Non-Traditional Therapies in Forensic Populations: Benefits of Human-Animal Interaction, Art Therapy, and Meditation-Based Interventions
Substance Use Disorders
DSM-IV-TR Description of Substance Use Disorders
Substance use disorders are diagnosed as either abuse or dependence and include 11 classes of intoxicants such as alcohol, inhalants, opioids, hallucinogens, nicotine, and sedatives, among others. Substance abuse is defined as significant and recurring harmful consequences of repeated use of substances that forms a maladaptive pattern. The abusing individual experiences an inability to fulfill obligatory roles such as parenting, may put themselves in physical peril, or endure legal, social, or interpersonal issues as a result of the abuse. Substance dependence is diagnosed when the maladaptive pattern of substance use leads to significant impairment, characterized by the following: tolerance of the substance; symptoms of withdrawal as a result of ceasing substance use or the taking of a similar substance to avoid symptoms of withdrawal; taking a substance in larger amounts or for longer than was intended by the user; repeated failed efforts to cease substance use or a persistent desire to quit; great amount of time invested in obtaining or recovering from substance; reduction or complete abandonment of activities that were previously important to the user; and continuation of substance use despite the individual’s knowledge that the substance is exacerbating or directly causing a physiological or psychological issue (APA, 2000).
Substance Use Disorders in Forensic Populations
Substance use disorders are common in forensic populations, occurring in approximately one-quarter of both State and Federal prison inmates and about one-fifth of individuals in local jails. Additionally, substance abuse and dependence is extremely co-morbid in inmates suffering from a second or more mental disorders. Reportedly, 64% of Federal prisoners, 74% of State prisoners, and 76% of local jail inmates present with both substance abuse or dependence and other mental illness (James & Glaze, 2006). Substance use disorders initiated before incarceration are often exacerbated by the stressful and demoralizing correctional environment as inmates continue or intensify abuse as a means of self-medication and escape from reality (Samuelson, Carmody, Kabat-Zinn, and & Bratt, 2007; Simpson et al., 2007). Similar to rates for other disorders, female inmates are particularly at risk for substance use disorders, with more than half of the female population in state prisons without a co-morbid mental illness and three-fourths of this population with co-morbidity meeting criteria for substance abuse or dependence. For example, in Utah state prisons at midyear 2004, approximately 63% of the female population was convicted of drug-related offenses, 78% confessed that they committed their crimes while under the influence of a substance, and half reported that their crime was perpetrated in order to obtain funds to purchase more drugs (Jasperson, 2010).
Borne out of a 30-year career in corrections, Donald Clemmer introduced in the 1940s the concept of “prisonization.” Despite controversy over the legitimacy of Clemmer’s original definition and the real implications of the phenomenon, prisonization has been observed and broadly defined as a process of assimilation undertaken by new inmates as they adapt to the unique circumstances of incarceration. Clemmer described this assimilation as including the development of intense loyalty to fellow prisoners and equally strong opposition to prison personnel who are viewed as representing the society who rejected them (Dettbarn, 2012). Research over the decades since Clemmer introduced prisonization has confirmed the existence of analogous patterns of change in inmates as they adapt to a new environment characterized by deprivation, a change that is beneficial within the confines of incarceration but can be destructive to therapeutic change and maladaptive to civilian life once the prisoner is released.
Six common attributes of prisonization have been identified as the following: 1) preoccupation with having the respect of others and overreaction (usually violent) to perceived disrespect, such as “mean-mugging” or perceived staring, 2) “Doing your own time,” in which inmates insist upon staying out of the personal affairs of others to such a degree that they may, for example, fail to report deadly infractions to personnel, 3) using threats or intimidation, also known as “wolfing,” to achieve one’s needs, such as in obtaining goods or creating a persona of strength, 4) refusal to comply with a medication treatment plan in order to avoid being identified as mentally ill and prevent vulnerability that may result from side effects of powerful psychoactives, 5) manipulative behavior in the pursuit of goals, and 6) social isolation from dangerous others as means of maintaining physical integrity (Carr et al., 2006, pp. 579-580). Prisonization encourages inmates to socially disconnect, regard others with suspicion, and react with aggression and hostility to perceived threats. This process of assimilation causes great obstruction to therapeutic change as evidenced by inmates’ difficulty in genuinely engaging in therapy or simply a complete refusal to participate in therapy (Carr et al., 2006).
