ill person who can get along outside a hospital be hospitalized without treatment. Attempts to stretch the decision to imply that dangerousness to self or others is a necessary condition cannot be justified, as mentally
REFERENCES
cannot
Ennis
attempts
to
do
when
he
writes,
“The
Supreme
Court apparently believes that involuntary confinement simply because of mental illness and the need for treatment is not constitutionally justified. There must be proof of some degree of danger to self or others” (2). The current national trend to make imminent danger a condition of civil commitment finds little to go on in the Supreme Court decision. The definition of dangerousness
to
decision
self
is not
quoted
as part
basically
of the
different
district
from
that
judge’s
would
disagree.
The
court
simply
for the state to confine a person where the person is to be confined) his benefit requires that the person by due criminal
process. law.
That,
to me,
is no
out
that
(and it doesn’t say and do nothing for be found dangerous than
traditional
In view of the limited nature of the decision, why are more courts insisting that criteria for commitment be “imminent danger to self or others?” I think it is because of the implication in Donaldson that if the mentally ill person is found dangerous, he can be confined without treatment, therefore relieving the court of the obligation to be sure treatment is really available. It would be well if we would all stop using the word “dangerous” in the two senses of “to others” or “to self.” As frequently stated by critics of psychiatry, the former can’t be predicted and the latter is hard to define. A different word for those who, because of mental illness, show gross incompetence to care for themselves would prevent all of us from slipping back and forth between the two meanings. Some
critics
confusion about
about into
theses
of institutional
which that
psychiatry
have
dangerousness got
more
they attention
parlayed
were than
talking they
de-
served (2-6). They assert, first, that the basis of commitment has been and is dangerousness, and since violent aggression against others by someone who has not repeatedly been violent cannot be reliably predicted, the commitment process itself is invalid. Of course, the obvious flaw in their reasoning is that except those
for who
the are
so-called civilly
criminally committed
insane, are
harmless
the
bulk
of
to others.
Because of illness, they fail to take care of their own needs for food, clothing, health, safety, or medical care and therefore must have something done for them. Conclusions drawn from observations made about those alleged to be dangerous to others simply cannot be applied to the majority of seriously mentally ill.
564
HOSPITAL
& COMMUNITY
Donaldson, “Judicial
422 U.S. Involvement
563(1975). in Public
Practice,”
in Law
Summer
1976, pp. 1084-1101.
5) B. Rubin, nals,” Archives 397-407.
“Prediction of General
6) A. M. Dershowitz, Psychology
of Dangerousness Psychiatry, Vol.
“The Today,
27,
in Mentally September
Psychiatrist’sPower February
1969,
pp.
in
Ill Crimi1972, pp. Civil
Com-
43-46.
commonly
points
more
V.
and the Mental Health Professions, W. E. Barton and C. J. Sandborn, editors, International Universities Press, New York City, 1978. 3) B. J. Ennis and T. R. Litwack, “Psychiatry and the Presumption of Expertise: Flipping Coins in the Courtroom,” California Law Review, Vol. 62, May 1974, pp. 693-711. 4) J. J. Cocozza and H. J. Steadman, “The Failure of Psychiatric Predictions of Dangerousness,” Rutgers Law Review, Vol. 29, Late
mitment,”
written into state laws. It states, “Even if there is no foreseeable risk of self-injury or suicide, a person is literally dangerous to himself if for physical or other reasons he is helpless to avoid the hazards of freedom either through his own efforts or with the aid of willing family members or friends.” If that is what is meant by dangerousness, few psychiatrists
1) O’Connor 2) B. J. Ennis,
PSYCHIATRY
DISPELLING SURROUNDING Irving
THE
MYTHS MENTAL
ILLNESS
Blumberg
#{149}inumber of common myths and half-truths concerning the nature and treatment of psychiatric disorders, the role of psychiatry, and the optimal settings for providing mental health services have permeated much of the professional and popular literature in the mental health field. Among these myths are the following: . The myth that mental illness is a myth-a false notion fostered by a few so-called “experts” afflicted with tunnel vision. This is a myth that has created considerable confusion among the lay public and even some circles of psychiatric sophisticates. Unfortunately mental illness is no myth, but a tragic reality. . The myth that psychiatric treatment, to have any value, must effect total cures. That can no more be expected of psychiatrists than to expect other medical specialists, dealing with a variety of physical disorders, to achieve complete success in their treatments. . The myth that treatment must always precede rehabilitation, and must be successfully completed before instituting rehabilitative efforts. In actual practice, treatment and rehabilitation go hand in hand, interact, and either one can follow or precede the other. There is no single successful method to follow. S The myth that treatment and rehabilitation are one and the same-that treatment is rehabilitation, and rehabilitation is treatment. We know there are common elements as well as unique differences in the two concepts and practices. Strictly defined, treatment seeks to alleviate or eliminate, through medical, psychological, and other processes, disordered cognition, emotions, or behavior, and to relieve distress, suffering, and anxiety. Rehabilitation, while sharing some of these goals, is designed primarily and directly to restore a person’s capacity to function, or, as in habilitation, to help an indiMr. Blumberg is executive vice-president mittee Against Mental Illness, Box 898, New York 10023.
