FIG1 The same behaviors and
attitudes adopted by jail and prison inmates to help them survive in an
environment that can often be brutal and unforgiving can later interfere with
Merrill Rotter, M.D.: Prisons and jails have their own culture, which
inmates often reflect in therapeutic settings after they are
However, one type of intervention developed at a state psychiatric hospital
in New York is helping patients challenge some of these attitudes to maximize
the effects of their therapeutic experiences, according to two forensic
experts who spoke at the annual meeting of the American Academy of Psychiatry
and the Law in Scottsdale, Ariz., in October.
Most inmates have heard the adage, "Snitches get stitches,"
according to Merrill Rotter, M.D., a clinical associate professor of
psychiatry at Albert Einstein College of Medicine and director of forensic
services at Bronx Psychiatric Center.
"Information is often seen as a commodity" in prison and jail,
Rotter said. "You can see how that belief would conflict with the
culture of treatment, which is that of sharing and openness."
He explained that about half of the patients admitted to Bronx Psychiatric
Center have served time in prison or jail, and 20 percent transfer directly to
the hospital from correctional facilities.
Many of these former inmates bring with them the culture of incarceration,
Rotter pointed out, in which inmates value physical strength, self-reliance,
and the ability to look tough. "These are survival techniques in an
environment in which there is a constant psychological threat of danger and
violence," he noted.
These survival techniques, when brought to the therapeutic setting, soon
become blockades to patients' clinical improvement.
In addition to negative attitudes about "snitching," Rotter and
his staff have identified other attitudes and behaviors displayed by former
inmates admitted to the Bronx hospital.
These include "clinical scamming," which happens when patients
misrepresent their symptoms to get what they desire;"
stonewalling," in which patients withhold important information
about themselves or peers from hospital staff; and threatening hospital staff
and fellow patients.
To help former inmates get the most out of treatment at the hospital and
improve the staff's understanding of the effects of incarceration and how
attitudes developed by jail or prison inmates can interfere with treatment,
Rotter and his colleagues developed a clinical intervention called Sensitizing
Providers to the Effects of Correctional Incarceration on Treatment and Risk
Management, or SPECTRM.
The intervention educates staff about adaptations common to incarceration
and uses psychoeducation and cognitive-behavioral techniques in individual and
group settings to help patients challenge the attitudes that once protected
them behind bars.
When patients hold fast to ideals such as "don't take care of anyone
but yourself" or view their stay at Bronx Psychiatric as "doing
time," staff help them "reframe some of these ideas about
hospitalization," said Michael Steinbacher, M.A., a clinical
psychologist at Bronx Psychiatric and Sing Sing Prison in New York.
For instance, staff emphasize to patients that release from correctional
facilities is based on a "legal event," while being discharged
from treatment is dependent on a patient's clinical status, Steinbacher
Without help from trained staff, "I think it's too much to expect for
a patient to make the shift from running out the clock to participating in
therapy," he remarked.
Staff also reviews with patients other important distinctions between
prison and the hospital that patients may not be making for themselves, such
as the meaning of locked doors or the meaning of talking to staff.
While jail or prison populations are characterized by "presumptive
distrust," Steinbacher noted, the SPECTRM program helps them develop
trust in other patients and in staff by highlighting the difficulties inmates
have developing trust in correctional settings and "helping patients to
see why trust might be a more viable option within a clinical
The SPECTRM program also provides a safe place for patients to "make
sense of their experiences in jail and prison" and talk about their
struggles in adapting to the new, clinical environment with staff, who listen
to and support patients, Steinbacher said.
Rotter noted that patients who have participated in group therapy for
longer periods often serve as models for newer patients, who see that their
peers "have a trusting relationship with staff."
In group therapy, patients explore their experiences in jail and prison and
how some of these experiences "may have been traumatic or at least
difficult for them," Rotter said. They also examine the difficulties
patients have adapting to the therapeutic environment and how these
difficulties are colored by their experiences during incarceration.
Rotter gave an example of how patients learned that the "prison code
of silence" can become problematic in a clinical setting.
A patient on one of the hospital units made a serious suicide attempt that
fellow patients "had seen coming," Rotter said, "but did not
necessarily share with staff because they believed that you don't snitch or
tell on other patients."
In group therapy, patients processed the implications of the suicide
attempt including the results of "stonewalling the staff"—a
strategy that clearly failed, Rotter pointed out.
He noted that patients with a history of incarceration have serious needs
related to mental health and substance abuse treatment, education, job
training, and social functioning. By addressing the barriers to treatment
success associated with coping techniques learned in prison and jail,"
SPECTRM helps facilitate the provider-patient collaboration necessary
for treatment and recovery," Rotter said. ▪