ENERGY
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GAIN ENERGY
APPRENTICE
LEVEL1
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THE
ENERGY BLOCKAGE REMOVAL
PROCESS
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THE
KARMA CLEARING
PROCESS
APPRENTICE
LEVEL3
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MASTERY
OF RELATIONSHIPS
TANTRA
APPRENTICE
LEVEL4
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2005 AND 2006 |
THE MASK OF SANITYSection 4: Some questions still without adequate answersPart 2: What is wrong with these patients?68. Treatment or control
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68. Treatment or control Several decades ago, while preparing the first edition of this book, I was profoundly impressed by two difficulties that stood in the way of dealing effectively with the psychopath. One of these was his apparent immunity, or relative immunity, from control by law. The other was his lack of response to psychiatric treatment of any kind. Today both of these difficulties exist and, it seems to me, with little alteration. Let us consider first the question of legal control, of the problems that arise when steps are taken to protect the community and the patient from his misconduct. It is only on very unusual occasions that a psychopath can be committed as legally incompetent, and even when this occurs it is not likely that he can be kept long under medical supervision. Let us consider an example: After years of expensive, fruitless, heartbreaking, and faithful efforts to keep him out of disaster, the family of a young (and in most respects typical) psychopath succeeded in having him pronounced incompetent and sent to a state hospital. Unlike most psychopaths, this patient had shown strong indications that he might murder one or more members of his family. This and the prodigious obviousness of his disability and his danger to the community strangely enough overbalanced the customary psychiatric concepts in this isolated instance, and he was admitted to be socially incompetent. There is no denying that this procedure was incorrect according to clearly defined medical rules. After a few weeks of study he was found not to show any of the technical signs of irrationality (none of which had ever been suspected), diagnosed as a "psychopathic personality," and sent home as "sane and competent." One of the psychiatrists at the hospital who had participated in this procedure explained his attitude as follows. He believed that this particular patient, no matter what his proper diagnosis might be, was more seriously disabled than a great many of the patients who would spend the rest of their lives in the institution. He also believed that the discharged patient was more dangerous to the community and more difficult to care for at home than, perhaps, half of those in the state hospital. The members of the staff, he felt, were motivated in their action by several impulses, directed by several judgments. First of all, it was not in accordance with official psychiatric concepts to call such a patient psychotic. It was also against the rules of the hospital to keep a nonpsychotic patient against his will. There was, in addition, in 434 THE MASK OF SANITY some members of the staff a tendency to resist efforts to slip in or palm off on the hospital these psychopaths who are considered technically not eligible for care. There was opinion expressed about how crowded the place was already and about the dangers of being overrun with psychopaths if an exception was made and this one kept. Some felt it would not serve the cause of justice if this man were admitted by the staff of the state hospital to have mental disability, because this appraisal might be utilized in the future dozens or hundreds of times to help him evade legal penalties for the antisocial acts these doctors, like everyone else, realized he would continue. There are not a few among those in charge of our state hospitals who feel that, with conditions as they stand, it would be more fitting for persons of this sort, when segregation or supervision of some type is urgently necessary, to be placed not in our present psychiatric institutions but in reformatories or prisons. There are others who feel that psychiatric care and many of the services and facilities now available in our mental hospitals could and should be made available to severely maladjusted psychopaths. As our evidence has shown, I hope, the psychopath notoriously avoids the petty and temporary restraints that might be legally imposed. Those imprisoned for serious crimes return at length no less prone to continue these crimes. Even when under life sentence, the psychopath tends more readily than others to obtain parole and become again a social menace. Not only can he (perhaps involuntarily) mimic sanity in superlative fashion but also moral rebirth, salvation, and absolute reform, or perhaps transformation into a supercitizen. Among many examples one patient stands out: This brilliant and charming young man, when in his early twenties, murdered another without provocation. Despite a typical record of psychopathic behavior, he so impressed the authorities that parole was granted after a few years. That which, if properly understood, would have warned the parole board against the extreme danger of releasing this man was interpreted as a mitigating factor, as grounds for giving him another chance. It was argued that emotional handicaps and variations from the normal personality patterns had played a part in his unfortunate deed. This, they reasoned, made him less culpable and more deserving of leniency. Like nearly all of his kind, he now showed no superficial signs of nervous or mental disorder (as this is generally understood) but indications of great promise. He inspired trust and confidence and gave a convincingly (theoretical) demonstration of reform, self-control, trustworthiness, sound ethics, and high ideals. Shortly after his release he again committed murder, this time of a woman and again with no discernible motivation of any consequence. In institutions where psychiatric treatment is given, the psychopath, I SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 435 believe, is much more likely than others who have committed serious crimes to convince his psychotherapist that treatment has been effective, that it has brought true insight and profound changes that now make him no longer a danger to society. This may lead to his being presented as one who richly deserves parole or pardon. The daily papers report many cases of armed robbery, rape, and murder resulting from such confidently optimistic estimates of therapeutic success. It is my impression that many of the attitudes underlying permissiveness have also contributed to this. And I think a gross overestimation