Treating Former Inmates Means Overcoming Prison Mind-Set

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 psychiatric treatment.

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 said

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 setting.”

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. ▪