Treating Mental Illness and Relational Concerns in Incarcerated Settings

High rates/prevalence of mental illness among incarcerated populations

The literature examining prevalence of mental illness among incarcerated populations in the past 10 years has indicated an overrepresentation of mental health diagnoses in this population. For instance, the U.S. Department of Justice found that over 50% of incarcerated adults have mental health issues, as compared to 11% of adults in the general population (Daniel, 2007). Unfortunately, many do not receive any type of mental health treatment while incarcerated. In fact, only one in three individuals in prison and one in six individuals in jail reported receiving services (Daniel, 2007). Comparing mental health diagnoses between the incarcerated population and the general public, mental illness is overrepresented and exists at approximately two to four times the rate of the general population (Tala et al., 2017). In fact, a disproportionate number of adults with serious mental illness (SMI) are without adequate care within the prison system (Tala et al., 2017).

An increase in depressive symptoms, as well as associated increases in suicidal ideation, is often observed in incarcerated individuals (Barretti & Beitin, 2010; Carlson & Cervera, 1991). A study was completed to better understand the prevalence of mental illness in incarcerated settings with a focus on the comorbidities with other conditions or habits. It was found that about 50% of incarcerated individuals are affected by a mental illness (Tala et al., 2017). A third of these reported mental illnesses were considered SMIs (Tala et al., 2017). A possible link to high rates of mental illness across incarcerated populations can be related to the limited access to effective, individualized care offered within the community prior to incarceration (Tala et al., 2017). It has been consistently displayed that there is a treatment gap in particular to this population and mental health (Daniel, 2007; Tala et al., 2017).

Substance use and mental health

Within the incarcerated population, in the literature, there seems to be a combination of contextual factors that influence the overall experience, particularly the intersection of substance use and mental health as it relates to incarcerated individuals. Approximately half of incarcerated individuals with mental illness also reported a history of substance use (Tala et al., 2017). Reports disclose that substance use and prior criminal involvement were both found to be prevalent in incarcerated men (Bir et al., 2015). A study utilizing survey data revealed that preincarceration substance use was found to be very prevalent. In fact, 71% of men reported using at least one illicit drug in the 6 months prior to their incarceration (Bir et al., 2015).

Individual-focused treatments

When reviewing existing literature on incarcerated populations, some of the individual therapies that have been utilized include experiential-existential therapy (Vanhooren et al., 2018), narrative therapy (White & Epston, 1990), and cognitive behavioral therapy (CBT; Beck, 1988). Although there is only one article on experiential-existential therapy and one article on narrative therapy as applied to the incarcerated population, it is important to review these two articles to display the need for a systemic approach in the incarcerated setting. CBT, on the other hand, has various articles that display its utility with this population.

Researchers have explored how experiential-existential therapy can be used with incarcerated individuals. Utilizing a case study application, Vanhooren et al. (2018) analyzed a case surrounding how experiential-existential therapy can create meaning and increase growth that may have been hindered due to posttraumatic instances from incarceration. Therapy aided the incarcerated female to discuss her crimes in a safe and judgment-free environment. In processing her past experientially, she was able to create new meanings about herself and others as well as the purpose of her life. This resulted in new meanings and more beneficial coping skills (Vanhooren et al., 2018).

Ikonomopolous et al. (2015) utilized narrative therapy within the incarcerated context. Researchers used a single-case small subject research design to assess the effectiveness of a 10-session narrative therapy intervention in reducing mental health symptoms in youth incarcerated at a juvenile justice facility. After establishing a baseline, mental health symptoms were assessed with the Brief Symptom Inventory in various phases of treatment. The narrative therapy sessions were delivered by one of two practitioners for 50–60 min each and included techniques such as externalizing conversations, mapping effects, evaluating effects, and reauthoring. Participants were chosen due to being identified as having clinically significant mental health needs identified by a screening tool, the Massachusetts Youth Screening Instrument. The study displayed moderate support for the effectiveness of integrating narrative therapy into rehabilitative programs for incarcerated youth.

