MAYBE MULTIPLES IN COURTS AND CORRECTIONS by Ralph B. Allison,M.D. California Mens Colony San Luis Obispo, California Presented at the Meeting of the American Academy of Psychiatry and the Law in Ottawa, Ontario, Canada October 15-18, 1987 Experience Outside Prison I For 16 years, I practiced psychotherapy in a private practice setting and in county mental health clinics in California, while doing forensic evaluations for courts and attorneys. In 1972, I met my first patient with Multiple Personality Disorder (MPD). This led to a decade of teaching, writing and consulting on that subject. During that decade, I conducted forensic evaluations of 13 men and women in whom there was a possibility that they were multiple. Of that group 69% (N=9) went to prison, 15% (N=2) were found not guilty of the crimes charged, 8% (N=l) were found not guilty by reason of insanity (NGI) and sent to a state hospital and 8% (N=1) were put on probation. I was able to follow the courses of three of the men who went to prison The insane one was followed for 2 years, when he returned to the community, subsequently becoming a subject for the "60 Minutes" program with Mike Wallace. Naturally, the primary concerns in evaluating these defendants prior to trial has been to determine the answers to the following questions: 1. Did they have a mental illness at all, or were they malingering? 2. Was the mental illness MPD or something else, such as schizophrenia? 3. Was the mental illness related to the criminal offense so that an insanity plea could be logicallv supported? 4. If I thought the defendant had MPD, how could I demonstrate the data supporting this opinion to the judge and jury so they would understand the reasons behind my opinion? In the majority of these cases, opinions and feelings about amenability to treatment were set aside, since ultimate disposition would be up to the judge and jury. In the only case where the defendant was found NGI and sent to a state hospital, two of us psychiatrists went to the hospital, oriented and educated the treatment staff on what needed to be done and conducted periodic re-examination of the patient until he was released as integrated and no longer dangerous. We felt he was eminently treatable, but not by the usual means used at the hospital for their most commonly admitted patients. II Experience Inside Prison For the past six years, I have been treating patients in a medium security prison in Central California which is assigned the responsibility for housing most of the State's inmates who have a documented history of major mental illnesses but who are able to function as outpatients. My case load has been approximately 400 inmates, whom I saw in 10 sick calls a week. When I came to work behind bars, I had seen a number of multiples, 85% of them women and 15% men. Among those seen only for court actions, the ratio was reversed. Therefore, I expected to be able to find quite a few male multiples in the prison. I also hoped to find out what could be done with them after my forensic colleagues had finished their work and the juries had found them sane and guilty. Such has not been the case. Since I do not have statistical information regarding those patients I have seen in prison whom may have been dissociators or multiples, I can only give you my rough impressions. Very few of those with solid histories of dissociation had entered pleas of NGI, so psychiatric evaluations were non-existent prior to conviction. They had amnesia for the crimes but were clearly responsible for the charged deed. They were so shocked at what they had done, they pled guilty and offered no excuses. It was only when I saw them at routine intake interview in prison that the story came out which could support a long standing history of MPD. They were not trying to escape punishment, but they certainly wanted to know why they did the deed charged, so they would never do it again. only one inmate admitted that he totally fabricated a story of MPD on the advice of his attorney. Obviously, no one bought it. While I was in private practice, I treated a male multiple who had spend most of the prior 20 years in one prison or another. While there, he kept waking up in the prison hospital after being in fights for which he had no memory. He knew he had done wrong and that he had some sort of serious mental disorder. When I asked him why he had never asked for psychiatric treatment, he said, "Doc, in prison there are two kinds of psychiatrists. The good ones are too busy with paperwork to treat patients. I wouldn't waste my time with the others." With this comment in mind, I attempted to keep the paperwork under control while I spent the majority of my time seeing patients. As a result of the marked limitations inherent within the system, I have only been able to treat one male multiple in the standard fashion. He was convicted of bank robbery committed by his alter-personality, which he had created in the image of his father, a Mafia Don in Chicago. He had vowed never to be like his father, so he became a Casper Milquetoast with hoodlum alterpersonalities. Therapy consisted of teaching him to be more assertive in everyday life, so his alter-personalities didn't have reason to come out and avenge him after someone walked all over him and his rights. This approach worked well, and he paroled in an assertive but not aggressive state of mind without any longer suffering blackouts during which he intimidated others. Another inmate I saw was one whom I had examined 10 years before for an arson charge. He then spent two years in California Youth Authority, and subsequently committed two murders while intoxicated on alcohol and drugs. I had seen what appeared to be an evil alter-personality during his days on parole, but he would not let me testify at his trial because of the fear I would reveal that he was also a voyeur. That would have embarrassed him too much! He went to Death Row where he had a psychotic break. His term was commuted to life, and I saw him when he came to my prison on a routine transfer. I went over his history with