PTSD and Addiction: A Cognitive Restructuring Approach

January 11, 2014
By Terence T. Gorski, Author
June 22, 2013
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Recovery Is Possible With
Cognitive Restructuring

 WHEN  TREATING PTSD AND ADDICTION, I don’t use a single approach – I use a consistent set of principles and practices. I strive to be sensitive and adaptive to the emerging needs of patients in the moment. The key seems to be a balance of flexibility and consistency.  Everyone responds in a uniquely personal way in learning to understand and manage PTSD. I like the idea that and the PTSD recovery process results in Post Traumatic Growth. People don’t just overcome their symptoms. They grow and change in positive ways.

PTSD ASSESSSMENT – A CRITICAL FIRST STEP

First I do a comprehensive assessment of PTSD. This includes an analysis of presenting problems, a life history, and a history of treatment and recovery. I include efforts at self-help to be important. Most people try everything they know to get a handle on their PTSD before seeking any formal or professional help.

ADDICTION ASSESSMENT – NOT A LUXURY, A NECESSITY

If the assessment provides confirmation of active PTSD symptoms, I do a comprehensive addiction assessment because addiction is so common in patients with PTSD. If the addiction is not identified and treated concurrently, the PTSD treatment can make the addiction symptoms worse, and the addiction symptoms can prevent patients from benefiting from the treatment/recovery of PTSD.

PSYCHO-EDUCATION – TEACHING A LANGUAGE OF RECOVERY

Then I use psycho-education to give people a new cognitive frame of reference about PTSD. This is extremely important because, although most people are familiar with the general idea of PTSD, most lack accurate information or a useful way of understanding the symptoms and the pathways to recovery.

SURVIVORS – NOT VICTIMS

The most important thing I want to teach is that patients are trauma survivors, not trauma victims. I also want to be sure that the trauma is over. You work differently with PTSD if the trauma is still ongoing It makes a difference if: a soldier needs to return to combat or is home from the war; if a battered child is still living under the control of violent parent and will have to go home; if the abused spouse is out of the marriage or still involved due to children or financial issues; if the person is in prison and going back to the cell block or if they have been released. If they are actively involved in an ongoing trauma teach survival and coping skills, safety plans, and ways to responsible get out and get safe.

GET PATIENTS SOME INITIAL RELIEF FROM PAIN

The first goal is to provide relief for the most painful mediate symptoms. This often involves referral for EMDR. I am not skilled with this method, but many patients find it helpful. This also involves basic training in relaxation, diet, and exercise as a part of overall stress management.

THE LIFE AND SYMPTOMS HISTORY – A COLLABORATIVE APPROACH

Then I do a guided life and symptom history so people can see how symptoms have affected their life negatively through pain, problems, and losses; and positively through a process of making decisions that lead to positive change, growth, and development. This is a positive psychology intervention called Post Traumatic Growth (PSG).

THE COMPREHENSIVE SYMPTOM LIST

I develop a comprehensive list of the PTSD symptoms that patients are struggling with. This often involves showing them a list of symptoms because they lack the words or language to describe what they are experiencing. It is easy for me to forget how important it is to give patients a language of recovery so they can identify and communicate their experiences.

Once I have a comprehensive symptom list, I ask patients to evaluate the frequency (how often) and severity (how disruptive) the symptoms tend to be.  Then explore each symptom. First I want them to tell me real-life stories about what happened when they experienced each symptoms. I like to get at least two stories about each – one story in which they managed it pretty well, and one story in which they managed it poorly. This helps them to take ownership of their symptoms and get a feel for the new language they are learning. I get stress enough how important I feel this process by relating symptoms to actual lived experiences is for most patients.

I look for patterns of symptoms. Many symptoms appear in clusters that are activated by the same trigger event and once they appear, they mutual reinforce and intensify each other. I treat these symptom clusters as a single symptom and help patients to find a meaningful name it.

