Category: Incarcerated Individuals

How to Use Play Therapy in Prisons to Create Hope

Posted on by Psychotherapy.net Team

Imagine this scene with me: 15 men sitting across from each other at a long table, deeply engrossed in building with LEGOs. Joking and laughter punctuate moments of serious concentration as pieces of LEGOs are found and various minifigures find their place within the emerging structures. In another group, there is the eruption of victorious joy and the groan of agonizing defeat as the men play a variety of board and skill-based games in small groups and pairs. Two of the men simply throw a rubber ball to each other, a timeless game of catch.

Common Therapeutic Themes in Inmates

Grown men playing and telling stories from their play?! Yes, the scenes described above take place in a prison, a place where themes of “play” and “play therapy” are not usually enacted.

This work was born from my realization that if play could heal wounds in my adolescent and adult private-practice clients, it could be a powerful agent in reconnecting a former inmate with his child. After witnessing that reconnection firsthand, I could not get the thought out of my head of how many fathers there must be sitting behind bars, isolated from their children.

I discovered that there are many. There is also a great deal of recidivism, as incarcerated men face not only the daunting task of assimilating back into life outside of prison walls and the demanding requirements of parole, but also of rejoining families, rebuilding careers, and adjusting to a new chapter post-incarceration.

For many, it is overwhelming and confusing. Low self-worth, lack of self-awareness, deficient resources for self-repair, and difficulties in self-regulation contribute mightily to probation violations, inability to establish steady jobs, and difficulty reassimilating into their families and communities.

I soon discovered that prior to their time in the penal system, many of these men had spent time in foster care. I heard stories of abandonment, abuse, and self-rejection, often resulting in alcohol and drug abuse. It became painfully clear that many of the men were in desperate need of self-repair, and that these unresolved wounds played a large part in not being able to rebuild their life after leaving prison.

I experienced firsthand through my visits that prison is terrifying and chaotic. I have never witnessed a more stressful and unpredictable environment. For each visit, I passed through four checkpoints with buzzers, and the ominous and jarring sound of iron and steel slamming behind me. I would then walk a quarter mile surrounded by razor wire that gleamed in the sun like wolf teeth. I was constantly reminded of the utterly unforgiving conditions and lack of beauty that embodies this place.

I was, and still am, continually alert for the unpredictable, while at the same time, buoyed by my playful interactions with the men. Deep within this place there is a room where something miraculous happens. It is where play transcends the bonds of despair, transporting men — if only for brief moments — to a place of inner freedom and exploration.

How to Use Play Therapy in Prison

The Play in Prison Project that I developed is multi-faceted. It is scaffolded within the framework of “self-development” built upon the psychic Lego pieces of self-regulation, self-understanding, self-acceptance/forgiveness, and self-repair. Group members are taught self-regulation skills, how to identify negative schemas and change them, and how to build tools to identify and express feelings in an adaptive, prosocial way.

Play is woven throughout each of the group activities which incorporate the use of building toys, toy figures, games, and expressive art material (drawing and painting) designed to create a sense of safety, while also stimulating a curious mindset as new narratives of self are created. Overall, play is the glue and the foundation, making it possible for these men to be anchored in the here and now, looking at the self through the lens of this very moment while staying regulated and processing emotions and thoughts in real-time with the other men in the group.

Within the structure of this group, my role is that of a play therapist: tracking, reflecting, affirming, and even joining in play if invited. Through the group processing, I facilitate discussion using summaries, reflections of content and meaning, and affirming the observations and insight of the group members.

As a play therapist, I have spent years observing and joining others in play. I play regularly as an open-water swimmer, basking in the feeling of being lost in something huge while adapting my body to whatever the ocean offers me that day. Play lessens defenses. After just a few minutes, the men are laughing and conversing; even those that are silent often emit a smile.

Play allows for self-expression and ownership with no apologies, as evidenced by a victory whoop, and the feeling of mastery as a creation finds its way to completion. Play creates pathways for language. The men share stories through their creations, identifying emotions, and expressing themselves without shame or pretense. Play breeds a spirit of authenticity and presence. During our play, many of the men have new realizations of their worth and value as they can be present and comfortable.

Play is healing. The men can return to something awful that occurred in their pre-prison life, playing it out sometimes non-verbally, and changing the outcome based on what they know about themselves in the present moment. Play allows for connection and relationship building.

An all-too-common theme within prison walls is the lurking paranoia of being unsafe and the urge not to trust anyone. The men practice bonding through play, and elements of rough and tumble play within competitive gaming allow for the testing of these bonds.

Finally, play allows for self-repair. Through storytelling, the men engage in working through conflict with others, opening pockets of shame and self-rejection, and finding forgiveness that comes through creative and intentional play.

Clinical Case Study: Hope Shatters the Darkness

Jimmy has three years left to serve on a 15-year sentence. He is a father of two adult children and has grandchildren.

Jimmy was raised by his grandmother after his own mother lost her parental rights due to drug use and incarceration. Jimmy never knew his father. His grandmother passed away when Jimmy was nine, and he went to live with extended family members.

Eventually, Jimmy ended up in foster care where he remained until he turned 18. This period of his life was turbulent and involved many foster placements, poor school performance, and return stays in various juvenile detention centers. As Jimmy entered adulthood, he became involved in street life, leading to arrests and eventually long-term incarceration.

Jimmy was drawn to the Play in Prison Project because of his desire to rebuild his relationship with his adult children. He admitted that he carried shame and suffered daily from remorse and self-loathing. Life had hardened him, and he wore that hardness as a shield.

The toy he chose to represent himself in the first session was a big truck with blacked-out windows. “I’m big, people see me coming, but I keep everything hidden from everyone. When things get hard, I drive away.” During LEGO play, Jimmy created a tall building and used LEGO minifigures to represent guards. “I’ve tried my whole life to protect myself because nobody was there to protect me.” During a play session using expressive arts, he drew a dark cave with a solitary figure. “My brain tells me I’m living the life I deserve. My choices have put me here and there’s no light in sight.”

Halfway through The Project, Jimmy told the group that he wrote a letter to his children and had received one back in return. He wept as he read part of it aloud — it contained words of anger and hurt. The group helped Jimmy see that even though the letter was painful, it was at least an opportunity to communicate.

Play in the form of competitive games helped Jimmy to see and slowly accept himself in the moment. Playing a game in which he and a partner were paired together, he realized that it was not realistic to judge himself based on his past. Using LEGO bricks and minifigures, he built a large house with windows and an open door. The minifigures represented his children, grandchild, friends, and other family members.

He told the group he felt empowered to respond to the letter he received because of slowly learning to evaluate himself more fairly and positively in the present, as opposed to the horrible and painful events of his past. “The old me would have just stayed away. I don’t want to do that anymore.”

At the final session of the group, Jimmy drew a shattered cave with light streaming out of it, emanating from the solitary figure. At the end of the rays of light were people that represented his family and community. At the top of the picture, he wrote the words, “Free in My Light.”

Final Reflections on the Healing Power of Play Therapy

The Play in Prison Project has provided me with a rare opportunity to witness the power of play in a dark place with forgotten people. At this stage in The Project, I am volunteering because I saw a need in my community.

I am gathering data with the hope of submitting a grant to expand this work with other practitioners of play into other facilities. I have learned to be particularly mindful of being respectful of the institution, its employees, and its residents.

There are far too many examples of good programs that were started in prison settings for the purpose of research but ended abruptly when the researchers moved on. Because play and play therapy are novel and nourishing experiences, they were quickly, and perhaps not unsurprisingly, embraced during participation in The Project. Group members enjoyed the opportunity for safety and self-expression in an otherwise hostile environment where self-defense, hopelessness, and a constant state of vigilance were necessary for survival, both emotional and physical.

Some of the incidental comments in the surveys I collected and positive behavioral outcomes of The Project were a testament to the power of play in creating self-understanding and self-regulation. “For the first time in my life, I have learned to stay relaxed and not react.”

Comments about play creating a pathway for self-forgiveness and self-repair often surfaced: “I finally understand that I’m not the person who did the things that got me here; it’s part of my story, but I am who I choose to be in this moment.”

Play for some of these men led them closer to authenticity, intentionality, and connection in their everyday lives, helping to step closer to erasing shame, isolation, anger, and despair. Not uncommonly, I heard comments like, “I reached out to my children/grandchildren; I rebuilt the relationship with my wife/family members; now I know how to play with my kids, and I look forward to seeing them at visitation because I’m not ashamed of who I am anymore.”

