What is Post-Incarceration Syndrome (PICS)?
Post-Incarceration Syndrome (PICS) refers to the difficulties individuals face upon reentry into society after incarceration. This multifaceted syndrome encompasses a range of physical, emotional, and psychological symptoms that make successful reintegration into society challenging. Among the complexities of PICS, trauma triggers significantly exacerbate the already daunting obstacles formerly incarcerated individuals face.
While the American Psychiatry Association doesn’t officially recognize Post-Incarceration Syndrome as a medical or psychiatric diagnosis, PICS is gaining attention among mental health professionals, policymakers, and advocacy groups to describe the unique challenges those recently released from prison or jail face.
How I Treated Post-Incarceration Syndrome as a Substance Use Disorder Counselor
While a substance use disorder counselor, I had the opportunity to be the first provider to meet with someone coming home after incarceration. And early in my career, I noticed no one was preparing them for life after they completed their sentence or went on parole.
Even today, most institutions, experts, and family members assume previously incarcerated individuals quickly adapt and return to “life as normal”—that they don’t carry trauma from inside prison to life outside.
As my experience in this field grew, I noticed undeniable common symptoms in those returning homes—and started to address those symptoms, including those commonly attributed to PTSD.
In my first sessions, I reminded clients, “Your body is out, but it will be six months to a year before your head catches up.” These words often opened the door for a deeper conversation about their experience in prison and their adjustment to life outside prison.
Most would start by sharing their need to always have their backs against a wall and their inability to fall asleep with someone else in the room.
They’d also talk about adverse reactions to going out into public. How they couldn’t breathe. How their heart raced. How they’d get lightheaded.
When I taught them about fight-flight-freeze responses and provided breathing techniques to manage these responses, I often noticed their shoulders drop just a little. These small pieces of psychoeducation helped normalize their reactions to an abnormal situation for their nervous system—being out of prison.
I developed a psychoeducation curriculum for my clients who suffered from PICS. It includes normalizing nightmares, implementing sleep hygiene, and talking to family members about what was happening to them now that they were home.
What are the signs and symptoms of Post-Incarceration Syndrome?
While the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not yet include Post-Incarceration Syndrome or its symptoms, a growing list of experts and advocates have identified the unique challenges that may arise out of the harsh conditions of prison life, the disruption of social connections, limited access to healthcare and mental health services, and the stigma associated with having a criminal record.
- Mental Health Challenges: Most Individuals leaving incarceration experience symptoms of anxiety, depression, and even Post-Traumatic Stress Disorder (PTSD) due to the trauma and stress of incarceration. The correctional system’s isolation, violence, and lack of access to mental health care can exacerbate preexisting conditions or lead to new mental health issues.
- Social and Familial Strain: Reconnecting with family and friends can be difficult due to strained relationships, lack of support networks, and feelings of shame or guilt. The stigma associated with incarceration can further isolate individuals from their communities.
- Unemployment and Financial Struggles: Finding employment can be a significant challenge due to the stigma associated with a criminal record. Limited job opportunities, lack of relevant skills, and difficulty obtaining professional licenses can contribute to financial instability and poverty.
- Housing Instability: Securing stable housing can be problematic, as many landlords are reluctant to rent to individuals with criminal records. Homelessness or unstable living situations can contribute to a cycle of recidivism.
- Substance Use Disorder: Individuals may turn to substance use as a coping mechanism for their post-release challenges. Lack of access to treatment for support for substance use disorders can further complicate the recovery process.
- Health Issues: Formerly incarcerated individuals often have limited access to medical care, leading to untreated health conditions that can worsen over time.
What are typical trauma responses of people with Post-Incarceration Syndrome?
For Post-Incarceration Syndrome, symptoms often show up due to trauma triggers, sensory cues, or situations that evoke intense emotional reactions in individuals who have experienced trauma.
For those with a history of incarceration, triggers can range from physical environments reminiscent of prison to interactions with authority figures that evoke feelings of powerlessness.
These triggers often lead to trauma responses or emotional and behavioral reactions developed as coping mechanisms in response to trauma. Trauma responses are adaptive coping mechanisms that individuals develop in response to traumatic experiences. The trauma of imprisonment can give rise to various responses that shape interactions with the world.
We know that incarcerated individuals often have a high Adverse Childhood Experiences (ACE) score, and the added trauma of incarceration reduces their already limited ability to bounce back from trauma.
Their trauma responses include hypervigilance, avoidance, emotional number, re-experiencing, self-blame, and shame.
- Hypervigilance: Individuals may remain alert and on guard, expecting potential threats even in non-threatening situations. This heightened vigilance is a survival strategy developed in the prison environment. Interactions with authority figures, such as law enforcement or probation officers, may elicit fear, distrust, or a sense of powerlessness reminiscent of the prison experience.
