EXPREMED FEARS OF PSYCHIATRIC INPATIENTS 279

SUMMARY

One hundred psychiatric inpatients (50 malea and 50 femaleg) were admin- istered the Fear Survey &hedule to determine the relative frequency and degree of expressed fears. Sex and age dif€erencea were found to be significant, with females obtaining higher fear more8 than malea, and with younger people obtaining higher fear scores than older people. Additionally, rank ditferencea for specific fears be- tween the sexes were reported.

REFERENCES 1. HANNA, F., STOBM, T. and C m , W. K. Sex difIarenoee rrnd redationahipe among neuroticism,

2. W o w , .f. and LANO, P. J. A fear survey ached& for uae in behavior therapy. Behw. Rcs. 3. WOLPID, J. and LACARUS, A. A. Behavk Therapy Techniqws. Oxford: Pergamon Prees, 1966.

eatravemion and e x p d fears. Pstcspt. Mot. SMh 1966, Sl, 12144216.

Therap., 1984, d, 27-30.

CRIMINAL BEHAVIOR

The historv of 8ocietv1s

AND MENTAL INSTITUTIONALIZATION* DAVID LEVINE

Universiry of Nebraska:

PROBLEM attemDts to deal with sociallv deviant behavior is

well known. What is beidg highlidted in this paper is the"recent blurring of the distinction between crime and mental disorder. A greater proportion of criminal behavior is now seen as the mul t of mental disorder, with the lawbreaker being sent to a mental hospital rather than to a penal institution. The most extreme position is expressed by those scientists who hold that all crime is a function of mental illness. SzaszO), on the other hand, holds that mental illness is a myth and considers all socially deviant behavior as a form of disordered interpersonal com- munication.

The theoretical position from which the present research derives is a social psychological one; it is baaed on the notion that when an individual acts in a way contrary to community standards, the community is threatened and takes steps to preserve itself and its structure. The nature of these etep is generally appropriate to the extent of the threat posed by the violator. The complex legal system of present-day Weatern civilination is an attempt to objmtify these steps 80 that justice may be done while sooiety is being protected. Paychological reaearoh, how- ever, has largely ignored this legal system of objeotive standards (the criminal code) for measuring socially deviant behavior.

This theoretical position generates several interrelated predictions: (a) People showing symptoms which threaten the community are more likely to be admitted to a mental hospital than people showing symptoms which do not threaten the community; (b) a siseable proportion of atients in mental hospitals diagnosed as

positive correlation between the extent to whioh the patient's behavior threatens the community and the length of his stay in the hp i t a l .

Theee predictions do not take into account nomodel pychological variablea such as genetic factors, psychodynamic variables, physical illness, and 80 on. It

%me of thiu wo!k WM comp!etad w y e the author WM mtl.ohed to the Clinical Fphiatry Grant,

mentally ill will have broken the laws o P the community; and (c) there wil l be a

Unit, Gmyhngwell Hoapitsl, Cluchsster, Sumex, Jhghd, supportad by NIM MI3 10993-01.

280 DAVID LEVINE

is intended to determine first if criminal behavior accounts for any variance in the extent of mental hospitalization. If it is found that it does, then future research will study the relationship between criminal behavior and mental institutional- ization as affected by the nonsocial psychological variables.

STUDY 1 Hypothesis I : People showing symptoms which threaten the community are

more likely to be admitted to a mental hospital than people showing symptoms which do not threaten the community.

Although this hypothesis has never been explicitly tested, data bearing on it are available. For example, in a study designed to evaluate a community psy- chiatric service, Grad and Sainabury(*) report the data in Table 1 indicating that admission rates for patients do differ depending on the symptoms which they show. But, these symptoms also differ in the extent to which they threaten the community. TABLE 1. PROPORTION OF PATIENTI3 REFERRED FOR PSYCHIATRIC CONSULTATION WHO WERE

ADMITPED TO A PSYCHIATRIC HOSPITAL AS RELATED TO THE SYMPTOMS M A N I ~ S T E D AT TIME OF PSYCHIATRIC CONSULTATION

Symptoms Chichester Salisbury

Suicidal 60% 68% Aggreeaive 60 69 confused 59 88 Unable to care for self Deluded

60 48

94 87

Hallucinated 43 89 Overactive Insomnia

54 22

71 53

Loss of concentration 19 52 Phobias Anxiety

5 9

38 46

NOTE: Total number of patients referred: Chichester 823; Saliibury 585. From Grad and Sainsbury (I), Table 16.