STRENGTH-BASED – WHAT ARE YOU DOING RIGHT

I make it a point to discuss how patients have managed to survive up to this point. I want to find periods of time when they have successfully managed their symptoms or been symptoms free. What were they doing at those times. What was going on or not going in their lives. What thoughts, feelings, behaviors, and social styles are associated with successfully coping with the symptoms?

THE IDEA OF PTSD SYMPTOM EPISODES

I also like to introduce the concept of PTSD symptoms episodes – moments in time when the symptoms get turned on by triggers and turned off by things like rest and safe environments. The idea is that the symptoms are not always there. Most patients believe that they are, but they are usually wrong. The symptoms are usually turned on some of the time and turned off at other times. Once a symptoms episode is activated by a trigger, it starts, runs a cycle, and then ends or significantly diminishes in intensity. Know that it will end gives strength in facing the symptoms. Naming the symptoms identifies the enemies or the monsters to be dealt with. At the very least, at some times the symptoms are less severe and more manageable than at other times.

SYMPTOM SELF-MONITORING

I encourage patients to do conscious self-monitoring o their symptoms at least four times per day (breakfast, lunch, dinner, and before bed) and note the specific symptoms experienced, how severe the symptom is, what is happening that is making it more severe, and what could be done to make it a little bit less severe. This starts patients on a journey of Post Traumatic Growth by showing them they are not totally at the mercy of these symptoms — that they can choose to do things to make their symptoms a little bit better or a little worse.

FLASHBACKS – TEACHING PATIENT TO GET OUT SAFELY

I find that many patients are fearful of the flashback and dissociative states that they get into that are often a part of PTSD. They fear that if they get into these states they will fall into a bottomless black pit and never be able to crawl out again. This is why a believe so many people are afraid to start talking about past experiences or the triggers that activate symptoms. They are afraid that once the symptoms start they won’t stop.

FINDING A SAFE PLACE INSIDE YOURSELF

To counter this, I like to have patients find a safe-memory or fantasy that they can go to and practice going there when they are feeling pretty good. I want them to learn and practice relaxation exercises that work for them. I give them a smorgasbord of relaxation methods to choose from. Giving choices, it seems, reduces resistance. I also avoid “one size fits all” methods of relaxation — but no methods really do work for everyone. I avoid using guided imagery at first because I find it unpredictable. Once patients relax and engage their imagery processes, they often are vulnerable to intrusive thoughts, feelings, and flashbacks.

IMMEDIATE RELAXATION METHODS – CHOICE AND SAFETY

I like to teach centering, deep-breathing, and mindful (detached) awareness, I want to be sure that patients learn how to get back into the here and now and stop intrusive symptoms as soon as they start.

I avoid what I call “big bang catharsis techniques” which take the patients quickly into deeply re-experiencing the memories of trauma. I have just had too many b ad experiences with patients regressing and getting worse as a result of these techniques. I personally don’t find using them worth the risk.

I would rather take patients into the memories as they emerge in the assessment and recovery skills training process. I want to be sure that patients have the ability to stop and crawl out of the experience and get back into a tight anchor with here-and-now-reality.

SUPPORT NETWORKS 0 CRITICALLY IMPORTANT

I also focus on building support networks of people, places, and things that can be used when things get tough. Simple things like: Who can you call if you need to talk? Who should you avoid if your symptoms are bad in the moment? What can you do that will help? What should you avoid doing because it will make things worse? I am especially concerned about having a support systems that can be used during the night. This is when the symptoms tend to be more intense and the support less available.

COGNITIVE RESTRUCTURING – TFUAR MANAGEMENT

The general structure I wrap these general principles of cognitive restructuring. I use the word cognitive to mean total information processing with the brain and the mind. This involves Thoughts (T), Feelings (F), Urges (U), actions (A), and relationships. It also involves subtle intuitions and openness to spiritual experiences which seem to be very common in people who survive trauma. using a cognitive restructuring process. I ask patients to complete these sentence stems, or I turn them into open-ended questions. Using active listing is critical. Patients must feel listened to, understood, taken seriously and affirmed as a person. This process turns a sterile and “objective” assessment into a highly personalized and collaborative self-assessment.

