1. The Clinical Impact of Doing Time
Merrill Rotter, M.D.
Associate Clinical Professor of Psychiatry
Albert Einstein College of Medicine
Divisional Seminar, April 15, 2008
Division of Law, Psychiatry and Ethics
Columbia University
2. 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.
5. “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
7. The Numbers – Disorder Prevalence
General Population
Jail Detainees (Teplin)
1.8%
Males 6.1%
Females 15.0%
Prison Inmates (Steadman)
Overall 15.0%
8. 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%)
9. “Those of us who do assessment research in correctional settings
must continually remember that we are dealing with atypical,
highly biased samples of people exposed to massive situational
influences specifically designed to alter their attitudes, personality
and behavior. Incarceration is a massive intervention that affects
every aspect of a person’s life for extended periods of time.”
Megargee, 1995
10. Adaptation To Incarceration
Is Prison or Jail a Culture?
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.
11. Shared Patterns of Behavior
Is Prison or Jail a Culture?
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.
12. Shared Attitudes
Is Prison or Jail a Culture?
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. .
13. Shared Beliefs
Is Prison or Jail a Culture?
“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.
14. Shared Values
Is Prison or Jail a Culture?
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.
15. Shared Language
Is Prison or Jail a Culture?
“Punk City” - “Push up on” - “Kite” - “Boomerang” - “Newjack”- “Hang
up” – “Juice” - “Box” – “Bing” – “Hole” – “SHU” – “Shank” – “Gun” –
“Bug” – “MO” – “Skittle” – “703” – “Jailin”
17. Incarceration as Cultural Adaptation
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.
20. 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%
21. 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)
22. New York State
NYS Beds occupied by “forensic” patients
60
50
40
30
20
10
0
OMH
FY 95-96
FY 90-91
FY 85-86
BPC
FY 85-86
FY 90-91
FY 95-96
23. New York State
NYS Beds occupied by “forensic”
patients
Not Fit and NGRI’s only
24. And when they get out…
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.
25. Clinical Impact
Do Your Own Time ---------- Isolate
Trust No One ------------------Manipulate
Don’t Snitch --------------------Don’t share information
Don’t Show Weakness ------ Look aggressive
26. 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
27. Prison & Jail Behavioral Categories
INTIMIDATION
Wolfing – use of verbal threats
Posing – use of nonverbal threats
Cliquing – gangs, crews or posses
DOING TIME
Hospital = Lockup
Privileges and levels = more or less lockup
Medication = trade merchandise
Staff = correction officers
CLINNICAL SCAMMING
Presenting through report or behavior what the client
thinks staff want to hear in order to get desired changes
CONNING
Misrepresentation and dishonesty to trick both patients
and staff for personal gain
SNITCHING
Trading in information about others for personal gain
STONEWALLING
Prison code of silence
28. SPECTRM BOS DISCRIMINATING ITEMS
ITEM DESCRIPTION
21
Makes general threats about the consequences if denied something.
INTIMIDATION
40
Speaks to other patients with implied threats if denied something.
INTIMIDATION
17
Lets people know they are dangerous.
INTIMIDATION
Makes threatening facial expressions and gestures .
INTIMIDATION
Wears chosen colors those worn by a specific group of patients.
INTIMIDATION
INTIMIDATION
23
Directs specific other patients to reward and punish staff and non-member
patients.
Organizes group pressure among patients to get favors paid back
24
Recruits other patients into an on-going group relationship.
INTIMIDATION
16
Advises other patients to keep staff involvement at a minimum .
STONEWALLING
56
Shows distaste for patients who are open with staff.
STONEWALLING
14
Threatens that patients who give information to staff will face retaliation.
STONEWALLING
50
Tries to use staff to punish people he/she dislikes or competitors.
SNITCHING
18
Lets staff know how brave they are for sharing information.
SNITCHING
36
Uses jail/prison language about C.O.’s, inmates,lockdowns, and release dates.
DOING TIME
55
Expresses concern that taking medication may make one vulnerable to attack.
UNCLASSIFIED
9
53
6
p<0.05 for full cohort
p<0.10 or better with gender as covariate
INTIMIDATION
29. SPECTRM BOS Advantages and Limitations
• Staff dependant
• Empirical assessment
More likely to report untoward behavior
Beliefs and Values not assessed directly
30. 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
31. SACA-R Development 2
Items and Scoring
Respect
Posturing
Trust
Wolfing
Isolation
Cliquing
Manipulation
Medication Concerns
Snitching
Doing Your Own Time
Stonewalling
Stigma of Mental Illness
Vigilance
Malingering
Bid Mentality
Dissembling
32. SACA-R Development 2
Sample Item/Definition
Possible
Ratings
0 = no
Rating Item
1 = maybe
•Respect
2 = yes
X = omit
1.
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
33. 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
Vigilance
Bid
Mentality
Posturing
Stonewalling
Malingering
Dissembling
Snitching
Wolfing
Do Your Own Time
Cliquing
Medication Concerns
Manipulatio
n
Stigma of Mental
Illness
34. 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
Vigilance
Bid
Mentality
Posturing
Stonewalling
Malingering
Dissembling
Snitching
Wolfing
Do Your Own Time
Cliquing
Medication
Concerns
Manipulati
on
Stigma of Mental
Illness
35. 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 (α = .67)
SACA total score associated with
Time sentenced
Frequency of disciplinary tickets
36. 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
37. SACA-R Development 2
Study 2
Jail (n=123)
No Jail (n=25)
Total (n=149)
38.7
26.6
38.4
13
92
Hispanic 32
7
39
Caucasian 11
5
16
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%)
Mean Age
Race
African American 79
Diagnosis
Schiz. Spectrum 111 (90.2%)
38. 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
39. 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*
40. 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
41. 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.
43. 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?
44. Correctional Cultural Competence:
Patient Focus - RAP Group
CONNECTING
War stories
EXPLORING
Psycho-Education: Setting Differences and Similarities
CHANGING
Cognitive Behavioral Technology: Script and Disputation
