In the following discussion, the authors of the preceding articles discuss and give their impressions of the effectiveness of current methods used in criminal rehabilitation. Moderator of the discussion is James J. Delano, M.D., senior consultant in child and adolescent psychiatry at the Mayo Clinic.
Judge Bazelon: It seems to me that none of the providers of treatment services have the know-how to implant our middle-class sensibilities into the youngsters who are ending up in our criminal- justice system. These are youngsters who have been actively neglected for 24 hours a day every day of their lives. There is no magic humanizing pill that any of the providers of treatment - psychiatrists, psychologists, or social workers - can give these youths. The point I was trying to make in my talk, Dr. Tyce, was that all of these after-the-fact treatment services have proved stunningly to be failures. Now where am I wrong?
Dr. Tyce: Well, I don't think you are wrong. Psychiatry acknowledges that parental neglect of children will bring us patients later on, when they are in adolescence and when they are adults. It will also result in some of the children being brought into the correctional system. When the symptoms stem from early neglect, there is nothing that the psychiatrist can do for the patient except deal with the present. My thesis is that we should deal with the present in dealing with the correctional system.
The correctional system - the institutional system in this country - has not learned a single damned thing from the history of mental health, from the history of institutional mental health. The improvements psychiatrists have been able to bring about in patients during the past 20 years have passed these people by. Psychiatrists have recognized many of their past mistakes during this period. Dr. Farnsworth was talking about the importance of the "climate" on the ward. All of us know how the climate changes when there is a switch from an open situation to a closed situation. Psychiatry has learned many things about institutions during these years and about what institutions do to people, but these insights have not been implemented in our correctional system.
I think the public climate in which children grow up today is a factor in violence. The constant exposure to contemporary violence on the news programs is something children see very early in life - not mythical violence, where the wolf eats up Red Riding Hood, but current violence, which is instantaneously transmitted four times a day. Children see it all the time - they live with it.
Perhaps there is nothing we can do about this public climate. But I think we can do something about what we are stuck with if we make the effort.
There is another matter I want to bring up, and that is labeling. We treated people for years by labeling them before we realized it was wrong. In our court system we are still treating people by labeling them, and 1 think we ought to do something to correct this.
What I mean is this: We are incarcerating people by label. This is wrong, because no two murders are the same. One thing I've learned in talking with prisoners is that violence occurs in many different ways. One person kills another for greed. In another case, a 60-year-old man finally shoots his 86-year-old mother because he can't stand to see her live any longer. Both men are likely to receive the same treatment when - to me - the situations aren't the same at all.
Judge Bazelon: Are you saying that you believe in rehabilitation and that we have means for effecting rehabilitation?
Dr. Tyce: If I didn't believe in rehabilitation, I'd be in another profession.
Judge Bazelon: What evidence is there that we have had any success at all at rehabilitation? The information that I have is that we haven't.
Dr. Tyce: If you mean rehabilitation in prisons, all the information shows that rehabilitation is impossible in prisons.
Judge Bazelon: That's what I'm saying.
Dr. Tyce: I'm convinced the only solution is to keep them out of prison, to put them in some other kind of prison * - a community-based system.
Judge Bazelon: Yes, but even with another system you'd have to put them back eventually into the community from which they came. And when you put them back in that community and subject them to the same conditions and circumstances that led to the original offense, you're involving them in the same situation that led to the crime in the first place.
Dr. Tyce: I'm not saying that we should put them back in the home. I'm talking about creating ...
Judge Bazelon: How can you legally separate the offender from his family and from his home environment and all his friends? Do you give him new friends and a new family?
Dr. Tyce: If you create a community facility - and I mean a domiciliary facility - offenders who are placed there are placed in a group with their criminal peers. But as we have found out, you can dilute the criminality of this milieu by getting other young people to live in this domiciliary facility with them. The idea is to give the offender a positive peer image and show him that other people of the same age can grow up without finding it necessary to break the law. Such a facility would have to be staffed with people who are competent in effecting behavioral changes in individuals.
