The Clinical Impact Of Doing Time

The Clinical Impact of Doing Time Divisional Seminar, April 15, 2008 Division of Law, Psychiatry and Ethics Columbia University Merrill Rotter, M.D. Associate Clinical Professor of Psychiatry Albert Einstein College of Medicine

The first night's the toughest, no doubt about it. They march you in naked as the day you were born, skin burning and half blind from that delousing shit they throw on you, and when they put you in that cell...and those bars slam home... that's when you know it's for real. A whole life blown away in the blink of an eye. Nothing left but all the time in the world to think about it.

The SPECTRM Project
Criminalization
The Culture of Incarceration
Community Considerations/Clinical Impact
Structured Assessment of Correctional Adaptation (SACA) Development
Outline

The Challenge: Clinical Impact of Doing Time The Approach: Cultural Competence The Objective: Therapeutic Engagement About SPECTRM

“ PART OF MENTAL ILLNESS IN AMERICA TODAY IS THAT YOU ARE GOING TO GET ARRESTED.” Laurie M. Flynn, Executive Director National Alliance for the Mentally Ill New York Times, March 5, 1998

Criminalization Causative Factors Deinstitionalization Restrictive Civil Commitment Criteria Access to Treatment Role of Police Lamb and Weinberger, Psychiatric Services, 1998

The Numbers – Disorder Prevalence General Population 1.8% Jail Detainees (Teplin) Males 6.1% Females 15.0% Prison Inmates (Steadman) Overall 15.0%

More Numbers 800+ mental health beds at Rikers: Largest psychiatric facility in New York State 15,000 individuals with mental illness released from Rikers each year 7500 prison inmates on mental health caseload (11%)

Megargee, 1995

Is Prison or Jail a Culture? Adaptation To Incarceration The way of life of a particular society, transmitted from one generation to the next, and reflected in behavior patterns, attitudes, beliefs, values, social organization, religion, language, structure, economic organization and material.

Is Prison or Jail a Culture? Shared Patterns of Behavior Prison and jail are environments of constant danger and threat of violence. They require a level of alertness which anywhere else would be characterized as hypervigilence.

Is Prison or Jail a Culture? Shared Attitudes Prison and jail populations typically are characterized by presumptive distrust – distrust of staff – distrust of peers . Guardedness and secretiveness are adaptive attitudes within correctional environments. .

Is Prison or Jail a Culture? Shared Beliefs “ Snitches get stitches” is a prison and jail belief shared by everyone. While snitching goes on all the time in prison and jail – because information is a commodity that can be traded for gain – everyone is aware of the consequences of being caught – of being identified as a snitch.

Is Prison or Jail a Culture? Shared Values Prison and jail populations typically value strength in all its manifestations - from physical strength to self reliance. Projecting an image of being tough and menacing as an example is highly adaptive in these environments.

Is Prison or Jail a Culture? Shared Language “ Punk City” - “Push up on” - “Kite” - “Boomerang” - “Newjack”- “Hang up” – “Juice” - “Box” – “Bing” – “Hole” – “SHU” – “Shank” – “Gun” – “Bug” – “MO” – “Skittle” – “703” – “Jailin”

Inmate Code Do Your Own Time Trust No One Don’t Snitch Don’t Show Weakness

These walls are kind of funny. First you hate 'em, then you get used to 'em. Enough time passes, gets so you depend on them. That's institutionalized. Incarceration as Cultural Adaptation

POLICE ER (EDP) COMMUNITY TREATMENT ARREST ARRAIGNMENT MENTAL HEALTH COURT TRIAL PART JAIL/PRISON Adapted from GAINS Sequential Intercept Diagram Pre-booking Post-booking

Release Brad H. Reentry CORP Diversion Mental Health Courts Medicalization The “Other” Deinstitutionalization

Community Considerations
Beds occupied by “forensic” patients
Canada, 1976-1997: 3% -> 18%
US (36 states), 1987-2000: 19%-32%
Missouri, 1997: 51%
California, 1993: 41%

