MENTAL WELFARE
(The
following paper
Mental Health >ome
was
read
Workers
at the and is
uoservations
recent
31
Conference of the Association of
published
with their
permission.)
on
By DENIS CARROLL, M.A., M.R.C.S., L.R.C.P., Co-Director of the Institute for the Scientific Treatment of Delinquency Madam Chairman, Ladies and Gentlemen, these observations are not intended to form a complete account of modern psychological methods of treating asocial individuals. They are intended simply to give you some idea of the point of view from which the psychiatrist observes the delinquent and of some of the reasons which lie behind his recommendations. Treatment may be purely medical in character, including all the various psychological methods and all the organic methods such as those employed in treating cases of encephalitis lethargica or persons whose asocial behaviour can be attributed to a curable glandular abnormality. Or it may be sociological, measures of prevention either by force, by education, by the superincluding vision of early and late environment and the modifications of it, by training or by the methods employed by probation officers for offenders placed on probation. This last group is on the border between the sociological group of methods and the penal group, which includes all those methods involving punishment and threats of punishment. The general tendency nowadays is towards the adoption of non-penal methods and especially to the development of prophylactic measures of a kind which can be applied in practice to a large number of people. The medical psychologist is concerned primarily with the treatment of an actual offender but the tendency is more and more to regard this as a stepping-stone to knowledge which will enable us to design sound prophylactic measures. Treatment is still largely experimental, but the results have been very encouraging and many real successes have been achieved. The object of treatment is not only to prevent the repetition of an offence but also to make a good citizen. The greatest success has, on the average, been achieved with the young; not only because they arc easier of approach by intensive psycho-therapeutic methods than adult criminals but also because it is easier to effect permanent changes of character in them by sociological measures, which are always easier to apply to large numbers. In deciding what treatment to give to a particular delinquent, we arc guided by various classificatory and diagnostic systems. For example, we might divide delinquents into organic types, mental defectives, psychotics, neurotics, epileptics, psychopathic personalities, sexual perverts and criminal personalities. This classification is rather rough and ready, but will serve to show what I In the organic type we have all those cases where the offence can be mean. regarded as a symptom of an organic disease, such as encephalitis lethargica, sufferers from which may exhibit very widely divergent kinds of asocial be-
32
MENTAL WELFARE
are peculiarly difficult to relieve, though it is often possible do something towards preventing offences. Many such cases require institutional care. Another example is provided by patients with a glandular disorder, and such cases often show a combination of an organic and a psychological abnormality. For example, Herbert, aged 20, had committed thefts sometimes with violence at intervals since the age of 14. At that age he had begun to develop abnormally in height owing to a disorder of his pituitary gland. At 16 he was 6 ft. 4 in. tall, and, with his disproportionately large hands and long limbs, presented an ungainly appearance. As a result of this he developed a feeling of great sensitiveness about his appearance and later a feeling of marked inferiority which he ultimately overcame (but not completely) by means of theft. He showed no signs of any text-book mental disorder, but investigation soon showed that he would not have reacted to his physical disorder in this way had he not been in quite serious unconscious mental difficulties which had shown themselves in the form of various social inhibitions. In view of this it was likely that measures directed to the relief of these psychological difficulties would cure the delinquency, although they would do nothing towards curing the gigantism, and this was found to be the case. Mental defectives may be regarded as severe, or borderline. The severe ones require institutional care; the milder types can often be helped by traineither in or out of institutions, while some have benefited from psycholoing gical treatment, and recent psychoanalytic work with such cases has been encouraging, though it could scarcely be applied to any large numbers. On the whole there is little to be done for the mental defective beyond training and control. The psychotic and neurotic cases may be divided into two groups; in the first the offence takes the form of a symptom of the