Psychiatry and Law: The Cost to Society

The following is a two-part feature on the relation of psychiatry and the law. The first part discusses the abuses resulting from criminal and civil commitments to mental institutions. The second part, to appear tomorrow, will discuss a recently proposed Massachusetts statute to deal with these problems.

IF CHAPTER 123 of the General Laws of Massachusetts were enforced rigorously, few of us would be able to escape confinement in the mental institutions of this state. The statute provides for the involuntary commitment of any person ". . . subject to a disease, psychosis, psychoneurosis or character disorder which renders him so deficient in judgment or emotional control that he is in danger of causing physical harm to himself or to others, . . . or is likely to conduct himself in a manner which clearly violates the established laws, ordinances, conventions, or morals of the community." (Emphasis supplied.)

And Massachusetts, unfortunately, is not unique. These vague criteria for civil commitment (i.e., for people who have not been charged with any crime), have their counterpart in practically every other state in the country. According to Alan M. Dershowitz, professor of Law at the Law School, "Almost one million persons are today confined behind the locked doors of state mental hospitals, though never convicted of crime." The figure of one million is perhaps overstated, but figures from the National Institute of Mental Health show that between 600,000 and 850,000 people--depending upon which institutions are included--are presently in state mental hospitals.

Free to Leave?

Many of these people are confined against their will. Neither Massachusetts nor NIH makes a distinction between voluntary and involuntary patients in their annual reports--though they do distinguish between voluntary and involuntary admissions each year. But the distinction is problematic, since even those patients who have "voluntary" committed themselves are not free to leave whenever they choose. As Dr. Thomas Szasz, professor of Psychiatry at Syracuse, points out, "Truly voluntary hospitalization is virtually nonexistent in public mental institutions in the United States."

In Massachusetts, as elsewhere in this country, the decision to commit a person against his will is made almost exclusively by psychiatrists. The loose language of the Massachusetts statute--which has not been substantially amended in almost a century--establishes such meaningless criteria for commitment that in practice it usually precludes effective court proceedings and review.

State legislatures have failed to make policy decisions specifying who shall be detained and why. Nor have they specified the necessary degree of likelihood for a person to commit a harm. In other words, it doesn't matter whether a person might commit a harm, is likely to commit a harm, or is more than likely to commit a harm. In practice, all a psychiatrist must say is that a person is "likely to be dangerous to himself or to others" to effect his incarceration.

ABDICATION of legal responsibility has led to a concession of power, by default, to the psychiatric profession. Individual psychiatrists have been empowered to make uncontested pseudo-legal decisions on purely medical bases. The result of this psychiatric involvement in the legal process, says Professor Dershowitz, "has been the gradual introduction of a medical model in place of the laws' efforts to articulate legally relevant criteria." In other words, the presence or absence of "mental illness," a poorly defined and widely questioned concept, about which even psychiatrists disagree, has practically become the exclusive basis for decisions of preventive detention.

Over the past century, these civil commitment procedures have deprived millions of "mentally ill" people of their liberty. And once a person has been committed to a mental institution, he stands a good chance of remaining there for the rest of his life.

W. Blomberg, writing in the American Journal of Psychiatry in 1960, claimed that 40 per cent of patients in state mental hospitals have been hospitalized for ten years or more. He said, "Once a person has remained in a large mental hospital for two years or more, he is quite unlikely to leave except by death."

There are many examples of people wrongly committed to mental institutions who have re-won their freedom. In most cases these people have the help of concerned friends or relatives who manage to secure their release. But wrongly committed people who are alone in the world, or who have been committed with the express consent of their relatives, present the greatest problem of all.

Miss Mae Dean

Take the case of Miss Mae Dean, a 64-year-old registered nurse who was involuntarily committed to a mental institution for four years. The New York Times of July 27, 1960, said:

"The woman, Miss Mae Dean, was admitted to the Jersey City Medical Center on July 4, 1956, while suffering from a severe attack of asthma. Twenty days later she was transferred to the Hudson County Hospital for Mental Disease in Secaucus (N.J.).