COGNITIVE RESTRUCTURING FOR PTSD

Here is a general structure for the process:

1.  The symptom that I am experiencing is …

2.  When I experience this symptom I tend to think …

  • A more helpful way of thinking might be ….

3.   When I experience this symptom I tend to feel …

  • A more helpful way of managing those feelings might be ….

4.  When I experience this symptom I tend to manage it by doing the following things …

  • A more helpful behavioral strategy for managing this symptom might be ….

5.  When I experience this symptom what I do to try to get help from other important people in my life is …

  • A more helpful strategy for getting the help and support if others in managing this symptom might be ….

6.   he overall daily plan I have for managing my PTSD recovery is …

  • Some ways of making my recovery plan more helpful for me might be …

A SIMPLISTIC SKELETON OF A COMPLEX PROCESS 

This is a simplistic skeleton of the basic principles and practices of a cognitive restructuring approach for PTSD. This sketch, of course, just covers some of the steps on the critical path to recovery and relapse prevention. It also presents my preferences as a therapist based upon my past experiences with clients. I am sharing this as a personal report on lessons learned.

 Gorski Books


Solitary Confinement: Research and Experiences

January 10, 2014
Has anyone following this blog been in prison and served time in solitary confinement. Dr. Grassian, a trusted colleague, is interested in interviewing people to further his research on the impact of solitary confinement. Please review the correspondence below.  If you can help Dr. Grassian find people willing to be interviewed please contact him.
Stuart Grassian  M.D.

401 Beacon Street
Chestnut Hill, MA 02467
(617) 244-3315
stgrassian@gmail.com 

Please read our correspondence below for more information.
Dear Mr. Gorski,
Thanks for your words of support.  As you know, addictions and imprisonment are so tightly connected;  I am pleased to learn of your work reaching out to those who have experienced both.
Earlier this year I made a commitment to try to collect stories of individuals who, now released back into the community, had spent a great deal of time in solitary confinement.  I would greatly appreciate any referrals you might have of individuals who have experienced this and might be willing to share their experience (of course, confidentiality would be maintained).
I hope the new year finds you well and that your work continues to make a difference.
Stuart Grassian  M.D.

401 Beacon Street
Chestnut Hill, MA 02467
(617) 244-3315
stgrassian@gmail.com

On Tue, Dec 24, 2013 at 12:46 PM, <stgrassian@aol.com> wrote:
—- original Message—–
From: ttgorski <ttgorski@gmail.com>
To: stgrassian <stgrassian@aol.com>
Cc: Tresa Watson <tresa@cenaps.com>; Terence T. Gorski <ttgorski@gmail.com>; Dr. Stephen Grinstead <sgrinstead@cenaps.com>
Sent: Mon, Dec 23, 2013 2:30 pm
Subject: Thank You For You Work

Dear Dr. Grassian,

I have been delinquent in expressing my gratitude and and telling you about how useful your work has been to me. As a means f introduction I am an author and a trainer/consultant specializing in addiction and related mental health problems. I have developed a popular model of Relapse Prevention Therapy (RPT).  and through me uncountable addiction professionals trying to understand the unusual and difficult to deal problem they have in treating http://salvationist.ca/2011/11/an-ounce-of-prevention/ patients who have been incarcerated. When I started trying to meet the needs of these counselors, I constructed a concept called Post Incarceration Syndrome (PICS). Initially it was very popular, until of course, the economy and climate of addiction treatment radically changed through the influence of Government Policy.
Here are links to several internet resources that show how your work has influenced me:
1. My blog republishing a basic article that has been reference and reposted many times:https://terrygorski.wordpress.com/2013/10/26/the-post-incarceration-syndrome-pics/
6. Relapse Prevention In The Salvation Army programs: http://salvationist.ca/2011/11/an-ounce-of-prevention/
This is just a sample of the many people who have spread your ideas which are contained in the concept of Post Incarceration Syndrome.
I wanted you to know that your has, is, and will continue to make a difference to me and countless lives that your research and writing have changed for the better. Thank you for your contributions and you career work.
Terence T. Gorski

