SIMPLE DISSOCIATORS IN A COMPLEX PRISON by Ralph B. Allison, M.D. (Retired Senior Psychiatrist, California Men's Colony State Prison, San Luis Obispo, California) Published in the American Journal of Forensic Psychiatry Volume 17, Issue 2, Pages 37-64 The views expressed in this paper are solely those of the author. Nothing in this paper should be construed as representing the official policies of the California Department of Corrections. Copyright 1996 Amer. J. Forensic Psychiatry P.O. Box 5870, Balboa Island, CA 92662 Summary Recommendations for treatment of patients with dissociative disorders are not usually suitable for implementation with prison inmates. Simple suggestions are provided for treatment of simple dissociators in prison, based upon 13 years experience in a California prison. Four inmates/patients are described. One needed encouragement to go to school. The second one required assertiveness training. The third one responded to a variety of insight oriented psychotherapy in the state forensic hospital. The fourth one was able to cope with prison life after he agreed to a contract for proper behavior. Success depends on the psychiatrist's awareness of the total prison environment and ability to teach appropriate coping methods to such patients. The futility of trying to analyze the institution and expect it to change is discussed. The debate between working full-time and part-time is presented. The changing goals of the state prison system from Rehabilitation to Work to Punishment is described. INTRODUCTION Although the diagnosis and treatment of free-persons with dissociative disorder is well described in the psychiatric literature (1-3), these authors provide no guidance for a psychiatrist treating similar patients in a prison. In 1924, Goodwin (4) stated that dissociation and conflict are the most important factors in the phenomenon of insanity. Since females greatly outnumber males in non-criminal patient populations but hypnotizability is equally common in both sexes, Bliss (5) suggested that there might be a group of males with dissociative disorders in the criminal population. After recommending a psychoanalytic approach to criminal patients with dissociative disorders, Lasky (6) admitted that this approach "does not lead to a general rehabilitative approach that is appropriate for all (p. 166)." In recent years there have been a number of publications regarding planning and monitoring mental health services in jails and prisons (7-13). Authors have described treatment approaches for inmates with schizophrenia (14), alcoholism (15), and drug abuse (16). Prout and Ross (17) have described the failure of good intentions and hard work to provide any adequate treatment behind bars. Until Culiner's recent presentation (18) with me (19) the only papers on treatment of inmates with dissociative disorders were my own (20-24). These case reports came from my dealings with mentally ill criminal defendants in Santa Cruz and Yolo counties in California between 1964 and 1981. My experience in Yolo county included an attempt to supervise treatment of an inmate with dissociative disorders in the California Medical Facility prison at Vacaville (22, 23). After leaving the Yolo county program, I joined the full-time psychiatric staff of the California Men's Colony state prison (CMC) in San Luis Obispo. THE PRISON CULTURE From inside the prison, it became clear that the political popular purpose of the penal system cycles approximately every decade. My first year there was the last year of the "Rehabilitation" decade. During that phase, the psychologists had organized a school on mental health subjects attended by an eager student body of inmates. In 1982, as I finished teaching my first class of inmates on the mental mechanisms of defense, the Work Incentive Program (WIP) was instituted in all California prisons. This began the phase I call the "Work is Good" decade. As a politically safe way of lowering the burgeoning prison population, the state legislature decided that work was now the activity to be most prized. Inmates now were given the chance to work off their sentences by being on the job or going to elementary or high school six hours a day. Any other activity had to be suspended during the inmate's work day. College courses and activities by health professionals had to be rescheduled after inmate working hours. This destroyed the school the psychologists had carefully created during the "Rehabilitation" decade. This rigid devotion to work as the greatest good was gradually eroded over the next decade by inmates' lawsuits complaining of inadequate health care as well as union grievances demanding that the doctors be allowed to see inmate/patients during the doctors' usual working hours. An increased number of mentally disabled inmates led to the granting of work/time credits for attending therapy activities by inmates deemed too disabled to be able to cope with even simple jobs, such as washing dishes and raking grass. In 1994, the prison system cycled from the "Work Is Good" phase into a "Punishment" phase, with the passage of the "Three Strikes and You're Out" law, which mandated tougher penalties for subsequent felonies. The policy to let inmates work their way to early release was revoked by a politically popular law which will require the state to build and staff as many prisons as seems needed to hold habitual criminals as long as possible. Rehabilitation and work are out of favor, and punishment is the policy of the day. In another decade, the state's officials and voters will be feeling the collective guilt and frustration of this approach, and they will be back to the next rehabilitation phase. From the point of view of the inmates, the atmosphere is best described by Hogshire (25): "U.S. prisons are full of some of the rudest, most violent and savage people on earth. They live by an ethic that is absolutely alien to anything in the outside world. In reality, there is nothing you can do to prepare yourself adequately for what is to follow. Just as there's no real preparation for war or any other extreme, life of death situation. In fact, perhaps war is the closest thing to prison. They are both maddening boring stretches of time punctuated by sheer terror."