Human-Animal Interaction with Forensic Populations
The first recorded therapeutic application of human-animal interaction (HAI) in mentally ill populations was at England’s York Retreat, a humane mental health establishment run by Quakers. Patients were encouraged to work with disabled farm animals from which they were positively reinforced when the patients displayed self-control in their interactions (Furst, 2006). Decades of research with a wide variety of populations ranging from at-risk children to the elderly and terminally ill provide evidence for myriad benefits provided by the unique bond between an individual and their animal-companion, including decreased blood pressure, greater self-esteem, and increased desire and aptitude for positive social interactions (Furst, 2006; Strimple, 2003). The first HAI program within a U.S. forensic population occurred, at first, by accident at the Lima State Hospital for the Criminally Insane. Despite the forbiddance of animals on wards, an inmate sneaked in an injured sparrow that he had found in the secure-hospital yard. Within the ward that housed the most depressed and non-communicative inmates, the bird was hidden in a broom closet, and the inmates worked together to nurse the injured animal back to health. Noting the newfound comradery between the inmates and increased positive interactions between the inmates and the staff due to the collective effort to care for the sparrow, the institution launched a year-long study in which two identical wards were considered, one ward with pets and the other ward without. The first ward reported decreased incidence of violence, a reduction by half in the amount of medication dispensed, and zero suicide attempts. Conversely, the ward without pets reported eight suicide attempts within the same period of time (Strimple, 2003).
HAI programs at a number of forensic institutions have been launched since this first study in the 1970s and include 8 different varieties, the most popular of which are Service Animal Socialization (SAS) programs and Community Service Programs. Both programs pair animals, typically a dog, with an inmate who cares for the animal 24 hours a day. Participants in SAS programs teach basic commands to dogs who then go on to specialized training in assisting disabled individuals. Community service programs allow inmates to train and care for animals, including cats and wild horses in addition to dogs, who are then adopted out to the community (Furst, 2006).
Treatment Outcomes for Human-Animal Interatction in Forensic Populations
Before discussing treatment outcomes, it must be noted that the majority of HAI programs, for obvious reasons, generally do not involve inmates who are severely mentally ill, such as those who are actively psychotic or who score high on tests for psychopathy, or those who have been incarcerated for crimes against animals or children. Inmates who do participate, though, consistently present with symptoms of depression and anxiety as well as suffer from substance abuse or dependence and show signs of prisonization, issues that are all greatly ameliorated by participation in HAI programs. The most thorough research describes the Wild Mustang Program, operated in a New Mexico prison from 1988 to 1992. Participants in the program sought to rehabilitate and tame wild mustangs who would then be sold to the community. In their work with the mustangs, inmates found a safe place to express affection and develop compassion for another living being, effects that emerged in direct opposition to common features of prisonization such as intimidation and social isolation. Approximately three-quarters of the participants reported improved self-esteem and self-confidence as well as greater ability to handle stressful situations, a skill often lacking in the offender population as noted in the previous section about anxiety disorders. Prison administration reported a reduced number and severity of disciplinary reports as a result of the program, and participants gained useful skills in obtaining and holding a job post-release, such as an increased sense of responsibility, enjoyment of challenging work, and recognition of pride earned through a job well-done. Another program that paired inmates with horses, this time in Colorado, reported in the late 1990s that participants exhibited increased self-esteem, patience, and respect for others. Additionally noted was a significant reduction in illegal drug use (Furst, 2006).
