Studies in Forensic Psychiatry

by Bernard Glueck

We cannot, however, arrive at a proper conception of the nature of a juvenile offender by merely studying a cross section of him at any given moment of his life. In order to understand man, especially abnormal man, we must study him in a longitudinal section; we must note his mode of reaction to experiences in everyday life, under all manner of conditions and circumstances; we must investigate the motives and desires which prompt his conduct; we must find out how effectually he adapts himself to the environment in which he happens to be placed and in how far he is able to modify the world about him so as to make it subservient to his needs and wants. The same problems which confront criminology today, psychiatry had to face some years ago. In order to be able to rationally and scientifically deal with the insane the psychiatrist found it essential to establish certain criteria which might enable him to tell, with some degree of certainty, what the future life of a given insane person will be. In the last analysis it is this same thing which we are aiming to attain in our dealings with the criminal. The problem which is constantly before us in dealing with juvenile delinquency is what might be expected of the future life of the juvenile under consideration and what must be done towards directing his future into proper channels. So, after all, it should be our aim to establish certain criteria by means of which we should be able to render a proper prognosis. That we possess no such criteria at present can be denied by no one.

As I have already stated, psychiatry had to face the same problems. With the advent, however, of the Kraepelinian school these have in a great measure been solved. Kraepelin, by studying the entire life history of his patients, was able to show that certain disease pictures when studied in cross section may simulate one another very closely clinically and at the same time be of the most diverse significance prognostically. He further showed that certain acute psychotic disturbances are merely the outward expressions of an underlying progressive disorder, and though the acute manifestations may disappear and leave no apparent trace behind them, the great majority of these individuals will spend the rest of their lives in institutions for the insane. By calling attention to certain symptom-complexes, which are especially characteristic of certain mental disorders, he gave us the means by which we are able at the present time to predict with a fair degree of certainty what the future life of a given patient will be. We can now tell without great fear of contradiction which of our patients are going to spend the rest of their lives in institutions.

Now, criminality is generally conceded to be an expression of a diseased personality and there is no reason why the same principles which served to advance our knowledge of psychiatry should not be employed here.

In the foregoing study we aimed to carry out these principles, but we believe that better results still could be obtained at the hands of a trained psychiatrist right at the penitentiary. The reasons for this are quite obvious. The relationship between prisoner and physician would then be quite a different one, the data could be more readily verified with the assistance of the machinery of the law, and the subjects would be in a more accessible mood than when suffering from a mental disorder. As a matter of fact the best work thus far done on the mentality and disorders of mentality of prisoners was done by a prison physician, Dr. Siefert, of Halle.

Thus we see that the question of the degenerative prison psychoses has an important relation to the question of criminology in general.

This becomes at once apparent, if we accept the contention of many authorities that the degenerative soil which makes the development of these psychoses possible, is likewise responsible for the criminality of these individuals; in other words,—if we agree that crime and psychosis are here branches of the same tree. Manifestly any discussion of the treatment of these psychoses must of necessity touch upon the vastly broader problem of the treatment of the habitual criminal, the recidivist, and therefore a slight digression from the subject at hand will be unavoidable.

If we admit that it is the prison environment which serves to bring out the prison psychosis, it is perfectly evident that the first therapeutic indication is the removal of the prisoner from that environment as soon as the disorder is recognized. This problem is at present dealt with in several ways. There are certain penal institutions, especially in Europe, which have within their walls a psychiatric department for the reception of these cases. Others send their insane convicts to the criminal department of some hospital for the insane. In this country there are States in which still a third system is in vogue, namely, the confinement of these cases in special hospitals for insane criminals. Now the points to be kept in mind in the treatment of the insane criminal are, briefly stated, these:—First, they should of course come under the supervision of a trained psychiatrist. Second, the transfer from prison to hospital must take place with as little delay as possible and not be burdened with a lot of red-tape procedures. Third, the hospitals for the housing of these patients must be fully equipped in accordance with the modern ideas of hospital construction, and at the same time afford ample security for the prevention of escapes. Fourth, the interest of the inmates of the general hospital for the insane and the feelings of their friends and relatives must be kept in mind, when we begin to advocate the populating of our hospitals for the insane with criminal characters.

