Acta psychiat. scand. (1979) 5 9 , 2 4 3 0 Psychiatric Clinic (Head K. A c M , M.D.), Helsinki University Central Hospital, Helsinki, Finland
Attitudes towards criminal and other patients M. Vmxuu, R. R I M ~ N AND S. SODERHOLM Staff attitudes towards mentally abnormal offenders were investigated on a forensic psychiatric assessment ward as reflected in a drug trial. The attitude towards drug trials was negative in 79 % of the personnel, in contrast to 71 % positive in three Swedish mental hospitals. Of the respondents 75 % considered that drug treatment did not benefit the patients. Then the attitudes of 21 general physicians towards assessment and drug treatment of mentally abnormal offenders as well as towards 10 illnesses were measured by self-rating scales employing a 10-cm line technique. Both the assessment and drug treatment of mentally abnormal offenders were the least favoured as compared with somatic illnesses. Other neuropsychiatric disorders ranked with them were also very significantly (P< 0.001) less favoured than pneumonia. They considered that these attitudes were shared in general by medical and nursing St&.
Key words: Attitudes - sociopathic personality - personnel - psychiatry. A person’s view of the future has a powerful effect on his present state. H o p e lessness can retard recovery or even hasten death, while the mobilization of hope plays an important part in many forms of healing. Favourable expectations generate feelings of optimism, energy and well-being and may actually promote healing, especially of illnesses with a large psychological or emotional component. Thus, the attitudes of the medical st& may often determine the outcome of treatment. Recently much attention has been focused on the therapist’s attitude towards the patient and treatment (Malm et al. (1974), Pate2 (1975)). It is of interest to note that psychiatrists had significantly more favourable attitudes towards the organic group of illnesses than the rest of the illnesses, and this despite a training which necessarily puts more emphasis on the emotional and social aspects of illnesses (MacDonald & Patel (1975)). Mentally abnormal offenders and their sociopathic character disorders produce therapeutic frustration in the staff and doctors, to whom they may appear incorrigible, inhuman, unfeeling, unaware of guilt, and unable to learn from experience. Nevertheless, they can be treatable. If the patients provoke feelings of fear, apprehension or terror in therapists, and consequently, as an emotional reaction or counter-transference, a more or less unconscious aggressivity and 0001-690X/79/010024-07$02.50/0 @ 1979 Munksgaard, Copenhagen
25
hostility against themselves, can the therapist-patient relationship be of any benefit? This relationship usually also reflects the relationship of the patient to his environment, for his “image” triggers off reactions in the doctor or nurse, just as in others around him, as stated by Balint (1964). On our forensic psychiatric assessment ward when a drug trial was under consideration we noted that the staff was very reluctant to co-operate as compared with other wards having usual psychiatric patients. This prompted us to conduct a study on the attitudes towards a drug trial. Staff attitudes towards a drug trial might also reflect the likelihood of their acting therapeutically towards mentally abnormal offenders. This can be interpreted with the use of a projective technique. This study tests the hypothesis that, in general, the attitudes of medical and nursing staff to mentally abnormal offenders are unfavourable. MATERIAL AND METHODS Forensic psychiatric assessment ward
At the Psychiatric Clinic of the Helsinki University Central Hospital a drug trial was started in the forensic psychiatric assessment ward, which contained 16 beds. The staff was told that the drugs would improve the mental state of the patients. The treatments to be compared were a mild psychostimulant pyrovalerone and placebo, administered in the double-blind cross-over manner, as well as “milieu therapy”. Therefore two groups of 20 consecutive cases each admitted to the psychiatric assessment ward were investigated. The patients were mostly sociopaths (86 %). The first test group was treated with pyrovalerone and placebo. The second group of 20 similar patients was followed and tested with exactly the same methods and at correspondingly the same times, but these patients were without drugs (non-treatment controls). Informed consent was always obtained and the patients could interrupt the trial at will. The methods and results of this part of the investigation are reported in detail elsewhere (Siiderholm et al. (1976)). The part of the study reported here was carried out by means of a questionnaire which was distributed during the trial to the 19 staff-members, but not to the doctors. Thus the sample consisted of nurses, mental nurses, assistants and aides. The questionnaire had 18 questions, the first four concerning attitudes towards drug trials, the others dealing with opinions about the working situation and the relations between different staff categories and the patients. The questions were easy to answer. A choice of alternative answers was given for each question and the respondent had merely to indicate the alternatives corresponding to his opinion. The respondents were anonymous. Health centre physicians
Another questionnaire was distributed to 21 general physicians (health centre physicians in the City of Helsinki) participating in their regular monthly meeting. This questionnaire was designed to measure attitudes on self-rating scales employing a 10-cm line technique as used by Patel (1975). The principle of this questionnaire is shown in Fig. 1. The 0-end of the lines represents greatest
26
“hostility” and the 10-end of the lines greatest “sympathy” (or extremes of unfavourable and favourable responses) to individual illnesses or to drug treatment of mentally abnormal offenders. The physicians were asked 12 questions, at first to assess the attitudes of the medical and nursing staff in general, and secondly, in a similar way, to judge their own personal reactions towards the different illnesses. These respondents were also anonymous. The measures on the 10-cm line scale were computed and the statistical differences of the neuropsychiatric disorders or drug treatment of mentally abnormal offenders were counted against pneumonia, a treatable, common somatic illness which does not cause apprehension. Paired t-test was used and the lowest significant t-value (general attitude, cerebrovascular accident against pneumonia) was checked with non-parametric Wilcoxon ordinal numbertest, which yielded to the same very significant difference.
