Correctional psychiatrists inevitably treat patients who have been convicted of a broad array of crimes. There is a correlation between the security level of the institutions in which one works and the severity of the crimes of the inmates being housed there.

Since I’ve treated inmates of minimum, medium, and maximum custody levels, I’ve had the opportunity to work with people who have been convicted of everything from drug possession to multiple murders.

What’s it like treating patients who have killed other human beings?

First, after one has treated inmates for a while, the crimes that they have committed lose their shock value. It’s neither glamorous nor anything like the interviews of Hannibel Lecter in “The Silence of the Lambs.” However, when working with them, I never forget that because of their past actions, many have the potential to kill again.

While the criminal history of my patients is pertinent to their psychiatric treatment, to me it’s usually just one piece of information that is of varying importance from one case to the next. However, it’s typically not the focus of my treatment of them.

Second, it’s not a simple question to answer, primarily because homicide perpetrators are a very heterogeneous group.

At one extreme are those whose actions have resulted in the accidental death of others, such as those who have caused a fatal motor vehicle accident while intoxicated. At the other extreme would be those who have intentionally committed multiple murders. In the middle would be inmates who may be remorseful for having impulsively killed out of anger, sometimes while under the influence of drugs or alcohol.

While inmates who have killed may be different from each other in many ways, one commonality is that many are serving life sentences and will someday die in prison. This results in a unique treatment situation, even for a prison psychiatrist. How does one help to give a prisoner hope when he’ll never get out of prison?

An article in Psychiatric Times focused on this issue in “Discussing the Meaning of Life with a Lifer.”

The author points out that the rate of mental illness in prison is even more pronounced among lifers (approximately one in four lifers has mental illness).

Consistent with my own observations, he also mentions that some lifers have a “nothing to lose” nihilistic approach to life while others in the same circumstances gradually accept their fates, find meaning in their lives by focusing their efforts on others in positive ways (an outward focus instead of being concerned only about themselves), and ultimately do well.

Not surprisingly, given that they want to better themselves, this latter group typically is the more rewarding for psychiatrists to treat.

I have also learned many life lessons from this cohort as well. One is the great degree to which happiness or life satisfaction is related to the way in which we respond to our circumstances much more than to the circumstances themselves.

It is because of this concept that some prisoners can be “free,” at least in their minds. Likewise, many of us who are not incarcerated may feel imprisoned by our own lives, primarily because of how we process our circumstances. It’s not difficult to understand this concept intellectually, but it is much harder to practice changing how we look at things in our own lives, especially when we face adversity.

On the other hand, treating the more nihilistic, hopeless patients can result in a psychiatrist feeling helpless and ineffective. Nevertheless, many of these patients still need our help even if the percentage who may benefit from our interventions is small.

Jeffrey Knuppel is a psychiatrist who blogs at Lockup Doc.

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