disease; in the second a known clinical disorder who we have persons who are suffering from commit an offence which cannot be regarded as in any way symptomatic of that disorder. In the first group, as with the organic types, the appropriate treatment is that of the basic disorder, and it would be as irrational, and usually as futile, to treat such offenders by punishment as it would be to treat pneumonia, insanity, or obsessional neurosis by punishment. This is not so obvious as it seems, since only a century ago they whipped maniacal patients, and at the present day it is still a widespread idea among laymen that hysterics are to be treated correctly and adequately by punitive measures of a milder kind. Common types of psychotic offenders are people suffering from manic depressive disease and people suffering from paranoia. The offence may be a method of ending intolerable anxiety, for example, when a man becomes so depressed and pessimistic about the future that he commits suicide or murders his family to end matters; or again, when a man commits an offence as the " strike him," and result of hallucination, for example, he hears a voice say he does, or, as with many paranoiacs, he believes a certain person is persecuting him and under the influence of this delusional belief he protects himself by persecuting the persecutor. A mild though good example of this was
haviour, and who to
MENTAL WELFARE
33
a woman who persisted in knocking on her neighbour's front door in the belief that this neighbour was doing the same to her, and would not stop unless she retaliated. The psychoses are notoriously difficult to treat, but many can be aided and many recover with a good prognosis, so that it is well worth while giving such cases the full benefit of modern psychiatric treatment. If they belong to the first group, it is unlikely that their delinwill be repeated when they are normal. quency The neurotic is fortunately much easier to treat, and cure is much more frequent. The neurotic criminal forms a large group. A type of neurotic criminal well worth noting is the obsessional type. Here the offence is a compulsive act, and is beyond the control of the individual in exactly the same way that an ordinary obsessional action such as compulsive washing is beyond his control. Such patients always show other signs of the obsessional neurosis, which is fortunate from the diagnostic point of view, since many criminals are only too ready to assert that the offence was the result of a sudden overwhelming impulse. Obsessionals are often difficult to cure, but are sometimes surprisingly easy, and it is an interesting point that when some obsessional delinquents have been treated psychologically, they have given up their asocial symptoms long before their obsessional state as a whole has disappeared. This is a very fortunate outcome of such treatment since it is otherwise very difficult to prevent the obsessional criminal from repeating his offence while treatment is achieving cure. Very often it is necessary in the public interest to commence treatment in an institution or to arrange for the patient never to be alone where repetition of the offence is possible. Indeed, it is very important when treating any offender never to lose sight of the need for protecting the public until treatment has reached a stage where repetition is really improbable. The neurotic criminal is the most approachable by psychotherapeutic measures from psychoanalysis to hypnosis. The principles of treatment follow the same general rules as in the neuroses with modifications to suit the circumstances of the criminal, who often comes under duress and has to be wooed into treatment before treatment proper can be carried out. The second group of psychotics and neurotics, whose asocial behaviour is not to be regarded as a symptom of their disorder, seem at first sight to be unsuitable for treatment by the doctor on the score of their delinquency. This is not so. The neurotic is more likely to succumb to temptation than the normal and his temptation is usually greater, so that if we cure the neurosis we are likely, incidentally, to cure the delinquency, and while the neurosis remains the delinquency is likely to recur. Moreover, the emotional factors underlying the neurosis are also involved in the factors underlying are the delinquency, whether these asocial, psychological, conscious or unconscious, so that in dealing with the one we automatically deal with the other. So that success is to be looked for in these cases too, though not so frequently, as in the neurotic criminal. The epileptics are found committing many different kinds of offences. The offence may follow or precede a fit or it may occur instead of the usual epileptic fit, and is followed by complete amnesia for the offence, e.g., he may
provided by
MENTAL WELFARE
34 undress in
