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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.