Punishment - viewed as a dignified alternative

THOMAS A. W. N. MACKAY Depute Principal Psychologist, Ayr Child Guidance Service, Child Guidance Clinic, Kilwinning Road, Irvine, Ayrshire

SUMMARY Punishment is clearly defined an3 re-examined as a treatment technique in a positive and not negative light. A treatment setting involving handicapped children is described and a system of punishment is outlined as an essential part of the regime. The objections to punish- ment are considered and, in conclusion, a philosophical basis is provided on which it is contended that punish- ment is a dignified alternative.

1980 is not an auspicious year in which to speak to the title, Punishment - viewed as a dignified alter- native. In Strasbourg on 6th November, the European Commission of Human Rights published its findings on two cases of the threatened use of physical punish- ment in Scottish schools. It had been submitted that such punishment was in violation of Article 3 of the European Convention of Human Rights, which states : “No one shall be subjected to torture or to inhuman or degrading treatment or punishment.” The majority verdict of the Commissioners was that physical punish- ment is degrading.

Earlier in the year, the Social Work Department of Strathclyde Region emphasised that, throughout the Region, no physical punishment (such as smacking) was to be given to any child in a children’s home or other social work establishment.

Punishment has long been outlawed also in the context of the Children’s Hearings. The Kilbrandon Report made it clear that “punishment” was to be replaced by “treatment”. I attended recently to the case of a child reported to the Children’s Panel on 51 offences, most of which were theft by house-breaking. In recommending a List D (approved school) place- ment, the assessment team wished it to be made clear to the child that the recommendation did not carry “punitive overtones”.

The word “punishment” has lost its neutrality. The term “punitive” has come to be associated with treat- ments which are by nature undesirable, while the term “non-punitive” is associated with desirable ones. And as far as mentally handicapped people are concerned, the Scottish Education Department recently restated its position that, throughout Scotland, no form of physical punishment should be used in special schools for handicapped children.

The non-punitive bandwagon has been rolling through society for several years. Personally, I have

This address was given at the BIMH conference, Behavioural management with the mentally handicapped - the present state of the art, at Gogarburn Hospital, Ediburgh, on 8th November, 1980.

no objection to joining a bandwagon - but only if I like the tune the band is playing. If not, I am quite content to walk in front playing a controversial solo piece.

The use of punishment in a clinical setting It would be possible for me to remove totally the

controversial element from this paper by doing two simple things. First, at a theoretical level, I could choose a definition of punishment which would carry the term quite out of the field of controversy. Punish- ment is a loose word, and can be defined in many ways. Second, at a practical level, I could describe a system of psychological treatment fully satisfying the require- ments of punishment, but carefully excluding any form of punishment of a controversial nature. Instead, 1 have chosen to confine myself to the definition of punishment provided in the concise Oxford English Dictionary :

“To punish: to cause an offender to suffer for an offence”.

To apply this definition to the mentally handicapped

A person who is mentally handicapped is already suffering from something, even though he is nor an offender. Can it be justified to cause him to suffer more by punishing him? Surely to cause suffering is the very antithesis of what psychologists (or other workers with the mentally handicapped) are called on to do? Are they not meant to be alleviating suffering? To punish someone is to define him as an offender, and to attribute to him knowledge and under- standing of the offence. Yet the mentally handi- capped person’s knowledge and understanding is limited by the very nature of the handicap itself.

I t is against the background of this definition and of these objections that I wish to put forward that punishment is a dignified alternative; that it is not merely dignified in terms of its practical outcome, that is, merely in terms of the end justifying the means. I have never pursued a treatment outcome by means to which 1 was not fully committed. I submit that punishment is dignified in its very theoretical foundations.

In the following psychological treatment regime punishment is used, not by default - like some kind of unsatisfactory second best “when all else fails” and

immediately raises three fundamental objections. 1.

2.

3.

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when people have reached the end of their ability to cope - but built in unblushingly and unashamedly as an integral, essential and premeditated part of a treat- ment plan.

The Kilmarnock Autistic Unit The Kilmarnock Autistic Unit was set up in 1974

as an educational day unit for autistic children of school age. I noticed, however, that all the children referred to me in the beginning had one thing in common: they had been (or were about to be) exclu- ded from all other provision because of seriously disruptive behaviour. I also noticed two other things. First, all the parents had a common fear: if the child were admitted to the Unit, how long would it last? Second, all the children brought for assessment were so heavily drugged that I spent more time assessing the effects of Largactil than the effects of autism.

