Is Treatment of Inmates with MPD Possible in Prison? A Debate The Negative Side of the Question by Ralph B. Allison, M.D. Presented at the 1994 ISSMP&D Fourth Annual Spring Conference Vancouver British Columbia Canada May 6, 1994 (c)1994 Ralph B. Allison, M.D. We are here today to debate the possibility and wisdom of doing psychotherapy with a prison inmate known to have MPD. After spending 12 years treating inmates in a California medium security prison called California Men's Colony, which specialized in providing a therapeutic atmosphere, I propose that such an effort is not only impossible, it may even unwise to try. Why do I say this? Who were my patients? They were males, of all races, whom judges and juries decided must be dissociated from the rest of society because they were the evil forces that must be separated and repressed to allow the rest of society to function better. They committed such crimes as bank robber, child molestation, murder, and auto theft. No crime can be excluded as a possibility. On arrest, these men were deprived of their manhood, which included their ability to work at their jobs, legal and illegal, to drink liquor, to take drugs, to sleep with their women, to beat up their enemies, or to ride their bikes. They were placed in a position of dependency upon THE MAN, their name for their jailer. Where were they living? Each was assigned to a small room with a toilet, two shelves, a counter and two beds, and a cellmate, in a concrete building with steel doors and barred windows. There were 50 cells to a wing with other ill tempered inmates who were observed night and day by one high school educated guard. His job was to order them to do as he wishes, to maintain control over all aspects of their lives. They ate all meals in a cafeteria under the watchful eyes of guards. They worked or went to school, under the watchful eyes of teachers, supervisors and guards. At any time, they might be ordered up against the wall for a clothed body search by a guard. If any inmate objected, he would be handcuffed and taken to the Administrative Segregation section, the jail within the jail, for further isolation housing and a hearing leading to punishment for disobeying orders. During my first year there, I met my first inmate multiple, Billy Blue, when he was put in Ad. Seg. because he stomped on the head of his cellmate. Because of depression, he was moved down the hall from Ad Seg to our then Psychiatric ward, which consisted of single, bare cells, each with a toilet and a bed. Since I had a light patient load in those days, I spent as much time as possible with him, talking with him in his cell. There was no interview room in the area. The guard assigned to the hospital was always standing just outside his door while I was there. Only later did I learn that the warden's rules were that anytime a doctor or nurse was with a patient in that section, a guard would be there also, for his/her protection. Therefore I innocently took up a guard's time for an hour at a time while I talked to Billy Blue. The guards didn't complain then, but, after the prison was more crowded, I was told that such extended visits to Ad. Seg. inmates was too time consuming for guards who had many other duties to perform that shift. I was then expected to conduct my business by standing out in the hallway and talking to subsequent inmates through the food slot in the steel door. Naturally, everyone, including all the other inmates, could hear every word we said. After release from Ad Seg, one of Billy Blue's alter-personalities told me, in sick call, that he had killed a dozen motorists by shooting at freeways from hillsides. According to Title 15, the prison manual, I was obligated to report this "confession" to the Security Squad Lieutenant, who passed it on to a Central Office staff which did nothing but check out confessions of inmates to see what other crimes they had not been caught for. They found no missing motorists or unaccounted bodies in any of the counties where Billy Blue had been known to have lived or visited. Since I was the one person on the staff who had had prior dealings with a multiple, I did figure out who was who and who did what. The primary criminal personality wanted to get away from me so that I could not do therapy with them, as the ambivalent alters were beginning to like me and wanted to switch allegiances and join the "good guys." Therefore the chief villain told the guards that he was lying to me and faking all of this to fool me. This made the guards suspicious of my diagnosis, as Billy Blue tried hard to split the delicate bond between me and the custodial staff. He was hoping to avoid being labeled a psychiatric case so he would be transferred to a tougher prison where he could be with inmates of his like nature. He half succeeded. He was declared a problem psychiatric case, and transferred to another prison which had more security, and some psychiatrists. None of them knew anything about multiples, though, and they declared him mentally healthy, in spite of my reports. He was then sent to a general population prison, from which he paroled in another month. A few months later he robbed five banks in Los Angeles, and was captured in a gun fight. When he acted peculiar in court, he was asked if he had ever seen a psychiatrist. He told them that I was his psychiatrist. I was then appointed by the court to do an evaluation, which I did in the federal penitentiary in Long Beach. He still had the same alters he had had