Mentally Ill or Just a Scumbag?

I recently watched the film What Doesn’t Kill You, starring Mark Ruffalo and Ethan Hawke [1]. Without giving spoilers, at one point in the film both men beat up a known Pedophile. As the two characters are punching and kicking and basically using the guy’s face as a speed bag they are both yelling, “You sick fuck! You sick bastard!”

I immediately had questions: if the two characters thought that the perpetrator was actually sick, why were they wailing on him? Was their labeling of him just a figure of speech and they saw his actions as simply that of a reprehensible asshole, or did they really believe he was ill?

These questions are what make mental health such a tricky animal. Conditions that tend to pull at our sympathy strings often don’t get questioned [2]. When a woman is crying all day long, loses 20 pounds from not eating and tells her friends that she is suicidal, we say that she’s depressed. That’s an illness and it’s not often scrutinized. When a man gets fired from his job because he can’t leave the house until he’s counted every ceiling tile in his home and washes his hand 200 times per day, we say he has OCD. That’s also an illness. And when voices that no one else can hear begin to pound in the head of a young woman, telling her that she’s worthless and that aliens are probing her brain, we call her Schizophrenic. Again, an illness. Even though we can’t see the actual disease the way we can when someone has the flu, most of us take the sickness at face value [3].

But what about those conditions that appear more nefarious? Narcissistic Personality Disorder is in the DSM-IV so does that make it an illness? What about Sociopathy? And of course sex offenders. These groups of people act in ways that, at a minimum, piss us off and, at worst, cause irreparable damage to people. When the schizophrenic woman runs out of the shrink’s office because she thinks he can read her mind, we feel sorry for her because she’s the only person suffering at that time. But when she drowns her children, she’s suddenly the most evil person on earth, condemned to Hell. Is she not sick anymore [4]? Of course she is still ill, but now she’s brought another person into the equation.

This is where when we cross that line from sympathy to anger. And this is why people like the characters in the film are praised by some. It’s not as if they would have kicked the shit out of someone who had thoughts about children, it’s because he took action on them, damaging a helpless child. It’s the hurtful behavior that leads many to move from Illness Model to Scumbag Model. Even in prison, you can’t beat up someone who is sick, but you can when he’s an asshole. When he crossed that line, the characters in the film decided he wasn’t sick, he was a scumbag. And while virtually all crimes have a victim, you don’t often hear about a prisoner getting beaten up for murdering a 35 year-old man. That’s because there isn’t an overt power differential between perpetrator and victim that’s seen in Pedophilia or perhaps abuse of the elderly. It’s when we see such a disparity in control some of us will laud the violent behaviors of others because in a way they have leveled the playing field.

So as not to oversimplify, perceptions of illness vs. choice will vary from person to person and even by mental health pro to pro. Cultural norms, religious views, personal takes on the conscious and subconscious mind, as well as knowledge of brain structure and biochemistry, all influence how someone views psychological/psychiatric problems. You can find plenty of shrinks to say that Michael Jackson was deeply and profoundly suffering from a psychological disorder, but turn around and there are just as many who say that he made conscious behavioral choices and isn’t deserving of any sort of “mentally ill” pass. Society allows us to think strange things but won’t accept behaviors that damage others. So if Michael believes his mission in life is to start a Boy Scout troupe he’s not going to be met with the same scrutiny as having young males sleep over his house. That’s because the latter is much more suggestive of harm.

I’ve said this before but it bears repeating: until we have dipsticks that we can put into people’s heads to give us a formal reading on how ‘sick’ someone is, there is going to be guesswork involved [5]. When I worked with sex offenders and heard about the horrific things they did it was hard for me not to think that only someone truly ill would engage in those acts. When I meet a certifiable Narcissist it’s hard for me to not empathize with the fact that he truly, deeply sees himself as special, independent of any evidence to support his claim. It’s as if the belief is so entrenched, almost like a delusion seen in people with psychosis. But the general population is going to cut him out of their lives. This isn’t necessarily a bad thing because Narcissists are generally toxic people, but most will drop him based on labeling the guy a dick rather than being ill. This, unfortunately, creates a culture of hate and anger rather than one based on what is healthy and pro-social. In other words, there are competing interests for what is best: removing the Narcissist benefits the people but not necessarily the Narcissist. Unless he says, “Wow, being a douchebag is upsetting a lot of people. I should probably stop acting that way,” he is not going to change his ways. And how likely is that? Instead our action of kicking him to the curb may in fact reinforce his behavior, because we “don’t get” how great he is or are simply jealous of his greatness.

So I view people who say and think and do messed up things as ill. Does that make it fact? No, of course not. Having expertise in a field doesn’t mean that what you say is gospel. But I will ask you to consider the notion that just because something doesn’t make you say “wow, poor guy” doesn’t mean it’s not pathological. A mental condition may not always pull at our heart strings, but that’s doesn’t mean it isn’t an illness.

[1] I’m not reviewing the film but feel free to click here for my mind-bogglingly awesome coverage of Star Wars.

