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Eades, David --- "Mental Health and the Impact of Relational Connections in Incarceration: Being 'Other-Orientated'" [2018] CICrimJust 11; (2018) 30(1) Current Issues in Criminal Justice 57


Contemporary Comment

Mental Health and the Impact of Relational Connections in Incarceration: Being ‘Other-Orientated’

David Eades[*]

Abstract

This contemporary comment reviews the shortcomings of the biomedical approach used in isolation in dealing with stress and mental health issues in the context of incarceration and explores the benefits of the biopsychosocial approach, focusing particularly on the positive social impact this model may have on the lives of those incarcerated. Interpersonal relations have been used by those incarcerated as a way to navigate the circumstances they face. The interpersonal relationships developed can have a transformational impact. This comment explores the concept of being ‘other-orientated’ as a major contributor in accumulating resilience and maintaining positive mental health by those incarcerated.

Keywords: incarceration – resilience – mental health – wellbeing –biomedical – biopsychosocial – interpersonal relations

Introduction

There is an emerging field within the criminal justice system termed ‘neurolaw’. Proponents of neurolaw are applying neuroscience to a variety of different contexts as a result of recent advances in pharmacology and genetics. Within neurolaw, consideration is given to how human behaviour can be modified using pharmaceuticals by transforming the biochemical composition of a person’s brain. Ryan (2013) highlights that, in the criminal justice system, biochemical interventions are increasingly being utilised in rehabilitation, rather than focusing on changing the characters of offenders. This comment highlights the need within the criminal justice system for a biopsychosocial focus that is not constrained by a biomedical approach to managing behaviour.

The biomedical model as it relates to mental health emphasises pharmacological means to treat biological abnormalities. Mental disorders are viewed as biologically based brain diseases, chemical imbalances, or abnormal brain functioning that need to be treated with psychotropic medicines. This model is the prevailing perspective through which mental health is assessed and treated. However, concerns have been raised regarding the effects of psychiatric medications used over prolonged periods. For example, Favor (2003), Fava and Offidani (2010) and Whitaker (2010) argue that the prolonged use of psychiatric medications may in fact cause a deterioration of mental health, and Insel (2010) argues that such medications may not be providing lasting relief. These concerns relate to the fact that the biomedical approach at times is used independently of concerns regarding the social, psychological and behavioural dimensions of people’s wellbeing. Despite the existence of alternative theories for the treatment of mental health, the biomedical model continues to dominate the mental health system, especially in the United States. It has also had a significant influence on the development of approaches used in clinical psychology (Wampold 2001). Deacon notes that biopsychosocial approaches are neglected in favour of medical theories because ‘in the biomedical paradigm, the primary aim of research into the nature of mental disorders is to uncover the biological causes’ (2013, p. 6) that relate to brain functioning, rather than the social aspects of life.

It is not the intention of this comment to discredit the biomedical model. Rather, this comment is concerned with the use of the biomedical approach in isolation, with little or no regard for other factors that influence mental health. Biological and social perspectives do not need to be incompatible. Kendler and Schaffner (2011) point out the need for more tolerance of various frameworks and simultaneously being self-critical of theories adopted, whether biological, social or psychodynamic. It is vital that mental health issues are viewed through a holistic paradigm. This comment considers the benefits of the holistic biopsychosocial model, a much-neglected perspective that has many advantages when used in conjunction with the biomedical approach to understand wellbeing.

Unpacking the term ‘biopsychosocial’, ‘bio’ relates to living organisms, ‘psycho’ relates to the mind and ‘social’ relates to the aspects of interaction. George Engel established the biopsychosocial approach in the 1970s, arguing that clinicians needed to take a more holistic view of illness. This incorporated the biological (genetic, biochemical, etc), psychological (mood, personality, behaviour, etc), and social (cultural, family, socio-economic, etc) dimensions of mental health (Engel 1977; see also Borrell-Carrrio, Suchman & Epstein 2004). Here, I am interested particularly in the impact of social interactions on the mental health of a small sample of people who are incarcerated, especially as it links to being ‘other- orientated’. This comment traces the possible positive impacts that focusing on the needs of others, rather than merely on the self, has on the mental health of those incarcerated. This social commentary was inspired by numerous informal conversations I had with people who had been recently incarcerated, all of whom expressed common experiences relating to stress and mental health.

