CHAPTER ONE
Conflicting Cultures Safety and Security vs. Treatment
Within the first week of the therapist being hired, she entered the lieutenant’s office in the housing unit. The lieutenant’s office was separate from the office that the security officers shared, but similarly, it had a wall of windows which provided a full view of the east dayroom. The second window portrayed a view of the Elk Horn mountain range through the security fence. The office was small, containing only a desk with a computer, and three additional chairs used primarily for disciplinary sessions. The therapist sat in one of these chairs and introduced herself. The lieutenant wasted little time before getting right to his point.
Lieutenant: “I need you to understand the importance of having structure and control over the population in a correctional facility. If I don’t keep a population busy and structured, they will keep us busy. In other words, if they aren’t held to a strict schedule and program expectations, they will start acting out on each other, or on the staff. A large part of keeping a correctional facility safe and secure is to maintain structure and control over the population.”
Therapist: “I need you to understand the importance of self-direction in a treatment facility. Power and control are effective only if the power and control continue to exist. If we are running a prison, then go for it. If you hold power over someone, they will comply unless they feel they’ve had enough. However, it has a potential to back-fire at times. This is not a prison, it’s a treatment program and we need to allow everyone to come to their own direction in order to really integrate treatment.”
Lieutenant: “We are providing treatment in a correctional facility to a population of inmates. Many of them have a history of being violent and manipulative. We need to acknowledge this, and I feel responsible for the safety of all staff, as well as inmates.”
Therapist: “We need to refer to the women in this facility as residents. If we continue to see the person for what they’ve done, and continue to treat them as ‘a violent person’ or ‘manipulative,’ or an ‘inmate,’ we won’t be providing treatment. How far do you think treatment will go? If you legitimately went to your doctor complaining of a headache or backache and the first thing your doctor did was to say to you, “stop manipulating me for pain pills,” how likely are you to feel that you received treatment?”
Lieutenant: “What if I was, in fact, manipulating the doctor for pain pills, but the doctor unknowingly or unwillingly, neglected to look at my history of medication seeking, resulting in the doctor subscribing the pain pills? Then, what if I overdose on the pills? Or worse, hurt someone else due to my misuse of the medication? What happens to that doctor’s license to practice?”
Therapist: “Would you please answer my questions rather than try to run me down a rabbit hole? Honestly, how would you feel about the treatment you received from your doctor? This is a treatment facility, not a prison.”
Lieutenant: “First of all, I am not taking you down a rabbit hole. You started the doctor analogy. The rabbit hole is yours, not mine. With that being said, I do see your point. If I was legitimately injured, and the doctor assumed I was being manipulative and therefore did not treat me for my injury, I would be upset, to say the least. In addition, I see the connection you are making to the level of treatment we would be providing if we treat people like they are their worst-case scenario. But how, then, do we trust the person who is seeking treatment, and how do we identify a dangerous or manipulative person? Now, can you answer the questions which I’ve asked you?”
Therapist: “I see your point that the doctor could be held liable. However, I believe we should provide a blanket of trust, while at the same time, demonstrating that trust by acknowledging the humanness of every female being treated in this facility. I believe if there are dangerous or manipulative people here, they will identify themselves through their behavior.”
Lieutenant: “You are killing me. Are you saying we just wait for the effects of the danger or manipulation to present itself, and then we respond? All my training instills the need to prevent danger and manipulation. When a person becomes a danger or is manipulating the treatment program, the consequence should be the removal from the program, as quickly as possible. This will send a message to the rest of the population that we will not tolerate dangerous behavior or manipulation.”
Therapist: “If we are transparent up front, and thoroughly explain that we do not tolerate abuse, violence or manipulation, we must also explain the direct consequences of such behavior. I think we can enforce the same consequences for someone not willing to engage in treatment. If we can properly communicate this to the residents, I would be more likely to agree with you.”
Lieutenant: “I agree. We need clear communication of the expectations and consequences. My officers will also appreciate these clear directives in managing the population and program expectations.”
Substance Abuse and Mental Health
Services Administration©
(SAMHSA)
As the pilot project was to be a Substance Abuse and Mental Health Treatment program, the therapist turned to the key principles of a trauma informed approach, as published by Substance Abuse and Mental Health Services Administration (SAMHSA)©.4 Having prior experience with these guidelines and knowing the resources and stakeholders needed to implement best practices, she turned to SAMHSA©. She printed out the Six Key Principles of a Trauma-Informed Approach and 12 bullet points on recovery culture, and then asked the lieutenant to review the information and implement their use as a daily tool. SAMHSA’s Six Key Principles of a Trauma-Informed Approach5 •Safety: Both staff and clients must feel safe physically and psychologically.
•Peer Support: Can help foster hope, build trust, and enhance collaboration.
•Trustworthiness & Transparency: A trauma-informed care setting will emphasize building honest and open relationships.
•Collaboration & Mutuality: A leveling of power between staff and clients.
•Cultural, Historical, and Gender Issues: Can be used as strengths that will facilitate healing and growth.
•Empowerment voice and choice: All individuals’ strengths and experiences are recognized and built upon.
Therapist: “Let’s go over the guidelines. Safety is most important, both staff and clients must feel safe physically and psychologically.”
Lieutenant: “My highest priority is the safety of all staff and inmates. Our policies and procedures are created to maintain the safety of everyone.”
Therapist: “Also, we need to implement peer support processes and enhance collaboration. It fosters hope.”
Lieutenant: “We can encourage inmates to support each other throughout their program.”
Therapist: “We need to have trustworthiness and transparency by building honest and open relationships between staff and residents.”
Lieutenant: “Honesty won’t be a problem, but I’m not entirely sure I understand what you mean by open relationships between officers and inmates. We have strict policies on professional boundaries with inmates. These policies will be followed.”
Therapist: “We also need to acknowledge cultural, historical, and gender issues as they become strengths that will facilitate healing and growth. All residents’ strengths and experiences should be recognized and built upon.”
Lieutenant: “This sounds good in theory and I would assume this will be implemented in the treatment curriculum. I don’t see how this will conflict with the safety and security requirements.”
Therapist: “We also need to empower the women and make sure they have a voice and choice in as many ways as we can.”
Lieutenant: “This is a correctional facility. They have the choice to comply with the rules and expectations. If they don’t comply, there will be written incident reports and appropriate sanctions. When they want to have a voice, they can fill out a...