The Mask of Sanity
Page 62
If such patients could be evaluated in terms of their behavior and committed, like other psychiatric patients, not to limited terms of confinement but for indeterminate periods, the community would obviously obtain far better protection. The patient could then be held until his condition, as appraised by experts, indicated that he could be released with safety to himself and others. Let us grant that even the best of experts is not likely to prove infallible in such an appraisal. Even the wisest and most experienced psychiatrist may be misled by the appearance of profound change in the true psychopath who will later show himself to be as dangerous as before.
Some practical help might be afforded in controlling the psychopath by the general application of laws designed to increase progressively the penalty and term of confinement for those who repeatedly demonstrate by antisocial acts that they have not learned through experience and that they are still dangerous to the community. Some of these principles are reported to be embodied in the Greenstein Act (Pennsylvania),104 which was so designed that the psychopath, as well as other disordered but generally neglected persons who commit legal offenses, can be dealt with by safer as well as more rational and humane methods. Perhaps there is a need for similar changes throughout the nation.
Persons who show evidence of schizophrenic illness or of almost any other psychiatric disorder (excepting that of the psychopath) can, through existing facilities, usually be reached and sensibly dealt with before any legal offense against others is committed. In addition to the valuable contribution offered through the Greenstein Act and similar legal measures, I believe there is also need for some means of committing psychopaths on the primary basis of their demonstrated disability and need. Perhaps all or nearly all of these patients will in the demonstration of their disorder eventually commit antisocial acts by which they might, through facilities such as those afforded by the Greenstein Act, be reached. It is nevertheless true that very serious disability or gross maladjustment may, as in other psychiatric patients, be obvious despite the relatively trivial nature of the offenses which usually bring the psychopath into court.
Relatives, long confused about the nature of this problem, often sacrifice themselves grievously to keep the patient out of court, to prevent his going to jail, to spare his reputation (and perhaps their own, also), and to give him every advantage in the vain hope he will soon change his ways. Effective and rational handling of many patients might be expedited if relatives could initiate legal action for commitment through the same courts and agencies set up to deal with other psychiatric patients, and in the same way, without having to wait for still another crime and another conviction of the patient for legal offense as an obligatory condition, a prerequisite, to such steps. If the same procedure followed in dealing with other serious psychiatric conditions could be utilized without what many relatives would regard as “branding him a criminal,” many advantages in addition to those afforded by the Greenstein Act might result.
Would this jeopardize the liberties of the citizen? Would it enable unscrupulous relatives, psychiatrists and jurists to deprive people of the right to make their own decisions concerning treatment and hospitalization without sufficient cause? Would just about anyone whose conduct did not suit his neighbors (or his spouse, or his old maid aunt) find himself in danger of being declared psychiatrically ill and put away indefinitely?
These are, indeed, important considerations. As pointed out so well by Hall110 and Cumming,64 among others, a basic safeguard of freedom provided by law exists in the right to trial by a lay jury. The law, with good reason it seems, is firmly resistant to encroachments upon the jury’s responsibility. It looks with distrust upon movements which may tend to place into the hands of an expert or specialist final decisions which might deprive a citizen of his liberty or arbitrarily determine the length of his incarceration whether it be in prison or in a psychiatric institution. This is very probably one of the reasons why it has been so difficult to devise legal measures to bring psychopaths under better control. Urgent as the need is for better control of these patients, we must recognize the grave danger which the law must take pains to avoid and try to work patiently with our legal colleagues toward some better solution of a very subtle and complex problem.
Even the laws that are now in force anywhere in our nation, if applied regularly and promptly, might enable us to gain far better control over the the psychopath and to curtail more effectively his trespasses against society and his persistence in a self-damaging career. If his parents, other relatives, and friends would no longer keep on coming to his aid and paying him out of his deliberately self-made troubles but instead would let him face the ordinary consequences and suffer the ordinary penalties, something important would be accomplished. Though one could not count on the true or typical psychopath learning adequately by his experience and achieving a cure, even he would, at least, be better controlled and not left free to continue without substantial interruptions his persistently destructive career.
If the nature of his abnormality were better understood it would not then be used as grounds for mitigating sentences, or for granting early parole, but might warn even the most permissive authorities against the dangers involved.
Over a period of many years I have remained discouraged about the effect of treatment on the psychopath. Having regularly failed in my own efforts to help such patients alter their fundamental pattern of inadequacy and antisocial activity, I hoped for a while that treatment by others would be more successful. I have had the opportunity to see patients of this sort who were treated by psychoanalysis, by psychoanalytically oriented psychotherapy, by group and by milieu therapy, and by many other variations of dynamic method. I have seen some patients who were treated for years. I have also known cases in which not only the patient but various members of his family were given prolonged psychotherapy. None of these measures impressed me as achieving successful results. The psychopaths continued to behave as they had behaved in the past.
