A Mental Health Treatment Program for Inmates in Restrictive Housing

Stepping Up, Stepping Out

Ashley B. Batastini, Robert D. Morgan, Daryl G. Kroner, Jeremy F. Mills

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351720274
• Edition: 1
• Topic: Psychology
• Subtopic: Forensic Psychology
• Index: Psychology

This treatment program targets the criminal, behavioral, and mental health problems of inmates in segregated housing that prevents them from living prosocially and productively within the general prison population.

The program makes use of a bi-adaptive psychoeducational and cognitive-behavioral treatment model to increase inmates' understanding about the psychological and criminal antecedents that contributed to their current placement, and to teach them the skills necessary for managing these problem areas. This flexible intervention assists inmates with significant problem behaviors by reducing psychological impairment and improving their ability to cope with prison life. This book includes a program introduction and guide for clinicians, the inmate workbook, and accompanying eResources to assist clinicians in both successful program implementation and evaluation of treatment outcomes.

Designed to account for the safety and physical limitations that make the delivery of needed mental and behavioral health services difficult, this guide is essential reading for practitioners working with high-needs, high-risk inmate populations.

Part I
An Introduction and Guide for Clinicians

Layout of This Book

This book is laid out in two primary parts. Part I speaks directly to you—the clinician—in describing the goals and implementation of the Stepping Up, Stepping Out program. This part will also provide guidance on how to track client progress and assess overall program impact at the institutional level. The audience for Part II of the book is the inmate participants themselves. Part II includes a list of program expectations to set the stage for the level of work and commitment required, an outline of the upcoming modules, and all module handouts, which can be photocopied for distribution. Prior to distributing module handouts, it is recommended that clinicians first provide inmates with the list of program expectations and outline, and allow participants to ask any questions. At this pre-treatment stage, clinicians can challenge and foster inmates’ motivation for treatment.

In addition to Parts I and II, the purchase of this book gives clinicians free access to a number of eResources. Among these resources are copyrighted but nonproprietary pre- and post-treatment assessment measures; a spreadsheet for clinicians to track treatment progress and engagement, pre- and post-module quizzes, modules; program completion certificates; a quick-reference glossary of key terms; and supplemental materials that accompany module content. Clinicians are encouraged to introduce these supplemental materials in conjunction with respective modules and to provide copies to inmates on a recurrent basis. When and how to use these supplemental materials is described in further detail in the following sections. In general, eResource materials are listed online in the order in which they will be used. Use of eResource material is referenced throughout the clinician’s guide (Part I).

Introduction to Stepping Up, Stepping Out

Following a similar theoretical framework as the Changing Lives and Changing Outcomes program developed by Morgan, Kroner, and Mills (2018; also part of the International Perspectives on Forensic Mental Health book series), Stepping Up, Stepping Out uses a bi-adaptive intervention model to address both mental health issues and antisocial (or criminal) patterns with the goal of reducing behavioral problems of inmates detained in restrictive housing settings, such as disciplinary segregation (DS) and administrative segregation (AS), and other types of units that limit access to resources and/or programming. Specifically, Stepping Up, Stepping Out aims to prevent inmates from remaining in and returning to long-term isolation by reducing behavioral misconducts and psychological impairment, and improving their ability to cope with prison life. Like Changing Lives and Changing Outcomes, Stepping Up, Stepping Out also uses both a psychoeducation and psychotherapeutic approach to teach and train inmates in skill acquisition. Principles of various empirically supported treatments, including Linehan’s Dialectical Behavior Therapy (1993), Hayes and colleagues’ Acceptance and Commitment Therapy (Hayes, 2004), Mueser’s Illness Management and Recovery (2002), and the Substance Abuse and Mental Health Services Administration’s Anger Management and Assertiveness Training (Reilly & Shopshire, 2015), are emphasized throughout. Although the program is primarily geared toward inmates with a history of more serious mental health concerns, inmates with less severe psychiatric symptoms (e.g., heightened levels of general stress, externalizing behaviors commonly associated with antisocial personality disorder, adjustment issues, problematic coping) are also appropriate candidates for program participation, perhaps with some modification to program content as determined by pre-treatment assessment results and clinical judgment. Further, this program may be used with inmates who are prone to restricted housing placements or at-risk of such placement, but not currently housed there.

