James Gilligan on the Psychology and Treatment of Violent Offenders

James Gilligan on the Psychology and Treatment of Violent Offenders

by Rebecca Aponte
Renowned Harvard psychiatrist and violence expert James Gilligan offers insight into working with violent offenders in prison settings. Learn about the tragic childhood origins of violent behavior, as well as the fundamental principles of psychotherapeutic treatment of forensic clients.
Filed Under: Prisoners


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Why Violence?

Rebecca Aponte: You worked with highly violent individuals for many years. Most people are not particularly inclined to work with those kinds of populations. What drew you to work with this population?
James Gilligan: That's a good question. I think the ultimate answer, as with most major life decisions that people make, goes back to my earliest childhood. I grew up in a family with a father who was quite violent toward my two brothers. He was only violent toward me when there was a medical excuse for it—he was a surgeon. But my brothers he would really whack around. He would knock them across the room to the point where I was really scared he would accidentally kill one of them.

Now, it's true, the level of violence didn't reach the extremes that I later became familiar with when I worked with prison inmates who were often the children of fathers or mothers who actually had killed a family member. My father didn't go that far. He was never arrested, and nobody ever made a complaint of child abuse or anything. That was in the days before people even had a concept of child abuse. The whole concept of the battered child syndrome wasn't articulated and expressed until around 1963 in the Journal of the American Medical Association. Before that, people didn't even talk about child abuse.

So this was, you might say, "invisible," even though it was happening in a small town in Nebraska where everybody knew everybody else. People could see the bruises on my brothers, but nobody would say a word.

So without consciously intending this at all, I became interested in becoming a peacemaker and trying to figure out how to prevent violence—how to get it stopped, or how to prevent it from happening in the first place. I wouldn't say that I consciously articulated that to myself at the time, and not until years and years later.

But when I became a psychiatrist, I was not at all interested in working with violent patients. I wanted to work with people more or less like myself.
When I became a psychiatrist, I was not at all interested in working with violent patients. I wanted to work with people more or less like myself.
I wanted to become a psychoanalyst and work with the ordinary neuroses that everybody has to one degree or another.

When I was in my residency training at the Harvard Medical School, the teaching hospital was paying me such a small salary that I couldn't afford the expenses I had, because I already had a wife and three children. I needed to supplement my salary, which I learned I could do by spending one day a week in a state prison doing something I had never heard of before and had no interest in, called prison psychiatry.

So I went into this project with no high hopes. I thought it would be an exercise in futility. I thought it would be boring. And I had been taught up to that point that the kinds of people who wind up in prison are totally untreatable—they have no motivation to examine themselves, no motivation for introspection. They wouldn't tell you the truth. They would try to manipulate you by lying to you so that you could help them get an early release date, and on and on.

I was taught all of this and believed it. Then I went into the prisons and discovered that almost everything I had been taught was wrong. And I discovered that it was the most moving experience I had ever had in psychiatry, because I was face to face with the deepest human tragedies on a daily basis. And I mean not just the tragedies these criminals had inflicted on their victims, but also the tragedies they themselves had been victims of in the course of their lives.

What I found was that the most violent among them, and many of those who weren't even at the highest level of violence, had been subjected to a level of child abuse that was beyond the scale of anything I had even thought of applying that term to. As I said earlier, the most violent people were really the survivors of lethal violence, either of their own attempted murders at the hands of one of their parents, or the actual murders of close family members who were often killed by other family members right in front of their eyes.

In the Danger Zone

RA: You have said that the first prerequisite for a therapist working with violent patients is to learn how not to become their victims. How do they do that?
JG: Let me just say two things I would emphasize there. One is simply a practical matter of common sense, which is when you are dealing with a dangerous population, make sure there is plenty of security around. [quote:One of my mentors said, "If you don't realize how dangerous these people are, you are more out of touch with reality than they are."
RA: Aside from the fact that prisoners are obviously in a situation where they are being humiliated so frequently, do you find that therapy with regular people and therapy with violent individuals is really all that different? Or is it very similar?
JG: That's a good question, because throughout the time I was doing this work in the prisons, I was working probably between 70 to 80 hours a week, but I had a very active private practice, too, with people more like myself—Harvard faculty members, Harvard graduate students, local professional people, and so forth.

First of all, the basic principle of respect certainly is universal—that is part of all therapy. But the main difference is the prison work was much more skewed toward crisis intervention. That is, the prisons are the environment in which crises are not just an everyday occurrence, but a several-times-a-day occurrence. Prisons are in a state of chronic recurrent crisis. So when I was actually talking with people in the prison, it often was in order to resolve a current crisis.

What I learned was, however, that when you learn how to deal with the crises, a lot of very constructive work can be done. The prisoner, for example, can learn how you can resolve a crisis by talking rather than by using your fists or a weapon, because they would see how we did it—and that, in fact, it was more effective than their way of trying to solve a crisis, which was to hit somebody, or try to strangle them or stab them.

So a lot of useful work got done that way, but certainly the prison environment and also the personalities of the kinds of people who wind up in prison were different enough from my ordinary private patients that we were certainly not even in any way attempting to mimic a lot of the ordinary routines of psychotherapy or psychoanalysis. We certainly didn't have people lying down on the couch five times a week, free-associating.