At the same time, 1 was conducting a major research project for the Scottish Education Department, on ascertainment procedures for special education throughout Scotland, in the course of which I visited many schools for maladjusted children. They all had one thing in common - they would admit a child if he were not too badly behaved. The most difficult children to place proved to be those who are mentally handicapped and maladjusted. For them, schools imposed a further criterion - not only must the child be not too oadly behaved, but also he must not be too severely mentally handicapped.

It was against this background that I established the Kilmarnock Autistic Unit, on four foundational principles which I believe make it unique.

There is no behavioural limit for admission. Irrespective of how violent, aggressive, or dis- ruptive a child might be, he is still eligible to be admitted. There is no lower intelligence quotient limit for admission. However severe the degree of mental handicap a child may still be admitted. Once a child is admitted it is the policy of the Unit never to exclude him. At the time of admission, arrangements are made to take the child off all drugs used to sedate, suppress, or otherwise control his difficult behaviour.

How punishment is used: an example The treatment procedures in operation at the Unit

owe a great deal to the first child to be admitted, a nine-year-old autistic boy called Malcolm. I had taken him on for treatment two years before the Unit opened when he was seven. He had already been excluded from every available form of provision, ranging from primary school (where he had lasted for one day) to a special unit for children with disorders of communication. He was then probably the most severely disturbed child I had encountered - even now I would have little cause to revise that opinion. He screamed and shouted, ran wild, destroyed any- thing in sight, and responded to no form of control. His last day at his previous unit was well summed up in two words - “absolutely uncontrollable”. Appli-

cation had been made for admission to a mental hospital and the parents were heartbroken.

As an interim arrangement Malcolm was to attend the Child Guidance Clinic for two hours a day. I was then one of four psychologists at the Clinic and we had agreed to each take the boy for half-an-hour every day. On my third day with him he was SO out- rageous that the only “treatment” I could think of was to hold him down by the wrists to the floor and pray that someone would come to tell me my half- hour was up. One-and-a-half hours passed. No one came. I was only a few months out of Glasgow University after studying psychology for six years. I recall saying to myself as 1 sat there on the floor, “What would Freud have done in this position?” I concluded that he would probably have pinned the child by the wrists to the floor.

It was then that I took three steps which must have appeared like an exercise in sado-masochism. First, I asked to be given full responsibility for the child’s treatment. Second, I cancelled the application for a residential placement. Third, I wrote on a piece ol paper, “I believe there is no such thing as an uncontrol- lable child”.

In co-operation with the parents I drew up a list of seven “intolerable behaviours”. The criterion for inclusion in the list was any behaviour which might lead to the child’s being excluded from the kind of day provision previously made for him. The seven items were : throwing sand, kicking furniture, tearing pictures down from walls, shouting and screaming, attacks on other children, attacks on staff, and running wild, When Malcolm arrived next day I held him firmly with both hands and told him that, as soon as he did one of these seven things, I would apply two sharp smacks to the back of his right thigh. Amidst the noise it is unlikely that he heard what I said and, even if he did, it is unlikely that he understood. Z let him go. Within seconds a poster was being ripped from the wall. The punishment was immediately applied, reinforced by a restatement of the offence. The reaction was dramatic. In a wild frenzy he flew at the wall and the ripping was resumed with renewed vigour. The treatment procedure was repeated, accompanied again by the clear instruction, “You must not tear pictures down from walls.”

Things continued like this for some short time. Behaviours on the list were immediately punished; all other behaviours were ignored. Two things were crucial : first, I must not through ill-conceived “kind- ness” flinch from the programme; and second, the smacks must be painful. After about six or seven applications of the punishment I observed one or two interesting phenomena. The gap between punishment and reaching for the pictures on the wall was increas- ing. Also Malcolm’s hand was beginning to stop about an inch short of the pictures.

Three days later 1 was myself astonished at the swiftness and effectiveness of the transformation - a transformation I have observed in more than a hundred children since that time. The child was under verbal control. He would respond to instructions to be quiet and to sit still. After a few days he was introduced to a remedial reading class, and to the unit from which he had been previously excluded. A programme for dealing with 3 1 behaviours was started, but any infringement of the seven “intolerable behaviours” was relentlessly followed by the punish- ment. It must be clearly understood that he was still a very difficult child to deal with, but he was no longer uncontrollable. When I opened the Autistic Unit he was admitted fulltime - on occasions he has

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tested its unique policies to the limit. T described the initial treatment programme as an “FRl Schedule of negative reinforcement”. Today, for the purpose of this paper, I am simply calling it “physical punish- ment”.

