Brooke Sheehan on Psychotherapy Behind Bars

Brooke Sheehand: I think, for social workers or any clinical staff that decides to get into correctional work, grit, toughness, and the ability to roll with quick-moving and unpredictable changes are important. I’ll give you an example. You might have a schedule of clinical and therapeutic activities like individual and/or group therapy, when all of a sudden, there might be an ICS (Incident Command System) alert, which calls for an immediate response to some type of problematic event.

A resident on the correctional side of the facility, what outsiders typically refer to as a prisoner, could be having chest pains, which obviously calls for immediate attention, or a piece of equipment goes missing, and you have to do a search for that equipment. These kinds of things, not to mention conflicts between residents, derail what you might have otherwise planned therapeutically for the day. I'm pretty lucky because I work on the mental health unit, as opposed to the correctional side of the facility, where the primary focus is on mental health events, and where we generally get to keep going. This shared focus really helps to maintain the stability of the therapeutic community, or milieu.

Another challenge is working with the residents on my unit for whom simply being locked in causes its own stress because they lack control over their immediate environment, their only world, at least for the present.

BS: Unlike the correctional side of the facility, the mental health unit feels very familial, which is interesting because that’s not a term you’re usually going to hear from residents in a correctional environment. And I think the staff would say the same thing. Despite the wide range of residents from the acute to the chronically mentally ill, we seem able to create a balanced environment. For example, our longer and long-term residents are able and willing to check in with new or acute folks, which allows them to introduce them to the way that we do business on the unit. And oftentimes, that includes letting these new or acute folks know that we don’t get caught up in typical prison politics, like if someone brings you coffee, they’re not looking to have a favor in return. We really stress the importance of residents on the unit doing things for each other because they care about other people. You might not see this nearly as much on the correctional side of the facility.

BS: Exactly. Folks end up doing treatment at different intervals that work for them and their clinician. We also have activity therapists, and they really help. If the clinician establishes a treatment plan, those activity therapists help with non-clinical activities, like social skills or physical activities that might be outside of the resident’s comfort zones. An example I usually give is that we have beachball bowling, which provides for social connection, teamwork, and goal-directed activity. And in addition, it’s fun for residents.

BS: Yes. I would also say that most commonly, we see people with psychotic disorders, either acute or related to chronic conditions like schizophrenia, bipolar disorder, or schizoaffective disorder. Those are all really common. And I would say most people who come into the facility are dually diagnosed, which is a very common and more recent trend; as well as both males and females.

BS: Absolutely. We definitely have people who experience major depression, and those who experience anxiety—although I would say that’s a little less. More commonly, we have people who are actively delusional or for other reasons are unable to navigate the regular prison environment.

BS: Our unit is really a need-to-know unit, which is so unique in the correctional realm. So, for example, the correctional officers on my unit do have more mental health training, which is a cool difference from other facilities that don’t have a mental health unit. But, like all the staff on the unit, whether they are mental health-trained or not, everyone is involved in all aspects of treatment planning and implementation. You just don’t see that in a lot of other correctional facilities.

BS: Absolutely. Everyone, from the behavioral health techs to intensive case managers, to the clinicians, to the correctional staff.

BS: I do an array of things. In addition to individual and group therapy, I still have my hand in the less exciting parts of day-to-day management in terms of staff supervision and training, as well as helping with intake and discharge planning.

BS: As far as I know, there is not another facility or unit that has something like this. We’ve had different people from different agencies even within our own umbrella trying to develop something similar. It’s really difficult if you don’t have a lot of stakeholders on board. Our unit is also quite unique because oftentimes facilities attempt to expedite stabilization by quickly treating residents from the correctional side with medications, getting them back to some baseline, and quickly sending them back. So their stay can also be very short. Our unit can take a little bit longer. These particular folks actually get a shot at trying to navigate their way out of the criminal justice system.

BS: It can vary. I think that's one of the other interesting aspects of our model, since we have those three levels of care (acute, sub-acute, and chronic) that for all intents and purposes, should not exist together in a single place.

