Special
Report
The Mentally Disabled and the Right to Vote U
At a candidates’ night in 1974, a resident of the Suffolk (N.Y.) Developmental Centerwanted to know if Roosevelt was going to run again. The candidate who was asked the question was obviously taken aback and did not know how to respond. Underlying the question is a basic issue that is increasingly being confronted in count rooms, at registration and voting places, and in mental health facilities around the country: are the mentally disabled competent to vote? He was not incompetent-just institutionalized,” Alan Sutherland, M.P.A., deputy director for administration at the center, explained in a recent telephone interview. I think if you check the records, you will find he was probably admitted when Franklin Roosevelt was president and thinks he still is. He contends that many of the institutionalized mentally disabled, who in some cases have been out of touch with society for years, are still citizens and therefore entitled to vote. The Suffolk Developmental Center is a mental retardation facility with about 1600 residents, 1200 of whom are severely or profoundly retarded. The remaining 400, however, are less severely retarded and ready or nearly ready for community placement; of those about 250 are registered voters. The center held a massive registration drive in the fall of 1974 that duplicated as closely as possible the conditions under which noninstitutionalized citizens register. There were educational programs, campaigning, and a candidates’ night attended by six candidates. At the candidates’ night, there were some absurd questions, Mr. Sutherland recalled, such as the one about Roosevelt, but he said most of the residents rose to the occasion’ and asked such lucid questions that one candidate turned to Mn, Sutherland and asked, Are you sure they’re retarded?” For example, one questioner wanted to know why he had to pay a sales tax when he bought items in town with his own money but did not when he used state vouchers. Suffolk was one of the first mental retardation facilities in the country, if not the first, to hold an orchestrated registration and voting drive. The catalyst for the drive was a change in the New York State law that now says no one may be deprived of his right to register and vote solely because he is receiving services for a mental disability. Regardless of whether the person is living in an institution or in the “
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community, he may not be disenfranchised unless he has been declared legally incompetent. There is a growing belief among patients’ rights advocates, the courts, and some state legislatures that except for extreme cases such as legal rulings of incompetence, the mentally disabled should not be depnived of their basic night to citizenship regardless of whether they fully grasp the election process and specific election issues. They argue that many people living in the community are incapable of fully understanding the election process; nevertheless they have a right to vote. For many of the mentally disabled who have spent most of their lives in institutions, voting may be a new and bewildering experience, just as it may be for the 18-year-old voting for the first time. One lawyer pointed to the May 4 presidential primary in Washington, DC., in which some 8000 ballots were invalidated because they were improperly filled out. I’m sure most of those people were not mentally disabled,” he said. Mental health professionals who have helped the mentally disabled register and vote say that voting can be a therapeutic and normalizing experience. Bernice Thompson, M.S.W., who in 1972 helped organize a registration drive at the Malcolm Bliss Mental Health Center in St. Louis, said, It is important to convey to the patient that in spite of the fact that a portion of his functioning is not up to par, other aspects of his functioning are, She said that voting gives the patient a much-needed opportunity to make decisions for himself and to stay in touch with society. She said that too often all of the decisions are made for the patient and added, ‘ We don’t really make as concerted an effort as we could to get people involved in the social aspects of their lives such as voting.” Patients’ rights advocates see the voting issue as symbolic of the current movement toward getting the mentally disabled out of large institutions and back into the community. Attorney Michael Perlin, director of New Jersey’s Division of Mental Health Advocacy, which successfully argued for the plaintiff in Carroll v. Cobb and thus secured for residents of New Lisbon State School the right to register, said, “One of the concepts of deinstitutionalization is that the patient will be allowed to live as normal a life as possible and become reintegrated into the community.” He sees a restora“
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1976
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lion of civil rights, especially the right to vote, as an important pant of the reintegration process. While the patients’ rights movement has been growing rapidly for the past five years and has resulted in many institutional reforms, only recently have advocates begun to champion the civil rights that the mentally disabled are entitled to as citizens. Paul Friedman, managing attorney for the Mental Health Law Project in Washington, D.C., recounted that when the patients’ rights movement first began, it dealt with gross abuses such as institutional peonage, unconstitutional commitments, and poor conditions in the hospitals. But underlying those main issues are more subtle and complex problems such as job discrimination and a lack of alternative housing in the community. As we move away from institutionalization to normalization, we must begin to deal with issues such as the right of the mentally disabled to obtain housing, jobs, and insunance, and to exercise their civil nights, including the right to vote,” Mr. Friedman said. His associate, attorney Robert Plotkin, said that while obtaining decent housing and jobs for the mentally disabled returning to the community may be a more important goal than securing their right to vote, Voting is an emotional, symbolic issue, almost implying that if they are entitled to vote, they are also entitled to other things such as housing. In the United States, the legal right to vote symbolizes that you are a firstclass citizen.” “
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movement
is building
op
the recent victories of other minorities. While the courts have had the power to scrutinize voting laws and restrictions made by individual states since the enactment of the 14th Amendment more than 100 years ago, they have traditionally allowed state legislatures to have the final say in placing permissible controls and restraints on the night to vote. States have been allowed to set their own age, residency, and literacy requirements and, as many still do today, to ban idiots, the feebleminded, and the insane’ from voting. But during the past 15 years, the courts have taken a more hard-line approach about what constitutes penmissible restrictions. In the 1960s the courts threw out as discriminatory many of the literacy tests that had been used in some areas to deny blacks access to the voting booth. The 1970 amendments to the Voting Rights Act of 1964 placed a national ban on literacy tests in federal elections and set the voting age at 18. In the early 1970s, college students in many localities WOfl the right to register and vote in their college communities instead of by absentee ballot in their home towns. The courts ruled that in determining domicile for voting purposes, local registrars could not subject students to any stricter questioning than they did other members of the community. But especially where the mentally retarded are concerned, the issues and problems are in many ways more complex than those raised in registration drives for blacks and students. Mr. Friedman said that to deny the mentally ill the right to vote is a more clear-cut abuse. “
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&COMMUNITY
PSYCHIATRY
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because a person has severe anxiety attacks or other emotional problems, for example, does not mean he is unintelligent. But retardation is directly related to the level of intelligence. The profoundly retarded may not be able to understand the issues or procedures. But he said it is difficult to develop an acceptable standard for determining which mentally retarded are capable of voting. “
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LEGAL
OBSTACLES
TO
VOTING