We were much more face-to-face, dealing with a concrete reality. But in the course of that, as we got the crises resolved, the prisoners then became capable and motivated to talk with us about their lifelong issues, and could talk to us about the most painful and formative experiences in their earliest childhood and so forth.

Common Misconceptions and the Meaning of Attention

RA: And you have trained a lot of therapists to work with violent individuals, haven’t you?
JG: Yes, I did, and I and many of my colleagues, over many years.
RA: Do you find that therapists have any general misconceptions about working with violent individuals?
JG: Oh, yes, I really do—just as I did before I first started working with violent people. I was full of misconceptions. One of the commonest, actually, was one I didn't share quite as much, and that was a total fear of working with people who had a history of violence or were at high risk of it. Every time I worked in the prisons, I was working as a member of faculty of one of the Harvard teaching hospitals. And we would try to make sure that part of the training of the psychiatric residents—or sometimes even medical students and forensic psychiatry fellows, along with clinical psychologists, psychiatric social workers—consisted of spending a certain number of months as clinicians in either the state prison mental hospital or the prisons themselves.

What we found was that we got a lot of resistance. Many of the people who were very happy to see mentally ill people at, say, Maclean Hospital or the Massachusetts Mental Health Center, the Harvard teaching hospital, didn't want to go near a prison or a prison mental hospital, and were scared to death of it. We tried to convince them that ironically, in some ways, because there is so much security, the prisons and prison mental hospitals can be some of the safer places to work, as long as you know how to do it.

So that was one misconception—that this population was too dangerous to work with. The other was the misconception I had had, which is that they were untreatable. I found it totally untrue. In fact, I would go so far as to say that, while I frequently had the experience of meeting somebody in the prison or the prison mental hospital who I thought was untreatable at first,
I came to the conclusion, over the course of working for 25 years, that nobody is untreatable. I wouldn't give up on anybody.
I came to the conclusion, over the course of working for 25 years, that nobody is untreatable. I wouldn't give up on anybody. I saw people who seemed intractably violent, and in some cases intractably psychotic, in the case of the mentally ill prisoners. And I reached the position that everybody can be brought to a point where they stop being violent toward other people. They just do not use that as a means of trying to solve their life problems anymore.
RA: Going back to what you were saying about people being afraid to work with these populations, I'm wondering about the times that you were assaulted when you were new to this. What do you think went wrong?
JG: In the 25 years I did this, I was really seriously assaulted about three times—I mean, punched in the face. I didn't get a broken nose or a broken jaw, though I easily could have if I hadn't been lucky. That was really it. And when I asked myself, "What happened? What led to this? What could I learn from it?" I began to realize that each of these incidents had occurred under almost identical circumstances. Namely, it was late in the afternoon, I was getting tired, I was eager to get home to see my wife and family. And what occurred to me was the analogy that skiing accidents typically around 4 o'clock in the afternoon, when the sun is going down and you want just one last descent along the ski slopes before you go home—people are tired, they are distracted, and that's when the accidents happen.

I found that that was what was happening, and I realized that the prisoners, in fact, were correct that they thought that I was really not giving them my full attention, that I was a little distracted or impatient, I wasn't really completely listening to them, and they succeeded in getting my attention. That's how you do it—you hit somebody, you sure get their attention.

And I realized another thing about it: the German word for attention, "Achtung," also means respect. And it struck me that paying attention to people is a form of showing respect for them.
The German word for attention, "Achtung," also means respect. And it struck me that paying attention to people is a form of showing respect for them.
And not paying attention to them is a way of disrespecting them. In fact, that's one reason that I think that psychotherapy is one of the most profound forums of showing respect toward another human being, because the therapist is sitting there giving that person his or her entire unadulterated attention. That alone is part of the curative therapeutic process, I'm convinced.

But I also realized that what I was doing in the prisons was I was not giving them my full attention, and I was disrespecting them. What I heard from the most violent inmates over the years when I would ask them why they had hit somebody—not myself but anybody—they would say, "It is because he disrespected me." And they used that term so often, they abbreviated it into the slang term, "He dissed me." It struck me that anytime a word gets used so often it gets abbreviated, it tells you how central it is in the moral and emotional vocabulary of the person using it.

Disrespect is central to the ideology of violence. When I became a victim of violence, I would say I had provoked it by inadvertently, unconsciously disrespecting the people I was supposedly talking with.

Confronting the Horror

RA: I want to talk a little bit more about that role of disrespect or shame in violence. When you are working with the prison population, how do you balance your sense of respect and dignity for them with the serious and grave impact of the actions that landed them in prison?
JG: Again, that's an excellent question I asked myself many times. I have tried to make the distinction, when I think about that, between the horror and the outrage that one can't help feeling when you realize how horribly this person mutilated somebody else or caused them horrendous suffering. So when I talk about respect for this population, I don't mean pretending that you respect somebody for that part of their behavior.

What I mean is something much more basic than that. First of all, no matter how horrified I am about the behavior that led them to be sent to prison, I'm not there to humiliate them about it.
No matter how horrified I am about the behavior that led them to be sent to prison, I'm not there to humiliate them about it.
I am there to try to understand what caused this behavior on their part. I am an investigator. It is a scientific process. I am a physician that is a part of science, and I am there to try to learn something from them. So it is precisely the most horrendous offenders who I regarded as my teachers, and I was their student. I was trying to learn from them what had led them to behave in this way, which of course I found just horrendous. So when I say I would treat them with respect, that doesn't mean I respected what they had done. But on the other hand, I also felt it was not my job to punish them or humiliate them for it. My job is to try to understand what had caused them to do it.