be arrested for indecent behaviour, or he may attack each case having no subsequent recollection of what he has done. Treatment is both organic and psychological, and the patient frequently requires institutional care. The sexual offenders are very frequently regarded as especially suitable for psychological treatment. They, more than any other type of offender, are This is undoubtedly true, and as mentally abnormal. generally regarded it is a commonplace that punishment gives disappointing results. They are frequently very unwilling patients, and often difficult, but much can be done. I remember a youth who had been several times convicted for indecent exposure. His behaviour was attributable to the fact that he had been brought up in an exclusively feminine environment, and to the way in which the women around him had dealt with his characterological peculiarities, and sufficed to cure him. measures comparatively simple psychotherapeutic There are two other large groups: one is that of the psychopathic personalities, people of an abnormal and weak type who do not fit into any other definite clinical group, and among whom are found many embezzlers, persons charged with false pretences, sneak thieves, etc.; the other is that of the socalled normal criminal, a person who is to be regarded as having a criminal character, and who shows no signs of mental abnormality apart from his asocial behaviour. Psychopathic personalities tend to sink to the level of the lower of their immediate associates rather than to rise to that of the better of their companions, and consequently punishment, especially imprisonment, does not tend to have a curative effect. Prolonged training is often useful, whether in a home, in an approved school, Borstal or elsewhere. Psychological methods have not been applied very extensively. As a rule these offenders make bad patients because they lack application even more than most. Good results have been obtained and with research there is reason to hope that good methods for their treatment will be devised. It is very difficult to assess how many offenders belong to these various groups, but apart from the normal criminal," the foregoing groups together probably represent about 60 per cent, of all offenders. If we group offenders according to a classification such as the above, it is often easy in theory to see what the treatment is?it is that of the basic disorder. In practice it is more complicated. Society has to be protected and ways and means have to be considered. The ideal treatment is not always available or possible, and so on. In this process of compromise all the known causative factors are considered too. Asocial behaviour is often the resultant of a number of causes, e.g., constitutional abnormalities, early and late emotional factors, education, opportunity, social conditions, economic stress, companions, etc., and it may be that the balance in favour of delinquent behaviour is so small that the removal of one of the more superficial of these factors will suffice for cure, e.g., there are many more offences against property during a wave of unemployment which lessen when prosperity returns. These temporary delinquents could be cured by financial aid. Unfortunately such methods are too superficial since they do not touch those deeper factors someone
public and violently, in
"
MENTAL WELFARE
35
the absence of which (as is the fact with the non-delinquent majority of unemployed) economic stress would not result in delinquency, so that in treating offenders by remedying very superficial causes we must beware of neglecting serious deeper factors which usually require long treatment. The normal criminal is the hardest to deal with and is probably similar as far as concerns treatment to the character case met with in ordinary psychiatric practice. Much more research is needed and is being carried out at the Institute and many other places on this type both into its aetiology and treatment, and there is reason to hope that effective treatment will become more certain. Even now successes have been achieved. The length of treatment is very varied, from a few weeks to years, but is usually a matter of a few months, much depending on the type of offence and the method of treatment. No doubt it would be beneficial to psychoanalyse all offenders in addition to whatever other treatment (penal, training, etc.) they had. In practice this cannot be done because, apart from expense, there are not, and are not likely to be, enough analysts to do it. Another reason is that many offenders are not suitable subjects for analysis because they only come to treatment under duress, and analysis of sufficient depth to produce cure is often impossible under such conditions. With others, social factors prevent attendance at a clinic for a sufficient time. It is desirable, however, to analyse offenders of all types for research purposes. It is in this field of research that analysis renders its greatest service to the study of delin-
in
"
"
quency.
