by and large, the people who come into and out of rehab go roughly the same route. they come in as hollow, dejected shells of themselves, under the sickening influence of their addiction and come out as close as to what one would describe a "normal" person (whatever that may be).
however, there are also quite a few people who don't seem to get better. as the veneer of the addictive drug of choice wears off a new layer of chaotic, unpredictable behaviour seeps to the foreground. these are the people with underlying conditions. such underlying conditions can vary greatly, from being a rageaholic to alcohol dementia to psychosis to schizophrenia. I once listened to this podcast that said that mental illness in our society is horribly under diagnosed and that likely somewhere between 60 to 70% of people are living with some form of mental illness. I used to find that percentage unbelievable, but now not so much.
and of course I get that I am in a very narrow subset of the culture at large, namely recovering addicts, but it still is shocking to me how many people seem to suffer from one form of neurosis or another. further, it is really difficult to disentangle the addiction from the underlying condition. did the drug cause the pathology or did the pathology drive the person to the drug? for most people it seems as though they were prone to a certain pathological state and that their descent into that state was readily fuelled and powered by their substance of choice.
it also depends on how broadly you define mental illness. one common trait amongst late stage alcoholics is an inability to control their impulses and emotions. this is due to the damage to the cerebral cortex which is normally the functional equivalent of your sober friend keeping your drunk ass from doing stupid shit. I cannot tell you how many "adults" I have met in rehab facilities that fail to act like adults. I have seen "kids" ranging from 18 to 25 that, once sobered up, behave far more like adults than the adults themselves. that is really one of the most depressing aspects of rehab, getting into contact with so many adults who can't seem to be able to behave like normal, rational grown ups.
defining mental illness very narrowly though, I have only encountered one psychopath and one sociopath in my rehab stays. a psychopath is basically someone who lives outside of society, in his own world. he has no conscience and no real use for or cognisance of consequences. for a psychopath consequences simply don't exist. a sociopath on the other hand does have a limited (albeit very weak) ability to "feel" empathy and have a conscience. typically a psychopath has no desire to fit into society at any level and is quite content (to the extent that you can even use that word in this situation) to operate wholly apart from it. on the other hand a sociopath has a vague desire and notion of society and attempts to join it on some level. however, due to his pathology he is unable to really integrate himself into society in any meaningful way and will largely "mess up" (i.e. act sociopathically) when trying to join society.
think of it as the difference between an immoral and an amoral person. an immoral person (sociopath) starts with a set of morals (whatever they may be) and then acts contrary to those morals (i.e. immorally). an amoral person (psychopath) doesn't even have a set of morals to begin with, so it is futile to talk about him in the context of moral or immoral acts as there simply is no baseline from which to begin.
I sit down next to P with my cup of coffee. For some moments P is just staring out into the distance. Always sitting somewhat rigidly, seemingly lost in his own world. I take a sip of coffee:
"Do you think John Wayne is Bruce Wayne?" P asks me.
P slides back into his rigid seated posture. It was as if a switch had been flipped. On, then abruptly off. His grey eyes landed on me again:
"You know I was married to Grace Kelly, a lovely girl." P has told me this a dozen times before, our conversations always follow the same route, "Do you know Grace Kelly the movie star?" P continues to inquire of me. "My father in law was Grace Kelly's uncle."
P turns silent again.
"You know I won an Oscar?" P is now on his next road of topics, this one I had heard before as well.
"Well not really 'won' the Oscar, but I took it," with this P gives me a devilish smile. Then he goes silent again.
P is a psychopath. He lives completely outside of society and reality in a sense. The problem with the term psychopath is that most people expect some serial killer. Psychopathology does not have to be that extreme, it can also occur in milder forms like P's. P is able to dress himself, shower, comb his hair, shave, carry on lucid, albeit rather brief conversations if you keep him focused on a certain topic; but for all intents and purposes, P lives in his own world, talking to his own voices that he hears from time to time.
P also suffers from Korsakoff syndrome, which is caused by heavy alcohol abuse. It basically means that P is not able to remember the details of his past, therefore causing him to come up with fables and tales (like the Oscar caper) in order to supplant the memories that have been irretrievably lost. So when you speak with P you mostly enter a world of fiction and fantasy with a few details actually attached to a vaguely remembered truth.
C was laughing maniacally again. You could hear C's laughter from anywhere in the house, it emanated in loud guffaws. C exhibited all signs of true sociopathic behaviour. Unlike P, who was content with sitting outside in a chair all day without any human contact, C craved human interaction. There wasn't a moment that C's voice could not be heard. By and large C's conversational topics were lucid but completely inappropriate.
"Have you ever nailed your nuts to a wooden board?" C loudly asks the breakfast room.
"I watched this video where guys nailed their nuts to a wooden board," and, after a brief pause, "I would do it, no problem."
Or another example of inappropriate (i.e. sociopathic) outbursts:
"Are those new shorts L?" C asks a woman, "You should never wear those again, they make your butt look big."
"You shouldn't eat fries K, you're already too fat."
"Hey, do you know what I do in my room all day? I masturbate."
"Move your fat ass, I can't close the door, you're shaped like a rhinoceros."
Each of the above sentences is punctuated by a wild guffaw as if to offset the absurdity (or rather the callousness) of the statement just made.
C will stare at you for an uncomfortable length of time for no real apparent reason other than to cause an upheaval in the current social milieu. When you acknowledge him he wildly laughs and claps his hands in wild glee brimming with the excitement that he has just forced you to acknowledge his absurdness. C very much wants to be a part of the social circle but it is difficult if not nearly impossible for him to integrate. Therefore, he says highly obnoxious things or behaves in highly erratic ways to upset the norms with which he cannot seem to abide. C is a sociopath in that he feels little awareness of the inappropriateness of his absurd interactions with others.
contrary to P though, C can be made aware of his inability to fit in and there have been many group sessions where he took the berating brunt of those whom he had offended with slight hints of contrition. this is unlike P who, if he were to be confronted by his actions would simply be oblivious to them.
P and C will be like they are forever. all that can really be done for them is to provide them with a safe and secure environment because living a normal life is simply no longer an option for them. medication can also help with the symptoms, but in general there is no going back; they are permanently stuck in their current states. at least P is oblivious, C catches glimmers of his state and seems to have a quiet desperation to cross a road he will never be able to cross.