Stepping Up, Stepping Out includes nine treatment modules: (1) Understanding Change and Making It Happen: An Introduction; (2) Surviving Segregation: What to Expect and How to Cope; (3) Suicide and Self-Injurious Behavior: Protecting You From You; (4) Understanding My Emotions: Identifying and Dealing With Anger, Fear, and Other Frustrating Feelings; (5) Exploring My Mental Distress and Criminalness: Where It Comes From, What It Looks Like, and How to Recognize It; (6) Managing My Mental Distress and Criminalness: Improving Functioning and Preventing Relapse; (7) Seeking Supportive Allies: Finding Helpful Others Among the Crowd; (8) Integrating “Us” and “Them”: Improving Inmate-Staff Relations; and (9) Road Map to Recovery: Creating Your Relapse Prevention Plan. Because Stepping Up, Stepping Out describes relatively complex psychological concepts throughout the program, a glossary of terms (eResource Appendix I) is also included to aid understanding.

The delivery of Stepping Up, Stepping Out is flexible and is intended to be implemented as a largely self-directed program, with inmates completing the handouts and exercises embedded in each module on their own with as little or as much staff contact as is available. At a minimum, it is recommended that clinicians provide written feedback following each handout to ensure completeness and understanding, and schedule in-person contact at least once per week to discuss progress or review stuck points. Although each module focuses on a specific problem area, modules are represented in a developmental progression—that is, basic treatment concepts and goals are discussed first, then immediate stressors related to segregation, then more global issues within the individual, and, finally, relapse prevention. None of the modules are designed as stand-alone modules; rather, broader concepts from all nine modules are integrated within each individual module to create a developmentally coherent and consistent program for inmates detained in segregated housing units.

Program Goals

The goal of Stepping Up, Stepping Out is not to cure mental illness, eliminate criminal risk, or even to negate the need for continued care. Instead, this intervention is designed to maximize compliance with institutional rules and foster adaptive behavioral change so inmates with mental health concerns (or those at risk of developing them) can successfully serve their time in segregation with fewer incidents of misconduct, return to the general prison population where more intensive services can be provided, and remain there. That is, Stepping Up, Stepping Out is conceptualized as a gateway intervention, meaning that inmates who complete the program are not expected to be “recovered” or “fixed.” This program is intended to reduce an inmate’s risk enough to allow for safe transition to the general population (GP). It is in GP where inmates must continue to build upon the skills learned while in segregation by engaging in treatment services that otherwise are unavailable to them in secure placement. The ultimate outcome for all inmates is to get out and stay out of segregation. Accomplishing this goal is not only dependent on the inmate’s willingness and motivation to do the necessary work but also on the ability of correctional staff to see change as possible.

Theoretical Rationale and Evidence Base for Stepping Up, Stepping Out

Although solitary confinement was first implemented in the late 1700s as a measure of criminal justice reform, the contemporary use of restricted housing (to include disciplinary and AS) in North American prisons and jails is a growing and controversial correctional practice. A survey out of Yale University Law School estimated that nearly 80,000 to 100,000 inmates were held in restrictive housing across the country (Liman Program & Association of State Correctional Administrators, 2015). Yet this number is likely an underestimate, as it did not include local jails, juvenile facilities, or military and immigration detention centers. Although the range of activities to which inmates have access varies depending on the facility (Suedfeld, Ramirez, Deaton, & Baker-Brown, 1982), all restricted housing units closely monitor inmate movement and limit access to mental health programing, educational and library services, religious services, personal possessions, and physical exercise (O’Keefe, 2008; Pizarro & Stenius, 2004). It is not uncommon for inmates to spend years, even decades, in these restricted units (see, for example, Goode, 2015; Landau, 2015). Typically, long-term or indefinite stays are most associated with AS. DS, on the contrary, is usually reserved for shorter-term, determinate sanctions in response to disciplinary infractions.