Mental Illness Hits 20% of the US Population

December 21, 2013

By Terence T. Gorski
December 21, 2013

images

Mental Illness Hurts!
Especially If You’re In Jail
When You Should Be In Treatment!

SAMHSA’s 2012 National Survey on Drug Use and Health brought out many new statistics that are not very encouraging.  I decided to share a recent SAMHSA Newsletter that reported the major findings.

– Nearly 20% of the population experienced a diagnosable mental illness in 2011. This is 43.7 million people. Less than half (43%) received any treatment.

– Adults who experienced mental illness in the past year were three times more likely to have met the criteria for a substance use disorder than those who had not experienced mental illness in the past year (19.2 percent versus 6.4 percent).

– Those who had serious mental illness in the past year were even more likely to have had substance dependence or abuse (27.3 percent).

– 9 million American adults (3.9 percent) had serious thoughts of suicide in the past year

– 2.7 million (1.1 percent) made suicide plans

-1.3 million (0.6 percent) attempted suicide

Our kids are not in very good shape either.

– In 2012 about 2.2 million youth aged 12 to 17 (9.1 %) experienced a major depressive episode.

– Young people suffering from depression were more than three times as likely to have a substance use disorder (16.0 percent) than their counterparts who had not experienced a major depressive episode (5.1 percent).

The White House has the answer!
Another website: www.mentalhealth.gov  

alcohol-effects-economyI am surprised that this newsletter DID NOT MENTION:

(1) The rising rates of depression and suicide in our military troops both during active duty and after discharge. (People tend to get depressed after serving multiple combat shifts and having their retirement benefits cut.)

(2) That every year there is an increasing number of educated and licensed mental health professionals at work in the USA. The wide variety of name brands, degrees, and licenses is too mind boggling for me to describe, so I will leave that to Mental Heath America.

(3) In spite of the growing number of mental health professionals the rate of mental illness and substance use disorders is still on the rise.

Question: Is there something wrong with this picture. More professionals working on the problem – the more people who are suffering from mental illness and substance abuse. Could there be something hidden in plain view that is driving up the rates of substance abuse and mental illness?

iStock_000005581302XSmall

Mental Illness On the Rise.

(4) The evidence that suggests mental health problems, substance use disorders, and other behavioral addictions such as gambling and sexual addiction all go up during economic hard times.  Hunger and homelessness is on the rise in this sluggish economy. The results of this prolonged economic turn-down is more severe than people think. Read the report for yourself.

(5) The rates of mental illness continue to rise in spite of record sales in psychiatric medications, especially antidepressants.

It has been a long-standing Federal and State Government policy to reduce costs by cutting mental health beds in long-term residential psychiatric hospitals. The government decided to return the severe and chronically mentally  ill to the community. As a result, in 2012 the USA has a shortage of psychiatric beds.
For every 20 public psychiatric beds that existed in the US in 1955, only one such bed existed in 2005.
The full story of the rise and fall of long-term psychiatric hospitals is clearly described in The Encyclopedia of New Zealand. The history closely parallels what was happening in the United States and world-wide.  When they can’t function in the community due to their mental illness, many end up in the worst possible place for a mentally ill person — prison.
According to The Human Rights Watch the prisons have become the primary psychiatric treatment facilities. The brutality to the mentally in prison is too horrible to imagine. Read the full report if your stomach is strong enough to see the truth.