RESULTS Attitudes of the nursing staff of the forensic psychiatric assessment ward Sixteen of the 19 persons (84 %) returned the questionnaire. Three nurses said
that they had such a negative attitude towards the drug trial that they refused to fill in the questionnaire. The attitude of 15 persons (79 %) to the drug trial was negative although 75 % of the respondents (12 persons) considered that it did not disturb the daily routine; 75 % considered also that drug treatment did not benefit the patients.
Pneumonia Myocardial infarction Asthmatic attack Congestive cardiac failure Diabetic ketosis
;/
Gastrointestinal bleed
//
Renal disease Cerebrovascular accident* Self-poisoning*
/:.
Senile dementia and confusion*
Psychiatric assessment of criminals*
...”
i?’’
Drug treatment of cl.iniinals*
. X
I
1
I
0
Greatest “hostility’.
I
I
1
I
I
I
5
I
I
10
cin Greatest sympathy,,
”
Fig. 1. Attitudes of medical and nursing staff towards differentdisorders as measured on self-rating scales employing a 10-em line technique
0-0
General attitude of medical and nursing staff (mean of 20). X - - - - - X Physician’s personal attitude (mean of 21). *P < 0.001, each against pneumonia
27 Table 1. A, General attitudes of medical and nursing stag, and B, personal attitudes of
the general physicians towards digerent disorders as measured on self-rating scales employing a 10-cm line technique B
A
Pneumonia Myocardial infarction Asthmatic attack Congestive cardiac failure Diabetic ketosis Gastrointestinal bleed Renal disease Cerebrovascular accident Self-poisoning Senile dementia and confusion Drug treatment of criminals Psychiatric assessment of criminals Mean 2 s.d. * P
8.7k 1.3 8.7f 1.6 8.3f 1.9 7.8f 1.6 7.8k 2.4 7.7f 2.0 7.3f 1.8 5.3f 2.3 * 3.9k2.4* 3.5k 2.1 * 2.6k1.8 * 2.3k 1.8 *
8.9f 1.1 8.5 f1.6 8.5f 1.5 8.4f1.3 8.2f2.4 7.7f 2.1 7.22 1.6 5.4f2.7 * 4.6f 2.9 * 4.7k2.3 * 2.8f 1.6 * 2.8 k 1.4 *
< 0.001,each against pneumonia (A, n = 19; B, n = 20).
Interestingly enough, 75 % of the respondents were also dissatisfied with the functioning of the forensic psychiatric assessment ward, although most of the staff stated that they had a positive attitude towards the criminal patients and towards developing a therapeutic milieu on the ward when they were directly asked about this in the second part of the questionnaire. However, only about half of the staf€ thought that the personnel and patients did not withdraw too much into their own separate groups. Over half of the respondents (56 %) considered a drug trial to be inappropriate even in a general hospital, because it is of hardly any benefit. When the drug trial was actually in progress the staff generally had an indifferent attitude towards it. Reactions of patients
The patients' attitudes seemed to be in some way ambivalent owing to the psychiatric assessment before the court could pass sentence, but the negative opinions of the personnel also inffuenced them. Some patients disliked their psychiatrist. They seemed to project these negative feelings onto the drugs and wanted to interrupt the treatment. Health centre physicians
All the 21 physicians responded, one of them for the personal part only, others completed all the questions concerning attitudes. The results are presented in Table 1 and Fig. 1. They are well in accord with the first part of the study. Both the assessment and drug treatment of criminal patients rank very badly as compared with the somatic illnesses although the other neuropsychiatric disorders showed also very significant differences (P < 0.001, more unfavourable than pneumonia).