(p. 69) Into this environment are thrust psychiatrists, psychologists and social workers who are expected by the administration to treat "patients" with mental illnesses. The California Men's Colony State Prison The author was one of those psychiatrists who was recruited in 1981 to work in the medium security state prison called the California Men's Colony (CMC) in San Luis Obispo, California. This prison is no ordinary prison. CMC was originally opened to care for disabled and geriatric inmates in vacant Army hospital barracks in 1954 (26). At that time, the Department of Corrections introduced personal counseling in prisons by requiring guards to organize discussion groups with the inmates under their supervision (27). When it was apparent that there were more waiting inmates/patients than cells, a 2400 bed prison with prefabricated single cells was built on land adjacent to the barracks. These cells provided decent accommodations for all inmates. The first warden selected inmates who needed protection from predators, which such cells provided, but he expected them to earn that privilege by sociable behavior. Over time, CMC became the prison where anyone could "do his time" and not be hassled by gang members or other predators. One section was designated to take care of ambulatory psychotic inmates and appeared to any visitor as a small state hospital. A medical/surgical hospital was developed with competent staff recruited from the local community of doctors. The treatment of the mentally ill and emotionally disturbed requires the use of verbal speech. All of these men come from county jails, where the wise advice given to them by Hogshire (25) is: "Don't speak to other prisoners about much at all. And never speak of the specifics of your crime -- jails are full of desperate men who will very quickly pick up on anything you say to fabricate a story about how you 'told all' to him. And prosecutors are more than happy to play ball with these parasites. "To this end it is best not to reveal even the most mundane parts of your life -- that you eat peanut butter sandwiches, have a green cadillac [sic], come from Florida, your wife's name -- anything can and will be used against you. Its probably not a bad idea to give misinformation to everyone you talk to in jail. Tell everybody lies and lie about everything. Even though this may be the loneliest time of your life and you'd give anything to take some comfort in another human being's company, realize that you can't do that in jail. "Don't write down anything about your crime and don't speak about anything incriminating on the phone. Don't speak of it anywhere or with anyone -- even a co-defendant. Cells may be bugged if nothing else." (p. 24) In orienting new prison employees, instructors make it clear to all new hires that they must consider any statement by an inmate to be a lie until proven true by other evidence. That code was well meant and was valuable to heed, especially for psychotherapists of inmates, as each inmate had an expectation of what he wanted to get out of each staff member. Inmates carefully craft what they say to persuade staff members to take specific action the inmates want. Results are what count, not veracity. In contrast to the situation at the other General Population (GP) prisons, at CMC inmates could talk to staff members without being considered snitches and betrayers of other inmates. Hogshire (25) has this advice to inmates on talking to any custodial staff: "Informers are the most hated people in the world. Even the cops think informers are scum; prisoners absolutely loathe snitches. If you're in prison there will be nothing you can do to prevent being raped, brutalized, tortured and killed. Even if you are set free, you will not sleep soundly ever again. "Once identified as a snitch, there is no way to get out of it. No apology can ever be sufficient and you will be hunted down. 'Protective Custody' in prison won't do you a bit of good. Even the most sophisticated 'witness relocation programs' might buy you a little time but cannot protect you forever. "Don't become a snitch and don't listen to anyone who advises you to do it (p. 41)." With that kind of discouragement of inmates talking honestly to prison staff members about any subject, for any of inmate to enter into a confidential relationship with a psychotherapist requires an act of faith few rational inmates would be willing to make. But the atmosphere at CMC had developed over time so that telling the truth about his situation to a staff member would not so detrimental to an inmate's health as it would be at another prison. CMC became the Protective Custody (PC) prison for snitches from other prisons. There were so many of them on the grounds that one of them could not say anything bad about another one, since all were equally guilty of some unforgivable sin. One reason that CMC was able to provide a somewhat different social environment was because of its geographical location. Most prisons have to be built in undesirable parts of the state, where the local citizenry have not raised a hue and cry against having inmates in their back yards. This did not happen in San Luis Obispo county, a primarily agricultural area at the time CMC was being planned. Governmental jobs have always provided a major alternative source of income to an otherwise sparsely populated county. Since staff members enjoyed living on the lovely Central Coast of California, they were usually in a good mood when they reported for work. This enabled them to have a positive influence on inmates under their supervision. Inmates with both medical and psychiatric problems were transferred to CMC for expert care, and the staff was able to concentrate on helping these inmates. Those who misbehaved were moved to high security institutions in undesirable parts of the state and lost the benefits of staying at what many inmates referred to as "The Country Club." Inside CMC The prison is built in the shape of a square, each corner of the square is a separate mini-prison, and each quadrangle (quad) developed its own culture and specialty. My first assignment was to A Quad, a GP quad with an Honor Unit. Many residents were lifers determined to behave perfectly so they could be paroled as soon as possible. B Quad was similar, but it also had "Fish Row" where newcomers were housed during orientation. One housing section was converted later into an "Administrative Segregation (Ad Seg) Annex," a jail within the jail. C Quad housed mostly GP inmates with a small portion of stabilized mentally ill inmates. Over time, this group increased as more mentally ill inmates poured into the prison system. This was my area of responsibility during my last six years there. D Quad was the section reserved for the chronically mentally ill inmates. In my view, "it was a state hospital that thought it was a prison." Here the seriously mentally ill were housed, including those too difficult to manage at the nearby Atascadero State Hospital (ASH). In contrast to D Quad, I considered ASH to be "a prison that thinks it is a hospital." Both beliefs are delusional, of course, but it seemed that CMC's delusion was the more functional of the two. After working one year on A Quad, I spent five years in D Quad, responsible for medication management of