Best Practices: The Impact of the "Incarceration Culture" on Reentry for Adults With Mental Illness: A Training and Group Treatment Model

People with serious psychiatric disorders experience high rates of incarceration (1). Through their experience in the uniquely demanding and dangerous environment of jail and prison, many develop a repertoire of adaptations that set them apart from persons who have not been incarcerated. The so-called inmate code—which includes rules and values such as do not snitch, do your own time, and do not appear weak—may be manifest in certain behaviors, such as not sharing any information with staff, minding one's business to an extreme, and demonstrating intimidating shows of strength.

Although these behaviors help the person adapt during incarceration and act as survival skills in a hostile setting, they seriously conflict with the expectations of most therapeutic environments and thus interfere with community adjustment and personal recovery. Simultaneously, mental health providers are frequently unaware of these patterns and misread signs of difficult adjustment as resistance, lack of motivation for treatment, evidence of character pathology, or active symptoms of mental illness. As a result, providers often experience unwarranted concerns about safety and lose opportunities for early and empathic engagement.

In this column we describe Sensitizing Providers to the Effects of Correctional Incarceration on Treatment and Risk Management (SPECTRM), an approach to client engagement that is based on an appreciation of the "culture of incarceration" and its attendant normative behaviors and beliefs. This column describes SPECTRM's systematic development as an emerging best practice for clinical training and group treatment.

The provision of mental health services with sensitivity to the beliefs, norms, and values of clients' cultural backgrounds is a well-accepted practice with nationally promulgated standards for competence (2). Cultural competence is similarly vital for the successful engagement of persons with mental illness who have a shared experience of an incarceration environment (3). Historically, rehabilitation programs have been available for offenders with substance use disorders who left jail and prison. These programs have focused primarily on linkage from prison treatment to treatment in therapeutic communities (4). Similarly, projects exist that are aimed at helping offenders with mental illness return to community living. However, these are also linkage rather than treatment models (5). We are unaware of a therapeutic model that specifically targets behaviors that are adapted for confinement, expands the more traditional ethnic-based concepts of cultural competence to incarceration, trains staff in culturally competent responses to these correctional adaptations, and teaches patients a new behavioral repertoire that facilitates reentry into the community.

Features

SPECTRM consists of a half-day training workshop for providers and a group treatment model for patients (Re-entry After Prison/Jail, or RAP). The SPECTRM training workshop reviews potential behaviors that are considered adaptive in jail and prison and uses a cultural competence approach to address them, showing providers how these behaviors are traditionally misinterpreted in community treatment settings.

The patient component, the RAP program, is a psychoeducational and social skills training curriculum informed by cognitive-behavioral techniques. This component focuses on developing an understanding of the effects of incarceration on interactions with peers and treatment providers. Patients learn about emotional triggers and associated behavioral patterns that are maladaptive in community living and subsequently begin to learn coping mechanisms that are more effective in solving interpersonal and practical challenges in the community.

Development

Phase I: early research

The SPECTRM project began with a descriptive exercise in distinguishing demographic and diagnostic features of clinical populations that had been previously incarcerated and elucidating behavioral characteristics engendered by incarceration. In 1996 we held a series of focus groups with inpatient, outpatient, and corrections-based mental health providers to identify behaviors that they believed distinguished the population of mentally ill offenders: intimidation, snitching, stonewalling, using prison and jail language, conning, and clinical scamming. Simultaneously, we videotaped patient interviews that were structured to elicit patients' experiences with jail and prison and their reactions to their current clinical environment.

In 1997 we initiated two research studies. In the first, the charts of 111 patients who were admitted to an urban state hospital during a six-month period were reviewed (6). Age, gender, diagnosis, and disruptive ward incidents (for example, fights and assaults and incidents that led to a need for emergency medication or seclusions and restraints) were examined for patients with a history of incarceration and those with no such history. The two groups were indistinguishable on all measures except for two: more males were in the formerly incarcerated group than in the other group (80 percent compared with 37 percent), and the mean severity of assault incidents was significantly higher among females with an incarceration history than among females who had not been incarcerated (p<.004) (6).

To further assess the behaviors that staff identified as being associated with patients with a history of incarceration, we developed a behavioral observation scale that staff could use to rate an individual patient's attitudes and behaviors. Its elements were drawn from the six behavioral categories noted above. The scale was administered to 30 inpatients with a history of incarceration and to 15 inpatients without such a history. Multiple ratings were done for each patient by different staff contemporaneously. Categories that were more prevalent among patients with incarceration histories included intimidation (aggressive or threatening posturing), stonewalling (not sharing with staff), and snitching (concern about being too open with staff). The other significant items related to feeling that the hospital was a prisonlike environment and a concern that taking medication made one vulnerable to attack (6). These items were consistent with actions and attitudes often described as adaptive by inmate populations (7).

Taken together with the focus groups and the videotaped patient interviews, these two studies support the idea that the jail and prison culture has a remarkable influence on consumers' attitudes and behaviors that could benefit from a targeted cultural competence approach. Consequently, we developed the provider training program, its accompanying manual, and the patient-focused RAP treatment manual.