Adversity, resilience and community

Different cultures have different ways of understanding suffering and its impact on people’s resilience. Western societies tend to focus on treating the symptoms of mental health issues with biomedical solutions, emphasising clinical solutions to personal problems.[†] Ibebeme et al. (2017) point out that ‘the predominant culture that governs health and health care activities in the Western world is scientific rationality or the biomedical model’ (p. 14). Ibebeme et al. (2017) assert that this model is generally assumed in the Western world as ‘a picture of reality’ rather than a mere ‘representation’ and that ‘the assumptions of the model are so deeply ingrained in the ways of thinking in Western medicine that health care workers tend to forget that it is a conceptual model or a way of thinking about the world’ (p. 14). In contrast, many non-Western societies apply a more social approach, adopting a more holistic, integrated approach to personal problems. In non-Western societies, issues in life may be viewed more within the context of family or community and less with regards to individual needs. Ibebeme et al. (2017) highlight that a conceptual representation of reality observed primarily in

non-Western societies defines illness as a disturbance in social relationships or to the balance of life, for example, and the cause of illness is framed in a social context, rather than as a biological process. Brucken, Giller and Summerfield (1995) support the notion that individual recovery of people of diverse cultures involves family and often the wider community.

For many cultures, resilience is based in community, drawing on interpersonal connections as a way of gaining strength to navigate adverse circumstances. Terms such as ‘community resilience’, ‘community capacity’ and ‘asset-building communities’ are used to describe the aspect of resilience that forms as a result of individuals finding meaningful involvement through attachments with others (Benson 2003; Tricket & Birman 2000; Ungar 2005). Incarcerated individuals can gain strength not only from what others give to them, but also through the way they assist others. Walsh notes that, in reaching out to others, people unlock resources that they may not otherwise have drawn upon (2007, p. 218). Staub defines the term ‘other-related’ as a ‘prosocial orientation’, focused on being of benefit to others and having concern for their welfare (1990, p. 49).

This comment proposes that a contributor to wellbeing is grounded in a person’s capacity to maintain resilience in adversity through being ‘other-orientated’. In this context, adversity is being incarcerated. The concept of resilience is more than a simple ability, personality trait or developed skill set. Here, resilience is understood as the capacity of individuals to navigate their way to health-sustaining resources, including feelings of wellbeing, when exposed to significant adversity (Ungar 2006), particularly through utilising interpersonal relations (Wilson 2013). It includes good mental health, functional capacity and social competence (Olsson et al. 2003).

In the context of incarceration, it is difficult for individuals to be resilient when they isolate themselves. Limiting interaction with others can lead to loneliness and depression. Studying patients in hospital, Catalano et al. (2013) found that those in isolation had significantly higher scores relating to depression than those who were not isolated. Steptoe et al. (2013) also document the fact that social isolation is an important associative of depressive symptoms. In contrast, an incarcerated person is likely to find meaning and a sense of heightened solidarity when he or she contributes to the lives of others (Wilson 2012).

The following section explores the experiences of a small group of people who have recently transitioned out of incarceration and examines their reflections as case studies of other-oriented action. These experiences were captured through an ethnography of engagement by way of field notes through informal conversations. Although the examples of other-orientated actions by those incarcerated were limited in number, these accounts mirrored what other people had shared informally who had recently been discharged from incarceration. I was able to be have contact with the people who formed the basis of the case studies through shared community connections. Not all people incarcerated share the same outlook of the experiences recorded as it is not necessarily a common occurrence of wanting to help another through a sense of altruism. However, these case studies were recorded as an example of the positive impact being ‘other-orientated’ can have on a person incarcerated.

Utilising the biopsychosocial model for healing: some case studies

Some of the relationships that form while people are incarcerated take on important symbolic meaning. In the cases I heard, this was a common theme. A former ‘bikie’ gang leader acted like a father figure or uncle to some of the younger men. In reaching what might be otherwise seen as a mid-life crisis, he felt obligated to be a better role model than previously as a bikie leader. He knew that under his leadership, many younger guys had ended up in prison.

He was also aware that he still held a sense of power over the younger men incarcerated.

A number of these young men were still discovering ‘who they are’ and were trying to work out their self-identity. They could have easily acted out to gain attention and approval from others. The former gang leader felt a sense of moral duty to encourage the younger men to stay out of trouble and walk away from arguments or trouble that did not need to take place. What helped him navigate incarceration was knowing that he could use his influence to curb antisocial behaviour in others. He told me that he consciously took on the role of a ‘mentor’ to guide the younger men on more positive future pathways. This man expressed the ‘sense of hope’ he felt after having passed on positive lessons from what otherwise seemed like his own wasted years, feeling that these lessons were used as a resource or reference point to help the younger men move in a different direction. He viewed his involvement in the lives of the younger men as giving him purpose and was a major contributor to his positive framework. Walsh (2007) highlights that many people find purpose and transformation through actions that benefit others and contribute to preventing future problems.