Attorney Michael Perlin said that one of the biggest obstacles now facing the mentally disabled who wish to vote are the archaic laws in many states that still bar idiots and the insane’ from voting without more precisely defining those terms long since abandoned by mental health professionals. Some local election boards have used that language to disqualify anyone living in a state school or hospital regardless of their level of disability, In the New Lisbon case, for example, the Bunlington County board of elections had refused to registen 28 residents who came by bus to the clerk’s office on October 3, 1974. The board also had voided the registration cards of five other residents who had registered on September 30. According to court records in the case, elections board clerk Carol Cobb said she had been instructed “not to permit the men to fill out the voter registration forms and to void those that had been previously completed on the grounds that they were ‘idiots on insane persons and thus precluded from exercising their right of suffrage due to the mere fact of their residence at New Lisbon State School. On February 23, 1976, the New Jersey appellate count said, “It should be abundantly clear that a lay person is completely unequipped to determine whether an applicant is either an ‘idiot’ or an ‘insane’ person, as those terms are used in the Constitution and the statute, and thus disenfranchised. Indeed, we suspect that those imprecise terms may be troublesome to experts in the fields of psychiatry and psychology. The court upheld a lower courts earlier ruling that the 33 residents had the right to register and vote in Burlington County. While that case was still being litigated, the New J ersey law covering admissions to state schools and hospitals was amended to protect the mentally ill and later the mentally retarded from losing their civil nights, including their voting rights, simply because they were receiving treatment. The law now states that, subject to certain regulations and restrictions necessary for medical care and treatment, every patient shall be entitled to exercise all civil and religious rights provided for unden the Constitutions and the laws unless he has been adjudicated incompetent and has not been restored to legal capacity; for the purpose of a patient’s exercising his civil rights there shall be no presumption of his incompetence or unsoundness of mind merely because of his admission to a mental hospital.” On October 30, 1975, the Massachusetts Supreme ‘ ‘
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Judicial Court made a similar ruling regarding the suffrage rights of the institutionalized mentally retarded. In Boyd v. Board of Registrars of Voters of Beichertown, the court ruled that voluntary residents who have not been either adjudicated incompetent or placed by the court under guardianship are entitled to vote. The case grew out of an aborted attempt by two long-term residents of Belchertown State School to register and vote in the town of Belchertown. The residents, Virginia Boyd and Ida Muntufesco, had voluntarily lived at the school for more than 30 years. Both are mentally retarded, but neither had been judged incompetent. As a result of that decision about 15 other residents of the school have thus fan registered. Barbara Valliere, assistant superintendent for adult services, said the number is small because staff members decided against holding a single massive registration drive following the court decision. Staff decided to use the normalization process, she said. Since it is not normal for large groups of citizens to go together by bus to register, we decided to take people individually or in small groups of two or three to register as the residents felt comfortable and ready to vote. She also said it would have stigmatized and labeled the patients to go by bus to register. Staff now hold civics classes before registration to teach interested residents not only about their right to vote but also about their responsibility. Last spring several of the newly enfranchised voters participated in a special town meeting called to discuss changing the name of the school to Colespring Village because of stigmatizing connotations associated with the school’s present name. The school’s administrators endorsed the name change, but some of the school’s residents did not. Two spoke out against the proposal at the town meeting. They said they had lived there for 35 or 40 years, were used to the old name, and wanted to keep it. The proposal was defeated. Mrs. Valliere was delighted not only that the two residents were able to address the town meeting, but also that they were not afraid to take a stand counter to the school’s. She thinks such participation is a healthy experience for the residents. Anything that gets these people into a normal lifestyle is therapeutic. They liked going to the town meeting and voting. Some of them did not understand everything that was going on, but I didn’t either the first time I registered and voted,’ she said. ‘ ‘
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DOMICILE One
of the
AND
VOTING
PATTERNS
central questions in the patient-voting issue the patients should register and vote in the community where the institution is located or in their home communities. Voting domicile can be a crucial issue, especially in towns where large numbers of newly enfranchised residents of a state institution could become a tremendous new political force in the community and conceivably alter voting trends. As Mr. Friedman put it, “A lot of small towns are afraid that if people from the institutions are given the right to vote, is whether
Voting domicile can be a crucial issue,
especially in towns where large numbers of newly enfranchised
residents of a state institution
could
become an important political force in the community. they will have too much power in elections and perhaps even outnumber other town residents.” Although residency determinations do not explicitly affect the institutionalized person’s right to vote, they can make it difficult for him to exercise that right. What can happen, according to legal scholars, is that local elections boards will ban the institutionalized mentally disabled from voting in the community where the facilityis located on the grounds that they are not really voluntary residents of the community. The residents will be told to vote in their home communities, However, many state absentee ballot laws disqualify the institutionalized individual from voting by absentee ballot. If the individual cannot get leave from his institution to return home on election day or if he does not have the money or transportation necessary for the trip, he may not be able to cast his ballot. Mental Health Law Project attorney Robert Plotkin said that the residency issue is one that surfaces every time a new minority is given the right to vote. The issue was hotly debated in college communities around the country when students attempted to vote. Since there has never been a U.S. Supreme Court ruling on the question, it is currently up to local jurisdictions and individual states to decide how voting domiciles should be determined, Mr. Plotkin explained. In New York the legal residence listed on the patient’s admission form is considered his voting domicile, and therefore most of the patients vote by absentee ballot. However, determining a legal residence may not always be that simple, especially in cases involving patients who have been in institutions most of their lives. A case in point is a 56-year-old woman at the Suffolk Developmental Center who was disqualified from voting because her absentee ballot contained an incomplete address. The woman had spent her entire life in institutions, beginning with her birth in a home for unwed mothers. The complete address of the home had been purposely omitted from her legal records to avoid stigmatizing her. In future elections, she will vote from the center since that is her only known legal residence, In Pennsylvania, an institutionalized mental patient named Clifford McGill went to court to obtain the right to vote by absentee ballot in his home town, His case was dismissed in a lower court. But on appeal, he
