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Post
Incarceration Syndrome and Relapse
By Terence T. Gorski (Terry
Gorski is available to speak or consult on these issues)
Permission is given
to reproduce this article with proper referencing.
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The Post Incarceration Syndrome (PICS) is a serious problem that
contributes to relapse in addicted and mentally ill offenders who are released
from correctional institutions. Currently 60% of prisoners have been in prison
before and there is growing evidence that the Post Incarceration Syndrome (PICS)
is a contributing factor to this high rate of recidivism. [i]
The concept
of a post incarceration syndrome (PICS) has emerged from clinical consultation
work with criminal justice system rehabilitation programs working with currently
incarcerated prisoners and with addiction treatment programs and community
mental health centers working with recently released prisoners.
This
article will provide an operational definition of the Post Incarceration
Syndrome (PICS), describe the common symptoms, recommend approaches to diagnosis
and treatment, explore the implications of this serious new syndrome for
community safety, and discuss the need for political action to reduce the number
of prisoners and assure more humane treatment within our prisons, jails, and
correctional institutions as a means of prevention. It is my hope that
this initial formulation of a PICS Syndrome will encourage researchers to
develop objective testing tools and formal studies to add to our understanding
of the
problems encountered by released inmates that influence recovery and
relapse.
Post Incarceration Syndrome (PICS) - Operational
Definition
The Post Incarceration Syndrome (PICS) is a set of symptoms that
are present in many currently incarcerated and recently released prisoners that
are caused by being subjected to prolonged incarceration in environments of
punishment with few opportunities for education, job training, or
rehabilitation. The symptoms are most severe in prisoners subjected to
prolonged solitary confinement and severe institutional abuse.
The
severity of symptoms is related to the level of coping skills prior to
incarceration, the length of incarceration, the restrictiveness of the
incarceration environment, the number and severity of institutional episodes of
abuse, the number and duration of episodes of solitary confinement, and the
degree of involvement in educational, vocational, and rehabilitation
programs.
The Post Incarceration Syndrome (PICS) is a mixed mental
disorders with four clusters of
symptoms:
(1) Institutionalized
Personality Traits resulting from the common deprivations of incarceration, a
chronic state of learned helplessness in the face of prison authorities, and
antisocial defenses in dealing with a predatory inmate
milieu,
(2) Post Traumatic Stress
Disorder (PTSD) from both pre-incarceration trauma and trauma experienced within
the institution,
(3) Antisocial
Personality Traits (ASPT) developed as a coping response to institutional abuse
and a predatory prisoner milieu,
and
(4) Social-Sensory Deprivation
Syndrome caused by prolonged exposure to solitary confinement that radically
restricts social contact and sensory stimulation.
(5) Substance Use Disorders caused
by the use of alcohol and other drugs to manage or escape the PICS
symptoms.
PICS often coexists with substance use disorders and a variety
of affective and personality disorders.
Symptoms of the Post
Incarceration Syndrome (PICS)
Below is a more detailed description of four
clusters of symptoms of Post Incarceration Syndrome (PICS):
1.
Institutionalized Personality Traits
Institutionalized Personality Traits are
caused by living in an oppressive environment that demands: passive compliance
to the demands of authority figures, passive acceptance of severely restricted
acts of daily living, the repression of personal lifestyle preferences, the
elimination of critical thinking and individual decision making, and
internalized acceptance of severe restrictions on the honest self-expression
thoughts and feelings.
2. Post Traumatic Stress Disorder
(PTSD)
Post Traumatic Stress Disorder (PTSD) [ii] is caused by both traumatic
experiences before incarceration and institutional abuse during incarceration
that includes the six clusters of symptoms: (1) intrusive memories and
flashbacks to episodes of severe institutional abuse; (2) intense psychological
distress and physiological reactivity when exposed to cues triggering memories
of the institutional abuse; (3) episodes of dissociation, emotional numbing,
andrestricted affect; (4) chronic problems with mental functioning that include
irritability, outbursts of anger, difficulty concentrating, sleep disturbances,
and an exaggerated startle response. (5) persistent avoidance of anything that
would trigger memories of the traumatic events; (6) hypervigilance, generalized
paranoia, and reduced capacity to trust caused by constant fear of abuse from
both correctional staff
and other inmates that can be generalized to others
after release.,
3. Antisocial Personality Traits
Antisocial
Personality Traits [iii] [iv] [v]are developed both from preexisting symptoms
and symptoms developed during incarceration as an institutional coping skill and
psychological defense mechanism. The primary antisocial personality traits
involve the tendency to challenge authority, break rules, and victimize
others. In patients with PICS these tendencies are veiled by the passive
aggressive style that is part of the institutionalized personality.