are applied to the problem, and a in the study of delinquency. is to include all methods policy The aim is to cure, where possible, and to develop preventive methods. The future is most promising in the field of prevention in childhood, and with the recognition and treatment in the widest sense of the pro-delinquent child, crime should show a marked decrease. Many years will pass before this is achieved. To conclude, it will be interesting to mention in a simple way something of the more advanced theories upon which psychological recommendations are often made. The particular example I give is only one of many, and I give it in a schematic way for the sake of clarity. We can regard the mind as divided into conscious and unconscious and also into id, ego and super ego. Simply, the conscious is that part of the mind of which we are aware, the The id is wholly unconscious unconscious that of which we are unaware. and consists of all the primitive, crude impulses, aggressive sexual, etc. The super ego is partly conscious and partly unconscious and is a sort of hyper-conscience. The super ego exercises a check on the id, it is critical towards it, and its severity depends on the severity of the id impulses, particularly the aggressive ones. The id is therefore antagonistic to the super ego and the two are at war. The ego tries to act as a mediator. The ego and super ego are influenced by environmental factors in their development. The stronger the super ego the harder it is for the ego?the logical and partly conscious self?to develop. In the normal the super ego is
At the Institute methods of all kinds
feature of
our
MENTAL WELFARE
36
In moderate and benign, the ego strong and the id under control. the neurotic the super ego is over strong and the patient is overmoral. The delinquent is amoral, and this is often regarded as due to a weakly developed super ego. Actually delinquency may result from too a strong super ego, in which case the offence represents a compulsive attempt to overcome the difficulties it causes and the patient feels, unconsciously, much more guilty than appears on the surface. Consequently in treatment we must modify the super ego so that these difficulties are removed; we must make it more benign; where it is weak we must strengthen it, and so on. These modifications can be produced ideally by analysis which reorganises the whole structure. It is often possible to do something in other ways. For example, the super ego is formed to some extent by incorporating into it the critical attitude (real or imagined) of parental figures with whom the child Now an over-severe or harsh super ego is likely to cause comes into contact. so that the more abnormality benign the super ego is the better (I say benign and not wea\ and mean firm though kindly," i.e., the criticism must come from figures who are felt to have a loving attitude to the child). Consequently the more loving and rational the parental figures with whom the child is in contact the more benign will be the super ego and the better will be the child. In the adult the same process continues though to a lesser degree, and the super ego can be modified to some extent in this direction by adopting a benign attitude to the offender. I recall a case in which this occurred very successfully. A burglar of over 50 with many convictions was treated by a probation officer. He became very friendly with the man and helped him in many ways of real practical value, and the man kept straight for two years. He then began to behave suspiciously and was arrested. The probation officer realised this was a critical moment and remained friendly and advised the As a result he was discharged for lack man how he should proceed in court. of evidence. He had not actually committed an offence as it happened. The result was that he remained straight till he died many years afterwards. The officer's attitude had enabled him to realise that a critic could also be a loving figure, and in this way he had been able?by incorporation?to render his super ego more benign and in that way lessen his tendency to delinquency sufficiently to give him conscious control over his impulse to steal. Some persons deal with the conflict between super ego and id by projecting one of the two on to the external world as a whole or in part. Suppose such a person projects his id impulses on to another person. He then identifies himself with his super ego and becomes harsh and critical to the other person and visits upon him all the severity with which his super ego formerly treated himself. But in doing this he is being righteous (in his unconscious) because he has identified himself with his conscience and is behaving as such. To punish such a person cannot result in cure because the punishment increases the conscience and therefore the severity of the super ego, and therefore the extent of the subject's behaviour which is asocial, i.e., it makes him more a delinquent than ever. Suppose he identifies himself with the id and the outer world with the super ego in order to deal with the conflict. His asocial "
MENTAL WELFARE
behaviour then represents the
37
struggle of the id to overcome the super ego. In such a case the ego is necessarily weak, and punishment cannot strengthen it because it acts by increasing the super ego, i.e., it gives the id all the more reason for attacking the super ego and may therefore result in still further delinquency. The only way punishment can cure in this group is by making the super ego (the external world for such people) so strong that the id is conquered but at the price of tremendous inhibition. Such cases are extreme and probably never occur in pure form, but the existence of either of them to any considerable extent means that we must consider them in advising the type of treatment and whether it is to be severe or mild, critical or non-critical, penal or not, etc., in character. The correct procedure is to advise a method of handling which will lessen the conflict and so permit the ego to develop and control the situation. This is very theoretical but nevertheless of great practical importance. We may conclude by saying that as a rule the more benign our treatment of offenders, the greater our successes will be, always remembering that and not a we mean carte blanche to commit crimes, and that kindly by benign the kindliness is combined with a watchful eye on the needs of society.
