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The United States has the highest prison population rate in the world, at 716 per 100,000 people. Though only five percent of the world’s population resides in the US, it holds 25 percent of the world’s prisoners.Mitch Abrams is a licensed psychologist who oversees all aspects of mental health services for seven of the state prisons in New Jersey, including those with inpatient psychiatric units and the state's sex offender specific institution. Mitch supervises all psychological testing, oversees domestic violence evaluations, and trains all of the mental health clinicians. After 18 years in the field, he’s seen it all, but says the most important thing for a therapist working with inmates is to remain curious.VICE: Hi Mitch, what's the thinking behind providing therapy for inmates?
Mitch Abrams: Ultimately, it comes down to rehabilitation and/or preventing re-offence. Inmates with mental illnesses that aren’t adequately treated are likely to continue down the path of their deterioration. Providing treatment can prevent the return of symptoms that may have played a part in their crime.Though surprising to some, inmates receive better mental health treatment in prison than in the community because it’s easier to keep them compliant with treatment, there’s better continuity of care, and if/when they [go backwards], they are seen earlier and stabilisation is easier. It’s important to understand though, that less than 20 percent of men in prison have a mental illness that interferes with their ability to adapt. That number is higher for women inmates, sometimes approaching 50 percent.How do inmates respond to therapy, typically, at the beginning? Do they find it hard to open up?
It’s variable. There’s an ultra-masculinity in male prison culture that often hardens people and leads them to be less receptive to treatment. It’s more difficult to incentivise younger inmate-patients about the benefits of treatment.That said, when they do figure it out, amazing work can be done. Very often, no one listened to them regarding the problems they face, or they felt there was just an expectation to become a criminal or become entrenched in a gang lifestyle. Any other option didn't seem possible [at the time]. When you’re able to get inmates to think about what they want their life to become, and understanding how their past may have presented obstacles, they start to see the benefit [of therapy]. However, there are some [inmates] who are near impenetrable.Do you think most people end up in prison as a result of unaddressed mental health issues or childhood trauma?
That’s a more complex question than people may realise. Most people are not in prison for violent crimes. I personally don't see the value in having people with drug addictions incarcerated. Further, many people who are violent were victims, but most people who are victims don't become violent… so it’s a factor to be addressed in their treatment, especially if there is an untreated trauma afoot, but it doesn’t explain the whole picture.Also, there are many people who are antisocial, meaning they don't care about the laws. This is not exactly a picture of great moral development, [but] it doesn’t necessarily reach the threshold of "mental illness" all the time. So, as a whole, do I think most people end up in prison because of unaddressed mental health issues? No. But would better educational systems, social supports, and access to mental health treatment decrease the likelihood of some people winding up engaging in criminal behaviour? Absolutely.What are some common topics or issues you explore with inmates in therapy?
You name it. I’ve worked in psychiatric units in city hospitals, state hospitals, and state prisons. No place has a wider array of psychopathology presented, including the severity and intensity of symptoms, than state prisons.How do you help prisoners come to terms with serving a life sentence?
I believe strongly that the greatest obstacle to providing good treatment to inmates is the belief that you, [the psychologist], are fundamentally different and better than them. Under the right circumstances, anyone could commit a crime. So I try to look for the commonality. It really is fascinating how inmates with life sentences learn to adjust and find meaning in their life. I don't know if I would be able to, if I were in their situation.What I have come to appreciate is that a "one size fits all" approach doesn’t work. Inmates that adapt to long sentences do so by redefining meaning. We don't have the answers for them; we hope to ask the right questions that help them find their [own] answers.What's the most insightful thing an inmate has ever shared with you?
I can't discuss any individual inmate's [case], but there’s a theme I’ve seen in many inmates. It may sound kind of cliche, but the most insightful thing is when they "get it"; when they understand something that happened to them early in their lives has led them down a certain path.Sometimes that could be the way they were the victims of similar crimes that they went on to commit (we sometimes call that “identification with the aggressor”). Or the fact they didn’t properly mourn the loss of their father when he left the family. Or watching domestic violence between family members. Or the impact that a family member's drug/alcohol abuse had on them. Or growing up in a violent neighborhood where being paranoid and always having your head on a swivel is required to survive.When they understand what they have learned, why they do what they do, and that they cannot change the past, but can change the way they think and feel in order to change the future… then that's good stuff.What is the worst thing you've heard in a therapy session, or seen on the job?