Hypothesis I leads to the prediction that there will be a positive correlation between the extent to which a symptom threatens the community and the admission rate for patients showing that symptom. To test this prediction, three psychiatrists were asked to “rank these symptoms (Grad and Sainsbury’s) in terms of the extent to which the patient showing them will be perceived by the community as a threat to the community.” Agreement among these psychiatrists was very good (Kendall’s W = 37). The three rankings were averaged to yield a single ranking reflecting the extent to which the symptom was considered to be threatening to the com- munity.

Then, the symptoms were ranked in terms of the admission rates of patients showing these symptoms, e.g., in the Salisbury sample “Unable to care for self” was ranked “l”, “Hallucinated” was ranked “2”, and so on. The rank difference correlation (rho) between the extent to which the symptom threatened the com- munity and the average admission rate for the two samples was .70, clearly sup- porting the hypothesis.

STUDY I1 Hypothesis 11: A sizeable proportion of patients in mental hospitals will have

broken the laws of the commnnitv.

CRIMINAL BEHAVIOR AND MENTAL INSTITUTIONALIZATION 28 1

The only data currently available on the incidence of criminal acts among mental patients are baaed on samples of patients who have already been discharged from the hospital; Giovannoni and Curel‘’) have reviewed this literature. However, these data are not relevant to the present theory since decision makers are likely to keep in the hospital those patients considered most likely to break the law. The present theoretical framework predicts that the crime rate among discharged patients will be lower than the rate among hospitalized patients.

Method. To test Hypothesis 11, it was necessary to obtain a random sample of hospitalized mental patients. Accordingly, 100 patients in a large state mental hospital were selected by taking every tenth folder from the active files. A research assistant copied from the file all the information concerning the events which led to the patient being admitted to the hospital. It was found, parenthetically, that this kind of straightforward, descriptive, and behavioral data are not presented in nearly as great detail as the family history, early life, or physical condition of the patient.

This material was typed on separate sheets with no other information except an identifying number. These sheets were then given to the local county attorney (the governmental representative who decides for the community which crimes shall be prosecuted). He was asked (a) to underline each bit of behavior which was a violation of the law, ignoring the possibility of a plea of “not guilty by reason of insanity” and focusing on the overt behavior; and (b) to state the specific statute which had been violated.

Table 2 furnishes a description of the sample by official hospital diagnosis, sex, age, and mean days of hospitalization. Table 3 is a summary of the crimes committed by these 100 randomly selected patients as reported in their files and which were relevant to their hospital admission. The total number of crimes is greater than 100 because, although 29 patients had committed no crimes, many of them had committed more than one. It will be recalled that these are only those crimes related to the patient’s hospital admission; one would w u m e that this is not a complete accounting of all the nonlawful behavior of these patients.

STATE MENTAL HOSPITAL (N = 100)

Results.

TABLE 2. DESCRIPTIVE CH.~RACIBRISTICS OF A NANDOM SAMPLE OF PATIENTS IN A

Me? days Mean age in

Diagnosib sex N in years hospital - _ _

CBS M 9 38.3 141.4 F 18 54.4 98.7

Schizophrenics M 23 30.0 259.3 F 26 37.0 207.0

Mental retardates M 6 26.1 172.8 F 6 26.5 218.8

()ther* M 6 28.8 135.5 F 6 41 . O 252.0

Total 100

NOTE: Patients were selected by taking every tenth folder from the active files. *Includes 6 manic-depmives, 2 sociopaths, and one each of pemnality disturbance, adjustment

It is obvious from Table 3 that many of the crimes committed pose no serious threat to the community and the question of why some people who disturb the peace go to a mental hospital, while others go to jail, and still others are not arreated remains an important one calling for further study. The number of serious crimes

reaction of adolescence, neurotic dependency react ion, and antisocial reaction.

