Cultural competence in correctional mental health

International Journal of Law and Psychiatry 36 (2013) 273–280

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International Journal of Law and Psychiatry

Cultural competence in correctional mental health Reena Kapoor a,⁎, Charles Dike a, b, Craig Burns c, Vinneth Carvalho d, Ezra E.H. Griffith a a

Law & Psychiatry Division, Department of Psychiatry, Yale University School of Medicine, 34 Park Street, New Haven, CT 06519, USA Whiting Forensic Division, Connecticut Valley Hospital, 70 O'Brien Drive, Middletown, CT 06851, USA c Connecticut Department of Corrections, 24 Wolcott Hill Road Wethersfield, CT 06109, USA d University of Connecticut Correctional Managed Health Care, 263 Farmington Avenue, Farmington, CT 06030, USA b

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Available online 11 May 2013 Keywords: Culture Prison Correctional mental health Cultural formulation

a b s t r a c t Cultural competence is an essential aspect of competence as a mental health professional. In this article, the framework of cultural competence developed in general psychiatry—acquiring knowledge, attitudes, and skills necessary to understand the interaction between culture and the individual—is applied to the prison setting. Race and ethnicity, extremes of age, gender, and religion are highlighted and examined as elements of the overall culture of prisons. The model of the cultural formulation from the DSM-IV is then adapted for use by clinicians in the correctional setting, with particular emphasis on the interaction between the inmate's culture of origin and the unique culture of the prison environment. © 2013 Elsevier Ltd. All rights reserved.

1. Introduction The field of cultural psychiatry has grown exponentially in the past 20 years, and the mental health professions now regard it as axiomatic that an understanding of culture is necessary in order to provide competent treatment. A framework for use of the cultural formulation has been included in the appendix of the Diagnostic and Statistical Manual of Mental Disorders (DSM) since the Fourth Edition (Table 1), and many scholars have developed tools to help clinicians and health care systems conduct cultural assessments (Kagawa-Singer & Kassim-Lakha, 2003; Lewis-Fernandez & Diaz, 2002; Parikh, 2012; Teal & Street, 2009). Although the literature in cultural psychiatry is vast, even a cursory review reveals a consensus about the important areas of focus: language, ethnic background and identification, family relationships, child rearing, spiritual beliefs, social networks, past traumatic experiences, and beliefs about mental illness. The principle behind cultural competence is simple. When mental health professionals understand culture, they are less likely to misinterpret cultural differences as signs of mental illness. Furthermore, an appreciation of culture helps to cultivate a fundamental respect for the patient and his life experiences that will, in turn, promote the development of a tolerant, thoughtful plan of care. In contrast to its ubiquity in general psychiatry, the concept of cultural competence has not been well developed in the subspecialties of correctional psychiatry and forensic psychiatry. The lack of emphasis on culture

⁎ Corresponding author at: 34 Park Street, New Haven, CT 06519, USA. Tel.: +1 203 974 7420; fax: +1 203 974 7178. E-mail addresses: [email protected] (R. Kapoor), [email protected] (C. Dike), [email protected] (C. Burns), [email protected] (V. Carvalho), ezra.griffi[email protected] (E.E.H. Griffith). 0160-2527/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijlp.2013.04.016

in prison psychiatry is understandable, given the struggles of many correctional systems to provide basic access to mental health treatment for the ever-increasing population of severely mentally ill inmates (Human Rights Watch, 2003; James & Glaze, 2006). However, scholarship in correctional psychiatry has flourished in recent years, and the field has now articulated formal guidelines and standards for the provision of mental health care in prisons (NCCHC, 2008; Scott, 2009). These guidelines acknowledge the importance of culturally competent care, though it has so far been only a small area of focus for correctional psychiatry. Although there is very little written in the psychiatric literature about culture and correctional mental health, prison administrators and scholars in the social sciences have been studying culture in prisons for more than half a century (Brodsky, 1975; Clemmer, 1960; Haney, 2001; Haney, Banks, & Zimbardo, 1973). From these studies, as well as from the writing of inmates themselves, a grim depiction of prison culture has emerged. Prison culture is widely portrayed as a struggle between “captor and caged” (Branham, 2011)—violent, predatory, and corrosive to mental health. More recent work has focused on the challenges faced by certain subcultures of prisoners, such as transgender inmates and inmates in supermax facilities, who are considered particularly vulnerable (Brown & McDuffie, 2009; Metzner & Fellner, 2010). Still other work has focused on advocacy for widespread reform, arguing that prison culture as it has developed in the U.S. is contrary to human dignity and simply unacceptable. For example, keeping prisoners in prolonged solitary confinement has been compared to torture (Haney, 2008; United Nations General Assembly, 2011). The challenge for scholars today is to marry the body of knowledge about prison culture developed in social science with the knowledge about prison mental health developed in medicine. Some initial attempts have been made to merge the disciplines, including textbook chapters that address multicultural counseling, psychological testing,