- Avoidance: Trauma survivors may avoid situations, places, or people that remind them of their traumatic experiences. For those with a history of incarceration, this could involve avoiding authority figures, unfamiliar situations, or even talking about their experiences. Social situations that resemble the lack of personal space and privacy within prison and situations that evoke isolation or exclusion can be triggering.
- Emotional Numbing: Trauma responses can lead to emotional numbing, where individuals disconnect from their feelings and emotions to protect themselves from overwhelming pain. A lack of emotional expression or difficulty forming meaningful connections leads to social isolation. Unfortunately, this numbing results in an inability to feel pleasure and pain, creating a lack of hope for the future.
- Re-experiencing: Vivid and distressing memories, nightmares, or flashbacks related to the trauma can resurface unexpectedly. In the context of PICS, individuals may re-experience memories of violence, isolation, or other traumatic events associated with their time in prison. Nightmares may also represent their fear of being incarcerated again. Lack of sleep reduces resiliency and increases the sensitivity to trauma triggers. Auditory and olfactory cues, such as sirens, loud noises, or specific scents, can trigger memories and emotional responses associated with incarceration. Seeing uniforms worn by law enforcement or reminiscent of prison garb may evoke memories of their loss of personal identity and autonomy.
- Self-Blame and Shame: Trauma responses can include guilt, self-blame, and shame. Formerly incarcerated individuals may internalize societal stigma, feel responsible for their past actions, and struggle with reintegration. Remember the avoidance response. Individuals will do anything to protect themselves from feeling shame. Yet, they must talk about their history whenever they meet with a service provider, prospective employer, or new acquaintance.
These trauma responses can evoke memories of the correctional setting, leading to anxiety, panic, or disorientation.
Why isn’t Post-Incarceration Syndrome officially recognized as a mental disorder in the DSM-5?
The absence of official recognition for PICS underscores the persistent biases against the formerly incarcerated. For many, the notion that imprisonment is a rightful consequence overshadows the potential for lasting trauma.
Unlike recognized mental health disorders, Post-Incarceration Syndrome hasn’t been widely studied or agreed upon within the mental health and medical communities. Diagnosis and classification of mental health conditions go through rigorous research and validation processes to ensure accuracy and consistency that PICS hasn’t.
However, PICS is gaining attention in research and clinical communities despite the associated biases against helping formerly incarcerated individuals adjust to their new lives.
Many involved with incarceration see imprisonment and all the negative experiences that go with it as part of the prison sentence— that those incarcerated deserve everything that happens to them while incarcerated.
The prevailing lack of compassion often sounds like, “Didn’t they bring this on themselves? Or “This is what happens when you break the law.”
To recognize PICS is also to acknowledge that what happens inside a prison may cause lasting trauma beyond the scope of a prison sentence. And it means all people deserve compassion regardless of their criminal histories.
As a result of this negative bias, PICS has gotten very little attention from researchers. However, attitudes are evolving, and the journey toward acknowledging PICS as a vital framework for understanding the complexities of reentry is gaining momentum.
How do you treat Post-Incarceration Syndrome?
Because PICS isn’t an official diagnosis in the DSM-5, there is no standardized treatment for it. However, many of the challenges individuals face after incarceration can be addressed using a combination of motivational interviewing and trauma-informed care.
The tools of Motivational Interviewing (MI) and trauma-informed care can be used by all who serve them—from probation officers to peer professionals to mental health providers.
MI and trauma-informed care skills help us develop the compassion and empathy needed to provide appropriate care while also helping maintain clear, professional boundaries. Most importantly, these skills help open difficult conversations that start the healing journey.
In pursuing a more compassionate and equitable society, we must recognize and validate the experiences of those incarcerated. The journey toward successful reintegration is fraught with challenges, and acknowledging PICS is a step toward providing the support and resources necessary to overcome them.
As researchers and clinicians unravel the complexities of Post-Incarceration Syndrome, a more comprehensive understanding of its impact will undoubtedly emerge, ushering in a new era of empathy, healing, and hope for those navigating the uncharted waters of post-incarceration life.
References:
- Liem, M., & Kunst, M. (2013). Is there a recognizable post-incarceration syndrome among released “lifers”? International Journal of Law and Psychiatry, 36(3-4), 333-337. https://doi.org/10.1016/j.ijlp.2013.04.012
- Huei-Jongh, G., Chihuri, S., Blow, M., Li, Guohua. Adverse childhood experiences and justice system contact: a systemic review. Pediatrics. 141. https://doi.org/10.1542/peds.2020-021030