28 DISCUSSION This study seems to confirm the previously suggested unfavourable attitudes towards mentally abnormal offenders and their drug treatment. Of the personnel 79 % had a negative attitude towards the drug trial, which is in marked contrast to the report of Mulm et al. (1974) that 71 % of the personnel in three different Swedish mental hospitals accepted drug trials. The second part of our study revealed that both the assessment and drug treatment of mentally abnormal offenders were the least favoured as compared with somatic illnesses among general phycisians and medical staff. However, all neuropsychiatric disorders, including cerebrovascular accident, received sign& cantly less “sympathy” than pneumonia (P< 0.001). An unfavourable attitude is sometimes likely to be secondary to the fact that active therapy and prognosis are so often restricted. Our findings are similar to those of Patel (1975) and MucDonald & Putel (1975) who found that medical and nursing staff tend to show unfavourable attitudes towards self-poisoners, and that alcoholism is the least favoured of the organic and psychiatric illnesses. Chappel & Schnoll (1977) have largely discussed negative attitudes towards chemically dependent patients. Senile dementia and confusion share also the unfavourable attitudes in our study ranking with self-poisoning. This differs from the findings of MucDonaZd & Patel (1975) but is in accordance with the conclusion of Arie (1973) who states: “Few patients are so taxing to doctors as the confused and demented. Many doctors and social workers cannot formulate a “psychogeriatric” problem in any other terms but as the need to get it instantly off their hands.” The origins of this neglect are many, but it is at least partially rooted in prejudice towards the elderly patient, termed “ageism”, in which he is regarded as a sickly, depressed, depressing object, whose medical problems are intractable and who has little to gain from medical attention (Rowe (1977)). Alcoholics and sociopaths are considered uninteresting and untreatable and are seldom and reluctantly accepted for treatment, for at the present time admissions caused by emotional troubles are not considered as true medical problems. The personality and behaviour of chemically dependent or self-poisoned patients or mentally abnormal offenders are often difficult to tolerate. Negative attitudes may exclude these patients from the health care provision system and lead to rejection. The fashion is to treat them with contempt and discharge them as soon as possible. Further, physician pessimism about treatment outcome has the effect of self-fulfilling prophecy. The physician should remember that his attitudes are reflected in his behaviour. Dysfunctional attitudes towards a patient lead to dysfunctional behaviour in diagnosis and treatment, which are frequently translated into the frustration of treatment failures (Chappel & Schnoll (1977)). Mentally abnormal offenders have perhaps most difficulties getting treatment. This seems nowadays to be a real problem in England because of refusal of “open” hospitals to accept patients considered to be dangerous. In an editorial the British Medical Journal (1977) writes: “Mentally ill people are entering
29
prisons and borstals in increasing numbers and people of previous good personality, whose offences frequently stem solely from their illnesses, are now being refused admission to psychiatric hospitals and are, instead, being received and detained in establishments. For example, not long ago nurses belonging to a particular union at one London hospital decided to ban the admission of potentially violent patients. What is important is that some patients are being denied the care and attention in hospital they require and are perforce being given prison sentences, sometimes life sentences”. The diagnosis “sociopathic personality” is in itself often the reflection of a failure in therapeutic communication and subconscious feelings that are detrimental to therapeutic progress. The therapist has his socially approved defensiveness against “enemies of society” which leads to a mutual hostility with the sociopath. The patient’s expectations also play an important role. The effectiveness of treatment is largely determined by its compatibility with the patient’s beliefs and expectations. Bromberg (1967) maintains: “With an orientation that views the psychopath as the recipient of unconscious and conscious social aggression, new clinical “findings” appear. The diagnosis responds to these less stereotyped descriptions. The psychopathic diagnosis yields then to that of character neurosis.” The crucial determinant seems to be the physician’s assignment of blame or responsibility for the patient’s condition. In general, more perfunctory examination and more apathetic care are the lot of all patients who, according to public opinion, could have avoided their present condition (Chappel & Schnoll (1977)).
