The Private Reflections Of A Prison Psychiatrist

• DOI: 10.1177/003288557405400203
• Author: Melvin S. Heller
• Published date: 01 October 1974
• Date: 01 October 1974
• Subject Matter: Articles

The Private Reflections Of A Prison
Psychiatrist
By Melvin S. Heller, MD.*
My impressions of prison work have stretched out over twenty
y ears. Prison medicine has been something I’ve done part time be-
cause I don’t think I could have handled it full-time. One would have
to be a combination of Albert Schweitzer and a supreme masochist
to spend twenty years in a prison if one didn’t have to. But that’s
just a personal opinion.
I think that one of the main problems is that prisons were
not originally set up to keep people for very long. Prisons are derived
from dungeons where people were kept at the king’s pleasure until
disposition was decided upon at the ruler’s leisure. The purpose of
keeping somebody alive in a dungeon in those days was simply so
that they would be able to appreciate a more excruciating punish-
ment if that turned out to be the king’s pleasure. So the prevention
of cheating the hangman was one of the unfortunate precursors of
prison medicine.
Another major problem is that prisons are a relatively recent
alternative to execution and exile. Many crimes today which receive
terms of two to five years were crimes punishable by death not
terribly long ago. So our attempt to cope with incarcerated prisoners
is one of our relatively newer follies.
We are all very ambivalent about prisoners: and I think
every one of us with any prison experience has doubts and disagree-
ments about what the goals and functions of prison experience
ought to be. There are those who very clearly are certain that the
function of a prison must be punishment and deterence, and the
more spectacular the punishment, the greater the deterence, they
say. There are others w ho say this is inhuman. They say that the
only purpose of a prison - if there is any at all -
should be rehabil-
itation. It should be a secure place in which people can find alterna-
tives to their previous ways of problem solving.
About the only honest function that a prison might serve. in
my experience, is the function of detention. It is a place where you
can hold people: and I suppose if you hold them under rather
human conditions they are less at to come out much more inhuman
than they went in. So much for some basics.
The problem of the physician who is interested in providing
services to prisoners begins with, &dquo;How come?&dquo; How come you want
* Dr. Heller is Director, Division of Forensic Psychiatry for the Commonwealth of
Pennsylvania, and also Clinical Professor of Psychiatry, Temple University Health
Sciences Center. This article is based on an informal talk at Norristown State
Hospital on March 29, 1974, Norristown, Pa.
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to go to a prison and provide services? I suppose the first thing you
have to ask yourself as a physician is, &dquo;Why do I want to do this
One could think of his motivation in terms of some altruistic
instinct, such as that of a medical missionary. Now medical mis-
sionaries were up to two things. They were providing a free medical
service, and also pushing a product. Medical missionaries were selling
something with what they gave away. They were selling a belief, a
religion. Thus, the function of the medical missionary was not
only to serve the prisoner or the so-called primitive population, but
to serve the prisoner’s sotti up to this person’s Almighty God. This
was really the basic function.
So, I would say- that anybody who goes into prison with
missionary zeal as his first motive ought to ask himself, &dquo;What am
I selling and why?&dquo;
Another motive for medical services in prison is *’Well, I can’t
t
do anything better and I need the money. A third motive is curios-
ity= ’I’d like to find out what’s going on in there.&dquo; A fourth motive
is to try to improve existing conditions. The rest of the motives, five,
six and seven, are probably neurotic, pertaining to combinations of
grandiosity, narcissism, maybe masochism and maybe a few others.
And I have probably been guilty of each and every one of these
motives to some extent. That is how I know them so well.
Let us then say that for a number of reasons, conscious and
otherwise, an individual physician who is well trained and qualified
decides to spend some time in a prison. If he goes into a prison full
time, he rapidly becomes dependent upon the institution unless he
is a person of independent means. If you make your money from
the system and you have loved-ones who are dependent on you-like
a wife, three or four children and perhaps an old mother-and the
warden or some other person tells you that you have got to do such
and such, you begin to think twice before you cut loose from the
economic and emotional benefits of going along with the system.
