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Patient and Prisoner Experiences ____________________________________________________________________ Major Mental Illness and Masculinity in the Context of Violent Offending Behaviour Christine Haddow Submitted for Examination for the Degree of Ph.D in Law University of Edinburgh 2013 DECLARATION I composed this thesis. This work is my own. No part of this thesis has been submitted for any other degree or qualification. Name:…Christine Haddow…..……………Date:…22/05/2013……………………… ACKNOWLEDGEMENTS While this thesis is an individual research endeavour, the support and guidance of many people have made its completion possible. The project was funded by an Economic and Social Research Council +3 scholarship, and I am grateful for this financial support which has facilitated the research. I am very fortunate to have been supervised throughout the project by Prof. Lesley McAra and Dr. John Crichton. Their insightful and constructive comments have been instrumental in this research. Their guidance has ensured that a challenging experience has also been an enjoyable one. It has been a pleasure to conduct the project within the Law School at the University of Edinburgh. The staff and students, particularly those within the Criminology department, create a supportive and stimulating research environment. In particular I would like to thank Gemma Flynn. While the research sites in this project must remain anonymous, the NHS and SPS professionals who allowed me access to their institutions and assisted with the project must be acknowledged. The research occurred in close consultation with these individuals, and benefitted significantly from their contributions. I would also like to thank my family and friends for their support and encouragement both during the project and before it began. Finally, I am indebted to the patients and prisoners who shared their life histories for this research. Without their openness and honesty the project would not have been possible. I have learned a great deal from their accounts and this thesis is dedicated to them. ABSTRACT Traditional understandings of violence by the mentally disordered largely look to mental illness to explain such behaviour. More recently, research has begun to examine the role of alternative factors in driving violent offending in this context. Masculinity is one such factor to which little consideration has thus far been given, in spite of a wealth of literature which associates the construction and maintenance of a masculine identity with violence in the non-mentally disordered context. This thesis proceeds from these current understandings, and examines the nature of the relationship between mental illness, masculinity and violent behaviour. In order to examine this issue, interviews were conducted with a group of 10 male patients diagnosed with major mental illness and with violent offending histories, in a medium secure forensic psychiatric hospital in Scotland. A group of 10 male prisoners serving life sentences in a Scottish adult male prison following convictions for homicide offences were also interviewed, and acted as a comparator group. Following an analysis of these interviews, findings emerged in relation to three key areas of patients’ and prisoners’ accounts: past experiences of violent offending, present experiences of institutional settings, and future hopes for recovery and desistance. In particular, significant similarities and divergences in the experiences of the two groups were apparent, and this thesis advances two key arguments in light of this. Considering first the similarities in patients’ and prisoners’ experiences, it is posited here that for both the mentally ill and non-mentally ill male population the task of constructing and maintaining a masculine identity is a particularly pervasive force in their life histories. It will be demonstrated that for patients and prisoners in this study, masculinity plays a significant role in past violent offending, as well as having important implications for adaptation to present institutional settings, and the creation of a recovered and desisting identity for the future. Second, in looking to the divergences in patients’ and prisoners’ accounts, it is asserted that where major mental illness is present it serves to intercede in these three areas of men’s lives. Extracts from interviews with male patients will illustrate the interceding role of mental illness in violent scenarios from their pasts. In addition, it will be demonstrated that patients’ and prisoners’ respective present situations in institutional settings vary, as diagnosis of mental illness leads patients to be placed in a secure hospital rather than the prison, and the differing nature of these environments results in divergences in adaptation to these settings. Finally, in relation to the future, while prisoners focussed on their hopes for desistance from offending, the diagnosis of mental illness led patients to place recovery from such disorders as the primary process at this point. TABLE OF CONTENTS Introduction ................................................................................................... 1 Chapter 1: Mental Disorder and Violence ................................................... 8 Chapter 2: Masculinity and Violence ......................................................... 36 Chapter 3: Treatment and Management of Mentally Disordered and Violent Offenders ........................................................................................ 71 Chapter 4: Methodology ........................................................................... 110 Chapter 5: ‘The Past’: Violent Offending Histories ................................ 149 Chapter 6: ‘The Past’: General Life Histories ......................................... 171 Chapter 7: ‘The Present’: Experiences of Hospital and Prison ............. 215 Chapter 8: ‘The Future’: Frameworks for Change .................................. 256 Conclusion ................................................................................................ 303 Appendices ................................................................................................. 311 Appendix A: Patient and Prisoner Biographies ........................................ 311 Appendix B: Matrix of Security ................................................................. 321 Appendix C: Ethical Materials .................................................................. 323 1. Patient Information Sheet ................................................................. 323 2. Patient Consent Form ...................................................................... 325 3. Patient Interview Schedule ............................................................... 326 4. NHS Ethical Approval ....................................................................... 330 5. Prisoner Information Sheet ............................................................... 332 6. Prisoner Consent Form .................................................................... 323 7. Prisoner Interview Schedule ............................................................. 333 8. Sources of Support in HM Prison X .................................................. 334 Appendix D: Glossary .............................................................................. 335 Bibliography ................................................................................................ 337 INTRODUCTION This thesis will demonstrate that mental disorder plays a surprisingly minimal role in driving violence, and that the causes of violent offending by mentally disordered and non-mentally disordered individuals are in fact similar. Masculinity will be highlighted as a significant factor linked to violence in both contexts. It will be argued that in spite of such similarities, criminal justice processes separate this population by labelling them as patients or prisoners and treating and managing them accordingly. The removal of this dichotomisation, both in our understandings of these groups and in practice, will be advocated. Ultimately it will be illustrated that what this thesis has termed the ‘collaboration of excuse’ at work in the secure forensic psychiatric hospital provides patients with a more effective framework for change than those in the prison setting. This will be done with reference to qualitative interviews with a sample of 20 male1 patients and prisoners with histories of violence, in a medium secure forensic psychiatric hospital and an adult male prison. By way of introduction, the development of this thesis and its research questions will be detailed, as well as the development