Patients with PICS tend to be duplicitous, acting in acompliant and passive
aggressive manner with therapists and other perceived authority figures while
being capable of direct threatening and aggressive behavior when alone with
peers outside of the perceived control of those in authority. This is a
direct result of the internalized coping behavior required to survive in a
harshly punitive correctional institution that has two set of survival
rules: passive aggression with the guards, and actively aggressive with
predatory inmates.
4. Social-Sensory Deprivation Syndrome:
The
Social-Sensory Deprivation Syndrome [vi] is caused by the effects of prolonged
solitary confinement that imposes both social isolation and sensory deprivation.
These symptoms include severe chronic headaches, developmental regression,
impaired impulse control,
dissociation, inability to concentrate, repressed
rage, inability to control primitive drives and
instincts, inability to plan
beyond the moment, inability to anticipate logical consequences of behavior, out
of control obsessive thinking, and borderline personality traits.
5. Reactive Substance Use Disorders
Many inmates who experience
PICS suffer from the symptoms of substance use disorders [vii]. Many of
these inmates were addicted prior to incarceration, did not receive treatment
during their imprisonment, and continued their addiction by securing drugs on
the prison black market. Others developed their addiction in prison in an
effort to cope with the PICS symptoms and the conditions causing them.
Others relapse to substance abuse or develop substance use disorders as a result
of using alcohol or other drugs in an effort
to cope with PICS symptoms upon
release from prison.
PICS Symptoms Severity
The syndrome is most
severe in prisoners incarcerated for longer than one year in a punishment
oriented environment, who have experienced multiple episodes of institutional
abuse, who have had little or no access to education, vocational training, or
rehabilitation,
who have been subjected to 30 days or longer in solitary
confinement, and who have experienced frequent and severe episodes of trauma as
a result of institutional abuse.
The syndrome is least severe in
prisoners incarcerated for shorter periods of time in rehabilitation oriented
programs, who have reasonable access to educational
and vocational training,
and who have not been subjected to solitary confinement, and who have not
experienced frequent or severe episodes of institutional abuse.
Reasons
To Be Concerned About PICS
There is good reason to be concerned because about
40% of the total incarcerated population (currently 700,000 prisoners and
growing) are released each year. The number of prisoners being deprived of
rehabilitation services, experiencing severely restrictive daily routines, being
held in solitary confinement for prolonged periods of time, or being abused by
other inmates or correctional staff is increasing. [viii]
The effect of
releasing this number of prisoners with psychiatric damage from prolonged
incarceration can have a number of devastating impacts upon American society
including the further devastation of inner city communities and the
destabilization of blue-collar and middle class districts unable to reabsorb
returning prisoners who are less likely to get jobs, more likely to commit
crimes, more likely to disrupt families. This could turn many currently
struggling lower middle class areas into slums. [ix]
As more prisoners
are returned to the community, behavioral health providers can expect to see
increases in patients admitted with the Post Incarceration Syndrome and related
substance use, mental, and personality disorders. The national network of
Community Mental health and Addiction treatment Programs need to begin now to
prepare their
staff to identify and provide appropriate treatment for this
new type of client.
The nation's treatment providers, especially
addiction treatment programs and community mental health centers, are already
experiencing a growing number of clients experiencing the Post Incarceration
Syndrome (PICS). This increase is due to a number of factors including:
the increasing size of the prisoner population, the increasing use of
restrictive and punishing institutional practices, the reduction of access to
education, vocational training, and rehabilitation programs; the increasing use
of solitary confinement and the growing number of maximum security and super-max
type prison and jails.
Both the number of clients suffering from PICS
and the average severity of symptoms is expected to increase over the next
decade. In 1995 there were 463,284 prisoners released back to the
community. Based upon conservative projections in the growth of the
prisoner
population it is projected that in the year 2000 there will be
660,000 prisoners returned to the community, in the year 2005 there will 887,000
prisoners returned to the community, and in the year 2010 1.2 million prisoners
will be released. [x] The prediction of greater symptom severity is based upon
the growing trend toward longer periods of incarceration, more restrictive and
punitive conditions in correctional institutions, decreasing access to
education, vocational training, and rehabilitation, and the increasing use
solitary confinement as a tool for reducing the cost of prisoner
management.