the chronically mentally ill inmates. This included one year organizing and operating a section for crisis management, after all psychiatric beds were reassigned to the Infectious Diseases service during reorganization of the medical/surgical hospital. Since I was trained in Community Psychiatry principles and the philosophy of "the therapeutic community" (28) during my residency, I soon realized that I was now working in a self-contained community called CMC. The same political structure existed as was in any county in the state, with its Board of Supervisors consisting of the warden and deputy wardens. Each town in the county (A, B, C, and D Quads) had a mayor, called the Program Administrator, and a police chief, called the Correctional Lieutenant. There were centralized factories, a fire department, entertainment facilities (gymnasium), restaurants (mess halls), a library, schools, chapels, a jail (Ad Seg Main), a laundry, and a hospital. I was again one of the psychiatrists in the County Mental Health Service, assigned to one of the branch clinics. TREATMENT STRATEGIES In spite of the important adverse influences mentioned above, there were some successes seen with dissociators. Since the environment does not match that in which patients are treated in the free community, one cannot apply methods that one learned outside of prison. One must adapt to what is and work within those new boundaries. The patients may be somewhat similar, and knowledge of personal psychodynamics is still essential to be able to pick and choose which approach to use. Below are described four different approaches which were found useful, each illustrated by a different dissociating inmate. Encouraging Education Jose came to prison on charges stemming from his life as the leader of a Hispanic street gang leader in a large city barrio. In the office, he presented as a mild mannered young man named Pedro, who didn't remember large blocks of time in the barrio. Pedro wanted nothing to do with the prison gang members. All he wanted to do was to go to school and make something of himself. Further interviewing revealed that Jose was an alter-personality who had formed after Pedro had been harassed by three bullies who demanded his lunch money each day on his way to school. One day he had had enough and exploded at them, knocking them to the ground in a burst of angry energy. At that moment, Jose, a hostile alter-personality, was born to protect the shy little boy inside. Over the years, this alter-personality had grown in stature in the gang subculture to become their leader, when he was arrested and imprisoned. Now that "they" were in CMC, in C Quad, where gang membership was not essential for survival, Jose, the gang leader alter-personality, was willing to take a back seat to Pedro's desire for education. He stayed watchful, but inactive, as Pedro finished high school and enrolled in the X-ray technology training program. My contacts with "them" were brief, infrequent visits, with an initial prescription for antidepressant medication. A friendly, understanding relationship was nurtured with both Pedro and Jose, his protector. Jose accepted the fact that he would fade in time as Pedro increased in his education, self-esteem and coping abilities. Neither of them was ever in disciplinary trouble in prison or needed any special attention from other members of the staff Because of my cordial contacts with his teachers, they would have warned me if Jose had ever given them reason for concern. As it was, none ever called, and Pedro is now a quiet member of the inmate group, awaiting his parole. The last time I saw him, he was awaiting reassignment to a GP prison as a certified x-ray technologist in that prison's hospital. An "identity disorder" unique to prison occurred with this inmate. He had been arrested and convicted under the name of his gang leader alter-personality, Jose. That was the name on his prison records. Staff members assume all inmates will be identified properly at the time of commitment. If a clerk misspells an inmate's name at the reception center, that name is engraved forever in the records for all staff to read in his file. Even an inmate with many aliases must pick the one he wants to use when committed to prison. In the case of Pedro, it seemed unwise to have the gang leader come out each time an officer called, "Jose, come here." I wanted the file renamed under the name of Pedro, but that required the inmate petitioning the records office. If the request were approved, that would create much work for the record room staff. Such changes are strongly discouraged, therefore, and the inmate might be advised to give his correct name at the time of his next arrest, when a new file would be created under the new name. Teaching Assertiveness Instead of Aggressiveness Harry was a white inmate who arrived at CMC during my first year in D Quad. He came to sick call because he was having blackouts at work, after which he would find other inmates being super-respectful of him. He was a master electrician assigned to the prison electrical repair shop crew. All of these blackouts occurred after another inmate on the crew verbally harassed him. As he became progressively more upset at that inmate, he would black out and wake up to find the inmate extremely respectful of him. Harry was in prison for committing a bank robbery while dressed in a clown costume! His wife had been committed to the women's prison as his co-defendant. The couple had given up their small child for adoption when they were first jailed, but his wife had delivered their second child while in prison. The Child Protective Service (CPS) had petitioned to place the newborn child for adoption and requested Harry relinquish his parental rights. He refused, as he felt he could be a good father, and his mother in Chicago had agreed to help him raise this second child when he was paroled. Harry had no memory of committing the bank robbery. He had worked as a traveling trouble shooter for his company, and he and his family lived in motels in the towns where he worked. His mother kept his funds and wired him money as needed. Before the bank robbery, they had run out of money, and he had called his mother for some, but he had not told his wife. Their child was hungry, so he put on a clown costume to entertain and distract him. His distraught wife drove him to the front of a bank, put a gun in his hand and told him to go inside and get some money. When he returned with the bank's money, she put him in the trunk of their car and drove back to the motel, with police cars following. The officers arrested him inside the motel room, still in his clown outfit, with the money in his pocket. At that time, Harry had no idea where the money had come from. Harry's father