The Crime Is Not The Person: 
Assessment and Treatment of Posttraumatic Stress in Correctional Settings

Background 
As a psychiatrist, my calling is to deeply listen to the people who come to me for help, and to help them understand who they are and how they’ve come to be in their present circumstances. Indeed, a central task of a mental health provider is to help people learn that their identities are larger than their symptoms or behaviors. 

In my work at the Suffolk County House of Corrections, I often hear themes of severe abuse and neglect in the narratives of my patients’ early lives, for example, growing up in households full of violence and drug abuse. Because of growing up in toxic environments, many of my patients developed chronic mental health conditions such as posttraumatic stress, mood disorders, and addictions. Tragically, without safety and guidance, they also missed opportunities to learn basic life skills, e.g., learning how to set appropriate boundaries in relationships, or how to deal with disappointments and stay on track with their intentions. Thus, they come to view themselves as failures and they continue to perpetuate maladaptive behaviors of drug abuse and criminal acts. When relevant, I help my patients understand the impact of their traumatic past on their present behaviors. This often helps them to have a little more compassion for themselves as they learn to contextualize their behaviors and to see that they are more than their symptoms or behaviors. This type of basic mental health approach to trauma is needed in correctional settings.  

Challenges of Addressing Mental Health Correctional Settings
Mental health care providers working in correctional settings often fear treating traumatic stress because of concerns that doing so could increase anxiety, aggression, or depression. Consequently, they often avoid the topic altogether. This concern is understandable because talking about traumatic experiences inevitably leads to emotional distress. Within correctional settings I would not, for example, do trauma exposure therapy. This type of therapy is a deep dive into traumatic memories with the goal of helping people to free themselves of the emotional burden of the past. This type of trauma therapy requires a safe and supportive environment, which correctional settings inherently are not. Nonetheless, there is still a lot of good trauma-focused clinical work that can be accomplished safely within correctional settings and the topic of trauma need not be avoided. For example, it is safe to conduct a diagnostic assessment of traumatic stress disorder, as well as to provide psychoeducation about the impact of trauma on present behavior. 

Along with my colleague, Barbara McCarthy, NP, we systematically assessed 68 people referred for psychiatric evaluation at the Suffolk County House of Corrections for the presence of traumatic stress disorders. We found that more than two-thirds of those referred for psychiatric evaluation met criteria for some type of traumatic stress disorder, with more than 50% meeting criteria for complex posttraumatic stress disorder, a more severe form of posttraumatic stress associated with repeated trauma and neglect. We found that if people had an opportunity to fill out a questionnaire about their past trauma experiences (versus talking aloud about their experiences), they were more likely to complete the evaluation and to better manage their emotional distress. Nearly all were appreciative of having a name for their symptoms and learning about what actions they could take to improve their lives.  

Quality Improvement Project
For anyone working within correctional settings, it is obvious that trauma and traumatic stress disorders are highly prevalent. Within the subset of people referred to me for psychiatric evaluation, it is the second most common diagnosis next to substance abuse. Despite the salience of trauma within correctional settings, no clearly defined programs have been implemented to address this issue. With the support of the MGH Center of Excellence and the Suffolk County House of Corrections, we are presently implementing a quality improvement project to meet this gap in trauma programming. 

This quality improvement project involves training the mental health teams at both the Suffolk County House of Corrections and Jail to conduct systematic trauma evaluations and, when appropriate, to provide a brief evidence-based trauma intervention. The intervention will help patients to develop emotional regulation skills and to recognize their symptoms and the impact of their past trauma on their present behaviors. For some, this will be the beginning of a journey to undo the damage caused by early abuse and neglect, as they may be able to better appreciate that they are not destined to repeat the past and that their identities are larger than their maladaptive behaviors and criminal acts.  

In the United States, we incarcerate far too many people with mental illness, substance abuse, and traumatic stress disorders. Fifty years of the War on Drugs policies and criminalization of the mentally ill have made it more challenging for these vulnerable groups to access and use the help they need. It is time to reimagine our correctional settings as places that not only keep violent offenders away from society, but also to provide meaningful rehabilitation opportunities for vulnerable groups who end up trapped in the criminal justice system.

“It is time to reimagine our correctional settings as places that…also to provide meaningful rehabilitation opportunities for vulnerable groups…”

 

Jose Hidalgo, MD
Director of Psychiatry, Wellpath, Suffolk County House of Corrections

The Crime Is Not The Person: Assessment and Treatment of Posttraumatic Stress in Correctional Settings