“Prisons are woefully ill-equipped for their current role as the nation’s
primary mental health facilities.” said  Jamie Fellner, Director,
U.S. Program of Human Rights Watch.
There are serious consequences of cutting back on the treatment resources for the mentally ill over the past several decades:The Treatment Advocacy Center reports that because there are so few beds available, individuals with severe psychiatric disorders who need to be hospitalized are often unable to get admitted. Those who are admitted are often discharged prematurely and without a treatment plan. The consequences of the radical reduction in psychiatric hospital beds are evidenced in the following areas:

  • Homelessness.  A 2005 federal survey estimated that approximately 500,000 single men and women are homeless in the United States at any given time and multiple studies have reported that one-third have a serious mental illness. A study in Massachusetts found that 27 percent of patients discharged from a state psychiatric hospital became homeless within six months of discharge; in a similar study in Ohio, the figure was 36 percent.
  • Jails and Prisons as Psychiatric Hospitals.  Since the radical reduction in public psychiatric hospital beds there has been a massive increase in severely mentally ill persons in jails and prisons. Conservative estimates have placed the number at 7 to 10 percent of all inmates, but some studies have put the figure at 20 percent or higher. The three largest de facto psychiatric institutions in the United States are the Los Angeles County Jail, Chicago’s Cook County Jail, and New York’s Riker Island Jail.
images“On any given day, between 25-30 percent of the inmates at Cook County Jail suffer from mental illnesses. The majority of these inmates are in jail for nonviolent offenses closely associated with their mental health issues and would be far better served by treatment rather than incarceration.” ~ Thomas J. Dart, Cook County Sherrif
  • Hospital Emergency Room Overflow.  Emergency rooms are often used as waiting rooms for people in need of a psychiatric bed. This backs up the entire hospital system and compromises other medical care. In Arlington, Virginia, county officials had to call 31 hospitals before finding one that would accept a patient.
  • Violent Crime.  Studies have shown that between 5 to 10 percent of seriously mentally ill persons who are not receiving treatment will commit a violent act each year. Such individual are responsible for at least 5 percent of all homicides.
The full SAMHSA newsletter is below. I wouldn’t worry, however, The Affordable Care Act will fix all of this right up. Kathleen Sibelius, Health and Human Services Secretary who reports to the President has promised it will all be fixed. She said: “The Affordable Care Act and new parity protections are expanding mental and substance use disorder benefits for 62 million Americans. This historic expansion will help make treatment more affordable and accessible.”

How Bad Does It Have To Get
Before We Rise UP And Say ENOUGH!!!

SAMHSA News Release

Date: 12/19/2013 9:00 AM
Media Contact: SAMHSA Press Office
Telephone: 240-276-2130

