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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, 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) 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 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.

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.


[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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