Phase II: training dissemination and treatment implementation

Because of increasing awareness among community mental health providers about criminal justice and related clinical issues and owing to a spontaneously expressed need for education, we deployed the model as a work in progress. Since its creation in 1997 the provider workshop has been in demand from providers in outpatient and inpatient settings, prison-based mental health facilities, and community-based mental health organizations, as well as from government and academic training programs. Participants consistently give the workshop good to excellent ratings for quality and usefulness. In an early survey of programs that received the training, four out of five responding programs reported that they found a decrease in staff's complaints about and reluctance to work with clients with correctional histories, as well as a sense that patients were more rapidly becoming involved in treatment.

The RAP program was first implemented on a 30-bed ward for men at an urban state hospital in 1998. Between one-half and two-thirds of the patients on that unit have a history of incarceration. This subgroup of patients who had been incarcerated participated in the RAP program. We hypothesized that the incarceration-related adaptations, which are the focus of RAP treatment, might create a ward environment in which there were disruptive incidents among all patients, even in the absence of direct violence by the subpopulation of offenders. Therefore, a possible measure of RAP's effectiveness would be a reduction in frequency of disruptive ward incidents. To demonstrate the efficacy of the RAP program, the medical records of all patients who were in the ward in 1998 were compared with the records of all of those who were hospitalized in 1997, before RAP was implemented (8). A total of 83 patients were inpatients in 1998, and 76 patients were inpatients in 1997. Data on demographic characteristics, diagnoses, and incidents were gathered for seven months during both years. Charts of a subset of each group (15 participants in the 1997 group and 18 participants in the 1998 group) were randomly selected and were used to rate the risk of violence according to the HCR-20 violence risk assessment scheme and the Psychopathy Checklist-Screening Version (9). Compared with the seven-month period in 1997, the comparable period in 1998 was accompanied by a 28 percent reduction in the overall frequency of disruptive incidents on the ward (95 incidents in 1997 compared with 64 incidents in 1998) and 40 percent fewer violent episodes (32 episodes compared with 19 episodes). No differences were found between the two groups in age, diagnosis, race or ethnicity, history of previous violence, or risk assessment ratings. These preliminary results supported the hypothesis that specialized treatment of patients with incarceration histories may benefit the atmosphere and safety of a general psychiatric ward.

In 2002 Project Renewal, a not-for-profit mental health and chemical dependency organization based in New York City, introduced SPECTRM provider training and the RAP program in two shelters, one men's and one woman's shelter, for single adults who were homeless and who had serious mental illness. The RAP program lasted for four months, and participants were surveyed before and after the program (10). Ten men began the RAP program, and seven men completed it; 15 women began the program, and eight women completed it. Although the relatively few participants in the evaluation precluded statistical analysis, responses to questionnaires combined with in-depth interviews of participants who completed the program, indicated that both men and women developed a greater sense of trust in staff and peers through the program—for example, 13 of 15 participants expressed concern at baseline about trusting peers and staff, whereas only 5 of 15 participants remained concerned at follow-up. Persons who completed the program had a greater sense of trust, despite the fact that they described the environment of the shelter as similar to jail or prison. Responses also suggest that men who completed the RAP program found that discussing the experience of incarceration with those who shared the same experience was relieving and that they experienced reduced concerns about vulnerability, especially in regard to the effects of medication. A majority of persons who attended the RAP program completed the group sessions, a completion rate that is rare for this transient and highly disaffiliated population.

Phase III: refinement and advancement

Staff continue to be trained in SPECTRM, and RAP programs are being incorporated into court diversion initiatives and prison-based community preparation and reentry programs. We are also studying the reliability and validity of the structured assessment of correctional adaptations that were pilot tested in the shelter study. We believe that this developing instrument can eventually be useful as a research tool in refining and studying the efficacy of our cultural competence approach and as an assessment tool to enhance the transfer of knowledge from the SPECTRM workshop to practice in a variety of clinical settings, both forensic and nonforensic.

Conclusions

Individuals with mental illness and an incarceration history constitute a significant percentage of the public mental health patient population. Meeting their needs is challenging, and doing so can be made more difficult by providers' reluctance to treat this poorly understood and particularly alienated clinical population. SPECTRM's contribution in this regard is to complete the best practices picture of cultural competence by recognizing the need for a special clinical emphasis on people's responses to incarceration. SPECTRM targets provider training and then couples it with a defined modality of rehabilitation. As a result clinicians may experience greater willingness and ability to help ex-offenders with mental illness reach their recovery goals. Simultaneously, ex-offenders may be better able to take advantage of community rehabilitation. The interest in the SPECTRM model within the provider and client communities and the continuing development of reliable tools for measuring the model's features will allow SPECTRM to bolster the early studies detailed above with the continued rigorous research required to demonstrate the effectiveness of this approach as a best practice.

Dr. Rotter is director of forensic services at Bronx Psychiatric Center, 1500 Waters Place, Bronx, New York 10461 (e-mail, [email protected]) and associate clinical professor of psychiatry at Albert Einstein College of Medicine in Bronx. Dr. McQuistion is chief medical officer at the Division of Mental Hygiene in the New York City Department of Health and Mental Hygiene and associate clinical professor of psychiatry at the Mount Sinai School of Medicine in New York City. Dr. Broner is senior research psychologist at RTI International in New York City and adjunct associate professor of liberal arts at New York University in New York City. Mr. Steinbacher is a psychologist for the Central New York Psychiatric Center Satellite Unit at Sing Sing Correctional Facility in Ossining. William M. Glazer, M.D., is editor of this column.