This is one of the problems of institutional work in every
aspect of the helping professions, including police work as a perti-
nent example. Most acute personal assistance is not provided by
welfare workers, physicians or psychiatrists but by the much-maligned
police, who along with allegedly clubbing people on the head and
doing other things, spend most of their time trying to solve inter-
personal problems. And many of them who go in with excellent
intentions then are quickly frustrated.
When the chips are down and all hell is breaking loose some-
where, people do not call a welfare worker, and they certainly do not
call a psychiatrist., because we rarely make night calls, and almost
never make street calls. Those who do are the police. That’s not a
pitch for the police: it’s just one of the things that must be recog-
nized about altruistic impulses that occur in almost all of us, and that
are very easily blunted no matter what our training may be. It is
hard to remain a truly altruistic policeman, and it is equally hard
to remain an altruistic prison psychiatrist.
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There are several levels of imprisonment for a physician in a
prison. One of the unique things about being a prison physician is
that you are locked in with your patients. You cannot walk away
from your mistakes. If you have made a mistake about your patient,
he is there to see you every day and every week, and you have to live
with your mistakes. If you are any kind of a good physician, you will
not only make mistakes, but you will recognize and admit your mis-
takes. The only physicians who feel they do not make mistakes are
those who cannot recognize their own errors of judgment, or who
no longer practice medicine with its enormous and inescapable
possibilities for error.
One of the reasons that more people do not die in prisons
from illnesses is that they are a generally healthy young population
being fed food that is calculated to sustain life, if not taste, indefin-
itely. If one pays a reasonable amount of attention to hygienic
conditions, the majority of prisoners should survive for a long time
and will probably out-live the best physicians who come to take care
of them. There are a few older people in prison. But most of the
medical illnesses you see are those which affect young people.
Let us talk for a moment about the problems of diagnosing
physical illnesses in a prison. Contrary to what you may have heard,
doctors could probably make 8U j’o of their diagnoses over the tele-
phone. Physicians do not like to do it, especially since the malprac-
tice liability is enormous if the diagnosis is missed.
The most important single factor that the physician relies on
-like a handicapper of horses-is the past track record. What is the
history? If you tell a well-tr ained physician where it hurts, what
kind of pain it is, how long it has been hurting, and give him a few
other little clues, nine times out of ten, even over the telephone,
without knowing anything else, he has a good working diagnosis
which is likely to prove correct. To make sure, in these as well as
in the other ten to twenty per cent of the cases, physical examination
is required. The physician listens and feels and looks and adds all
his sense impressions to the history. That tells him more things,
and further refines the diagnosis. There is a smaller percentage of
cases where laboratory findings are essential. The history remains
crucial and there is very little excuse for missing most important
deadly, acute illnesses if you obtain a careful history.
Of course, young people can and do have surgical emergencies.
Acute appendicitis is the best known example; but people can get a
lot of other things too. They can get kidney stones and pneumonia.
You do not get pneumonia without a fever unless you are so old or
debilitated as to lack enough metabolic energy even to raise a fever.
So, you need certain medical rules of thumb when you say to your-
self, &dquo;Well, this could be pneumonia.&dquo; If, however, the patient’s
temperature is normal several times, and his pulse is relatively nor-
niai, the chances of his having pneumonia are diminished. Neverthe-
less, you take a look at him the next day, once satisfied that the
telephone symptoms do not represent an emergency.
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Let us look at the population from the viewpoint of other
causes of pain. Those are the emotional causes, encountered by both
internists and psychiatrists.
Psychiatry is a reputedly strange and frequently difficult
branch of medicine. It takes longer to become a good psychiatrist
than it does to become any other kind of specialist. This is not only
because cerebral functioning is so complex, but also because the
fewer facts we know about something, the longer it takes to teach
the multiple theories which could explain the few facts we know.
The fewer the facts, the more...