Judge Bazelon: As I understand what you're describing, we've tried a lot of that, and it hasn't worked. We have made all kinds of attempts - halfway houses . . .
Dr. Tyce: Can I add one more thing? All the houses we've tried have been halfway-owf houses. What I'm talking about are halfway-/« houses - that is, places that would be alternatives to going to prison.
Dr. Usdin: Our attempts so far have been feeble, to say the least. Not only do psychiatrists and mental health professionals look down upon this kind of a careeer as a dirty type of thing to be involved in, but so do members of the legal profession. There are a few judges who sit on high benches who are willing to address themselves to the problem; but by and large the average lawyer is not, and the average lowercourt judge is not.
I realize that there have been noble efforts, but they are small in relation to the size of the problem. We have some 2.1 million United States citizens who are caught up in some process of the legal system right now - either incarcerated, on parole, or on probation. That's an overwhelming number of human beings. Many of them do not have adequate legal counsel and/or are being neglected. I don't think that psychiatrists or lawyers should take the total blame for it. But the correctional system is a dirty thing to be involved in. It's low status for lawyers and low status for psychiatrists. By and large, the lawyers who work in the criminal courts are not the ones who are the most highly respected in the profession. As for psychiatrists, a dramatically low number are involved with the correctional system. However, I think we are making some slight headway in this area and are getting a broader spectrum of psychiatrists involved in the legal process.
As far as the public's attitude is concerned, it is not one of sympathy. Rather, it is a talion type of outlook, with vindictiveness. Many people are concerned that there may be "mollycoddling" of criminal offenders. They believe punishment should be severe - so severe that it will be a lesson to others and a deterrent to the commission of future crimes. Legislators recognize the lack of any vote potential among criminals, and, as we know, there is no consumer lobby emanating from the incarcerated.
Judge Bazelon: I seem to have a single theme, and that is that you have to look for causes. Why does the offender get caught up in the correctional system in the first place? I don't hear anyone talking about dealing with causes. I hear about treatment - honest, sincere efforts to effect better treatment - but nothing about causes.
I think we have to be concerned with the cause of criminal behavior, because for every one person who is arrested as an offender there are a hundred others coming up right behind him - because the conditions that led to the offense, the causes, are still there.
If you think I am harping on this one theme too long, I may just be like the man who had the idea that he could play the cello. Every night after dinner he would ask his wife to sit and listen, and he would take out the cello. He was awful, terrible. His wife was long-suffering, and she took it for a while. Finally she said: "John, stop!" She said: "You know, when I go down to the symphony and watch the cellist, he's moving his left hand up and down the neck of the cello, and his fingers are pressing down on different strings while he draws the bow. But you don't do that. You just keep your left hand in one place as you draw the bow. How come?" He looked at her and said: "I'm glad you saw that. I'm glad that you observed it. You see, I've found the right note."
Dr. Farnsworth: If we want to think about causes, we've got to give some consideration to the families these offenders come from. I'm concerned about the weakening of the family in this country. The nuclear family is being pushed around more and more, and the extended family is getting more and more extended.
At the same time this is happening, two other forces are at work putting pressure on the individuals in the family. There is the public climate of violence Dr. Tyce mentioned. And, at the same time, there has been a gradual development of a situation in which we teach people to feel aggrieved because there are conditions in their life or their work that do not seem just to them.
I have two proposals. One is that we as a people must develop the theme of constructive intolerance - constructive intolerance of things that are known to be detrimental to the welfare of the young.
The second refers to those nuclear families who do not have the extended families of uncles, aunts, and grandparents to help them, as so many families did in past generations. If, in some way or other, we could get some of the energies of these people who feel aggrieved - people who have energies to spare and time to spare - to help the nuclear families who do not have extended families, we might solve two sets of problems at once. What I'm about to say is a gross oversimplification of a very complex problem, but the fact is that some of the happiest retired people I know are the ones who are helping people less fortunate than themselves. This seems to be particularly true when the people being helped have young children in the family, and the young children find out that old people do occasionally have something to say that is worthwhile, that they are nice to have around as supplements to parents.