had been a Chicago Mafia Don whose wife, Harry's mother, had testified against him during the Kefauver Organized Crime hearings in the 1950's. Harry was so ashamed of his father he had vowed never to be like him. During the time he lived in Chicago, he frequently entered restaurants where he believed he had not dined before. He was often amazed to find the manager rushing to get him the best table in the house and provide him with free food and drink. He didn't understand why, until somehow he learned he had been running a restaurant protection racket during his amnesic spells, just like his father had done, In our few meetings together, Harry's main concern was how to cope with the harasser on his electrical crew. It seemed reasonable that clarification of exactly how he robbed the bank would provide an explanation what was going on during his amnestic spells. With my dictating machine set on "record," I hypnotized him and asked him to relive the day he had robbed the bank. Out came Angelo, an alter-personality who explained how he had entered the bank and told the manager to give him money, using his usual persuasive style plus the gun in his hand. He also admitted being responsible for running the restaurant protection racket in Chicago. He was the one who took over when Harry couldn't stand his irritating co-worker and gave him a tongue lashing that made the other inmate's bones shutter. Angelo was a practiced mob enforcer. I played the tape back for Harry to hear, but he could not listen to all of it. But the mystery had been solved. He had created Angelo as a carbon copy of his hated father, since he had long ago vowed never to be angry, as his father always was. Although we both now understood the situation, Harry still didn't know what to do differently. In prison any inmate has to be careful when threatening another inmate, as the other one could have "homeboys" willing to back him up in a confrontation. Harry was also afraid to confront the harasser for fear he might lose his job and become unwelcome at another job, a reasonable fear in prison. My suggestion was simple, but based on an understanding of how free-person supervisors operate at CMC. What Harry needed most was to understand was the difference between assertiveness and aggressiveness. I advised him to be assertive for a change, but to do it in a way that would improve his chances of success. I told him that it was his boss's job to deal with harassing inmates on his crew. He should tell his free-man boss the basic facts of the matter and leave the problem in his hands to solve. I did not advise him to confront the inmate himself, as he, Harry, only had an internal "homeboy," one who so far had not improved his situation with his aggressive behavior. He followed my advice and told his boss about the problem. Since Harry was a professional electrician and highly valued for his skills and knowledge, the boss fired the other inmate, solving the problem. From that day forward, Angelo never showed up, and Harry had no more blackouts. Harry then decided to battle the CPS over the custody of his infant son. He used his attorney and the court process to fight that battle very assertively. After his parole, his attorney called me and reported that Harry was pursuing the custody issue very assertively in court, insisting that his parental rights being recognized. He no longer had any amnestic spells, as far as the attorney could tell. Providing Insight Oriented Psychotherapy George was a neat, clean black man who was sentenced to a life term because he had been the driver of the car when his crime partner killed a store clerk during a holdup. In prison, he was the antithesis of the typical inmate, as he always wore neatly pressed clothes, combed his hair, and walked in a straight, proud manner. But at night in his cell, his other self came out and terrorized his cellmate. (By the time he arrived, overcrowding had required that two-thirds of the single cells be fitted with a second bunk.) He remembered nothing of these nighttime explosions, but they led to his placement in Ad Seg, where the correctional officers observed him closely. His cellmate's father managed a Board & Care Home, so he was "used to crazy people." He described George getting up at night in a completely different state of mind, yelling and cursing and banging on the walls. State law provides that an inmate can be transferred to a forensic state hospital if the inmate is too mentally ill to be properly treated in prison. This man was not wanted back in his quad, because he could not be celled with any other inmate. Policy prohibited using a single cell for him as single cells were only assigned to inmates who had earned them by good behavior. All other inmates had to house with a cellmate, often one as mentally ill as they were. Since he was too violent at night to risk with any cellmate, a referral was made to ASH for inpatient treatment. On the first ward to which he was assigned there, the psychiatrist decided he could not be mentally ill, since he was so neat and clean. He tried to explain that his mother had trained him to dress and act that way, and it was an ingrained habit. A nurse suggested trying him on another ward, one specializing in drug and alcohol abuse, which was one of his problems. On the second ward, he came under the care of a unique psychiatrist who became his father figure for the next fiv``e years. He lived in a dormitory with nine other inmates who became his emotional brothers, providing them all a new family in which to grow up again. The psychiatrist gave them a didactic lecture each day on the normal stages of personal development. Then, in two hour group meetings, the psychiatrist age regressed one patient per session and had him review his own personality development. (29) This approach was what I had used with individual patients with Multiple Personality Disorder (MPD) (known as Dissociative Identity Disorder [DID] after 1994) in my office in private practice. The only difference at ASH was that his "brothers" were observers of each session, and each patient had his turn at being age regressed. During the five years he was in that treatment program, he worked through all his emotional problems. He was then returned to CMC, where he was assigned to D Quad as a Recreational Therapy Aide. His job was to be a buddy to several of the severely disabled inmates and help them learn necessary social skills. When I asked him what he learned about the angry alter-personality that used to come out each night in prison, he told me that it was just his "angry self." With the individual/ group/ family therapy he had received from this creative and compassionate doctor at ASH, he had resolved his problems. Agreeing to a Contract It is commonly stated