Clients with PICS are at a high risk for developing substance
dependence, relapsing to substance use if they were previously addicted,
relapsing to active mental illness if they were previously mentally ill, and
returning to a life of aggression, violence, and crime. They are also at
high risk of chronic unemployment and homelessness.
Post Release Symptom
Progression
This is because released prisoners experiencing PICS tend to
experience a six stage post release symptom progression leading to recidivism
and often are not qualified for social benefits needed to secure addiction,
mental health, and occupation training services.
· Stage 1 of this Post Release
Syndrome is marked by Helplessness and hopelessness due to inability to develop
a plan for community reentry, often complicated by the inability to secure
funding for treatment or job training;
·
Stage 2 is marked by an intense immobilizing fear;
· Stage 3 is marked by the
emergence of intense free-floating anger and rage and the emergence of
flashbacks and other symptoms of PTSD;
· Stage 4 is marked by a
tendency toward impulse violence upon minimal provocation;
· Stage 5 is marked by an
effort to avoid violence by severe isolation to avoid the triggers of violence;
· Stage 6 is marked by the
intensification of flashbacks, nightmares, sleep impairments, and impulse
control problems caused by self-imposed isolation. This leads to acting
out behaviors, aggression, violence, and crime, which in turn sets the stages
for
arrest and incarceration.
Currently 60% of prisoners have been in
prison before and there is growing evidence that the PostIncarceration Syndrome
(PICS) is a contributing factor to this high rate of recidivism.
Reducing
The Incidence Of PICS
Since PICS is created by criminal justice system policy
and programming in our well intentioned but misguided attempt to stop crime, the
epidemic can be prevented and public safety protected by changing the public
policies that call for incarcerating more people, for longer periods of time,
for less severe offenses, in more punitive environments that emphasize the use
of solitary confinement, that eliminate or severely restrict prisoner access to
educational, vocational, and rehabilitation programs while incarcerated.
The political antidote for PICS is to implement public policies that:
(1) Fund the training and expansion
of community based addiction and mental health programs staffed by professionals
trained to meet the needs of criminal justice system clients diverted into
treatment by court programs and released back to the community
after
incarceration;
(2) Expand the role
of drug and mental health courts that promote treatment alternatives to
incarceration;
(3) Convert 80% of our
federal, state, and county correctional facilities into rehabilitation programs
with daily involvement in educational, vocational, and rehabilitation programs;
(4) Eliminate required long mandated
minimum sentences;
(5) Institute
universal prerelease programs for all offenders with the goal of preparing them
to transition into community based addiction and mental health
programs;
(6) Assuring that all
released prisoners have access to publicly funded programs for addiction and
mental health treatment upon release.
[i] Ditton, Paula M. Mental
Health and Treatment of
Inmates and Probationers, Bureau of
Justice
Statistics, July 11, 1999
(NCJ-174463),
(http://www.ojp.usdoj.gov/bjs/)
[ii] American
Psychiatric Association, Diagnostic and
Statistical Manual of Mental
Disorders (DSM IV),
Fourth Edition, 1994 (Pg 424 – 429)
[iii] American
Psychiatric Association, Diagnostic and
Statistical Manual of Mental
Disorders (DSM IV),
Fourth Edition, 1994 (Pg 645 – 650)
[iv] Forrest,
Gary G., Chemical Dependency and
antisocial Personality Disorder –
Psychotherapy and
Assessment Strategies, The Hawthorn Press, New
York,
April 1994
[v] Hempphill, James F.; Templeman, Ron;
Wong,
Stephen; and Hare, Robert D. Psychopathy and Crime:
Recidivism
and Criminal Careers. IN: Cooke, David J.;
Forth, Adelle E., and Hare,
Robert D. ED:
Psychopathy: Theory, Research, and implications
for
Society, Kluwar Academic Publishers, Boston, 1995
[vi] Grassian,
Stuart, Psychopathological effects of
solitary confinement, American Journal
of Psychiatry,
140, 1450 - 1454 (1983)]
[vii] American Psychiatric
Association, Diagnostic and
Statistical Manual of Mental Disorders (DSM
IV),
Fourth Edition, 1994 (Pg 175 – 272)
[viii] Ditton, Paula M.
Mental Health and Treatment
of Inmates and Probationers, Bureau of
Justice
Statistics, July 11, 1999
(NCJ-174463),
(http://www.ojp.usdoj.gov/bjs/)
[ix] Sabol, William,
Urban Institute, Washington DC
[x] Abramsky, Sasha, When They Get Out,
Atlantic
Monthly, June, 1999 p. 30
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60430,
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60430
info@enaps.com; www.tgorski.com,
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