282 DAVID LEVINE

reported in Table 3 is obviously higher than the base rates reported for discharged patients(*), and it is higher than most mental health professionals would have expected.

Tmm 3. CBIUEJ ~ A D I N O M ADMISSION TO MENTAL HOBPITAL IN A RANDOM SAMPLE OF 100 HOSPITALIZED PATIENT^

Crimes Number of patients

No crime

Feloniea h u l t with Intent to Kill, Wound or Maim statutory Ra Murder-1st Eegree ~~ar&f.obbety and Mail Robbery

Sodomy Abortion Arson-1st Degree Carrying a Concealed Weapon Petit Larceny-2nd Offense Debauching a Minor

Disturbing the Peace and Disorderly Conduct Assault and Battery +u!t in a Threptp' Manner Mficioue Deetruhony Property Intoxication Petit Larceny Adultesy Prustitution obecene Lang Contributing b%quency of Minor Resist' bat Loade?!hoe in Car c rue l ty toc dren

Misdemeanor

:iZ;ig JuBticce Wueing.to Sin Income Tax z x l c o h o l i c Liquor for a Minor

29

6 4 2 4

1 1 2

33 20 10 17 13 5 3 2 3 2 1 1 3 4 1 5 1 1 1 1 2 1

&sue1 Psychopath 1

NOTE: Patients were selected by taking every tenth folder from the active files.

STUDY 111 Hypothesis 111: There will be a positive correlation between the extent to

which the patient's behavior threatens the community and the length of his stay in the mental hospital.

In this study, we have defined the extent to which a patient's behavior threatens the community as the number of months he would have been sentenced to jail had he been tried and convicted of-the crimes which he committed during the period immediately prior to his adnuspon to the mental hospital. This measure has never been utilieed and has the obvious advantages of specificity and reliability, as well as some claim to face valldlty.

Method. A new sample, 100 consecutive admissions to a large state mental hospital beginning on January 1, 1955, was studied using the same methods as in Study 11, with one addition. The county attorney was asked to state, in addition,

CRIMINAL BEHAVIOR AND MENTAL INSTITUTIONALIZATION 283

the jail sentence set by law for each violation, e.g., “Disturbing the Peace: not more than three months in jail’,; “Malicious Destruction of Property: if under 8100, the crime is a misdemeanor punishable by a fine of up to $500 and a jail sentence of not more than six months; if value is more than 8100, the crime is a felony, punish- able by one to three years in the State Penitentiary.”

During a 10-year follow-up period, 24 patients died without leaving the hospital; an additional 16 patients were excluded from the study because their files were lost, misplaced, or transferred to other institutions, leaving a final sample of 60 patients.

By far the largest attrition due to death occurred among the elderly brain- damaged patients; of the original 32 patients diagnosed aa having neurological involvement, 21 died in the hospital. The final sample consisted of 11 brain-damaged patients, 28 schizophrenics, and 21 patients with an assortment of diagnoses. The descriptive characteristics of the total sample (including the 24 patients who died during the 10-year follow-up) and the nature of the crimes they had committed were very similar to that reported for the sample in Study 11.

For each patient, two scores were obtained: (a) The total number of months he had spent in the mental hospital during the 10-year follow-up period (Hospital- ization Score) ; and (b) the total number of months he would have been sentenced to jail had he been tried and convicted of the crimes which he committed during the period immediately prior to his hospital admission (Punishment Score). Since it was not possible to obtain complete information about transfers or subsequent admissions to other institutions, it was decided to record only that time spent by the patient in the hospital being studied. It waa felt that this procedure would introduce only random error, the effect of which would be solely to lower any correlation between the two variables.

To obtain the 8’s Punishment Score, every crime which he had committed was assigned a single “jailJJ score by taking the mean number of months of the shortest and longest possible sentence, e.g., a crime punishable by 1 to 3 years in the penitentiary has a “jail’J score of “24 months”. These “jailJJ scores were summed for each S to obtain his Punishment Score.

Since both the Hospitalization Score and the Punishment Score yielded mark- edly skewed distributions, these scores were transformed to log scores which normalized the distributions to some extent.