CBT has an excess of support in effectiveness with the incarcerated population (Mpofu et al., 2018). In one study, researchers conducted a systemic literature review looking at rates of recidivism of moderate- to high-risk sexual offenders who underwent CBT-type treatments (Mpofu et al., 2018). The article discussed 10 empirical studies from 2001 to 2014 that met the criteria of CBT intervention programs being used. The participants were adult males of moderate- to high-risk sexual offenders and included follow-up data for up to a year. The findings displayed that different forms of CBT were effective in reducing recidivism rates.

Another article discussed treating trauma symptoms experienced by children with an incarcerated parent (Morgan-Mullane, 2018). The researcher provided a case conceptualization and application of trauma-focused cognitive behavioral therapy within a clinical community–based setting for treating children and adolescents affected by parental incarceration. This article posed a model for applying this theory to this population as well as advocated for community-based settings to utilize a trauma lens. The family ended treatment reporting that they were feeling that their symptoms have improved and that they had reached their initial treatment goals.

Yoon et al. (2017) studied the efficacy of psychotherapy in prisons through a systematic literature review. In conducting randomized clinical trials, they found 37 studies of psychological therapies with mental health outcomes in prisoners. Results displayed that no differences were found between group and individual therapy or other types of treatment. However, it was found that CBT and mindfulness-based therapies were modestly effective in prisoners specifically for depression and anxiety outcomes.

The literature yielded two articles examining systemic models with incarcerated individuals—one article on experiential-existential therapy and one on narrative therapy. However, there were various articles that displayed efficacy in the usage of CBT with incarcerated populations. Additionally, it is noteworthy that experiential-existential therapy and narrative therapy can be applied as systemic models but discussed in the literature as being utilized in practice as individual treatments. Although there is evidence that individual therapy can be beneficial, it appears as though there is a gap in including family into treatment for this population. It is important to incorporate family into treatment in order to strengthen the family system, which currently seems to be lacking in the literature.

Group treatment

In addition to individual treatments, there is evidence showing that participating in a community-based psychoeducational group counseling programs may be beneficial for incarcerated individuals (Lancaster et al., 2011). A program at a community agency was evaluated and compared recidivism rates with a control group of incarcerated individuals who received different probationary services but not the psychoeducational life skills group intervention. The sample group consisted of 120 youth, and a control group of 120 individuals was chosen through matching the variables of sex, age, ethnicity, and status of first offense. Recidivism data were collected at 3-, 6-, 12-, 18-, and 24-month intervals following treatment and compared to recidivism data over the same intervals for the control group. A small to moderate positive effect was recorded, with 60% of youth who received the intervention refraining from reoffending within a 24-month period and 46% who did not receive the counseling intervention refraining from reoffending. This psychoeducation group emphasized life skills resulted in a statistically significant reduction in recidivism. The program consisted of seven 2-hr sessions conducted weekly. Researchers aimed to address the need for peer-reviewed literature correlating counseling treatments with incarcerated outcomes as well as to present a model of program evaluation for service providers.

Another program, the Prevention and Relationship Enhancement Program (PREP Inside and Out), help incarcerated individuals in strengthening their marriage, gaining skills, and improving communication. This program helps the separation of those who are married or in relationships when barriers arise such as inadequate meetings for face-to-face contact. PREP was developed to assist incarcerated individuals and their spouses in developing a strong and healthy marriage. The goal is for couples to learn how to prevent and/or reduce any negative patterns in their relationship and to enhance their emotions. For example, some Department of Corrections have designated PREP as an official program to implement in their state prisons. Group leaders are trained to provide voluntary classes to incarcerated individuals and their partners who are interested in either learning more about the program or enrolling in it. The PREP program consists of 2-hr classes that take place once a week for 6 weeks. The program focused on communication skills, commitment, negative affect management, respect, mate selection, aggression, and positive family connections (Einhorn et al., 2008). The program improved relationship satisfaction and marital communication within the couples (Einhorn et al., 2008). Both studies speak to the importance of considering the relationships incarcerated individuals have with their family members.