of the Ansonia
International Station, New
CornYork,
vid#{252}alacquire skills not previously possessed. . The myth that individuals usually suffer from only one kind of disorder-such as being mentally ill, or mentally retarded, or alcoholic, an idea fostered by our rather rigid diagnostic categories and specialized facilities. We now realize that an increasing number of mdividuals are victims of more than one disorder and that consequently treatment and rehabilitation must be varied and flexible. . The myth that a clinical diagnosis should serve as the sole or main criterion for determining what kind of rehabilitation might be most useful. We are now beginning to give greater importance to functional assessments, which take into account a patient’s skills and assets as well as his or her deficits or disorders. . The myth that the chronically mentally ill cannot function in normal community life. Facts prove otherwise. There are literally hundreds of thousands of mdividuals “officially” classified as schizophrenics who are continuing to live and work in community settings. We must realize that such individuals should always have ready access to personal support systems to tide them over the rough spots and crisis situations. . The myth that psychiatrists and mental health delivery systems should have sole or main responsibility for the aftercare of a discharged mental patient. We now recognize that such care must be a shared responsibility with social service, education, welfare, income maintenance, vocational, and other systems participating in the total effort. . The myth that all state facilities should be closed forthwith, and that all services should be supplied by local governments or voluntary agencies. While many existing state facilities should be phased down or out, there will always be a need for secure facilities to provide either acute or long-term care for restricted populations. They may but need not be state operated. It is essential that these myths be dispelled by a clear presentation of facts. Failure to do so impedes progress in providing effective services to those who look to mental health professionals to provide some of the answers to their needs.
FEEDBAG( FURTHER COMMENT OF GENERAL HOSPITAL Karl
Menninger,
ON
THE HISTORY PSYCHIATRY
Modern Hospital unit at Christ’s describes
the
for July 1924, where I discuss Hospital in Topeka (2) and Carl architectural
design
for
the
unit’s
an early Erikson expan-
that I felt kind of bad that Erikson and I didn’t make it. We were right proud of ourselves at the time. Also, he should look up the account of the elegant hospital at St. Paul, Minnesota, called, I believe, “the Miller Hospital,” with the psychiatric department developed by colleague Ernest Hammes of St. Paul, about 1925. I got some ideas from him since it was an outstanding and much admired innovation. That unit, like my own, preceded the Rockefeller-financed university hospital idea correctly discussed by Dr. Greenhill in his article; they came a decade later. Dr. Greenhill says Franklin Ebaugh is “undoubtedly” the father of units in general hospitals. I don’t agree with him there, but he has a right to his opinion. Ebaugh was a great talker and he advertised the idea well, but his own work was not, as I remember it, in a general hospital. Incidentally, Harvard had something similar to a general hospital psychiatric unit when I was at Massachusetts General Hospital during medical school days, but it was not so labeled. We students assigned there did not see psychiatric patients except in neurology, but there was a visiting psychologist who met with us and had all of us read Hart’s Psychology of Insanity (4). sion
(3).
Dr.
Greenhill’s
article
was
so
scholarly
REFERENCES 1) M. H. Greenhill, “Psychiatric Units in General Hospitals: 1979,” Vol. 30, pp. 169-182. 2) K. A. Menninger, “The Place of the Psychiatric Department in the General Hospital,” Modem Hospita4 Vol. 23, July 1924, pp. 1-4. 3) C. A. Erikson, “The Psychiatric Department of Christ’s Hospital, Topeka, Kansas,” Modem Hospltal Vol. 23, July 1924, pp. 5-7.
4) B. Hart, 1912.
Cambridge
Reply
Maurice
From
University
Press,
H. Greenhill,
Cambridge,
England,
M.D.
Dr. Menninger’s colorful letter indicates that I missed what is probably one of the earliest articles on psychiatry in the general hospital as well as the first architectural description of a psychiatric unit in such a hospital. What is truly remarkable is that these articles contained much material about the psychiatric unit in the general hospital that could have been written today and predicted some of the key problems that such units have subsequently encountered.
M.D.
aI enjoyed Dr. Greenhill’s fine article on general hospital psychiatric units in the March issue of Hospital & Community Psychiatry (1). When he comes to revise it for book publication, he may want to take a look at Dr. Menninger is chairman of the board of trustees of the Foundation in Topeka, Kansas, and chairman of the board lages in Topeka.