The value of punishment Kilmarnock Autistic Unit is not preoccupied with

physical punishment. Visitors usually find a quiet atmosphere, with the children (during the morning session) sitting at their desks with appropriate work as in a normal classroom. However, the punishment system is always immediately available the moment a listed behaviour occurs. During the past six years we have worked experimentally with all forms of positive and negative reinforcement. It is my opinion that, for the violent and disruptive child, the scheme of physical punishment described (when properly carried out) has never been improved on. On admis- sion, every child is subject to the rkgime (with the written approval of the parents) - and we expect, and obtain, immediate results.

It must be remembered, of course, that we are here considering the treatment of children. Procedures for dealing with handicapped adults who are violent and disruptive must be carefully considered within an appropriate context. I am still responsible for the treatment of Malcolm, who is now almost 16. I t is nearly two years since he last required physical punish- ment. If he were to engage in intolerable behaviour at this stage, the kind of punishment outlined would no longer be the first choice of treatment. It would still be considered if necessary but in view of a number of difficulties its use would require careful thought.

There are, however, circumstances in which punish- ment may be in the best interests of the older adoles- cent or young adult.

For a number of years I have watched the progress of a family in which there is an 18-year-old girl who suffers from tuberous sclerosis. As a result, she is mentally handicapped and presents severe manage- ment problems. Her violent behaviour has been found to be exacerbated by the use of certain anti-convulsant drugs, but withdrawal of these could lead to status epilepticus. Years ago, when the child was young enough to be handled, the parents asked professional people for advice on behavioural management. With the best of motives they said, “Don’t smack her. She can’t help being like that, and smacking will only make matters worse.”

The advice was followed, until the parents were faced with an 18-year-old weighing 14 stone and with enormous strength. The scenes of disruption through which the family has lived in a desperate attempt to keep her at home are beyond description. As a friend who can be contacted easily I have sometimes been called to the house at night to provide extra man- power when glass doors have been broken and furniture smashed. At this stage the mother was unable to smack the child, as she was violently attacked in return.

Evidently the situation was going to break down irrevocably, and after an emergency admission to a mental hospital the parents were asked to agree that the girl be certified under the 1960 Mental Health Act. They refused, and took her home again. I am not professionally involved with the case but at this stage

I gave the following advice: ‘‘If you are prepared to put up with one week of chaos, I can offer a pro- cedure which will change patterns of disruptive behaviour which have been established for years.”

During a long discussion with the son, a medical student, I outlined in detail the principles of behaviour and 1 explained in particular the factors governing the patterns of behaviour displayed by the girl, and the relation of these patterns to reinforcing contingencies. 1 also outlined the only measures which I believed could reverse these patterns. Despite the girl’s age, these measures were based on physical punishment. It was utterly essential that this should be a painful process for the girl (to fall short of that would have spelled disaster), and it was necessary in the circum- stances that more than one person be available to carry out the treatment and to deal firmly and decisively with the threatened consequences. The system was introduced, and for the first time control of the life of the household passed from the girl to the parents. I have also observed - and have heard i t observed by others - that the girl is happier and more content than she was before, and I have seen in her a completely new attribute : helpfulness towards other people.

I t would be possible for me to provide a lengthy list of case studies involving the use of punishment. From time to time 1 have organised demonstration sessions in a clinic setting with very disruptive children (both normal and handicapped) under the heading “No child is uncontrollable”. On interview the parents almost invariably say, “We’ve tried smacking, but it doesn’t work.” 1 do not reply, “Then we must try something else”, but rather, “I will show you why it did not work”. During the session the parents then carry out the procedures themselves under observation.

The objections to punishment

examples that follow. Common objections to punishment include the six

A system which uses punishment is open to abuse. I am only too painfully aware of the inquiries

into recent hospital cases in which mentally handicapped or psychologically disturbed patients, both adults and children, were physically abused by staff. However, in not one of these cases was any physical punishment ever authorised, so it cannot be argued that the availability of punish- ment was a contributing factor. Clearly, every system of treatment may be abused, but it is not abandoned because it is associated with difficul- ties. In my experience a properly organised and closely supervised regime, such as I have des- cribed, leads staff to a greater rather than a lesser awareness of the caution and concern which must mark their dealings with the individuals under their care. Punishment may get results (indeed, it can be used to make children behave like trained rats) but it makes children unhappy in the process. I utterly reject this common criticism. I have often heard it before, but never after, a visit to the Unit, where all the children have been subjected to the same regime. In fact, I believe the very opposite of this objection. Disruptive children are

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marked by a sense of insecurity, and no one can offer them the security they need better than the person who brings them under control. I t has been our common finding that the children relate most happily to the member of staff responsible for punishing them.