Another young man I spoke with was from an English-speaking background and he reached out to others who had very limited English in order to help them gain confidence. He stated that people from non-English-speaking backgrounds easily felt intimidated and embarrassed at their lack of competency in English. This young man took these people ‘under his wing’ to help them integrate with others. Often, humour was used to deepen the friendship between these individuals. The English speaker developed a unique bond with the people from a different culture and gained a sense of satisfaction in knowing he was enabling the lives of other people to be less stressful. This young man conveyed to me that he ‘felt appreciated’ and that helping another brought ‘more meaning’ in his daily routine. He experienced a unique situation through building close relationships with people from other cultures who he might formerly never have met. His circumstances were notably more stable and he felt positive that he could actually help other people, despite his challenging situation.

I spoke with another man who had made a routine of playing the guitar each afternoon in an activities room. He had started showing a few others the basic chords and teaching them how to start playing simple songs. He told me that he used this time as a way of ‘chilling out’ and he expressed the fact that the experience had a major therapeutic impact on his day. He also really enjoyed seeing others play the guitar. He told me that he finished each day with a ‘sense of satisfaction’ that he had shared his knowledge with others and allowed them to experience the same pleasure that he received from playing music. He started writing his own music and wondered if perhaps one day he could do something with his songs.

Another man spoke to me about how he had developed his own form of mentoring through a physical exercise program. He would wake another guy every morning and have him come out to the exercise area to do an hour of fitness. He led this other man through a personal circuit training program he had developed. This experience contributed to a close friendship, but also assisted the other man to lose a significant amount of weight. The man I spoke with talked about the way the process helped him be ‘motivated’ each day to help another person turn his life around by losing weight and getting fit. He told me that this gave him a sense of purpose and a reason to get up in the morning.

The dynamic of one person reaching out to another was not restricted to those incarcerated. Some of the men I spoke with commented on the impact various staff had on their lives. A few of the younger men spoke of the lack of boundaries in their life previously. They simply had not had someone to guide or advise them to maintain a healthy focus in life. These men expressed the felt need for a ‘mother’ figure. They explained that they had grown up without a mother, or with an absent mother who was out working or more focused on chasing her own relationships rather than investing her time in her children. As a result of this, some of the more mature female officers took on the role of the ‘mother’ figure. The younger men expressed feeling ‘safe’ because the officers were firm in telling them not to do something and the officers were committed to maintaining a safety net for them. These men stated they experienced a greater sense of peace, calmness and stable mental health as a result of the positive, consistent influence of the female officers. The men’s ongoing interactions with these officers had an important impact on changing the men’s way of thinking.

Such relational connections, as outlined, had a major impact on the mental health of those incarcerated. Krovel (2013) asserts that dense networks of social connectedness are related to wellbeing. The personal commitment shown by a person who had no other reason to help other than a sense of ‘moral duty’ or ‘compassion’ provided a significant ‘kick start’ to ‘doing life’ differently. These experiences gave those involved a sense of ‘hope’ for a better future and also contributed to a strong sense of resilience. Peres et al. (2006) note that hope is a critically important factor for better health. Walsh (2007) suggests that hope ‘fuels energies, and investment to rebuild lives’, it accepts what has been ‘lost and cannot be changed, while directing effects to what can be done and seizing opportunities for something good to come out of the tragedy’ (p. 213). In addition, special practical skills or interests were also developed, and these skills provided a foundation for the future and hope that life could be better.

The former bikie gang leader realised that he had a skill for working with troubled youth. The person who built a friendship with people from a non-English background contemplated enrolling in a short-term certificate course on tutoring with the aim of establishing a business running evening conversational classes for non-English-speaking people. The person who helped others learn to play the guitar considered guitar tutoring and perhaps setting up a music store. The person who helped others in the gym thought about the possibility of finding work as a personal trainer. One of the men I spoke with talked about the help he received from the female officers and expressed his interest in wanting to do some youth work for juveniles to help turn their lives around. In each instance, future hope had become embedded in the outlooks of these men, which motivated them to have a plan after leaving incarceration. The positive residual impact on their mental health occurred as an outcome of this process. They knew that their skills were able to enrich the lives of others.

The institution the men were held in had utilised a ‘meaningful activities program’. However, using their own volition to help others was a different experience which elicited very different outcomes to the other program offered. Those incarcerated spoke about the difference between attending an activities program and their own initiated assistance to another person. These cases outlined are examples of self-initiated care-giving. The actions were not compulsory or pre-organised. Rather, these individuals were building interpersonal relationships with others by using their own talents. There was no requirement for this other than a personal sense, shared by those incarcerated, that they ‘needed to be there’ for someone else.