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sought representation from the Pennsylvania Mental Patient Civil Liberties Project, which argued that a 1937 state law barring persons confined in mental institutions from voting by absentee ballot was unconstitutional. State Attorney General Robert P. Kane agreed and advised the defendants to enter into a consent decree. The decree, signed last January, said that ‘ ‘ Persons confined to mental institutions must be considered ‘qualified absentee electors’ entitled to absentee ballots. The Pennsylvania case, McGill v. Alton, is believed to be the first such case in the country concerning the absentee voting rights of the institutionalized mentally disabled. Mr. Plotkin contends that public fears about the political impact of newly enfranchised disabled voters are unjustified. He said that with the exception of newly enfranchised black voters, experience has shown that the new voters generally do not vote very differently from other members of the population. When the voting age was lowered to 18 several years ago, a lot of people thought that students were going to take over their college communities. That didn’t happen. In fact, very little has changed. They were not the flaming liberals people thought they were going to be.” A study of the voting patterns of mental patients at Bronx (NY. ) State Hospital revealed that the patient vote there closely resembled the actual vote in the community where the hospital is located,’ In the 1965 mayoralty election, 45.8 per cent of the hospital voters cast their ballot for John Lindsay, as compared with 42.6 per cent of the other voters in the hospital district. And 42,9 pen cent of the hospital voted for Abraham Beame, compared with 40.2 pen cent of the other district residents. The study’s authors said, Each group cast over 80 per cent of the vote for the two major candidates. Comparing the margin of victory in the vote between the two major candidates, we found that the hospital sample resembled most closely the election results of the hospital district. No significant difference was found between the 2,9 pen cent margin of victory by Lindsay in the hospital sample, as compared to the 2.4 per cent victory margin by Lindsay in the hospital district.” Both the hospital’s and the hospital district’s voting patterns were significantly different from the voting patterns in the entire borough of the Bronx and in New York City. The authors concluded that “There would be no significant effect upon the election results if all psychiatric patients in a community hospital were permitted to vote. The fact that mental patients in a community-based hospital resemble the population in the community in the matter of voting highlights one of the benefits of community-centered mental health facilities. It indicates that persons hospitalized for severe mental illness are nevertheless able to maintain ties with the family and community.” The authors also found that “There is no evidence of a tendency on the ‘ ‘
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If ealth Journal,
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Grossman, State
3, Summer
HOSPITAL
“Voting
Hospital,”
Patterns Conznzunity
of
Mental Mental
1967, pp. 149-152.
& COMM
UNITY
PSYCHIATRY
part of hospitalized mental patients toward extremism on toward any unusual voting patterns, since the three minor candidates received an insignificant percentage of votes.” POLITICAL
BARRIERS
While the mentally disabled have gained greater voting rights in states such as New Jersey, New York, and Massachusetts, many of them are still being turned away from the voting booth in other parts of the country. In Brown County, Ohio, the registration cards of 25 mentally retarded trainees from a local workshop there were voided last spring. The trainees all live at home with their families and attend a county-run workshop during the day. The local board of elections, after initially allowing them to register, decided that they were ineligible to vote because they could not answer some of the routine questions such as birthdate and address needed to complete the registration cards. Richard Lodwick, superintendent of the Brown County Board of Mental Retardation, which runs the workshop, contends that the disenfranchisement was politically motivated. A bond issue to build a new mental retardation facility and workshop was slated for the June 8 primary ballot. The issue had been defeated by only four or five votes in the previous November election, Mr. Lodwick claims that the 25 trainees, if allowed to vote, could have swung the election and cost the taxpayers money. The controversy began last March when Karl Peters, director of the workshop, took the 25 trainees by bus to register. It was the first time that an organized effort had been made to register them, and Mr. Peters candidly admits that it was done to give them a chance to vote on the bond issue. He and other staff members discussed the bond issue with them prior to registration but did not prepare them for voting for the presidential primary candidates on the ballot. He explained that the trainees would not have much interest in the presidential primary but would in the bond issue since it affected them directly. Elections board director Kathleen Stephan said that the bond issue had nothing to do with the board’s decision to disqualify them. Ms. Stephan, who was one of two registrars present when the trainees came to register, said that the same procedure was followed with them as with other citizens. She said that after conferring with the Ohio secretary of state’s office, she and the board decided that since they were unable to verbally supply such basic information as name, birthdate, and street address, they had not met the minimal registration requirements and were therefore ineligible to vote. Workshop staff subsequently worked with the trainees, going over and over with them their names, addresses, birthdates, and polling places until 19 of them could recite the information as election officials had required. The 19 were taken back to the registration office in mid-May and were successfully registered. Center
staff, who had been accused by some of unduly influencing the trainees, left it up to the registrants’ families to take them to the poi1s on election day. Mr. Lodwick reported that the 19 did vote, but the bond issue was defeated by 169 votes. Mr. Plotkin said that one of the confusing aspects of the case is whether the Brown County election board’s insistence that the registrants be able to verbally supply the information without receiving outside help would constitute an illegal literacy test. The 1964 Voting Rights Act prohibits polling officials from applying ‘ ‘ any standard, practice, or procedure different from the standards, practices, on procedures applied under such law or laws to other individuals. And the 1970 amendments to the act say that No citizen shall be denied the right to vote because of his failure to comply with any test or device, defined as any requirement that a person as a prerequisite for voting or registration for voting (1 ) demonstrate the ability to read, write, understand, on interpret any matter, (2) demonstrate any educational achievement or his knowledge of any particular subject.” Complicating the issue is the question of whether the ban on literacy tests can be applied to state and local elections or whether it involves only federal elections, Another question is whether the Brown County requirements would actually be considered a literacy test or simply minimal registration requirements. Requirements for supplying registration information appear to vary from locale to locale, Whereas the Brown County election board said that the registrants must be able to verbally answer the questions without referring to previously prepared sheets of paper containing the information or without receiving help, the registrants at the Suffolk Developmental Center were able to get help in completing their registration forms without threat of disqualification. Mn, Plotkin contends that there are probably many people living in the community, such as elderly residents, who cannot remember the exact year of their birth but who can produce a birth certificate, driver’s license, or other official documents to prove that they meet the minimal registration requirements. He said that many mentally retarded or mentally disturbed people living in the community are never questioned about their right to vote because they have not been formally labeled as mentally disabled, The Brown County case points up other problems related to intellectual, speech, and emotional factors that may make it difficult or impossible for a retarded person to register and vote. Mr. Peters claims that the trainees were intellectually capable of voting although they had problems. He said, for example, that while some of them could not cite exact street addresses, they could point out on a map approximately where they lived, Others would be able to give their birthday but would get confused about what year they were born. He thinks another problem was that “The registrars were not used to dealing with the mentally retarded and were simply not able to understand their way of
Many mentally retarded or mentally
disturbed
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mentally ill or retarded.