of the influence of psychiatric treatment on criminals, whether or not they are psychopaths, has played a major role in these tragic events.57,165 Although some protection to society is afforded by dealing out sentences of varying length to psychopathic offenders on the assumption that they are normal and to be punished in accordance with the degree of blame their crimes are judged to deserve, such protection is not reliable. The assumption that they will thereby learn their lesson and become safe inhabitants of the community is an assumption at sharp variance with simple facts. Poorly adapted as our present methods are to prevent the repetition of crime, we find them rapidly approaching travesty and farce when we look for what security they offer against initial crimes of tragic magnitude. An example will make the point clear: In big letters on the front page of newspapers all over the United States the "Bestial Sex Slaying" of an 11-year-old girl by a boy 17 years of age is proclaimed. Details of torture and dismemberment follow. The horrible impact of impulses perverted from the aims of Eros and fused with those of hate and brutality arouses disgust and vengefulness in millions upon millions. Additional articles point out that the murderer, now remarkably callous and undisturbed by his act, had, over a period of many years, shown gross maladjustment and indifference to social values, to ordinary aims, and to the rights of others. He had on several occasions been placed in a reform school and kept for various periods determined in accordance with the legally estimated seriousness of his antisocial acts and with the amount of punishment these were officially regarded as deserving. Had this boy expressed a few delusions or reported even once that he heard an imaginary voice (like many people who are quite harmless), he could have been hospitalized as long as hospitalization was regarded by experts as advisable. Lacking these and the other accepted technicalities which are presumed to determine competency and sanity, he could not be held in any institution beyond the arbitrary term to which he had been sentenced. His conduct had so strongly indicated that he could not without danger to others be left unrestricted in the community that his parents protested to 436 THE MASK OF SANITY the authorities against his release from custody. They urged that he be kept in the institution and gave adequate reasons for their plea. The authorities had no means of heeding this warning - no legal grounds for an alternative to the technically correct procedure of dismissing the patient. The regrettable results reflected in newspaper headlines soon followed. 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 Greestein 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 SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 437 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 selfdamaging 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 438 THE MASK OF SANITY 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 SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 439 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 440 THE MASK OF SANITY 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 SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 441 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 442 THE MASK OF SANITY 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. On the other hand, we have the penal system with its preordained terms of restraint graded arbitrarily in what, perhaps during the last century, was agreed upon as a proper dosage of punishment for this or that misdeed. Such punishments were presumably considered as having corrective (and perhaps prophylactic) effect on antisocial tendencies. Whatever efficacy this method may show for dealing with citizens in general, it has demonstrated year after year its lack of success in controlling the grave problems that continually multiply about the psychopath.104 Largely inaccessible to ordinary social agencies, this type of patient capers, reels, or plunges along his disastrous course. 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 longrange 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. Without restraint and without any effective treatment, the psychopath continues, progressively accumulating in his social wake, woe, confusion, despair, farce, and disaster, beyond any measure of these things I can convey. Exonerations in courts on the grounds of "insanity" are followed by discharges SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 443 from hospitals because "no nervous or mental disease" is found. Sometimes when incompetency cannot be medically or legally established, common sense attempts a compromise and, perhaps unofficially, shows recognition of an aberration through leniency of judgment or an assumption of mitigating circumstances with the practical result of reducing terms of confinement in proportion to the degree of dangerous abnormality evident. This all too frequently amounts to diminishing whatever protection is offered the public directly in proportion to the degree of menace indicated by the disorder. When given long-term psychotherapy in either prison or hospital the psychopath has more ability than any other type of patient to simulate the changes of attitude that may convince even the most conscientious therapist that he has effected a cure and that his patient is now ready for release and no longer a source of danger to others. Often the psychopath is clever and convincing enough to make the therapist feel also that the cure was specifically effected through cherished items of the therapist's creed of psychiatric theory. We must remind ourselves once more of the gross and tragic misunderstanding that determined legal and medical attitudes toward patients suffering from ordinary types of psychosis in past centuries before we can realize the monstrous inefficacy of our present methods of dealing with psychopaths. Pinel, who is so justly venerated by the world today, did not discover any cure or any satisfactory treatment for the psychotic patients whom he liberated from the chains and dungeons into which they were thrown by a society that apparently could not realize they were ill but assumed them merely evil and vicious. Indeed, a hundred or more years passed before any regular therapy even remotely effective became available for patients in most psychiatric institutions. Even if another hundred years should pass before we discover a truly effective method of treatment for psychopaths, or for other offenders who commit brutal crimes, we must make a beginning by reappraising them as Pinel did by reappraising psychotic patients and revising methods for their care. Such a step in understanding these other kinds of disordered