Parenting education programs

On a more formal level, parenting education programs, gaining popularity over the years, have proven to be an effective and systemic treatment approach in incarceration settings (Barretti & Beitin, 2010). Research has demonstrated that parenting education within incarcerated settings can have a positive impact on incarcerated individuals’ parenting attitudes (Palusci et al., 2008). Additionally, designed to prevent marital distress and divorce by teaching skills and principles to couples to maintain healthy and lasting relationships, the PREP implemented in Oklahoma prisons aimed to prevent marital distress and divorce by teaching skills and principles to couples to maintain healthy and lasting relationships (Barretti & Beitin, 2010).

Turney and Goodsell (2018) explained that for incarcerated mothers, the use of Nurturing Parenting Curriculum (8 weeks), Systematic Training for Effective Parenting Program (10 weeks), an unnamed 8-week curriculum aimed to reduce parenting stress and improve communication patterns, and another 12-week program focused on self-esteem, legal issues, and parenting attitudes have helped incarcerated mothers become better parents and improve self-esteem. The same went for programs designed to help fathers become better parents: Helping Your Child Succeed (10–20 hr), Parenting From Prison (20 sessions), and the effectiveness of parenting skills programs such as parent–child interaction therapy, which encouraged mothers to practice learned communication skills.

The conclusion of the study emphasized the importance of interventions for the whole family including the incarcerated parent. Findings implied boys are the most affected by incarcerated parents, especially if they lived in the home. Researchers proposed taking a closer look at the consequences of parental incarceration and propose a series of programs for fathers, mothers, and children that can help mitigate the pain of parental incarceration. Researchers also urged to look at the larger impact of policies and how they affect the well-being of the children. They also stated that incarceration does not significantly affect just one group of people (Turney & Goodsell, 2018).

As evidenced from the literature review, group therapy has advantages for incarcerated individuals, particularly in programs that are skills-based. Nonetheless, despite the increase in educational programs on marital relationships and parenting, family therapy programs that concentrate on relationship enhancement and family stability are not often utilized in correctional facilities (Barretti & Beitin, 2010). The studies reviewed display the vitalness of strengthening the relationships incarcerated individuals have with their families.

Family therapy

There is a shortage of literature examining the role of family therapy in incarcerated samples. Despite providing couple and family community–based services, these service professionals seldomly work within adult criminal justice settings (Datchi et al., 2016; Tadros et al., 2020b). Traditionally, family services have not been provided in incarcerated facilities (Datchi & Sexton, 2013; Datchi et al., 2016; Tadros et al., 2020b, 2021; Tadros & Ogden, 2020). While reviewing the literature, only a few articles discussed family therapy in the incarcerated setting.

A pilot study was conducted involving a family psychoeducation program within a low-security forensic mental health facility. The program is a biopsychosocial intervention further combining behavioral and psychological approaches with participants and their families (Nagi & Davies, 2015). Researchers evaluated the utilization and effectiveness of the family psychoeducation program and found promising results. Feedback from the participants, their families, and staff displayed that they hold positive beliefs regarding family interventions (Absalom-Hornby et al., 2012; Nagi & Davies, 2015). Further, results of the study concluded that the program provided participants and their families with useful tools and information (Nagi & Davies, 2015). Moreover, it was reported in the feedback from families that they felt they had gained insight into linking their loved ones’ mental health and their offending behaviors (Nagi & Davies, 2015).

Datchi and Sexton (2013) studied the efficacy of functional family therapy (FFT) on incarcerated individuals’ mental health, familial relationships, and risk of reoffending. The study displayed that the incarcerated individuals who underwent FFT significantly improved individual and relational functioning. They also reported fewer symptoms of distress, less family conflict, and higher levels of family cohesion and structure. Additionally, findings showed significantly lower levels of criminogenic risk than incarcerated individuals who did not undergo FFT (Datchi & Sexton, 2013).