Among such patients I recall a young millionaire whose family was able to place him in an institution where every possible resource of psychiatry was available, including psychoanalysis by one of the best-qualified and best known men in our country. Everyone was eager that the patient stay as long as advisable and that every means of therapy be utilized, however expensive, time-consuming, or protracted. Despite these apparent advantages nothing of importance was accomplished. At first the patient expressed great determination to obtain help and to get well. Evidence of such a desire steadily diminished, and eventually it became apparent that he had no real interest in the goals he had set for himself and of which he spoke for a while so eloquently. After a long and tremendously expensive period of hospitalization he left, apparently without regret, discontinued all pretense of seeking treatment, and returned to his familiar ways of behavior.
I am impressed also with the recollection of another patient, a woman in her thirties, for whom almost limitless wealth and strong family cooperation provided every therapeutic advantage. I referred her, long ago, to a colleague outstanding as a leader not only in psychiatry but also in psychoanalysis. Everything conceivable that might be needed in the most ambitious plans for treatment was available. After a careful study of the patient, this able and honest physician advised against any prolonged therapeutic endeavor, since he felt that the chances for substantial benefit were not sufficient to justify the attempt.
The family of still another patient had been told that a distant and renowned psychiatric institution might find some way to alter a persistent pattern of antisocial and self-defeating behavior in their 34-year-old son. I believed that he was a psychopath and did not feel hopeful. Psychiatrists at the hospital, after studying him at length and in depth, concluded that his maladjustment was probably a result of complex influences in early childhood, that it could be accounted for in dynamic terms.
They concluded also that long-term psychoanalytic treatment offered a fairly good chance of success, especially if
it could be undertaken with the patient living outside an institution in a large city where he could find employment but where his financial affairs could be strictly controlled, not by his analyst, but by another medical person. There were several other features to a complicated situation that was set up in the hope of maintaining control of the patient and keeping him under analytic treatment, for years if necessary. This plan called for the expenditure of funds available to few families. Despite all these efforts no notable changes occurred, in behavior or in outlook.
These failures are typical of many others I have observed over the years. For a while I had hoped that long-term treatment might be more effective if the patient could be induced voluntarily or constrained by commitment procedures to remain with the therapist for enough time to give his methods a thorough and adequate trial. I am no longer hopeful that any methods available today would be successful with typical psychopaths. I have now, after more than three decades, had the opportunity to observe a considerable number of patients who, through commitment or the threat of losing their probation status or by other means, were kept under treatment not only for many months but for years. The therapeutic failure in all such patients observed leads me to feel that we do not at present have any kind of psychotherapy that can be relied upon to change the psychopath fundamentally.
Nor do I believe that any other method of psychiatric treatment has shown promise of solving the problem. Physical methods of therapy including electric shock have been attempted.66 Prefrontal lobotomy, topectomy, and transorbital lobotomy have been used in a few patients with severe disorder.18,67,126,173,213 Some encouragement was expressed by a few observers about the effects of these measures, but apparently they have not proved to be a real solution of the problem.
I wish I could be optimistic about the accomplishments of psychiatry in treating and curing the psychopath. Some spokesmen for mental hygiene movements and for greater extensions of psychiatric influence tend to credit us, I fear, with far more power and effectiveness than we have really attained. Hundreds of millions of dollars are being spent to promote mental hygiene and psychiatric care. Many seem to believe that if we only had enough psychiatrists, or enough dynamically oriented psychiatrists, all problems of mental health, crime, and delinquency could be solved.44 This claim is seldom made directly in such absolute terms, but the implication plainly underlies many eloquent appeals for more and more funds from the state and federal governments.44,165,185 Some of the more zealous spokesmen even seem to feel that psychiatry has recently made such profound discoveries and devised such effective methods of eliminating not only illness and crime but also prejudice, superstition, and human error that we can and should settle racial and international problems and even revise the basic standards of morality.44,185
Despite these enthusiastic and at times embarrassing claims in our behalf, our actual achievements should encourage profound modesty. So far no statistical evidence has been obtained to support a belief that our most ambitious, protracted, dynamic, and reputedly scientific methods of psychotherapy have proved more effective even in the psychoneuroses than the warmhearted but unpretentious methods used over the years by kind and wise physicians in the general practice of medicine.42,57,77,251,276 There is, we must conclude, no evidence to demonstrate or to indicate that psychiatry has yet found a therapy that cures or profoundly changes the psychopath.107
I find that I am still in thorough agreement with these opinions expressed in 1969 by Lothar Goldschmidt:97
Psychiatrists have participated in legal proceedings (actively on behalf of clients and passively on behalf of the court) on the assumption that treatment is superior to the penal system. What treatment consists of has rarely, if ever, been described. Is it psychoanalysis on the traditional couch five times a week? Drug therapy? Electroconvulsive therapy? Whatever the case, psychiatry has been subjected to much abuse and has become an object of legal manipulation.