CONCLUSION Unfavourable attitudes towards mentally abnormal offenders and related neuropsychiatric disorders linger among medical and nursing staff. They are unlikely to improve the success of treatment programmes or to encourage the early seeking of help. REFERENCES Arie, T. (1973): Dementia in the elderly: diagnosis and assessment. Brit. med. I. 4,
540-543. Balint, M . (1964): The doctor, his patient and the illness. Pitman, London-New York. Brornberg, W. (1967): Psychopathic personality concept evaluated and reevaluated.
Arch. gen. Psychiat. 17, 641645. Chappel, J . N , & S. H . Schnoll (1977): Physician attitudes. Effect on the treatment of chemically dependent patients. I. Amer. med. Ass. 237, 2318. MacDonald, E. B., t A . R. Patel (1975): Attitudes towards alcoholism. Brit. med. J. 2,
430-431. Matrn, U., C.Perris, W . Rapp & 0 .Rornin (1974): Environmental factors and drug trials. 1. Staff attitudes to drug trials at psychiatric hospitals. Acta psychiat. scand., Suppl. 249, 7-21. Patel, A . R. (1975): Attitudes towards self-poisoning. Brit. med. J. 2, 426-430. Rowe, J . W. (1977): Clinical research on aging: strategies and directions. N. Engl. J.
Med. 291, 1332-1336.
30 Soderholm, S., N . M . A . Viukari & R . Rimdn (1976): Die psychotrope Wirkung von Pyrovalerone (F-1983), Placebo, Milieutherapie und psychischer Zustand bei gerichtspsychiatrischen Patienten. Nervenarzt 47, 88-93. British Medical Journal (Editorial) (1977): Inhumanity to man. Brit. med. J. 3, 591-592.
Received January 23, 1978 (Address for reprints) Matti Viukari, M.D. Koskela Geriatric Hospital SF-00600 Helsinki 60 Finland Ranan Rimdn, M.D. Gdud Haivri 10 Raanana Israel
Seppo Soderholm, M.A. Health Center of Lappeenranta SF-53100 Lappeenranta 10 Finland
Attitudes towards criminal and other patients M. Vmxuu, R. R I M ~ N AND S. SODERHOLM Staff attitudes towards mentally abnormal offenders were investigated on a forensic psychiatric assessment ward as reflected in a drug trial. The attitude towards drug trials was negative in 79 % of the personnel, in contrast to 71 % positive in three Swedish mental hospitals. Of the respondents 75 % considered that drug treatment did not benefit the patients. Then the attitudes of 21 general physicians towards assessment and drug treatment of mentally abnormal offenders as well as towards 10 illnesses were measured by self-rating scales employing a 10-cm line technique. Both the assessment and drug treatment of mentally abnormal offenders were the least favoured as compared with somatic illnesses. Other neuropsychiatric disorders ranked with them were also very significantly (P< 0.001) less favoured than pneumonia. They considered that these attitudes were shared in general by medical and nursing St&.