when I first met him plus a new one he had created shortly before the bank robberies. It was that new alter who was caught when he found himself running from police while toting a bag of money. He dived under a car, having no idea where the money had come from. He was convicted of five bank robbery charges and sentenced to prison for 12 years. I next heard from a psychologist at the Lompoc Federal Penitentiary that he was acting up there. After several transfers, he was paroled from a maximum security prison in Pennsylvania in 1933. Two months later, he robbed a bank in Palm Springs, and again, when caught, told them I was his psychiatrist. The last I heard, he was again awaiting trial in the federal prison in Long Beach. Since most of those with MPD have a history of serious abuse by parental figures, how do these men fare in prison?. In prison, all staff members are authority figures who can bring all necessary power of the state down upon them, deserved or not. Some guards are mature enough to avoid using this power for the sake of using it, but many will use it to prove the point that no inmate is going to push this officer around. Keeping their jobs depends on their being able to keep their inmates under control. What is the goal of therapy of the multiple? According to the our Committee on Standards of Practice, it is "an increased sense of connectedness or relatedness among the different alternate personalities." Is that wise in prison, however? Here is a true example to consider. I visited an inmate on San Quentin's Death Row two years after I evaluated him for the defense during his trial for murder by torture. In jail he had shown four alters: the nice quiet fellow who didn't know what was going on, the killer of his nine year old stepdaughter, the killer's junior accomplice turned snitch, and an weak angelic rescuer who only worked on Sundays. On Death Row, I interviewed them again. The rescuer was absent; the nice guy was the favorite of the guards, as I could tell by their greetings to him; the killer was very popular with the other inmates as he was smuggling drugs to them (a trade he also conducted before arrest); and the snitch was working with his attorney on their appeal. If anyone had been able to integrate all of these entities into one person, I doubt if he could have survived prison life, where all those roles would have had to be managed by him "alone." In his state of ill mental health, he kept happy all of the important people in his life . Who would have been his therapist on Death Row, anyway? One of my private male outpatients had spent over 20 years of his life in various prisons all the while knowing he had a major problem with amnesia. I asked him why he never asked for therapy from any of the prison-hired psychiatrists. His answer was, "Doc, in prison there are two types of shrinks. The good ones soon get promoted and spend all their time doing paperwork. I didn't want to have anything to do with the others." After spending a decade on a prison psychiatric staff, I have to agree with him, for the most part. There is no fame or fortune in being a good psychotherapist in prison. Under what conditions do we psychiatrists work in prison? If we are lucky, we have our own office, but that is not guaranteed, as office space is at a premium, with so many staff members being required for supervision, counselling, medical service, clerical work, etc. The window blinds must always be open, so that any guard who walks by can see inside. That is for the security of the staff member inside. I never knew when an inmate might take offense and assault me. I was lucky, and I always sat behind a large desk, for my protection, and sat the patient near the door, so he could get out quickly if I ordered him to. Occasionally, I had to phone the sergeant down the hall to come in and escort the man out, if he refused to obey my order to leave. Even that arrangement was contrary to custody advice, which was to sit between the inmate and the door, so that the inmate could not block my escape out the door. Psychotherapy requires that the therapist expects the patient to tell the truth. During the orientation given my first week on the job, the instructor told us, "Don't believe a thing any inmate tells you. Always check it out with another staff member before taking action on it." How could I match that warning, given in all sincerity, with my stance of trusting patients to tell me the truth, a stance that had served me well for two decades? Checking out stories might require violating confidentiality of the therapist-patient relationship. Would I do that? You bet I would! If a patient told me anything that made me feel I should take an action, such as writing a note that would go into his central file, I asked his correctional counselor or floor officer if they knew about this issue. Usually the inmate had told one or both of these custody staff members about the very same thing, as it was something he was trying to get someone to do as a favor for him. The floor officer could be very informative as to the inmate's usual mood, his behavior with other inmates, his homosexual partners, his work performance, etc. The counselor knew about his family situation and his history. At the very least, I would read the inmate's central file in the record room before doing anything, to check out the background of the matter. There I would frequently find evidence of misbehavior that staff members had recorded, but which the inmate would never