43.7 Million Americans experienced mental illness in 2012

$31 Million Announced to Improve Mental Health Services for Young People
Nearly one in five American adults, or 43.7 million people, experienced a diagnosable mental illness in 2012 according to the Substance Abuse and Mental Health Services Administration (SAMHSA). These results are consistent with 2011 findings.
SAMHSA also reported that, consistent with 2011, less than half (41 percent) of these adults received any mental health services in the past year. Among those who had serious mental illness, 62.9 percent received treatment. Among adults with mental illness who reported an unmet need for treatment, the top three reasons given for not receiving help were that they could not afford the cost, thought they could handle the problem without treatment, or did not know where to go for services.
The findings also shed light on mental health issues among young people. According to the report, 2.2 million youth aged 12 to 17 (9.1 percent of this population) experienced a major depressive episode in 2012. These young people were more than three times as likely to have a substance use disorder (16.0 percent) than their counterparts who had not experienced a major depressive episode (5.1 percent).
“The President and Vice President have made clear that mental illness should no longer be treated by our society – or covered by insurance companies – differently from other illnesses,” said Health and Human Services Secretary Kathleen Sebelius. “The Affordable Care Act and new parity protections are expanding mental and substance use disorder benefits for 62 million Americans. This historic expansion will help make treatment more affordable and accessible.”
“People will only benefit from all the progress we’ve made if they aren’t afraid to get help,” said SAMHSA Administrator Pam Hyde. “That’s why President Obama called for a national conversation on mental health and proposed a budget initiative to support making it easier for young people, adults, and families struggling with mental health problems to seek help and support.” (http://www.whitehouse.gov/omb/budget/factsheet/improving-mental-health-prevention-and-treatment-services)
The Administration recently launched www.MentalHealth.gov to help people find easy-to-understand information about basic signs of mental health problems, how to talk about mental health and mental illness, and how to locate help.
In addition, SAMHSA is announcing two grant funding opportunities to help improve mental health services for young people:
  • Planning Grants for Expansion of the Comprehensive Community Mental Health Services for Children and Their Families Program – this grant program will provide $8 million in funding to assist states, political subdivisions, tribes, or territories to develop a comprehensive strategic plan for improving, expanding, and sustaining services provided through a system of care approach for children and youth with serious emotional disturbances and their families.
  • Implementation Cooperative Agreements for Expansion of the Comprehensive Community Mental Health Services for Children and their Families Program – this grant program will provide $23 million in funding to enable states, political subdivisions, tribes, or territories to improve behavioral health outcomes for children and youth with serious emotional disturbances and their families.
The new findings from SAMHSA also found that 9 million American adults 18 and older (3.9 percent) had serious thoughts of suicide in the past year–2.7 million (1.1 percent) made suicide plans and 1.3 million (0.6 percent) attempted suicide.
Those in crisis or knowing someone they believe may be at immediate risk of attempting suicide can call the National Suicide Prevention Lifeline 1-800-273-TALK (8255) or go to http://www.suicidepreventionlifeline.org. The National Suicide Prevention Lifeline network, funded by SAMHSA, provides immediate free and confidential crisis round-the-clock counseling to anyone in need throughout the country, every day of the year.
According to SAMHSA, adults who experienced mental illness in the past year were three times more likely to have met the criteria for a substance use disorder than those who had not experienced mental illness in the past year (19.2 percent versus 6.4 percent). Those who had serious mental illness in the past year were even more likely to have had substance dependence or abuse (27.3 percent).
The new findings come from SAMHSA’s 2012 National Survey on Drug Use and Health. In the survey, mental illness among adults aged 18 or older is defined as having had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) in the past year based on criteria specified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.
In this survey, serious mental illness is defined as mental illness that resulted in serious functional impairment, which substantially interfered with or limited one or more major life activities. A major depressive episode is defined as a period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had at least four of seven additional symptoms reflecting the criteria as described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.
The complete survey findings from this report are available on the SAMHSA Web site at:http://www.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/Index.aspx

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

 


Is there a recognizable post-incarceration syndrome among released “lifers”?

November 5, 2013

Terence T. Gorski developed a construct for counseling long-term offenders returning to the community which he called THE POST INCARCERATION SYNDROME (PICS).

A study conducted by Marieke Lima and Maarten Kunst reviewed Gorski’s PICS model which suggests that some released prisoners experience a unique set of mental health symptoms related to, but not limited to, post-traumatic stress disorder. They sought to empirically assess whether there is a recognizable post-incarceration syndrome that captures the unique effects of incarceration on mental health.

They conducted in-depth life interviews with 25 released “lifers” (individuals serving a life sentence), who served an average of 19 years in a state correctional institution.

They assessed to what extent the symptoms described by the participants overlapped with other mental disorders, most notably PTSD.

They found that a specific cluster of mental health symptoms that is related to long-term incarceration. In addition to PTSD, this cluster was characterized by:

1. Institutionalized personality traits,
2. Social–sensory disorientation, and
3. Alienation.

Our findings suggest that post-incarceration syndrome constitutes a discrete subtype of PTSD that results from long-term imprisonment.

Recognizing Post-Incarceration Syndrome (PICS) may allow for more adequate recognition of the effects of incarceration and treatment among former inmates and ultimately, successful re-entry into society.