BS: To different gen pop settings, which could be a different correctional facility—whether that’s back to the county jail or to another state facility. We also have folks who will go to a state hospital. And then we also have folks who will be released.

BS: I’m also thinking of that criminal justice realm, where they’re perpetually in this cycle which leads them out but inevitably back to prison for reasons that might be more related to mental health issues. We try to get them into outside settings that are really focused on mental health.

BS: We are fortunate enough to have a psychiatrist who is embedded in our team, which is wonderful. And they really are an essential part of the team. Because what is very different, I think, about an intensive mental health unit in a correctional setting, is that if and when the residents are acutely psychotic, they’re going to need a med adjustment, you know, at the drop of a dime. And we’re really able to do that because that prescriber is embedded with us.

BS: Yes. Exactly.

BS: Entering into the world of the correctional environment as a clinical person can be quite distressing. You see people engaged in a broad array of challenging behaviors, including self-injury or hunger strikes. When people are confined, they can resort to some really desperate measures. And so I think that’s definitely one of the more challenging aspects of the job. 

BS: I think one of the biggest components and barriers for these folks is the lack of control over their own life. I mean, I’ve got a lot of folks I work with who are lifers or simply won’t outlive their sentences. When they have people on the outside whom they’re still trying to be connected to, there’s so much that they miss or are not able to participate in, or celebrate, or grieve. This leaves many of these residents feeling absolutely cut off and without meaningful or rewarding outlets.

BS: That’s one of those predicaments where you have to be really comfortable being uncomfortable and able to walk together through this barrier of acknowledging that this person is in this very limited environment forever. And oftentimes, I’ve found that by just calling that what it is and not trying to tiptoe around it, you become better able to provide the necessary supportive interventions. These particular residents really just want to talk about that and acknowledge that this is a different walk and a different journey for them than for someone who might be getting out in nine months.

BS: The fundamental difference that I often see is that our training as social workers is really based on a systems orientation as opposed to an individualistic one. I see systemic barriers and challenges more quickly on the unit and am prepared to think and act more quickly to address those.

BS: The unique part of this type of job is that I’m working right there in the middle of the intersection, so to speak. We do a lot of work with families, especially in the world of mental health, because many of our residents still typically have connections, both on the inside and outside, and in many cases that includes family members who care. And for these family members, it can really be difficult to navigate the system of care that their loved one is embedded in. That can often leave family members on the outside feeling both hopeless and helpless. And the flip side is that working in the milieu requires constant attention to the politics on the unit, as well as the ebb and flow of policies that flow from the Governor’s office.

BS: I worked with one of the residents and his mother who was actually able to come into the facility for visits. We were able to do some family work right there, which was pretty unique. And even before the pandemic, we were able to do a lot of family work through Zoom and Skype. And we are also able to provide extra assistance to those families who struggle due to enmeshment, which can be exacerbated by the confinement of one of the family members.

BS: Oh, yes. In fact, we do. And that’s been very therapeutic. One of our lifetime residents has family members who live out of state. It’s been a gift to be able to work with the resident and his family on a fluid, continual basis, through which they actually get to mend and work on enhancing their relationship even though they will never live under the same roof or close to one another again.

BS: One that comes to mind is a gentleman who was able to do some inner younger-child work that he really hadn’t been able to do when he was actually young. It was the safety of distance, both from his own childhood and his family members, that allowed him to work through these complex issues. And so, they have, let’s say, like a 30-minute video conference that they’re able to do. Doing it this way gave both sides the time and space between these remote sessions to sort through things.

BS: It absolutely did have an impact. I think you’re right in saying that there are some folks who really are pretty fortunate. In my experience with folks in this system, particularly those with mental health needs, many have burned a lot of bridges, and they don’t have people who come anymore. But for the others, and a couple come to mind, not having those connections has been a challenge. But video conferencing has really lifted people’s spirits and allowed them to stay connected.