Genital mutilation. An inmate removing his penis or destroying his testicles or sterilising him or herself. The very severe self-injurious behaviour, whether due to psychosis or some other severe mental illness. Those have been the worst situations.Has working with inmates affected how you view perpetrators of crime, and the prison system in general?
To say that working in prison doesn't affect you would be naive. It does. I know the system very well. I know where it works and where it needs improvement. I have learned, by being exposed to the worst behaviours that humans have to offer, to become somewhat—and not completely, I assure you— desensitised to the "evil" people can do. So [then] it’s not "what" they do that becomes important [so much] as the "why" and "how". When we figure those things out, we can target treatment to prevent those factors from reoccurring.Have you ever come across inmates who you suspect are psychopathic, and therefore fail to respond to therapy?
Yes, [although] psychopaths are comparably rare. While many may have psychopathic tendencies, less than 5 percent [of inmates] represent true, "hardened" psychopaths that can’t be touched by traditional psychotherapy. That doesn’t mean that you can’t help change their behaviours; you can, when you can teach them how to get what they want by navigating inside the rules. Many [psychopathic inmates] can be shaped that way, but not all. We don't presume anyone is beyond improvement until we really have tried everything we have in our arsenal.What are the biggest emotional hurdles inmates face when preparing to re-enter society?
First, if they’re returning to the neighbourhood they lived in before, there will be expectations, triggers, and factors that may pull them back to a criminal lifestyle. It’s hard to get out of prison and earn good wages and make a living: returning to crime is sometimes, unfortunately, a business decision, especially if they know "how to jail". Although they don't want to return to prison, they know they can navigate that environment if they need to. So there is often a pull back to criminality if they don't change their life, acquaintances, and so on.But the other side of the coin is that, when they understand themselves better, and have come to appreciate that a lot of their [past] behaviour was self-protective, they [know] they don't have to be defined by their past actions. When they get out, though, they may find themselves feeling more vulnerable, because they aren't using the defences they used to use on the street. That can be scary and lead to regression too. I think the best thing that can happen is when we help inmates redefine “toughness”. It’s not being tough to get into a fight; being tough is being smart enough to manage your emotions to navigate life, in and out of prison, to find peace and happiness with those you care about. “Tough” is resisting the temptations: they are always out there.
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Mitch Abrams: Ultimately, it comes down to rehabilitation and/or preventing re-offence. Inmates with mental illnesses that aren’t adequately treated are likely to continue down the path of their deterioration. Providing treatment can prevent the return of symptoms that may have played a part in their crime.Though surprising to some, inmates receive better mental health treatment in prison than in the community because it’s easier to keep them compliant with treatment, there’s better continuity of care, and if/when they [go backwards], they are seen earlier and stabilisation is easier. It’s important to understand though, that less than 20 percent of men in prison have a mental illness that interferes with their ability to adapt. That number is higher for women inmates, sometimes approaching 50 percent.How do inmates respond to therapy, typically, at the beginning? Do they find it hard to open up?
It’s variable. There’s an ultra-masculinity in male prison culture that often hardens people and leads them to be less receptive to treatment. It’s more difficult to incentivise younger inmate-patients about the benefits of treatment.That said, when they do figure it out, amazing work can be done. Very often, no one listened to them regarding the problems they face, or they felt there was just an expectation to become a criminal or become entrenched in a gang lifestyle. Any other option didn't seem possible [at the time]. When you’re able to get inmates to think about what they want their life to become, and understanding how their past may have presented obstacles, they start to see the benefit [of therapy]. However, there are some [inmates] who are near impenetrable.
