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An Act of Violence: A Psychiatrist’s Perspective on Equus

Dr Peter Misch 
Consultant Adolescent Forensic Psychiatrist 

One of the central themes of Equus is that it examines and questions the mental health of children and young people who act out horrific, sadistic or seemingly twisted violent behaviour. This theme is central to the professional role of child and adolescent forensic psychiatrists such as ourselves and within a few lines of the play starting I found myself intrigued. 

Equus was written and informed at a time when the boundaries of mental health and ill-health were being challenged by writers such as RD Laing, shifting from a medical deterministic view of human behaviour to a systemic psycho-social approach and Equus remains as relevant now as when it was first written. 

The role of the adolescent forensic psychiatrist in these cases is not to determine guilt or innocence; this is the role of the Court. It is to ascertain an understanding of the motivations underpinning the behaviour and advise about both treatment strategies for the young person and about future risks to others and how best to manage these risks. 

Engaging a young person in this type of forensic psychiatric assessment is a two-way process that inevitably requires give-and-take between doctor and patient. It requires respect by the psychiatrist for the young person and an interest in that individual that extends beyond the violent act, combined with compassion tempered by honesty about the non-acceptability of the violence. 

In order to build up a level of trust and engagement so that the patient’s feelings and thoughts can be fully shared, some young people need some control in the relationship. As is reflected in the play, this may require some personal disclosure from the psychiatrist. 

In order to gain an understanding of the young person’s relationships with their parents, teachers, their peers and any intimate partners, an assessment inevitably extends to interviewing other informants. A young person’s interests, their hobbies and increasingly their online relationships also inform an assessment. 

The play illustrates some of the multiple dilemmas that can arise for both the ‘patient’ and the forensic psychiatrist of engaging in the assessment process.  

Whilst a sadistic act of violence by a young person evokes both horror and revulsion in others and sympathy for the victim, the violent act may well have a very different ‘meaning’ for the patient. In some cases the violent act may have been experienced as being empowering by the young person. Removing this sense of power by providing insight for a young person in this situation can result in a depressive reaction and if this is not understood and the patient supported, this can result in suicide.  

Extreme cases involving violence inevitably have some degree of emotional impact on the assessing psychiatrist and other professionals, especially where relationships between the patient or victims have been established. 

Compared to men, children (and women) who commit sadistic crimes tend to be demonised by English society, both the press and the Judicial system. England and Wales has one of the highest rates of incarceration in the world and for children, the age of criminal responsibility set at 10 years of age, one of the lowest. 

Equus highlights that there is no simple answer in these cases, but in effect, multiple victims, including the guilty perpetrator. English society has a great compassion for domesticated animals such as horses, which makes the wish for revenge and punishment seem a logical response.  

Hesther Salmon, the female magistrate, in the play takes a different approach to her bench and seeks understanding and care for the offender, Alan Strang. Not all forensic psychiatrists take this approach and some use their skills to ensure long custodial sentences. Whilst it is my professional duty to protect society from violence and recognise the central importance of addressing the impact on victims of crime, including the need for punishment, I am behind the magistrate, Hesther, and psychiatrist, Martin Dysart, in Equus.