Key words: Attitudes - sociopathic personality - personnel - psychiatry. A person’s view of the future has a powerful effect on his present state. H o p e lessness can retard recovery or even hasten death, while the mobilization of hope plays an important part in many forms of healing. Favourable expectations generate feelings of optimism, energy and well-being and may actually promote healing, especially of illnesses with a large psychological or emotional component. Thus, the attitudes of the medical st& may often determine the outcome of treatment. Recently much attention has been focused on the therapist’s attitude towards the patient and treatment (Malm et al. (1974), Pate2 (1975)). It is of interest to note that psychiatrists had significantly more favourable attitudes towards the organic group of illnesses than the rest of the illnesses, and this despite a training which necessarily puts more emphasis on the emotional and social aspects of illnesses (MacDonald & Patel (1975)). Mentally abnormal offenders and their sociopathic character disorders produce therapeutic frustration in the staff and doctors, to whom they may appear incorrigible, inhuman, unfeeling, unaware of guilt, and unable to learn from experience. Nevertheless, they can be treatable. If the patients provoke feelings of fear, apprehension or terror in therapists, and consequently, as an emotional reaction or counter-transference, a more or less unconscious aggressivity and 0001-690X/79/010024-07$02.50/0 @ 1979 Munksgaard, Copenhagen
25
hostility against themselves, can the therapist-patient relationship be of any benefit? This relationship usually also reflects the relationship of the patient to his environment, for his “image” triggers off reactions in the doctor or nurse, just as in others around him, as stated by Balint (1964). On our forensic psychiatric assessment ward when a drug trial was under consideration we noted that the staff was very reluctant to co-operate as compared with other wards having usual psychiatric patients. This prompted us to conduct a study on the attitudes towards a drug trial. Staff attitudes towards a drug trial might also reflect the likelihood of their acting therapeutically towards mentally abnormal offenders. This can be interpreted with the use of a projective technique. This study tests the hypothesis that, in general, the attitudes of medical and nursing staff to mentally abnormal offenders are unfavourable. MATERIAL AND METHODS Forensic psychiatric assessment ward
At the Psychiatric Clinic of the Helsinki University Central Hospital a drug trial was started in the forensic psychiatric assessment ward, which contained 16 beds. The staff was told that the drugs would improve the mental state of the patients. The treatments to be compared were a mild psychostimulant pyrovalerone and placebo, administered in the double-blind cross-over manner, as well as “milieu therapy”. Therefore two groups of 20 consecutive cases each admitted to the psychiatric assessment ward were investigated. The patients were mostly sociopaths (86 %). The first test group was treated with pyrovalerone and placebo. The second group of 20 similar patients was followed and tested with exactly the same methods and at correspondingly the same times, but these patients were without drugs (non-treatment controls). Informed consent was always obtained and the patients could interrupt the trial at will. The methods and results of this part of the investigation are reported in detail elsewhere (Siiderholm et al. (1976)). The part of the study reported here was carried out by means of a questionnaire which was distributed during the trial to the 19 staff-members, but not to the doctors. Thus the sample consisted of nurses, mental nurses, assistants and aides. The questionnaire had 18 questions, the first four concerning attitudes towards drug trials, the others dealing with opinions about the working situation and the relations between different staff categories and the patients. The questions were easy to answer. A choice of alternative answers was given for each question and the respondent had merely to indicate the alternatives corresponding to his opinion. The respondents were anonymous. Health centre physicians
Another questionnaire was distributed to 21 general physicians (health centre physicians in the City of Helsinki) participating in their regular monthly meeting. This questionnaire was designed to measure attitudes on self-rating scales employing a 10-cm line technique as used by Patel (1975). The principle of this questionnaire is shown in Fig. 1. The 0-end of the lines represents greatest
26
“hostility” and the 10-end of the lines greatest “sympathy” (or extremes of unfavourable and favourable responses) to individual illnesses or to drug treatment of mentally abnormal offenders. The physicians were asked 12 questions, at first to assess the attitudes of the medical and nursing staff in general, and secondly, in a similar way, to judge their own personal reactions towards the different illnesses. These respondents were also anonymous. The measures on the 10-cm line scale were computed and the statistical differences of the neuropsychiatric disorders or drug treatment of mentally abnormal offenders were counted against pneumonia, a treatable, common somatic illness which does not cause apprehension. Paired t-test was used and the lowest significant t-value (general attitude, cerebrovascular accident against pneumonia) was checked with non-parametric Wilcoxon ordinal numbertest, which yielded to the same very significant difference.
RESULTS Attitudes of the nursing staff of the forensic psychiatric assessment ward Sixteen of the 19 persons (84 %) returned the questionnaire. Three nurses said
that they had such a negative attitude towards the drug trial that they refused to fill in the questionnaire. The attitude of 15 persons (79 %) to the drug trial was negative although 75 % of the respondents (12 persons) considered that it did not disturb the daily routine; 75 % considered also that drug treatment did not benefit the patients.
Pneumonia Myocardial infarction Asthmatic attack Congestive cardiac failure Diabetic ketosis
;/
Gastrointestinal bleed
//
Renal disease Cerebrovascular accident* Self-poisoning*
/:.
Senile dementia and confusion*
Psychiatric assessment of criminals*
...”
i?’’
Drug treatment of cl.iniinals*
. X
I
1
I
0
Greatest “hostility’.