that over 80% of MPD/DID patients have a history of severe sexual abuse in childhood (2). The assumption is then often made that the abuse caused the dissociative disorders. That is not what I have described in the above cases. But the last inmate to be described was a severely abused child grown up, a member of a group that fills too many of our prison cells. Chuck was a white man who arrived at CMC after receiving a 75 year sentence after conviction of multiple counts of child molestation. He had been arrested while a patient in a Veterans Administration hospital, where one of his alter-personalities told a hospital staff member of the molestations. Previously, he had been on female hormones in the transsexual surgery program at a university medical center, awaiting castration and surgical construction of external female genitalia. Before surgery was scheduled, a male alter-personality came forth and discovered what the female alter-personality had been planning for "their" body. He left the transsexual program and entered the VA hospital for psychiatric treatment. Shortly after his arrival in CMC, he was sent to ASH for clarification of his diagnosis and appropriate treatment. In 13 years of referring patients to ASH, this was the only time an admitting psychiatrist there called to gleefully report he had caught the patient lying about his documented history. He sent Chuck back to prison as a malingerer. The patient's explanation of his expulsion from ASH was that the doctor had been so rude to him one of his angry male alter-personalities came out and tried to strangle the doctor, which guaranteed his return to prison. The discharge summary said nothing about any assault on the psychiatrist, and the inmate was not charged with any crime. The hospital policy was to file criminal charges against any patient who assaulted a staff member. Therefore the inmate's story was never confirmed. Since he had been rejected by the intake psychiatrist at ASH, the prison staff had to cope with him on C Quad. A mature female psychologist who had previously worked on the sex offender ward at ASH agreed to be his individual therapist. His 16 year old female alter-personality was promiscuous and seduced many of the homosexuals on the quad. That misbehavior looked like homosexual behavior to the officers, of course, and is banned by CDC regulations. All staff members on C Quad accepted the reality of his many alter-personalities in contrast to the disbelief expressed at ASH. When asked his childhood history, he told how he had come from some far off galaxy on a space ship, where he had barely escaped from an exploding planet with his lady love. She had then been killed by the enemies of his galactic empire. While I am accepting of any reasonable history, even I recognized a Star Trek story line. When I later interviewed his older sister, she told me of the extensive physical and sexual abuse he had suffered at the hands of his psychopathic Sicilian father. She had tried to protect him as best she could, but he was his father's preferred target for continuous personal assault. His father also loaned him out to his friends so they could abuse him, too. When Chuck reached his 21st birthday, he and his sister celebrated that he was still alive! It seemed logical to me that his abuse history was so horrendous and repetitive he could not put it into words to anyone but his sister. But, as a "Trekkie" since his early childhood, he was able to describe his troubles in that type of scenario. As the only psychiatrist on C Quad, I was responsible for managing all of the mentally ill inmates there, and I needed to get his behavior under control. With the aid of his understanding female correctional counselor, a former teacher, I prepared a contract for him to sign, listing all the behavioral requirements needed to allow him to stay at CMC. [Attachment] I knew he wanted to avoid transfer to a mainline prison where no one would understand him or tolerate his misbehavior. He and all his available alter-personalities signed the agreement, and five years later he swore to me that he had followed all my terms in the intervening time. His behavior improved so much he became a student in the Vocational Electronic Repair class. He eventually was made a GP inmate and moved to B Quad, where he had no psychiatric supervision. His sister informed me that he carefully picked his cellmate there as the one inmate who could be his best confidant and lay therapist. He then developed adrenal carcinoma, and had his right kidney and adrenal gland surgically removed. However, metastases developed, and he became physically debilitated. After three years of physical decline, he died in December, 1993. During the months before his death, I interviewed him several times, and he manifested an angry alter-personality named David, when talking about his experiences at ASH. Usually, Chuck, the very bright and manipulative one, was out to deal with the doctors and nurses. He told me he had arrived in prison with about 50 alter-personalities, but, at the time of his death, there were only six, and they were all in constant communication with each other. He no longer had amnesia and could follow any plan the committee of alter-personalities decided upon. Chuck was so badly traumatized as a boy that it appears that psychotherapeutic treatment would have been impossible in any setting. He broke all the rules in one alter-personality or another. He was very bright and more talented at manipulating staff members than anyone I have ever met. That skill must have been what kept him alive at home. That he adhered to the terms of our contract is the important point to emphasize. His willingness to operate by the prison rules led to a gradual loss of alter-personalities and the breakdown of amnesic barriers. His most effective psychotherapist was his last cellmate, who lived with him seven days a week and had no other patients. Nowhere but in prison could he have received such service. RECOMMENDATIONS Treatment Options Simple dissociators may be managed in prison by simple means, such as education of the primary personality which leads to "atrophy" of the hostile protector alter-personality. Assertiveness training may be what is needed, but can only be done if the antisocial behavior is kept within the tolerance of the custodial staff. In the case of short term inmates near to parole, all that can be done is to recognize their need for competent psychotherapy and assist them to locate a suitable therapist in the town to which they plan to parole. It is generally unwise to be pulled into discussing their psychopathology when only brief, infrequent sick call meetings are all that are possible in the prison. In the case of severe cases of MPD/DID, every prison psychiatrist