Billy Milligan and Dr. David Caul’s therapeutic relationship

Billy Milligan and Dr. David Caul’s therapeutic relationship joined intensive work on Milligan’s control and understanding of his condition to a gradual effort to restore autonomy. Caul used hypnotherapy, taught autosuggestion, and adjusted Milligan’s privileges as he improved. Their work became increasingly contentious when Milligan’s unsupervised leave drew public criticism and restrictions, placing the therapeutic goal of trust against institutional and political pressure.

From legal evaluation to treatment

Before Caul’s work is described, Milligan’s ability to participate in his defense had become a pressing concern. While Milligan was in prison, Gary Schweickart and Judy Stevenson continued visiting him despite receiving a letter dismissing them. The public defenders’ office paid for a psychological evaluation, and Dr. Willis C. Driscoll tested Milligan on January 8 and 13, 1978. Driscoll reported that depression had lowered Milligan’s IQ score of 68 and diagnosed acute schizophrenia. He also described severe difficulty distinguishing self from surroundings, voices that directed and berated Milligan, and his belief that good and bad people entered his body. Driscoll concluded that Milligan could not adequately understand events or assist in his defense and urged hospitalization.

On January 19, Stevenson and Schweickart presented the report to Judge Jay Flowers as evidence that Milligan could not assist with his own defense. Flowers proposed an examination by the forensic psychiatry unit at Southwest Community Mental Health Center. The defense worried that the unit would act in the prosecution’s interest. The dispute centered on whether statements made during the examination could later be used against Milligan. The parties reached a compromise: prosecutors could question him about incriminating statements only if he testified in his own defense. The defenders then allowed the examination to proceed on those terms. This legal struggle established the circumstances in which psychiatric assessment and treatment would shape Milligan’s case, but it was distinct from the later question of his responsibility at the time of the charged offenses.

Methods and growing autonomy

Caul’s treatment aimed to strengthen Milligan’s control of consciousness. Alongside general therapy, Caul used hypnotherapy and taught autosuggestion techniques to relieve tension. Weekly group therapy with two other patients diagnosed with multiple personality gave Milligan a chance to understand his condition through comparison with others. His switching became less frequent, and Caul considered him to be improving.

As the work progressed, Caul enlarged Milligan’s freedom in stages. He first permitted Milligan to leave the building with an attendant, then to sign himself out for short walks on the hospital grounds. Milligan used those walks to test pollution levels at several points along the Hocking River. He planned to study physics, biology, and art at Ohio University in the spring of 1979, and began charting his moods. These activities show treatment extending beyond symptom management: Milligan was making plans, observing his own condition, and using limited independence for projects of his choosing.

In mid-January, Milligan asked to go into town to get a haircut, visit the bank and his lawyer, and buy art supplies and books. Caul initially allowed trips with two hospital employees, then reduced the requirement to one attendant after the visits went well. Students who recognized Milligan from newspapers and television waved to him. The attention mattered to him as evidence that he might not be universally rejected. He then argued that trust should become reciprocal: having followed the program and learned to trust the people around him, he wanted the same unaccompanied town privileges given to other patients. Caul agreed he was ready. After consulting Superintendent Sue Foster and law-enforcement officials, the hospital set conditions requiring it to notify Athens police and the Adult Parole Authority in Lancaster whenever Milligan left or returned. Milligan agreed to comply.

Public controversy and withdrawn privileges

The arrangement became politically vulnerable. Legislators Claire “Buzz” Ball, Jr., and Mike Stinziano criticized the hospital and Caul, called for hearings, and pressed for reconsideration of the statute under which Milligan had been sent to Athens. Hospital staff members opposed to Milligan’s opportunity to sell paintings also leaked reports about the money he had received. When he used proceeds from the sale of “The Grace of Cathleen” to buy a compact Mazda for transporting his paintings, the purchase became headline news.

Ball and Stinziano demanded an investigative hearing at Athens hospital. Amid mounting criticism and frequent front-page coverage, Caul and Foster asked Milligan to surrender his furloughs and his privilege of leaving the grounds unattended until the uproar subsided. Milligan had obeyed the rules and, since his illness had been diagnosed and treated, had broken no laws; nevertheless, the privileges were taken away. The reversal made the terms of their therapeutic relationship plain: Caul had judged increased freedom to be part of treatment, while public pressure made that freedom difficult to sustain. Saddened by the withdrawal, the Teacher gave up and left the spot.

The dispute extended to Caul’s standing and professional judgment. After Milligan’s treatment plan again included furloughs, attacks on Caul resumed. The Ohio Ethics Commission began investigating whether he had improperly granted special privileges, amid an allegation that Milligan was receiving them because Caul was secretly writing a book about him. Caul filed an affidavit on July 17, 1979, arguing that his clinical decisions had been supported by professionals knowledgeable about the case and that the attacks had compromised his efforts to treat Milligan. After months of legal maneuvers, including subpoenas, depositions, and countersuits, Caul was unanimously cleared of wrongdoing. The process nonetheless consumed more of his time and energy as he defended his reputation and family. He knew that keeping Milligan confined could stop the threats, but refused to yield when he believed treatment required treating Milligan as any other patient.

Clinical judgment and legal outcome

The pressures surrounding treatment did not themselves determine the legal findings. At Milligan’s trial, Judge Flowers dismissed the first rape count for lack of corroborating evidence and a similar modus operandi. On the remaining counts, the medical evidence was stipulated: the doctors testified that Milligan was mentally ill when the offenses occurred, could not distinguish right from wrong, and could not refrain from the acts. Flowers found him not guilty by reason of insanity on counts two through ten. The ruling concerned Milligan’s mental state at the time of those offenses, rather than simply his current ability to participate in legal proceedings.

Later proceedings again addressed hospitalization and present risk. On December 10, 1979, a court found that Milligan had a substantial disorder affecting thought, mood, perception, orientation, and memory, and identified his condition as multiple personality. It also found grounds for court-ordered hospitalization, citing threats of suicide, recent violent behavior, and the need for treatment. That decision placed a limit on the autonomy Caul had tried to increase, but it did not erase the clinical question at the heart of their work: how to provide treatment while recognizing Milligan’s capacity to participate in it. Their relationship is therefore marked both by a practical progression toward trust and by the conflict between individualized care and the institutional demands surrounding a highly publicized patient.