(The
following paper
Mental Health >ome
was
read
Workers
at the and is
uoservations
recent
31
Conference of the Association of
published
with their
permission.)
on
By DENIS CARROLL, M.A., M.R.C.S., L.R.C.P., Co-Director of the Institute for the Scientific Treatment of Delinquency Madam Chairman, Ladies and Gentlemen, these observations are not intended to form a complete account of modern psychological methods of treating asocial individuals. They are intended simply to give you some idea of the point of view from which the psychiatrist observes the delinquent and of some of the reasons which lie behind his recommendations. Treatment may be purely medical in character, including all the various psychological methods and all the organic methods such as those employed in treating cases of encephalitis lethargica or persons whose asocial behaviour can be attributed to a curable glandular abnormality. Or it may be sociological, measures of prevention either by force, by education, by the superincluding vision of early and late environment and the modifications of it, by training or by the methods employed by probation officers for offenders placed on probation. This last group is on the border between the sociological group of methods and the penal group, which includes all those methods involving punishment and threats of punishment. The general tendency nowadays is towards the adoption of non-penal methods and especially to the development of prophylactic measures of a kind which can be applied in practice to a large number of people. The medical psychologist is concerned primarily with the treatment of an actual offender but the tendency is more and more to regard this as a stepping-stone to knowledge which will enable us to design sound prophylactic measures. Treatment is still largely experimental, but the results have been very encouraging and many real successes have been achieved. The object of treatment is not only to prevent the repetition of an offence but also to make a good citizen. The greatest success has, on the average, been achieved with the young; not only because they arc easier of approach by intensive psycho-therapeutic methods than adult criminals but also because it is easier to effect permanent changes of character in them by sociological measures, which are always easier to apply to large numbers. In deciding what treatment to give to a particular delinquent, we arc guided by various classificatory and diagnostic systems. For example, we might divide delinquents into organic types, mental defectives, psychotics, neurotics, epileptics, psychopathic personalities, sexual perverts and criminal personalities. This classification is rather rough and ready, but will serve to show what I In the organic type we have all those cases where the offence can be mean. regarded as a symptom of an organic disease, such as encephalitis lethargica, sufferers from which may exhibit very widely divergent kinds of asocial be-
32
MENTAL WELFARE
are peculiarly difficult to relieve, though it is often possible do something towards preventing offences. Many such cases require institutional care. Another example is provided by patients with a glandular disorder, and such cases often show a combination of an organic and a psychological abnormality. For example, Herbert, aged 20, had committed thefts sometimes with violence at intervals since the age of 14. At that age he had begun to develop abnormally in height owing to a disorder of his pituitary gland. At 16 he was 6 ft. 4 in. tall, and, with his disproportionately large hands and long limbs, presented an ungainly appearance. As a result of this he developed a feeling of great sensitiveness about his appearance and later a feeling of marked inferiority which he ultimately overcame (but not completely) by means of theft. He showed no signs of any text-book mental disorder, but investigation soon showed that he would not have reacted to his physical disorder in this way had he not been in quite serious unconscious mental difficulties which had shown themselves in the form of various social inhibitions. In view of this it was likely that measures directed to the relief of these psychological difficulties would cure the delinquency, although they would do nothing towards curing the gigantism, and this was found to be the case. Mental defectives may be regarded as severe, or borderline. The severe ones require institutional care; the milder types can often be helped by traineither in or out of institutions, while some have benefited from psycholoing gical treatment, and recent psychoanalytic work with such cases has been encouraging, though it could scarcely be applied to any large numbers. On the whole there is little to be done for the mental defective beyond training and control. The psychotic and neurotic cases may be divided into two groups; in the first the offence takes the form of a symptom of the disease; in