I Never Thought I'd End Up In Prison!

H. Steven Moffic, M.D. (smoffic@mcw.edu)

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I’m not talking about being an inmate in prison. This has not happened to me yet and hopefully never will. I mean that I had never worked in prison, or even set foot into one, until three years ago.

Sure, I had some outpatients who had been in jail or prison and had wondered about the overlap of psychology and criminology. But I had generally ended up focusing on the psychiatric symptoms, such as mania or command auditory hallucinations, that may have had something important to do with the patient getting into trouble. “The voices made me do it, doc”. Or, “I felt so good and thought I could do anything”. If the antipsychotic medication helped the patient to no longer hear voices in his head or to not hurt someone else, I felt that I had done my job. Other than alcohol and substance abuse, I didn’t think much of other explanations for crime or what some may call “evil.”

Nor did I ever have any particular education on criminal behavior and psychiatry. When I obtained my MD from Yale back in 1971, I did not have any exposure or experience with being a physician in a jail or prison. We did not have that kind of rotation for medical students, and there were not any lectures on the topic. Criminology only interested me in the sense of staying out of the neighborhoods surrounding the medical school, which I had been warned were dangerous.


The Evidence

After I finished medical school, whatever I heard about prison psychiatry was not very positive. I had the impression that it was a setting where poor psychiatrists did poor (and dangerous) work. I thought that perhaps Yale had ignored this kind of setting due to anticipating that no Yale medical school graduate would be interested in working there. However, knowing that the "Yale system" (without tests or grades) encouraged independent thinking, there probably wouldn’t be any surprise if some graduates became interested in crime over time.

Therefore, when I was given the “opportunity,” as it was deemed, to work part-time in a medium-security prison a few years ago, I very much hesitated but also felt a slight tinge of intrigue. After all, I had worked in, or led, virtually every other kind of psychiatric setting over the years and wrote scholarly articles on the experiences, so what was I afraid of?

Trying to become up-to-date, research and contemplation revealed that some of my perspectives were out-of-date. I leared that thanks to federal lawsuits, prisoners were the only citizens in the USA that had a right to healthcare. Other lawsuits greatly enhanced the provision of mental health services in the prisons of some states. In our Wisconsin state system, two of the psychiatrists were former successful Chairs of Departments of Psychiatry in major medical schools. In a reversal of reimbursement outside of prison, I was told that psychiatric services were free, while routine general healthcare required a small but significant fee-for-serve. I thought this was appropriate from a clinical standpoint, given that half of prison populations were found to have a significant psychiatric disorder and that medical complaints were often exaggerated for secondary gain, such as medication distribution. I also found out that the percentage of people in prisons in the USA had been escalating - most especially for young African-American males - so that we now had the highest rate of known incarceration in the world.

A former exemplary and compassionate student of mine highly recommended I join him in the prison. He said that it might be one of the best places to practice psychiatry nowadays, especially given cuts in the public sector due to politics and the economic recession. He also told me that my hourly reimbursement would not bad at all. I found myself more interested but still wary and asked if there was anything like what I had been hearing about the California prisons, where prisoners were housed in make-shift beds in a gym, and patients were put in cages for their group psychotherapy sessions?

Though I was assured that Wisconsin was not California, I decided that I had to make a visit to decide. Unfortunately, the first impression turned out to not be too impressive. As I approached the medium-security prison in a beautiful  spring countryside where the vegetation was just beginning to green, the prison started to emerge. At first, it looked like the boys residential school that it once was. Then, the barb-wired fence that came into view instantly reminded me of the Teresenstadt concentration camp. After the gate clicked closed after my security check, the rest of my visit was in a state of partial mental dissociation. That night, I had nightmares of being in some sort of Holocaust. I hadn’t been this fearful since the night before my surgery rotation in medical school.

 I had gotten through the surgery rotation way back then, and while not very skilled myself, came to appreciate the skills of surgeons. That sort of flashback helped to reassure me that this reaction to the prison was at least partially irrational. And the psychiatrist I was to replace said that there would be more danger to me from a deer on the country road I would be taking to arrive on site.

Around that time, in order to make the best use of brief sessions with patients, I had been asking them what gave their life the most meaning and to see how treatment could fit that. That perhaps led me to also think of one of the psychiatrists I most admired, Viktor Frankl. He had found meaning in life even while in a Nazi concentration camp and lived to write about that in his renowned book, Man’s Search For Meaning, and to develop a related treatment, Logotherapy. If he could survive and even thrive in some way in a concentration camp, surely I could try a prison.