Efforts to better understand the impact of segregation on the well-being of inmates have been occurring for decades. To help clarify the effects of restricted housing, a team of researchers (Morgan et al., 2016) undertook two independent meta-analytic reviews in which over 40,000 search results relating to solitary confinement, protective custody, DS, and AS were identified. These researchers reported small to moderate effects across most physical, behavioral, and mental health outcomes. The largest of these effects (compared to non-segregated inmates) were for increased hostility, anxiety, hypersensitivity, general mental health functioning, and post-release criminal recidivism. Although these researchers concluded that the adverse effects of restricted placements might be over-stated, they also acknowledged two of the major limitations in the literature: (a) the limited time that study participants spent in these units (i.e., one year or less; see Coid et al., 2003; Haney, 2003; O’Keefe, Klebe, Stucker, Sturm, & Leggett, 2010; Suedfeld et al., 1982) and (b) the lack of pre-post testing to determine baseline functioning of inmates and rule out the possibility that psychological impairment and/or behavioral problems existed prior to segregated placement.

A subsequent study (Chadick, Batastini, Levulis, & Morgan, 2018), which included assessments at initial booking and at least one-year post-booking, inmates detained in AS for up to four years, and a comparison group of GP inmates, similarly concluded that AS alone did not appear to cause debilitating psychological effects. While segregated inmates reported higher levels of distress (particularly on measures of anxiety, depressed mood, posttraumatic stress, and somatic complaints) compared to the GP at post-assessment, scores did not reach the clinical cutoff. Further, inmates did not deteriorate as time in restrictive housing increased. However, compared to those in GP who showed some improvement over time, AS inmates remained relatively stable from baseline to follow-up. The authors concluded that, rather than causing significant psychological damage, it is more likely that segregation is a barrier to opportunities for continued growth. Notably, this study was limited by its small sample size (AS = 24; GP = 24) and lack of severely mentally disordered offenders (e.g., 30% had no psychiatric diagnosis at booking, and none were diagnosed with a psychotic disorder). Another study published in 2018 by Walters revealed that prison inmates with a history of mental health need were more likely to experience severe psychological consequences from restricted housing than those without such a history. However, these differences in psychological reactions also held for GP placement, suggesting that aversive outcomes for those with mental health problems may have more to do with incarceration generally than restricted housing specifically.

Although the totality of consequences for inmates placed in segregation remains unclear and likely depends on other institutional factors (e.g., staff-inmate dynamics, emphasis on punishment, physical conditions; e.g., Gendreau & Labrecque, 2015), it appears that at least small to moderate adverse effects are associated with segregation (Morgan et al., 2016; Chadick et al., 2018). Thus, correctional systems must strive to minimize the risk of inmate decompensation that could result from segregated placement. Furthermore, prevention of harm is not just an aspirational goal—it is a legal obligation. That is, correctional departments are responsible for the well-being and care (including the provision of mental health services) of inmates (Ruiz v. Estelle, 1980). Perhaps even more concerning is that inmates with preexisting and serious mental health problems tend to be over-represented in restricted units, often to contain their odd or disruptive behaviors (Haney, 2003; O’Keefe, 2007, 2008; Metzner & Fellner, 2010). The fact that inmates with mental health concerns are at greater risk for restricted placements may be the product of misguided responses to behavioral issues by untrained correctional staff and/or insufficient treatment options. Little empirical data exists regarding the additive effects of segregated placement on this high-needs and unique group, especially for those with longer placement periods. Unfortunately, the availability of mental health services in general is limited in segregation due to higher safety and security restrictions (Beven, 2005; Metzner & Fellner, 2010), and interventions that uniquely target the needs of this population are lacking. Though there is a trend in the United States to remove inmates with serious mental illnesses from segregation units—following a number of law suits (Madrid v. Gomez, 1995; Disability Law Center v. Massachusetts Department of Corrections, 2007)—many correctional agencies struggle to implement specialized units (e.g., Secure Treatment Programs, Behavioral Management Units) that are not simply alternative forms of restricted housing. Further, combating behavioral problems that are rooted in the cross-section between antisocial patterns and poor psychological coping remains a goal even in more treatment-oriented environments.

The few programs currently available for inmates prone to longer-term restricted placements are limited in scope and seem to address only one side of a two-sided problem. First, many mental health programs for offenders are based on the false assumption that mental distress or illness is the underlying caus...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• About the Authors
• Acknowledgments
• Part I An Introduction and Guide for Clinicians
• Part II Inmate Workbook
• Index