Traumatic Brain Injury in Corrections

By Orli Shulein,¹ Risa Klemme,² Kurt Johnson, Ph.D.,¹ and Mark Harniss, Ph.D.¹

Researchers estimate that up to 60% of incarcerated individuals are living with traumatic brain injury (TBI) in our prisons. Why do so many of these individuals have TBI? Although we don’t have enough evidence to know for sure, there are many theories.

Substance abuse may be part of the issue. There is a strong correlation between TBI and substance abuse for incarcerated individuals. Perhaps having a TBI makes someone more susceptible to coming into contact with law enforcement. One study suggests that people with TBI are 2.5 times more likely to be incarcerated, and another study found that it may be more common for incarcerated individuals to have multiple TBIs. This may be because TBI can affect one’s ability to predict the consequences of his or her actions and can make it difficult to control emotions.

There is also the idea that risky behaviors place a person at increased risk for TBI. Having a history of offenses prior to TBI is associated with post-TBI arrest. Furthermore, general risk factors for arrest are similar between people with TBI and those without. Those arrested tend to be young, single, less educated males.

Individuals with TBI may experience disabilities that make prison life challenging and make the transition from the correction setting to the community setting more difficult. Additionally, staff in prisons and community corrections often lack understanding of TBI and may unknowingly respond in ways that worsen TBI symptoms. This may reduce the ability of incarcerated individuals to conform to prison expectations and may limit their ability to benefit from programs and interventions.

To address these issues, the Washington State Department of Corrections (DOC) and University of Washington formed a partnership in 2014 from which the TBI in Corrections project was born. The project addresses the DOC’s mission and vision of improving public safety and working together for safe communities through research-based TBI education and interventions that target front-line DOC staff, incarcerated individuals with TBI, and those under community supervision.

Since its inception, members of the TBI in Corrections project team – which comprises UW researchers and a comprehensive group of DOC staff from across the agency, including administrators, Americans with Disabilities Act (ADA) coordinators, front-line staff, and health, mental health, and classification services staff – have worked hard to identify simple, effective ways to make Washington State prisons safer. The pay-off of this hard work will come in fall 2019, when a program to develop a screening tool for incarcerated individuals with a history of TBI will begin in one Washington State prison. The goal of the screening program will be to identify incarcerated individuals who would benefit from additional services or accommodations and help DOC staff learn tangible skills to interact with individuals with TBI. The hope and expectation of the program is that it will eventually expand to all Washington State DOC prisons, and that the services and interventions will help reduce infractions and improve compliance.

Supporting incarcerated individuals with TBI

Having a TBI when incarcerated may present individuals with challenges unique to the prison setting. These challenges can include:

• Having difficulty understanding directions
• Appearing to be slow or nonresponsive to staff requests
• Having trouble remembering instructions from staff
• Acting impulsively with staff or other incarcerated individuals
• Having difficulty organizing one’s cell and keeping it tidy
• Having rapid mood swings with no apparent reason, making a person more volatile in public spaces
• Responding too aggressively to other incarcerated individuals or staff
• Having anxiety or depression and withdrawing from social interaction
• Being more sensitive to lights and sounds, especially in crowded common areas

While TBI can cause a wide range of challenges in a correctional setting, there are some ways to help these individuals:

• Talk slowly and pause when shifting between ideas or topics. This will allow someone more time to process what you are saying.
• Use concrete examples. Avoid hypotheticals. The more complicated the information, the less understandable it is.
• Break information into small chunks and repeat it several times. It is easier to remember what someone is saying when it is provided this way.
• Ask clarifying, open-ended questions, rather than yes/no questions, to gauge a person’s understanding. For example, “Tell me what you understand” will be more informative than “Do you understand?”
• Use a calm, low voice – the louder the voice, the more difficult it is for someone with sound sensitivity.
• Have important conversations in quiet, dimly lit spaces (as they are available). Loud, bright spaces can make some individuals with TBI more agitated and can make it difficult for them to focus.

The services and strategies noted above are likely to improve interactions between staff and incarcerated individuals and may increase safety in correctional settings. The ADA also entitles incarcerated individuals with TBI to accommodations. Individuals with TBI who are incarcerated can work with their ADA compliance managers to discuss possible accommodations.

Supporting corrections staff with TBI

Many DOC corrections officers have prior law enforcement and military backgrounds that place them at increased risk for TBI. If you or someone else you know works in this setting and is concerned about the effects of a prior TBI, there are a few things you can do.

Given that many of the cognitive and behavioral symptoms associated with TBI are not unique to TBI, proper diagnosis is an important first step. If you do not have a diagnosis, speak with your primary care physician as he or she can help you develop a plan to move forward. If you already have a diagnosis but continue to struggle with TBI symptoms, seek specialized care from a physiatrist or neurologist.

As injury severity varies so widely and recovery is unique to each individual, some people can find coping strategies to compensate for areas of challenge while selecting activities and jobs that speak to their areas of strength. Others are not so lucky. If you are continuing to deal with the physical effects of TBI, you may benefit from working with a physical or occupational therapist. Cognitive difficulties are typically evaluated by a neuropsychologist and treated by a speech-language pathologist. If you find yourself feeling depressed or anxious, or if you are having difficulties controlling your emotions, you may benefit from seeing a psychologist with a background in brain injury. A vocational rehabilitation counselor can provide you with work-specific tools if the effects of your brain injury are affecting your work. Navigating these services can be challenging, so seek assistance if necessary.

For more information about the TBI in Corrections project, click here.

References

1. Correctional Services Canada. (2010). Traumatic brain injury and substance use among offenders.
2. Davies, R. C., Williams, W. H., Hinder, D., Burgess, C. N., & Mounce, L. T. (2012). Self-reported traumatic brain injury and postconcussion symptoms in incarcerated youth. J Head Trauma Rehabil, 27(3), E21-27. doi: 10.1097/HTR.0b013e31825360da.
3. Durand, E., Chevignard M., Ruet, A., Dereix, A., Jourdan, C., Pradat-Diehl, P. (2017). History of traumatic brain injury in prison populations: A systematic review. Archives of Physical and Rehabilitation Medicine, 60(2), 95-101.
4. Elbogen, E. B., Wolfe, J. R., Cueva, M., Sullivan, C., & Johnson, J. (2014). Longitudinal Predictors of Criminal Arrest after Traumatic Brain Injury: Results from the Traumatic Brain Injury Model System National Database. J Head Trauma Rehabil. doi: 10.1097/HTR.0000000000000083.
5. Farrer, T. J., & Hedges, D. W. (2011). Prevalence of traumatic brain injury in incarcerated groups compared to the general population: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry, 35(2), 390-394. doi: 10.1016/j.pnpbp.2011.01.007.
6. Kim, H., Bayley, M., Dawson, D., Mollayeva, T., & Colantonio, A. (2013). Characteristics and functional outcomes of brain injury caused by physical assault in Canada: a population-based study from an inpatient rehabilitation setting. Disabil Rehabil, 35(26), 2213-2220. doi: 10.3109/09638288.2013.774063.
7. McIsaac, K. E., Moser, A., Moineddin, R., Keown, L. A., Wilton, G., Stewart, L., A., Colantonio, A., Nathens, A. B., & Matheson, F., I. (2016). Association between traumatic brain injury and incarceration: A population-based cohort study. CMAJ Open, 4(4), DOI:10.9778/cmajo.20160072.
8. Phillips, A. (2013). Identifing Traumatic Brain Injury and Developmental Disability in Prison. Washington: Washington State Department of Corrections.

¹Department of Rehabilitation Medicine at the University of Washington
²Washington State Department of Corrections