I
I
1
I
I
I
5
I
I
10
cin Greatest sympathy,,
”
Fig. 1. Attitudes of medical and nursing staff towards differentdisorders as measured on self-rating scales employing a 10-em line technique
0-0
General attitude of medical and nursing staff (mean of 20). X - - - - - X Physician’s personal attitude (mean of 21). *P < 0.001, each against pneumonia
27 Table 1. A, General attitudes of medical and nursing stag, and B, personal attitudes of
the general physicians towards digerent disorders as measured on self-rating scales employing a 10-cm line technique B
A
Pneumonia Myocardial infarction Asthmatic attack Congestive cardiac failure Diabetic ketosis Gastrointestinal bleed Renal disease Cerebrovascular accident Self-poisoning Senile dementia and confusion Drug treatment of criminals Psychiatric assessment of criminals Mean 2 s.d. * P
8.7k 1.3 8.7f 1.6 8.3f 1.9 7.8f 1.6 7.8k 2.4 7.7f 2.0 7.3f 1.8 5.3f 2.3 * 3.9k2.4* 3.5k 2.1 * 2.6k1.8 * 2.3k 1.8 *
8.9f 1.1 8.5 f1.6 8.5f 1.5 8.4f1.3 8.2f2.4 7.7f 2.1 7.22 1.6 5.4f2.7 * 4.6f 2.9 * 4.7k2.3 * 2.8f 1.6 * 2.8 k 1.4 *
< 0.001,each against pneumonia (A, n = 19; B, n = 20).
Interestingly enough, 75 % of the respondents were also dissatisfied with the functioning of the forensic psychiatric assessment ward, although most of the staff stated that they had a positive attitude towards the criminal patients and towards developing a therapeutic milieu on the ward when they were directly asked about this in the second part of the questionnaire. However, only about half of the staf€ thought that the personnel and patients did not withdraw too much into their own separate groups. Over half of the respondents (56 %) considered a drug trial to be inappropriate even in a general hospital, because it is of hardly any benefit. When the drug trial was actually in progress the staff generally had an indifferent attitude towards it. Reactions of patients
The patients' attitudes seemed to be in some way ambivalent owing to the psychiatric assessment before the court could pass sentence, but the negative opinions of the personnel also inffuenced them. Some patients disliked their psychiatrist. They seemed to project these negative feelings onto the drugs and wanted to interrupt the treatment. Health centre physicians
All the 21 physicians responded, one of them for the personal part only, others completed all the questions concerning attitudes. The results are presented in Table 1 and Fig. 1. They are well in accord with the first part of the study. Both the assessment and drug treatment of criminal patients rank very badly as compared with the somatic illnesses although the other neuropsychiatric disorders showed also very significant differences (P < 0.001, more unfavourable than pneumonia).
28 DISCUSSION This study seems to confirm the previously suggested unfavourable attitudes towards mentally abnormal offenders and their drug treatment. Of the personnel 79 % had a negative attitude towards the drug trial, which is in marked contrast to the report of Mulm et al. (1974) that 71 % of the personnel in three different Swedish mental hospitals accepted drug trials. The second part of our study revealed that both the assessment and drug treatment of mentally abnormal offenders were the least favoured as compared with somatic illnesses among general phycisians and medical staff. However, all neuropsychiatric disorders, including cerebrovascular accident, received sign& cantly less “sympathy” than pneumonia (P< 0.001). An unfavourable attitude is sometimes likely to be secondary to the fact that active therapy and prognosis are so often restricted. Our findings are similar to those of Patel (1975) and MucDonald & Putel (1975) who found that medical and nursing staff tend to show unfavourable attitudes towards self-poisoners, and that alcoholism is the least favoured of the organic and psychiatric illnesses. Chappel & Schnoll (1977) have largely discussed negative attitudes towards chemically dependent patients. Senile dementia and confusion share also the unfavourable attitudes in our study ranking with self-poisoning. This differs from the findings of MucDonaZd & Patel (1975) but is in accordance with the conclusion of Arie (1973) who states: “Few patients are so taxing to doctors as the confused and demented. Many doctors and social workers cannot formulate a “psychogeriatric” problem in any other terms but as the need to get it instantly off their hands.” The origins of this neglect are many, but it is at least partially rooted in prejudice towards the elderly patient, termed “ageism”, in which he is regarded as a sickly, depressed, depressing object, whose medical problems are intractable and who has little to gain from medical attention (Rowe (1977)). Alcoholics and sociopaths are considered uninteresting and untreatable and are seldom and reluctantly accepted for treatment, for at the present time admissions caused by emotional troubles are not considered as true medical problems. The personality and behaviour of chemically dependent or self-poisoned patients or mentally abnormal offenders are often difficult to tolerate. Negative attitudes may exclude these patients from the health care provision system and lead to rejection. The fashion is to treat them with contempt and discharge them as soon as possible. Further, physician pessimism about treatment outcome has the effect of self-fulfilling prophecy. The physician should remember that his attitudes are reflected in his behaviour. Dysfunctional attitudes towards a patient lead to dysfunctional behaviour in diagnosis and treatment, which are frequently translated into the frustration of treatment failures (Chappel & Schnoll (1977)). Mentally abnormal offenders have perhaps most difficulties getting treatment. This seems nowadays to be a real problem in England because of refusal of “open” hospitals to accept patients considered to be dangerous. In an editorial the British Medical Journal (1977) writes: “Mentally ill people are entering
29
prisons and borstals in increasing numbers and people of previous good personality, whose offences frequently stem solely from their illnesses, are now being refused admission to psychiatric hospitals and are, instead, being received and detained in establishments. For example, not long ago nurses belonging to a particular union at one London hospital decided to ban the admission of potentially violent patients. What is important is that some patients are being denied the care and attention in hospital they require and are perforce being given prison sentences, sometimes life sentences”. The diagnosis “sociopathic personality” is in itself often the reflection of a failure in therapeutic communication and subconscious feelings that are detrimental to therapeutic progress. The therapist has his socially approved defensiveness against “enemies of society” which leads to a mutual hostility with the sociopath. The patient’s expectations also play an important role. The effectiveness of treatment is largely determined by its compatibility with the patient’s beliefs and expectations. Bromberg (1967) maintains: “With an orientation that views the psychopath as the recipient of unconscious and conscious social aggression, new clinical “findings” appear. The diagnosis responds to these less stereotyped descriptions. The psychopathic diagnosis yields then to that of character neurosis.” The crucial determinant seems to be the physician’s assignment of blame or responsibility for the patient’s condition. In general, more perfunctory examination and more apathetic care are the lot of all patients who, according to public opinion, could have avoided their present condition (Chappel & Schnoll (1977)).
CONCLUSION Unfavourable attitudes towards mentally abnormal offenders and related neuropsychiatric disorders linger among medical and nursing staff. They are unlikely to improve the success of treatment programmes or to encourage the early seeking of help. REFERENCES Arie, T. (1973): Dementia in the elderly: diagnosis and assessment. Brit. med. I. 4,
540-543. Balint, M . (1964): The doctor, his patient and the illness. Pitman, London-New York. Brornberg, W. (1967): Psychopathic personality concept evaluated and reevaluated.
Arch. gen. Psychiat. 17, 641645. Chappel, J . N , & S. H . Schnoll (1977): Physician attitudes. Effect on the treatment of chemically dependent patients. I. Amer. med. Ass. 237, 2318. MacDonald, E. B., t A . R. Patel (1975): Attitudes towards alcoholism. Brit. med. J. 2,
430-431. Matrn, U., C.Perris, W . Rapp & 0 .Rornin (1974): Environmental factors and drug trials. 1. Staff attitudes to drug trials at psychiatric hospitals. Acta psychiat. scand., Suppl. 249, 7-21. Patel, A . R. (1975): Attitudes towards self-poisoning. Brit. med. J. 2, 426-430. Rowe, J . W. (1977): Clinical research on aging: strategies and directions. N. Engl. J.
Med. 291, 1332-1336.
30 Soderholm, S., N . M . A . Viukari & R . Rimdn (1976): Die psychotrope Wirkung von Pyrovalerone (F-1983), Placebo, Milieutherapie und psychischer Zustand bei gerichtspsychiatrischen Patienten. Nervenarzt 47, 88-93. British Medical Journal (Editorial) (1977): Inhumanity to man. Brit. med. J. 3, 591-592.
Received January 23, 1978 (Address for reprints) Matti Viukari, M.D. Koskela Geriatric Hospital SF-00600 Helsinki 60 Finland Ranan Rimdn, M.D. Gdud Haivri 10 Raanana Israel
Seppo Soderholm, M.A. Health Center of Lappeenranta SF-53100 Lappeenranta 10 Finland