The other thing—in my first book on the subject of violence, called Violence: Reflections on a National Epidemic, one of the epigraphs was a quotation from a book by a political scientist who said, "Of human beings, none are good but all are sacred." Now that is, in a sense, a religious way of putting it. But actually you don't have to commit yourself to a particular form of religious belief to believe that some things are sacred and that, just being human, there are some things we just don't do. And I felt the one thing I would not do, no matter what the person was in front of me had done—I was not going to strip that person of their human dignity. They still were human beings no matter what they had done.

And that there was something about the human personality or the human soul or psyche, whatever you want to call it, that is sacred. There are just some things that you don't do to a person's psyche.
RA: But you must have negative feelings from time to time towards the person that you are working with. How do you manage that countertransference?
JG: I will tell you about one of the most horrendous case that affected me personally, that really forced me to confront that in myself. This is a man who had raped and murdered a 14-year-old girl who lived in the house next door to him, and he then buried her body in his basement. He dug a hole in the dirt floor of the basement and buried her in it. Then he went upstairs and watched a football game on television, and waited until his wife and daughters got home, and acted as though nothing had happened.

When her family realized she was missing, a group of citizens was formed in the community to have a search party and try to find her. He joined the search party as if he did not know where she was. He finally was caught and apprehended, and convicted of murder.
RA: That's chilling.
JG: When he told me this story I felt literally sick in my stomach. I thought I was going to throw up. I was so offended. The whole story was so horrible. How can you sleep after hearing something like this? And I felt a sense of compassion for this girl that is just endless. How much more horrible can anything be?

Then I realized, "Well, I have experienced that feeling before." When I was a medical student, we learned anatomy by dissecting a cadaver that smelled of formaldehyde. And you worked very hard in medical school. Sometimes people had to eat lunch while they were dissecting a cadaver. It would make you sick to your stomach. And then in the pathology lab, the same thing. We would be doing autopsies and dissecting disease tissue, tumors and so forth. And, again, totally disgusting. I would feel sick in my stomach.

But when I was in medical school, the attitude I took was, "Well, okay, that's a normal response to something that in fact is a source of illness in pathology. And, yes, you should be disgusted by it. It's a normal, human, biological response. But I will tolerate the disgust and nausea in order to learn what caused this person to die—in order to learn more about the pathology that was involved." So I realized, with this murderer, I was doing the same thing—but as a psychiatrist, not as a surgeon or pathologist. I was, in a sense, dissecting his soul, which was full of pathology, and it was disgusting. It was horrible. It made me nauseated. But I said, "Again,
I am doing this in order to try to learn something. I'm trying to learn what was the pathology that killed this girl.
I am doing this in order to try to learn something. I'm trying to learn what was the pathology that killed this girl." And that was the only way I could do it—by tolerating the sense of nausea in order to try to learn something.
RA: If the person that you are speaking with is expressing remorse, do you find that your own sense of disgust is mitigated by that?
JG: I would absolutely say that. And I think it's true for several reasons. One is, when a person has a sense of remorse, I am less worried that they are going to be likely to repeat the same behavior. I feel that also there is more to work with. They are more treatable. One thing that I learned over the years, though—I would see people who had committed murders and felt no sense of remorse whatsoever. They felt totally justified. They felt they were the victims, and on and on.

Finally, when they began to realize what they had done, how much human suffering they had caused to other people, when they finally reached the point where they could recognize how much pain they had caused, then they would begin starting to feel remorse and say, "Oh my god, what have I done?" And at that point I was dealing with a suicidal person, because the remorse is one aspect of feelings of guilt. When people feel guilty, they typically have a need to punish themselves. In many cases these were the people who would kill a family member, a wife or a child, and minimize it at first. Then, finally, when they were able to face what a horrible thing they had done, they really were seriously suicidal, and the staff and I would spend a year or two trying to prevent a suicide before the prisoner could finally integrate what they had done, who they were, and where they could go from there.

Once they had learned to live with the remorse and not kill themselves over it, the one thing they seemed to find that made life livable for them was when they found out how they could be of service to other people. And when these men in the prison, who otherwise just seemed unremittingly suicidal, realized they could actually be useful to other people, they had something to live for.

It might be as simple as they could teach other inmates how to read or write. A lot of prisoners are illiterate, and those who knew how to read or write could teach the others to read and write. Another person might become the librarian at the law library in the prison, and kind of be the jailhouse lawyer and help prisoners to write up a legal brief for themselves and so forth. Or they might help out with the school educational programs, or cooking things in the cafeteria. It almost didn't matter what they did, but if there was something that was useful and had a useful place, they then had something to live for.

What struck me about that was, after all, in a sense, that is true of all of us. What makes life meaningful and worthwhile for anybody is the sense that actually they are useful to other people.
RA: Once someone has reached that point of experiencing remorse, is it dangerous to bring that up, to try to treat it directly? What do you do at that point?
JG: At the concrete level, we would certainly put them on suicide precaution and try to make sure that they didn't have access to anything they could hurt themselves with. But I would talk with them. I would try to acknowledge their pain—the pain of realizing how much pain they had caused others—and try to talk with them about how they are actually not helping anybody if they kill themselves. They are not undoing anything. In fact, maybe they could find a way to, so to speak, try to make up for what they had committed. I would certainly try to steer them in the direction of finding some way to make their own lives useful to other people.