[2] Unless you are one of those uber-conservative types who don’t see anything in the brain as an illness but simply a conscious choice. You’re probably not a person who would be reading this site anyway so it is kind of a moot point.

[3] Dr. Gail had the flu last week and she looked like the offspring of Golom and the Crypt Keeper. Scary stuff.

[4] Note that this is not an argument for or against imprisonment versus psychiatric treatment or a comment on the plea of Not Guilty by Reason of Insanity. These are topics that can’t be covered in entire textbooks, let alone this website.

[5] That data is starting to accumulate. For example, some fMRI results show differences in brain blood flow in depressed vs. non-depressed people, while PET scans show a trend of low neural activity in the frontal cortex in Schizophrenia.

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20 Responses to “Mentally Ill or Just a Scumbag?”

  1. Agnes Davis says:

    I do have to ask about footnote #5. I know how most of these fMRI studies are done: You take people that you already know to be depressed and non-depressed, scan their heads, and compare. Will we ever be at the point that we can do it in reverse: scan someone’s head and by the blood flow diagnose depression?

  2. It may be helpful to view SOs as compulsive instead of “sick”. For many, it is a compulsion to commit the sex acts, so while they may plan meticulously, I believe fulfilling the act is more about fulfilling the cycle.
    I don’t personally work with sex offenders, as I do not believe they can be treated. The research is a bit mixed (depending on which studies you give more credence); I generally believe that short of chemical castration/imprisonment/execution….there really isn’t an effective treatment.

  3. Clindos says:

    Chemical castration is not a treatment for SOs. All it does is take away the ability to become erect. It does nothing for the desires and an offender will just use a foreign object to violate their victims. (lol, thank you CSI).

  4. Jessica says:

    A psychologist needs to view people as sick in order to treat them, but I don’t think it should be a general societal view that people who do messed up things are sick and not morally reprehensible. Forgiveness of behavior, and the label of “sick” instead of “asshole/dick/horrible person,” gives people too much permission to continue in their behavior, in my opinion.
    My brother is a narcissist, and was diagnosed with NPD, and proclaims it, and uses it as an excuse when he is criticized. He turns it into a positive personality trait. I see far too many people using psychiatric diagnoses as excuses. “I can’t help it, I’m bipolar.” “I have OCD, what do you expect?” “Well, the treatment didn’t work, so you’ll just have to live with me being this way.”
    I wonder if it’s detrimental for a child to be labelled with a mental illness. Telling a child or an adolescent, “You are bipolar” or “You have OCD” or even worse, a personality disorder — does it become a part of their self-image? Do they start to see themselves as broken? Can you separate self-image from the disorder? Are efforts at “externalizing” the disorder successful (when they’re even implemented)? What if a child would have done better without being told “You have XXXX?” Doesn’t a diagnosis make the problem seem more real, more salient?
    It’s part of the reason why I think positive psychology is such a good thing and needs more attention (research-wise). Paying attention to the positive, encouraging strengths, not giving too much attention to flaws – maybe that would work better than current treatments (or maybe that’s how some psychologists actually do it, but research regarding that is pretty limited). It’s also why I like the overall ideology of Acceptance and Commitment Therapy, which in my opinion deserves a lot more attention and is a really exciting development, especially since it’s so adaptable to the various mental illnesses — shown to work for depression, schizophrenia(!!), OCD, smoking cessation, even epilepsy(strangely enough). It could even be adapted for sex offenders. I wonder how well it would work.

  5. Dr. Rob says:

    These are great points, although it’s worth noting that viewing someone as ill doesn’t necessarily translate to either forgiveness or a tacit reinforcement of antisocial behaviors.

  6. marcia says:


  7. jackmo says:

    great post Rob,
    I’ve often wondered about other criminals judging pedos and bashing them in Jail. Obviously I’m not saying pedophelia is ok, but why is it that someone that may have murdered a child for example, thinks they are morally superior?

  8. Chad says:

    i could really here your “doctor” voice coming through on this one….not necessarily a bad thing…a very good post, all and all

  9. Joe says:

    Last night, I was watching Gone Baby Gone on the TV. There’s a scene where a child molester has raped a little kid to death and Casey Affleck’s character shoots him in the back of the head. I’ve read about similar stories happening in real life, including one where a couple of neighborhood men held down a pedophile and branded his genitals with a superheated metal spatula.
    In no case have I felt the least bit sorry for the pedophile. Maybe its necessity. Maybe the need to protect the normal people and children just overrides any concerns about the pedophile being treated like a human being. Of course, this can obviously be overridden by things like religion or liberal concerns about human rights. Just a thought.

  10. Risto says:

    I think the movie “Little Children” does a great job with its portrayal of a pedophile and the surrounding society. It doesn’t justify the retribution people attempt on him and even shows that trying to help and understand them is a much better direction than shunning them (which drives them back to their old behaviors).
    I’ve always attempted to understand the motivations of people of who commit “interesting” crimes. Most people simply judge them based on their own personal moral compass and value system, but this is a flawed view because the offender obviously doesn’t share it. Take Michael Vick, for instance: obviously did not care about dogs in the same way the members of PETA do (for instance), and he is demonized because of it. Yet a huge number of people in Korea eat dogs, and I don’t see us declaring war on them to stop the “senseless violence.” People who say “how could he do such a thing?” must subscribe to the notion of a universal morality, which is not true. Sadly, truly ill people are in the even worse position of potentially knowing something is wrong yet are unable to control their actions.