BS: Before we even get in the room for group treatment, they’re all there. Everyone is there, which is so cool. I’ve worked in a lot of places and with other populations, and folks just don’t show up at the same rate for group therapy. They all really push each other to get outside of their comfort zones and be there for the group.

BS: Working with this very interesting and mixed cohort means that we have to get creative a lot. We do a lot of processing, a lot of meeting people where they’re at during the day. And I’m telling you, that’s where the magic is. People really seem to connect with that and feel like they’re able to be heard. We’ll have people who—even if they’re chronic—still struggle with a lot of delusional thoughts. It’s amazing to watch group members patiently help these particular folks get back on topic. The group knows how to re-center itself and continue on.

BS: When it comes to the work in this type of environment, I’ve never felt more successful or seen therapists be more successful then when they’re able to forge a relationship. And that takes that kind of grit that I was talking about earlier, because people can be afraid, coming into an environment like this. I have done a lot of work in homes and have even delivered meds to people, so I’ve seen the importance of connection. In here, staff are always available and willing to respond to the residents’ needs, and quite honestly, the residents are very protective of the staff.

BS: Absolutely. But I do want to mention that we use all those other modalities as well. Because each has something to contribute, depending of course on where people are. But definitely, the relational aspect goes far and beyond.

BS: Many of the women in here are on a new journey of their own. It has really tugged at my heart working with the women, because there were so many folks who are in the throes of losing their children or have lost children. And I have had both of my pregnancies while working here. I worked with a pregnant resident who understood that she was going to have to give up her child, which was very hard to witness. But being able to navigate those waters in a truthful way, particularly as I happened to be pregnant at the same time, I was grateful to be able to help her get to a place where she was like, “Looking at you is so difficult for me.” A lot of growth and healing came from that relationship.

Being with the men can result in a range of unexpected and awkward questions. That has to do with the elephant in the room of human sexuality, which can also be very uncomfortable. I’ve gotten some really bizarre questions.

BS: I think that is a huge component in this type of work, especially from the vantage point of being someone who identifies as female and working with folks who identify predominantly as male, and who are constantly trying to figure out their own equilibrium. Oftentimes, a lot of the men I work with have had really either horrific or very challenging relationships with women. Or didn’t get any education around human sexuality. So they’re trying to guess how to piece this all together. Most younger males have gotten a lot of their sexual and even relational references and experiences through pornography. So that’s their lens, and they don’t have the context for how to have healthy interactions with women.

BS: Postpartum depression and anxiety are huge. The depression piece, I think, is so important. I think, oftentimes once you have a child, the mom kind of gets left behind. And you can see that, too, in an environment like this where people are kind of like, “Okay. You’re separated. Now, let’s just move on.” But there’s so much there happening, you know, hormonally and mentally, that requires a lot of attention. Because, if you don’t, someone could end up suicidal.

BS: This is one of the points I’m always eager to talk about. One thing that really jumps out is that most women who are incarcerated are here because of substances or some type of interpersonal relationship. It takes about 15 months from arrest to sentencing, which is the amount of time that it takes to be away from a child before an agency like a Department of Human Services would take away or petition to take away a child. So the system kind of sets these women up for failure and undermines their ability to build a relationship with their child.

BS: And so many of these folks are impoverished, which means that the bail system makes it that much harder for these women to reconnect with their children during that very sensitive bonding/attachment period.

BS: BS: Absolutely.

BS: A correctional system is just not built for folks on the autism spectrum or with intellectual disabilities, despite the fact that we’re seeing more people with these types of disabilities entering the system. I think this environment is really confusing for folks with such an obtuse vulnerability, because it’s really easy for other folks to take advantage of them by using them for their own gain. There’s a lot of data to support the idea that folks with these types of disabilities do better in smaller, contained units. And it can be really dangerous, because they are more easily victimized physically and emotionally, which contributes to their already fragile coping skills.

BS: Absolutely.

