Empathy, correctional populations, and your clinical practice

1. Empathy, correctional populations, and your clinical practice Elizabeth Marlow, NP, PhD Pastor William T. Grajeda USF School of Nursing July 15, 2009

2. Overview of Day • Prison Experiences and the reintegration of male parolees • Pastor William T. Grajeda • NVC Empathy

3. 60% to 70% of all individuals released from prison return within 3 years.

4. Definition of Reintegration • Reintegration encompasses: • Desistance from criminal activity • Abstinence from drugs and alcohol • Permanent home and regular employment • Positive engagement with family and community life • Some improvement in health problems and general well-being

5. Limited attention to and understanding of how prison experiences influence reintegration

6. Methods - Hermeneutic Phenomenology • Explains specific patterns of meaning and action in the lives of those studied, i.e. chronically ill men on parole • Brings to light what was previously unseen in the phenomena within the context of participants’ experiences and points of view • Data collection: unstructured interviews with narrative and reflexive questions • Data analysis: narrative and thematic analysis; moving between the whole and the parts of interview texts

7. Sample and Setting • 17 men aged 40 to 62 years, average age 48 • Chronic physical and mental health problems • 14 uninsured, 3 with Medi-Cal/SSI benefits • 8 African-American, 5 White, 2 Hispanic/Latino, 2 mixed-ethnicity: Native American/White and Filipino/White • Incarcerated average 15 years (range 2 to 38 years) • Average of 2 parole discharges (range 1 to 5 parole commitments)

8. Sample and Setting • Time in the community averaged 5 months (range 2 weeks to 24 months) • 32 90” to 2 hour interviews were completed • 2 participants were lost follow-up • Recruitment and interviews were completed at 32-bed residential SAT facility in northern California

9. Key Findings • Participants articulated 2 main themes about their prison experiences: • Necessary Adaptations • Acquiescence and inaction • Aggression • Dependence • Reluctant Acceptance • Complete Reliance

10. Necessary Adaptations: Acquiescence & Inaction - Mark • R: Then when I was in the hospital and the guy across the street (the hallway) from me, he was a older guy too, maybe 60 somewhere, you know, there. From his window, he’s trying to talk to me, he’s going like this: “Give me some water, water,water, water.” And I’m saying, “how can I give you some water?” [Laughs] I’m locked in. . . . And the guard comes, and they open the guy’s room. He was dead. . . . So that’s what happened . . . he tried to get from the bed to the toilet, and that’s when he had his heart attack. So . . . that was a hell of an experience . . . I: And why was it such an experience for you? R: Because they made a big issue out of it . . . they made me sign papers. . . . Like saying that . . . it was a accident—I told them, I don’t hear, I don’t see, I don’t know, man. “All right, sign here,”you know? And . . . they had the people (other inmates) to sign papers too . . . that they (the prison) were not the cause of his dying, you see what I’m saying? When actually maybe they coulda helped him. Had the door been open. See?

11. Complicity with the system provided protection from its brutality. Tacit consent led to inaction: moral action was pointless and would result in more punishment.

12. Class Question • How do you think this incident influenced Mark’s ability to function in free society? (This was only one of many in his life.)

13. Necessary Adaptations: Aggression - Matthew • R: . . . prison made me a very violent person . . . I learned that you don’t stop until somebody else has stopped . . . that’s what prison did to me when I first went in. It made me into a predator. . .. the first time I actually seen somebody get stuck, stabbed. Fucked with me for over a month . . . I’m standing on the yard and one of the guys come said “Excuse me, you know, I have to get something”and he pulls out a rusty piece of steel and virtually goes, puncturing it into this guy. He sticks it in about 27 times, and it’s like I’m new in the system, and everyone else has just adapted to it; it’s a common thing, and I’m over there freaking out . . . It took me to actually do another violation (another sentence) and to actually have to do it to someone else for me to get used to it. This is just common.You would prey on someone or they would prey on you.

14. An aggressive stance garners respect (fear from others) and creates safety in prison. At home, it can lead to alienation and reincarceration.

15. Dependence: Reluctant Acceptance • Did not want to acknowledge their acceptance of and reliance on the correctional system to take care of them • Participants were unable to succeed or remain in their home communities for long periods

16. Dependence: Reluctant Acceptance - Louis • R:. . . I start getting scared about leaving (prison) . . . ’Cause I don’t know where to go. So I know I’m gonna be homeless. Nowhere to sleep. Do you know what it feels like, not having nowhere to sleep? Or waking up somewheres and it’s cold or rainy, and you don’t know where you’re gonna go? You’re stuck outside. So I’m not really looking forward to going to the streets sometimes. So I get to—you know, I don’t care. So what I do is what I do best—is go get some drugs and don’t worry about when I go back.

17. Prison may be unwanted but community life is often marked by isolation, poverty, and addiction.

18. Class Question If you were Matthew’s or Louis’s clinician what else would you want to know about them to better understand their experiences and circumstances?