But I was certainly aware that they were dangerous to themselves, for often a year or two. In fact, the only suicides that I did see happen in this world were of people who had reached that point, who had originally felt totally justified in the homicide they committed and then later realized that they really weren't—there's no justification for killing somebody else.

The Point of It All

RA: As you know, the “bread and butter” of psychotherapy is to help people reduce anxiety and depression and adjust to new life situations. What are typical treatment goals in working with violent offenders?
JG: First of all, to prevent further violence. That's not the ultimate goal—that's just the first step. But we would have to reach that point before we could do anything further. In other words, as long as violence was continuing, any other therapy was a waste of time. It's beside the point. So the first goal would be to help them to reach a point where they would stop using violence as their optional tool for solving life problems.

A second one would be to give them the tools they needed and the resources they needed in order to gain the sense of self-respect, which they simply had never been able to develop. The reason they were hypersensitive to being disrespected by others was because they were so lacking in self-respect, and that means lacking in the precondition that any of us need in a given day to be able to respect ourselves.

For example, everybody gets humiliated at one time or another, but most people never commit a serious act of violence in their lives. And I would say one reason for that is because most people have enough internal and external resources available to them that they can restore their self-esteem, even when they have felt humiliated. You have an education, you have some skills, knowledge that you can respect and that other people will respect. The guys in the prison, almost all of them had none of those. They were often illiterate. They had often been unemployed, homeless. They have been abused and treated as worthless from the time they were born. I mean, their self-respect is zero.

I learned that if we gave them the tools they needed, they could gain self-respect just through the process of education and development. For example, I always regarded education as a therapeutic tool. Education can serve a lot of purposes—people can get better jobs if they have a good education, and so on. But I felt it was therapeutic for this population to gain a set of knowledge and skills that they could respect themselves and treat other people with respect.

In fact, we found that the single most effective therapy in the prisons in preventing violent recidivism after people left the prison was prisoners getting a college degree while in prison.
We found that the single most effective therapy in the prisons in preventing violent recidivism after people left the prison was prisoners getting a college degree while in prison.
We had a program like that that had been in effect for 25 years. Professors from Boston University taught courses for credit, and the prisoner could get a college degree from Boston University.

We found that over a 25-year period, several hundred prisoners had gotten a college degree, and not one of them had been returned to prison in that time. When we extended the study to 30 years, we found that two people had been returned. That was much less than a 1 percent recidivism rate. Phenomenal compared to the usual recidivism rate of 65 percent in three years—this was less than 1 percent over 30 years.

But, for me, the reason was they built up their self-esteem. They could respect themselves.
RA: So preventing future violence and tools for self-respect—are those the core of the work that you are doing?
JG: Certainly that was, at the level of emotions, prerequisite to everything else. For example, I felt that certainly one thing that had been missing that had made it possible for them to commit serious harm to others was their lack of a capacity for empathy with the suffering of others, and a lack of the capacity to care about others or to love others.

But what struck me was they couldn't respect other people or treat other people with esteem if they were lacking in self-esteem and self-respect. So helping them reach the point where they gained self-respect and self-esteem was really a prerequisite to their being able then to care about others enough so that they would not violate the rights or inflict harm on other people.

But that is all at the emotional level. At a more cognitive level, one major thing that we did in the jails of San Francisco when I worked there over a ten-year period was to focus on cognitive issues—namely what we call the Male Role Belief System, which we felt had underlain the violence these men had committed. And by that we meant all of the assumptions they had been taught as to how you define masculinity and what you need to do in order to be a man, what you are entitled to do, what you are obligated to do, how should women treat you, how should you treat them, and on and on—the whole set of assumptions that almost all men in our society are raised with. The assumption underlying this very skewed patriarchal, somewhat misogynistic view is that the social universe, that is, the whole population, is divided into the superior and the inferior. In that division, men are supposed to be in the superior part and women in the inferior part. And, in fact, the really superior man has also got to be superior to other men. So they are also inferior.

This is a recipe for violence because most people don't want to be cast into the role of the inferior.
RA: And it is a roadmap for feeling disrespected.
JG: Exactly. So we engaged in intensive group therapy with these jail inmates—all of them were in for a violent crime. I was amazed how quickly they grasped that point. And not only did they get the point, they began to say things like, "I've been brainwashed by the society I have grown up in." They would want to then start educating the new inmates about what they had learned.

So we said, "Great," and we would train them to lead the groups themselves, kind of like Alcoholics Anonymous where the people suffering from the problem are sometimes the best therapists. So we trained them to lead these groups, and we found the level of violence in the prison dropped to zero, and the level of recidivism after they left the prison was down 83% compared with people who had been in an ordinary jail without these kinds of programs.
We found the level of violence in the prison dropped to zero, and the level of recidivism after they left the prison was down 83%.
So that is a concrete example.

At a more abstract level, we were trying to increase their ability to be self-aware, to recognize their own motivations, to recognize how they were behaving in ways that were really self-defeating—this wasn't helping them get what they really wanted. In fact, their behavior was often costing them relationships that they actually wanted to maintain.