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Table 1 Components of cultural formulation. DSM-IV-TR cultural formulation (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) Cultural identity of the individual Cultural explanations of the individual's illness Cultural factors related to the psychosocial environment and levels of functioning Cultural elements of the relationship between the individual and the clinician Overall cultural assessment for diagnosis and care

physical plant limitations, and working with religious extremists in correctional settings (Ortega, 2010; Tseng, Matthews, & Elwyn, 2004). Other academic work has focused on the differences between law enforcement and mental health cultures, highlighting the adaptation required by mental health professionals working within a correctional culture (Appelbaum, 2009). This article seeks to add to the growing body of knowledge about culture in correctional mental health. The majority of the article discusses race and ethnicity, gender, age, and religion as they contribute to the overall culture of prisons. By doing so, the article aims to provide mental health clinicians with basic principles and ideas that will serve as building blocks for culturally competent clinical care. However, we acknowledge that cultural competence is more complex than simply learning a few facts about different sub-populations of prisoners, and instead requires multiple layers of knowledge and sensitivity about culture both inside and outside of the prison. Thus, the discussion section of the article moves beyond generalizations and creates a flexible framework for approaching questions about culture in the prison population. 2. Race and ethnicity American prison populations comprise a disproportionate number of African American and Hispanic individuals. In contrast to the roughly 29% Black and Hispanic population of the United States (U.S. Census Bureau, 2011a, 2011b), the prison population in 2010 was roughly 60% minority—38% Black and 22% Hispanic (Bureau of Justice Statistics, 2012). Furthermore, mentally ill racial minorities are also overrepresented in prison populations (Grekin, Jamelka, & Trupin, 1994). This vastly different racial makeup creates a unique culture for the mental health professional working in prison to understand, as such a minority-dense population is rare in other settings. As a starting point, the framework of the cultural formulation, developed in general psychiatry, is still applicable in the prison setting. For example, it is no less important to consider the impact of an inmate's ethnic background upon his beliefs about mental illness in prison than it is outside of prison. As has been well documented in the cultural psychiatry literature, mental illness in African American and Latino cultures carries an enormous stigma. Patients from these backgrounds may be unfamiliar with and mistrustful of the therapeutic process (Evans & George, 2008; Gonzalez, 1997). In addition, Hispanic patients often express emotional distress as somatic complaints such as headaches, dizziness, or abdominal pain (Lewis-Fernandez, Das, Alfonso, Weissmann, & Wolfsson, 2005), or they may attribute symptoms to drug use rather than mental illness, as this carries less stigma. Knowledge about these cultural idiosyncrasies, as well as about specific culture-bound syndromes, can well serve a mental health professional in prison, particularly when working with large minority populations for the first time. However, considering the impact of race and ethnicity on expressions of mental illness is not the only task that faces the prison mental health professional. When working with large populations of African Americans and Hispanics involved with the criminal justice system, it is incumbent upon the mental health professional to learn how these populations understand crime and punishment. In other words, he must ask not only, “How is mental illness understood in this culture?” but also, “How is incarceration understood in this culture?” Without this understanding, the mental health clinician may fail to establish a

therapeutic alliance with the patient, and he may also misinterpret culturally normal beliefs as signs of mental illness or personality disorder. For example, most African American young men are aware of the popular idea of the “criminal black man” (Russell-Brown, 1999)—the young, dark-skinned man who must be feared and avoided because of his dangerousness. They may even be aware that African American men are, as a group, incarcerated at a rate 6 times higher than their Caucasian counterparts (Bureau of Justice Statistics, 2012). If they were raised in an impoverished, urban environment, incarceration may be viewed not as an aberration or a sign of a life gone astray, but rather as a rite of passage. Incarceration may even be viewed as a form of institutionalized oppression of people of color—slavery by another name (Wacquant, 2002). Phrases such as “mass incarceration” and the “prison-industrial complex” (Schlosser, 1998) have become commonplace in describing the phenomenon of a 500% increase in incarceration—most of it in minority communities—in the past 30 years (Bureau of Justice Statistics, 2012). Mass incarceration has led to significant changes in the communities that have been disproportionately affected. In many inner cities, it is common for children to grow up fatherless and without positive male role models. In an effort to form an alternate community, many young men look to gangs both for leadership and for peer support (Morris, 2012). Gang leaders are respected, and time spent in prison is often seen as an initiation into the group rather than as a punishment for an unlawful act. Bravado—even pride—around incarceration is not uncommon (Morris, 2012). The mental health professional who is unfamiliar with these culturally normal views of the criminal justice system may interpret statements about the unfairness of the American courts as a failure to take responsibility for one's actions. When a young, African American patient complains about receiving a harsher sentence than a Caucasian peer, the clinician may think that the patient exhibits antisocial traits: lack of remorse and failure to accept societal norms. While this may be the case, the clinician must use caution and interpret the patient's statements through a culturally informed lens, as the patient may simply be expressing the beliefs of his community. Understanding a patient's beliefs about the criminal justice system is essential when working with African American and Hispanic populations, but it is also important when working with immigrant and refugee populations, which make up an increasing number of prisoners each year. In 2010, more than 400,000 immigrants from many different countries were detained in jails, prisons, and private detention centers (Bernstein &, 2011, 2011). Therefore, the mental health professional working in prison is likely to encounter patients from a variety of foreign cultures. A common thread among many refugees is that they come from countries in which the rule of law is not enforced in the same way as it is in the United States. For all of its problems with systemic racism, the U.S. criminal justice system largely operates without the level of corruption and secrecy found in other countries. Therefore, mental health professionals may find it difficult to understand the mistrust of the legal system that immigrants from other countries sometimes display. For example, a prisoner from China may be accustomed to an authoritarian government in which people with views opposing the state can be imprisoned or even “disappeared” simply because of their political beliefs (Kline, 2011). Similarly, a prisoner from Nigeria may believe that the government is inherently corrupt, and a favorable outcome in court is not possible for a person without the means to pay bribes. While it is impossible for a prison psychiatrist to become familiar with every culture in the world, let alone its political problems, it is important to keep in mind that individuals from other countries may have a very different understanding of the criminal justice system from the average American. What may appear to be paranoia (and therefore a sign of a psychotic illness) may actually be a culturally appropriate belief about the rule of law in the patient's country of origin.

