Forensic psychiatric institutions have long recognized an in-between type of inmate, who is destructive, disruptive, and erratic, yet not meeting criteria for any major mental illness. For this reason, these inmates typically earn a diagnosis of personality disorder and are redirected to a punitive disposition rather than a therapeutic milieu.
Recognizing prison disposition dilemma, Nikki Gorsuch, a clinical psychologist working on a secure hospital unit in England, studied a group of ten troubled women on the psychiatric wing. Each had a history of arson or other violence, and had difficulty gaining admission to the secure hospital facility. Through extended interviews and administration of the MCMI-II, examiners explored the inmates' perceptions of their needs, psychological dilemmas, conflicts, and what was helpful or unhelpful about being in the prison environment. Ms. Gorsuch utilized "attachment theory" principles, as developed by Bowlby (1969), to give these findings a social and developmental context.
Most of the women expressed a sense of profound isolation, though they felt they had a measure of safety in prison and even coped by being cut off from the world. Most said they did not talk to anyone about their feelings. Lack of control and disassociation from contact were important aspects of distress. The women acknowledged repeated self-harm as provoking contact with staff. They were troubled by a frequently turning over staff that had difficulty coping with their behavior.
The MCMI-II results showed only one woman with elevations in her antisocial scale. Most of the women did show high levels of sadness and anxiety, and were most commonly socially detached, shy and hypersensitive to criticism but emotionally dependent and desperate to be taken care of. This unusual coexistence is understandable given that all the women interviewed experienced abusive childhoods. Most with insecure attachments from childhood develop consistent ways of responding to a main caregiver. Abused children, however, experience constantly changing impulses toward caregivers. In adulthood, these ways of relating (even in prison) express themselves as sudden changes of mood and perception, fluctuating between avoidance and clinging. Their care-givers could not tolerate their expressions of anger; in prison, the inmates likewise provoke, then endure, abandonment, rejection, and punishment.
This model translates into a proposed prison management approach with a secure base, allowing the institution to become an attachment caregiver by offering consistency and reliability in day-to-day matters and in response to crisis. Care-taking that is responsive can modulate the inmate's overwhelming feelings. And any perceived threats to the attachment can give rise to angry protest or violence, even displaced toward symbolic caregivers.
The elegance of attachment theory rests in its applicability at the corrections level, independent of the hospital environment. Simple approaches that often parallel successful parenting, coordinated by responsible staff, can provide foundations for inmates to foster more adaptive attachments in the outside world. In this manner, the milieu transcends preoccupation with diagnosis-based care. Conceiving the inmates beyond DSM-IV might provide a formula for offering assistance to disturbed and dangerous women who are traditionally rejected from prison hospital admission. Gorsuch has raised a provocative and pragmatic challenge for how prisons can help even without formal treatment.
Gorsuch, N. (1999). Disturbed female offenders: helping the 'untreatable'. Journal of Forensic Psychiatry, vol. 10, no. 1, April, 98-118