would be fortunate to have competent treatment available at the forensic psychiatric hospital to which such inmates would be transferred. Such is not likely to be the case, but the situation may improve with time. Whereas I had one poor outcome, I also had one excellent outcome. As younger staff members arrive out of training programs where treatment of dissociators is taught, we can expect dissociators to be recognized for what they are and appropriate treatment programs to be developed for them. Since the culture in the forensic hospital is different than that in a prison, there can be individualized treatment approaches and long term therapy with the same therapist. Transference Problems For those who stay in prison, the attitude of the therapist is one essential variable which must be appropriate, or no treatment contract will ever be established. At a recent convention on dissociative disorders, I was confronted by a male multiple who had spent 12 years behind bars. He said over and over to me that he and his fellow inmates needed to be "loved and accepted" by us psychiatrists. While I agree with him philosophically, I hesitate to use the work "love" in a prison environment. The words "care what happens to them" seem more suitable and mean the same in terms of the transference process. How one shows that care is different in each case and with each therapist. Since these men usually give a history of never having been loved by their parents, it may seem "logical" that the therapist can correct the damage by loving them now, as was insisted by the ex-inmate mentioned above. Such a belief can lead the therapist into a reparenting trap, and that opens up the therapist to total manipulation by the inmate, a position that would mean total disaster for any prison employee. Teaching Coping Skills Poor coping skills is a problem with the vast majority of inmates, be they patients or not. These men have never learned to use even the most elemental social support services in the community. With the exception of lifers, they will all be paroled someday, and they will return to the free community. It is incumbent on intelligent responsible staff members to take a proactive stance in the education of these men when it comes to such resources. This is concrete demonstration of the psychiatrist "caring what happens" to the inmate. In each professional dealing with any inmate/patient, I tried to find some issue to use as a lever to get him to think about how he could do better in the future, especially on parole when his choices are greater. I asked direct questions and offered concrete advice about resources he may not know existed. The phone book yellow pages have been like hieroglyphics to many inmates, but there they will find social service resources they should know about. I talked to them, but I was not always nice in what I said. If I thought I was being lied to, I said so and told them they were hurting no one but themselves by not being straight with me. I earned their respect by never lying to them and by not being so gullible as to believe everything they told me. Acceptance is also essential, but must not be confused with agreement with their behavioral standards. I accept wherever they are and try to comprehend how they see the world. Only then can I provide any kind of a lever to move them into another pathway in the future. Working in Prison Full-time or Part-time? One expert in correctional psychiatry (30) strongly recommended that no psychiatrist should work full-time behind the bars. He felt that the mental stability of the psychiatrist needed exposure during half the working day to non-criminally oriented patients. When I first joined the CMC prison staff as a full-time psychiatrist, I ignored that advice. The patient load was relatively light, so I had time to get acquainted with how the system worked. This became important later on as I knew personally how administrative actions were accomplished and by whom. As a health care provider, I was only an advisory member of the disciplinary and classification system. I knew I would only be welcome at those meetings if I behaved in a non-threatening, non-judgmental, and non-criticizing fashion. So I quietly sat in on all the custody staff meetings I could while maintaining that posture. My community psychiatry training taught me it was the only way to learn what my patients went through. As a result, I might finish an Inservice Training session how to chain prisoners for transport, and then sit as an advisory member of the Main Disciplinary Committee, which allotted punishment for major infractions. I often sat with Quad Classification Committees, learning first hand how staff and inmates interacted when dealing with issues important to both groups. I once even sat in for an inmate before the Board of Prison Terms (BPT or parole board). The inmate was too physically ill to leave the hospital and asked me to be his proxy. I sat in the inmate's chair with his attorney at my side, while the three BPT members questioned me about him. I realized from that experience that they don't know how to ask questions that don't require crystal ball gazing. But now I knew what they asked and what they ignored, and I have since written my BPT reports to take into account the realities of that situation. Only by being a full-time employee did I have the time and opportunities to learn first-hand about these administrative activities. If I had only come in on a part-time basis to see selected patients, I would never have had these experiences. I would always have been an outsider guessing what my patients had to face in their jaunt through the prison system. The price I paid came later when overcrowding became a problem. The department was accused of under-diagnosing mental illness since a survey in another state's prisons showed they had more mentally ill than did California. That the two methods of counting were completely different was ignored and, under threat of federal court suits, our department urged us to label more inmates as mentally ill. We did that by changing the criteria for defining mentally ill inmates. While previously we had excluded those with a primary history of drug and alcohol abuse, we now included them if they had any complaints of a psychiatric nature. Suddenly we found hundreds of inmates who claimed to hear voices after use of PCP, LSD, cocaine, heroin and amphetamines for a decade or more. This elevated the statistics to an acceptable level and loaded up our clinics with men who now expected legal drugs to replace the illegal ones they had been ingesting for so long. This brought into our offices many inmates who were quite different from the ones with chronic schizophrenia and bipolar disorder we had been used to seeing over the