reveal to me if he could avoid it. In the description of standards of practice, one to two individual sessions a week are recommended. In my last assignment, I once had overall responsibility for over 500 mentally ill inmates. I had to run military style sick calls, with visits averaging 7 minutes apiece, twice a day. I could see stable patients once every three months. In addition, I had to attend mandatory staff meetings, handle phone calls, dictate reports, proofread and sign dictation, and respond to any crisis which was called an emergency by the sergeant. Just where was I supposed to find time to see one patient for 2 hours a week, on a regular basis? Even if I made the time, that inmate would then become something special, in his eyes and in the eyes of his friends in blue Levis. He could well be pressured to ask me for favors for his friends, as the patient spent so much time with me compared to any other inmate. I could not forget that, once any inmate left my office, he was back with his buddies, all of whom wanted to know how to read me so as to get something they wanted but were sure I wouldn't give them if they were straight with me. Who was paying me to do all this work, the inmate or the prison administrator? The administrator, of course. The administrator therefore had the right to tell me how to use the time he was paying for, and individual therapy was not one of the things that he was paying me to do. Half of my working day was spent on sick call, but the other half was spent reviewing central files and conducting interviews of inmates so that I could write reports the prison administrator considered necessary in running the prison. I had deadlines to meet for writing reports to committing judges, to the Board of Prison Terms, and to prison committees. My opinion might be the crucial one in deciding if a patient stayed at CMC, otherwise known as the Country Club, or was sent to a prison known for its shootings by guards to stop stabbings by inmate gang members. This, then, gets into the issue of boundary violation. At the last ISSMP&D meeting, there was a great deal of talk about the need to avoid violating boundaries with such patients. Yet, on the job I was being asked by the administrator to write official reports to custodial staff about any of my patients whom they asked about, since their jobs required that they know the health facts before making housing and transfer decisions. I would often conduct sick call and then spend the rest of the morning with the classification committee which was reviewing my patients' cases for disciplinary actions and possible transfer. I also had to write a yearly report on each of patients for this board, so I was often found it wise to be there to clarify anything in the report they didn't understand. This was helpful to me, too, as I saw a different side of the inmate, the one he put on for the administrators. In recent years there has been a great increase in hospital units specializing in dissociative disorders. In prison, where was my suicidal MPD patient hospitalized? The "hospital" unit was one 50 cell wing of a housing building, where a dozen cells had been prepared for suicidal watch patients by stripping them of all shelves, light fixtures or other parts that someone could use to hurt themselves. Being on suicidal watch meant the patients were kept in that cell 24 hours a day, with no clothes on, having only a "strong blanket" for cover. The psychiatrist in charge of that section would usually keep the man there until he/she felt the man could be safely released back to my section. That was usually only overnight, since he quickly got the message that we did not reward suicidal threats with special favors, such as a plush hospital bed and pretty female nurses. Of course, there was a long, drawn-out procedure I could use to transfer him to the nearby state hospital for the criminally insane, where over half the population is from the prison system. But when I tried that several times, the patients were declared malingerers and sent back to prison as soon as the admission service doctor could arrange it. These were patients that everyone in the prison agreed were multiple, but the hospital admissions psychiatrist knew we must be fools for believing in such a farce as MPD. Only one of my multiples was allowed to stay at that hospital, and that was because he was relabeled a drug and alcohol abuser, which he was, and they kept him in a ward for substance abusers. He was fortunate enough to be assigned to a ward psychiatrist who did appropriate therapy with him, and after five years he returned to prison an integrated inmate. But that psychiatrist is no longer working there. The rumor I heard was that his therapeutic approach was too unorthodox for the rest of the staff. Beyond these more obvious reasons, there is the question of what is prison for? When my patients complained how unhappy they were because they were locked up, my usual response was, "Good, that is exactly why the governor built this place this way! Now what else do you want to talk about?" Since the whole atmosphere was deliberately created and maintained to punish inmates by dissociation and repression of them, how was I, through psychotherapy, supposed to get them to stop using those same mechanisms that had served them so well for so long? My best advice might often be for them to line up a competent therapist at home and then behave well enough to stay there on parole. 

  Copyright© 2018 - Ralph B. Allison