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That’s a more complex question than people may realise. Most people are not in prison for violent crimes. I personally don't see the value in having people with drug addictions incarcerated. Further, many people who are violent were victims, but most people who are victims don't become violent… so it’s a factor to be addressed in their treatment, especially if there is an untreated trauma afoot, but it doesn’t explain the whole picture.Also, there are many people who are antisocial, meaning they don't care about the laws. This is not exactly a picture of great moral development, [but] it doesn’t necessarily reach the threshold of "mental illness" all the time. So, as a whole, do I think most people end up in prison because of unaddressed mental health issues? No. But would better educational systems, social supports, and access to mental health treatment decrease the likelihood of some people winding up engaging in criminal behaviour? Absolutely.What are some common topics or issues you explore with inmates in therapy?
You name it. I’ve worked in psychiatric units in city hospitals, state hospitals, and state prisons. No place has a wider array of psychopathology presented, including the severity and intensity of symptoms, than state prisons.How do you help prisoners come to terms with serving a life sentence?
I believe strongly that the greatest obstacle to providing good treatment to inmates is the belief that you, [the psychologist], are fundamentally different and better than them. Under the right circumstances, anyone could commit a crime. So I try to look for the commonality. It really is fascinating how inmates with life sentences learn to adjust and find meaning in their life. I don't know if I would be able to, if I were in their situation.
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I can't discuss any individual inmate's [case], but there’s a theme I’ve seen in many inmates. It may sound kind of cliche, but the most insightful thing is when they "get it"; when they understand something that happened to them early in their lives has led them down a certain path.Sometimes that could be the way they were the victims of similar crimes that they went on to commit (we sometimes call that “identification with the aggressor”). Or the fact they didn’t properly mourn the loss of their father when he left the family. Or watching domestic violence between family members. Or the impact that a family member's drug/alcohol abuse had on them. Or growing up in a violent neighborhood where being paranoid and always having your head on a swivel is required to survive.When they understand what they have learned, why they do what they do, and that they cannot change the past, but can change the way they think and feel in order to change the future… then that's good stuff.What is the worst thing you've heard in a therapy session, or seen on the job?
Genital mutilation. An inmate removing his penis or destroying his testicles or sterilising him or herself. The very severe self-injurious behaviour, whether due to psychosis or some other severe mental illness. Those have been the worst situations.Has working with inmates affected how you view perpetrators of crime, and the prison system in general?
To say that working in prison doesn't affect you would be naive. It does. I know the system very well. I know where it works and where it needs improvement. I have learned, by being exposed to the worst behaviours that humans have to offer, to become somewhat—and not completely, I assure you— desensitised to the "evil" people can do. So [then] it’s not "what" they do that becomes important [so much] as the "why" and "how". When we figure those things out, we can target treatment to prevent those factors from reoccurring.Have you ever come across inmates who you suspect are psychopathic, and therefore fail to respond to therapy?
Yes, [although] psychopaths are comparably rare. While many may have psychopathic tendencies, less than 5 percent [of inmates] represent true, "hardened" psychopaths that can’t be touched by traditional psychotherapy. That doesn’t mean that you can’t help change their behaviours; you can, when you can teach them how to get what they want by navigating inside the rules. Many [psychopathic inmates] can be shaped that way, but not all. We don't presume anyone is beyond improvement until we really have tried everything we have in our arsenal.What are the biggest emotional hurdles inmates face when preparing to re-enter society?
First, if they’re returning to the neighbourhood they lived in before, there will be expectations, triggers, and factors that may pull them back to a criminal lifestyle. It’s hard to get out of prison and earn good wages and make a living: returning to crime is sometimes, unfortunately, a business decision, especially if they know "how to jail". Although they don't want to return to prison, they know they can navigate that environment if they need to. So there is often a pull back to criminality if they don't change their life, acquaintances, and so on.But the other side of the coin is that, when they understand themselves better, and have come to appreciate that a lot of their [past] behaviour was self-protective, they [know] they don't have to be defined by their past actions. When they get out, though, they may find themselves feeling more vulnerable, because they aren't using the defences they used to use on the street. That can be scary and lead to regression too. I think the best thing that can happen is when we help inmates redefine “toughness”. It’s not being tough to get into a fight; being tough is being smart enough to manage your emotions to navigate life, in and out of prison, to find peace and happiness with those you care about. “Tough” is resisting the temptations: they are always out there.