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speech. It is like working with a spasmatic,’ he explained. “At first, it is difficult to understand what they are saying but after you get used to it, you realize they are making sense,” He added that emotional problems caused by a new experience could also have contributed to the difficulties at least one of the trainees had in supplying information. One man who was usually fluent enough to answer the questions asked became so socially inhibited that he would not even give his name. In a similar incident at Suffolk Developmental Center, one 22-yearold woman who had successfully registered became so distraught when she was handed the absentee ballot that she never was able to vote, Mr. Sutherland recalled. Other factors can also make it more difficult for the mentally disabled, especially the retarded, to register and vote than it is for the general public. One such factor is the attitude of the retarded person’s family. Families may object and even try to prevent their retarded relatives from voting. In the Brown County case, for example, a parent of one of the 25 trainees told Mn, Peters that she did not want her daughter voting for the bond issue because it might raise her taxes. When the Suffolk Developmental Center decided to have its first registration drive in 1974, one parent wrote a letter to the district attorney and local election board to try to prevent it. Also that year a candidate for town council who had a retarded sister said that she was an imbecile and had no right to vote. The sister, Mr. Sutherland said, made it clear she had every intention of voting and did not intend to vote for him.” Some parents and families are enthusiastic, however. In fact, the initial push for holding a registration drive at Suffolk came from the parents’ organization. But why do some families want to prevent their retarded relatives from voting? Mr. Sutherland thinks there are two main reasons, one being that they simply do not want to accept the fact that their child is no longer a child. The other is associated with the guilt feelings some people have about institutionalizing their child. If he is capable of voting, they may begin to think that perhaps he should not be at the center at all. Another barrier the mentally disabled face is the physical problem of getting to registration and voting booths. Even in states where many of the mentally ‘
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1976
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disabled are legally entitled to vote, they may not be able to exercise that right because of poor accommodations. The physically impaired retarded and the institutionalized aged may be blocked from voting by architectural barriers such as a lack of wheel-chain ramps at polling places or specially equipped voting booths. Or they may simply not have transportation to the polling booths. Several states such as Maine and California have enacted laws to make polling places more accessible to the physically handicapped. And, as has already been
noted, in New York registration and voting drives have actually been held in the institutions to assure maximum voter participation. Mr. Plotkin says that as the mentally disabled are given their right to vote, other affirmative-action measures can be legislated where necessary to assure that the newly enfranchised citizens have the opportunity to vote and to remove the barriers that keep them from doing so. Barbara Assistant
Armstrong Editor
Applying Psychiatric Techniques to Patients With Cancer MARY L. S. VACHON, R.N., Mental Health Consultant w. ALAN L. LYALL, M.D., Staff Psychiatrist Community Resources Service Clarke institute of Psychiatry Toronto, Ontario
MA. D.PSYCH.
A patient wit/s cancerfrequently experiences significant stress in adjusting to his disease, The authors feel that cancer patients who are receiving physical care in a general hospital may benefit from psychiatric techniques used regularly by mental health professionals. They describe weekly group meetings in which newly diagnosed cancer patients talk with the hospital staff, coiisultantsfrom a psychiatric institute, and more experienced cancer patients about problems in adjustment, misconceptions about cancer, reactions of family and friends, and problems in relating to their physician. To date approximately 2000 patients have attended the meetings. in most cases their anxiety has decreased as they talk with other cancer patients who have learned to live with their disease, and as they see alternative methods for dealing with their problems.
Cancer reactions
U
patients usually experience in adjusting to their disease
significant stress and its treatment.
Ms. Vachon’s address at the institute is 250 College Street, Toronto, Ontario, Canada M5T iRS. Ms. Vachon is also psychiatric nurse consultant and Dr. Lyall is psychiatric consultant at Princess Margaret Hospital in Toronto. The authors wish to express their appreciahon to the staff of the hospital, particularly Patricia Walker, RN., Phyllis Burgess, RN., and Derek Pestelle, RN.
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The stress may manifest itself in numerous ways and is often complicated by misconceptions about the illness, by the reactions of family and friends, and by problems in the physician-patient relationship. While such stress reactions seldom require psychiatric intervention, patients in general hospitals might benefit from the application of insights and techniques that have been the stock-in-trade of psychiatrists for years. For example, a 25-year-old patient had a radical neck dissection for a parotid tumor. Before the surgery he was unaware that such an extensive procedure would be necessary. When he awoke from anesthesia he was told, “ We had to do a lot of surgery, but it would have been worse if you were a woman, His wife, who was 20, was told, We did a lot of surgery on your husband; you’ll have to come and see for yourself what he looks like now.” Several years later the couple appeared for marital therapy, stating that they were considering separating. Both said they felt their marriage had begun to deteniorate at the time of surgery because each had been afraid to speak to the other about the impact of radical surgery, the mutilation it caused, and the fears it aroused. They felt that if they had been helped to talk then, they would not be in a crisis now. As Abrams points out, cancer is one of the few diseases an individual feels he cannot control.’ An alteration of life style or eating habits will not affect the course of his disease. Thus the patient has a sense of ‘ ‘
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1 R. D. Abrams, “The Patient With Cancer: of Communication,” New England Journal February 10, 1966, pp. 317-322.