For the people described, much of their daily routine had not changed while being incarcerated. These same men presented themselves each morning to the medical centre for their daily methadone and for sleeping tablets at night to help calm their minds. All of the individuals in this present case study had undergone pharmacological treatment during incarceration. They commented that these medications were ‘stop-gap’ measures they relied upon until their lives were ‘back on track’. They expressed the view that their daily medication (biochemical intervention) was issued by nurses to help stabilise their behaviour during their time of incarceration. What surprised them, however, was the overall improvement in their moods through the impersonal connections they established with others. In my conversations with these individuals, they told me that they felt a greater sense of meaning and hope that life could be different and bring positive experiences. They felt that all was not wasted and there was still time left to invest their energy in contributing to the needs of others. They had already started this process through their self-initiated interpersonal intervention into the lives of others while being incarcerated. This provided a stimulus to bounce back from the hardships they had experienced and, through this, their resilience was also heightened. Walsh (2007) affirms that relational connections support a pathway in resilience.

The people profiled here have started a process of transitioning from being ‘self-orientated’ to becoming ‘other-orientated’. Their determination to go on and make a difference in life emerged from the development of meaningful interpersonal connections. These individuals may need to continue to take prescribed medications to stabilise their day-to-day lives. However, in my conversations with these men, many stated that as they became more established in following their dreams and aspirations in life, there was less need for various other substances (especially illicit) to keep their life stable.

As a caveat to the emphasis placed on interpersonal relations, I do not suggest that this is in anyway a substitute for the need for medication by people with mental health challenges such as bipolar disease. As I have highlighted in the opening of this article, the biopsychosocial perspective can supplement the biomedical approach. Being other-orientated, however, is likely to have clear benefits to people with mental health issues for which they need daily medication. The focus of the biopsychosocial model can provide inspiration for people incarcerated to move beyond any biomedical assistance that they have received in the past. Their ongoing wellbeing can be positively influenced by their capacity to draw inspiration from interpersonal connections while they are incarcerated. Those incarcerated (discussed in the case studies) expressed that being released from incarceration was not the answer to fulfilment. They reinforced, however, the benefit of shifting their focus from

self-interest to being other-orientated.

The feedback I received through my interactions with those who were incarcerated supports previous research concerning the development of resilience through community connections. Walsh (2007) highlights community connections as an essential resource in trauma recovery and the impact of utilising communities for healing and resilience. Westoby (2009) presents the perspective of healing as a social paradigm and social process through which a sense of collective agency is built. Incarcerated individuals develop their own community within the institution. Their healing is found within the community more than through any individual self-help program. They have stumbled upon a natural way of building meaningful interpersonal relationships with others and have been able to share a skill or talent that has also helped enhance the lives of others. Through being ‘other-orientated’, the minds of these individuals were redirected to the needs of others, and through this process they themselves felt more relaxed and shared a greater hope for their future. There was still a high likelihood of them re-offending after being released from incarceration. However, many have put strategies in place to mitigate this risk. There is a strong possibility that the impact of the interpersonal relations already built has contributed to a permanent change in their perspectives. In becoming ‘other-orientated’, they have found a dynamic reflected within the biopsychosocial model that may have a lasting impact on their lives.

Conclusion

This comment has profiled the limitations of relying purely on a biomedical approach as it pertains to resolving mental health issues. It presents the potential for resilience-building through redirecting attention to reaching out to others through being other-orientated. Those incarcerated found hope for the future through becoming more other-orientated. These people utilised elements within a biopsychosocial model that enriched their lives beyond what a biomedical perspective is able to provide. There is no need, however, to create an either/or paradigm in relation to a biomedical or a biopsychosocial outlook. What this comment addresses is the neglect of a biopsychosocial perspective and the positive impact it plays in the lives of those incarcerated. Examples of the impact of interpersonal relations illustrated how the biopsychosocial approach is worked out in the context of incarceration. This is shown to make a major difference in building resilience and enhancing the wellbeing of those incarcerated.

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[*] Researcher, WSU Institute for Culture and Society, Building EM, Parramatta NSW 2751, Australia. Email: 2friends@tpg.com.au.

[†] Classifying the world by way of descriptions such as ‘Western’ and ‘non-Western’ is limiting and in many ways counterproductive. However, for the purposes of this comment, such terminology effectively encompasses the differences being discussed.


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