Trauma exposure prior to incarceration is nearly ubiquitous. In a sample of 592 incarcerated men, 99% endorsed experiencing at least one lifetime traumatic experience prior to incarceration, with 59% scoring above the clinical threshold for Posttraumatic Stress Disorder (PTSD) on the PCL-5 (Wolff et al., 2014). Meta-analyses on international samples show prevalence of PTSD ranged from 0.1% to 27% for male and from 12% to 38% for female incarcerated populations (Baranyi et al., 2017). This stands in stark contrast to PTSD rates in the general population, which range between 3 to 8% (Kilpatrick et al., 2013).
Further, incarcerated persons are frequently exposed to potentially traumatic experiences (PTEs) during incarceration, which can give rise to or exacerbate existing PTSD symptoms. A review from Piper and Berle (2019) notes an alarming 89-97% of incarcerated individuals report exposure to PTEs while incarcerated, with one study reporting PTEs as a near monthly occurrence among incarcerated populations (Hochstetler et al., 2004). A random sample of approximately 7,500 inmates across 13 prisons found over a third of men and women reported experiencing sexual or physical assault within the past six months (Wolff et al., 2009). These experiences of in-custody assault as well as experiences with solitary confinement have been associated with PTSD during incarceration and post-release (Piper & Berle, 2019). Individuals holding multiple marginalized identities, who are already overrepresented in prisons (Hinton & Cook, 2021; Ogunbajo et al., 2023), are also at highest risk for experiencing victimization in these settings, which can widen existing disparities in mental health and post-release outcomes (Jenness et al., 2019).
Living with PTSD in a forced environment where violence is common, agency is restricted and social supports are limited amplifies suffering and poses a significant barrier to recovery. When incarcerated persons with PTSD already face considerable burdens on their psychological resources to cope with the harsh prison environment, there leaves significant room for the worsening of underlying mental health conditions. It is therefore imperative that correctional settings offer appropriate treatment necessary to support the needs of incarcerated individuals.
Recognizing the unique vulnerabilities of incarcerated persons suffering with mental health difficulties, there are a myriad of U.S. and international human rights standards outlining the provision of mental health services in prisons. Prisons have an obligation under the Eighth Amendment of the U.S. Constitution to provide incarcerated individuals with adequate medical care, including mental health care. The United Nations (UN)-approved Standard Minimum Rules (SMR) for the Treatment of Prisoners state, “Every prison shall have in place a health-care service tasked with evaluating, promoting, protecting and improving the physical and mental health of prisoners, paying particular attention to prisoners with special health-care needs or with health issues that hamper their rehabilitation” (UN, SMR, 2015). PTSD is a diagnosable condition that can lead to other significant impairment, and thus interfere with rehabilitation if left untreated (Facer-Irwin et al., 2019). In line with these human rights standards, and given the high prevalence of PTSD within these settings, it would be considered negligent to ignore adequate screening and treatment for incarcerated individuals exhibiting PTSD symptomology.
Despite the need for PTSD treatment in these settings, the availability of trauma-focused interventions within U.S. prisons is far from universal. Based on 2016 data from 44 state Departments of Corrections (DOCs), only 32 states offered some form of trauma-relevant treatment (Renn et al., 2020). Among these 32 states, 97% offered treatment to women and 67% offered treatment to men. Thus, more than half of the surveyed DOCs offer no trauma treatment for men in prison despite high rates of PTSD. Seeking Safety (Najavits, 2002) was the most common program offered, which has been shown to be effective at reducing PTSD and depressive symptoms among incarcerated women (King et al., 2017). The program is designed to focus on present-focused coping rather than discuss aspects of prior trauma, which is likely due to prevailing perspectives that prisons do not meet standards for exposure processing due to the stressful environment (Miller & Najavits, 2012). This perspective has largely been challenged in recent years, and yet its impact appears to have stalled opportunities for process-based treatments (e.g., Prolonged Exposure [Foa et al., 2008], Cognitive Processing Therapy [Resick et al., 2008]) with strong empirical support to be evaluated in these settings (Malik et al., 2023). It is evident that more research is needed to understand the most efficacious PTSD treatments within prisons, including necessary adaptations to accommodate the diverse needs of incarcerated populations.
National and international standards are clear that adequate mental health care is necessary to preserve the dignity of individuals experiencing incarceration. Indeed, many DOCs have acknowledged the pervasive issue of trauma and PTSD within their prisons, evidenced by the inclusion of trauma programming and initiatives such as the Prison Rape Elimination Act (PREA) to address in-custody violence (2003). Yet, the question remains: what is truly “adequate” PTSD treatment? With approximately 1.2 million individuals currently incarcerated and one-third of U.S. states failing to offer any trauma-focused programming, hundreds of thousands of incarcerated individuals are left without access to crucial care (U.S. Bureau of Justice Statistics, 2021). A necessary step in addressing this gap is calling upon policy makers to increase resource allocation for quality implementation of evidence-based trauma treatments. Ensuring adequate access to effective PTSD treatment should not be optional. It is necessary to ensure compliance with constitutional and international standards for mental health treatment and to protect the dignity and rights of those experiencing incarceration.
About the Author
Haley Church, MA (she/her) is a clinical psychology doctoral student at the University of Nebraska-Lincoln in the Violence Intervention for Survivors of Interpersonal Violence (VISTA) Lab (https://psychology.unl.edu/vistalab/) under the mentorship of Dr. David DiLillo. Her research focuses on understanding posttraumatic dissociation and emotion dysregulation as well as ways to promote access to interventions addressing the impact of trauma among incarcerated individuals. She has developed a partnership with a local non-profit, RISE, to evaluate their in-prison program focused on promoting post-release success among participants.
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