years. Most of the new ones were thieves. They stole money and goods outside of prison to support their drug habits. Inside prison, they stole time, attention, energy and pills. They wore out the medical staff with their demands and expectations, leaving us exhausted at the end of the day. By then a part-time role seemed very attractive. By taking all my accrued vacation time and finally retiring, I gradually withdrew my investment in the prison psychiatric service. New staff members were hired and trained, and competent custodial administrators rotated to other assignments. The Chief Psychiatrist asked me to come back and handle a case load on a half time basis, and I tried that for a few months. But it proved impossible to be 100% responsible for all duties on a 50% time schedule. Then, when I had to step in to handle a crisis, I was told by the Program Administrator that I was being too decent to the inmates/patients, and I could leave, as far as he was concerned. It seemed the proper time to depart again. So what do I suggest for others -- full-time or part-time work? I knew what to do on a part-time schedule because I learned it while on a full-time assignment. But now there is so much more work to do, there is little time left to become acquainted with non-psychiatric functions of the prison system. When dealing with inept patients, such as dissociating inmates who need clear advice in coping better with the prison system, accurate knowledge of the system is essential. If the psychiatrist does not know much about the real world of the inmate, he cannot be of much help to those patients. Each correctional psychiatrist will have to decide what might work best for him or her, in the setting in which the work is to be performed. Providing Psychotherapy of the Institution? Some psychiatrists feel that the prison culture and organization is pathological and should be changed (31). They are discouraged to find the institution will not lie down on their analytical couch and submit to such introspection as would a neurotic human being. This view is very misguided, I believe, as a person can only work for change in another person, and even that is very difficult. An institution can only be changed by another institution. In the case of state prisons, the most powerful institution is the federal court, which has the responsibility for seeing that the constitutional rights of inmates are not violated. A single federal judge may make the decisions, but he/she invokes it as the duly appointed representative of the federal government, which contributes a major share of the money needed to run the state prisons. The other institution that has a major impact on prison philosophy and operation is the state legislature, which determines legal penalties and grants operating funds to run the prison. The passage in California of the "Three Strikes and You're Out" law is guaranteed to drain tax resources to meet its requirements. The legislature will then have to figure out where the money is to come from and which non-custodial services to finance as well. Optional treatment programs could well suffer cuts to allow more inmates to be housed for longer periods of time. If some of those long term inmates have dissociative disorders, as is highly likely, who is going to rush in to treat them? Already, optional treatment programs for lifers have been severely curtailed while the BPT still mandates extensive psychiatric treatment for lifers before they will grant parole dates. With federal court mandates insisting on more treatment of the identified mentally ill inmates, there are fewer therapists left to treat the lifers for their character disorders. CONCLUSIONS Hopefully a small ray of light has been shed on a complicated subject and on some of the simple and effective approaches to those inmates who manifest an alter-personality. The easy patients are those who have reacted to a difficult home life situation by "identification with the aggressor," with the creation of a protective entity to fight their battles for them. They need the chance to improve their own self worth through education and vocational training, in a relatively protected prison environment, where they need not expend all their energies keeping themselves alive. Another simple approach that is often needed with dissociating inmates is teaching them the difference between aggressiveness and assertiveness. They need permission to look after their own well being by taking mature, appropriate steps to solve problems in a way that is condoned in their prison culture. It behooves the correctional psychiatrist to have learned what these methods are by acquainting himself with how his prison runs so he can accurately guide the dissociating inmate in the proper fashion. When the dissociating inmate cannot be treated safely within the prison walls, referral to an appropriate forensic hospital is in order. Unfortunately, the treatment services for dissociators may be no more readily available there than in the prison, but improvements can be expected with training of students now in courses of study which will prepare them to work in such institutions. Psychiatrists working in prisons need not feel negligent if they have not been able to psychoanalyze the institution and improve it. Only an agency can change an agency. The question of a full-time position versus a part-time position depends on the nature of the institution and the opportunities the psychiatrist has for learning enough about institutional procedures to be of effective help to his or her patients. There is hope for the future in this difficult area of clinical activity. Dissociating inmates/patients will not disappear, of that we can be certain. It therefore seems reasonable for those who are responsible for the treatment of such individuals, who have been convicted of crimes, to devise practical ways to encourage their charges to improve. If the penal institutions start working with the easy ones first, they will have made a start in learning how to send some individuals back into society in a frame of mind which is better than the one they had when they were sent to prison. AGREEMENT For the purpose of future peaceful co-existence between himself and the custodial and psychiatric staff of C Quad of CMC-E, the following actions are agreed upon by Chuck Multiple (regardless of the name used by said Multiple), hereafter known as the Inmate. The Inmate, to earn the right to remain in C Quad, agrees to the following conditions, in addition to obeying all CDC Director's Rules and Regulations: 1.) No personality which considers "herself" to be female shall be allowed out of the mind, to take control of the body, including speech mechanism, except in a Staff member's office on request of said Staff member. The offices where a female personality may come out on request shall be limited to those occupied by the psychologist-therapist, the C Quad psychiatrist and the C Quad counselor. Said female personality shall go back inside the mind when requested by the Staff member prior to the body leaving the office for the prison yard. 2.) Only male personalities shall control the body of the Inmate when operating in all other areas of the prison, at all other times. The only exception may be within his own cell during lockup hours. During such time out, all behavior by all personalities shall conform to institutional rules and regulations. 