BS: My experience has been that we have these gaps in our community services network, not only in my state but across the country. What I’ve seen happen is that someone with these particular difficulties who lives in a residential setting typically acts up in response to a stressor that is beyond their ability to cope with. They end up in emergency rooms or in police custody. And then, very quickly, charges are filed against them. And once they’re in the system, it’s really challenging to get them to where they need to be. Another thing we’re seeing is related to their difficulty navigating the sexual realm, where they may end up committing a sexual offense, albeit unknowingly.

BS: You really have to find ways to teach the concrete skills—it’s almost like going back to middle school for them—and really helping them get that formative education on just, first, how to have a social relationship. And then bridging that with behaviors that are socially appropriate and what behaviors they need to have hard boundaries around.

BS: We definitely do a lot of normalizing around this huge gap that exists between the world inside and the world outside. One of the things that I think has been most pronounced is technological advances. Sure, we use tablets in here, as I mentioned before, but there’s still a huge plethora of technological skills that they just don’t have, like chip cards, which seem so second-nature to us on the outside. Even cell phones have changed so rapidly and can be so very confusing. So we try to do a lot of practical things in these areas to prepare our residents who will need to catch up to the technology on the outside.

BS: Absolutely. I think one of the biggest ones—and you kind of hit on it in your remark—is the anxiety that is inevitable upon their release and the temptation to push everyone away as they try to wrap their head around this very big transition. We really try to work with them to stay aligned with the values that make them individuals and some of the important insights and messages they got while they were inside. Many of these folks are kind and loving people who enjoy humor and relationships. So in getting them ready to reconnect on the outside, we kind of try to wrap them back together and cinch them up and allow them that space to move through this big impending change.

I think COVID has added a whole other layer to this, especially for those residents who will need to quickly connect with resources for substance abuse support on the outside, many of which are virtual. And these folks have been so accustomed to face-to-face groups on the inside. They desperately need continuity in their sense of community.

BS: I love that question. I think one of the biggest things clinicians on the outside can do is to look at their own intrinsic biases about this population of clients. While a lot of momentum has been generated towards working with people who are incarcerated, I worry that many struggle with the idea that these folks are bad seeds. A lot of people, in their lifetime, have driven drunk or violated some rule. But there’s a fine line that is easy to overlook, especially in the United States where we incarcerate more people than anywhere else. Many of us are connected to someone in our family or close circle of friends who has crossed the line, so we really need to look at that and try to wrap our arms around these people.

BS: My residents are particularly challenging because they’re coming from an intensive mental health setting. I worry that clinicians assume that they’re automatically going to be violent, that they’re not going to be someone who follows the rules, and that they’re not going to be able to handle the treatment. You know, if you build that bridge, people are going to be able to meet you there. But it takes immense vulnerability to walk out of a correctional facility and try to get back into the world. So, if we could kind of build that bridge together, that would be huge.

BS: That is an awesome question. I think through this journey I’ve definitely been able to see people as fellow walkers in this life. We’re all human beings. And I really, truly believe that no one should be judged on their worst day. And I’ve definitely worked with a lot of people who have committed a lot of different crimes and come with a lot of different baggage who will adamantly say that—we are really just fellow human beings. So it’s definitely changed my mindset to viewing the world as this place where we’re all just doing our best.

BS: I think a correctional environment, just by sheer nature, was not designed to house women. When they first decided that they were going to have prisons in the world, they were really designed around men. So there’s that. Then, you have a hypermasculine environment, which is not a criticism. It’s a paramilitary society—so it’s very based on order. It can be very strict at times. The challenge of being a female clinician is that people sometimes think I’m like a hug-a-thug or something like that, where, oh, gosh, you’re just going to have no regard for the rules, and you’re definitely going to be someone who doesn’t have boundaries because you’re a woman. And that’s really not true. I think having a doctorate has also been a very interesting experience. Because I will be with a male colleague who also has this doctorate, and they will call him “Doctor” and me by my first name.