Liddle (2014) reviewed articles that utilized multidimensional family therapy in a juvenile detention center. Specifically, these studies discussed the therapeutic process and change mechanisms facilitated by multidimensional family therapy. Liddle advocated that therapists build successful therapeutic alliances with teens and parents (Diamond et al., 1999; Liddle, 2014). Findings displayed that evidence-based family therapies such as multidimensional family therapy can be applied in various contexts such as incarcerated facilities (Liddle, 2014).

Tadros and Finney (2018) conducted a case study utilizing Structural Family Therapy (SFT); the case study displayed effectiveness in using SFT with an incarcerated father and his son. SFT was chosen as the treatment of choice due to its systemic principles in viewing the family a whole. Treatment was measured by the family reaching their goals of restructuring the family in terms of hierarchies, rules, roles, boundaries ultimately leading to the overall structural change. The family was able to achieve the goal of rebuilding and strengthening the parent–child relationship by establishing an appropriate hierarchy and forming clear, healthy boundaries that fit within the context of their family. Another study explored the usages of structural and medical family therapy with an incarcerated mother living with HIV (Tadros & Finney, 2019). This case study displayed the efficacy of SFT in conjunction with medical family therapy within the incarcerated population. Researchers integrated two theories to provide the best client care to incarcerated individuals and their families who are experiencing physical health concerns. Treatment was shown to be effective as evidenced by mother and daughter gaining insight into their dysfunctional interactional patterns that perpetuated their conflict leading to a change in the overall family structure.

A literature review showed that all studies analyzed were able to show benefits of family interventions within this population. In fact, research shows that many therapeutic skills and interventions that help provide a safe and healthy recovery from incarceration are imperative not only to the individuals themselves but to their families, communities, and peers (Ford et al., 2016). Through the inclusion of marriage and family programs in correctional settings, it would appear that there has been progress in improving marital and family satisfaction for incarcerated persons and families (Gendreau, 1996). Integrating families into treatment of incarcerated individuals may assist in enriching relationships as well as increasing the likelihood of successful reentry into the home and community (Tadros & Finney, 2018, Tadros et al., 2021). The literature displays that systemic models applied to the incarcerated population seem to be those adolescent-focused models and in juvenile settings (Dragomir & Tadros, 2020). Despite evidence from the literature that both individual-focused and systemic models have various benefits for the incarcerated person, there is still a deficiency in the literature about how the family is impacted by the experience of incarceration.

High rates/prevalence of people of color

African Americans account for 33% of the U.S. population but account for 58% of the incarcerated population (Porter et al., 2016). The New Jim Crow identified that people being committed for a criminal offense was a new way for the government to control people of color (Alexander, 2010). Lofstrom and Raphael (2016) explain that in consequence of the changes in criminal justice sanctioning, many low-income, mostly African American communities have disproportionately experienced inequality. Researchers analyzed the apparent racial, ethnic, socioeconomic disparities resulting in inequalities and explained that suffering brought upon by criminal victimization is vastly different from the inequality of the excessiveness of criminal justice sanctioning, so much so that it cannot be compared (Lofstrom & Raphael, 2016).

Kochel et al. (2011) found that African Americans had a higher chance of arrest, after controlling for certain factors (demeanor, offense severity, evidence quantity, prior record, victim request for arrest), as compared to White youth. Concerningly, in comparison to White children, Hispanic children are 2½ times more likely to have a parent in prison and African American children are 7½ times more likely (Glaze & Maruschak, 2009). African American children with mental health issues have been documented to receive harsher punishment within the juvenile justice system. It was speculated this may be due to judges implicit racial biases and negative stereotypes, as they may inaccurately ascribe negative attributes to African Americans such as believing they are dangerous (White, 2016).

Graham and Lowery (2004) point toward the role of racial profiling by police probation and unconscious racial stereotyping among law enforcement officials. Additionally, there are deficits in the broader system, including lack of resources for counsel, pretrial services, and drug treatment. Other researchers say the disparity may come from individual offending behaviors, justice system policy and practices, and/or environmental and social contexts. There appears to be a broader, macrolevel systemic problem at play. Gase et al. (2016) report that contextual variables are driving factors of people of color to have more contact with the justice system, as African American–White disparities are not present after one accounts for the racial composition of neighborhoods.