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3. Age The majority of American prisoners are between 20 and 35 years of age (Bureau of Justice Statistics, 2012). Given that the average prison sentence in the U.S. is just over 2 years (Bureau of Justice Statistics, 2012), it can be reasonably inferred that incarceration is largely an experience of young adults. Prison culture is heavily influenced by the kinds of emotional problems common in the twenties and thirties: romantic conflict, raising children, and finding meaningful employment. In Eriksonian terms, the issues of “intimacy v. isolation” are central (Erikson, 1980). This developmental stage is made particularly challenging in the prison environment, where isolation is part of the package, and maintaining intimacy is extraordinarily difficult. As a result, prison has the potential to cause arrested development for many young adults. In addition to posing challenges for its dominant age group, prison brings special problems to those at the extremes of age: juveniles and the elderly. These groups will be considered separately as subcultures within the prison population. 3.1. Juveniles Juvenile court systems were instituted throughout the U.S. beginning in the late 1800s in order to place greater emphasis on the welfare and rehabilitation of youth in the justice system (Austin, Johnson, & Gregoriou, 2000). The Juvenile Justice and Delinquency Prevention Act (JJDPA) passed by Congress in 1974 required the separation of juvenile offenders from adult offenders and the deinstitutionalization of status offenders. In addition, a 1980 amendment mandated that juveniles could not be placed in adult jails, with a few exceptions (National Report Series, 1999). The goal of these programs was clearly to separate juveniles from adults in the criminal justice system and focus more on rehabilitation than punishment. However, as the incidence and severity of crimes committed by juveniles continued to increase, public outcry and political pressure led to a shift in the management of juvenile offenders. Juveniles charged with serious crimes are now increasingly being tried in adult courts, sentenced as adults, and subsequently placed in adult correctional facilities. Two states, Vermont and Kansas, have statutory provisions for trying children as young as 10 years old in adult criminal court (OJJDP, 2003). The more punitive approach to juvenile criminal justice has resulted in a dramatic increase in the incarceration of young offenders. In 2002, the United States had the highest rate of youth incarceration of any developed nation—336 out of every 100,000 youths (Sickmund, 2007). Though the majority of these youths are detained in juvenile facilities, a significant number are held in adult correctional institutions. One study estimated that 107,000 individuals younger than 18 are incarcerated on any given day, with 14,500 housed in adult facilities—9100 in local jails and 5400 in adult prisons (Austin et al., 2000). Racial disparities in the youth population are no less striking than in the adult system; African American youth are nine times as likely to be sent to adult prisons as Caucasians (National Institute of Corrections, 2011). Incarceration of juveniles in adult correctional facilities poses serious challenges for both the juveniles and the staff, as young prisoners have different characteristics and needs than their adult counterparts (Sedlak & McPherson, 2010). More than two-thirds of incarcerated youth reported serious substance abuse problems, more than 60% suffered with anger management issues, half exhibited symptoms of anxiety, and half, of depression. Exposure to trauma was also significant. Seventy percent said they had personally “seen someone severely injured or killed,” and 72% said they had “had something very bad or terrible happen to [them].” Additionally, 30% had been physically and/or sexually abused, and 3 of every 10 had, on at least one occasion, attempted suicide. The suicide rate of juveniles in adult prisons is 7.7 times higher than that of juvenile detention centers (Flaherty, 1980). These data suggest that

