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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

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