3. A system of punishment does not bear the mark of love and care - the essential attributes o f those who deal with the handicapped. In answer, let me ask, “Where does the normal child receive most of the physical punishment he will ever get?” It is in the place where he is loved most - home. It was one wiser than me (and I believe wiser than any) who with a wisdom that trans- cends the to-ings and fro-ings of psychological and philosophical opinions wrote, “He that spareth his rod hateth his son; but he that loveth him chasteneth him betimes” (Proverbs 13:24.)

4. Punishment is intrinsically wrong because it causes suffering. I agree that it does, and indeed by definition it must. The whole point of punish- ment is that it causes suffering; if not, it would be a totally purposeless exercise. It is a form of suffering from which I could altogether have saved my children by outlawing its use, but my doing so would have resulted in three things. First, they would have been removed from home and family. Second, they would have been placed in hospital wards (and I mean no offence to those who work in that setting). And third, they would have been placed on high doses of behaviour- controlling drugs. Which course of action, I must ask, would have been associated with the greater suffering?

5 . The effect of punishment is to eliminate part of the person’s behaviour. Our aim should always be to extend the handi- capped person’s repertoire of behaviours, not to reduce it. I agree that punishment can remove “bad” behaviour but cannot replace it with “good” behaviour. However, many times I have watched people trying, with the best of intentions, to increase behavioural repertoires, but failing completely because certain “bad” behaviours, such as disruptiveness, had not been dealt with. Almost all of the treatment in which I am engaged is designed to increase behavioural reper- toires by positive reinforcement techniques, but 1 must first prepare the way by removing the aggressive and disruptive responses which vitiate any treatment programme.

6. Punishment is violence - and it just breeds more violence. I have never encountered an objection which is more belied by practical experience than this very common criticism of punishment. There seems to be a fear that to employ any “violence against the person” will result in violent responses being nurtured within the person. I am dealing frequently with children who have a history of violence, and I am routinely engaged in reducing the frequency and intensity of their violent behaviours by punishment. It is much more likely that violence will be bred by a failure to take effective measures to eliminate it.

Why punishment is a dignified alternative A final criticism of punishment reaches the very

heart of the matter: that punishment is an assault on the dignity and freedom of the individual.

Does punishment involve a loss of dignity? Yes, it does. In this respect it is no different from any other form of control. Nevertheless, I must claim that for the children in my Unit the system of punishment used has brought about for them a greater measure of dignity and freedom than they had ever known before. This, however, is not the main issue.

There is one over-whelming reason why I believe, in principle as well as in practice, that punishment is a dignified alternative. I f you decide: that it is not appropriate to punish a child because he is mentally handicapped, autistic or maladjusted; because he cannot fully understand an instruction; because lower expectations have to be set for him; because he cannot be viewed as an “offender”; because it is felt that he is unable to distinguish right from wrong; because he cannot be held responsible for his own actions; then, I believe that by definition you have undermined the dignity of that child. A normal child enjoys the pero- gative of being responsible, of being held to understand what he is not supposed to do (whether he understands or not), the perogative of being an offender. To treat the handicapped child in a different way is to lower his status.

I want the children with whom I deal to be treated by methods which might be applied to a normal child in a normal home. And I believe that those of my children who can speak would tell you that they want that too.

References Concise Oxford Dictionary. Oxford : Oxford Univer-

sity Press.

European Convention on Human Rights and Funda- mental Freedoms. Strasbourg : Council of Europe, 1953.

Holy Bible. Old Testament: The Proverbs, Ch. 13, v. 24.

Kilbrandon Report on Children and Young Persons.

Mental Health Act, 1960. London, HMSO.

Report by the European Commission of Human

London: HMSO, 1964.

Rights. Strasbourg : Council of Europe, 1980.

Author’s correction The Editors have been informed by Janet

Hill-Tout that there was an error in the first table of the Results section of her article How useful are staff meetings? which appeared in the March 1981 issue of Apex. The first figure in the column headed “no change” should have been 14, not 4.

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