Menninger of the Vil-
VOLUME
30 NUMBER
8 AUGUST
1979
565
REFERENCES
cannot
Ennis
attempts
to
do
when
he
writes,
“The
Supreme
Court apparently believes that involuntary confinement simply because of mental illness and the need for treatment is not constitutionally justified. There must be proof of some degree of danger to self or others” (2). The current national trend to make imminent danger a condition of civil commitment finds little to go on in the Supreme Court decision. The definition of dangerousness
to
decision
self
is not
quoted
as part
basically
of the
different
district
from
that
judge’s
would
disagree.
The
court
simply
for the state to confine a person where the person is to be confined) his benefit requires that the person by due criminal
process. law.
That,
to me,
is no
out
that
(and it doesn’t say and do nothing for be found dangerous than
traditional
In view of the limited nature of the decision, why are more courts insisting that criteria for commitment be “imminent danger to self or others?” I think it is because of the implication in Donaldson that if the mentally ill person is found dangerous, he can be confined without treatment, therefore relieving the court of the obligation to be sure treatment is really available. It would be well if we would all stop using the word “dangerous” in the two senses of “to others” or “to self.” As frequently stated by critics of psychiatry, the former can’t be predicted and the latter is hard to define. A different word for those who, because of mental illness, show gross incompetence to care for themselves would prevent all of us from slipping back and forth between the two meanings. Some
critics
confusion about
about into
theses
of institutional
which that
psychiatry
have
dangerousness got
more
they attention
parlayed
were than
talking they
de-
served (2-6). They assert, first, that the basis of commitment has been and is dangerousness, and since violent aggression against others by someone who has not repeatedly been violent cannot be reliably predicted, the commitment process itself is invalid. Of course, the obvious flaw in their reasoning is that except those
for who
the are
so-called civilly
criminally committed
insane, are
harmless
the
bulk
of
to others.
Because of illness, they fail to take care of their own needs for food, clothing, health, safety, or medical care and therefore must have something done for them. Conclusions drawn from observations made about those alleged to be dangerous to others simply cannot be applied to the majority of seriously mentally ill.
564
HOSPITAL
& COMMUNITY
Donaldson, “Judicial
422 U.S. Involvement
563(1975). in Public
Practice,”
in Law
Summer
1976, pp. 1084-1101.
5) B. Rubin, nals,” Archives 397-407.
“Prediction of General
6) A. M. Dershowitz, Psychology
of Dangerousness Psychiatry, Vol.
“The Today,
27,
in Mentally September
Psychiatrist’sPower February
1969,
pp.
in
Ill Crimi1972, pp. Civil
Com-
43-46.
commonly
points
more
V.
and the Mental Health Professions, W. E. Barton and C. J. Sandborn, editors, International Universities Press, New York City, 1978. 3) B. J. Ennis and T. R. Litwack, “Psychiatry and the Presumption of Expertise: Flipping Coins in the Courtroom,” California Law Review, Vol. 62, May 1974, pp. 693-711. 4) J. J. Cocozza and H. J. Steadman, “The Failure of Psychiatric Predictions of Dangerousness,” Rutgers Law Review, Vol. 29, Late
mitment,”
written into state laws. It states, “Even if there is no foreseeable risk of self-injury or suicide, a person is literally dangerous to himself if for physical or other reasons he is helpless to avoid the hazards of freedom either through his own efforts or with the aid of willing family members or friends.” If that is what is meant by dangerousness, few psychiatrists
1) O’Connor 2) B. J. Ennis,
PSYCHIATRY
DISPELLING SURROUNDING Irving
THE
MYTHS MENTAL
ILLNESS
Blumberg
#{149}inumber of common myths and half-truths concerning the nature and treatment of psychiatric disorders, the role of psychiatry, and the optimal settings for providing mental health services have permeated much of the professional and popular literature in the mental health field. Among these myths are the following: . The myth that mental illness is a myth-a false notion fostered by a few so-called “experts” afflicted with tunnel vision. This is a myth that has created considerable confusion among the lay public and even some circles of psychiatric sophisticates. Unfortunately mental illness is no myth, but a tragic reality. . The myth that psychiatric treatment, to have any value, must effect total cures. That can no more be expected of psychiatrists than to expect other medical specialists, dealing with a variety of physical disorders, to achieve complete success in their treatments. . The myth that treatment must always precede rehabilitation, and must be successfully completed before instituting rehabilitative efforts. In actual practice, treatment and rehabilitation go hand in hand, interact, and either one can follow or precede the other. There is no single successful method to follow. S The myth that treatment and rehabilitation are one and the same-that treatment is rehabilitation, and rehabilitation is treatment. We know there are common elements as well as unique differences in the two concepts and practices. Strictly defined, treatment seeks to alleviate or eliminate, through medical, psychological, and other processes, disordered cognition, emotions, or behavior, and to relieve distress, suffering, and anxiety. Rehabilitation, while sharing some of these goals, is designed primarily and directly to restore a person’s capacity to function, or, as in habilitation, to help an indiMr. Blumberg is executive vice-president mittee Against Mental Illness, Box 898, New York 10023.