A more cautious approach is long overdue. Psychiatry cannot pretend omnipotence. Members of the profession are fully aware that at the present state of our knowledge, treatment (in any form) is not a feasible means of either cure, rehabilitation, or even improvement of a large number (if not the vast majority) of sociopaths, many other character disorders, and many patients with a chronic psychosis with or without criminal tendencies. Often, custodial care remains the only alternative to prevent a patient from acting in a way dangerous to himself or to society.
Since psychiatrists are not keepers of public morality, they cannot be designated a role of either jailers or judges. Their function is frequently limited to that of consultant.
There are many who believe that the relations between law and psychiatry have become increasingly unscientific and unmedical, at times with disastrous impact on our society. The time-honored system of reward and punishment, in spite of its known limitations, cannot be arbitrarily replaced with vague though beautiful sounding statements about “treatment” as long as there is no sound medical or scientific evidence showing better results with the newer concept. Utopia has not yet been reached.
There seems to be an urgent need for the American Psychiatric Association and for state and local representatives of psychiatry to take a firmer stand to dissociate psychiatry from this abuse of psychiatry. Misinterpretations and distortions of mental hygiene principles should be exposed and prevented. No legislative decisions about treatment should be encouraged unless they are based on documented and scientifically proven results. Should the profession neglect to do so, it will be argued that psychiatry passively condones the release of dangerous criminals into society.
If we have not yet devised adequate legal methods of controlling these destructive people and do not at present have a therapy to offer that has been demonstrated as effective, what, then, can we do?
Let us try to promote a general understanding of the serious nature of the psychopath’s abnormality and of its strong tendency to persist despite all efforts toward correction or treatment. Let us cooperate with our legal colleagues in efforts to devise a more effective means of keeping psychopaths under adequate control. The degree of control should, insofar as possible, be regulated by the need, that is, by the degree of disability that the patient continues to demonstrate. Let us recognize psychopaths as differing greatly from the psychotic and psychoneurotic patients for whom our present hospitals and clinics have been designed and our current methods of treatment or control established.
It is urgent and obvious that we devise some more effective means of restraining these people in their persistently destructive careers. Henderson says: “It is amazing and almost paralyzing to realize the extent to which some of these cases may go before any action can be taken legally or medically to exert adequate control.”128
If a proper general understanding could be reached that such people have a serious psychiatric abnormality and are not likely under prevailing conditions to become better and if this fact could be disseminated, their families might be able to reconcile themselves better to a major problem and seek more realistic ways of dealing with it.
By systems of parole, probation, and supervision designed specifically for patients of this type and devised to meet the tort of problems they present, it is probable that reasonably effective guidance could be maintained after hospitalization and, when necessary, restraint be applied pertinently and effectively. We must remember that under present conditions nearly all psychopaths are entirely on their own in the community and that the few with whom society gets any opportunity at all to heal fall under one or the other of two methods. Neither of these methods was evolved with any cognizance of the psychopath, but each for quite a different sort of problem.
On one hand, the existing psychiatric hospitals, parole arrangements, and mental hygiene clinics, are set up to meet situations that arise in dealing with (legally) psychotic and psychoneurotic patients. With patient’s in these two groups, our methods, imperfect as they may be, are relevant to the situation.
Without medicolegal apparatus to reach him, without social instrumentalities designed to cope with his problems or those he makes for others, and with no general recognition even of his presence, we find ourselves emulating the ostrich and its proverbial tactics of evasion.48 When the situation becomes too alarming or too monumentally fantastic for us to continue these tactics and when it cannot any longer be blandly ignored, we find ourselves fumbling between the only two methods available, neither of which, we find immediately, is applicable to the real issues we confront.49 Psychiatrists finding its impossible under existing circumstances to continue any long-range plans are hardly to be blamed if they tend to regard these people as birds of passage through their institutions, that is, as patients in name only who seek temporary refuge there from other legal restraints, create much confusion and disorder, then leave when it suits their whim or convenience, to continue in their former maladjustment.
Turning now to penal facilities, now to psychiatric institutions, relatives, friends, doctors, lawyers, or the community at large, all find themselves at a loss, somewhat as if they were trying to measure areas in kilowatts or color in inches. Since the fire extinguisher did not particularly help the child’s fever, which has become alarming, we gravely decide to apply a plaster cast. There are no really appropriate remedies available.