Community Considerations
More numbers - histories of CJ contact
42 % ICM clients (Draine, 1992)
45% of outpatients (Theriot, 2005)
36% conviction
19% felony conviction
59% of patients with schizophrenia (Lafayette, 2003)
66% of people entered into ACCESS case management services across 18 states (Mcguire, 2004)

New York State
NYS Beds occupied by “forensic” patients

New York State
NYS Beds occupied by “forensic” patients
Not Fit and NGRI’s only

There is a harsh truth to face. No way I'm gonna make it on the outside. All I do anymore is think of ways to break my parole. Terrible thing, to live in fear… All I want is to be back where things make sense. And when they get out…

Clinical Impact Do Your Own Time ---------- Isolate Trust No One ------------------Manipulate Don’t Snitch --------------------Don’t share information Don’t Show Weakness ------ Look aggressive

Clinical Impact
Series Of Focus Groups
Inpatient, Outpatient and Jail-Based Mental Health Staff
Behavioral Categories Emerge
Intimidation, Doing Time, Clinical Scamming, Conning, Snitching, Stonewalling
SPECTRM Behavioral Observation Scale
61 Items Extrapolated
Instrument Application
300 Staff Rate 45 Patients
Identification of Discriminating Items
Rotter et al, 2005

Prison & Jail Behavioral Categories Prison code of silence STONEWALLING Trading in information about others for personal gain SNITCHING Misrepresentation and dishonesty to trick both patients and staff for personal gain CONNING Presenting through report or behavior what the client thinks staff want to hear in order to get desired changes CLINNICAL SCAMMING Hospital = Lockup Privileges and levels = more or less lockup Medication = trade merchandise Staff = correction officers DOING TIME Wolfing – use of verbal threats Posing – use of nonverbal threats Cliquing – gangs, crews or posses INTIMIDATION

SPECTRM BOS DISCRIMINATING ITEMS  p<0.05 for full cohort  p<0.10 or better with gender as covariate UNCLASSIFIED Expresses concern that taking medication may make one vulnerable to attack. 55 DOING TIME Uses jail/prison language about C.O.’s, inmates,lockdowns, and release dates. 36 SNITCHING Lets staff know how brave they are for sharing information. 18 SNITCHING Tries to use staff to punish people he/she dislikes or competitors. 50 STONEWALLING Threatens that patients who give information to staff will face retaliation. 14 STONEWALLING Shows distaste for patients who are open with staff. 56 STONEWALLING Advises other patients to keep staff involvement at a minimum . 16 INTIMIDATION Recruits other patients into an on-going group relationship. 24 INTIMIDATION Organizes group pressure among patients to get favors paid back 23 INTIMIDATION Directs specific other patients to reward and punish staff and non-member patients. 6 INTIMIDATION Wears chosen colors those worn by a specific group of patients. 53 INTIMIDATION Makes threatening facial expressions and gestures . 9 INTIMIDATION Lets people know they are dangerous. 17 INTIMIDATION Speaks to other patients with implied threats if denied something. 40 INTIMIDATION Makes general threats about the consequences if denied something. 21 ITEM DESCRIPTION

SPECTRM BOS Advantages and Limitations
Staff dependant
Empirical assessment
More likely to report untoward behavior
Beliefs and Values not assessed directly

SACA-R Development 2 Identification of Core Adaptations Definitions Development of Structured Interview (SACA) Implementation in NYC Shelter Study SACA Revision for clarity (SACA-Revised) Item and Interview Definition Revision SACA-R Study 1 SACA-R Study 2

SACA-R Development 2 Items and Scoring Respect Trust Isolation Manipulation Snitching Stonewalling Vigilance Bid Mentality Posturing Wolfing Cliquing Medication Concerns Doing Your Own Time Stigma of Mental Illness Malingering Dissembling

SACA-R Development 2 Sample Item/Definition
Respect
expresses concern over being disrespected
indicates that disrespect from others is a challenge or provocation
perceives staring as disrespectful
describes innocent behaviors of others as disrespectful
Possible Ratings Rating Item 0 = no 1 = maybe 2 = yes X = omit 1. Respect

