In considering what the previous authors in this symposium have brought out regarding the relations between psychiatry and the law, I cannot help thinking about the definitions of a philosopher and a theologian given to me by a person who was both. He said the philosopher spends his professional life in a dark room looking for a black cat that is not there. The theologian does the same thing, but he finds the cat. Sometimes the search for a way to engage both psychiatrists and lawyers in a collaborative effort to reduce dangerous conduct by individuals can seem quite similar.
My own introduction to psychiatry occurred as a result of a dangerous student's remaining at large in a college community, despite clear evidence that he was far from well adjusted. This student always ran from one class to another during the period when his propensity for violence was developing. He had unusual diet practices, not in themselves significant, such as eating apple sandwiches (strange at that time but, I am told, not so now). He had few friends. He gave earnest lectures on the dangers of Communism, charging 25¢ admission. Then he bought a pistol and ammunition and showed them to a few other persons. This was reported to the dean of students, who remarked that boys and such instruments went well together. One night the youth took his gun to the room of another student and said, "Smith, I am going to shoot you." With considerable presence of mind. Smith replied, "I don't have time tonight; I have an exam in the morning. Come back tomorrow night, and I can accommodate you." He left, but the next day he killed one student, wounded another, and then killed himself. Smith left college.
During the ensuing investigation, it became painfully obvious that the awareness of what constituted potentially dangerous behavior was regrettably low among both college officials and students. I was sent to the Austen Riggs Foundation at Stockbridge, Massachusetts, for six months to see if I could determine why students would act that way. I am still trying.
A few years ago I participated in an attempt to develop an Institute of Justice. This was a proposed organization that had the backing of the Chief Justice of the Supreme Court, the president of the American Bar Association, presidents of various colleges, chiefs of police, and many others. At that time we were encouraged to believe that some of the problems under discussion here could be solved.
That stimulated my already strong interest in forensic psychiatry. And if we have not found all the answers to the problems that we thought we would - as the authors of the previous articles in this issue of Psychiatric Annals have made clear - we at least have a better understanding of some of the problems.
And the problems are severe. One of my colleagues became the physician in a state correctional system a few years ago. After he had been on the job a few months, he realized that it was a unique experience: he had never before been asked to work in a system where there seemed to be almost a deliberate attempt to furnish the patients the poorest possible medical care. His conclusion was the same as that arrived at by many of the people in the Institute of Justice meetings: We are acting as if we knew nothing at all about people who are in distress.
When I chose the topic of dangerousness for this presentation, I did not realize what a task I was setting for myself. While it is a very important subject, it is an ambiguous one; its meaning changes constantly, depending on what kinds of circumstances are being considered. It may involve potential for harm to others or to oneself. It can be direct (physical force) or indirect (not following safety principles, medical advice, or other rational courses of action). I plan to concentrate here on the potential for harm to self or others by persons who are considered to be mentally ill.
The more I considered the problem, however, the more I became concerned that we are perhaps using the wrong subjects in our attempt to determine individual potential for violence. Are the mentally ill likely to be any more dangerous than angry, bitter, disillusioned, or disappointed persons? We have good evidence to suggest that the mentally ill are perhaps less dangerous than so-called normal peopel. When one reflects on the rise of violence in this and many other countries during the past two decades, it becomes apparent that the great majority of capital crimes, serious assaults, and crimes against property are committed by persons who are not thought to be mentally ill.
To add still another dimension to the total problem of violence, which is essentially synonymous with dangerousness, we now have highly organized programs of instruction in methods of exerting violence. Even though they were originally designed as entertainment, the television programs, movies, and plays featuring violence and lack of personal standards serve well to educate the public, particularly children, in how to commit crimes. It is encouraging that countermoves against this education in violence are now being organized, with some degree of support but not yet enough by the general public.
DETERMINATION OF DANGEROUSNESS
The term "dangerousness" can be broken down into at least four component elements: (1) magnitude of harm, (2) probability that the harm will occur, (3) frequency with which the harm will occur, and (4) imminence of the harm.
Violence to the person is ordinarily viewed as more serious than harm to property. Physical harm is likewise regarded generally as more serious than psychic harm, although the reverse can sometimes be the case, and physical harm usually includes an emotional component. Psychologic harm may consist of uttering offensive words, engaging in sexual deviations (such as exposing oneself), acting in a bizarre and frightening manner with children, or threatening physical violence.
If a person goes about on the street loudly shouting obscene words and phrases, he causes embarrassment but is not necessarily dangerous; nor is a person who lectures at the top of his lungs in a crowded city. If a person can find sexual release only in setting fires, however, one can confidently predict that dangerous acts will occur. It would be helpful if some members of society could identify who will kill, rape, or burn, but at present this is not possible.
Some dangerousness that stems from physical damage to the brain can be identified and remedial action taken.