The psychiatric annex in connection with the penal institution meets all these requirements better than any arrangement for the care of the insane criminal. An annex of say fifty beds, in connection with every State Penitentiary would obviate entirely the delay in transferring a patient from prison to hospital and vice versa. As soon as a prisoner begins to show signs of mental disorder, and a prison physician trained in psychiatry will be able to recognize these early signs, or as soon as there is the least suspicion of mental disorder, the patient could be transferred without delay to the psychiatric department. Here they should be kept under observation for at least six months. This will be sufficiently long in most instances to enable the physician to determine whether he is dealing with a progressive deteriorating psychosis or with one of those transitory prison psychoses. In the cases of the former, i.e., if it is definitely established that the patient is a dementing præcox or a paretic, the fact that he happens likewise to be a criminal is really of little or no importance. A demented individual is never dangerous enough to require confinement in an especially secure hospital, though he is a prisoner, and unless he is criminally insane, i.e., unless he manifests dangerous or criminal tendencies as a result of his mental disorder, really forms no special administrative problem. He could be kept either in the prison annex until the expiration of his sentence, if there be room for him, or could be transferred to the nearest hospital for the insane and treated the same as any other insane patient.

It is the second group, however, i.e., those patients suffering from the transitory prison psychoses, which especially justify the establishment of psychiatric annexes in connection with prisons. We have seen how detrimental to prison discipline these individuals are, even when in a condition which might be considered normal to them, and we can easily surmise what it must mean to care for them in prison during one of their mental upsets. It is therefore of the utmost importance, both for the prison administration and for the individual, that these patients should be transferred to a properly appointed hospital in as short a time as possible, and this can be done most readily when the hospital and prison are within the same walls, and more or less under the same management. On the other hand, we owe it to the prisoner to bring him under proper care as soon as possible. The practice of sending these individuals to criminal departments of general hospitals for the insane has many objections. In the first place, no matter how modern the equipment of such departments, most of them cannot afford the proper kind of treatment to these individuals. The idea that the removal from prison to a criminal department of an insane hospital will have a beneficial effect upon the prisoner because of the more lenient environment into which he is taken is entirely delusional in the case of the degenerated habitual criminal. These individuals, if the public safety is to be kept in mind, can receive but very limited privileges in a hospital for the insane. The modern hospital is not constructed with the idea of caring for dangerous criminals, and in many instances the habitual criminal, who because of his dangerous tendencies and ever readiness to escape, has to be constantly kept under lock and key, would be much better off if he were treated within the enclosure of the prison. There the construction of the place permits of a wider latitude of outdoor exercise. An annex located within the enclosure of a prison could well afford to allow its patients the freedom of the enclosure, while this can manifestly not be done in a general hospital for the insane. Then again, there is the unavoidable delay attendant upon the commitment of a prisoner to an insane hospital. As I have already stated elsewhere, it is not a rare occurrence to receive patients into the hospital who have entirely recovered from their mental disorder before leaving the prison. Furthermore, the expense and danger always connected with the transfer of insane criminals from prison to hospital and back again, if the hospital is any distance from the prison, must be kept in mind.

A word to those who, from a false altruistic standpoint, insist that the insane criminal requires no different treatment from that which the ordinary insane patient does. This is very true in the case of prisoners who develop mental disorders which have no relation to crime or imprisonment. These do not require special measures of treatment. It is likewise true of the psychoses of the accidental criminal, but it is entirely different with the criminal who suffers from a degenerative prison psychosis. Here we are not dealing with individuals who tend to dement, who have little or no conception of whether they are in a prison or in a hospital. In short, we are not dealing here with paretics or senile dements, who, although being at the same time prisoners, remain subject to the same unavoidable lot of the paretic or the senile dement. The habitual criminal who suffers from a degenerative psychosis, unless he is in a stupor, is constantly on the alert for a chance to escape. No matter how delusional or hallucinated he may be, he always manages to keep in mind that the thing which he most desires is to be free from the hands of his captors, and anyone who has had to deal with this class will bear me out in this. The shrewdness with which they carry out their escapes is amazing, and some of the more depraved ones do not hesitate to commit serious assaults in order to gain their freedom. Here, measures other than those used with the ordinary insane patient are required.