Psychiatric clinicians must understand the cultural gap between prison and the world in which the rest of us live if they are to treat current or former prisoners, said participants in a daylong workshop presented by psychiatry residents at the University of Maryland School of Medicine in Baltimore in March.

The event was part of an annual series of programs presented by psychiatry residents exploring different cultures.

About 2.5 million people now are incarcerated in American jails and prisons, and as many as 10 million have cycled through those systems in recent years. Half are African American. Most—80 percent—are believed to have been physically or sexually abused at some time in their lives. A similar percentage have abused substances.

Many had mental disorders before they were imprisoned, and others developed them behind bars, said psychiatrist Terry Kupers, M.D., of the Alta Bates Summit Medical Center in Oakland, Calif., at the Maryland workshop.

"Many people who should be receiving psychiatric services are put into prisons," where services are less than optimal, noted Kupers.

There are two cultures in prison, the official and unofficial, he said. As expected, the official culture is nominally under the control of the warden and the correctional officers (who, said Kupers, hate to be called "guards").

"In prison, there are 10 rules for every one rule in the outside world, and they are stringently enforced," he said. Even minor exceptions can't be made at the line level and are passed up the chain of command. Once, on his way to interview a prisoner, Kupers asked the officer at the gate if he could bring his computer in. The officer couldn't answer and had to ask his superior, who passed the question up to his commander.

The unofficial culture is the world of the inmates. It places a premium on toughness and vengeance against informing to officers. Officers have their own "nosnitch" rule, too, one that discourages anyone from reporting misbehavior by officers.

The unofficial culture is also ruled by a code that reflects a dominance hierarchy, said Kupers. "You have to be the top dog or you get used as a sexual object." Mentally ill prisoners have real problems navigating between the unofficial and official cultures.

In prison, friends count, said Kupers. "You don't hit, rape, steal from people with friends," he said. "People with severe mental illness don't have friends. They're loners, so they become targets. If they report assault or mistreatment, they only invite retaliation."

In addition, use of isolation cells is becoming more common today, which leads only to more anxiety, more anger, and more paranoia. About 56 percent of prisoners held in isolation units (formerly called solitary confinement) endorse symptoms of mental illness, according to Kupers.

Furthermore, staff and prisoners are more and more isolated from each other, he said. Prisoners are frequently locked into their cells and kept in isolation. They avoid even the most innocuous conversations with officers, fearing that such interactions might be misconstrued from across the yard as snitching. The two groups don't know how to talk to each other, further decreasing understanding between them and leading to more anger, confrontations, and violence.

Mental health care is generally poor in the American prison system because society has decided not to provide much of it, and conditions within prisons make the work of mental health professionals difficult, said Kupers.

For one thing, the prison staff is concerned about malingering by prisoners. For another, in some prisons, security issues or staff shortages preclude moving prisoners held in isolation units to an office for confidential interviews.

"That means that the psychiatrist talks to the patient through the bars or through the food port in a solid cell door, within earshot of prisoners in neighboring cells or staff passing by," Kupers explained in an interview. "When prisoners with mental illness are stigmatized as ‘dings’ or worse, the clinician must ask in a voice loud enough to be overheard, ‘Are you still hearing voices?,’ ‘How is that new medication working?,’ ‘Are you feeling suicidal?’ More often than not, the prisoner refuses to respond, so the information gleaned from the cell-door interview is not even reliable."

For that reason, mental health personnel should refuse to do cell-door interviews, said Kupers.

Mental health staff members are also pressed from the opposite direction by the "blue code," he said. If they observe an inappropriate use of force by officers, they must decide whether to keep silent or turn in the offending officer and risk retaliation.

Retaliation may take several forms, said Kupers. Officers can refuse to escort mental health staff on rounds, they can stall and keep mental health staff waiting to see prisoners, or, in more extreme situations, they can delay responding when a member of the mental health staff is assaulted by prisoners.

"I am certainly not claiming that all prison staff are unethical and unprofessional in this way," he said. "However, mental health staff sometimes overidentify with the officer culture and the blue code, and then they, like the nonabusive officers who fail to report, become complicit in the abuses of the minority of ‘bad apples’ among officers even though, if asked, they do not really condone maltreatment."

In general, said Kupers, providing mental health care in prisons is difficult for a number of reasons. Funding often fails to cover services urgently needed for the many individuals with serious mental illness in prison. There is a very high suicide rate in jails and prisons. Security concerns can hamper providing adequate care. Finally, a relatively small number of very disturbed prisoners are prone to act out and need a lot of clinical attention.

"Still, correctional psychiatry offers opportunities to devise new and creative interventions to treat patients who would not be treatable in other settings," said Kupers.

Treating prisoners is a major challenge, agreed Merrill Rotter, M.D., a forensic psychiatrist and an associate clinical professor of psychiatry and director of the Division of Law and Psychiatry at Albert Einstein College of Medicine in New York City.

To succeed in therapeutic engagement, clinicians must understand the impact of "doing time" and then take a culturally competent approach in engaging people who are or have been in prison.

"Incarceration is a form of cultural adaption," said Rotter. "The psychological environment is full of danger and the threat of violence. The social environment is rife with rules, codes, gangs, and race."

Shedding that world view isn't easy, said Rotter. Distrust of staff and peers is normal inside, but distrusting everyone after release is dysfunctional.

In fact, life inside prison distorts the prisoner's value system and makes it hard to function in the outside world after release. Lifesaving adaptations to prison life and correctional codes tend to be seen as "resistance" to therapy, inside or outside prison.

Minding one's own business, trusting no one, not sharing information, or manipulating others are unhelpful traits in a therapeutic milieu, job market, or relationships, said Rotter.

Thus, to help ex-prisoners adjust to the outside world, mental health clinicians must understand the cultural environment inside prisons, he said. Simply knowing that the patient has been incarcerated is not enough. "That's just the tip of the iceberg."

For instance, psychotropic medications carry different meaning inside and outside prison. Inside, being strong and self-reliant are behavioral assets, so accepting medications (an external support) is seen as weakness. Where hypervigilance is a necessity, some side effects (like sedation) may prove deadly when danger lies around any corner.

So, clinicians working with prisoners or ex-prisoners must learn more about this population to overcome their own resistance to it and to minimize stigma, just as they would with any other subculture, Rotter believes. Then they must help patients decrease resistance engendered by immersion in prison culture.

"Be willing to listen and learn about patients' experiences behind bars," he said. "Ask what the experience was like and how they got by and if those patterns are helpful when not in prison. Be aware of the differences and similarities between the cultures of prison and therapy."

Finally, Rotter advocates using cognitive-behavioral therapy variants to lessen the effects of cultural behaviors learned in prison and develop the skills to create new lives on the outside.

More information is available in Psychiatric Services in a study by Rotter and colleagues, "Best Practices: The Impact of the ‘Incarceration Culture’ on Reentry for Adults With Mental Illness: A Training and Group Treatment Model," posted at <http://ps.psychiatryonline.org/cgi/content/full/56/3/265>.