Alexander (2010) explained that throughout the course of mass incarceration, the American society and criminal justice system has a predisposition to target and incarcerate African American men. In the McClesky v. Kemp case (2010), racial bias facilitated law enforcement’s excessive traffic stops (Alexander, 2010). These stops were used as probable cause to unfairly target ethnic minorities in the war on drugs. Petitioners claimed that the actions in this case were going against the fourth amendment right of all U.S. citizens. Courts explained that whether or not law enforcement made the decision based on race, their behavior is still considered to be “reasonable” (Alexander, 2010). Therefore, the courts deemed racial bias by law enforcement is being tolerated which further perpetuates the problem of diverse injustice.

The overrepresentation of individuals of color in the criminal justice system leads to long-term consequences in reference to individual mental health and the family system (Alexander, 2010). This problem adds a layer of complexity when an individual is a member of a marginalized group as well as being incarcerated. Within the incarcerated population, individuals are experiencing multiple layers of stigma (Logie et al., 2018). It has been reported that there is an overrepresentation of minorities in the U.S. criminal justice system as compared to the general population proportions (Desai et al., 2012).

Socioeconomic status (SES) factors

In examining treatment within the context of incarceration, it is necessary to discuss the diverse disparities among incarcerated individuals in the context of SES. The major focus of this subsection is on the factors that encompass SES. These factors are residential areas where an individual lives and income that is acquired and how they contribute to diverse disparities as it relates to incarcerated individuals. Incarceration among individuals from already marginalized groups exacerbates economic inequality (Schneider & Turney, 2015).

Maroto (2015) conducted a study on the negative effects of incarceration in the context of wealth. Using the National Longitudinal Study of Youth data (from 1985 to 2008), the researcher explored the relationship between incarceration, home ownership, and net worth. Indirect effects of incarceration on wealth were also explored, such as health, income, and family formation. The findings of the study displayed that previously incarcerated individuals are less likely to be homeowners when compared to individuals who were never incarcerated and their probability of being a homeowner decreases additionally after incarceration. Overall, results displayed that incarceration decreases the ability to acquire wealth. Furthermore, formerly incarcerated individuals began with smaller wealth trajectories as well as experienced additional losses postincarceration.

Chauhan et al. (2009) report that African Americans are more likely to live in impoverished neighborhoods as compared to their White counterparts. Impoverished neighborhoods are described by having high unemployment, poverty, public assistance dependence, and thus higher crime rates (Chauhan et al., 2009). Thus, the African American and White crime rate difference may be a result of varying levels of economic disadvantage. Peterson and Krivo (2005) state that when disadvantage is factored out, antisocial behavior is balanced across races. This agrees with the notion that the disproportionate numbers for African American youth are linked to socioeconomic factors. Socioeconomic factors contributing to African American girls’ higher rates of recidivism include neighborhood violence, disadvantaged neighborhoods, higher police surveillance, easier access to weapons, willingness of police to arrest in high-crime areas (Chauhan et al., 2009). These outcomes only reinforce the fact that the disproportionate number of minorities in the justice system is related to neighborhoods where they live.

Schneider and Turney (2015) studied the Black–White disparities in wealth, particularly the contributions to this widened gap by incarceration. Researchers used state-level panel data (from 1985 to 2005) to explore the relationship between Black and White homeowning individuals to measure wealth. Findings indicated that incarceration does impact rates of homeownership, which leads to the widening of the Black–White inequalities in homeownership. Additionally, the findings imply that the gaps of racial and wealth inequalities between Black and White individuals are widened when incarceration is a factor.

The literature review yielded articles that provided evidence to display that SES contributed to an individual’s arrest as well as a lowered SES being a consequential outcome of incarceration. There is a socioeconomic disparity among individuals who are incarcerated and those are not (Alexander, 2010). Additionally, in synthesizing the literature on socioeconomic disparities, it appears that this disparity is typically coupled with being a person of color. In the next subsection of diverse disparities, gender will be discussed in terms of disparities between men and woman within the incarcerated system.