So, like any psychotherapy, you are ultimately trying to get at the greater sense of self-awareness and a greater degree of self-control that comes from the self-awareness. If you are lucky, that is what will happen. The goals of therapy and the methods of therapy did share those features in common with psychotherapy with any population.

Violence in Childhood: Bullying and Corporal Punishment

RA: I want to transition into talking about the earliest possible interventions. We know that violent behavior begins fairly early in life. How do you think that child and school counselors should be responding to bullying? Do you think parents are to blame? Should they be involved in the response?
JG: First of all, I certainly think that bullying is a prime example of the kinds of experiences that stimulate violence. That is hardly an original observation on my part, but I think people in general are increasingly aware how much school violence and violence out of school is caused by bullying.

I would like to see a truly cooperative effort on the part of schoolteachers, school administrators, and parents to identify and respond to a bullying situation and to get it stopped. Whenever there is a bullying situation, there are three parties involved. It's not just the bully and the victim. The third party is the bystander, the witness, whether that is a schoolteacher or whoever. I really think that it is vitally important that nobody take this as just normal. Many of the people I saw in prison, for example, would talk about how they had been bullied in school, come home and tell their parents about it, and the parents, instead of going to the school and saying, "This is a problem we should work together to solve," would tell their son, "You go back and beat him up, and if you don't beat him up I will beat you up myself."

That's how you teach children to be violent.
RA: Do you feel that the chronic victims of bullying are at a similar risk for violence as the chronic perpetrators?
JG: That's a good question. I don't want to give you an answer that would imply that I am sure I know what the answer is. That is one I am not sure off the top of my head. Very often, bullies also have been victims. They aren't necessarily just one or the other. Often you find they are overlapping categories.

Without being able to be sure how I could predict which of those groups is most dangerous in the future, I would share pretty much an equal sense of concern for both. I would want to pay just as much attention to one as to the other—to the bully in order to get the bullying stopped, and to the victim in order to make sure that the victim doesn't ultimately turn into a bully.

Whenever I see a situation like that, I would want to intervene. But I would like to do so in a way that is not aimed at humiliating or at punishing, but is really aimed at restraining, in the sense of saying, "This is not permissible. You can't do this. We will not tolerate this. But we are not going to bully you ourselves. We are not going to beat you up or spank you. What we are going to do is limit your freedom to do this until the point you can stop yourself. If you can limit yourself from doing this, then fine, we don't need to do anything."

In other words, the only way to stop violence is with nonviolent means. That doesn't mean you don't need restraint, but it does mean that I would make a sharp distinction between punishment and restraint. I think parents who have two-year-old children running in front of traffic need to restrain the children so they don't get hurt. But that doesn't mean they have to hurt the children themselves. The whole point of restraining them is so the children won't get hurt.
RA: You mentioned not using spanking. Every time there has been a new movement to try to outlaw spanking, it has been met with quite a bit of controversy in the name of parental rights. What would you say to parents who think that spanking is a necessary tool?
JG: First of all, I think most of the empirical research on this subject has found that spanking is counterproductive. Over the last 60 or 70 years, there have been literally dozens of studies, if not hundreds, about child rearing and child development. The whole process of child development is so complicated and there are so many variables that not very many generalizations have been almost universally replicated. But the one conclusion on which there is the highest degree of consensus is that the more severely a child is punished, the more violent the child becomes. Using violent means to limit violence is just self-defeating. Violence stimulates violence. Obviously, you can talk about different degrees of spanking, and you talk about it so that it is not really painful—not going to cause bruises and so forth. But just the sheer idea that an adult can do something to a child which would be called assault and battery if they did it to another adult—I mean, the legal system recognizes the difference between a violent and a nonviolent intervention. And I just don't think an adult is doing anything except stimulating violence. To me, that is what the empirical research has shown. From my experience working with prisoners, I have already mentioned the most violent prisoners are the ones that have experienced the most violence at home. If violent punishment would prevent violence, then the people who wound up in the prisons would never have become violent in the first place, because they had suffered as much violent punishment as you could inflict on a person without actually killing them. As I said, many of them were the survivors of their own attempted murders.

I understand people who believe in spanking and say, "Well, we are not attempting murder." One problem is that people who have studied child abuse have found over and over again that it often starts just as so-called harmless spanking and escalates—parents get carried away.

I have treated parents who came to me in my private practice because they were afraid they were losing control and they were going to really injure the child more than they intended. They couldn't stop themselves once they got started. I would recommend that the United States follow the example of an increasing number of nations around the world—I think Sweden was one of the first, but by now there are at least a dozen if not more—who have made it a law that corporal punishment of children is assault and battery. [editquote: I would recommend that the United States follow the example of an increasing number of nations around the world who have made it a law that corporal punishment of children is assault and battery.

Intervening with Victims of Violence

RA: I'm wondering also whether you have any insights from your work with violent individuals that would be helpful to therapists who primarily work with victims of violence, maybe a battered spouse or adult children of violent parents.
JG: First of all, I would begin the work I do with the victim of violence with the unequivocal assertion that violence is not justified. Nobody deserves to be victimized by violence. It is important that they realize that they weren't the cause of this. No matter what they did, that doesn't justify the person who harmed them.

The second thing is that, precisely because nobody deserves to be treated this way, it is vitally important that they do everything they can to protect themselves from it and to make sure that they don't expose themselves to the risk of further violence of this sort. If they are involved with somebody who does not appear to be capable of renouncing violence as a form of trying to influence the person they are involved with, it is vitally important that they separate themselves from this person.

