columbia 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:The Challenge: Clinical Impact of Doing TimeClinical Impact of Doing Time

The Approach:The Approach: Cultural CompetenceCultural Competence

The Objective:The Objective: Therapeutic Engagement 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 PrevalenceThe Numbers – Disorder Prevalence

General Population 1.8%

Jail Detainees (Teplin) Males 6.1%

Females 15.0%

Prison Inmates (Steadman) Overall 15.0%

More NumbersMore 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%)

“Those of us who do assessment research in correctional settingsmust continually remember that we are dealing with atypical,highly biased samples of people exposed to massive situationalinfluences specifically designed to alter their attitudes, personalityand behavior. Incarceration is a massive intervention that affectsevery aspect of a person’s life for extended periods of time.”

Megargee, 1995

Is Prison or Jail a Culture?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.


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.


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. .


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.


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.


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

ReleaseBrad H.

ReentryCORP

DiversionMental Health Courts

Medicalization

The “Other” Deinstitutionalization

Community ConsiderationsCommunity Considerations

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

Community ConsiderationsCommunity Considerations

More numbers - histories of CJ contactMore numbers - histories of CJ contact 42 % ICM clients 42 % ICM clients (Draine, 1992)(Draine, 1992) 45% of outpatients 45% of outpatients (Theriot, 2005)(Theriot, 2005)

36% conviction36% conviction 19% felony conviction19% felony conviction

59% of patients with schizophrenia 59% of patients with schizophrenia (Lafayette, (Lafayette, 2003)2003)

66% of people entered into ACCESS case 66% of people entered into ACCESS case management services across 18 states management services across 18 states (Mcguire, (Mcguire, 2004)2004)

New York StateNew York State

NYS Beds occupied by “forensic” NYS Beds occupied by “forensic” patientspatients

OMH BPC

FY 85-86FY 90-91

FY 95-96

0102030405060

FY 85-86FY 90-91FY 95-96

New York StateNew York State

NYS Beds occupied by “forensic” NYS Beds occupied by “forensic” patientspatients Not Fit and NGRI’s onlyNot 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 silencePrison code of silenceSTONEWALLINGSTONEWALLING

Trading in information about others for personal Trading in information about others for personal gaingain

SNITCHINGSNITCHING

Misrepresentation and dishonesty to trick both Misrepresentation and dishonesty to trick both patients and staff for personal gainpatients and staff for personal gain

CONNINGCONNING

Presenting through report or behavior what the Presenting through report or behavior what the client thinks staff want to hear in order to get client thinks staff want to hear in order to get desired changesdesired changes

CLINNICAL SCAMMINGCLINNICAL SCAMMING

Hospital = LockupHospital = Lockup

Privileges and levels = more or less lockupPrivileges and levels = more or less lockup

Medication = trade merchandiseMedication = trade merchandise

Staff = correction officersStaff = correction officers

DOING TIMEDOING TIME

Wolfing – use of verbal threatsWolfing – use of verbal threats

Posing – use of nonverbal threatsPosing – use of nonverbal threats

Cliquing – gangs, crews or possesCliquing – gangs, crews or posses

INTIMIDATIONINTIMIDATION

SPECTRM BOS DISCRIMINATING ITEMS

UNCLASSIFIEDExpresses concern that taking medication may make one vulnerable to attack.55

DOING TIMEUses jail/prison language about C.O.’s, inmates,lockdowns, and release dates. 36

SNITCHINGLets staff know how brave they are for sharing information.18

SNITCHINGTries to use staff to punish people he/she dislikes or competitors.50

STONEWALLINGThreatens that patients who give information to staff will face retaliation.14

STONEWALLINGShows distaste for patients who are open with staff. 56

STONEWALLINGAdvises other patients to keep staff involvement at a minimum.16

INTIMIDATIONRecruits other patients into an on-going group relationship.24

INTIMIDATIONOrganizes group pressure among patients to get favors paid back23

INTIMIDATIONDirects specific other patients to reward and punish staff and non-member patients.

6

INTIMIDATIONWears chosen colors those worn by a specific group of patients.53

INTIMIDATIONMakes threatening facial expressions and gestures. 9

INTIMIDATIONLets people know they are dangerous.17

INTIMIDATIONSpeaks to other patients with implied threats if denied something.40

INTIMIDATIONMakes general threats about the consequences if denied something.21

ITEM DESCRIPTION

p<0.05 for full cohort

p<0.10 or better with gender as covariate

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


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


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


Sample Question

Respect Trust Isolation Snitching Do Your Own Time

Vigilance Bid Mentality

Posturing Wolfing Cliquing Medication Concerns

Stonewalling Malingering Dissembling Manipulation


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?


Sample Question 2

Respect Trust Isolation Snitching Do Your Own Time

Vigilance Bid Mentality

Posturing Wolfing Cliquing Medication Concerns

Stonewalling Malingering Dissembling Manipulation


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?


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


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


Study 2

Jail Jail (n=123)(n=123)

No JailNo Jail (n=25) (n=25) TotalTotal (n=149) (n=149)

Mean AgeMean Age 38.738.7 26.626.6 38.438.4

RaceRace

African AmericanAfrican American 7979 1313 9292

HispanicHispanic 3232 77 3939

CaucasianCaucasian 1111 55 1616

DiagnosisDiagnosis

Schiz. SpectrumSchiz. Spectrum 111 111 (90.2%)(90.2%)

24 (96.0%)24 (96.0%) 135 (97.1%)135 (97.1%)

Affective DisorderAffective Disorder 11 (8.9%)11 (8.9%) 1 (4.0%)1 (4.0%) 12 (8.1%)12 (8.1%)

Substance AbuseSubstance Abuse 70 (56.9%)70 (56.9%) 8 (33.3%)8 (33.3%) 78 (52.3%)78 (52.3%)


Study 2 - Factor Analysis

Intimidation Isolation Deception

Respect Trust Manipulation

Vigilance Stonewalling Cliquing

Posturing Bid Mentality Malingering

Wolfing Do your Own time Dissembling


Study 2 - Concurrent Validity

IntimidatioIntimidationn

IsolationIsolation DeceptionDeception SACA 13SACA 13

AgeAge 0.410.41 .01.01 .01.01 .04.04

Jail (vs. no Jail (vs. no Jail)Jail)

.19*.19* .25*.25* .16.16 .28*.28*

Disciplinary Disciplinary TicketsTickets

.32*.32* .09.09 .19*.19* .31*.31*

Working Working Alliance - Alliance - BondBond

-.11-.11 -.21-.21 -.21-.21 -.27*-.27*

PCL - Total PCL - Total ScoreScore

.53*.53* .26*.26* .26*.26* .49*.49*

BPRS Total BPRS Total ScoreScore

.29*.29* .02.02 .07.07 .23*.23*


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