Spitting Truth from My Soul: A Case Story of Rapping, Probation, and the Narrative Practices- Part II

Posted on by Psychotherapy.net Team

Recapitulation

This is the second part of a two-part case story that focuses on a 24-year-old African American client named Ray who was referred to me (TH) by probation services. In this brief introduction I will try to summarize what transpired in Part I. Whenever possible, I will attempt to provide phrases or “pieces” of Ray’s language so the reader can begin to get a “feel” for him and our work.

Rap music was introduced as an entry point to our work. After our first session Ray could probably best be described as equal parts skeptical and intrigued. He enjoyed sharing rap songs that were meaningful to him as well as having the opportunity to create rhymes of his own.

We rather quickly discussed ways in which rap music was misunderstood (“Adults throughout my whole life telling me it’s violent and the music of the devil . . .”) and how others could not or were not willing to hear the important messages that can be contained within certain songs. We proposed a pair of magic headphones (“Magic Beats”) as a way to help those who would not listen begin to hear rap’s message. This idea will prove particularly important as our conversation progresses in Part II.

As our first conversation continued, we started exploring the sociopolitical implications of rap music and hip-hop culture. We framed rap as a kind of philosophy (“But without all the white cats . . .”) that served as a voice for the voiceless. We also stumbled across a connection between Ray’s grandmother and rap music (“I’m rapping about the same s**t she’s saying but in my own way . . .”). This struck him as perplexing (“That’s crazy bro . . .”) and also enlightening (“I never thought of it like that . . .”) given the disdain she had expressed for rap music throughout his youth. Our first meeting came to a close by having a conversation about our conversation.

We explored the difference between just talking and rapping, to which Ray responded, “It’s like when I rhyme . . . I spit truth from my soul.” We both agreed that inviting rap to our future meetings would be of benefit. More specifically, we discovered that rapping might serve as a pathway to liberation (“Remove the shackles from my soul . . .”). I invited Ray to consider composing a rhyme that paints the part of the picture that probation services doesn’t see. He responded enthusiastically but seemingly nervous that probation services would discover the way we were working and somehow veto it (“You’re the weirdest shrink they have ever sent me to. Not weird like bad, not bad at all, but does probation know you do this?”). We then decided that calling our work together a “studio session” was a better fit than therapy.

Ray picked up in our second meeting directly where he left off in the first. He came prepared with a rhyme that would be the foundation of a counter-story. He noted in that rhyme the importance of challenging rules (“Just because these are the rules you play the game by doesn’t mean these are the only rules . . .”). The conversation evolved into looking at whether or not Ray had found some ways of challenging rules more effectively than others. He then traced the relationship between rap and anger (“It’s like my anger would leave my mouth through my rhymes . . .”). Part I concluded with a pensive Ray searching for a rhyme that captured this most important function of rap music as an antidote to anger and aggression. The following rhyme picks up where our original story concluded.

An Antidote to Anger

Judicial system mad puzzling

DA presents two options
Jail cell or rat on my cousin
Death sentence if I’m released
Seen on the streets
All free
They’ll be like “who you dropped a dime on g’”
Obscene language make them ends
So I’m squeezing my pen
That’s mightier than the blade
Not trying to see death
Strategize and not be so impulsive
Quiet cats survive
Bullets for the ones boasting
Friday night drive on Colfax
Enjoying the madness
That was created by fascists
Reagan-nomics took our tools away it’s so savage
Regardless of politics
This my Mile High life
Shout out to my bail bonds-man.

Travis (T): What speaks to you in this verse?

Ray (R): The line, ‘So I’m squeezing my pen, that’s mightier than the blade,’ is the main one. I mean, the rhyme talks about the stress, the penitentiary, but then boom (begins rapping) So I’m squeezing my pen, that’s mightier than the blade.

T: Did you fight with your pen instead of your blade before you ended up on probation?

R: Usually, yes. But there are these times where I just lost it.

T: The pen was knocked out of your hand?

R: Yeah, you could say that.

T: What happens when the pen gets knocked out of your hand?

R: It’s like I’m a different person. I do these things I know are stupid, but I just do them, anyway. It makes no damn sense.

T: But when you have the pen?

R: I can do anything.

T: Would it be accurate to say that when you have the pen you can spit truth like you said in our last meeting and that’s when Ray The Philosopher comes out (I uttered the term Ray The Philosopher without giving it much thought and certainly without an understanding of how it would later be adopted in our work together)?

R: For sure. That’s kind of a dope name right there, brother… Ray The Philosopher (said with gusto)

T: Do many people in your life know Ray The philosopher?

R: My homies do.

T: Is there anyone else you can think of?

R: No, not really.

T: What do you think would happen if we introduced more people in your life to Ray The Philosopher and his rhymes?

R: I think it would be good, but like I said last time, nobody wants to listen. They think rap is corrupt.

T: What if we were to inform them that when you can think ahead and fight with your pen through rap it helps you avoid anger and thus probation? Do you think they know this about you?

R: Nah, they don’t know that. I still don’t know if they would hear me.

T: Even if they knew that it would help you avoid future relationships with probation, they still wouldn’t hear you?

R: (silence for 15-20 seconds) Maybe. I mean, I hope so.

T: What do you think your grandmother would think about rap as a way to fight with your pen instead of your fists? Have you spoken with her about how you and rap have this kind of relationship?

R: No. I’ve never spoken much about my rhymes at all with my grandmother. I’ve just always known how much she hates rap. Like if I bring it up, I know she’s going to roll her eyes at me.

T: Do you think the kind of rap she hates and the kind of rap you’re tight with when you’re fighting with your pen are different?

R: Oh, yeah! She thinks rap music is just about cursing, talking about hoes and drugs and shit like that.

T: If she truly knew how rap music unshackled your soul do you think she might begin to have a change of heart?

R: Yeah, I still just don’t know if she would listen, though.

T: What if we created a space in here where you could perform for her, and we constructed a marquee (points upward) that lights up and says Ray The Philosopher!?!

R: (Laughs)

T: If you rapped for her and she could feel the words instead of just hearing them, what do you think might happen?

R: I really don’t know.

T: Would you say that your grandmother’s wisdom finds its way into your rhymes?

R: Oh yeah, I know it’s in there a lot.

T: Can you think of an example in the rhyme that you shared with me at the beginning of our conversation today?

R: My grandmother has always wanted the best for me. That’s why I started out that first line with her. You know, (begins rapping) Grandma said I should reconsider law school. I was sampling from another rhyme that starts with mama instead of grandma, but it’s because I know she wants the best for me and that’s why she’s always bothering me about school.

The thing is, she also taught me to be street smart, which is why I like to challenge the whole foundation that student loans and shit are built upon. It’s like a scam for poor people. You know what I mean? I would have never thought about shit in these terms if it weren’t for her. I would have never looked deeper. And that’s what that second verse is about, too, with people on TV commercials acting like they can save your life and shit. You ever watched TV at like 2:00am?

T: I have a few times, yes.

R: Then you know what I mean, right? There’s these cats trying to sell hocus-pocus. They are saying shit like, (changes voice to that of a highly embellished television salesperson) “For 20 years now I’ve been helping people change their lives. For only three easy payments of $99.95 you can get the 7 secrets that will make you rich. Order now!”

(Both bellowing with laughter)

T: I didn’t know you were an actor, too, Ray?!

R: (Laughs)

T: In all seriousness, if I’m hearing you right, Ray, your grandmother’s wisdom is everywhere in your rhymes, and she doesn’t even know it?

R: Yeah, I guess you’re right.

T: Do you think we might be able to invite your grandmother to see, hear, and feel that rap can be a philosophy of street smarts and wisdom and not just a form of music that young people like to listen to?

R: I think so.

T: If we are successful do you think this would be sort of like putting the Magic Beats we talked about on your grandmother’s ears?

R: Yeah, but the rhymes will need to be just right.

T: Perhaps we should take some time in here to get them where you want them?

R: For sure.

Turn Up the Sound

Ray and I spent our next two conversations focused on taking the various rhymes rapped during our first two meetings and worked on creating a mega-anthology. It was a scintillating process that saw KRS-ONE, Tupac Shakur, and other artists rapping in unison through Ray’s mouth. I brought in my laptop computer to help with the process, and Ray made it do things I did not know it was capable of.

He turned my computer, and my office along with it, into a fully functioning recording studio. I even created a marquee (clearly the work of a second-rate artist) that read “Ray The Philosopher,” which always led to a hearty chuckle from Ray every time I hung it up at the beginning of our meetings.

“Yo, Travis. Turn up the sound a little bit,” Ray said as I scurried over to the computer. “Yeah, that’s good right there,” he reassured me making an ‘a-ok’ sign with the finger and thumb on his right hand. I watched, often in awe, as Ray meticulously perfected his craft. He was locked in his element, and I was an enthusiastic fellow traveler.