Otherwise, you have to then shift the focus to the question of, where is their need for punishment coming from? I would really focus on trying to prevent violence there by trying to prevent their victimization. You have heard of the Tarasoff Rule and the Tarasoff Warning—the legal rule that if the therapist has reason to believe that a patient of his or hers is at risk of being injured by someone else, they have a legal obligation to inform the patient of their concern and to clarify who it is they feel they are in danger from, and to recommend that they do everything that they can to separate themselves from that person and to protect themselves.

We had a terribly tragic situation in Massachusetts when a man was sent to the prison mental hospital because he had been threatening a woman he had had a love affair with, and he would keep breaking up with her and then wanting to get back together. Finally she got tired of it and said, "No, forget it, go away." And he couldn't, he was obsessed with her, and would keep threatening her. He was sent to the prison mental hospital for the crime of threats, which he had been convicted of.

We reported to the court that we thought this man was indeed dangerous to her. We also sent her a letter saying that we thought he was dangerous and she should do everything she could to escape from him, to not let him know where she was, and to leave. The letter went to the judge, it went to the sheriff of the jail this man went to. But the man was not psychotic. We couldn't commit him to the prison mental hospital on grounds of insanity because he wasn't insane. And he got sent to the jail with the letter in which the judge ordered the sheriff to notify the police in this woman's hometown when this man was going to be released from jail, because the maximum sentence for the crime of threats was only six months.

So this guy, after only six months, was released from jail. The sheriff screwed up and didn't notify the police in her hometown, didn't notify her, and the man went to her home and killed her.

It was a tragic, tragic case where the victim could have been saved. On the other hand, you might say it is one of the difficulties in our legal system that this man could only be locked up for six months according to the law. I could understand this woman's sense that she wouldn't want to be going into a witness protection program like where the FBI puts informants against other criminals or something. She would literally have to change her social security number, and move to the other end of the country or something, change her name—literally, because this man was obsessed with her and was very dangerous, and was willing to do something.

He now has a natural life sentence. He will never be out of a prison in his life. So clearly he didn't care; he wasn't restrained by anything. You talk about dealing with the victims—that was the worst case I think I have ever seen. It was not just frustrating, but horrendous. It was appalling. The Boston Globe reviewed all the circumstances and concluded this could have been avoided if the sheriff and the police had provided some protection as the judge had ordered. But it's even more complicated than that. [quote:It's a very difficult thing to help the people who have been victimized to realize how much danger they may be in.

How to Abandon the Prison System, and Why

RA: I want to give you a chance to talk about your more recent work, which is violence prevention at the societal level. You have said that prisons should be demolished and replaced with secure residential schools, colleges, and therapeutic communities. I wonder if you could briefly outline your theory behind this.
JG: The modern prison system is a fairly recent invention. It was only in the late 18th to early 19th century, starting in countries like England and the United States, to some extent Italy and other European countries, that prisons became long-term residential facilities for purposes of punishment rather than being short-term settings just awaiting trial, and at the outcome of the trial they would either be executed or tortured and mutilated, or acquitted and just let go.

But what we have now, where people come into prison and spend years there, or maybe the rest of their lives—that is a new development. It is a well-meaning experiment that has failed. It was well meaning because it was originally developed as an alternative to torture and execution. It was an attempt to protect people from such horrendous experiences. But in fact, it does not work in its stated purpose, which is to make society safer, except insofar as it certainly serves purposes of restraint. I mean, you keep somebody violent from the community—that I am in favor of, and I think we do need to do.

But if you want to look at the long-term effect on society, more than 90 percent of the people who get sent to prison are back in the community within a few years. They would have to be, or otherwise the prisons would be ten times larger than they are now, and they are already something like 7.5 times larger than they were in the mid-1970s on a per-capita basis.

Humanizing Predators

RA: Aside from the cost of doing something like that, probably the biggest resistance to that idea would be the conventional wisdom that there is a certain subset of people who are true sociopaths who are not going to be helped. You said earlier that nobody is untreatable. Is the "predator personality" a myth?
JG: Well, in one sense it is. But let me make clear, too, that I do not mean to imply that I am so optimistic about everybody that I think everybody that comes into the prison, no matter how violent they have been, can necessarily be returned to the community.

What I am saying is they can be rendered nonviolent. But I certainly have known people that I think should in fact remain institutionalized, because I think they have been too damaged. I will give you a case example. We had a man sent to us when I was running the prison mental hospital in Massachusetts, an African-American man who had been a pimp of a stable of prostitutes. He killed several people in the community, including some of his own prostitutes, was arrested for multiple murders and sent to the Charles Street Jail in Boston to await trial for murder.

He promptly killed one of the other inmates. So they realized he was too dangerous to await trial there. He had to be sent to the maximum-security prison to await trial, even though that is where you would normally be sent only after being convicted. And he killed an inmate in the prison. So they sent him to me at the prison mental hospital.