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adult prisons are ill-equipped to protect children from the frequent abuse and desperation that encourages suicidal acts. Young prisoners are also particularly vulnerable to assaults when confined in adult prisons. In one study comparing adult and juvenile institutions, five times as many youth confined in adult prisons answered yes to the question “Has anyone attempted to sexually attack or rape you?” as those confined in juvenile institutions (Fagan, Frost, & Viviona, 1989). Close to 10% of youth in the adult prison reported a sexual attack or attempted rape, as compared to 1% in the juvenile institution. The rates of physical assaults and violence against juveniles in adult prisons are no less striking. One study showed that one in ten juveniles in adult prisons reported being physically assaulted by staff (Murray, Baird, Logghran, Mills, & Platt, 2006). Mental illness and learning disabilities are more the norm than the exception in incarcerated youth. Approximately two-thirds of confined youth suffer from one or more diagnosable mental health problems, and about one of every five youth in custody has a mental health disturbance that significantly impairs his ability to function (Leone, Krezmien, Mason, & Meisel, 2005). In addition, youth confined in correctional facilities suffer from many types of disabilities, the most prevalent of which are learning disabilities and emotional disturbance (Leone et al., 2005). These facts are particularly noteworthy in light of the fact that, nationwide, more than half of incarcerated youth are held in facilities that do not conduct mental health assessments for all residents. Although educational services, including those for students with disabilities, are mandated for young prisoners (Donnell, 1993; Green v. Johnson, 1981; MTC Institute, 2003), the capacity of prisons to provide specialized educational plans for highly impaired students is limited. Therefore, the potential for mistreatment of these at-risk youth is high. It is imperative for mental health professionals working in the correctional setting to understand these unique vulnerabilities of young prisoners—their exposure to trauma, cognitive and emotional problems, susceptibility to physical and sexual assaults, and lack of pro-social role models—in order to appreciate their culture fully. However, it is equally important for mental health professionals to consider one other characteristic of young prisoners when providing them with care: their stage of development. Juveniles have not yet fully formed their personalities and attitudes about the world, and therefore the mental health professional can have a tremendous impact on the development of a young prisoner's identity. For example, the mental health professional should consider what message is sent to a young prisoner by the routine use of physical force and restraints to maintain control in the prison setting. Nonviolent strategies for coping with adversity may be novel ideas for many young inmates, but their emphasis during the crucial stages of personal development can ultimately have a positive effect upon long-term behavior. In essence, the mental health professional must always remember when working with young prisoners that their treatment at this vulnerable stage of life will have a significant impact upon the development of their adult identities. If the goal is to change antisocial attitudes and cultivate pro-social behaviors, mental health intervention must focus on providing youth with the tools they need for long-term growth, such as education, vocational training, and coping skills. Young prisoners are, first and foremost, young people. Therefore, considering the longitudinal impact of treatment on the development of individual identity cannot be overlooked. 3.2. Elderly Prisoners are considered “old” or “geriatric” at a much younger age than they would be in the community. Those who are as young as 50 years can be geriatric in the prison context, and they represent a growing proportion of the total number of inmates. 2010 data indicates that approximately 16% of male prisoners were over 50, as were 13% of female prisoners (Bureau of Justice Statistics, 2012). This is a substantial increase from the 5.7% of prisoners over 50 in 1992, and 8.6% in 2002 (Mitka, 2004). Though 50 years may be considered middle-aged in

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many communities, the lifestyles of prisoners prior to incarceration— including low socioeconomic status, frequent drug abuse, and lack of access to routine medical care—contribute to accelerated aging. Furthermore, the environment of prison itself contributes to aging, as has been demonstrated in studies that show a decreased average life span for some prisoners serving long sentences (Rosen, Wohl, & Schoenbach, 2011; Spaulding et al., 2011). Older prisoners have needs and concerns that are distinct from their younger counterparts. As one study found, inmates over 50 are concerned with decreased privacy, inconsiderate younger inmates, being victimized by younger inmates, lack of friendships, lack of sameage peers, inadequate space and ventilation, and lack of proximity to bathroom and dining facilities (Vito & Wilson, 1985). These unique concerns often lead older inmates to segregate themselves informally from the general population, forming communities in which their concerns for privacy and tranquility are respected. Prison is a young man's game, and older inmates are well aware of their potential for victimization. Furthermore, they have often achieved a level of relative wisdom, and therefore are less interested in the violence and power struggles that preoccupy younger inmates. The easiest way to protect themselves and exist peacefully is through self-segregation. When older prisoners begin to develop serious health concerns and cognitive decline, they can pose a major challenge to prison management. Whereas healthy older prisoners are typically easier for corrections officers to handle than their younger, more confrontational counterparts, unhealthy older inmates can require special accommodations in order to comply with prison rules. The most dramatic example of this is the inmate who has begun to show signs of dementia. Prison officials and other inmates may not notice early signs of cognitive decline, and the first evidence of a problem may be the accrual of disciplinary infractions for being “out of place” (i.e. getting lost), refusing to “lock up” (i.e. forgetting the daily routine), or “insubordination” or public indecency (i.e. becoming disinhibited and hypersexual). As the dementia progresses, inmates may be totally unable to comply with the rules that govern life in general population. Several prison systems have already been forced to develop creative solutions to the problem of caring for geriatric inmates. These solutions have included the increased use of compassionate release programs, construction of nursing homes and hospice facilities within the prison walls, and development of peer support programs that utilize the skills of younger inmates to care for the elderly (Belluck &, 2012, 2012; Linder & Meyers, 2007; Ornduff, 1996). Each of these approaches has advantages and drawbacks, and no one solution has emerged as the answer to the problem of geriatric inmates. What is clear, however, is that this population and its needs will represent an ever-larger part of prison culture in the coming years.