3.) The Inmate shall behave in such a way that breaks no rules or regulations of CMC, so that no Correctional Officer shall ever have a valid reason to write a CDC 115 disciplinary action on him. 4.) The Inmate shall locate a suitable job where he could likely be employed on a long-term basis. 5.) The Inmate shall take the medications ordered for him reliably. If he has a problem with any of them, he will promptly notify the C Quad MTA or psychiatrist so changes can be made. 6.) The Inmate shall refrain from calling his relatives with complaints of being suicidal and worrying them unnecessarily. If he has suicidal tendencies, in any personality, that personality will notify in person or in writing the C Quad MTA or psychiatrist, identifying which personality is feeling suicidal. 7.) The Inmate will continue in weekly psychotherapy with his current psychologist and do whatever he can to take full advantage of her talent and skill. 8.) When a given personality has written an interview request to any Staff member, and another personality arrives at the office for the scheduled visit, the personality who wrote the request shall be allowed to come out to discuss the problem with the Staff member. When the discussion is completed, the personality who requested the visit shall return to inside the mind and allow out the personality who first case into the office to resume control of the body. The basic rule WHOEVER COMES IN SHALL GO OUT shall be followed. The following individuals sign this agreement on behalf of all alter-personalities of Chuck Multiple. __________________ __________________________ ELON DEVU B'ARADUR __________________ __________________________ X JANUS ESNE MIRI'EL ESNE MULTIPLE, CHUCK D-12345 CMC-E MARCH 8, 1988 REFERENCES 1. Kluft RP, Fine CG (eds.): Clinical Perspectives on Multiple Personality Disorder. Washington, DC, American Psychiatric Press, 1993 2. Putnam FW: Diagnosis and Treatment of Multiple Personality Disorder. New York, Guilford, 1989 3. Ross CA: Multiple Personality Disorder: Diagnosis, Clinical Features and Treatment. New York, John Wiley and Sons, 1989 4. Goodwin JC: Insanity and the Criminal. New York, De Capo, 1980 (Original work published in 1924) 5. Bliss EL: Multiple Personality, Allied Disorders and Hypnosis. New York, Oxford University Press, 1986 6. Lasky R: Evaluation of Criminal Responsibility in Multiple Personality and the Related Dissociative Disorders. Springfield, IL, Charles C. Thomas, 1982 7. Eisler RL, Weinstein HC: Quality assurance in jails and prisons, in Manual of Psychiatric Quality Assurance. Washington, DC, American Psychiatric Press, 1992; 107-112 8. Dunn CS, Steadman HJ (eds.): Mental Health Services in Local Jails: Report of a Special National Workshop. Rockville, MD, U.S. Department of Health and Human Services, 1982 9. Landsbert G: Developing comprehensive mental health service in local jails and police lockups. in Innovations in Community Mental Health. Edited by Cooper S and Lentner TH. Sarasota, FL, Professional Resources Press, 1992; 97-123 10. Monahan J, Steadman HJ: Mentally Disordered Offenders: Perspectives from Law and Social Science. New York, Plenum, 1983 11. Sourcebook on the Mentally Disordered Prisoner. Washington, DC, U.S. Department of Justice, National Institute of Justice, 1985 12. Steadman HJ, McCarthy DW, Morrissey JP: The mentally ill in jail: planning for essential services. New York, Guilford, 1988 13. Warren MQ: Correctional treatment in community settings: Report of current research. Rockville, MD, National Institute of Mental Health, 1972 14. Morgan DW, Edwards AC, Faulkner LR: The adaptation to prison by individuals with schizophrenia. Bulletin of the American Academy of Psychiatry and the Law, 1993, 21:4:427-433 15. Ziegler R, Kohutek K, Owen P: Multimodal treatment approach for incarcerated alcoholics. Journal of Clinical Psychology. 1978; 34:4:1005-1009 16. Chiles JA, Von Cleve E, Jemelka RP, Trupin EW: Substance abuse and psychiatric disorders in prison inmates, in Dual Diagnosis of Mental Illness and Substance Abuse: Collected Articles from H&C. Washington, DC, American Psychiatric Press, 1993; 57-59 17. Prout C, Ross RN Care and Punishment: The Dilemmas of Prison Medicine. Pittsburgh, University of Pittsburgh Press, 1988 18. Culiner T: Is treatment of inmates with MPD possible in prison? A debate: The positive side of the question. Paper presented at the ISSMP&D Fourth Annual Spring Conference, Vancouver, BC, Canada, 1994 19. Allison RB: Is treatment of inmates with MPD possible in prison? A debate: The negative side of the question. Paper presented at the ISSMP&D Fourth Annual Spring Conference, Vancouver, BC, Canada, 1994 20. Allison RB, Schwarz T: Minds in Many Pieces. New York, Rawson/Wade, 1980 21. Allison RB: Multiple personality and criminal behavior. American Journal of Forensic Psychiatry 1981;2:1:32-38 22. Allison RB: The multiple personality defendant in court. American Journal of Forensic Psychiatry 1982;3:4:181-192 23. Allison RB: Managing the multiple in prison. Paper presented at the First International Conference on Multiple Personality & Dissociation, Chicago, Illinois, 1984 24. Allison RB: Maybe multiples in courts and corrections. Paper presented at the annual meeting of the American Academy of Psychiatry and the Law, Ottawa, Ontario, Canada, 1987 25. Hogshire J: You are going to prison. Port Townsend, Washington, Loompanics Unlimited, 1994 26. Anderson DJ: Orientation Manual, San Luis Obispo, CA, California Men's Colony, 1988 27. Mailes RM: Life behind bars: memoirs of a California prison guard. The Californians, July - August, 1987; 43-50 28. Manning N: The Therapeutic Community: Charisma and Routinisation. London, Routledge, 1989 29. Schulte J: Personal communication, 1994 30. Roth LH: Correctional psychiatry, in Modern Legal Medicine, Psychiatry, and Forensic Science. Edited by Curan WJ, McGarry AL, Petty CS. Philadelphia, F. A. Davis, 1989;676-719 31. Hinshelwood R: Locked in role: A psychotherapist within the social defence system of a prison. Journal of Forensic Psychiatry 1993; 4:3:427-440 

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