ON THE INTERNET:
The Psychological Impact of Incarceration: Implications for Post-Prison Adjustment The Psychological Impact of Incarceration: Implications for Post-Prison Adjustment
Craig Haney
University of California, Santa Cruz
December 2001
http://aspe.hhs.gov/hsp/prison2home02/haney.htm

Comprehensive Incarcerated Persons Reform,Rehabilitation, And Reentry Act
(C.I.P.R.A.), Presented To Hon. Eliot Spitzer, Governor of The State of New York
http://www.realcostofprisons.org/writing/cipra.doc

PICS Article In Science Direct
http://www.sciencedirect.com/science/article/pii/S0160252713000344

The Psychological Impact of Incarceration: Implications for Post-Prison Adjustment:
The Psychological Impact of Incarceration: Implications for Post-Prison Adjustment Craig Haney University of California, Santa Cruz December 2001 http://aspe.hhs.gov/hsp/prison2home02/haney.htm


The Post Incarceration Syndrome (PICS)

October 26, 2013

By Terence T. Gorski
Permission is given to reproduce this article with proper referencing.

BARS_Black_HandsThe 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. (Haney 2001, Ditton 1999)

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, and restricted 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) Hyper-vigilance, 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.

PTSD related to PICS may be the result of the traumatic grief that arises as a result of interpersonal trauma experienced as a betrayal of attachment. Leach and colleagues reported in The distinct set of symptoms associated with it were first recognized in the 1990s. Losses associated with traumatic grief can be either death or non-death related. A variety of studies have demonstrated that many prisoners have suffered from losses and trauma throughout their lives, and in many instances they have never received any support or interventions to address resultant problems. There is convincing evidence that there could be a relationship between many of the maladaptive behaviors demonstrated by the prisoners reported in the paper as PICS and may be related to  the high rates of recidivism seen in many developed countries (and which in Australia have been reported as high as 77%) may be related to traumatic grief. (Leach et al 2008)

3. Antisocial Personality Traits
Antisocial Personality Traits (APA 1994,  Forrest 1994, Hemple et al 1995) 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 a compliant 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. (Leach et al 2008)

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 Post Incarceration 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.

READ PERSONAL ACCOUNTS OF EXPERIENCES WITH PICS:
– A Personal Case Study With Post Incarceration Syndrome
– http://www.prisontalk.com/forums/archive/index.php/t-327414.html

REFERENCES:

Abramsky, Sasha; When They Get Out, Atlantic Monthly, June, 1999 p. 30
ON THE INTERNET: http://www.theatlantic.com/past/docs/issues/99jun/9906prisoners.htm

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM IV), Fourth Edition, 1994 (Pg 424 – 429; Pg 645 – 650; Pg 175 – 272)

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/)

Forrest, Gary G., Chemical Dependency and antisocial Personality Disorder – Psychotherapy and Assessment Strategies, The Hawthorn Press, New York, April 1994 

Haney, Craig, The Psychological Impact of Incarceration: Implications for Post-Prison Adjustment: 
The Psychological Impact of Incarceration: Implications for Post-Prison Adjustment
, University of California, Santa Cruz
December 2001 (ON THE INTERNET: http://aspe.hhs.gov/hsp/prison2home02/haney.htm

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

Grassian, Stuart; Psychopathological effects of solitary confinement, American Journal of Psychiatry, 140, 1450 – 1454 (1983)]

Leach, Raelene M.; Burgess,Teresa; and Holmwood, Chris(2008) “Could recidivism in prisoners be linked to traumatic grief? A review of the evidence”, International Journal of Prisoner Health, Vol. 4 Iss: 2, pp.104 – 119   ON THE INTERNET: http://aspe.hhs.gov/hsp/prison2home02/haney.htm; Permanent URL: 0.1080/17449200802038249

Sabol, William, Urban Institute, Washington DC

 

 


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