They are likely to have experienced sexual and physical trauma, and rates of substance abuse are extremely high (Lewis, 2009). They are often incarcerated for non-violent offenses and for committing crimes together with opposite-sex partners (Lewis, 2006). Seventy percent are mothers (Brooks, 1993). Given these facts, one can quickly build a mental image of the typical female prisoner: a young, minority woman of low socioeconomic status, who has been traumatized and abuses drugs, and who struggles to raise her children alone. For the mental health professional, a few basic points about women's prison culture can be helpful in gaining alliance with patients and understanding their struggles. Several classic studies from the 1960s and 1970s about the social order of women's prisons still have relevance today (Giallombardo, 1966; Heffernan, 1972; Kassebaum & Ward, 1965). All of these studies emphasize the increased sense of isolation felt by women prisoners in comparison to their male counterparts. This isolation occurs in part because women are typically imprisoned farther away from home as a result of having fewer correctional facilities overall. It also occurs because women are commonly the primary caretakers of their children, and so they feel a greater sense of loneliness and longing when separated from them. This sense of isolation and the need for companionship form the foundation upon which society in women's prisons is built. Many researchers have observed that women cope in prison by forming pseudo-families, often including homosexual relationships (Beer, Morgan, Garland, & Spanierman, 2007). For the mental health professional, it is important to understand that these relationships are adaptive and not necessarily a sign of an unstable personality or sense of identity. For example, while frequent questions about sexual orientation or relationships with partners of both sexes may be interpreted as evidence of borderline personality disorder or even gender identity disorder on the outside, in prison this is not always the case. Same-sex relationships may simply be a normal form of adaptation to the prison environment. In addition to the creation of pseudo-families through homosexual romances, it is important to consider one other aspect of the culture of women's prisons: surviving and recovering from trauma. At least one out of three incarcerated women meets criteria for PTSD (Lewis, 2009), and many more have experienced physical, sexual, or emotional trauma prior to incarceration. Many have learned to cope with the emotional consequences of trauma only through substance abuse, and they experience a resurgence of trauma-related symptoms when placed in the substance-free environment of prison. Thus, a large focus of mental health treatment for women prisoners is on teaching coping mechanisms and recovery from traumatic events. This focus, as well as a focus on building motherhood skills, can help women rebuild their lives in preparation for returning home to their children and communities of origin.

4. Gender 5. Religion The overwhelming majority of prisoners are men (Bureau of Justice Statistics, 2012). It is not surprising, then, that the majority of research on prisons has focused on male prisons, with women historically receiving little attention. However, as the U.S. prison population overall has grown, so has its population of female prisoners. Data from 2010 indicates that there were approximately 100,000 incarcerated women in the United States—a small percentage of our 2 million prisoners, but still the largest number in history (Bureau of Justice Statistics, 2012). Women prisoners are not just different from men because they adapt to the experience of prison differently; their characteristics prior to incarceration are also different from those of their male counterparts. In addition, incarcerated women differ greatly from women not involved with the criminal justice system. Incarcerated women are likely to be from communities of color (38% African American, 14% Hispanic), dependent upon welfare, unmarried, and raising children without a male partner (Bureau of Justice Statistics, 2012; Lewis, 2009).

In any American prison, on any given day, a number of religions are being practiced. Adapting information from Religion in Prison: Pew Forum on Religion and Public Life (Pew Forum on Religion & Public Life, 2012), Christianity, Islam, Judaism, Mormonism, Buddhism, Native American spiritual practices, Hinduism, the Baha'i faith, Sikhism, Santeria, Voodoo, and the Rastafari faith, as well as other religions/spiritual pursuits may be found in our prisons. Identifying what is being practiced helps us to understand the potential diversity of religious practice for the incarcerated. However, exploring why religion is an active part of prison culture is a separate, and possibly more important, pursuit. Understanding why religion is practiced both links and transcends the individual traditions and provides the mental health professional with a framework to understand “why God is often found behind bars” (Maruna, Wilson, & Curran, 2006). Religion has always had an influence on the American penal system, not only as a potential coping mechanism for inmates, but also in its

