Publication: Sensitizing Providers to the Effects of Incarceration on Treatment and Risk Management (SPECTRM)

People with serious psychiatric disorders experience high rates of incarceration. Through their experiences 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. Although these behaviors help the person adapt and survive during incarceration, they seriously conflict with the expectations of most therapeutic environments and interfere with community adjustment and personal recovery after release.

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. Sensitizing Providers to the Effects of Correctional Incarceration on Treatment and Risk Management (SPECTRM) targets provider training with a defined modality of rehabilitation to expand the willingness and ability of clinicians to help individuals with mental health issues reach their recovery goals.

History of SPECTRM

Despite recent increased attention to the prevalence of persons with mental illness in the criminal justice system, little attention has been paid to the cultural impact of incarceration when these individuals are released from incarceration and enter civil inpatient or community-based treatment settings. Rotter and colleagues found that when individuals were directly transferred upon release from prison to a civil hospital inpatient unit, they experienced difficulties adjusting to their surroundings and displayed more disruptive behaviors and serious incidents.

In 1996, Rotter and colleagues obtained an Occupational Safety and Health Administration (OSHA) grant as part of a workforce development initiative with the hypothesis that increased staff awareness of the incarceration experience and specialized treatment of patients with incarceration histories may benefit from the therapeutic atmosphere, which is likely to improve safety on a psychiatric inpatient ward.

To develop some empirical underpinnings for this program, initially a series of focus groups was developed with inpatient, outpatient, and corrections-based mental health providers to identify behaviors that they believed distinguished the population of offenders struggling with mental health issues. Concurrently, the authors videotaped patient interviews that were structured to draw out offenders’ experiences in jail and prison and their reactions to their current clinical environment.

Further, a behavioral observation scale was developed that staff could use to rate an individual patient’s attitudes and behaviors. Its elements were drawn from six behavioral categories: (1) intimidation, (2) snitching, (3) stonewalling, (4) using coercion and jail language, (5) conning, and (6) clinical scamming. The scale was administered to 30 inpatients with a history of incarceration and to 15 inpatients without such a history. Categories more prevalent among patients with incarceration histories included intimidation, stonewalling, and snitching.

Individuals adapt to the culture of incarceration by adopting the inmate code. While adaptive in a correctional setting, these beliefs and behaviors may obstruct engagement in treatment and residential programs. The table (over) illustrates the transference of inmate code to the therapeutic setting, where these behaviors become maladaptive. In the clinical sense, staff may misinterpret these behaviors as resistance to treatment and/or as acute symptoms of mental illness (e.g., depression-related passivity or guardedness secondary to paranoia).

In 2002, Project Renewal in New York City, introduced SPECTRM provider training and the Re-Entry After Prison / Jail (RAP) program in two shelters (one men’s and one women’s shelter) for single adults who were homeless and had serious mental illness. The duration of the program was four months, and participants were surveyed before and after the program. Ten men began the RAP program, and seven completed; fifteen women began the program and eight completed. Throughout the training program, it was discovered that both men and women developed a greater sense of trust in staff and peers, despite the fact that they described the environment of the shelter as similar to jail or prison. 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.

Inmate Code	Behaviors in a Therapeutic Setting
Adaptations dictated by inmate code and environmental factors	The same behaviors are interpreted by staff as resistance in the therapeutic setting
Do your own time	Lack of treatment involvement
Don’t be a snitch/rat	Don’t talk to staff
Don’t trust anyone	Don’t engage with staff or other patients
Respect	Violent or threatening behaviors
Strength and Weakness	Medication refusal, Violent or threatening behaviors
Fear and Vigilance	Medication refusal, Violence as a response to threat
Freedom Limited	I did my time, Hospital or Prison
Extortion, Gambling, Drug Trafficking and Use	Treating the hospital or residence program as an extension of prison; e.g., trading cigarettes and commissary
Transiency	Lack of treatment involvement; does not engage with staff or other clients
Lack of Privacy	No eye contact; strict demands regarding personal space
(Rotter, Larkin, Schare, Massaro, & Steinbacher, 1998).

Features

The provider training component of SPECTRM reviews potential behaviors that are considered adaptive in jail and prison and uses a cultural competence approach to address them. Through teaching treatment providers about the incarceration experience and showing them how behaviors adapted therein are traditionally misinterpreted in community treatment settings, staff are better able to understand their clients and engage them in treatment more effectively and efficiently.

The Re-Entry After Prison / Jail (RAP) Program is designed to assist providers in working with people with serious mental illness who have histories of correctional incarceration. The purpose of this program is to help participants make a successful transition from correctional settings to therapeutic settings and the community. It provides participants with the skills necessary to better engage in therapeutic services and to help avoid further hospitalization and/or incarceration.

Based on a cultural competence model, the program is based in cognitive behavioral theory and utilizes psycho-educational and reframing techniques. It helps participants to relinquish behaviors learned or reinforced in the cultures of jail and prison that interfere with successful readjustment and to replace them with skills that will help them better achieve their own personal goals.

Conclusion

Cultural competence requires that agencies be able to identify and understand the help seeking needs of the population they serve and deliver services tailored to their unique needs. Meeting the needs of individuals with mental illness who have histories of incarceration is challenging, and compounded by providers’ unwillingness to treat this poorly understood and estranged clinical population. SPECTRM is an approach to increase the mental health workforce capacity to provide quality clinical work in therapeutic settings and add a best practice dimension to cultural competence by recognizing the need for a special clinical emphasis on adaptations to incarceration. Simultaneously, individuals with incarceration histories and now receiving services in civil and community treatment settings may be better able to take advantage of community rehabilitation.

To learn more about the SPECTRM training, contact Dr. Merrill Rotter (Bronx Psychiatric Center, Bronx, NY / Albert Einstein College of Medicine, Yeshiva University, Bronx, NY 10461) at Brdomrr@omh.state.ny.us.

Resources

Broner, N. (2002). Evaluation of SPECTRM implemented with male and female shelter populations: A final report. North Carolina: RTI International.

Lamb, HR, & Weinberger, LE. (1998). Persons with severe mental illness in jails and prisons: A review. Psychiatric Services, 49, 483-492.

National Center for Cultural Competence (2006). Conceptual Frameworks / Models, Guiding Values and Principles. Retrieved November 7, 2006, from http://www11.georgetown.edu/research/gucchd/nccc/foundations/frameworks.html

Rotter, MR, Larkin, S, Schare, ML, Massaro J, & Steinbacher, M. (1998). The Clinical Impact of Doing Time: Mental Illness and Incarceration. Albany, New York: New York State Department of Labor.

Rotter, MR, Larkin, S, Schare, ML, Massaro J, & Steinbacher, M. (1999). The clinical impact of doing time: Mental illness and incarceration, Resource manual. Albany: New York State Department of Labor.

Rotter, M, McQuistion, HL, Broner, N, & Steinbacher, M. (2005). The impact of the “incarceration culture” on reentry for adults with mental illness: A training and group treatment model. Psychiatric Services, 56(3), 265-267.

Rotter, M, & Steinbacher, MA. (2002, October). Reducing ward violence by working with mentally disordered offenders. Paper presented at the Annual Meeting of the Institute of Psychiatric Services, Chicago, IL.

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