Britton and Button (2005) reviewed three programs operating in two Kansas prisons in which male and female inmates rehabilitated and trained dogs, some of them rescued from euthanasia-lists at local shelters, to later be adopted out to the community. Findings from the program in the male-inmate facility cited noteworthy changes in attitude and behavior, an overall calming effect on the prison environment, and personal meaning found through participating in a program that gave back to the community. The program coordinator shared the story of an inmate named Jackson who filed weekly grievances to prison administration and suffered from serious emotional disturbances, particularly angry outbursts, that regularly consigned him to administrative segregation. When Jackson was asked what could be done to encourage him to be more cooperative, he responded that he would like to have a dog. Taking a chance, the prison administration granted Jackson’s request, and the program coordinator described his subsequent change from “the most nasty, angry, hostile [inmate], fighting [them] every step of the way” to a much calmer individual who reported at the time of the interview that he had been free of disciplinary reports for six months and was even teaching the program course, training others to become dog handlers (Britton & Button, 2005, pp. 90-91). Reports of emotional and behavioral improvements were echoed by other participants who claimed that the presence of the dogs in the prison units resulted in an overall change in the environment from hostile and tense to much calmer with less incidence of anger and violence and an increase in positive social interactions between the inmates and personnel and between the inmates, themselves. The authors concluded that, like the Wild Mustang Program, the dog-training program in this Kansas facility provided inmates with an acceptable and conflict-free outlet for expressing affection. It also served to reduce barriers of mistrust and fear between inmates and administration, a common effect of prisonization, and resulted in self-reported emotional transformation that could have implications for treating depression and anxiety in forensic populations (Britton & Button, 2005).
Similar sentiments were shared by participants in a HAI program administered by the Indiana Canine Assistant and Adolescent Network at a medium-security prison for adult males. The six inmates from whom the researcher gathered qualitative data had been paired with a dog to train and care for 24 hours a day. Self-reported skills developed from the program included 1) increased patience, the practice of which has been found to be ameliorative to aggression and anger, 2) elevated self-esteem and personal fulfillment through participating in a program that assists others, both of which can positively affect symptoms of depression, and 3) improved social skills, including the ability and desire to communicate with others and the development of compassion. Additionally, the presence of the dogs had a normalizing effect on the prison environment as evidenced by a decrease in conduct reports and a deflation in overall subjective levels of stress and tension, especially beneficial to those inmates who struggle with anxiety (Turner, 2007).
These same effects were replicated in a study done on incarcerated female offenders. Animal-Assisted Therapy was utilized in a treatment group of five female inmates who were diagnosed with disorders ranging from schizophrenia to bipolar disorder and major depression, all co-morbid with substance abuse or dependence. A therapy dog was used in conjunction with Cognitive-Behavioral based group therapy that focused on the development of coping and social skills and self-awareness. The dog was used to facilitate the therapy sessions by serving as the subject of lessons and being present as a comfort to the inmates, who often showed affection to the dog throughout the meetings. Group members exhibited increased willingness to participate in therapy, more frequent prosocial behaviors, and improved self-awareness and optimistic outlook. Also reported was a large decrease in depressive and anxious symptoms, all of which the author proposed may be the result of the inmates utilizing their interactions with the dog in therapy to challenge their negative internal self-representations that manifested as maladaptive coping patterns, such as drug abuse and other criminal behaviors (Jasperson, 2010).
Overall, HAI appears to be quite effective in reducing symptoms of anxiety and depression and promoting positive affect and prosocial behaviors in offenders, which can, in turn, ameliorate issues of substance abuse and effects of prisonization. HAI programs are generally limited to model or more cooperative inmates, though, whose symptoms of illness manifest with decreased severity. Non-traditional therapies that are more accessible to offenders who present with greater severity of illness, such as Art Therapy, must also be explored.Continued on Next Page »