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Copyright © 2011 by the American Psychiatric Association.
Seven men sit before me, eyes closed, heads bowed, and hands resting in their laps. They concentrate on their breathing, chests rising and falling, a few softly intoning the words "in" and "out" while others shift to find a comfortable position. Calming music plays, overlaid with my own half-mumbled encouragements. This might be mistaken for a community meditation group, were it not for the uniform white jumpsuits and individual steel-mesh cages into which each man is padlocked.
This is the Administrative Segregation Unit, or ASU, at the California Men's Colony State Prison in San Luis Obispo. The Men's Colony, or CMC, one of 33 prisons in the Golden State, is considered by many experts to provide the best general health, mental health, and dental care in any of California's institutions. The seven men who meditate with me have all been accused or convicted of rules violations within the prison itself. Their punishment is time in the ASU or, as they call it, "the hole." They spend most of their time isolated in their cells. They come out only for scheduled doctor visits, weekly individual exercise yard time, or the occasional group activity, such as mine.
Having allowed them a few minutes to focus on breathing, I now lead them through a series of stretches, tensing and relaxing our muscles, sometimes called progressive relaxation. My hope is to teach them skills they can use when they go back to their cells or when they are having trouble falling asleep. Insomnia is ubiquitous in ASU. One key to relaxing the mind, I suggest to them, is relaxing the body. They nod in agreement.
My approach to teaching meditation to prisoners is based on a lot of trial and error. Formerly a clinician in the California prison system's highest level of care, just below acute crisis care, I started out just evaluating inmates' medication regimens. At most institutions these monthly contacts are the primary responsibility of the psychiatrist's practice. I am fortunate, however, in that CMC not only allows but encourages us to lead groups. After a year or so of solely evaluating medication regimens, I was struck by the realization that many of my patients were suffering from the sorts of ailments that benefit from meditation.
So I started a meditation group. Originally, we practiced several types, including walking meditation. This turned out not to be such a good idea when one of the inmates twisted his ankle in a pothole! But the classes have proved successful. One reason for this success is how I run the groups. My approach to treating these men has always been to regard them first as human beings, second as patients, and only finally as inmates. This approach seems to work fairly well. My attitude is not always shared by the custody staff, but we on the mental health services staff work alongside custody, and our relationship is usually collegial. Such a multidisciplinary effort is essential given CMC's nearly 1,800 mental health patients.
CMC is not unique. Thousands of inmates throughout California's penitentiaries are treated for mental health issues. California prisons are not unique, in that all other states in the Union offer such services to prisoners who require them. What makes California unusual is the number of individuals who are incarcerated: almost 170,000. This huge population demands large mental health services departments in each institution. The demand increases almost daily, as more felons arrive at the gates; the supply fluctuates, but at present, there are not enough psychiatrists to fill the void.
Many psychiatrists do not want to work with inmates. This is understandable. As I scan the room where we are having our group meditation and look at each man, isolated, trying to learn some relaxation skills to help him deal with his stress, I consider their commitment offenses. The list reads like a litany of FBI statistics: murder, battery, assault, kidnap, rape, manslaughter, robbery, carjacking, arson, and torture. But there is a counterbalance. I've seen inmates care for baby birds and show surprising degrees of empathy to one another. There are rays of enlightenment.
We move on from progressive relaxation to guided imagery. I now ask them to imagine, in their mind's eye, a place. It can be any place—a forest, a desert, the ocean, a city park—any place they feel safe, any place they can "go" to escape the everyday horrors of prison life. I then try to guide them around their safe place, hoping they will formulate in their own minds a unique vision of it. At times this can seem ironic, such as when I ask them to "hear" the birds singing, when the only actual sounds are heavy tier gates crashing open and closed, or when I ask them to "feel" the grass beneath their feet, when the floor beneath them is stone or tile. Their bodies are literally trapped in cages, euphemistically called "individual treatment modules," but their minds can soar.
Most of the time, they make an effort at meditating. Over time, a winnowing process narrows the group to just the inmates who really want to be there. These men now close their eyes and try to imagine some place better than where they are. In the process, some might learn mindfulness. Others might be surprised to find how challenging and enjoyable it is just to relax and focus on breathing or clearing the mind. And I think they get something out of these groups. Not every man in every group benefits, but many do. As physicians, though we treat many and heal few, we hope we can offer comfort to most.
These men have been convicted of crimes, often heinous ones. But serving the prison term is the punishment, not how they are treated in prison. They have a right to a minimum standard of health care, including mental health care. Unfortunately, groups such as mine are rare in the California Department of Corrections and Rehabilitation. But for physicians who are committed to helping the underserved, this can be a rewarding challenge. Groups like mine go a long way toward treating the mental health needs of our inmates. My hope, always, is to offer some measure of comfort.
Often, the group is comforting to me, as well. After endless committee meetings, lengthy treatment team meetings, and on-call duties, it is nice just to sit and reflect. I usually learn as much from the inmates as they do from me. We wind up our relaxation with a few minutes of silence, except for the music. I then invite them to return to the room, opening their eyes when they are ready. As the custody officers escort the inmates from the room, shuffling, handcuffed, they all thank me, and I thank them for coming, praising them for their participation, offering my wish that they have benefited from their efforts. They nod in agreement.
So, while I can readily understand why many psychiatrists would not want to work in a prison setting, my own feeling of satisfaction is unalloyed. Although I did not start out in corrections doing "forensic" psychiatry, as it is called, I expect to finish my career here. Do I always love my job? Of course not. Is it hard to gear up for my group every week? Certainly. Would I stop doing it, though, if I could? Probably not. It helps me retain my humanity in a place often devoid of this quality.
My advice to psychiatrists who are just finishing residency, and even to those who have been in practice for some time, is to consider corrections work. The work is far more rewarding than you might imagine, and the drawbacks often far less onerous than you might think. It is not for everyone. But put it on your short list of job options. Visit a penitentiary to see what working there is really like. Talk to the folks who have chosen to practice there. What you see and hear might surprise you.
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