“Nah, we need to change up that baseline a little bit,” he said shaking his head and taking a swig of water. “It doesn’t quite pop. I need more time.”

I have had the great fortune of working on similar projects with people who had sought my counsel in the past, but this was among the most ambitious ventures I had encountered. As we started to make our way toward the end of our fourth session together, I started to wonder if perhaps we had bitten off more than we could chew. Now I knew that Ray had similar feelings. It wasn’t as though we hadn’t been aware of time but more like we had lost ourselves in it.

T: Ray, the last thing I want to do is rush you through this process.

R: But I only get to come here one more time.

T: Well, I know that’s the initial agreement you had with probation, but I can see you as many times as we think would be best.

R: What about you, though? I don’t want to be a leach?

T: What do you mean?

R: You’ve got to get paid, man. This ain’t no charity. This is your livelihood, bro.

T: I really appreciate you thinking of me, Ray. Tell you what, how about I give probation a call and tell them a bit about the situation and see if we can get some more time? In the past this is something they have often been willing to do.

R: What if they’re not?

T: Then we will see the work through to its completion anyway, Ray. As long as it takes. This is just too important. Don’t you agree? Besides, I have been thinking about something. Would it be okay if I shared it with you?

R: Of course.

T: I know your grandmother is going to come in at the conclusion of our work to celebrate with us. I was wondering what you thought about perhaps inviting other people to meet Ray The Philosopher? Is there anyone else you who you think it might be good to invite to wear the Magic Beats?

R: Hmm… I haven’t really though about it too much.

T: I’m just thinking out loud here, Ray, so stop me if this doesn’t make sense, okay?

R: Okay.

T: What do you think would happen if your probation officer were introduced to this idea of you fighting with your pen instead of your fists?

R: I mean, I’m sure he would like it. He just wants me to keep my hands clean for the next year.

T: What do you think would be the consequences of us not bringing him up to speed on this?

R: I don’t know.

T: As it stands now, do you think your PO views you as someone who is going to fight with his fists and get into trouble again or someone who is going to keep his hands clean?

R: (Laughs cynically) I damn sure don’t think he trusts me. I think he believes I’m going to be out gang-banging (a hip-hop term for engaging in violent acts as a member of a street gang), and I don’t even do that shit.

T: How has it come to be that you don’t even do that shit and yet your PO thinks you do? Do you think we should try and set the record straight and let him know how rap allows you to fight with your pen instead of your fists?

R: But he’s going to give me that same old bullshit about how I don’t take responsibility and blah, blah, blah (uses his right hand to imitate a talking mouth).

T: Do you think if you rapped for him and let him know how rap can strangle the advances of anger and aggression, he would look at you as more likely to keep your hands clean or less likely?

R: (Pauses for 10-15 seconds) More likely to keep my hands clean.

T: What do you think the consequences would be if we weren’t to set the record straight?

R: Yeah, I get what you’re saying now.

T: How do you mean?

R: Like, it’s not enough for just me to come up with this plan if he still thinks about me a certain way… like I’m a criminal.

T: Do you believe this is an opportunity for Ray The Philosopher to replace the other names that have been placed on you in the past like criminal?

R: Now that you mention it, yeah, I guess so.

T: Would you say that sometimes your PO is a tough nut to crack?

R: C’mon, now! That dude is like impossible to crack.

T: Do you think then that we might have to prove to him just how effective fighting with your pen can be?

R: Sure, but how the hell are we going to do that?

T: How long have you seen me for now, Ray?

R: (Pauses to think) Like about a month.

T: I know this is a tricky question because I’m asking you to guess what another person might be feeling, but do you have any sense for how your PO would say this last month has been for you.

R: I actually talked to him about this last week. I’ve been squeaky clean. Not one single issue, homie.

T: What do you think he would have told me about how things were going if I had talked to him prior to you coming to see me?

R: Man, he was always in my grill about shit saying I was defiant, I was going to go to jail, and this and that.

T: Fair to say then that he believes things are going better now?

R: No doubt.

T: Has one month been enough to convince him that you are on the right track?

R: Hell no! It’s like he’s just waiting for me to fuck up.

T: How many months do you think it might take to convince him that you are on the right track and ready to end your relationship with probation?

R: I mean, I still have over a year of this.

T: Do you think it will take all of that time to show him just how effective fighting with your pen can be?

R: Probably so.

T: What if we were to invite him in here, bring him up to speed on your philosophy of fighting with your pen and not your fists, and then make a commitment to this going forward?

R: I don’t know if he’ll believe it.

T: You make a good point. Like you’ve told me, he can be a bit stubborn and so can your grandmother! Even as tough as it is going to be, are you willing to fight with your pen and prove to your grandmother, your family, and your PO the true character of Ray The Philosopher? You already have one-month under your belt!

Ray paused after my question. I started to wonder if perhaps my query had pushed him a bit too far. His face remained stoic as the silence continued beyond 30 seconds. Just as I started to ponder my next move fearing I had lost him, he replied, “I’m down (a hip-hop term voicing agreement).”

After the conclusion of our fourth session Ray and I agreed that it would be good to check in with his PO together. We decided that in addition to talking about the need for more sessions, we would also let his PO know (a signed release was already in place) about how Ray had been fighting with his pen instead of his fists. The PO acknowledged that things were going better the past month, but he remained skeptical. He agreed to get payment covered for half of every session for the next month. The way the following month was structured it would afford us five more weekly meetings.

Two Different Stories

Ray seemed somewhat relieved that more sessions had been granted but also a little bit ticked that his PO was still unconvinced. He felt his PO was “playing games” and “testing me.”

Our next three meetings were spent wrestling with these feelings. Ray began discovering that restoring his reputation burned nearly as many calories as he was taking in. Instead of being consumed by anger towards his PO, Ray stayed true to his word to fight with his pen. He remixed a song by the artist Common:

We should name the block poverty
That rock stole our humanity
You hear that glock pop?
For dough we perform beastiality
“Fucking each other over
What you expect they animals”
Then act like they the ones offended
When TMZ release the audio
If life’s a game
They withhold that playbook
But playas make that scratch
We get the itch
Run your shit
This a jook
Or a lick
See that’s a stick-up if you down with my click
We starving in the darkness
Force upon us they man made eclipse
Is it a curse?
Mad poisons in our blood?
My pops tried to disinfect it
Chugging that rum
And I do the same (word?)
Like father like son.

Ray no longer waited for me to inquire about the lyrics. He would deconstruct them now almost as a natural part of our process. “See, this is what he (probation officer) doesn’t understand. I was born behind the god damn eight-ball. No father. Poor. I’ve always had to hustle to survive. He doesn’t know my pain. Does he even care to know it? But that don’t even matter. Is he testing me? I’m going to pass that test.”

Ray began rapping the second verse from this song:

To my reflection I scribed
What I be feeling inside
Can’t leave it buried in the dirt
Gotta breathe it and give it life
My neighborhood taught us no self-control
That boom-bap made us feel like it’s our right to explode
No positive role-model
The hustlers were our fathers
Rappers instructed us to spit rhymes
And don’t bother
With the life of an outlaw
It’s a trick to keep us blind
And deny our title as God
Preventing our rise
They been doing this for centuries
Stolen lands from our North and South American fam
Jews burnt
Japanese thrown in determent camps
Hatred can hide
Right in front of our eyes
But I flipped that same hate
Used it as fuel to survive
I’m of a mind that believes love will conquer hate
They be seeing black and white
While my crew is dazed by all the gray
So gather around the fire
Light it up
Continue the cipher
Cause in the darkness of nights
Our stars still shine brighter
This is my dream!

T: Ray, are there two different stories in the two beats you have shared with me today?

R: Yeah, the first one is the pain and strife. The second is what happens when I look ahead and fight with my pen.

T: Pain and strife and fighting with your pen… both of those are rhymes that you brought into our work earlier, right?

R: Yep.

T: Would it be right to say then that these last two verses are a sort of remix of all of the beats we’ve heard in here so far?

R: Pretty much.

T: Would these verses be good to share with the folks who join us for our final celebration of the work you’ve accomplished in here?

R: Yeah, but I might tweak them throw in a couple of other verses from different rhymes to get it just where I want it.

Our second to last session was a dress rehearsal. Ray came with the beats he wanted to perform and refined them. We also talked about how he wanted our final celebration to commence, what would happen, and who to invite.

He joked that it “would be kind of like a block party, but where a therapist lives in the house on the corner.” We also decided that those in attendance would have an opportunity to voice their support of Ray’s efforts over the past two months as well as hopes and dreams for the future. As this session came to a close I could detect a nervousness that was following Ray.