Now this man, when he came to the door, was mute—he was like a zombie. He was paranoid. He couldn't relate to anybody. Everybody was, of course, scared to death of him, knowing his history. And he seemed equally terrified and suspicious of everybody. When saw this guy, I thought, "This is someone who is untreatable. He is actively violent. You can't do psychotherapy with somebody who is mute, with his kind of history. The best we can hope for is to limit the violence that he would commit." So I had him put in a maximum-security residential unit we have where he would be in a locked bedroom at night so he couldn't hurt anybody and they couldn't hurt him. And I told people during the day to just keep a six-foot invisible wall between him and everybody else so that nobody would crowd him. One of our staff wanted to try to engage him in psychotherapy and I said, "Don't even bother. That he would experience that as a violation of his space." I said, "Give him space."

And after a month or two of this he didn't harm anybody; nobody harmed him. He found that there was a profoundly retarded 18-year-old man in the same residential facility there, same dormitory building, and this kid was so retarded he could hardly tie his shoelaces. He really needed somebody to look out for him. This multiple murderer took this guy under his wing and would walk with him to and from the dining hall and make sure that nobody abused him, robbed him, raped him, assaulted him, anything. He protected him.

And from the moment I saw this happen I said, "Thank god. This may be this guy's restoration to humanity." But I wasn't sure. He still didn't seem treatable in any conventional sense. But we let this go on, and for several months he was the caretaker of this kid, and still not talking much to anybody.

Finally he reached the point where he was relaxed enough that he did start wanting to talk. I sat down with him several times, and he basically told me the story of his life. His childhood was horrifying, blood-curdling. But he got this off his shoulders. By the way, we gave him very small doses of medication as he came in looking paranoid, but actually, he wound up to be more depressed than anything else. And we gave him very small doses of an antidepressant. As far as I know, he is probably still taking it.

But it was minimal medication involved. He really wasn't psychotic. Once he got to the point of talking, he was perfectly sane. But he had had horrendous child abuse in his lifetime. He still is at the prison mental hospital. He has several life sentences. He will never be out of prison. He will never be back in the community. Frankly, I don't think he would know what to do if somebody sent him back into the community.

So when I say that I wouldn't give up on anybody, I don't mean that this is somebody that is really going to be fit to return to the community and live in it. I think he is too badly damaged. But on the other hand, I think we don't need to keep punishing him. We can provide him a place where, for example, he has a job in the hospital. So, again, he is of use to other people. He gets some degree of self-respect from that, and people are grateful. He has filled a useful role in the hospital. When I come back to visit from time to time, he will smile and say, "Hello, Dr. Gilligan, how are you?" You know, behave like a normal human being—no longer mute, paranoid, menacing. And he has not harmed a hair on anybody's head since coming to that prison mental hospital.

So when I say I don't give up on anybody, this was somebody who was still killing people even after he was sent to prison. He has been there for 25 years now, and hasn't harmed anybody. And to me, that's success. I don't care if he goes back into the community. I think he would die if he went back into the community.

Discipline, Not Punish

RA: In a therapeutic community in a prison setting, how are rules enforced? Obviously you would have a no-violence policy. Does that mean that somebody can be ejected from the program or not be allowed to do certain group activities that they like? How do you do that in a way that manages respect but also enforces rules?
JG: I would try to focus on attempting to learn what was motivating the person to break the rules, including the most important rules, which would be rules against violence.

Again, let me give a case example to illustrate how I would approach it. We had a fellow at the state prison mental hospital who, on a regular basis, would engage in what we called sucker punching. That means hitting somebody just out of the blue with no provocation, no warning—being in an ordinary conversation with them, and then just suddenly punching them in the face, and sometimes really injuring people.

When that would happen, he would be immediately removed to a locked individual room where he would be isolated from other prisoners so he couldn't hurt anybody. Then a therapist would go over to talk with him repeatedly, day after day, until we figured out whether he was ready to come back into the community and not hurt people. After awhile, he would come back in and then he would be nonviolent for a couple of weeks or a couple of months, and then he would repeat the same behavior.

Finally, we sat down with him and said, "What's going on here? Why are you doing this? You know you get locked up when you do it." What we learned was that he wanted to be locked up. There were times that he just felt either he was losing control and felt he needed to be locked up, or he was afraid other people were dangers to him and he wanted to be saved, locked up. I think he was more afraid of himself than of others, but he knew that this was a way that he could get locked up for several days and feel safe. But everybody around him was safe.

What we said to him was, "Look, you don't need to hit anybody in order to be locked up. If you just tell us that you feel you need to be locked up, we will do that. We will put you in this room and lock the door, and we will keep the door locked until you can tell us you feel ready to come out again."

And what was amazing was that worked. He stopped sucker punching. He would tell us that he really wanted to be locked up. We said, "Fine, we will do it right now." And then we would go and talk to him about why he felt the need to be locked up. We wouldn't deny him the wish.

That would be one way in a therapeutic community that one would deal with rule violators. It's try to learn why they are breaking the rule, and to approach it not in the spirit of, "We are going to punish you for doing that," but rather, "We are going to try to help you to reach the point where you don't need to do that in order to get what you want"—and try to clarify what their goal is.

That's only one example, and I'm sure we can think of a hundred others that might not be so easily or neatly resolved. But the basic principle is you restrain people from hurting other people, absolutely. Clearly there are some people not ready to be in the group, like I mentioned with the multiple murderer. I didn't want him in a group at first. I thought he would experience that as an assault on his living space. He needed to be separate from other people for a while. So my emphasis would be less what are the rules than on what is motivating this person, what is his current mental status, to what degree is he in control of himself, what are his goals—in other words, a very psychological approach to everything, rather than a kind of rules-based approach.