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influence on the very structure of our correctional system. Dating back to colonial America, biblical guidelines have provided not only the justification for punishment, but even guidelines for its severity, down to the very number of lashes one would receive for a given crime (Clear, Hardyman, Stout, Lucken, & Dammer, 2000). Further evidence of religion's centrality in the prison system may be found in the 19th century development of the penitentiary, where a prisoner (or penitent) would engage in hard labor and reflection with the goal of developing the spiritual resources to manage future entanglements with moral dilemmas (Clear et al., 2000; Maruna et al., 2006). In the twentieth and twenty-first centuries, science and economic considerations have replaced the more spiritually-driven approaches to the design, operation, and philosophical stance of jails and prisons (Clear et al., 2000). However, for the inmate, the experience of imprisonment remains essentially unchanged. Deprivation is and always will be a universal constant for the incarcerated (Clear et al., 1992; Clear et al., 2000; Maruna et al., 2006; Thomas & Zaitzow, 2006). As described above, socioeconomic deprivation is a cornerstone in the lives of many incarcerated people long before they enter into the criminal justice system. Once in the system, prisoners—whether presentence detainees or the convicted— face the reality of numerous additional forms of loss. Arrest and processing create an immediate loss of freedom. Next, an inmate faces a number of material losses, including losing his job or access to finances (Clear et al., 1992; Maruna et al., 2006; Thomas & Zaitzow, 2006). Additionally, a number of non-material, and potentially more damaging losses, like the loss of access to family and friends, must be weathered by the inmate (Clear et al., 1992; Maruna et al., 2006; Thomas & Zaitzow, 2006). Even basic forms of identity and self-esteem, presuming they existed before incarceration, are replaced with the message that the offender is a social outcast who has lived a flawed life and must now be prepared to struggle and survive (Clear et al., 1992). To be fair, the deprivations suffered by a prisoner are the result of an extended process of adjudication and often have been earned. The adversity faced by prisoners must also not be overstated or exaggerated, as the vast majority of offenders survive their incarceration experience (Clear et al., 1992). However, when almost everything is taken away from a prisoner, the deprivation creates a potential void, and it is here that religion in prison finds its place. Intrinsic motivations for engaging in religious practice include coping with guilt, finding a new way of life, and coping with loss (Clear et al., 1992; Clear et al., 2000). In addition, religion provides the basis for an exculpatory narrative in which inmates can view their lives and crimes in terms of being unprepared to deal with evil in the world and falling victim to its powerful forces. If the inmate's past approach to life did not either guide him in an adaptive direction or shield him from evil, embracing religion allows him a new path of pro-social, adaptive practices that promise to change him from societal burden to active contributor (Clear et al., 1992; Clear et al., 2000). Lastly, the peace of mind available through religious practice can ease the discomforts created by the many losses an inmate experiences while incarcerated (Clear et al., 1992; Clear et al., 2000). Extrinsic motivations for engaging in religious practice in prison include safety, inmate comforts, access to outsiders, and improved social relations (Clear et al., 1992; Clear et al., 2000). Safety is one of the first challenges faced by the newly incarcerated individual, and religion can provide physical safety (i.e. the chapel as a sanctuary) or interpersonal safety (i.e. members of a particular religious community are obligated to defend a fellow member) (Ammar, Weaver, & Saxon, 2004; Clear et al., 1992; Clear et al., 2000; Thomas & Zaitzow, 2006). Escape from the monotony of prison life, with access to the special foods and meal schedules permitted for particular religious groups, serves as another draw for religious practice (Clear et al., 1992; Maruna et al., 2006; Pew Forum on Religion & Public Life, 2012). Many prisons use civilian volunteers at services, and a limited number allow families to worship with inmates at religious services (Clear et al., 1992, 2000).

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Both of these opportunities for contact with the outside world have huge implications for the inmate, as they provide an opportunity to maintain important relationships and community ties. Additionally, the community contacts that an inmate develops, often through faith-based volunteer involvement, serve as a potential means to aid with the transition into the community after incarceration (Clear et al., 1992; Miller, 2009; Nedderman, Underwood, & Hardy, 2010). This access serves as incentive for a better-behaved inmate in prison and also can reduce recidivism (Johnson, 2004; Johnson, Larson, & Pitts, 1997; Thomas & Zaitzow, 2006). Lastly, finding a community of inmates through religion provides an alternative to reliance on gang affiliations, self-induced isolation or withdrawal, and other maladaptive coping mechanisms in the prison setting (Clear et al., 1992; Clear et al., 2000; Thomas & Zaitzow, 2006). Skepticism about inmates' motivations toward religious practice is unavoidable (Clear et al., 1992; Clear et al., 2000; Thomas & Zaitzow, 2006). Spiritual pursuits, or the appearance of adherence to these pursuits, provide obvious opportunities for exploitation, manipulation, circumventing correctional authorities, covering up maladaptive behaviors, and escaping accountability for past wrongs (Clear et al., 1992; Clear et al., 2000; Johnson, 2004; Thomas & Zaitzow, 2006). Of course, there are psychopaths in prison who will use religion as another means to exploit their circumstances. However, religious practice sits on a continuum of authenticity that is bounded by poles from counterfeit to complete (Clear et al., 1992; Thomas & Zaitzow, 2006). Consistency of practice over time and authentic, durable changes in behavior and attitudes can be used as measures of inmates' seriousness about their religious practice (Clear et al., 1992; Clear et al., 2000; Thomas & Zaitzow, 2006). For the mental health professional, an appreciation for the many roles religion plays in prison can foster understanding of the patient and development of better treatment plans. For example, for patients having difficulty adjusting to the prison environment at the beginning of their incarceration, access to a chaplain or other spiritual leader can be very comforting and provide a sense of connection to their community of origin. Religious leaders, like mental health professionals, wish to promote healthy coping skills, and they can therefore serve as useful adjuncts to the treatment team. They can encourage the use of organized religious services or informal spiritual practices to help inmates tolerate adversity and work through feelings of guilt and shame, often without the stigma associated with mental health treatment. In addition, religious leaders can alert mental health clinicians to practices such as fasting during Ramadan, which may necessitate adjustments to patients' medication regimens. By maintaining an alliance with religious leaders, mental health professionals gain an avenue of insight and intervention with patients they may not otherwise have. Adopting a curious, open stance about religious practices can help facilitate a richer understanding of the patient's culture and identity, both before and after incarceration. 6. Discussion The examination of the cultural factors above—race, religion, age, and gender—obviously excludes other important variables, such as education, language, sexual orientation, physical disabilities, and socioeconomic status. It is impossible to convey every nuance of prison culture in one article. Therefore, we have chosen to highlight the aspects of prison culture that we consider essential for mental health professionals providing care in that setting. However, we understand that conveying a few interesting facts about subpopulations of prisoners is insufficient to achieve cultural competence, and we must also suggest a means through which clinicians can use the information to enhance their work with individual patients. We now seek to combine the knowledge presented above with existing frameworks for cultural formulation in order to create a prison-adapted model of cultural assessment.