T: Ray, I could be wrong here, but I am wondering if some nervousness is hanging with us right now.

R: Yeah, I guess so.

T: Do you mind if I ask you what kind of nervousness it is? People I’ve worked with before have taught me that there are different kinds? Do you know what I mean?

R: You know, I’m not like a professional rapper or anything like that, but I’ve performed in my neighborhood before. It feels like that. Like, you think you have a good rhyme, but you never know for sure until you get on stage and the crowd is feelin’ it.

T: What gives you confidence that the rhyme you have created in our work together will deliver just the message you hoped it would?

R: I put my whole heart and soul into it. I didn’t leave one drop.

T: Do you think the people who are here with us next time will feel your heart and soul coming out through your lyrics?

R: (Pauses for 10 seconds or so) I really think so.

T: Do you remember when I first asked you about what would happen if you rapped for your grandmother or your probation officer?

R: Yeah, I said they wouldn’t hear it.

T: Are you saying that you feel differently about that now?

R: Yeah, I guess so.

T: What would you say has shifted?

R: These rhymes are me but just in lyrical form.

T: And you don't believe your grandmother or those who love and care about you would reject this gift that is a lyrical manifestation of you?

R: No, my grandmother always tells me that she’ll never run out of love for me.

T: Hey, something just struck me, Ray. Would it be okay if I share it with you?

R: For sure.

T: I wonder if you just discovered the Magic Beats?

R: What do you mean?

T: Do you believe that when you create a rhyme that fully represents you and comes from the deepest depths of your soul that even those who don’t prefer rap music could still hear it?

R: (A smile overwhelmed the now dwindling doubt on his face as he nodded affirmatively)

T: Ray! This is great! What an incredible discovery you have made!

Ray often tried to minimize any expressions of emotion, but even he smiled loudly at this development. In our excitement we almost instinctively exchanged daps (gesture similar to a handshake) with our right hands before giving one another a quick hug. With this we had established an unspoken agreement that we were ready for Ray’s performance and celebration next week.

A Celebration of Hope

Ray and I agreed to meet about a half an hour before everyone else to prepare the room for the celebration. As we moved tables and chairs and geared up the laptop computer everything was coming together. “Alright, I think we’ve got it,” I said looking in Ray’s direction. He then shook his head ‘no’ and looked upward to indicate to me to direct my gaze towards the ceiling. “What?” I said with a perplexed look.

He nodded upward once more. I stared skyward still trying to decipher what Ray was communicating. Then I realized that in my haste to make sure there were enough chairs for everyone I had forgotten to hang up the marquee. Like a dog with his tail between his legs I went back to my desk in the back room and removed from the top drawer the “Ray The Philosopher” marquee. I dashed back out to the main office and hung it up in its customary location. “Now we got it,” Ray asserted.

Soon, Ray’s grandmother, his sister, and a few other people from his neighborhood began making their way into the office. There was a sort of nervous excitement that filled the room. Lost in conversation, time had escaped me. I

reached into my pocket and pulled out my phone to take a quick look at the time. In doing so I noticed a message was waiting for me from Ray’s probation officer. Oh no, I thought to myself. He had left me a message stating that something had come up and he wasn’t going to be able to make it. Just as I was about to hold the phone to my ear to listen to it, he lumbered through the front door. “Sorry I’m late,” he said. “Did you get my message? I got caught up with a few things at the office.”

Relieved that everyone was now here, I looked at Ray to see if he was ready to go. Ray had asked that I start by saying a few words to give folks a sense of what today’s meeting was all about. After welcoming everyone and thanking them for attending, I began discussing a bit about Ray’s journey.

“During our two months together, Ray has reaffirmed how rap music can be an ally in helping him be the person he wants to be. He has composed a series of beats he would like to perform for you today. Ray suggested that

Psychotherapy Behind Prison Walls. Does it Really Help?

Posted on by Psychotherapy.net Team

Despite working in the field of corrections for the past seven years and in mental health for ten, there are still aspects of this work that I find jarring. One of the most distressing elements of my work is when working with individuals who have been diagnosed with Autism or some form of neurodevelopmental disorder in which their thinking and relating is impaired. Oftentimes, these clients present as adults but function at a prepubescent to early adolescent level, all while being confined to an environment with other adults whose intellectual functioning remains age-appropriate. This is the equivalent of placing a juvenile with an incarcerated adult.

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I wish that I could say that my experience in working with these individuals has been limited, but the sad reality is that this is an area in which I have unfortunately become well-versed. Not understanding social norms, the criteria for healthy relationships, the importance of consent, and boundaries have been the most common characteristics shared by these particular clients. The challenge of working with these neuro-atypical individuals within the prison setting centers around discussing and helping them address issues of sexuality, not only their own, but as they impact relationships with other inmates who are often far more sophisticated, opportunistic, and at times predatory.

I’ll never forget the day I met Ronald (a fictitious name) because my immediate thought was, “How did we get here?” Ronald functioned much lower intellectually than his stated age, and as a result entered the penal system after misunderstanding social and relational cues. Ronald was then admitted for more specialized treatment after he was taken advantage of while housed in the general population setting. This is not uncommon when impaired individuals like Ronald live side-by-side, day-to-day with others whose primary interests are their own needs, oftentimes sexual. Ronald would often parrot the phrases he heard from other residents, even when they were racially charged or otherwise provocative. He didn’t do these things because he was prejudiced, but because doing so was a symptom of his condition and something that he often did when he felt uncertain of how to fit in. He would then begin emulating those around him that he perceived to be “cool.” In a correctional environment, this is particularly dangerous because it often results in the neurodivergent individual’s being either severely assaulted or deliberately used as a pawn to antagonize someone else or a group of individuals.

Another challenge I’ve noticed with these individuals is when they openly discuss or share their money or possessions without making sure that either or both are returned or made good on in some fashion. Ronald struggled immensely in this domain, as he would often buy things for others who would never return the favor and who wanted to take as much from him as possible. Fortunately for Ronald, staff members became aware that this was occurring, and he was moved to a smaller pod with a focus on psychiatric well-being.

In this regard, the best that neurodivergent individuals entering correctional environments can hope for is attentive staff members and genuine peers who look out for them and help protect them from becoming victimized or taken advantage of. Unfortunately, these helpers are not omnipresent, leaving these residents vulnerable for no other reason than their difficulty interpreting social cues and relating to others who would intentionally hurt them.

I remember talking with Ronald about how he came to the psychiatric unit, and wondering aloud about his understanding of the situation. Ronald was not at all aware of the risks that existed in his peer interactions while in the general population, but did understand quite quickly that he felt more comfortable in a smaller, more specialized, protective unit. Treatment of Ronald has included basic social skills, education around the topic of consent, and continuously openly discussing what a healthy versus unhealthy relationship looks like. Ronald was very clear that he had never before had such discussions, which solidified for me the importance of ensuring that people who are neurodivergent are not left out of conversations that have to do with sexuality. Therapists in the carceral system can be life-altering for these individuals when they take the time to go over the “basics.” It is critical that we put our own egos aside and look at the ways we can be most effective with these particular clients, rather than quibble over which therapy or technique is more effective than the other. When I have opened myself to creative treatment interventions that addressed the developmental needs of my clients, I have done some of my best work and influenced these clients in unexpected and at times very wonderful and rewarding ways.

The treatment unit where I work strives to provide a close knit, therapeutic milieu that allows for individuals with major mental illness and neurodivergence to feel safe, cared for, and to receive the highest possible quality of care. And this has happened when I haven’t been afraid to step outside of the box.  

Brooke Sheehan on Psychotherapy Behind Bars

Posted on by rezendevknowfully.com

On the Inside

Lawrence Rubin: Brooke, you are the director of the intensive mental health unit in a correctional facility in the Northeast with acute, subacute, and chronic clients. What are some of the greater challenges that you’ve experienced working therapeutically in this facility?
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.

to get into correctional work, grit, toughness, and the ability to roll with quick-moving and unpredictable changes are important

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.

LR: I used to work in a forensic unit of a state psychiatric hospital, which had a very particular feel for me, and it wasn’t pleasant—far from it. What’s the “feel” of a mental health unit within a prison?
BS:

Unlike the correctional side of the facility, the mental health unit feels very familial

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.

LR: So the residents live in the mental health unit as opposed to visiting a clinic for an hour or so for individual or group therapy?
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.
LR: Is the mental health unit comprised of both male and female residents, as well as mixed pathologies, from acute all the way to chronic?
BS:

most commonly, we see people with psychotic disorders, either acute or related to chronic conditions like schizophrenia, bipolar disorder, or schizoaffective disorder

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.