SACA-R Development 2 Sample Question What do you think of the staff here? How do they treat you? Are you treated fairly? Are there particular staff you like or don’t like? How come? Are you treated with respect? How important is that to you? What would be an example of someone disrespecting you? What would you do about it? Do you feel you can trust the staff? Are there particular staff you can trust? What makes them trustworthy? How can you tell who to trust? Do you feel you can share information with staff? Are there things you would not share with staff? About yourself? About others? How come? Respect Trust Isolation Snitching Do Your Own Time Vigilance Bid Mentality Posturing Wolfing Cliquing Medication Concerns Stonewalling Malingering Dissembling Manipulation Stigma of Mental Illness

SACA-R Development 2 Sample Question 2 Vignette #2: If you got into an argument about what TV channel to watch and it turned into a fight that led to staff intervening. And when it was all over the staff member who got involved asked you to come get staff to help next time an argument like this began. Would you take this advice? If no, Why wouldn’t you? How would taking the advice be a problem? Respect Trust Isolation Snitching Do Your Own Time Vigilance Bid Mentality Posturing Wolfing Cliquing Medication Concerns Stonewalling Malingering Dissembling Manipulation Stigma of Mental Illness

SACA-R Development 2 Study 1 Findings Structured Assessment of Correctional Adaptation (SACA) Carr et al (2006) n= 64 male patients with history of incarceration Good interater reliability (ICC = .83) Reliability of individual items varied Acceptable internal consistency (  = .67) SACA total score associated with Time sentenced Frequency of disciplinary tickets

SACA-R Development 2 Study 2 - Method
Subjects: 147 male patients at state hospital
Method: Chart review and structured interview
SACA-R
Psychopathy Checklist - Revised
Working Alliance Inventory
Brief Psychiatric Rating Scale
PICTS

SACA-R Development 2 Study 2 Jail (n=123) No Jail (n=25) Total (n=149) Mean Age 38.7 26.6 38.4 Race African American 79 13 92 Hispanic 32 7 39 Caucasian 11 5 16 Diagnosis Schiz. Spectrum 111 (90.2%) 24 (96.0%) 135 (97.1%) Affective Disorder 11 (8.9%) 1 (4.0%) 12 (8.1%) Substance Abuse 70 (56.9%) 8 (33.3%) 78 (52.3%)

SACA-R Development 2 Study 2 - Factor Analysis Intimidation Isolation Deception Respect Trust Manipulation Vigilance Stonewalling Cliquing Posturing Bid Mentality Malingering Wolfing Do your Own time Dissembling

SACA-R Development 2 Study 2 - Concurrent Validity Intimidation Isolation Deception SACA 13 Age 0.41 .01 .01 .04 Jail (vs. no Jail) .19* .25* .16 .28* Disciplinary Tickets .32* .09 .19* .31* Working Alliance - Bond -.11 -.21 -.21 -.27* PCL - Total Score .53* .26* .26* .49* BPRS Total Score .29* .02 .07 .23*

SACA-R Development 2 Conclusions
Construct Validated
Continuing Effect of Incarceration
Effect on Adaptation Clinical Culture
Total SACA-R Score & 2/3 Factor
Particularly Isolation
Moderate association with Psychopathy
Particularly Intimidation
Working Alliance Affected
Isolation Factor

I have trouble sleepin' at night. I have bad dreams like I'm falling. I wake up scared. Sometimes it takes me a while to remember where I am.

Challenges and Targets Provider Reluctance Patient Adaptation

Correctional Cultural Competence: Provider Focus CONNECTING Be willing to listen and learn: Where were you and what was it like? EXPLORING Be aware of differences and similarities in the two cultures: What are the cues? CHANGING Be neutral: Is it working for you here?

CONNECTING War stories EXPLORING Psycho-Education: Setting Differences and Similarities CHANGING Cognitive Behavioral Technology: Script and Disputation Correctional Cultural Competence: Patient Focus - RAP Group

The Clinical Impact Of Doing Time

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