For the second of half of his three-decade prison stint, Robert Moore lived by one rule: "The less I say, the better I play."
Moore remembers coming up with the maxim after another inmate bashed his head with a metal rod in 2001, sending him to the infirmary of State Correctional Institution Graterford, Pennsylvania's largest prison. After the incident, Moore couldn't focus and was prone to long pauses as he fumbled for words. "I have a tendency to get stuck in traffic when it comes to expressing myself," Moore, who's spent most of his 56 years in prison or juvenile detention and was paroled last year, tells me.
Inside, Moore was aloof and short-tempered. During the endless rec-room card games that fill up a prison sentence, he would lose and then snort in frustration before growing coldly silent. He recalls younger inmates being intimidated and refusing to play against him, and a prison physician prescribing Paxil to calm his nerves.
Once they saw he was "slow," others took advantage of him, borrowing things and never returning them, according to Moore. "I was not able to talk to [other] inmates or gain any trust with them," he says. Moore disappeared into the prison's shadows, silenced by the impact of the blow.
"I knew that we had a lot of men with brain injuries. I was shocked to find out how many." —Matthew Mauriello
No one has a good estimate of the number of US prison inmates who have suffered traumatic brain injuries. The Centers for Disease Control estimates the portion of the male incarcerated population with these kinds of problems somewhere in their past at a frustrating 25 to 87 percent. It is clear that the percentage is far higher than the roughly 8.5 percent of the general population that reports traumatic brain injury.
The proliferation of head trauma adds another mental health challenge to America's mess of a prison system. Depression and anxiety, substance abuse, violence and suicidal thoughts are all associated with head injuries. Cognitive impairment can also make prison life—rife with rules, jobs and social norms—more difficult, and the culture shock and byzantine prohibitions imposed by parole practically unbearable.
For these reasons, the state Commission on Crime and Delinquency awarded the Brain Injury Association of Pennsylvania a $250,000 grant to screen for head trauma among men on track to be paroled from Graterford, the idea being to smooth their transition back into the outside world. The prison, with more than 3,000 inmates, is about 35 miles from Philadelphia and releases men into the five counties around the city. The program is one of a few around the country aimed at tailoring reentry to the unique needs of a traditionally brain injury-prone population as some states and localities (and for now, at least) the federal government scale back incarceration.
"I knew that we had a lot of men with brain injuries," says Matthew Mauriello, Graterford's psychological services specialist. "I was shocked to find out how many."
Along with her interns, MJ Schmidt, a neuro-resource facilitator with the Brain Injury Association of Pennsylvania (BIAPA), screened more than 150 inmates. According to her, about 75 percent had accidents and assaults in their past that could have triggered head trauma, and 75 percent of that 75 percent showed signs of cognitive impairment while taking a memory and skill test. This meant a significant majority of the men tested probably had head trauma.
"There's no reason to think [that population] is different from any other male prison population," notes Dr. Drew Nagele, a neuropsychologist at Beechwood NeuroRehab in Langhorne, Pennsylvania, who consults with BIAPA.
The association is still preparing its data, compiled over the last three years, for academic publication, but Schmidt teased an overview of the injuries. Assaults, which she says make up about 10 percent of head injuries in the general population, unsurprisingly doubled in frequency within a prison sample. Meanwhile, falls—the number one cause of brain trauma in the outside world—were less common in inmates' history. Vehicle accidents and military combat injuries, on the other hand, were well represented.
The trick lies in teasing out cause and effect.
"This is a population that's involved in a lot of high-risk behavior," says Schmidt. "Some of them rode bikes down the steps as kids. Did that cause an injury that lead to certain behavior or was that part of a pattern of risk-taking?"
What is known is that head injuries often lead to more head injuries. After an initial one, a person is three times more likely to experience a second. After a second, he or she is eight times more likely to suffer a third.
The metal-rod attack wasn't Robert Moore's first head injury. At the age of nine, he says, a car struck him, sending him face first into the pavement, and he describes enduring countless blows in the boxing ring as a teenager. Then, in 1987, Moore was sentenced for his role in a three-man home invasion and gang rape near the University of Pennsylvania.
Check out the VICE News special on group therapy behind bars in America.
To be released, most Pennsylvania inmates have to complete classes on anger management, sex-offender recidivism prevention, drug and alcohol abuse prevention and/or basic decision-making. Of course, any kind of learning can be daunting for someone whose brain has been rattled.
"One guy didn't know that a nude picture his girlfriend sent could have constituted pornography." —MJ Schmidt
Moore said the homework of his violence-prevention class perplexed him. He had to read a workbook full of scenarios of characters who are angered or rattled and point out how they should best react. "My attention span is very short and my reading level is low," he admits. Sometimes, he just didn't complete the work.
The Parole Board is a separate entity from the Department of Corrections, yet Graterford officials and the BIAPA knew inmates with brain injuries didn't come across very well. "They were looking for a consistent story from the offender to retrieve the same set of facts with each meeting," says Monica Vaccaro, BIAPA's program manager. "This was a tough feat for someone with a memory impairment. Also, brain trauma causes people to repeat themselves and have flat facial expressions, demonstrating a nervousness not indicative of remorse."
If and when inmates make it to the outside, things just get harder. New parolees are expected to keep appointments, rely on resources that have dizzying application processes, deal with the culture shock of a world that may have aged decades while they were stagnant in prison, and follow a complex set of rules. "One guy didn't know that a nude picture his girlfriend sent could have constituted pornography," says Schmidt. Keeping pornography is an offense that could be stacked on top of others to send someone back inside. "He didn't understand. 'She sent it to me. How can it be porn?'"
Schmidt coached the impaired to advocate for themselves. "I told them that it's important to acknowledge certain things," she says. "They should tell people, 'I'm sorry. I understand I have a habit of repeating myself.'"
The association is currently instituting the same program in a youth prison and trying to create a set of guidelines for other prisons to use to recreate their efforts.
Perhaps the greatest benefit of the program for Moore was that Schmidt helped connect him to cognitive therapy on the outside. Twice a week, he attends a Moss Rehab in Philadelphia—which he says is much needed. "When I came home, the world was nothing as I had known it," he says. "I had to be navigated various places around the city, to the clinic, to the parole office, home. I felt naked."
Moore says he now works part-time as a monitor in a home for veterans and spends time with his daughter and granddaughter. But the worst times are the empty hours when he has nothing to do, a sharp and jarring contrast to life on the inside.
"That's when I feel uneasy," he says, with a tremble in this voice. "But thanks to some things I have learned, I am able to regroup."