of
His Changing Medicine,
Pattern Vol. 274,
Report
The Mentally Disabled and the Right to Vote U
At a candidates’ night in 1974, a resident of the Suffolk (N.Y.) Developmental Centerwanted to know if Roosevelt was going to run again. The candidate who was asked the question was obviously taken aback and did not know how to respond. Underlying the question is a basic issue that is increasingly being confronted in count rooms, at registration and voting places, and in mental health facilities around the country: are the mentally disabled competent to vote? He was not incompetent-just institutionalized,” Alan Sutherland, M.P.A., deputy director for administration at the center, explained in a recent telephone interview. I think if you check the records, you will find he was probably admitted when Franklin Roosevelt was president and thinks he still is. He contends that many of the institutionalized mentally disabled, who in some cases have been out of touch with society for years, are still citizens and therefore entitled to vote. The Suffolk Developmental Center is a mental retardation facility with about 1600 residents, 1200 of whom are severely or profoundly retarded. The remaining 400, however, are less severely retarded and ready or nearly ready for community placement; of those about 250 are registered voters. The center held a massive registration drive in the fall of 1974 that duplicated as closely as possible the conditions under which noninstitutionalized citizens register. There were educational programs, campaigning, and a candidates’ night attended by six candidates. At the candidates’ night, there were some absurd questions, Mr. Sutherland recalled, such as the one about Roosevelt, but he said most of the residents rose to the occasion’ and asked such lucid questions that one candidate turned to Mn, Sutherland and asked, Are you sure they’re retarded?” For example, one questioner wanted to know why he had to pay a sales tax when he bought items in town with his own money but did not when he used state vouchers. Suffolk was one of the first mental retardation facilities in the country, if not the first, to hold an orchestrated registration and voting drive. The catalyst for the drive was a change in the New York State law that now says no one may be deprived of his right to register and vote solely because he is receiving services for a mental disability. Regardless of whether the person is living in an institution or in the “
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community, he may not be disenfranchised unless he has been declared legally incompetent. There is a growing belief among patients’ rights advocates, the courts, and some state legislatures that except for extreme cases such as legal rulings of incompetence, the mentally disabled should not be depnived of their basic night to citizenship regardless of whether they fully grasp the election process and specific election issues. They argue that many people living in the community are incapable of fully understanding the election process; nevertheless they have a right to vote. For many of the mentally disabled who have spent most of their lives in institutions, voting may be a new and bewildering experience, just as it may be for the 18-year-old voting for the first time. One lawyer pointed to the May 4 presidential primary in Washington, DC., in which some 8000 ballots were invalidated because they were improperly filled out. I’m sure most of those people were not mentally disabled,” he said. Mental health professionals who have helped the mentally disabled register and vote say that voting can be a therapeutic and normalizing experience. Bernice Thompson, M.S.W., who in 1972 helped organize a registration drive at the Malcolm Bliss Mental Health Center in St. Louis, said, It is important to convey to the patient that in spite of the fact that a portion of his functioning is not up to par, other aspects of his functioning are, She said that voting gives the patient a much-needed opportunity to make decisions for himself and to stay in touch with society. She said that too often all of the decisions are made for the patient and added, ‘ We don’t really make as concerted an effort as we could to get people involved in the social aspects of their lives such as voting.” Patients’ rights advocates see the voting issue as symbolic of the current movement toward getting the mentally disabled out of large institutions and back into the community. Attorney Michael Perlin, director of New Jersey’s Division of Mental Health Advocacy, which successfully argued for the plaintiff in Carroll v. Cobb and thus secured for residents of New Lisbon State School the right to register, said, “One of the concepts of deinstitutionalization is that the patient will be allowed to live as normal a life as possible and become reintegrated into the community.” He sees a restora“
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27 NUMBER
8 AUGUST
1976
577
lion of civil rights, especially the right to vote, as an important pant of the reintegration process. While the patients’ rights movement has been growing rapidly for the past five years and has resulted in many institutional reforms, only recently have advocates begun to champion the civil rights that the mentally disabled are entitled to as citizens. Paul Friedman, managing attorney for the Mental Health Law Project in Washington, D.C., recounted that when the patients’ rights movement first began, it dealt with gross abuses such as institutional peonage, unconstitutional commitments, and poor conditions in the hospitals. But underlying those main issues are more subtle and complex problems such as job discrimination and a lack of alternative housing in the community. As we move away from institutionalization to normalization, we must begin to deal with issues such as the right of the mentally disabled to obtain housing, jobs, and insunance, and to exercise their civil nights, including the right to vote,” Mr. Friedman said. His associate, attorney Robert Plotkin, said that while obtaining decent housing and jobs for the mentally disabled returning to the community may be a more important goal than securing their right to vote, Voting is an emotional, symbolic issue, almost implying that if they are entitled to vote, they are also entitled to other things such as housing. In the United States, the legal right to vote symbolizes that you are a firstclass citizen.” “
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patient-voting-rights
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movement
is building
op
the recent victories of other minorities. While the courts have had the power to scrutinize voting laws and restrictions made by individual states since the enactment of the 14th Amendment more than 100 years ago, they have traditionally allowed state legislatures to have the final say in placing permissible controls and restraints on the night to vote. States have been allowed to set their own age, residency, and literacy requirements and, as many still do today, to ban idiots, the feebleminded, and the insane’ from voting. But during the past 15 years, the courts have taken a more hard-line approach about what constitutes penmissible restrictions. In the 1960s the courts threw out as discriminatory many of the literacy tests that had been used in some areas to deny blacks access to the voting booth. The 1970 amendments to the Voting Rights Act of 1964 placed a national ban on literacy tests in federal elections and set the voting age at 18. In the early 1970s, college students in many localities WOfl the right to register and vote in their college communities instead of by absentee ballot in their home towns. The courts ruled that in determining domicile for voting purposes, local registrars could not subject students to any stricter questioning than they did other members of the community. But especially where the mentally retarded are concerned, the issues and problems are in many ways more complex than those raised in registration drives for blacks and students. Mr. Friedman said that to deny the mentally ill the right to vote is a more clear-cut abuse. “
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&COMMUNITY
PSYCHIATRY
J ust
because a person has severe anxiety attacks or other emotional problems, for example, does not mean he is unintelligent. But retardation is directly related to the level of intelligence. The profoundly retarded may not be able to understand the issues or procedures. But he said it is difficult to develop an acceptable standard for determining which mentally retarded are capable of voting. “
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LEGAL
OBSTACLES
TO
VOTING