I don't mean to say you don't need rules. You do need very clear rules, something that is acceptable to others. That does need to be made clear and unambiguous. But a violation of them should be not punishment but rather, first of all, restraint, and then inquiry and an attempt to learn, what was going on? Why did this happen?

Never a Boring Day

RA: You have obviously had a career full of very challenging work. What has been rewarding to you about it?
JG: That's, in a way, almost too easy to answer. It has been constantly rewarding. I have felt so fulfilled by this work. I felt so fortunate to be able to engage in it.

First of all, it satisfied my curiosity. I was able to learn a lot about things that I didn't understand earlier and I wanted to learn about. Secondly, this wish of mine that goes back to childhood to try to find ways to limit violence or prevent violence—I have certainly been able to gratify that wish through this work.

The third thing is I have talked to many of my colleagues who went into an ordinary psychoanalytic or psychotherapeutic career and finally, after 30 or 40 years of that, would tell me they were feeling bored—they were just doing the same thing over and over again, but they weren't learning anything new. I felt sorry for them, because I felt
I have never had a boring day of work in my life. I look forward to every opportunity to engage in this work.
I have never had a boring day of work in my life. I look forward to every opportunity to engage in this work. It's endlessly interesting, gratifying, moving. And I would recommend it unreservedly. And I mean I really recommend it. I'm not like Freud, who, when the Gestapo arrested him in Vienna and required him to write a note telling how well they treated him, ended it by signing, "And I would recommend the Gestapo to anyone." It's probably ironic and sarcastic, so I don't mean it in that sense. I mean that I really would recommend this kind of work to anybody.

I would love to see the mentally ill moved out of the prisons, where they really don't belong, and back into the mental health system. But I also want to see the prisons themselves really turn into therapeutic communities rather than being just places for punishment.

I think one of the biggest mistakes we have made—and when I say "we" I mean all of western civilization—over the last two or two and a half centuries has been this mistaken belief that punishment would prevent violence. I think in fact it just stimulates more violence. But that doesn't mean we should unlock the doors and let everybody run free. I do believe in restraint—in restraining those who hurt others, stopping them from hurting others through coercion and restraint and constraints and force—when necessary. But that doesn't mean violence and punishment. That is the vital distinction I would like to make.
RA: Do you have any final thoughts that you would like to share?
JG: I want to thank you for your interest in this work. Let me say one thing that I think applies to all psychotherapy. Again, what I have talked about is certainly very, very different from the population that 99 percent of therapists work with. But I do think it is worth recognizing that psychotherapy is a modern invention, a great social experiment in self-education. Sure, it has roots in everything from confession in the church to philosophic introspection and so on. There are antecedents for modern psychotherapy, but nothing really comparable.

It is a great, unprecedented social experiment, and I think we are only beginning to realize how important it is and how valuable it can be. When I first was trying to decide whether to become a psychoanalyst, I talked with a friend of mine, the late Peter Newbauer, who was a psychoanalyst in New York. I said, "Peter, if I become a psychoanalyst, I can only treat a few hundred people in my whole lifetime, and yet the need for this is so overwhelming. There are six billion people on this planet, and all of the psychoanalysts in the world can't treat more than a tiny handful. How can I think about this?"

He said, "Of course, you are right." But he said he felt that the ultimate benefit of psychoanalysis would come not simply from the actual treatment of individuals you are seeing, but from what you learn from treating them that could then be applied in other contexts such as in child rearing, in education, in the criminal justice system, and so on. Even in ordinary medicine—psychological insights have transformed so much of what we do in medicine.

When my children were born, I wasn't allowed in the delivery room. Nowadays people bend over backwards to try to increase the bonding between parents and children and to protect the bond between the father and mother and so on. That is one of gazillions of examples. The way children are treated in hospitals now is totally different from what it was when I was a medical student. These are examples of applying psychoanalytic knowledge into completely different contexts. So I have often felt that what I have done is applied psychoanalysis. It is not psychoanalysis as such—we don't put prisoners on the couch and have them free-associate five days a week—but we apply what we know from psychoanalysis in that different context, and then we can learn more things.

© 2011, Psychotherapy.net, LLC
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James Gilligan James Gilligan, MD, spent more than 30 years serving on the faculty of the Department of Psychiatry at the Harvard Medical School, where he led a team of colleagues from Harvard teaching hospitals in providing mental health and violence prevention services to the Massachusetts prisons and prison mental hospital. He is the author of Violence: Reflections on a National Epidemic and Preventing Violence: Prospects for Tomorrow. His latest book, Why Some Politicians are More Dangerous Than Others, is devoted to his research into how rates of both suicide and homicide in the US change based on which political party is in power.

Rebecca Aponte Rebecca Aponte was the Operations Manager for Psychotherapy.net from 2008-2012. She then left California for graduate school, earning a PhD in Psychology from Colorado State University - an experience that only deepened her appreciation for the experience she was exposed to during her time with Psychotherapy.net. Rebecca now works for the California Department of State Hospitals.

CE credits: 2.5

Learning Objectives:

  • Describe the early childhood environments of adult violent offenders
  • List the diverse range of therapeutic strategies for prison inmates
  • Explain the reasoning behind prison reform directed toward an education-focused model

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here