people must be made before we can hope to progress far toward the solution of their problem. Let us without delay recognize them for what they are and begin more realistically to plan medical and social facilities through which they can be intelligently treated or, at the very least, through which they will not be mistreated or left without control to endanger the community. In properly set-up hospital or detention units and through adequate outpatient control, efforts might be made to utilize the excellent abilities of these patients and to provide whatever degree of supervision is found 444 THE MASK OF SANITY necessary to keep them occupied and out of trouble. This supervision would, as with other socially disabled patients, vary widely with various persons. Such institutions and other community facilities and the regular practice of committing suitable patients to their supervision would soon bring new viewpoints to countless parents who, in shame and grief, blush over what they take to be the deeds of wickedness and depravity of their children and who wreck their own lives and fortunes seeking to protect, to rehabilitate, and to reform them. Women might learn in time not to sacrifice so readily their fortunes, their life plans, their grief, and their energy in indefatigable and fruitless struggles to support and nurse and pamper maturity into husbands and lovers whose profound deficit makes such maturity (by such means) impossible. In speaking of hospital units and other facilities for parole and supervision, I do not propose that vast and expensive institutions be built in addition to those designed for patients with the traditional problems of psychiatry. I suggest rather that psychopaths be recognized clearly as a separate group and dealt with by rules and methods specifically adapted to cope with their problems and their behavior. Units for their care and control might be maintained in our existing institutions. It seems possible that such a step might lead to substantial economies instead of an additional burden of expense to the public. Vast sums of money are now being is used daily by the state to bring psychopaths repeatedly through due processes of the law, and all to no avail. At great cost relatives send them hopefully for treatment in expensive hospitals, which they leave on personal whim or prankish impulse. Enormous sums are wasted in futile efforts to reestablish them in business and to compensate victims for their continual malfeasances and follies. It is doubtful that the cost of even a most elaborate setup of detention units and outpatient facilities, which I do not propose, would equal the financial loss they now inflict, in addition to their socially damaging effects upon the community. Even if no really adequate therapeutic measure should become available in the foreseeable future, it seems reasonable to hope that with facilities specifically designed for the direction and control of the psychopathic group these people might be maintained at a better level of adjustment despite the continued need of support and restriction. Even if we cannot count on curing their disorder, the goal of bringing about improvement in control and adjustment is not to be despised. Impressed by points of similarity between the psychopath and the spoiled child, some psychiatrists have maintained that promising therapeutic possibilities might lie in establishing a really effective control SOME QUESTIONS STILL WITHOUT ADEQUATE ANSWERS 445 whereby the patient would regularly, promptly, and persistently experience the logical results of (1) socially acceptable conduct and (2) irresponsible and destructive conduct. Mangun196 long ago reported encouraging results from such a program and Woolley299 also expressed hopefulness about this approach to the problem. Subsequently Thorne279 emphasized similar measures. Hare in 1970 gives this interesting summary of Thorne's approach:116 On the assumption that the psychopath's behavior reflects a maladaptive life style that is maintained by reinforcement from family, friends, and associates, Thorne has outlined what he considers to be the requirements of successful therapy with psychopaths. These are summarized as follows. 1. The therapist must have complete control over the financial resources of the psychopath, usually by being made trustee of his accounts. 2. Relatives and other interested parties must agree not to bail the psychopath out of his difficulties; he must be required to face the consequences of his own behavior. 3. The therapist must be very persistent in gradually getting the psychopath to exert some limits and controls over his own behavior. 4. The therapist should not protect the psychopath from the legal and social consequences of his actions. 5. The therapist should make it clear to the psychopath that he understands him thoroughly, knows what to expect, and will be convinced of his good intentions only through actions and not words. 6. The psychopath must be shown repeatedly that his behavior is self-defeating. 7. The therapist should search for a leverage point to stimulate more socially acceptable behavior. As a last resort, the therapist may have to use money, which he controls, as an incentive. In addition to these points, Thorne suggested that a great deal of patience, time, and money are required; in several cases, an investment of $15,000 per year for as long as 10 years was needed to effect a satisfactory outcome. It is not surprising therefore that no controlled research using Thorne's methods has been carried out; the investment in time and money is far too great and, many would say, not worth the effort. [p. 112] Is it not our responsibility as psychiatrists to agree, despite all our notable differences about etiology, terminology, and technicalities of method that such patients as those discussed here need medical reappraisal? My proposals and opinions may be in many respects incomplete, superficial, or erroneous. It is too much to ask that the viewpoint of any one observer in so complex and confusing a matter be generally accepted as final. The whole field of psychiatry, by its very nature, abounds in questions still unanswered and about which diverse opinions naturally exist and 446 THE MASK OF SANITY arguments inevitably arise. If we cannot agree that the psychopath has anything like a "psychosis" or even a "mental disorder," can we not all agree that some means is urgently needed of dealing more realistically with whatever it is that mayb be ther matter with him? If some practical means of controlling the psychopath can eb devised, perhaps eventually, we may find his disorder to be not altogether beyond our practice. |
Energy Enhancement Enlightened Texts Psychopath The Mask Of Sanity
Section 4, Part 2
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