Attorney Michael Perlin said that one of the biggest obstacles now facing the mentally disabled who wish to vote are the archaic laws in many states that still bar idiots and the insane’ from voting without more precisely defining those terms long since abandoned by mental health professionals. Some local election boards have used that language to disqualify anyone living in a state school or hospital regardless of their level of disability, In the New Lisbon case, for example, the Bunlington County board of elections had refused to registen 28 residents who came by bus to the clerk’s office on October 3, 1974. The board also had voided the registration cards of five other residents who had registered on September 30. According to court records in the case, elections board clerk Carol Cobb said she had been instructed “not to permit the men to fill out the voter registration forms and to void those that had been previously completed on the grounds that they were ‘idiots on insane persons and thus precluded from exercising their right of suffrage due to the mere fact of their residence at New Lisbon State School. On February 23, 1976, the New Jersey appellate count said, “It should be abundantly clear that a lay person is completely unequipped to determine whether an applicant is either an ‘idiot’ or an ‘insane’ person, as those terms are used in the Constitution and the statute, and thus disenfranchised. Indeed, we suspect that those imprecise terms may be troublesome to experts in the fields of psychiatry and psychology. The court upheld a lower courts earlier ruling that the 33 residents had the right to register and vote in Burlington County. While that case was still being litigated, the New J ersey law covering admissions to state schools and hospitals was amended to protect the mentally ill and later the mentally retarded from losing their civil nights, including their voting rights, simply because they were receiving treatment. The law now states that, subject to certain regulations and restrictions necessary for medical care and treatment, every patient shall be entitled to exercise all civil and religious rights provided for unden the Constitutions and the laws unless he has been adjudicated incompetent and has not been restored to legal capacity; for the purpose of a patient’s exercising his civil rights there shall be no presumption of his incompetence or unsoundness of mind merely because of his admission to a mental hospital.” On October 30, 1975, the Massachusetts Supreme ‘ ‘
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Judicial Court made a similar ruling regarding the suffrage rights of the institutionalized mentally retarded. In Boyd v. Board of Registrars of Voters of Beichertown, the court ruled that voluntary residents who have not been either adjudicated incompetent or placed by the court under guardianship are entitled to vote. The case grew out of an aborted attempt by two long-term residents of Belchertown State School to register and vote in the town of Belchertown. The residents, Virginia Boyd and Ida Muntufesco, had voluntarily lived at the school for more than 30 years. Both are mentally retarded, but neither had been judged incompetent. As a result of that decision about 15 other residents of the school have thus fan registered. Barbara Valliere, assistant superintendent for adult services, said the number is small because staff members decided against holding a single massive registration drive following the court decision. Staff decided to use the normalization process, she said. Since it is not normal for large groups of citizens to go together by bus to register, we decided to take people individually or in small groups of two or three to register as the residents felt comfortable and ready to vote. She also said it would have stigmatized and labeled the patients to go by bus to register. Staff now hold civics classes before registration to teach interested residents not only about their right to vote but also about their responsibility. Last spring several of the newly enfranchised voters participated in a special town meeting called to discuss changing the name of the school to Colespring Village because of stigmatizing connotations associated with the school’s present name. The school’s administrators endorsed the name change, but some of the school’s residents did not. Two spoke out against the proposal at the town meeting. They said they had lived there for 35 or 40 years, were used to the old name, and wanted to keep it. The proposal was defeated. Mrs. Valliere was delighted not only that the two residents were able to address the town meeting, but also that they were not afraid to take a stand counter to the school’s. She thinks such participation is a healthy experience for the residents. Anything that gets these people into a normal lifestyle is therapeutic. They liked going to the town meeting and voting. Some of them did not understand everything that was going on, but I didn’t either the first time I registered and voted,’ she said. ‘ ‘
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DOMICILE One
of the
AND
VOTING
PATTERNS
central questions in the patient-voting issue the patients should register and vote in the community where the institution is located or in their home communities. Voting domicile can be a crucial issue, especially in towns where large numbers of newly enfranchised residents of a state institution could become a tremendous new political force in the community and conceivably alter voting trends. As Mr. Friedman put it, “A lot of small towns are afraid that if people from the institutions are given the right to vote, is whether
Voting domicile can be a crucial issue,
especially in towns where large numbers of newly enfranchised
residents of a state institution
could
become an important political force in the community. they will have too much power in elections and perhaps even outnumber other town residents.” Although residency determinations do not explicitly affect the institutionalized person’s right to vote, they can make it difficult for him to exercise that right. What can happen, according to legal scholars, is that local elections boards will ban the institutionalized mentally disabled from voting in the community where the facilityis located on the grounds that they are not really voluntary residents of the community. The residents will be told to vote in their home communities, However, many state absentee ballot laws disqualify the institutionalized individual from voting by absentee ballot. If the individual cannot get leave from his institution to return home on election day or if he does not have the money or transportation necessary for the trip, he may not be able to cast his ballot. Mental Health Law Project attorney Robert Plotkin said that the residency issue is one that surfaces every time a new minority is given the right to vote. The issue was hotly debated in college communities around the country when students attempted to vote. Since there has never been a U.S. Supreme Court ruling on the question, it is currently up to local jurisdictions and individual states to decide how voting domiciles should be determined, Mr. Plotkin explained. In New York the legal residence listed on the patient’s admission form is considered his voting domicile, and therefore most of the patients vote by absentee ballot. However, determining a legal residence may not always be that simple, especially in cases involving patients who have been in institutions most of their lives. A case in point is a 56-year-old woman at the Suffolk Developmental Center who was disqualified from voting because her absentee ballot contained an incomplete address. The woman had spent her entire life in institutions, beginning with her birth in a home for unwed mothers. The complete address of the home had been purposely omitted from her legal records to avoid stigmatizing her. In future elections, she will vote from the center since that is her only known legal residence, In Pennsylvania, an institutionalized mental patient named Clifford McGill went to court to obtain the right to vote by absentee ballot in his home town, His case was dismissed in a lower court. But on appeal, he