the second a known clinical disorder who we have persons who are suffering from commit an offence which cannot be regarded as in any way symptomatic of that disorder. In the first group, as with the organic types, the appropriate treatment is that of the basic disorder, and it would be as irrational, and usually as futile, to treat such offenders by punishment as it would be to treat pneumonia, insanity, or obsessional neurosis by punishment. This is not so obvious as it seems, since only a century ago they whipped maniacal patients, and at the present day it is still a widespread idea among laymen that hysterics are to be treated correctly and adequately by punitive measures of a milder kind. Common types of psychotic offenders are people suffering from manic depressive disease and people suffering from paranoia. The offence may be a method of ending intolerable anxiety, for example, when a man becomes so depressed and pessimistic about the future that he commits suicide or murders his family to end matters; or again, when a man commits an offence as the " strike him," and result of hallucination, for example, he hears a voice say he does, or, as with many paranoiacs, he believes a certain person is persecuting him and under the influence of this delusional belief he protects himself by persecuting the persecutor. A mild though good example of this was
haviour, and who to
MENTAL WELFARE
33
a woman who persisted in knocking on her neighbour's front door in the belief that this neighbour was doing the same to her, and would not stop unless she retaliated. The psychoses are notoriously difficult to treat, but many can be aided and many recover with a good prognosis, so that it is well worth while giving such cases the full benefit of modern psychiatric treatment. If they belong to the first group, it is unlikely that their delinwill be repeated when they are normal. quency The neurotic is fortunately much easier to treat, and cure is much more frequent. The neurotic criminal forms a large group. A type of neurotic criminal well worth noting is the obsessional type. Here the offence is a compulsive act, and is beyond the control of the individual in exactly the same way that an ordinary obsessional action such as compulsive washing is beyond his control. Such patients always show other signs of the obsessional neurosis, which is fortunate from the diagnostic point of view, since many criminals are only too ready to assert that the offence was the result of a sudden overwhelming impulse. Obsessionals are often difficult to cure, but are sometimes surprisingly easy, and it is an interesting point that when some obsessional delinquents have been treated psychologically, they have given up their asocial symptoms long before their obsessional state as a whole has disappeared. This is a very fortunate outcome of such treatment since it is otherwise very difficult to prevent the obsessional criminal from repeating his offence while treatment is achieving cure. Very often it is necessary in the public interest to commence treatment in an institution or to arrange for the patient never to be alone where repetition of the offence is possible. Indeed, it is very important when treating any offender never to lose sight of the need for protecting the public until treatment has reached a stage where repetition is really improbable. The neurotic criminal is the most approachable by psychotherapeutic measures from psychoanalysis to hypnosis. The principles of treatment follow the same general rules as in the neuroses with modifications to suit the circumstances of the criminal, who often comes under duress and has to be wooed into treatment before treatment proper can be carried out. The second group of psychotics and neurotics, whose asocial behaviour is not to be regarded as a symptom of their disorder, seem at first sight to be unsuitable for treatment by the doctor on the score of their delinquency. This is not so. The neurotic is more likely to succumb to temptation than the normal and his temptation is usually greater, so that if we cure the neurosis we are likely, incidentally, to cure the delinquency, and while the neurosis remains the delinquency is likely to recur. Moreover, the emotional factors underlying the neurosis are also involved in the factors underlying are the delinquency, whether these asocial, psychological, conscious or unconscious, so that in dealing with the one we automatically deal with the other. So that success is to be looked for in these cases too, though not so frequently, as in the neurotic criminal. The epileptics are found committing many different kinds of offences. The offence may follow or precede a fit or it may occur instead of the usual epileptic fit, and is followed by complete amnesia for the offence, e.g., he may
provided by
MENTAL WELFARE
34 undress in