LR: So, it’s not a substance abuse unit per se. But you might have people with substance abuse problems mixed in with other folks who do not abuse substances and who may be experiencing depression or bipolar disorder.
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.
LR: What are some of the clinical or therapeutic challenges that the residents on your unit experience?
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.
LR: So this is a true therapeutic milieu, where everyone is technically a part of the treatment team.
BS: Absolutely. Everyone, from the behavioral health techs to intensive case managers, to the clinicians, to the correctional staff.

A One-Stop Shop

LR: You have a DSW (Doctor of Social Work). What is your primary function?
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.
LR: Parenthetically, is this mental health venue common in the prison system in your state or, as far as you know, across the country? Because it sounds rather unique.
BS:

Our unit is also quite unique because oftentimes facilities attempt to expedite stabilization by quickly treating residents from the correctional side with medications

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.

LR: So, some are referred directly from court into the intensive mental health unit, after which they go back into society? Or do they go back into the general population on the correctional side of the prison? Sorry to use television terms like “gen pop.”
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.
LR: Where do folks go after completing treatment on your unit, if that is the correct term?
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.
LR: These gen pop residents are the ones who are not living in the intensive mental health unit, but rather what you refer to as the correctional side.
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.
LR: Do you have a psychiatrist who works on the unit or just visits the unit and prescribes meds?
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.
LR: A one-stop shop.
BS: Yes. Exactly.

Working Within the System

LR: What are some of the nontherapeutic aspects of your work, when you’re not sitting in a session with a resident, doing traditional therapy?
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.
LR: So, there are issues that some of the residents bring with them into the facility, but some psychiatric behavioral issues that evolve as a result of being in the facility. What other kinds of behavioral and emotional problems develop as a result of being in the facility?
BS:

I’ve got a lot of folks I work with who are lifers or simply won’t outlive their sentences

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.

LR: What are some of the unique therapeutic challenges of working with a so-called “lifer”?
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.
LR: How has your training in social work, as opposed to that of a clinical psychology background, prepared you to work in this particular environment?
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.
LR: Can you explain that?
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.
LR: In this context of the systemic orientation, what kind of family work are you able to do as a therapist in the facility?
BS:

even before the pandemic, we were able to do a lot of family work through Zoom and Skype

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.

LR: Would you do family work with someone who is a lifer?
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.
LR: Can you think of another family with whom you’ve worked that was particularly poignant for you as a clinician?
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.
LR: How did the isolation that COVID forced upon us impact the family work with some of these residents who depended on family members’ coming to the facility?
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.
LR: In this context of connection, what are some of the benefits that you’ve found by doing group therapy with the residents?
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.
LR: Are your groups process groups, or are they psychoeducational groups, and are they unique to being inside of a prison?
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.
LR: It sounds like an incredibly cohesive group of residents, despite the diversity of their psychiatric needs. Have you found any particular method or theory of therapy more useful with these incarcerated residents?
BS:

staff are always available and willing to respond to the residents’ needs, and quite honestly, the residents are very protective of the staff

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.

LR: So, we’re not talking about CBT being preferred over DBT or being more appropriate than ACT—we’re talking about core relationship-building skills that you might find in client-centered therapy?
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.

Gendered Issues

LR: You’ve written a few blogs for us on some of the challenges of working with women around pregnancy, parenting, and even your own pregnancy while working here.
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.

LR: Oh, that you got pregnant as a result of sexual activity and they’re not allowed to have sexual activity! I get it now. Does sexuality—sexual behavior, sexual behavior problems—come to the fore in your clinical work?
BS:

a lot of the men I work with have had really either horrific or very challenging relationships with women

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.

LR: Can we circle back to some of the issues that pregnant inmates experience?
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.
LR: What about those residents who have lost access to their children, who lose their parental rights after they give birth, or who have—as a result of their criminal or mental health histories—lost connection to their own children? What are some of the challenges in working with them?
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.
LR: And the children lose precious and necessary early attachment to their mother.
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.
LR: It sounds like there’s an inevitable cycle of attachment disruption, depression, alienation from the children, and attachment disturbance.
BS: BS: Absolutely.

Developmental Impairment

LR: You mentioned in one of your blogs that you work with incarcerated residents who are on the autism spectrum or have intellectual disabilities. What are some of the challenges that you face in working with these residents?
BS:

A correctional system is just not built for folks on the autism spectrum or with intellectual disabilities

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.

LR: I would think, then, that for these folks you would have to focus on life skills, survival skills?
BS: Absolutely.
LR: Why do you think that the residents on the autism spectrum or those with intellectual disabilities end up in prison as opposed to residential treatment centers on the outside? Have they committed crimes? It seems so complex.
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.
LR: They don’t really understand what they’ve done. Are they amenable to corrective therapeutic work in your facility?
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.

Preparing for Re-Entry

LR: How do you prepare soon-to-be-released residents, and what are some of their psychological needs that need to be addressed in therapy before they go?
BS:

We definitely do a lot of normalizing around this huge gap that exists between the world inside and the world outside

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.

LR: With no experience in this domain, I think of the movie Shawshank Redemption and wonder about the psychological challenges of freedom from incarceration.
BS:

getting them ready to reconnect on the outside, we kind of try to wrap them back together and cinch them up

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.

LR: What suggestions would you offer to fellow clinicians on the outside who might be working with these released residents?
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.
LR: Have you come across any misconceptions or particular biases that clinicians on the outside have when they see the clients that you discharge?
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.

Summing Up

LR: Brooke, how has working in a prison impacted you as a person, as a mother?
BS:

I think through this journey I’ve definitely been able to see people as fellow walkers in this life

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.

LR: You will have wonderful insights to offer your own kids when they’re old enough to appreciate them. Last question. What obstacles have you encountered as a woman coming into corrections in a clinical facility with a doctorate?
BS:

The challenge of being a female clinician is that people sometimes think I’m like a hug-a-thug or something like that

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.

LR: Sounds like you’ve had your challenges, Brooke. But you’ve also found your stride.

Attending to Attachment in the Treatment of Incarcerated Women

Posted on by Psychotherapy.net Team

It was a sunny August day when I took a brisk walk across campus to get to the part of the facility that housed the incarcerated women with whom I would soon be working. I remember feeling fully ready for this new endeavor and eager to have a new clinical experience. As I entered the facility, waiting to be buzzed in through the double locked and heavily-reinforced doors, I immediately noticed how bustling the unit was. Looking around, I saw women hustling to their textile-industry jobs, rushing to their various group rooms, meeting for education classes, and heading outdoors to play volleyball. Taking in all of these varied activities, I became poignantly aware of one of the obvious similarities among the residents—most of these incarcerated women were of child-bearing age.

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In my clinical experience with incarcerated men, I have worked with some invested fathers, but the theme around children has tended to be less pronounced than it has been when working with their female counterparts. With the women, I conducted more grief and loss groups than I ever had before, with waitlists that never seemed to get any shorter. In those groups, I became immersed in the nuances of the lives that lead women to lose their parental rights. My heart broke for these women who found themselves in the position where they were perpetuating family traumas despite their best efforts not to.

Jillian, I will call her, was a woman similar in age to myself, whom I worked with up until her release. She and her child’s father both struggled with substance use, having been consumed by the nation’s opioid epidemic. Jillian came from an impoverished family in a rural area that was severely under-resourced, often having to make the decision between paying the electric bill or being able to afford prescription medications. Jillian was very candid that she used illicit drugs, but that she was drawn to selling them because doing so was a direct road to fast money, which in turn allowed her to provide for her daughter in a way that she had not been provided for herself. Jillian and I would meet weekly in sessions that almost always focused on her daughter. She was fortunate enough to have her daughter reside with a family member rather than lose custody of her, but in essence, she was one fragile relationship away from losing that precious custody, and that weighed on her like a boulder. I remember one conversation in which Jillian shared, “I’m so worried about my mother. She doesn’t have enough money for gas, her prescriptions, and the heating bill. If she doesn’t get her prescriptions, she will get sick and could end up not being able to take care of my daughter. If she goes to get the prescriptions, she won’t have money for both that and the gas to get there.”

Jillian is but one representation of the near-constant fear that incarcerated mothers experience. If they have a sentence longer than 15 months, it is completely likely their parental rights will be terminated, and most sentences for drug offenses, which are often non-violent crimes, typically carry more than 15 months. Pair this with the glacially slow legal system which leaves women like Jillian in limbo, waiting for their sentences to be assigned all the while knowing the custody of their children is at risk.