I remember one time when an elderly professor - a man who had been perfectly reliable in his conduct - suddenly began to display erratic behavior. I was summoned and quieted him down. Then I gave him a brief, emergency physical examination and noted that one of his optic disks was choked. I suggested a neurologic examination; sure enough, he had a brain tumor. So, in some instances, dangerous behavior that is quite out of character can be a symptom of increased intracranial pressure. In this particular case, the tumor was surgically removed and the patient recovered.
Any person can become dangerous at some time, either positively or negatively; that is, either what he does do or what he does not do may result in harm to others. Dangerousness from neglect, however, is looked upon quite differently from dangerousness from positive action.
Predictions regarding dangerousness in mentally ill persons are notoriously unreliable. Most observers who have done considerable work on this subject suggest that most predictions of dangerousness are inaccurate. Whether or not a disturbed person resorts to violent behavior depends to a considerable extent on how he is treated. Some persons who feel suspicious to the point of paranoia can control themselves if those around them indicate, by their actions, that such behavior would not be helpful or appropriate. Furthermore, patients tend to react to kindness as do persons who are not disturbed. If a person is confined in notably unpleasant surroundings, is given few or no choices as to what work he is allowed to do, receives little or no compensation for any constructive efforts he makes, and has few opportunities to express himself with impunity, the probabilities that he will engage in violent behavior are increased significantly. Mental illness does not cause most patients to lose their capacity to be resentful at unattractive surroundings and companions. Mental patients are remarkably like other people - particularly those with medical or surgical disorders. They appreciate friendliness and understanding. They also appreciate the opportunity to express themselves without being judged prematurely or being punished for something they do not understand or for responding to impulses that they cannot control without help.
Persons not mentally ill may be dangerous, but this prediction in them is no more accurate or reliable than it is in the mentally ill. Mental illness simply adds another factor.
What are some of the factors of dangerousness in everyday life? Dangerousness is common in terms of the actions of drunk drivers. It is common in the widespread neglect of the correct care of mechanical devices. The factors that can give one person a propensity toward violent behavior can start quite early in life. The child who has been the victim of child abuse is more likely to grow into an adult who will engage in similar behavior than one who has not. Children who show cruelty to animals often grow into adults who show cruelty to people. The use of stimulants and the excessive use of alcohol are other obvious factors that should be taken into consideration. Violence is much more common among the poor and minorìty groups than among people who are well off, since a "brooding sense of injustice" causes many people to want to tear things down.
If a person has never engaged in any dangerous behavior or violent action before, prediction of dangerousness is very uncertain. Prediction is more certain in the reverse case: a person who has committed a violent act is more likely to do so again. One tends to think of the possibility of dangerousness in others in somewhat the same way as one thinks of the danger of suicide in a depressed person. An angry person is more likely to react strongly to threats (either actual or implied) than one who is not angry, just as a person who is very depressed is more likely to resort to suicide attempts than one who is not.
In any consideration of dangerousness, the physician most likely to be involved is the psychiatrist. Psychologists, social workers, nurses, religious advisers, and others may also play an essential role. A major difficulty at once becomes apparent when a specific situation arises centering on the problem of just how dangerous a suspicious, angry, or psychotic person may become and what legal action, if any, should be taken.
The recent series of conflicts between the professions of law and medicine has distressed me considerably. I have always looked with great admiration at the two professions, because of the esteem I have developed toward my own teachers and later associates in the field of medicine and the respect I have gained for the profession of law in working with my lawyer colleagues. I have always assumed that, by and large, lawyers were more skilled than physicians in intellectual discourse and that physicians were more facile in dealing with the complex disorders of body and mind that constitute their day-to-day sphere of activity.
The truth is that no one can be sure whether or not threats will be carried out. It is not just a question of how angry the person is. The outcome depends more on how the person interprets the words, mannerisms, or facial expressions of those with whom he or she comes in contact. The psychiatrist (or other mental health worker) is presumably in the best position to judge what is going on in the patient's mind, but his knowledge is usually far from complete. He often gets the idea that a lawyer questioning him during a court procedure is saying, "You know what is wrong, you know what the patient is thinking about and what he will do under various circumstances." The implied assumption is that if the psychiatrist does not give definite answers, he is just plain ignorant. When the questioner is belligerent and the psychiatric witness is cautious, the stage is set for strong feelings that will impede rather than enhance communication between the two professions.
LIMITATIONS OF ACTION
A person who is likely to become dangerous but who is not mentally ill cannot be confined to prison for an act that he has not done. A person who is mentally ill can be confined to a mental hospital if a psychiatrist testifies that he is likely to commit a physically dangerous act. Commitment is justified on the basis that the confinement might be beneficial to him. It is never known whether or not violence has been prevented, for if one prevents something he destroys the evidence that he has done so.
During World War II, I had one pleasant but strenuous two-year tour of duty at Bethesda Naval Hospital, in charge of NPSOQ, which means Neuro-Psychiatric Sick Officers' Quarters. When the new building (completed in 1943) was planned, no provision was made for naval officers who might need psychiatric care. The explanation was that members of the planning committee assumed that there was no need for such a ward, because naval officers were all gentlemen and hence not likely to need care for emotional problems. So the service had to be housed in the maternity ward for a few months until other quarters were found for us.