him trying to understand what I had seen 10 years before. He saw himself Primarily as an alcoholic. He had not dissociated in prison, although he may have done so while in CYA. He left our prison after trying to escape and then putting out a contract on the life of the inmate who had snitched on him. At that point, the best diagnosis was Borderline Personality Disorder. Another inmate was seen two years after conviction of murder so I could write "the rest of the story." At the trial he showed a very evil alter-personality who had killed his stepdaughter. I wanted to find out if I had been led astray or if the same entities were still present in the prison environment. We spent the visit in a wire cage in the visiting room at San Quentin. With the exception of one entity, a highly religious one, all of those I had met in the county jail during the trial were still there. The "Nice Guy" who would't hurt a flea was clearly the favorite of the guards, who greeted him warmly when he came to the visiting area. The "Killer" was still involved in all the prison games such as drug smugglinq and gambling, as he had been on the outside. The "Tattletale" who had informed me of the gory details of the murder was working with his public defender on his appeal of the death sentence. Each entity had a necessary role to play in his prison life. Any psychotherapy would have seemed to be contrary to his own best interest in that environment. III Institutional Interferences with Treatment When I started working in prison, I was encouraged to see some inmates for traditional psychotherapy in individual hourly sessions one to four times a month. The next year, the Department of Corrections instituted a Work Incentive Program which paid inmates in work or school assignments with day-for-day credit on their terms. Work supervisors were literally threatened with prison themselves it they let inmates leave the work site to get medical attention. This forced doctors into working evening so inmates could be seen after leaving the shoe factory and before the evening lock up time. For some workers, that meant 40 minutes was available for all sick call. This effectively wiped out a large part of our organized psychotherapy program and it has not yet recovered. It did totally block my ability to schedule patients when I was mentally fresh enough to deal with them. At that time, I was transferred to a quad where the population is made of up mostly chronic patients with major mental illnesses. Some inmates came through with histories highly suggestive of MPD, but I was too busy with triage of acute and chronic psychotics to follow up on their cases. Fortunately. I usually had one or two second year psycholoqy interns working with me, and I could refer these "teaching cases" to them for evaluation and treatment. But that is not the some as working up .a problem patient by myself. Another problem is that violent behavior by an inmate beyond a certain point administratively leads to his transfer to an institution with a higher security level and out of psychotherapy of any kind. Also, for a doctor to talk to any inmate in a total lockup situation awaiting such a transfer requires the presence of two correctional officers wearing body armor. They have many things to do besides stand there and listen to the doctor talk to the inmate, so the doctor does not feel free to spend an hour at the door of the patient's cell. Likewise, the custody staff are not allowed to leave the inmate/patient in the doctor's office without the same two officers present in the room. This can be inhibiting for both the patient and doctor. I saw one young inmate, who clearly manifested alterpersonalities, while he was in the Disciplinary Detention Unit (DDU) because he had stomped on the head of another inmate. No matter what I might do therapeutically to calm down the personality who did the stomping, that behavior was all the Warden needed to send him to a higher security prison. He did go, and there the psychiatrist deemed him perfectly normal, in spite of my exhaustive workup. He was sent to a general population prison, where he did well because his most antisocial personality was in charge most of the time. On parole, he played football for his junior college. But his football player personality became irate when the coach would not let him play in games where big league scouts were known to be in attendance. The coach had good reason, since, in practice, another personality who didn't know the Plays often took over. He stormed out of the coach's office in anger, blacked out, leaving an antisocial personality in charge. This personality robbed five banks before being caught. The capture occurred because a new personality came out while leaving the last bank and didn't know why he was carrying money bags down the street being chased by shooting officers. He hid under a car instead of running to the getaway vehicle. At his arraignment in Federal Court, an attention getting personality came out, dropped his pants, urinated on the floor of the courtroom, barked like a dog and meowed like a cat. The judge wisely suggested to the defense attorney that his client might have a mental problem. The attorney asked him if he had ever been treated by a psychiatrist and he give my name. I was appointed to examine him for the court in Federal prison, which I did, finding much the same clinical picture as I had found in State Prison. He was found sane and guilty and sentenced to Federal Prison for 12 years. A psychology intern there called me to report that he created chaos there and was sent to the Federal Prison Hospital but was sent him back as a malingerer. By this time the inmate was giving the story that he had studied drama in college and thus had learned how to play all these Parts. You can see how such an inmate can tie up many parts of the criminal justice system. We have much more to hear from this young man, I am sure, when he paroles the next time. IV A New Breed of Dissociators? After dealing with a number of neurotic patients with MPD who did not go to prison, some who went to prison for non-lethal felonies and those seen because of murder charges, I am coming to the conviction that the neurotic ones may commit various and sundry crimes while acting out their internal conflicts, but they are highly unlikely to murder anyone. The only exception might be when the victim has previously tried to kill the multiple. But the murderers I have seen who had a documented and reliable history of manifesting some type of alter-personality have a number of unique factors not seen in the neurotic, non-killer multiples. These differences are not included in the DSM-III-R definition of MPD, which does, superficially, describe the murderer accurately as well as the neurotic multiples I have treated. The definition is as follows: "1. The existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). 