If you are both a therapist and parent, the following is likely not difficult to appreciate. In my clinical experience, mothers who lose custody of their children are at risk to reoffend because they lose what is very often their entire sense of purpose. Oftentimes, although women such as Jillian use and sell drugs—which is obviously an unsafe atmosphere in which to raise children—they engage in far less risky behavior than if they were childless. Not uncommonly, the women with whom I have worked in correctional custody have been victims of human trafficking, sometimes even prostituted by their own family members while adolescents. Many of them grew up in poverty, having experienced horrific abuse, multiple pregnancies, school dropout, addiction, and the absence of their own parents, who were often imprisoned.

To highlight the dark hues of this already bleak picture, I remember a client I will call Mary-Beth, who took a five-year sentence rather than accepting probation so that she would have a chance of being able to spend some quantum of time with her mother, who was also incarcerated and would be released within nine months. Mary-Beth had her own daughter at home, but this did not waive her choice to take a prison bid over probation, because she was that entrenched in trying to have an interaction with her mother.

It has been relatively easy for me to see how the patterns of familial and often multigenerational trauma have played out in Mary-Beth’s life, and the lives of other women who have desperately tried to salvage their parental identities and bonds while behind bars. Had Mary-Beth not spent her childhood chasing her mother out of bars, waiting in cars in the dark while her mother turned tricks, or watching her use substances in between prison bids, Mary-Beth might have been able to develop an identity grounded in secure attachment that could have protected her from imprisonment and resulted in a tangible, rather than ephemeral, relationship with her own child. Now as a young woman, she is perpetuating the same scenario she experienced in the past with her own daughter, which inescapably manifests in pathology around abandonment and paves a direct route to addiction high-risk relationships and self-destruction in seemingly futile attempts to fill the void left by disrupted attachments.

***

I learned more than I ever would have thought possible from this clinical work with incarcerated women and mothers. Whenever possible, I work on parenting skills and psychoeducation around attachment theory with these clients so that together, we prioritize maternal and self-care skills they can utilize upon release. The additional work of helping promote mother-child bonds, even from behind bars, is critical in helping them break the vicious cycles that will inevitably undermine the attachment security of future generations. The last I heard, Jillian had completed her probation, maintained a job in the community, and was upholding her parenting responsibilities. She seems to be one of the lucky ones, and the implications for her daughter will hopefully be tenfold. The next chapter in Mary-Beth’s story is yet to be written.

Ninety-Five Percent: Preparing to Work with Previously-Incarcerated Clients

Posted on by Psychotherapy.net Team

On the heels of my previous blog about the stigma experienced by previously-incarcerated clients with mental illness, I find myself once again in a reflective state around the idea of re-entry for these challenged and challenging clients. I draw attention to the title of this writing, which reflects the staggering reality that, according to a recent congressional study, 95% of those who become incarcerated will return to the community. Let that sink in for a second. This means that almost everyone who is sent away to a penal institution will be back on the streets. Why, then, haven’t we pushed ourselves to view crime and the “criminal” as less of that individual’s moral failure, and more of a societal one that must be addressed upon their departure from incarceration?

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It is easy to sit in judgment of others, especially those who have transgressed, and it takes only seconds to formulate a first impression of someone. Pair this with the biases and prejudices that incarcerated clients experience, and they leave prison or jail with a complete narrative that may very well not be their own. Clients returning to the world beyond prison gates live with these preconceptions from the moment they interview for a residence and/or job to the moment they seek follow-up services for physical, mental health or substance use treatment. And in my experience, these particular clients know full well that welcome mats, smiling faces, and open arms will not abound upon their release. That being said, unless clinicians acknowledge their own fears and judgmental attitudes towards these clients and fully lean into their own discomfort, the cycle that perpetuates stigmatization and diminishes rather than enhances their successful re-entry will continue to imprison them.

I recently worked with a client I will call Brennan, who has been diagnosed with a serious mental illness as well as a substance use disorder. Brennan is intelligent, resourceful, and sociable, but when taking his psychiatric medications tends to become more reserved, something that I have found occurs frequently with individuals experiencing psychotic or more severe mood disorders. Brennan does not have a lengthy history of incarceration, nor does he demonstrate an antisocial personality which would lead to a callous disregard for others. Instead, Brennan’s psychiatric challenges of late seem to have led him to correctional facilities, which, in turn, has made it difficult for him to re-engage with the world upon release. Recently, upon pursuing post-release community services, Brennan was left in limbo rather than being accepted into the program after he spoke honestly about an interest in smoking marijuana. Although he appropriately utilized the skills we taught him prior to release, Brennan was shamed and unable to successfully reintegrate into the community as he had hoped and, quite frankly, deserved.

As I continue to help facilitate re-entry for my clients and assist them in navigating the confusing labyrinth of providers, I’ve noticed that the doors for treatment do not fly open for them, which makes the struggle to resume or begin a life beyond the walls that much more difficult. Their psychiatric conditions, which often incorporate psychotic features, frequently lead to their presenting with strange or bizarre thought content that is even more evidence to community providers that they should be feared and turned away rather than assisted. One of the most potent interventions I’ve used when preparing these clients for life on the outside has been the process of reality checking and reality check sheets. For individuals with major mental illness, and especially for those who struggle with psychosis, this allows them to speak openly about whatever thoughts enter their minds in a safe space where they can receive supportive, rather than dismissive, feedback and learn that their thoughts do not have to be a source of shame or be given authority over their lives.

A client I will call Kent believed that he was related to a very powerful and influential celebrity. This was a persistent and fixed delusion. He did not typically converse openly about this except for when his paranoia was triggered, which could in turn contribute to erratic and sometimes volatile behavior. However, Kent felt safe with the staff members, who helped him to develop a small list of reality checks on printer paper in his cell. One such note asked him to respond with a “yes” or “no” to the question of whether he had been particularly invested or rigid in this belief on that particular day. He would then communicate his response to staff who could provide reality-based and instructive feedback for him while helping him to monitor himself. This intervention was effective because Kent trusted the clinical team, who always promoted safety as the most important value to the correctional community in which he lived. Kent exemplifies the importance of assisting these clients by providing concrete tools they can use once released and can share with providers on the outside.

***

What I wish for all of us is to continue challenging the status quo. To go outside of our comfort zones and take on the more complicated clients, the ones who keep us on our toes and challenge our clinical minds. I challenge you to push members of other professions, often the individuals we work with to establish services or provide housing, to do the same and, perhaps most importantly, to get more clinicians involved in services such as housing, substance use treatment, or community intervention upon intake. Let us truly meet people where they are on their journeys. There is no “perfect” client, and any client who says and does exactly what is expected of them is probably not getting all of their needs met either. Let’s keep our advocating voices strong and help those who need it the most, as in the case of the client who is trying to forge a life outside of prison walls.

Battling Stigma: Serving Previously-Incarcerated Clients in the Community

Posted on by Psychotherapy.net Team

Another week has ended. I am feeling those familiar pangs of disappointment—the kind that make me shake my fists and yell to the sky as I continue to battle decades and layers of systemic challenges outside of my control. I’ve watched my team work tirelessly to find yet another needle in a haystack which itself seems to be on fire. From a systemic standpoint, I work with arguably one of the most difficult-to-place populations—those with a history of incarceration and major mental illness. To be clear, this is not the fault of any of the clients I serve, but clearly a societal issue characterized by a continued and seemingly unrelenting stigmatization of its incarcerated citizens with mental health needs. It’s an ugly truth, but that doesn’t change that it needs to be confronted.

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Ned (not his real name) is a man with a complex case history, not unusual to corrections. He is dually-diagnosed and no stranger to the criminal justice system. His supports are extremely limited, and he, not unlike most of his peers, feels that he has a real sense of community and care in the mental health unit at our facility. Ned once said something that profoundly impacted the staff who work with him. It was a typical day of patient care when Ned walked into the room full of clinicians and told the team members how simultaneously sad but wonderful it was that he felt so at home and cared for inside the correctional facility. This was not an easy win with Ned—it took much time and consistency in his relationship with the staff and unit to really feel that he was and is looked after.

Ned is an exceptionally charismatic and humorous individual who deserves the opportunity to have a life outside of the correctional system, no matter how well cared for he feels there. He is someone who responds to redirection and is the epitome of how and why Rogerian therapy can be so impactful, despite its many detractors. Building rapport and a strong therapeutic alliance with Ned has allowed the team members to assist him in moving forward in his life and to spend less time in the justice system than he may have without such extensive support.