In short, we've got to move in the direction of developing preventive medicine to keep our families healthy if we are going to solve several of these problems at once. We already have the nucleus of a partial solution to these problems, but we aren't getting any further because we are regrettably ignoring the good movements that are already under way.
Dr. Tyce: I wonder, Dana, if you would say something about the relationship between acts of violence by juveniles and chemical intoxication. I mean alcohol and drugs. In your experienee, is there a fairly direct relationship - I mean, perhaps a one-to-one relationship - between the person who is chemically intoxicated and the violent offender?
Dr. Farnsworth: I'm glad you mentioned both alcohol and other drugs. You frequently hear parents say, "Oh, thank God, my children are getting drunk! They're off drugs." What has been happening in the past few years is that the greatest drug problem in this country now involves the abuse of alcohol. We have about 10 million people in this country who are alcoholics and another 10 million who are problem drinkers. That is a lot of people. Alcohol can be used constructively, as all of us who have attended cocktail parties are aware. We can't go back to prohibition. But we do have a problem with major dimensions, and it is not being helped by the state agencies created to regulate the consumption of alcohol.
One group that I am associated with has just completed a study of all the state alcohol beverage control commissions. Not one of the commissions is considering alcohol from a public health point of view. Every one of them is out for one thing: to stimulate the sale of more alcohol to whoever will buy it.
So, when we are talking about causes, I think we as a nation have got to find ways to teach young people how to use alcohol constructively - to use it in a way that is not going to harm them.
Dr. Tyce, you asked about the relationship between chemical intoxication and violent behavior. I believe there is a fairly direct relationship between alcoholic intoxication and acts of violence, and the relationship holds true whether the individual is a juvenile or an adult. So many accidents are caused by the loss of judgment when alcoholic intoxication has occurred.
Insofar as most other drugs are concerned, they are nowhere near as likely to result in violent behavior. Marijuana, in particular, is more likely to lessen than to increase the possibility that a person will do something violent.
Dr. Usdin: We're all aware of the relationship between alcohol abuse and violence. To take just one example, alcohol is frequently a factor in those automobile fatalities that have suicidal or homicidal connotations. And it is a factor in 55 to 60 per cent of the direct homicides.
Dr. Farns worth: Yes, we've got our priorities mixed, and we haven't got them unscrambled yet. We've spent all our energy damning marijuana, which is no good anyway. And we've overlooked the real danger.
Dr. Delano: Perhaps some of you in the audience would care to comment.
Dr. Manuel M. Pearson, Philadelphia: I'd be interested in hearing all of the panel members comment on the victim of the crime. Why does one become a victim? And how do others who make a point of victimizing them discover who the victims are?
For example, I recall a young adolescent who was psychotic, with a history of drug indulgence over many years, and who came in with the classic picture of being terribly depressed. She just wanted to die. She was placed in the adolescent unit. Of all the people in the unit to associate with, she chose the 13-year-old boy who was the most violent person on the floor to badger. And, sure enough, he choked her and darned near killed her. The question of how - and why - she selected this particular person out of the whole 20 in the unit seems to me to be important. It would appear that she wanted to become a victim.
Dr. Usdin: One hunch is that she would pick someone who would punish her, whom she knew would be likely to act on her desire to die.
Judge Bazelon: The fact that she was suicidal doesn't tell you very much - you can't solve the problem simply by knowing that she was suicidal. What was the cause of her being suicidal?
Dr. Pearson: As I mentioned, she was psychotic and had been taking drugs for such a long time that she was in this delusional state.
Judge Bazelon: Why was she psychotic?
Dr. Pearson: The drugs were a factor. She had a very disturbed relationship with both parents and had been in therapy for years. She had been a very disorganized person for at least four years.
Dr. Delano: Are you asking about victims in general? Do you mean that some people choose to be victims, and other people victimize them, and that this may be an issue in crime prevention?
Dr. Pearson: Yes.