2. At least two of these personalities or personality states recurrently take full control of the person's behavior." These are the unique characteristics which I have found in murdering men who also met the above definition of MPD: 1. Origin of criminal entity: Whereas angry alterpersonalities most frequently develop during the course of overwhelming physical and/or emotional abuse by a parental figure, a more frequent story in the murderers is this: The little boy is locked in the closet by a hated boyfriend of his mother while the boyfriend is sexually molesting the boy's sisters. He can't do anything to protect his sisters, and he asks in his head how he can kill the boyfriend. A voice answers, "I will help you." That voice is the first appearance of the criminal entity. 2. Relationship between the primary personality and the criminal entity: Instead of the usual massive one-way amnesia between the two entities, with the primary personality having little or no direct awareness of the angry alter-personality, as is usual in the neurotic multiples, in the murderers there is an ongoing communicative relationship between the two entities. it might be a teacher-student relationship as in the man whose criminal entity spent many hours teaching the primary personality the principles of the Cabalistic religion (whatever that might be), to the point that the primary personality listed that name in the "Religion" box on his arrest and booking sheets. 3. First Psychiatric Examination for Court: When first examined for possibility of MPD, most neurotic patients do not know how to make contact with the negative alter-personality which may force its way out against the will of the primary personality sometime during the interview. They have no first hand knowledge of the alter-personality and do not believe anyone who tells them that such a thing exists. The killers have been able to go inside their heads and easily locate the criminal entity with no trouble at all. If I tell one, "I'd like to meet the Joe you told me about," he says, "Sure, I'll go get him." In a few seconds, the face and body posture changes, and Joe is in charge, telling you whatever he is willing to divulge of his criminal career. Such facility in the ability to change personalities comes about in neurotic multiples only after months of hypnotherapy during which they get practice at locating the alter-personalities and learning how to open the door to consciousness. 4. The Killer's Victim: I have had only one neurotic multiple who may have killed someone and that was unproven. She remembered killing her stepfather and his two friends after they had attempted to kill her. Bodies were never found, so I don't know if her memory was truth or fantasy. The killers I have seen for trial killed persons who were not objects of revenge. One mentioned before killed his seven year old stepdaughter, and one killed the driver of a car in which he had hitched a ride. Such senseless and irrational choices of victims make these defendants very unsympathetic to juries. 5. Psychological Testing by Rorschach: There is a pattern of responses to the Rorschach test which seems to be typical of neurotic multiples, which has been described by Wagner & Heise(1974). These killers do not show that same pattern of response, but show a pattern which Wagner considers more consistent with schizophrenia. 6. Criminal History of the Antisocial Entity: In neurotic multiples, there are often alter-personalities who do isolated illegal acts, when the primary Personality gets angry and loses control of the body. But they don't seem to have the ability to maintain a complex criminal lifestyle over a long span of time. But in the killers, there has been a documented criminal history of the type that required recurrent association with the criminal subculture, with gun smuggling, narcotic trafficking, arrests, court appearances, jail time, etc., all managed by the criminal entity. These acts may have been completely hidden from the Primary personality who is convinced he has a clean record. These acts were not done to embarrass the primary personality, when he wakes up in jail, as is the common case in neurotic multiples. The criminal entity is perfectly willing to undergo the punishment of the criminal justice system and not inflict it upon the passive primary personality. V Conclusions With this paper I have tried to mention some of the important factors that seem to exist when a "maybe multiple" man comes to prison. I have covered the problems of identifying and working up such patients in a busy prison practice and the institutional problems of giving minimal treatment. The problems of security and placement in other institutions has been mentioned. Lastly, I have tried to provide a thought provoker for those of you who do frequent forensic evaluations of murderers. There may be a group of maybe multiple murderers who have bona fide histories of long standing dissociation, and who may need to be given a new cubbyhole in DSM IV due to significant differences in the clinical and dynamic characteristics they demonstrate. REFERENCE Wagner, E.E., & Heise, M. A comparison of Rorschach records of three multiple personalities. Journal of Personality Assessment, 1974, 38, 308-331. 14