be arrested for indecent behaviour, or he may attack each case having no subsequent recollection of what he has done. Treatment is both organic and psychological, and the patient frequently requires institutional care. The sexual offenders are very frequently regarded as especially suitable for psychological treatment. They, more than any other type of offender, are This is undoubtedly true, and as mentally abnormal. generally regarded it is a commonplace that punishment gives disappointing results. They are frequently very unwilling patients, and often difficult, but much can be done. I remember a youth who had been several times convicted for indecent exposure. His behaviour was attributable to the fact that he had been brought up in an exclusively feminine environment, and to the way in which the women around him had dealt with his characterological peculiarities, and sufficed to cure him. measures comparatively simple psychotherapeutic There are two other large groups: one is that of the psychopathic personalities, people of an abnormal and weak type who do not fit into any other definite clinical group, and among whom are found many embezzlers, persons charged with false pretences, sneak thieves, etc.; the other is that of the socalled normal criminal, a person who is to be regarded as having a criminal character, and who shows no signs of mental abnormality apart from his asocial behaviour. Psychopathic personalities tend to sink to the level of the lower of their immediate associates rather than to rise to that of the better of their companions, and consequently punishment, especially imprisonment, does not tend to have a curative effect. Prolonged training is often useful, whether in a home, in an approved school, Borstal or elsewhere. Psychological methods have not been applied very extensively. As a rule these offenders make bad patients because they lack application even more than most. Good results have been obtained and with research there is reason to hope that good methods for their treatment will be devised. It is very difficult to assess how many offenders belong to these various groups, but apart from the normal criminal," the foregoing groups together probably represent about 60 per cent, of all offenders. If we group offenders according to a classification such as the above, it is often easy in theory to see what the treatment is?it is that of the basic disorder. In practice it is more complicated. Society has to be protected and ways and means have to be considered. The ideal treatment is not always available or possible, and so on. In this process of compromise all the known causative factors are considered too. Asocial behaviour is often the resultant of a number of causes, e.g., constitutional abnormalities, early and late emotional factors, education, opportunity, social conditions, economic stress, companions, etc., and it may be that the balance in favour of delinquent behaviour is so small that the removal of one of the more superficial of these factors will suffice for cure, e.g., there are many more offences against property during a wave of unemployment which lessen when prosperity returns. These temporary delinquents could be cured by financial aid. Unfortunately such methods are too superficial since they do not touch those deeper factors someone
public and violently, in
"
MENTAL WELFARE
35
the absence of which (as is the fact with the non-delinquent majority of unemployed) economic stress would not result in delinquency, so that in treating offenders by remedying very superficial causes we must beware of neglecting serious deeper factors which usually require long treatment. The normal criminal is the hardest to deal with and is probably similar as far as concerns treatment to the character case met with in ordinary psychiatric practice. Much more research is needed and is being carried out at the Institute and many other places on this type both into its aetiology and treatment, and there is reason to hope that effective treatment will become more certain. Even now successes have been achieved. The length of treatment is very varied, from a few weeks to years, but is usually a matter of a few months, much depending on the type of offence and the method of treatment. No doubt it would be beneficial to psychoanalyse all offenders in addition to whatever other treatment (penal, training, etc.) they had. In practice this cannot be done because, apart from expense, there are not, and are not likely to be, enough analysts to do it. Another reason is that many offenders are not suitable subjects for analysis because they only come to treatment under duress, and analysis of sufficient depth to produce cure is often impossible under such conditions. With others, social factors prevent attendance at a clinic for a sufficient time. It is desirable, however, to analyse offenders of all types for research purposes. It is in this field of research that analysis renders its greatest service to the study of delin-
in
"
"
quency.