Dr. Tyce: Well, I doubt that many people who are victims choose to be victims. If you are talking about people who get victimized by being assaulted, raped, robbed, murdered, burglarized, and run over in the streets, why, I doubt that many of these individuals have been looking for that sort of opportunity.
Dr. Pearson: Right here at the Mayo Clinic there has been some excellent work, by the late Dr. Adelaide Johnson, to indicate that victims do feel a need - an unhealthy need - to be punished.
Dr. David G. Nesset, Rochester, Minn.: I think Dr. Farnsworth used an appropriate phrase when he said that violent conduct often stems from a brooding sense of injustice. Since psychiatry is oriented towards the individual, it may not be the place to seek the genesis of violence occurring on a much broader social basis. I think that ties in with what we have been saying about victimology: People who have that sense of injustice engage in violence as a self-fulfilling prophecy. Thus, when they are punished, they are once again victimized by the system that contributed to their brooding sense of injustice.
Dr. Farnsworth: These are frustrating problems that we are trying to solve, and it is easy to throw up our hands and quit working on them. But we'd better not do that. There are many things each of us can do if we can only persuade each person to do his share in his own community with the people he knows about.
Dr. Howard P. Rome: I have a question, gentlemen. Why are you engaged in this Sisyphean task?
Dr. Usdin: I have a question first. Once again, Dr. Rome's fabulous vocabulary leaves me behind. Will somebody define "Sisyphean"?
Dr. Delano: Sisyphus was the legendary king who was condemned to spend eternity rolling a heavy rock up a hill in Hades. As soon as it neared the top, it rolled back down again and he had to start all over.
Dr. Farnsworth: I'm engaged in trying to find a solution to some of these problems because I think they demand a solution, and I enjoy looking for one.
Judge Bazelon: And I'm engaged in it because, I suppose, I see injustice more than most people. I've been on the bench for a long time, and I see society blindly slashing away at human beings without showing any regard as to why they are unhappy. Society is ignoring this injustice.
We're not going to solve all the crimes of violence that occur. We're not going to solve all offenses against society. But I think it is useful, in talking about the problem, to consider four different categories of crime.
First, there is the white-collar crime. Nobody is much interested in the white-collar crime. It is important, but we don't lock the door at night or keep the women off the streets because of white-collar crime. Punishment is an effective deterrent to this type of crime, because the people involved understand the values. They have an incentive to conform: they have a lot to lose if they don't conform. If a man is sent away for three months or six months or a year for stock fraud or for tax evasion, everybody in his country club will run down and pay his taxes or cut out his stock frauds. So here punishment works.
Next, there are crimes of passion. I don't believe any of us really think that there is much that can be done about them. You have 10 times as much chance of being killed by a member of your family as you have of being killed by a stranger.
The third category involves organized crime. Bad as it is, even this kind of crime usually doesn't make us lock our doors at night or keep our women off the streets. Because it is a link between the political or financial world, on the one hand, and the underworld, on the other, organized crime is combated best by exposure. Exposure is the most effective deterrent you can have.
The fourth category is the type of crime I was talking about earlier, and it is the type of crime that has forced everyone to change his way of life. This is the violence in the streets. Even if our fear of that type of crime is exaggerated, it is not exaggerated by very much. This is the crime that is bothering people, and so far there has been no evidence that punishment is an effective deterrent.
What causes this type of crime? Ninety-nine per cent of these crimes are committed by those who are right at the bottom of the barrel - the people at the real bottom of the barrel. So you know that the cause of this type of crime is rooted in social injustice. You don't have to try to analyze it - you know it's true.
These are the people who are causing the crimes that everyone is worried about. And we're not doing anything about the causes because we think it would be too expensive to correct them.
There was a time in our society when that sort of approach seemed to work. The poor were always with us, and it seemed cheaper for society to suffer the effects of poverty than to do something to improve the lot of the poor.