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The DSM-IV (APA, 2000) presents a helpful starting point for considering the interaction between culture and mental health in prison. By identifying five areas that the clinician should consider when creating a cultural formulation, the DSM guides the clinician through a thorough assessment of cultural factors (APA, 2000, Appendix I). The DSM cultural formulation urges the clinician to think about the cultural identity of the individual, cultural explanations of illness, the impact of the psychosocial environment on functioning, the role of culture in the clinician– patient relationship, and the development of a culturally-informed treatment plan. However, it does not prescribe specific actions to be taken, instead leaving that decision to the clinician and allowing him to take a flexible approach. This type of flexible approach to cultural formulation is ideally suited for use in the correctional environment, where the number of different cultures a clinician may encounter in his work is vast. Furthermore, even with a perfect understanding of culture, the clinician's ability to use that information to provide treatment may be limited by external factors, such as facility regulations or security concerns. Even in the most progressive prison culture, mental health needs still play a secondary role to safety and security, and so there will always be limitations placed upon the usefulness of the cultural formulation. Nonetheless, we have attempted to adapt the DSM-IV cultural formulation guidelines to the prison setting, which are presented in Table 2. The first component of the cultural formulation is the patient's cultural identity. In the prison setting, it is useful not only to consider the patient's cultural identity prior to incarceration, but also the degree of assimilation into the prison environment. For example, if the patient was a member of a particular gang outside of prison, has he retained that affiliation in prison, or has he renounced the gang? Has he undergone a religious conversion? Does he associate with people from his neighborhood of origin, or prisoners of his age group, or members of a certain religious faith? The second component of the cultural formulation is to consider cultural explanations of the patient's illness. When applied to the prison setting, this assessment comprises not only explanations of mental illness in the patient's culture of origin, but also within his prison culture. For example, if the patient associates mostly with other mentally ill inmates, there may be a great deal of acceptance

of mental illness and its treatment in his community. Conversely, if he associates mostly with inmates who have little knowledge of mental illness, he may face a great deal of stigma if he seeks treatment. In addition to cultural ideas about mental illness, clinicians must assess cultural ideas about crime, punishment, and incarceration. As described above, the belief that going to prison is shameful and stigmatizing is not universally held, and may vary widely based on the individual's culture of origin. Thus, cultural ideas about incarceration may be as important, if not more, than cultural ideas about mental illness in the prison setting. The third aspect of the cultural formulation—the impact of the environment upon functioning—is very complex when applied to the prison setting. The feelings of loss, isolation, and deprivation that are common to all incarceration experiences can manifest in many different ways. In addition, some aspects of the prison routine, such as prolonged lockdown and segregation from other inmates, can exacerbate symptoms of mental illness, such as depression and psychosis. Conversely, some behaviors that may be indicative of mental illness outside of prison (such as self-starvation or hunger strikes) may be normal or adaptive behavior in the prison environment. One must also remember that the mental health professional in prison is rarely alone; a guard is usually present in the room or nearby, which may influence the manifestations of mental illness displayed by the patient. The presence of ongoing legal stressors (trials, appeals, civil suits) may also affect the patient's behavior. Thus, assessing the impact of environmental factors on the patient's behavior and functioning is an essential part—if not the single most important part—of cultural formulation in prison. The fourth component of cultural formulation is to consider cultural elements in the relationship between patient and clinician. In the prison context, this can include differences between the clinician's culture and the patient's culture of origin, or between the clinician's culture and the patient's culture inside the prison. Furthermore, the clinician must acknowledge the presence of a third party in the treatment relationship—the custody staff. Correctional culture is very different from that of mental health staff, as it is based on a law enforcement model rather than a therapeutic model (Appelbaum, 2009). This culture clash can have an important influence on the relationship between

Table 2 Adapting the DSM-IV cultural formulation to the correctional setting. DSM-IV-TR cultural formulation Cultural identity of the individual