The disappointing aspect of all this is that the community mental health system does not know how to respond to Ned. He deserves competent and caring outpatient mental health care, access to substance use treatment, and opportunities for vocational rehabilitation. He has many strengths and is much more likely to stay connected to providers if he feels they are genuinely invested in his well-being. However, despite all of his strengths, he requires a lot of contact with staff members Living in the time of COVID-19 has only made it more challenging for community providers to stay fully staffed and for resources to be obtainable; as a result, the patience that Ned deserves from community caregivers may not be as plentiful. Ned was removed from a community placement twice within the last year, and typically within a very short amount of time. Any time a community setting doesn’t work out, it’s hard to not let the disappointment set in because we are so genuinely invested in the outcomes and well-being of those we serve.

We live in a nation that incarcerates more individuals per capita than any other developed nation, which means that many of us and our clinical colleagues have had professional, or perhaps even personal contact with someone who has been incarcerated. Yet despite this fact, I have found that there is so much fear in the field of human services when it comes to working with previously-incarcerated individuals with mental health needs. Time and time again, the job of finding placements for these individuals has proven to be excruciating. Community providers often want assurance that these individuals aren’t too psychiatrically sick or require resources beyond their capability or willingness to provide. There may even be the implicit fear that previously-incarcerated clients, especially those with a history of mental illness, may be violent and/or physically dangerous. And these are but a few of the barriers for placement and treatment once these individuals are released from prison.

To be fair, we are living in the time of a pandemic, and staffing and resources in the human service world are at an all-time low. Closures are happening left and right, and the competition for resources has intensified. I appreciate the gravity of this, but the fact is that we were struggling with this long before the pandemic began. Deinstitutionalization had a direct impact on the criminal justice system, leading prisons and jails to become the largest providers of mental health in the nation. John F. Kennedy had the right idea with the Community Mental Health Act in 1963—unfortunately, America has never had the infrastructure to support the aftermath of deinstitutionalization in community settings. Pair this with the time of the pandemic, and people with mental health needs are becoming psychiatrically sicker and for longer periods of time, which has immense consequences on their long-term prognosis.

The weight of this has often felt crushing to me and my clinical colleagues in corrections. Agencies need to be equipped to provide treatment to individuals like Ned who have been incarcerated and also live with major mental illness. People reintegrating into society from prison or jail may need more assistance to get on their feet and figure out the fast-moving world that they were removed from and to which they are returning. Yes, individuals with major mental illness may require more staff time and patience. Yes, as those providers, we should step up to the plate and meet this challenge head-on. Furthermore, as clinical providers, we cannot expect marginalized people who often have become very adept at pushing others away or having people ignore them or reject them to instantly acclimate to new surroundings and not need anything from us.

***

So why do I write all this? I write this because I’m betting there are other correctional social workers and clinicians out there who feel the weight of this just like I do. Society has an interesting way of tucking away those it sees as “undesirable” and then looking away, assuming either that these individuals will not reintegrate into society or somehow magically will. These individuals will of course be walking down our streets with us, they may live next door, or they may stand behind us at the pharmacy. If we know people who end up incarcerated will return back into society, why are we not providing them access to services? If services continue to screen for those who are “high-functioning” and “less needy,” then we are truly perpetuating stigma and preventing people like Ned from having the opportunities that they not only deserve, but are fully capable of having. A friend of mine once told me, “We’re all just walking each other home.” I hope community, psychiatric, and correctional providers can work together to make this journey better for our fellow walkers.

The Pregnant Correctional Practitioner: Challenges and Benefits

Posted on by Psychotherapy.net Team

In my previous blog, I addressed my own personal growth and development that occurred during my time as a clinical social worker specializing in the area of correctional mental health. Working in a correctional environment has taught me valuable lessons about compassion and empathy, who I am, and how to sit with others who are attempting to heal in the long shadow of the darkest moments of their lives. My own experience of having been twice pregnant while working in this capacity has deepened my appreciation of the human condition.

We clinicians know full well how demanding graduate and post-graduate training are, and how these demands don’t simply stop while we are moving forward professionally. And this includes family-building. However, despite the fact that 83% of social workers identify as female, the topic of pregnancy and how clients respond to a pregnant clinician is rarely discussed in the confines of a classroom. As a result, most clinicians who experience pregnancy will out of necessity learn how to navigate these 40-plus weeks in an on-the-job-training fashion.

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Having to navigate pregnancy as a professional was challenging in its own right. Both my experience and research have suggested that women often experience far fewer advancement opportunities as a result of preconceived and outdated notions about their ability to simultaneously manage their professional and family lives. This concern often occupied my thoughts as I wondered what my professional life would look like after my children were born. These thoughts and concerns were often unwelcome add-ons to the actual physical challenges that occurred during and after pregnancy, including nausea, extreme fatigue, and decreased reliance on caffeine to provide that occasional boost. I often experienced periods of heightened anxiety with regard to my baby’s fetal growth and health. As my body changed, revealing the undeniable reality of pregnancy, my body was on greater and greater display, which made for an interesting addition to the already demanding emotional and physical nature of my correctional work.

Deciding how to respond to curious clients was always a challenge for me. This was brought into bold relief when working with those clients who, because of separation from their own families, experienced grief and deep feelings of sadness and loss. Sometimes that grief was profoundly complicated in younger clients who faced the prospects of never becoming parents due to extended prison sentences. Others, whose incarceration followed child abuse, frequently faced the possibility of never seeing their children again. As a clinician, this was always difficult to witness while I was, at the same time, navigating my own journey toward childbirth and parenthood.

My first pregnancy occurred while I was working in a women’s correctional facility. The experience was interesting, albeit complicated. I had just transitioned from working in a men’s facility and all of my rapport building in the women’s facility was done while I was pregnant. Working in this environment, I was constantly in the presence of women who had lost custody of their children, been at odds with their children due to chronic incarceration and substance use, killed their children, miscarried after a violent interaction with a male counterpart, were themselves pregnant, had given up their children for adoption, and/or had stillbirths. The questions were never-ending regarding where I was in my pregnancy, how I was feeling, and what it was or would be like to be a parent. My growing belly was always the elephant in the room, and quite honestly, practically a constant reminder for these women of what they had lost.

I worked with several women who were due around similar time frames to myself. One of the women, we will call her Melody, looked at me one day and said something that put this into perspective for me. She angrily lamented, “I can’t even look at you, it’s not fair! You’ll get to keep your baby, and I will have to give my baby up as soon as I’m ready to leave the hospital!” Before this comment, I didn’t realize how significantly impactful my own pregnancy was on the relationship I had with Melody and others in similar situations.

Fast forward to my second pregnancy, in which I was back working with incarcerated men. There were fewer questions, but the stares were more frequent and the outlandish comments about my reproductive choices would fly frequently. Since I had my two children 22 months apart, there were a few times I was asked about what I wanted for a family size—“Do you want a big family?” Or, “Are you just going to be one of those people who pops a lot of kids out?”

However, despite the loaded commentary, both the men and women I worked with showed a lot of compassion during my pregnancies. Despite the pain that this pregnancy evoked in them, particularly around their own losses and desires to themselves be parents, the clients always took care to make sure I was safe from harm and didn’t do any heavy lifting, and they were extremely understanding if I had to leave early for an appointment and their schedule was changed.
                                                                ***
Ultimately, my experiences as a pregnant practitioner have taught me more about empathy and the depths of a parent’s love. They have also taught me about the trauma and tragedy that abound when pregnancy and parenting intersect with unmanageable circumstances, restricted choices, and limited resources. Working clinically while pregnant has taught me how to sit with discomfort and the pain that life offers, which ultimately has made me a more compassionate, empathetic, and astute social worker. I encourage pregnant practitioners, regardless of whether they work in corrections or elsewhere, to lean into the experience so that they can develop as yet undiscovered skills and qualities.

Fellow Therapists: Do You Work With Sex Offenders?

Posted on by Psychotherapy.net Team

I have had a career-long commitment, or understanding, primarily with myself, but also with insurance companies, that I choose to not work with child-abusers. It is not that I can’t see redemptive possibilities. It is just that I know I have a strong bias and am not willing to forge a pathway to empathy for those who molest children. It is a boundary I set when deciding whom and who not to treat. My thoughts about this dilemma came to the forefront very recently.

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Yesterday, a man who had been on my therapy waiting list finally arrived at my office. On his intake he noted a recent breakup with his girlfriend of several months. He stated he experienced depression and needed help to “get over the relationship.” It was only in session that the rest of his concerns emerged. At the beginning of their relationship, he told her that he had been married and had several children, but lost custody of them in the divorce. At that time, he was in deep financial trouble, having lost his then recently-purchased home, cars, and his wife to her drug addiction. Nevertheless, the Department of Children and Families (DCF) had determined that neither he nor his ex-wife were capable of raising their children, who were subsequently placed into foster care.