During my tour of duty one of the Wave officers became psychotic, and we were readying her for transfer to St. Elizabeths when I got an urgent telephone call from a high government official requesting that I keep the patient in the open ward at Bethesda. I explained to him that if I did not send her to St. Elizabeths I would have to explain in the record why I did not do so, and he and I would both share the responsibility if anything went wrong - as I thought it very probably would. There was dead silence for about 20 seconds, after which he responded, "Well, Doctor, you know and I know that she should be transferred. If you do not get a call back from me in half an hour, go ahead and use your own best judgment."
I realize that collaboration between law and psychiatry is not always easy, particularly when dangerousness is at issue. But the price of the failure to collaborate is dreadful. A few years ago, for example, pressure began to build for nonhospitalization of mentally ill patients unless they had actually committed an illegal act. Right at this time an alumna of one of our noted women's colleges became psychotic while visiting another city and was taken to a public hospital for treatment. She was refused admittance on the grounds that she looked all right and had done no harm to anyone. Having no place to go, she just wandered around the downtown area near the railroad station. What happened could almost have been expected: She was found in a garage within a few hundred yards of the station cut to pieces by unknown assailants. It was dangerous for her to be abroad even though she may not have been dangerous herself.
This "dying with her rights on" was, of course, a tragedy of the first degree - a tragedy that could, and should, have been prevented by cooperation between our two professions rather than the adversary process that was used.
I acknowledge that if all persons who were feared to be dangerous were committed to mental hospitals, most of them would be deprived of their liberty needlessly.
Collaboration between lawyers and psychiatrists should be attempted even when the likelihood of a meeting of mind seems considerably less than promising. I think that in cases like this, the psychiatrist must be candid and honest and must explain things in a straightforward manner as he sees them.
Each of our professions, by their very nature, must face a number of uncertainties. I would like to see a way worked out by which we could have a more effective and a more frequent dialogue between the members of our two professions. I believe that such a dialogue would help us in working out better ways of dealing with the mentally ill. To put it another way, lawyers and psychiatrists can solve more problems by collaborating with one another than by trying to utilize the adversary process against each other.
MANAGEMENT OF THE POTENTIALLY DANGEROUS PATIENT
An angry person is more likely to react to implied or actual threats than one who is not angry. Similarly, a person who is very depressed is more likely to attempt suicide. The central factor in the treatment or management of such persons is to try to work through their tensions and help them find ways of dealing with these, a process that gives some feeling of accomplishment or satisfaction.
Can an atmosphere be developed in a mental hospital that will reduce rather than encourage hostility? I believe it is possible. Many very paranoid patients will react positively to friendly explanations of their feelings when assured that their strong feelings can be understood and appreciated.
For those of you who are not used to it, I might point out that it takes a little courage to sit close by a very angry, paranoid patient and carry on a conversation with him quietly, without moving your chair back a few inches in case he decides to lunge at you. But it is surprising to me how often, if one does not act afraid, he can gradually communicate some little indication of warmth. And after a while, you can get the feeling across to the patient that you do care.
I would like to suggest the possibility of setting the stage for a therapeutic community within the hospital ward. Those in charge can develop a program to make the hospital unit itself a form of therapy, with all members of the staff showing understanding and kindness, doing all they can to improve communication between themselves and with the patients, and giving concrete signs of approval and encouragement when a particular patient makes progress in managing himself.
One time I was asked to treat four paraplegics with aphasia. I learned for the first time that aphasies can sing. So we had a quartet of aphasies, and it was quite astonishing to the rest of the hospital staff to see how well they could sing. The point is that there may be a variety of ways for a patient to accomplish something even when there is not much he can do.
In short, every ward or unit should be, insofar as possible, a therapeutic experience. I realize that this is asking for the seemingly impossible. But I know from experience, as well as observation, that when a favorable therapeutic environment is developed by a coordinated effort on the part of psychiatrists, nurses, social workers, and attendants, the patients make faster progress toward recovery. Even patients whose plight is considered hopeless can be helped by concerted efforts devoted to helping them understand themselves and capitalizing on the limited activities that they can enjoy.
Unfortunately, the treatment of seriously disturbed patients is grossly neglected in a large proportion of our mental hospitals, for a number of reasons. Many find such work unpleasant. Compensation is usually inadequate for competent persons. The history of care for the mentally ill consists of alternating periods of despair, indignation, extensive plans for reform, temporary success, ultimate discouragement, and scapegoating, followed by another round of the proposed reforms and another cycle of the same things, with variations dependent on the relatively small progress that may have been achieved. We need a continuing series of Dorothea Dixes, Harry Solomons, Robert Felixes, and other pioneers, who have tried to get people interested in the plight of the mentally ill, to use the principles we already know, and to persuade our legislatures and policymakers to make known principles and procedures available on a large scale.
The total cost to society of optimal treatment for the emotionally disturbed and mentally ill is indeed great, exceeded only by the cost of completely neglecting them.