Relevant questions in the correctional setting

With what cultural group(s) did the patient identify before entering the prison system? With what culture/subgroup does the patient associate within the prison? To what extent has the patient continued to associate with his culture of origin, vs. assimilated with prison culture? Does the patient's current cultural association represent an adaptive or maladaptive response to imprisonment? Cultural explanations of the individual's illness How is mental illness experienced/expressed/explained in the patient's culture of origin? To what degree is there stigma (or not)? How are incarceration and the criminal justice system explained in that culture? To what degree is there stigma (or not)? How is mental illness perceived in the patient's prison subculture? By the custody staff? How is the patient's crime (such as sex offense, violence against child, etc.) perceived in the prison subculture? By the custody staff? Cultural factors related to the psychosocial What effect does the prison environment itself have upon the patient? environment and levels of functioning How is the patient adjusting to the experience of isolation, loss, and deprivation common in all prisons? Is the prison environment masking or exacerbating particular symptoms of mental illness? For example, is prolonged solitary confinement exacerbating psychosis or depression? Is the physical plant or presence of other people, such as custody officers, affecting the patient's expression of symptoms or trust of the clinician? Cultural elements of the relationship between the What are the differences between the patient's cultural identity (both before and after prison) and the clinician's? individual and the clinician Is the clinician able to appreciate the effect of the cultural influences on the interactions with patient? What effect does the prison environment have on the clinician? Is the repeated exposure to manipulation and malingering causing burnout in the clinician, or perhaps adversely affecting perception of the patient? Is the clinician over-identifying with custody staff or with the patient (especially if one or the other is of same culture as clinician)? Can the clinician appreciate differences between the culture of mental health staff and correctional officers? Overall cultural assessment for diagnosis and care Does the understanding of cultural factors change the clinician's approach to patient care? How can the clinician's understanding of cultural factors be translated into correctional language and made acceptable in a correctional culture? How can culturally aware treatment best be explained to officers focused on safety and security? To what extent can custody officers be involved in treatment planning, particularly when they share aspects of the patient's culture?

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patient and clinician. For example, the patient may try to ally with the clinician to bend the rules established by custody staff, or he may mistakenly assume that the clinician is part of the custodial, law-andorder culture. Finally, all of the information gathered during the first four steps of the cultural formulation must be incorporated into an overall assessment and plan. While this step may seem self-explanatory outside of prison, it can be very difficult in the correctional setting. Corrections officers may not agree with the culturally-informed plan proposed by the mental health staff, and since they have ultimate control over the facility, they may hinder implementation of a treatment plan. Conversely, custody staff may serve as effective partners and advocates in treatment planning or communicating with the patient, as they often share important aspects of the patient's culture and understand how best to convey information. Thus, taking into account the role of corrections officers in clinical formulation and treatment planning is crucial in the prison environment. Completion of such a detailed cultural assessment certainly creates a substantial additional burden for the already overworked prison mental health professional. Therefore, the cultural formulation runs the risk of becoming—much like the paperwork about suicide or violence risk assessment that clutters hospital charts—more troublesome than clinically relevant. In addition, cultural formulation may seem like a niche interest of a small set of scholars that cannot be applied by the general clinician. We acknowledge these critiques, particularly in the chronically understaffed environment of prison mental health treatment, where the ability to focus on culture can seem like a luxury. However, an appreciation of culture has important, tangible benefits, and cannot be ignored by competent mental health professionals in the prison setting. On an individual level, an understanding of culture helps to foster the type of genuine, fundamental respect for patients that forms the basis of any good treatment. Appreciating a patient's cultural identity allows the clinician to understand his life story and how he came to be in his current predicament. This, in turn, aids in formulating a more sophisticated treatment plan. For example, if a patient is particularly sensitive about certain aspects of his cultural background or identity, efforts can be made to approach those topics with caution and empathy. The alliance with the patient is strengthened, and treatment is more likely to be successful. On a systems level, understanding culture is essential for the mental health professional trying to advocate for the needs of patients and create new treatment programs. Ideas that may seem obvious in mental health culture, such as teaching parenting skills and allowing newborn babies to stay with their mothers in prison, can be foreign to corrections officials. Thus, mental health professionals must be skilled in translating their ideas into correctional language in order for them to be endorsed and implemented by prison authorities. Without a working knowledge of culture, this task is impossible. However, when armed with an appreciation of culture (both of prisoners and corrections staff), mental health professions can effectively convey the needs of their patients, and tangible benefits, such as a safer prison and reduced recidivism, can be achieved. 7. Conclusion Cultural competence in the correctional setting has been growing in importance as prison systems seek to improve mental health assessment and treatment. Achieving cultural competence first requires a baseline level of knowledge about prison culture, which is discussed in the body of this article. An understanding of the role of age, race, gender, and religion in the prison setting is essential. However, cultural competence also requires the clinician to apply this knowledge to individual patients in a flexible and dynamic manner. We have suggested a framework for applying the cultural formulation in the prison setting. We understand that this article is only an initial foray into scholarship in this area, and we welcome additional contributions.

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