'At today's hearing . . . Dr. John J. Scott, assistant medical director of the county medical hospital, testified that as far back as 1957, . . . Miss Dean had been adjudged sane.

"Asked why she had not been released in view of her many requests for freedom since that time, Dr. Scott said that the woman was without relatives and it had been feared that she would become a public charge.

"While a patient at that hospital, Miss Dean performed the duties of a registered nurse, without pay."

But the abuses which occur under the civil commitment statutes are exceeded (in degree, though not in number) by the effects of criminal commitments. Through claims of either "incompetency to stand trial" or "not guilty by reason of insanity," thousands of accused criminals have spent decades imprisoned in institutions that authorities benignly call "hospitals for the criminally insane." In the vast majority of cases, these people have been convicted of no crime. The medical and legal problems that they present have been reversed and confused, since a psychiatrist's statement that there is mental illness is enough to cause incarceration in these institutions. But the euphemism of "hospital" rarely corresponds to the reality.

TAKE BRIDGEWATER. According to Paul Tamburello, President of the Massachusetts Bar Association, "The present medical staff is able to see less than half of the 650 men in the hospital once a year, and then for only 20 minutes." After a personal study last year, he described the conditions as follows:

"None of the cells has a toilet. Every cell has a solid wood door, with a small peek-hole, and an uncovered bucket for toilet purposes. In the morning the men bring their buckets to a central depository. . . . There is not a thermostat in the entire 87-year-old institution. When it is too hot, the windows are opened. When it is too cold, there is no relief.

"Last December the temperature in three hospital sections fell to 39 in the daytime. . . . The superintendent and his men brought in a hay dryer from the barn, rigged it up Rube Goldberg style, and this helped push hot air to the sections involved . . . water coming into the hospital has been found to be polluted."

Frederick Wiseman's award-winning documentary, "Titicut Follies," attempts to bring these conditions to public attention. But it cannot be seen at any public theatre in the country. The film has been banned by order of the Court in Massachusetts, and the Commonwealth has sued its producer, Grove Press. It is curious, indeed, that a film which has been honored in the New York Film Festival, won first prize in the Mannheim Film Festival in Germany, and two of the three prizes in the Festival dei Populi in Italy, cannot be seen by the citizens of this state.

The Authorities

And it is ironic to note the passion with which Massachusetts authorities have prevented the film from being seen and the fervor of their prosecution of the producer and director for "violating the rights of patients" and for "breach of contract." This apparent concern for the "rights" of patients seems hardly compatible with the stark reality of Bridgewater State Hospital.

Recent studies comparing Bridgewater with Walpole State Prison have shown that on almost every objective standard, Walpole is far superior. Besides having better physical conditions, prisoners in Walpole know when they will be released. Bridgewater inmates don't have this luxury. The first question for the Bridgewater inmate is, "Will I be released?"

Matteo Calacocci was seven years old when he stole $7 from the counter of a North End grocery store. That was in 1927. After being judged "incompetent to stand trial," he was sent to the Lyman School, where he was found "not feeble-minded," "not psychotic," and of "average" intelligence. Transferred to Worcester State Hospital in 1930 and to Boston State in 1933, he attempted to escape in 1935 and was transferred to the maximum security facility at Bridgewater. His records show that he was charged with "bad habits" and with "resisting authority."

Matteo Calacocci was released in 1963, after 28 years in Bridgewater. And he was lucky. He was lucky, that is, if you compare his case to others who still remain in Bridgewater. The records speak for themselves: J.D., committed as incompetent to stand trial on May 1, 1935, still awaiting trial on a charge of simple assault and battery; W.K., committed February 11, 1951, still waiting to be tried for disturbing the peace; J.M., committed September 14, 1921, still awaiting trial for breaking and entering. These men and hundreds of others in similar positions at Bridgewater and at other state mental institutions await trials which may never take place.

Senator Beryl Cohen (D-Brook-