Gender

The literature review uncovered that the rate of men incarcerated is much higher than the rate of incarcerated women. The literature review also yielded results that the majority of incarcerated individuals are male, consequently, the number of fathers incarcerated are much higher (Chesa, 2011). Spjeldnes et al. (2014) conducted a study on gender-based needs in urban jail populations. The study explored gender differences in social, medical, and human needs due to the rise in rates of females incarcerated. Findings from the study displayed that there are significantly greater problems for women than men. Women in comparison to men reported a higher need for chemical dependency and mental health services. Women also reported a greater willingness to be involved in these treatment services, thus displaying a need to attend to gender differences in the form of providing proper services according to the needs of specific genders.

Power et al. (2016) expanded on the findings of previous research and explored the relationship between types of childhood abuse, suicide attempts, and nonsuicidal self-injury (NSSI) in incarcerated adults. A sample of 268 men and 147 women were examined, and it was found that men and women were equally likely to experience childhood abuse. In terms of likelihood to report, men were more likely to report emotional neglect, and women were more likely to report sexual abuse. Physical abuse and neglect were deemed significant predictors of suicide attempts and NSSI in men. Sexual abuse was found to predict suicide and attempts of NSSI in women. The results of this study imply that there are vital gender differences in reference to the risk factors discussed. Therefore, it is important to explore gender disparities within the incarcerated population as men and women both experience trauma; however, the types of traumas are found to differ.

Butcher et al. (2017) reviewed administrative records and found that women typically receive lighter sentences than men. Fedock et al. (2013) stated that the incarcerated population consists of mostly men, women are entering at increasingly higher rates. Additionally, it was found that, when studying gender differences, women presented with higher rates of issues in relation to homelessness, SMI, substance use disorder, and trauma (Fedock et al., 2013). In sum, men are incarcerated at higher rates (thus driving the stereotype of absent fathers) in comparison to women. Men and women experience incarceration differently; thus, the impacts of incarceration are different based on gender. It is vital to explore the gender disparities in reference to incarceration in order to understand this problem holistically and systemically.

Family treatment impacts on recidivism

Recidivism is a term used to describe a formerly incarcerated individuals’ return into the criminal justice system due to committing or recommitting a crime, parole violations, and/ or any kind of violation of a court-mandated request (Alexander, 2010). The recidivism rate of which former inmates recriminalize and return to incarceration has remained at 75% for the past 40 years (Porter et al., 2016). Choate and Manton (2014) also confirm that prior incarceration is one of the highest predictors of arrest for future crimes. Initial research has shown that the mere visitation by family members and people with close ties to an incarcerated individual can postpone and reduce recidivism. Approximately 50% of previously incarcerated individuals reenter prison within 3 years of last release (Daniel, 2007). This may be due to the lack of treatment and rehabilitation in prison and the inadequate treatment and rehabilitation within the community postrelease (Daniel, 2007).

Lancaster et al. (2011) aimed to address the need for literature correlating counseling treatments with incarcerated persons’ outcomes as well as to present a model of program evaluation for service providers. This research evaluated an existing program at a community agency and compared recidivism rates with a control group of incarcerated individuals who received different probationary services but not the psychoeducational life skills group intervention. The experimental group consisted of 120 youth, and a control group of 120 individuals was chosen through matching the variables of sex, age, ethnicity, and status of first offense. Recidivism data were collected at 3-, 6-, 12-, 18-, and 24-month intervals following treatment and compared to recidivism data over the same intervals for the control group. A small to moderate positive effect was recorded, with 60% of youth who received the intervention refraining from reoffending within a 24-month period and 46% who did not receive the counseling intervention refraining from reoffending.

Moreover, research displays the need for sufficient mental health services within incarcerated settings in order to reduce recidivism. Specifically, individual and family counseling services, in addition to other innovative and multicultural treatment programs in correctional facilities, must be pursued to prevent a high rate of recidivism and morbidity of incarcerated individuals as well as to facilitate their adjustment in the community (Daniel, 2007). Reducing recidivism is connected to treatment received during incarceration and following release.