are applied to the problem, and a in the study of delinquency. is to include all methods policy The aim is to cure, where possible, and to develop preventive methods. The future is most promising in the field of prevention in childhood, and with the recognition and treatment in the widest sense of the pro-delinquent child, crime should show a marked decrease. Many years will pass before this is achieved. To conclude, it will be interesting to mention in a simple way something of the more advanced theories upon which psychological recommendations are often made. The particular example I give is only one of many, and I give it in a schematic way for the sake of clarity. We can regard the mind as divided into conscious and unconscious and also into id, ego and super ego. Simply, the conscious is that part of the mind of which we are aware, the The id is wholly unconscious unconscious that of which we are unaware. and consists of all the primitive, crude impulses, aggressive sexual, etc. The super ego is partly conscious and partly unconscious and is a sort of hyper-conscience. The super ego exercises a check on the id, it is critical towards it, and its severity depends on the severity of the id impulses, particularly the aggressive ones. The id is therefore antagonistic to the super ego and the two are at war. The ego tries to act as a mediator. The ego and super ego are influenced by environmental factors in their development. The stronger the super ego the harder it is for the ego?the logical and partly conscious self?to develop. In the normal the super ego is
At the Institute methods of all kinds
feature of
our
MENTAL WELFARE
36
In moderate and benign, the ego strong and the id under control. the neurotic the super ego is over strong and the patient is overmoral. The delinquent is amoral, and this is often regarded as due to a weakly developed super ego. Actually delinquency may result from too a strong super ego, in which case the offence represents a compulsive attempt to overcome the difficulties it causes and the patient feels, unconsciously, much more guilty than appears on the surface. Consequently in treatment we must modify the super ego so that these difficulties are removed; we must make it more benign; where it is weak we must strengthen it, and so on. These modifications can be produced ideally by analysis which reorganises the whole structure. It is often possible to do something in other ways. For example, the super ego is formed to some extent by incorporating into it the critical attitude (real or imagined) of parental figures with whom the child Now an over-severe or harsh super ego is likely to cause comes into contact. so that the more abnormality benign the super ego is the better (I say benign and not wea\ and mean firm though kindly," i.e., the criticism must come from figures who are felt to have a loving attitude to the child). Consequently the more loving and rational the parental figures with whom the child is in contact the more benign will be the super ego and the better will be the child. In the adult the same process continues though to a lesser degree, and the super ego can be modified to some extent in this direction by adopting a benign attitude to the offender. I recall a case in which this occurred very successfully. A burglar of over 50 with many convictions was treated by a probation officer. He became very friendly with the man and helped him in many ways of real practical value, and the man kept straight for two years. He then began to behave suspiciously and was arrested. The probation officer realised this was a critical moment and remained friendly and advised the As a result he was discharged for lack man how he should proceed in court. of evidence. He had not actually committed an offence as it happened. The result was that he remained straight till he died many years afterwards. The officer's attitude had enabled him to realise that a critic could also be a loving figure, and in this way he had been able?by incorporation?to render his super ego more benign and in that way lessen his tendency to delinquency sufficiently to give him conscious control over his impulse to steal. Some persons deal with the conflict between super ego and id by projecting one of the two on to the external world as a whole or in part. Suppose such a person projects his id impulses on to another person. He then identifies himself with his super ego and becomes harsh and critical to the other person and visits upon him all the severity with which his super ego formerly treated himself. But in doing this he is being righteous (in his unconscious) because he has identified himself with his conscience and is behaving as such. To punish such a person cannot result in cure because the punishment increases the conscience and therefore the severity of the super ego, and therefore the extent of the subject's behaviour which is asocial, i.e., it makes him more a delinquent than ever. Suppose he identifies himself with the id and the outer world with the super ego in order to deal with the conflict. His asocial "
MENTAL WELFARE
behaviour then represents the
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struggle of the id to overcome the super ego. In such a case the ego is necessarily weak, and punishment cannot strengthen it because it acts by increasing the super ego, i.e., it gives the id all the more reason for attacking the super ego and may therefore result in still further delinquency. The only way punishment can cure in this group is by making the super ego (the external world for such people) so strong that the id is conquered but at the price of tremendous inhibition. Such cases are extreme and probably never occur in pure form, but the existence of either of them to any considerable extent means that we must consider them in advising the type of treatment and whether it is to be severe or mild, critical or non-critical, penal or not, etc., in character. The correct procedure is to advise a method of handling which will lessen the conflict and so permit the ego to develop and control the situation. This is very theoretical but nevertheless of great practical importance. We may conclude by saying that as a rule the more benign our treatment of offenders, the greater our successes will be, always remembering that and not a we mean carte blanche to commit crimes, and that kindly by benign the kindliness is combined with a watchful eye on the needs of society.