The Sentence

All of this new evidence and emotional processing turned out to be more than I could put aside, and I decided to begin. Soon, I was to wonder whether all my basic medical training left me feeling a bit like Alice in Wonderland. For instance, in medical school and most of the time thereafter, I was taught to trust the patient (to tell me what was wrong). Here, I was told to take what the patient said with many grains of salt as they may try to manipulate me for abusable or divertible medications. Apparently to help us naïve new physicians out, and going well beyond any managed care system that I knew, the chief psychiatrist made any such medication to only be authorized under special circumstances. These medications not only included routine benzodiazepines for anxiety and stimulants for attention deficit disorder (ADD) but even the antipsychotic Seroquel. I had been using Seroquel quite a bit outside of prison, so I was surprised to learn how often it was abused and sold outside of prison for its desired “high.” The company drug rep had never mentioned this use of Seroquel!

Then I was told by administration to not shake hands with these male prisoners. If I did, they might suddenly twist my arm behind my back. How then, I wondered, to make up for this lack of male-to-male nonverbal bonding interaction? I assumed this warning included no “high-five” hand slaps. I was also told not to wear a tie for it might be used to strangle me. Really! I was always taught to dress like a professional physician, and even though we psychiatrists tended not to wear a white coat, here I was being told to dress down in casual attire.


The Rehabilitation

My predecessor had diagnosed most of his patients as sociopaths, a diagnosis I had rarely used outside of prison. He focused mainly on their sleeping patterns. Was this practically wise, I wondered at first, or was it an avoidance of more complicated issues?

 After I had worked for some time in this prison, I began to learn that some of these practices may be unnecessary. Now, three years later, I still don’t wear a tie because I am more comfortable without it. However, I did decide to wear a shirt and pants of similar color to what the inmates wear. The clinic secretary asked me about why I did so and wondered if it was to convey some special nonverbal meaning. Yes, I answered, that I hoped such attire provided some identification and modeling  with me, even if it was unconscious. For the Correctional Officers, I had a staff badge so they wouldn’t mistake me for an inmate. I do shake hands with some patients, especially those who extend their hand in a show of what seems like gratitude. I never show such friendliness in front of the guards, aka Correctional Officers, for they seem to feel like we psychiatrists are “too soft” on the prisoners.

Sometimes, I wonder whether these guards are right or not. This prison has been uncommonly devoid of violent incidents. Alternatively, some patients complain that guards are too sadistic and that things are too strict in the prison. One of the psychology staff complained about some of the guards and was summarily let go. As I was told before I came, security comes first here, over patient care. I accepted that because even on the outside, a goal like saving and making money by private managed care companies did not preclude being able to provide some help.

Recently, I was stopped short in my secure tracks by finding out that in another Wisconsin prison, a chaplain was held as a hostage for several days. Prisoners were able to use him to get to controlled opiates, which they had complained weren’t being prescribed enough for their alleged pain by the primary care docs. Eventually, he was released safely, but the incident has not yet been adequately processed to date. A note from the Chief Psychiatrist said: “I am planning to find a speaker who can effectively talk with us about security issues, including how to behave (and hopefully survive) a hostage situation.” Hopefully survive?! My sleep has been disrupted again by nightmares.

Clinically, this experience has been somewhat of a revelation for me, even after all my years of experience. Providers work together in a multidisciplinary clinic in one building. Primary care physicians do not prescribe any psychiatric medications, unless they are for a medical reason like pain, and they seem to like that. Nor do I prescribe any other “medical” medications, and I like that. More importantly, I think we thereby provide better quality of care because we strictly stay within our areas of expertise.

For me, the experience has also necessitated expanding my knowledge of sleep medications, both because there are so many complaints about sleep and, in reality, it is more noisy and frightening for the inmates. Now, I could appreciate better why my predecessor focused so much on sleep. Then, since we can’t provide certain sleep medications like Ambien, I’ve had to become more familiar with higher doses of Benadryl and trazadone, as well as trying prazosin for nightmares. I’ve resumed using older generic antidepressants like the tricyclics, and antianxiety medication like hydroxyzine, because they are cheaper, as well as being safer for overdose in prison since patients can’t accumulate them readily. They seem to work pretty well for the most part.

Diagnostically, if one looks below the surface and trust is gained, a history of early trauma (often verifiable through criminal records) emerges. Posttraumatic Stress Disorder often supplements – or supplants – Sociopathic Personality Disorder as the primary diagnosis in my assessments. Sure, I’m fooled at times, probably more than I realize, but then again that also happens outside of prison. Actually, I think it happens less to me outside of prison now that I am more sensitized to the possibility.

We seem to stay on top of new research faster than in my academic setting. Citalopram above 40 mg (and above 20 mg if also on Proton Pump Inhibitors) was quickly banned in our prison recently when the FDA conveyed its cardiac risks and accompanying admonition.