Results. The correlation between log Hospitalisation and log Punishment for the sample of 60 patients is .22. Although not accounting for much variance, this r is statistically significant (p < .05; two-tailed test).

Since the sample waa made up of a heterogeneous group of patients and the brain-damaged patients had much lower Punishment scores than the rest of the sample, Pearson r’s were also computed for the separate diagnostic groups. For the 11 patients with neurological involvement, the t waa .40 (not significant); for the 28 schizophrenics, the t waa .51 ( p < .005); for the remaining 21 patients (7 alcoholics; 7 character disorders; 3 manic depreaeives; 2 undiagnosed; 1 anxiety reaction; and 1 mentally retarded), the r waa -.13 (not significant).

DISCUSSION Although the present studies support those theories of mental disorder which

implicate social psychological variables, one aspect of the data needs further dis- cussion. Why is the correlation between socially deviant behavior and length of institutionalization high in the schizophrenic group, but not in the miscellaneous diagnostic group? One possibility is suggerrted by the fact that the miscellaneous category contains three d e p d patients who may have been kept in the hospital “for their own protection. ’ None of these three patients had committed a crime (their Punishment scores were “O”), yet one was hospitalized for 23 months and one for 66 months. Clearly, there are other sources of variance h i d e s socially

284 DAVID LEVINE

deviant behavior which need to be taken into account in explaining length of mental hospitalization. What this report does demonstrate, however, is that the extent to which a patient threatens the community is one important factor de- termining the length of time he spends in a mental hospital.

The results of these studies have important social implications. The traditional state mental hospital is serving several independent social functions: Custody of patients threatening society; nursing for elderly brain-damaged patients; pro- tection for patients from their own self-destructive impulses, as well as rehabili- tation for people who simply cannot cope with society’s demands. Social planners need to consider whether it is desirable for one institution to try to fill all these roles simultaneously.

SUMMARY People showing symptoms which threaten the community are more likely to

be admitted to a mental hospital than people showing symptoms which do not threaten the community. About 70% of a random sample of mental hospital patients have broken the law; the precise nature of their crimes was reported. There is a positive correlation (r = .51) between the number of months a schizo- phrenic patient spends in a mental hospital and the number of months he would have been sentenced to jail had he been tried and convicted of the crimes which he committed during the period immediately prior to his hospital admission.

REFERENCES 1. GIOVANNONI, J. M. and GUREL, L. Socially disruptive behavior of ex-mental patients. Arch. Ben. Psychid., 1967,17,146-153.

2. GRAD, J. and SAINBBURY, P. Evaluating the community psychiatric services in Chichater: Results. The Milbank M d Fund Quart., 1966,&, 246-278.

3. SZMZ, T. S. The Myih of M d Illness. New York: Hoeber-Harper, 1961.

THE RELATIONSHIP OF SELF-CONCEPT AND PARENT IlMAGE TO RULE VIOLATIONS IN A WOMEN’S PRISON

JOHN R. SNORTUM THOMAS E. W N N U M AND DAVID H. MILLS

Chrenwnt Men’s College Ioum Stale University U n k s i l y of Maryland

PROBLEM

McPartland, Cumming, and Garretson(*) have demonstrated that the measure ment of a patient’s self-concept upon admission to a psychiatric hospital can serve to predict his mode of social response to other patients on the ward. Similarly, there is evidence“. 4, that a S’s conception of his parents may have utility in the p d i c - tion of juvenile delinquency in males. Medinnus(‘8 P. conjectured that, “The distrust and antagonism frequently shown by delinquents toward police apd parole officers and other societal figures are not surprising in view of their attitude toward their fathers.” Watt and Maher“) failed to substantiate a relationship between perception of parents and attitudes toward the law, but cautioned that the negative findings might have been due to a lack of urndimensionality in the attitude measures. It is also possible that there would be a methodological gain if “attitude toward the law” were replaced with a behavioral measurement, e.g., frequency of rule violations within a correctional institution. The present research examined the relationship of rule violations to each of the following: The self-concept, the ideal self, the con- cept of parents and the PD and MA scales on the MMPI.