of the Ansonia
International Station, New
CornYork,
vid#{252}alacquire skills not previously possessed. . The myth that individuals usually suffer from only one kind of disorder-such as being mentally ill, or mentally retarded, or alcoholic, an idea fostered by our rather rigid diagnostic categories and specialized facilities. We now realize that an increasing number of mdividuals are victims of more than one disorder and that consequently treatment and rehabilitation must be varied and flexible. . The myth that a clinical diagnosis should serve as the sole or main criterion for determining what kind of rehabilitation might be most useful. We are now beginning to give greater importance to functional assessments, which take into account a patient’s skills and assets as well as his or her deficits or disorders. . The myth that the chronically mentally ill cannot function in normal community life. Facts prove otherwise. There are literally hundreds of thousands of mdividuals “officially” classified as schizophrenics who are continuing to live and work in community settings. We must realize that such individuals should always have ready access to personal support systems to tide them over the rough spots and crisis situations. . The myth that psychiatrists and mental health delivery systems should have sole or main responsibility for the aftercare of a discharged mental patient. We now recognize that such care must be a shared responsibility with social service, education, welfare, income maintenance, vocational, and other systems participating in the total effort. . The myth that all state facilities should be closed forthwith, and that all services should be supplied by local governments or voluntary agencies. While many existing state facilities should be phased down or out, there will always be a need for secure facilities to provide either acute or long-term care for restricted populations. They may but need not be state operated. It is essential that these myths be dispelled by a clear presentation of facts. Failure to do so impedes progress in providing effective services to those who look to mental health professionals to provide some of the answers to their needs.
FEEDBAG( FURTHER COMMENT OF GENERAL HOSPITAL Karl
Menninger,
ON
THE HISTORY PSYCHIATRY
Modern Hospital unit at Christ’s describes
the
for July 1924, where I discuss Hospital in Topeka (2) and Carl architectural
design
for
the
unit’s
an early Erikson expan-
that I felt kind of bad that Erikson and I didn’t make it. We were right proud of ourselves at the time. Also, he should look up the account of the elegant hospital at St. Paul, Minnesota, called, I believe, “the Miller Hospital,” with the psychiatric department developed by colleague Ernest Hammes of St. Paul, about 1925. I got some ideas from him since it was an outstanding and much admired innovation. That unit, like my own, preceded the Rockefeller-financed university hospital idea correctly discussed by Dr. Greenhill in his article; they came a decade later. Dr. Greenhill says Franklin Ebaugh is “undoubtedly” the father of units in general hospitals. I don’t agree with him there, but he has a right to his opinion. Ebaugh was a great talker and he advertised the idea well, but his own work was not, as I remember it, in a general hospital. Incidentally, Harvard had something similar to a general hospital psychiatric unit when I was at Massachusetts General Hospital during medical school days, but it was not so labeled. We students assigned there did not see psychiatric patients except in neurology, but there was a visiting psychologist who met with us and had all of us read Hart’s Psychology of Insanity (4). sion
(3).
Dr.
Greenhill’s
article
was
so
scholarly
REFERENCES 1) M. H. Greenhill, “Psychiatric Units in General Hospitals: 1979,” Vol. 30, pp. 169-182. 2) K. A. Menninger, “The Place of the Psychiatric Department in the General Hospital,” Modem Hospita4 Vol. 23, July 1924, pp. 1-4. 3) C. A. Erikson, “The Psychiatric Department of Christ’s Hospital, Topeka, Kansas,” Modem Hospltal Vol. 23, July 1924, pp. 5-7.
4) B. Hart, 1912.
Cambridge
Reply
Maurice
From
University
Press,
H. Greenhill,
Cambridge,
England,
M.D.
Dr. Menninger’s colorful letter indicates that I missed what is probably one of the earliest articles on psychiatry in the general hospital as well as the first architectural description of a psychiatric unit in such a hospital. What is truly remarkable is that these articles contained much material about the psychiatric unit in the general hospital that could have been written today and predicted some of the key problems that such units have subsequently encountered.
M.D.
aI enjoyed Dr. Greenhill’s fine article on general hospital psychiatric units in the March issue of Hospital & Community Psychiatry (1). When he comes to revise it for book publication, he may want to take a look at Dr. Menninger is chairman of the board of trustees of the Foundation in Topeka, Kansas, and chairman of the board lages in Topeka.
Menninger of the Vil-
VOLUME
30 NUMBER
8 AUGUST
1979
565