Now we're coming to the point where we realize this approach isn't working. So we have to make a hard choice: either we're going to have to do something in a meaningful way about these conditions that breed crime - confront the problems of injustice that are producing most of this crime - or we're going to have to deal with it by means of repression, by getting tough.
That is what happened in Germany and Italy and in other places. There are cheap and easy ways to get the job done, we are told. But they are not cheap and easy at all.
Dr. Farnsworth: Another aspect of the problem is that youngsters tend to imitate what their elders do rather than what they say. And the low esteem in which many of our major professions and occupations are now held is a manifestation of this, and it is very distressing. Physicians are still at the head of the list of most-esteemed professions in the opinion polls until they are called psychiatrists, and then they're way down there with the advertising men and members of Congress.
What I'm saying is that something has happened to a large segment of the so-called responsible people in our society. And we must work on this area at the same time we are working to correct the injustices Judge Bazelon is talking about.
Dr. Delano: Perhaps it's our failure to work on those injustices that produces the failure at the other end of the spectrum. Are there any more comments?
Dr. Gerald J. Sarwer-Foner, President of the American Academy of Psychiatry and the Law and Professor and Chairman, Department of Psychiatry, University of Ottawa: I'd like to comment on Judge Bazelon's presentation. Most of us have an enormous respect for the main thrust and general conclusions of your work. Judge Bazelon. If s very difficult to be critical . . .
Judge Bazelon: No, it's easy. [Laughter.].
Dr. Sarwer-Foner: . . . but I think I have to make this criticism. It seems to me that the baby is being thrown out with the bathwater. What I mean is this: When psychiatry is characterized as the emperor who is found to be not wearing his clothes or when psychiatric diagnosis or opinion is considered as being at the best an informed or educated guess, I think this ignores what has been going on for some time. The psychiatric diagnosis properly made on the basis of a thorough examination is not "labeling"; it is as accurate a diagnosis as an orthopedic surgeon's or that of a practitioner in any other branch of medicine. When these conditions are met (that is, a good examination, etc.), it is wrong to call other medical diagnoses "diagnoses" and psychiatric diagnosis "labeling." Of course, no one is defending sloppy psychiatric work. Dr. Usdin made the point that, in his court experience, psychiatric testimony was often poor - poorly made and not based on verifiable facts. When he says this, I think we can only listen and agree that this is sometimes the case and benefit from the criticism. Poor diagnosis based on poor examinations is just that. That, too, is not labeling but poor and faulty work, leading to inaccuracies.
But that is not all that is happening in forensic psychiatry. In this regard, I think it is significant to mention that the American Academy of Psychiatry and the Law - an organization that had only a few members several years ago - now has some 500 members and is growing by leaps and bounds. Another thing of significance is the number of conferences and courses in this field that are now being provided by law schools and medical schools. The American Foundation of Forensic Scientists has just helped establish an American Board of Forensic Psychiatry. This board will now examine psychiatrists, provide a syllabus, and give certifying exams. These developments indicate - to me, at least - that in the not too distant future there will be a much better level of psychiatric testimony before the courts than there has been. That is devoutly to be desired, and I think it's coming.
The low esteem in which psychiatry is now held is a matter of great concern. This is partly because of the kind of publicity we have been discussing and partly because of the facts Dr. Usdin and Dr. Farnsworth brought out.
Another subject of great concern is the intrusion of law into the practice of psychiatry in a massive way. For example, the Committee on Psychiatry and Law of the American Psychiatric Association has been holding discussions preparatory to issuing a series of guidelines for the construction of a model commitment code. The thrust of these discussions has been very different from what we have been hearing here. That is, the psychiatric patient would be treated like all other patients. He would not be brought up for a court hearing (unless there was a challenge) every time there was a question of a balky patient. Rather, he would be treated in the tradition of medicine - with informal but nevertheless legal due process. The damage done to psychiatric patients, when they are forced every time to a court hearing on their reputation, is very considerable.
