observed,” his slim account of the months after the death of his wife, from cancer. Scientists have found that grief, like fear, is a stress reaction, attended by deep physiological changes. Levels of stress hormones like cortisol increase. Sleep patterns are disrupted. The immune system is weakened. Mourners may experience loss of appetite, palpitations, even hallucinations. They sometimes imagine that the deceased has appeared to them, in the form of a bird, say, or a cat. It is not unusual for a mourner to talk out loud—to cry out—to a lost one, in an elevator, or while walking the dog.
      The first systematic survey of grief was conducted by Erich Lindemann, a psychiatrist at Harvard, who studied a hundred and one bereaved patients at the Harvard Medical School, including relatives of soldiers and survivors of the infamous Cocoanut Grove fire of 1942. (Nearly five hundred people died in that incident, trapped in a Boston night club by a revolving front door and side exits welded shut to prevent customers from ducking out without settling their bills.) Lindemann’s sample contained a high percentage of people who had lost someone in a traumatic way, but his main conclusions have been borne out by other researchers. So-called “normal” grief is marked by recurring floods of “somatic distress” lasting twenty minutes to an hour, comprising symptoms of breathlessness, weakness, and “tension or mental pain,” in Lindemann’s words. “There is restlessness, inability to sit still, moving about in an aimless fashion, continually searching for something to do.” Often, bereaved people feel hostile toward friends or doctors and isolate themselves. Typically, they are preoccupied by images of the dead.
      Lindemann’s work was exceptional in its detailed analysis of the experience of the grieving. Yet his conception of grief was, if anything, more rigid than Kübler-Ross’s: he believed that most people needed only four to six weeks, and eight to ten sessions with a psychiatrist, to get over a loss. Psychiatrists today, following Lindemann’s lead, distinguish between “normal” grief and “complicated” or “prolonged” grief. But Holly Prigerson, an associate professor of psychiatry at Harvard, and Paul Maciejewski, a lecturer in psychiatry at Brigham and Women’s Hospital, in Boston, have found that even “normal” grief often endures for at least two years rather than weeks, peaking within six months and then dissipating. Additional studies suggest that grief comes in waves, welling up and dominating your emotional life, then subsiding, only to recur. As George A. Bonanno, a clinical psychologist at Columbia University, writes in “The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss” (Basic; $25.95), “When we look more closely at the emotional experiences of bereaved people over time, the level of fluctuation is nothing short of spectacular.” This oscillation, he theorizes, offers relief from the stress grief creates. “Sorrow . . . turns out to be not a state but a process,” C. S. Lewis wrote in 1961. “It needs not a map but a history.” To say that grief recurs is not to say that it necessarily cripples. Bonanno argues that we imagine grief to be more debilitating than it usually is. Despite the slew of self-help books that speak of the “overwhelming” nature of loss, we are designed to grieve, and a good number of us are what he calls “resilient” mourners. For such people, he thinks, our touchy-feely therapeutic culture has overestimated the need for “grief work.” Bonanno tells the story of Julia Martinez, a college student whose father died in a bicycling accident. In the days after his death, she withdrew from her mother and had trouble sleeping. But soon she emerged. She went back to school, where, even if sometimes she felt “sad and confused,” she didn’t really want to talk to her friends about the death. Within a few months, she was thriving. Her mother, though, insisted that she was repressing her grief and needed to see a counsellor, which Julia did, hating every minute of it.
      Bonanno wants to make sure that we don’t punish this resilient group inadvertently. Sometimes the bereaved feel as much relief as sorrow, he points out, especially when a long illness was involved, and a death opens up new possibilities for the survivor. Perhaps, he suggests, some mourners do not need to grieve as keenly as others, even for those they most love.

The above text covers the first two pages of this six page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.