Psychiatrists Discover Rewards Behind Prison Walls
To gain admittance to the prison, you must first obtain security clearance and go through several security check points. After that, the prison iron gate opens electronically, and you step inside. The gate slides swiftly shut as you are locked in a small room called a sallyport. A gate on the other side of the sallyport then slides open, and finally you step into the prison.
Inside, hundreds of men in orange jumpsuits or standard blue prison uniforms can be seen working, going to school, and playing basketball or chess. Some are young, muscular, and tattooed, others middle-aged or senior. “Escort!” a corrections officer bellows out. You step aside quickly so that two corrections officers can escort a condemned-row inmate in handcuffs to a dental appointment within the prison. As the grey-haired, stocky inmate passes within a yard of you, you think: “He looks like a regular guy. Could he really have killed or tortured somebody?”
San Quentin is a world far removed from what most Americans know—in fact, from what most psychiatrists are familiar with. However, during the past academic year, two fellows from the Psychiatry and Law Program at the University of California at San Francisco worked in the prison two days a week. They are Robert O’Brien, M.D., a tall, amber-haired 37-year-old who once considered becoming a lawyer, and Linda Francis, M.D., a 46-year-old who shows her sense of humor by proudly declaring, “I like being tall. I don’t get elbowed in the eye!”
Here, then, is their story—what it was like practicing forensic psychiatry this past academic year in California’s oldest prison.
Responsibilities Behind Bars
Correctional psychiatry is the only area of forensic psychiatry where people receive treatment, Francis explains. What’s more, while some correctional psychiatrists are forensic psychiatrists, not all are.
The major duties that Francis and O’Brien carried out at San Quentin as forensic psychiatrists this past year consisted of psychiatric evaluations.
For instance, San Quentin is one of the reception centers for men who break the law in California. Some 2,000 men arrive there every month. O’Brien and Francis were two of the psychiatrists who conducted evaluations of these men, and the evaluations in turn helped the California Department of Corrections decide in which of California’s 33 prisons the men should be placed.
A number of inmates in San Quentin are serving terms of 15 years to life and become eligible for parole from time to time. O’Brien and Francis also conducted psychiatric evaluations of these inmates—that is, determined whether they had psychiatric problems that might affect their success with parole and estimated their risk for violence if paroled. The final decision about whether an inmate should be paroled lies with the parole board, officially called the Board of Prison Terms, Francis points out.
Further, Francis and O’Brien evaluated unruly inmates to determine whether their actions were a product of mental illness. The two were also occasionally asked to conduct a psychiatric evaluation of inmates who had completed their sentences and were about to be released, yet were feared to be dangerous still.
Even though conducting psychiatric evaluations were their major responsibility, the two fellows had occasion to treat a few inmates and also to offer opinions about the psychiatric treatment of some difficult cases.
Finally, they were able to pursue some of their own interests while working in the prison as well. For example, “there are hundreds of people on condemned row in San Quentin,” O’Brien says. “We had the opportunity to talk with them. Of course, it was always with an inmate’s consent, giving full disclosure as to what we were doing. But often the inmates were willing to talk with us about their crimes and the factors that led up to them.”
Challenges Daunting
Not surprisingly, the two forensic psychiatry fellows faced some challenges in carrying out their work in San Quentin. “One thing about working in the prison,” Francis explains, “is that you have to give up your notion of what kind of space you are willing to work in. For instance, you may have to see an inmate in an office in the mental health unit. Or you may have to talk with him while you are standing in front of his cell.”
Privacy with inmates was also hard to come by in some instances. For instance, when inmates were in the adjustment center, sort of the prison within the prison, it was because they were unruly. If O’Brien or Francis wanted to see one of these inmates, they had to meet with him in an office in the center while two corrections officers were present. In contrast, O’Brien points out, “I saw a number of condemned-row inmates while it was just the inmate and I in the room.”
Yet another challenge was dealing with their fears of working in a prison. “When I first got there, it was a bit intimidating to be in that environment,” O’Brien admits. “It had to do with my lack of familiarity with the prison, not having ever been there before. But over time it became quite clear what the routine was as far as seeing inmates and how to maintain safety.”
Francis says, “I thought the inmates who would be the most frightening were the ones there for murder and life sentences, but that didn’t turn out to be the case. The ones I found to be the scariest were the younger inmates—those who have gang involvement and who bounce in and out of prison for lesser convictions.”
And while the corrections staff did a good job of protecting the two psychiatrists, they also had to be alert to circumstances where they could have put themselves at risk, O’Brien points out. For instance, they might ask whether an inmate had been spitting at corrections officers or throwing things at corrections officers recently before deciding to see him.
It was important to be alert for “tall tales,” too, Francis observes, especially from “skilled sociopaths who are very charming.” In other words, “you’d hear a story, it hangs together, it sounds great, but then you’d go and do the forensic work, and you’d find out it was a lovely story, but not the real one.”
The difficulties of working with inmates were balanced by positive experiences. And one of the biggest for O’Brien, he says, was talking with some condemned-row inmates convicted of multiple murders to understand what drove them to commit their acts.
“I don’t think you can put your finger on any one cause,” he concludes. “I think it is a combination, because for any one factor, you can find individuals who were exposed to the same things, yet who didn’t go on and commit such acts.”
Nonetheless, he adds, some of these inmates definitely had narcissistic personalities. “They’d rationalize their behavior, project blame, see others as potentially dangerous to them so that they felt entitled to act out violently.”
Still another meaningful aspect of his work, O’Brien reports, was being able to help out in a system that is strained and limited in resources. “Often it didn’t take very much to make a difference,” he asserts. One example is “spending a little extra time with an inmate to identify problems or to help him make progress in therapy.”
Another satisfying aspect of his work, O’Brien emphasizes, was helping some inmates who “carried a lot of baggage as far as guilt and remorse are concerned.” He would try to make them realize that whereas their past behavior was unacceptable, they should not continuously punish themselves for it, and that “if they have become a better individual since then, then they should give themselves credit for that.”
Indeed, during her work with inmates who had been in San Quentin for a number of years and who were eligible for parole, Francis came to know some who, she is convinced, have changed for the better. And getting to know them, she says, was definitely one of the most rewarding aspects of working in San Quentin. “It’s gratifying to see that people who have done a horrible thing like killing another human being have the potential for positive change,” she declares. ▪