The most perplexing part of this experience remains the question of evil. I had not thought about evil much in my practice nor in my life, but here it seemed unavoidable. What about patients who committed horribly destructive acts all alone, did not seem to have a diagnosable mental illness that would explain this behavior, were not religious, and predicted they would do the same thing again once they got out? One patient in particular encompassed this question and so many of the unusual challenges that I’ve encountered.


Of An Inmate

In my fifth session with this charming 24 year old Caucasian male, disguised for the purpose of this report, he matter-of-factly stated: “I just threw him in the lake and expected him to die . . . My only regret is that he lived.”

His old records and my earlier sessions with him indicated a variety of diagnostic possibilities and an array of medication trials initiated by a number of clinicians. He admitted he hadn’t been very compliant with any of the treatment regimens. Mr. X wasn’t sure whether he wanted – or needed – medication.

As my chills subsided after that statement regarding his crime, and I automatically touched my neck to be sure I didn’t have a tie on, I moved closer to the door, ready to pick up the phone to alert security. He then told me that he was preoccupied with “necrophilic” thoughts. At first, he did not want to describe these thoughts in any detail. Over the next few weeks, he tried another trial of lithium and, for the first time, propanolol. He also saw a psychotherapist but decided that he didn’t want to explore his thoughts further because he “didn’t want to do anything to cause me to not feel like myself.” On the one hand, I was comfortable with this lack of progress. Leave well enough alone, I thought. On the other hand, the mention of “necrophilic” thoughts made me very uneasy. If there was something attractive to him about dead bodies, was he even more dangerous than I had supposed? So I came back to these thoughts and asked if they were any different without medication than with. He quickly brushed aside a direct answer and instead shared more about his fantasies. He told me he thought his crime was almost a fulfillment of a fantasy – that he was bound to hurt or kill someone. In contrast to so many other inmate patients, who felt they were innocent or sentenced too harshly, he was almost proud of what he had done. After a long pause, in his usual dramatic way, he told me he’d been at a party. All of a sudden, as if in a trance, he intervened in a quarrel. He described slugging a stranger, knocking him out, dragging him away, putting him in the trunk of his car, and then dumping him in the lake. Mr. X did not seem worried that he would do something like this again, but he was worried that he’d get into more trouble if he did.

I suggested that it might help me to understand him better if he shared more about his upbringing. He reported that his parents divorced when he was 3. He was raised by his mother, who had intercourse in the presence of all her children. Occasionally, she would beat him with a dog chain. He went to special education classes and had been in and out of psychiatric treatment since he was 6 years old. By the time he was 10, he was shooting birds and small animals and hiding them when they were killed. Later, for a while, self-cutting made him feel better because it reduced the unbearable tension he felt inside. Religion was of no help or interest. Mr. X was basically a loner.

What to do now? I consulted other prison psychiatrists, who advised me to proceed gingerly, lest I could be incorporated into his necrophilic tendencies. So, I did. But I was also almost desperate to help in some way. I decided to get detailed psychological testing for possible ADD, an area of some special interest and expertise for me, and it was confirmed. I prescribed Wellbutrin to see if it might at least dampen the impulsivity associated with ADD, and maybe also help a possible underlying depression. It did seem to help him a bit subjectively, and then to my relief, he was transferred to a different prison.


Back In Society

It should be apparent that there is much that I’ve learned that seems relevant to my psychiatric practice outside of prison and possibly relevant for many physicians. My experience has even helped me outside of direct clinical work. It now seems clear, and research confirms, that sociopathy is also quite common outside of jails and prisons, including Wall Street, other corporations, and even medical organizations. Commonly associated with crime is social support or fear, alcohol or substance abuse, a history of severe trauma in childhood, and extreme poverty. Beyond that, we all may have vulnerability for evil, whatever that may mean exactly, and we need to recognize and accept that in order to see it in others and still be empathetic. Prison psychiatry can be the utmost test to the best of medical values, as one needs to try to help those who have hurt others so badly.


“A Zen master, when asked where he would go after he died, replied, ‘To hell, for that’s where help is needed the most’.”-Rashi Philip Kapleau  


About the Author

  • Photo of authorH. Steven Moffic, M.D. is currently a tenured Professor of Psychiatry and Behavioral Medicine & Family and Community Psychiatry at the Medical College of Wisconsin. During his 40-year career in psychiatry, he has been dedicated to the underserved. Dr. Moffic is an award-winning academician, administrator, artist, clinician, and writer. He has just been appointed to the Group for the Advancement of Psychiatry (GAP), known as the "think tank" of psychiatry. He will be on the newly appointed Committee on Leadership and Administration. .

  • Published: January 28, 2012