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sought representation from the Pennsylvania Mental Patient Civil Liberties Project, which argued that a 1937 state law barring persons confined in mental institutions from voting by absentee ballot was unconstitutional. State Attorney General Robert P. Kane agreed and advised the defendants to enter into a consent decree. The decree, signed last January, said that ‘ ‘ Persons confined to mental institutions must be considered ‘qualified absentee electors’ entitled to absentee ballots. The Pennsylvania case, McGill v. Alton, is believed to be the first such case in the country concerning the absentee voting rights of the institutionalized mentally disabled. Mr. Plotkin contends that public fears about the political impact of newly enfranchised disabled voters are unjustified. He said that with the exception of newly enfranchised black voters, experience has shown that the new voters generally do not vote very differently from other members of the population. When the voting age was lowered to 18 several years ago, a lot of people thought that students were going to take over their college communities. That didn’t happen. In fact, very little has changed. They were not the flaming liberals people thought they were going to be.” A study of the voting patterns of mental patients at Bronx (NY. ) State Hospital revealed that the patient vote there closely resembled the actual vote in the community where the hospital is located,’ In the 1965 mayoralty election, 45.8 per cent of the hospital voters cast their ballot for John Lindsay, as compared with 42.6 per cent of the other voters in the hospital district. And 42,9 pen cent of the hospital voted for Abraham Beame, compared with 40.2 pen cent of the other district residents. The study’s authors said, Each group cast over 80 per cent of the vote for the two major candidates. Comparing the margin of victory in the vote between the two major candidates, we found that the hospital sample resembled most closely the election results of the hospital district. No significant difference was found between the 2,9 pen cent margin of victory by Lindsay in the hospital sample, as compared to the 2.4 per cent victory margin by Lindsay in the hospital district.” Both the hospital’s and the hospital district’s voting patterns were significantly different from the voting patterns in the entire borough of the Bronx and in New York City. The authors concluded that “There would be no significant effect upon the election results if all psychiatric patients in a community hospital were permitted to vote. The fact that mental patients in a community-based hospital resemble the population in the community in the matter of voting highlights one of the benefits of community-centered mental health facilities. It indicates that persons hospitalized for severe mental illness are nevertheless able to maintain ties with the family and community.” The authors also found that “There is no evidence of a tendency on the ‘ ‘
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M. Patients
M. in
Klein
and
a
Communit
If ealth Journal,
580
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Vol.
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S. A.
Grossman, State
3, Summer
HOSPITAL
“Voting
Hospital,”
Patterns Conznzunity
of
Mental Mental
1967, pp. 149-152.
& COMM
UNITY
PSYCHIATRY
part of hospitalized mental patients toward extremism on toward any unusual voting patterns, since the three minor candidates received an insignificant percentage of votes.” POLITICAL
BARRIERS
While the mentally disabled have gained greater voting rights in states such as New Jersey, New York, and Massachusetts, many of them are still being turned away from the voting booth in other parts of the country. In Brown County, Ohio, the registration cards of 25 mentally retarded trainees from a local workshop there were voided last spring. The trainees all live at home with their families and attend a county-run workshop during the day. The local board of elections, after initially allowing them to register, decided that they were ineligible to vote because they could not answer some of the routine questions such as birthdate and address needed to complete the registration cards. Richard Lodwick, superintendent of the Brown County Board of Mental Retardation, which runs the workshop, contends that the disenfranchisement was politically motivated. A bond issue to build a new mental retardation facility and workshop was slated for the June 8 primary ballot. The issue had been defeated by only four or five votes in the previous November election, Mr. Lodwick claims that the 25 trainees, if allowed to vote, could have swung the election and cost the taxpayers money. The controversy began last March when Karl Peters, director of the workshop, took the 25 trainees by bus to register. It was the first time that an organized effort had been made to register them, and Mr. Peters candidly admits that it was done to give them a chance to vote on the bond issue. He and other staff members discussed the bond issue with them prior to registration but did not prepare them for voting for the presidential primary candidates on the ballot. He explained that the trainees would not have much interest in the presidential primary but would in the bond issue since it affected them directly. Elections board director Kathleen Stephan said that the bond issue had nothing to do with the board’s decision to disqualify them. Ms. Stephan, who was one of two registrars present when the trainees came to register, said that the same procedure was followed with them as with other citizens. She said that after conferring with the Ohio secretary of state’s office, she and the board decided that since they were unable to verbally supply such basic information as name, birthdate, and street address, they had not met the minimal registration requirements and were therefore ineligible to vote. Workshop staff subsequently worked with the trainees, going over and over with them their names, addresses, birthdates, and polling places until 19 of them could recite the information as election officials had required. The 19 were taken back to the registration office in mid-May and were successfully registered. Center
staff, who had been accused by some of unduly influencing the trainees, left it up to the registrants’ families to take them to the poi1s on election day. Mr. Lodwick reported that the 19 did vote, but the bond issue was defeated by 169 votes. Mr. Plotkin said that one of the confusing aspects of the case is whether the Brown County election board’s insistence that the registrants be able to verbally supply the information without receiving outside help would constitute an illegal literacy test. The 1964 Voting Rights Act prohibits polling officials from applying ‘ ‘ any standard, practice, or procedure different from the standards, practices, on procedures applied under such law or laws to other individuals. And the 1970 amendments to the act say that No citizen shall be denied the right to vote because of his failure to comply with any test or device, defined as any requirement that a person as a prerequisite for voting or registration for voting (1 ) demonstrate the ability to read, write, understand, on interpret any matter, (2) demonstrate any educational achievement or his knowledge of any particular subject.” Complicating the issue is the question of whether the ban on literacy tests can be applied to state and local elections or whether it involves only federal elections, Another question is whether the Brown County requirements would actually be considered a literacy test or simply minimal registration requirements. Requirements for supplying registration information appear to vary from locale to locale, Whereas the Brown County election board said that the registrants must be able to verbally answer the questions without referring to previously prepared sheets of paper containing the information or without receiving help, the registrants at the Suffolk Developmental Center were able to get help in completing their registration forms without threat of disqualification. Mn, Plotkin contends that there are probably many people living in the community, such as elderly residents, who cannot remember the exact year of their birth but who can produce a birth certificate, driver’s license, or other official documents to prove that they meet the minimal registration requirements. He said that many mentally retarded or mentally disturbed people living in the community are never questioned about their right to vote because they have not been formally labeled as mentally disabled, The Brown County case points up other problems related to intellectual, speech, and emotional factors that may make it difficult or impossible for a retarded person to register and vote. Mr. Peters claims that the trainees were intellectually capable of voting although they had problems. He said, for example, that while some of them could not cite exact street addresses, they could point out on a map approximately where they lived, Others would be able to give their birthday but would get confused about what year they were born. He thinks another problem was that “The registrars were not used to dealing with the mentally retarded and were simply not able to understand their way of
Many mentally retarded or mentally
disturbed
people living in the community
are never
questioned about their right to vote because they have not been formally labeled as
mentally ill or retarded.