19. Dependence: Complete Reliance

20. Dependence: Complete Reliance • Dependent on prison system to meet basic needs and higher-level activities • Correctional system provided a structure not available in the free world

21. Dependence: Complete Reliance - Luke • R: I’ve made life-long friends there. You can learn a lotta things, and there’s programs you can take advantage of . . . prison can be helpful. . . . You’re gonna learn to go to work on time. . . . There’s things that you have to do there that you don’t have to do on the streets. And it makes you somewhat be more responsible and be a man . . . • I: Why does all of that fall away when you get out? • R: It’s easy. You don’t have to pay for your room and board. You don’t have to get a job. It’s gonna be provided for you. When you come out of prison, there’s not resources available to you. Your job’s not like right around the corner, a quarter block away at the kitchen. Or your laundry’s not gonna be brought back to your dorm, and you’re just sitting on the bed, so you fold it. And you gotta go out and get meals and have a place to cook them. It’s not at the chow hall, where somebody can make it and wipe your table. So there’s lots that’s provided for you that, when you come out the gate, it’s not provided for you no more. And it’s a lotta stress to find those things.

22. Prison provides a structure and support system often not available in the free community.

23. Conclusion • Necessary adaptations were useful for prison life but ineffective for life in free world. • Acquiescence and inaction, hampered participants’ self-motivation, self-organization and self-efficacy required for free world life. • Unconcerned about what happened to them upon release from prison and often used drugs to manage the alienation and stress of free world life. • Participants with an aggressive stance struggled to control their anger, they reacted disproportionately to the situation at hand, and were often isolated from family and friends or quickly rearrested. • Increasingly reliant on the correctional system to meet their basic needs. • Reluctant but grateful. Prison was unwanted, but it provided security, comfort, and companionship not accessible to them in their home communities.

24. Interest in and understanding of parolees’ complex circumstances can encourage their engagement with the health care system.

25. Overview • What empathy is • Why is it important to your practice • NVC Empathy - a way of using empathy • Empathic listening exercises - (Fun!)

26. What is empathy?

27. What is empathy • Identification with and understanding of another’s situation, feelings and motives • The action of understanding, being aware of, being sensitive to and vicariously experiencing the feelings, thoughts, and experience of another without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner.

28. What is empathy? • There is then a direct grasp of what is right there before you that can never be heard with the ear or understood with the mind. - Chuang-Tzu

29. What is empathy? • The parolees say, “do you feel me?”.

30. Empathy is a powerful healing tool.

31. Why is empathy important? When…someone really hears you without passing judgment on you, without trying to take responsibility for you, without trying to mold you, it feels damn good…When I have been listened to and when I have been heard, I am able to perceive my world in a new way and go on. - Carl Rogers in Rosenberg (2005), p. 113

32. Other reasons why empathy is useful • Allows for a full understanding of the patient’s problem or need • Equalizes the power dynamic • Offers you protection • Sustains you in your practice (self-empathy)

33. NVC Empathy - A way to use empathy in your practice • Principles of NVC Empathy: • All humans share the same universal needs • Feelings are a result of our needs being met or not met • We are interdependent - Everyone’s needs matter (including the nurse’s)

34. Three Skills of NVC • Self-empathy/Self-Connection • Empathy for the other person • Self-Expression (From Newt Bailey www.newtbailey.com)

35. Four Components of NVC • Observations • Feelings • Needs • Requests (From Marshall Rosenberg, NVC - A Language of Life)

36. The NVC Process: The Thinking Circle(www.newtbailey.com)

37. Feelings and Needs in NVC Empathy • The Language of NVC Empathy • A vocabulary to identify what might be going with someone else (empathy) or what is happening within ourselves (self-empathy) • Feelings and Needs language allows for self-expression that is curious and inquisitive

38. Developing your empathic skill - Listen first Listen for the feelings and needs behind what the person is saying

39. Developing your empathic skill - Empathy Guessing • Take a guess: • For feelings: Wow! Were you scared? Angry? Happy? Sad? • For needs: Wow! It sounds like you needed some respect? Consideration? Space? Understanding? Ease?

40. What does this have to do with resolving someone’s clinical problem???

41. EVERYTHING! (Here’s why.)

42. Listening with empathy • Find a partner • Take turns speaking and listening • When the speaker is finished, the listener repeats what she/he thinks the speaker was saying • Try some empathy guesses • Listeners: notice what your mind is doing as you are listening.

43. Role Playing with Pastor • Pastor is an patient angry at having been kept waiting for so long. What are his needs? What is he feelings? What are your needs? What are your feelings?

44. Questions? Concerns? • Questions? • Concerns? • Comments? • Compliments?

45. Some info • Elizabeth Marlow, NP, PhD • Pastor William T. Grajeda • email: emarlownp@yahoo.com, billygrajeda@yahoo.com • Ph#: 415 552 0932 • http://friendsofthehomeless.wordpress.com • For info on NVC go to: • www.cnvc.org • www.baynvc.org • www.newtbailey.com • www.communecology.com