I don't want to belabor the point, but I do think that psychiatric evaluation has been unduly maligned in the public eye. We have 100 years of experience in this, and if you examine the work done by the best psychiatrists, as well as the worst, I believe you'll find that on balance there has been good diagnosis, good description of mental illness, reliable statements as to the natural course of the illness, prognosis, categories of patients, and so on.
"Dangerousness" is used to describe an individual who is considered to be dangerous over a period of time. We use an examination which I believe can determine whether the patient is a danger to himself, to property, or to others. I think our results in predicting who will be dangerous and who will not have been much better than has been indicated in this discussion.
The contrary argument, that any educated layman can parade through a ward and spot illness by using his common sense, is of course true up to a point. Any seriously agitated person who is armed is going to be obviously dangerous to any sensible person. But this reasoning holds true for any aspect of medicine. It doesn't address the clinical situation the physician faces: that refinement of judgment and experience are necessary to provide therapeutic care for somebody on a daily basis. Similarly, I don't think it's true that psychoanalytic theory is unprovable. After all, theory is theory and fact is . . .
Judge Bazelon: No. I said "undisprovable." Undisprovable.
Dr. Sarwer-Foner: It's the same as unprovable.
Judge Bazelon (Laughing): I don't think so, I don't think so.
Dr. Sarwer-Foner: The point is that one can distinguish clearly between the fact and the theory. The facts of psychoanalysis are really demonstrable. The theory is just that - theory, subject to being changed as we go along.
To conclude, I don't think that Judge Bazelon is really unfriendly to psychiatry. But I do think he has made some overgeneralizations at times which could lead others to think that he was. I regret this, because I believe he has rendered us all yeoman service by the basic thrust of his work and his observations.
Dr. Delano: Do you wish to say anything, Judge Bazelon?
Judge Bazelon: I always thought of myself as a person who was not throwing out the baby with the bathwater. You haven't been listening to my colleagues as long as I have!
Remember, I'm the one who's been saying that psychiatry shouldn't get a divorce. But I think you have to face realities. And the reality is that there is knowledge we don't have. There's no shame in admitting this. There's a lot of knowledge in many areas that none of us have, and we do ourselves greater harm by not making it perfectly clear (to use an idiom!) that we don't know it all. Otherwise you disappoint people.
When the psychiatrist does this, he helps people grow up. He helps them live with the uncertainty. That's what you're really supposed to be trying to do with people.
Dr. Farnsworth: This interchange reminds me of one of Dr. George Buttrick's famous quotations: "You arrive at the truth through the friction of friendly but independent minds."
Judge Bazelon: Friendly, yes. I suppose that takes care of it. But a person only learns by challenge. Manfred Guttmacher was one of the best people I knew. He was a really fine man in every sense of the word. In Baltimore he became the impartial psychiatrist, and whatever Manfred said, that was it. Nobody would argue about it.
One day I said to him, "Manfred, you're lousing up the system." I could say that to him, because we were good friends. He said: "Why? I'm trying to do the right thing, and I want to be sensitive to other people," and so forth.
I said: "Manfred, when I get in trouble, I want you to be the 'impartial' arbitrator - because I know you are an understanding, warm, and humane person." I could count on a bias in my favor. But not everybody is a Manfred Guttmacher. There are an awful lot of people I don't want for an "impartial" arbitrator. I would want them fully exposed to challenge in an adversary proceeding.
And I think that is one of the good things about our legal system. I live in a world, because I'm a lawyer and a judge, where there is constant challenge. There are a lot of things wrong with our adversary system - I could go on much longer than anybody in this room telling you what's wrong with it. But nobody has been able to come up with another system that is better.
The scientific method absolutely demands the adversary process. You write a paper, and everybody shoots at it. Sometimes it's not so friendly, I'm told by my friends in science. But we don't have any better way to seek the truth. You can get pretty sloppy and lazy if what you say is constantly accepted without challenge.
Dr. Sarwer-Foner said something about medicine involving due process. Well, if it did, that really would be something - because I believe that is the one thing that medicine does not do, particularly psychiatry.
Dr. Delano: If there are no more questions, that concludes our discussion. Thank you all for your participation.