The divorce and subsequent foster placement of the children occurred several years prior to my meeting with him. Several of the children had since reached the age of majority. For a seemingly inexplicable reason, the foster parent who later became the adoptive parent of several of the children took it upon herself to contact my client’s girlfriend (I have no idea how she learned about her) in order to warn her that my client had been accused by his then young daughter of inappropriately touching her. True? Not true?

My client vehemently denied that this ever happened and maintains that position to date. According to him, there had been no legal proceedings, and instead, four hours of reported verbal assault by the local police. He was then purportedly presented with paperwork which he signed without reading. Why? As it turned out, he could not read. He only recently discovered that the paperwork was an affirmation of his guilt, precipitating removal of his contact privileges with his children. The most important sentence, that he could not read and was not read to him, was that he was (and possibly still is) forbidden to be around all children under a certain age. He was later told by his ex-wife that he had been placed on the state Registry of Sex Offenders. Boundary alert! But there was something about this man that compelled me to search a bit deeper.

It was easy for me to confirm that he had never been placed on that Registry through a simple request form and a phone call to the state. But what about the other accusations? I suggested he engage an attorney to find out whatever he could from the DCF offices in his state. As stated, he and his wife had been deemed unfit and the children were placed in foster care, from which they were eventually adopted. He has not seen these children since.

If he was and still is a concerned parent, I wondered why would he not have fought this and tried for all these years to see his children? He did admit that one of his older children had recently contacted him and said that the child abuse was a fiction delivered to DCF by his mother, no doubt out of anger and rooted in her addiction. This child, now an adult, refuses to make a legal statement.

As it turns out, DCF initially denied him access to any of the historical paperwork, reportedly stating that it was too late that they could not find electronic versions of it. As the children were no longer “his,” no documents could or would be turned over to him. Nevertheless, his newly-retained attorney persisted and indicated that there was indeed a document my client is not aware of indicating only that in saying goodbye to his children he was “observed hugging his daughter tightly.” This seemed appropriate to me, as he was saying goodbye to her for an indeterminable length of time. As per the attorney’s suggestion, I have not disclosed the existence of the document to my client. There may be more information forthcoming, and while I trust my intuition and am fairly accurate in “reading” my clients, I would be profoundly sad to learn that these accusations of child abuse against this man are true. It will be up to his attorney to share any “new” findings of legal significance. For now, my client is very relieved to know that he is not listed on his state’s offender registry.

Given that he has recently lost another relationship, I believe that my job at this point is to help this man try and understand why that relationship ended and to move forward if possible. His only response in this context thus far is that he just feels more broken. In light of my long-term and deeply-held conviction to not treat child abusers, I question whether I am comfortable treating him. Or, I wonder, am I too far in right now to bow out should more information come forth indicating that the charges of child abuse were indeed valid? As a parent, I intellectually appreciate how the trauma and drama of those events converged in a legal mess for this naïve, then-illiterate man who struggles to date, but am disturbed by his seeming inability or lack of initiative to have fought for custody and have found a way to hold on to his children.

***
 

As a therapist, I have asked myself new questions about how to set professional boundaries as to who I do and do not choose to treat. Do I believe everyone deserves a second chance? No—not when it comes to abusing a child. But this is not a matter of another shot at life. This is partly a story of a man who carries with him the stigma of assuming he was listed as a sex offender in the state for all these years. That was simply not true. A victim of a vicious ex-wife, a potentially inept police team, the inability to read, and the lack of good legal counsel at the time, conspired to trap this man, holding him hostage for wrongs not committed. Had he been found to be an abuser, DCF would have reported him to the state and he would have been on their list. That was never the case. And what about when these boundary lines become blurred? How do I (re)define my role in order to help a client like this one to establish new goals in the center of a complicated and lingering legal morass that may never be resolved? I have decided, at least for now, to continue to meet with him. But what if information does indeed emerge that implicates him? Do I search for redemption or reestablish my professional boundaries? I do not have that answer, at least at this moment in time.
 

The Pygmalion Effect and Treating Incarcerated Individuals with Severe and Persistent Mental Illness

Posted on by Psychotherapy.net Team

For as long as I can remember, I’ve always been fascinated by locked doors; what does society do with the individuals it tucks, or perhaps sends away, and why are they sent away to begin with? Prisons and psychiatric hospitals were always talked about so ominously, and as a young child I remember thinking, “I need to know what goes on in there.” Fast forward to the year 2015, when I signed an offer to begin working as a correctional social worker. I had spent the last year working in a correctional facility as an intern and made the decision that working in corrections was where I needed to be. I’ve always had a passion for mental health, and when I was offered a position in a psychiatric correctional unit, I knew I had to take it.

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Upon walking onto the psychiatric unit that first day, I knew instantly that I’d found my place. This place, this “unit” was just the opposite of what I expected it to be and believed as a child they were. It was painted with bright colors, residents’ art was on the walls, groups were running, and security and mental health staff members were working together to provide treatment to the men on the unit. The air on the unit was lighter—residents were able to joke with staff and clearly felt safe in this niche of the prison. I had always hoped a program like this could exist in corrections, and somehow I was lucky enough to stumble into this in one.

***

“I never thought it would work,” Melvin* said. This is a line I’ve heard Melvin repeat time and time again in our clinical sessions as he reflected on the birth and development of an innovative psychiatric unit where he resides inside a correctional facility. Melvin is a long-standing community member in the unit, and his role is anything but benign. He and a few other permanent residents serve as institutional memory—not only do they keep the mission of the unit alive, but they also keep the cultural expectations and norms of the unit thriving.

It may be tempting to think the culture of a unit inside a correctional facility to be harsh, ruthless, and violent; but with the right balance of residents and staff, the most astounding transformations can be seen—just ask Melvin. Melvin, an individual living with psychotic illness who walked onto the unit upon its inception, will be the first to tell you he never thought a structured mental health unit would survive in corrections. Having lived a life riddled by poverty, substance use, abandonment, dual-diagnosis, and trauma, it is not surprising Melvin ended up in an institutional setting. When he first arrived onto the unit, he appeared hardened and unreachable and had just returned from a hospital trip due to an injury inflicted during the throes of a psychotic episode. “Ya, I used to sit in the corner over there (referencing the group treatment room) and just stay silent all group, purposefully choosing to stay uninvolved.” Melvin is honest in his reflections that he didn’t think a unit could exist inside a correctional facility without strong-arming, victimization, and prison politics. He didn’t know then the power of the Pygmalion Effect.

The “Pygmalion Effect”¹ describes the way individuals present themselves in a manner akin to the expectations set before them, whether they are positive or negative. The psychiatric unit where Melvin resides was able to cultivate the expectation that individuals residing on the unit would drop behaviors typically seen in the prison culture (intimidation, bullying, violence) and promote ideals such as asking staff for help, utilizing town halls to address community issues within the unit, and speaking honestly about their lives in group treatment. The vulnerability and effort to curb well-developed criminal tendencies it took residents like Melvin to exhibit was extraordinary, and over time the unit has become what Melvin describes as a “safe place” and “my family.” Although staff may have initially brought forth these ideals and stayed dedicated and consistent to the mission of providing treatment rather than simple stabilization, the therapeutic and pro-social culture of the unit now comes directly from Melvin and other long-term residents. The “Pygmalion Effect” tends to be cyclical in nature and is seen daily in this psychiatric unit. The staff members show unconditional positive regard and a belief that typical prison behavior and defenses can be dropped in the unit because the residents are much more than their prison sentence or mental illness. The residents, in turn, begin to believe themselves to be individuals who are worthy and can contribute to the world through human connection. This spreads amongst the men through groups and psychotherapy, and eventually, the entire unit is finding positive ways to support one another along their journeys with mental illness, recovery, and imprisonment. The “Pygmalion Effect” has allowed for something uncommon to occur in a correctional environment—people are actually getting well, not just stabilized.

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Here we are in 2021, and I now hold my doctorate in social work and am the director of this unit in which I whole-heartedly believe. The evolution of the unit has been extraordinary to watch. In an interesting way, we’ve grown together. I started working in the unit as a conditionally licensed professional, left and explored other avenues of corrections, and then returned as a fully licensed professional completing a doctorate program. As I’ve gained my clinical footing and found my stride, I’ve watched the men on the unit do the same. The residents who have been on the unit since its inception, such as Melvin, have gone from being acutely ill to now being peer mentors on the unit. Throughout these years on the unit these men have developed self-esteem and practiced being able to trust; skills they struggled with for most of their lives. If this is what happens in six years’ time, I cannot wait to see the growth that occurs within the next six.

1. Chang, J. (2011). A case study of the “Pygmalion Effect”: Teacher expectations and student achievement. International Education Studies, 4(1), 198–201.