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speech. It is like working with a spasmatic,’ he explained. “At first, it is difficult to understand what they are saying but after you get used to it, you realize they are making sense,” He added that emotional problems caused by a new experience could also have contributed to the difficulties at least one of the trainees had in supplying information. One man who was usually fluent enough to answer the questions asked became so socially inhibited that he would not even give his name. In a similar incident at Suffolk Developmental Center, one 22-yearold woman who had successfully registered became so distraught when she was handed the absentee ballot that she never was able to vote, Mr. Sutherland recalled. Other factors can also make it more difficult for the mentally disabled, especially the retarded, to register and vote than it is for the general public. One such factor is the attitude of the retarded person’s family. Families may object and even try to prevent their retarded relatives from voting. In the Brown County case, for example, a parent of one of the 25 trainees told Mn, Peters that she did not want her daughter voting for the bond issue because it might raise her taxes. When the Suffolk Developmental Center decided to have its first registration drive in 1974, one parent wrote a letter to the district attorney and local election board to try to prevent it. Also that year a candidate for town council who had a retarded sister said that she was an imbecile and had no right to vote. The sister, Mr. Sutherland said, made it clear she had every intention of voting and did not intend to vote for him.” Some parents and families are enthusiastic, however. In fact, the initial push for holding a registration drive at Suffolk came from the parents’ organization. But why do some families want to prevent their retarded relatives from voting? Mr. Sutherland thinks there are two main reasons, one being that they simply do not want to accept the fact that their child is no longer a child. The other is associated with the guilt feelings some people have about institutionalizing their child. If he is capable of voting, they may begin to think that perhaps he should not be at the center at all. Another barrier the mentally disabled face is the physical problem of getting to registration and voting booths. Even in states where many of the mentally ‘
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1976
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disabled are legally entitled to vote, they may not be able to exercise that right because of poor accommodations. The physically impaired retarded and the institutionalized aged may be blocked from voting by architectural barriers such as a lack of wheel-chain ramps at polling places or specially equipped voting booths. Or they may simply not have transportation to the polling booths. Several states such as Maine and California have enacted laws to make polling places more accessible to the physically handicapped. And, as has already been
noted, in New York registration and voting drives have actually been held in the institutions to assure maximum voter participation. Mr. Plotkin says that as the mentally disabled are given their right to vote, other affirmative-action measures can be legislated where necessary to assure that the newly enfranchised citizens have the opportunity to vote and to remove the barriers that keep them from doing so. Barbara Assistant
Armstrong Editor
Applying Psychiatric Techniques to Patients With Cancer MARY L. S. VACHON, R.N., Mental Health Consultant w. ALAN L. LYALL, M.D., Staff Psychiatrist Community Resources Service Clarke institute of Psychiatry Toronto, Ontario
MA. D.PSYCH.
A patient wit/s cancerfrequently experiences significant stress in adjusting to his disease, The authors feel that cancer patients who are receiving physical care in a general hospital may benefit from psychiatric techniques used regularly by mental health professionals. They describe weekly group meetings in which newly diagnosed cancer patients talk with the hospital staff, coiisultantsfrom a psychiatric institute, and more experienced cancer patients about problems in adjustment, misconceptions about cancer, reactions of family and friends, and problems in relating to their physician. To date approximately 2000 patients have attended the meetings. in most cases their anxiety has decreased as they talk with other cancer patients who have learned to live with their disease, and as they see alternative methods for dealing with their problems.
Cancer reactions
U
patients usually experience in adjusting to their disease
significant stress and its treatment.
Ms. Vachon’s address at the institute is 250 College Street, Toronto, Ontario, Canada M5T iRS. Ms. Vachon is also psychiatric nurse consultant and Dr. Lyall is psychiatric consultant at Princess Margaret Hospital in Toronto. The authors wish to express their appreciahon to the staff of the hospital, particularly Patricia Walker, RN., Phyllis Burgess, RN., and Derek Pestelle, RN.
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The stress may manifest itself in numerous ways and is often complicated by misconceptions about the illness, by the reactions of family and friends, and by problems in the physician-patient relationship. While such stress reactions seldom require psychiatric intervention, patients in general hospitals might benefit from the application of insights and techniques that have been the stock-in-trade of psychiatrists for years. For example, a 25-year-old patient had a radical neck dissection for a parotid tumor. Before the surgery he was unaware that such an extensive procedure would be necessary. When he awoke from anesthesia he was told, “ We had to do a lot of surgery, but it would have been worse if you were a woman, His wife, who was 20, was told, We did a lot of surgery on your husband; you’ll have to come and see for yourself what he looks like now.” Several years later the couple appeared for marital therapy, stating that they were considering separating. Both said they felt their marriage had begun to deteniorate at the time of surgery because each had been afraid to speak to the other about the impact of radical surgery, the mutilation it caused, and the fears it aroused. They felt that if they had been helped to talk then, they would not be in a crisis now. As Abrams points out, cancer is one of the few diseases an individual feels he cannot control.’ An alteration of life style or eating habits will not affect the course of his disease. Thus the patient has a sense of ‘ ‘
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1 R. D. Abrams, “The Patient With Cancer: of Communication,” New England Journal February 10, 1966, pp. 317-322.
of
His Changing Medicine,
Pattern Vol. 274,