  11. Colleen says:

    Agnes: I work in clinical fMRI research, and to answer your question, yes the current hope is to be able to do diagnostic imaging eventually. However first we need to identify universal patterns of activity associated with disease, and that is an extremely complicated process. It may take multimodal imaging (i.e. fMRI plus PET and DTI) to do this. Once methods are established, the cost may still be prohibitive, since fMRI is a specialized and very expensive scan. Right now it is approved for presurgical planning for brain surgery but that’s it.
    To address this post – Dr. Rob, I am interested on your take on disease vs. temperment. Obviously at some point it becomes impossible to distinguish between the two, but do you think that all behavior of the mentally ill is related to their illness? To put it frankly, can you be ill but also a jerk? In the lab we deal with people who have all manner of cognitive and personality issues, but some are self aware and apologetic, while others are quick to become aggressive. What are your thoughts on how underlying traits influence disease?
    Dr. Rob: Pete is a complete tool most of the time, so definitively you can be ill and a jerk. I’ve rarely viewed an illness as completely all-encompassing and of course this depends on the nature of the disorder. Personality disorders are generally going to get more slack than symptom disorders b/c the very nature of the condition, but just because you’re a Narcissist doesn’t mean you don’t experience normal levels of obnoxiousness like the rest of us.

  12. Sean says:

    Clindos, if you’re getting your data about human behavior from CSI, perhaps you are ill, heh.

    The thing a lot of people ignore is the chain of abuse. I wish you had addressed it in this piece, Dr. Rob. Some victims of abuse are at risk of becoming perpetrators, either as an adult, or as children on other children. The victims of the victim-turned-perpetrator are even more screwed up if they are both kids.
    By the time an adult is victimizing children, it’s probably too late for them to do much good. But I think we need aggressive, perhaps even mandatory, lifelong checkups on child victims and investigations into whether the damage has spread from that child victim to other children (friends/family) so we can at least try to stop the cycle.
    It won’t eliminate the problem, but I think society can devote a lot more resources than we are, a lot more usefully, than focusing so much on cathartically hurting the lost cause perpetrators. Yes, it makes US feel better, but it doesn’t do much more to solve the actual problem than locking them up in the first place did.

  13. mike says:

    It is like you read my mind. This article is amazing. I wish I could find the site that has my life recorded.

  14. Tina says:

    Interesting post, Dr Rob.
    While I’m not in the mental health proession, the issue of mental illness and crime fascinates me. I can’t help but think all of us are a few misfiring neurons away from having our neighbors for lunch, literally.
    As far as the issue of pedophiles being “ill”, you’re probably right. I’m sure most of them have some type of mental illness. For me, the difference between someone who is bi-polar (for example) and someone who is a pedophile, is how their illness affects other people. A bi-polar person, in most cases, is not causing harm to another person. A pedophile is not only hurting someone else, but is hurting someone who is naive and defenseless. Maybe they (the pedophile) could control it if really wanted to. maybe it is beyond their control. Honestly, I don’t know. I can logially look at a person like that and see that they are not mentally healthy and their illness is at the root of their actions. However, I also know that, illness or not, if anyone ever hurt my child in that way, being attacked in prison would be the least of their worries and would likely be mild compared to what I’d do to them.

  15. Van says:

    The REM and Nirvana successes don’t mean much to me except as a potential distraction for bands who want to cash in on the trend. Don’t try to sound like someone else. REM and Nirvana don’t sound like anyone else.

  16. enriqueta says:


  17. smitty says:


  18. Anonymous says:


    Dr. Rob: Unfortunately, no. If you have specific quotes, questions or ideas, however, please use the Contact tab and I’ll definitely get back to you.

  19. piano rapidshare…


  20. Irritated says:

    I’m sorry, but I don’t view narcissism as a disease. It is a mindset; as far as I have been able to ascertain, there is no biological cause to it.

    Having dealt with someone who is bipolar with narcissism recently, the medication has stabilized the bipolar side. The entitlement is still there, and the narcissism is still there. She still thinks that she has license to point out people’s failings with sarcastic digs, and that she is entitled to the special treatment she has received since birth, being the baby of the family.

    The result has been that she has alienated friends, family and co-workers repeatedly (I think she has now had 40 jobs) by expecting special treatment and by being rude to people.

    She is decidedly inferior on most scales, but is still narcissistic.

    People with a personality disorder like NPD need to be re-trained, and not enabled.That means they should get no tolerance for their rudeness or expectations of special treatment. Call them on their behavior (unless he or she is your boss, in which case, swallow it or change change jobs). If they don’t like it and decide to cut you out of their life, let them.

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