Empathy, correctional populations, and your clinical practice

Elizabeth Marlow, NP, PhDPastor William T. Grajeda

USF School of NursingJuly 15, 2009

Overview of Day

Prison Experiences and the reintegration of male parolees

Pastor William T. GrajedaNVC Empathy

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

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

Limited attention to and understanding of how prison experiences influence

reintegration

Methods - Hermeneutic Phenomenology

o Explains specific patterns of meaning and action in the lives of those studied, i.e. chronically ill men on parole

o Brings to light what was previously unseen in the phenomena within the context of participants’ experiences and points of view

o Data collection: unstructured interviews with narrative and reflexive questions

o Data analysis: narrative and thematic analysis; moving between the whole and the parts of interview texts

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)

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

Key Findings

Participants articulated 2 main themes about their prison experiences:

Necessary Adaptations Acquiescence and inaction Aggression

Dependence Reluctant Acceptance Complete Reliance

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?

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

more punishment.

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.)

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.

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

and reincarceration.

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

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.

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

addiction.

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?

Dependence: Complete Reliance

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

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.

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

community.

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.

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

system.

Overview

What empathy isWhy is it important to your practiceNVC Empathy - a way of using empathyEmpathic listening exercises - (Fun!)

What is empathy?

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.

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

What is empathy?

The parolees say, “do you feel me?”.

Empathy is a powerful healing tool.

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

Other reasons why empathy is useful

Allows for a full understanding of the patient’s problem or need

Equalizes the power dynamicOffers you protectionSustains you in your practice (self-

empathy)

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)

Three Skills of NVC

Self-empathy/Self-ConnectionEmpathy for the other personSelf-Expression

(From Newt Bailey www.newtbailey.com)

Four Components of NVC

ObservationsFeelingsNeedsRequests

(From Marshall Rosenberg, NVC - A Language of Life)

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

The Water Line

Observations: The patient said, “Why I have been waiting for an hour.”

Thoughts: The nurse thought, “Doesn’t he know how busy I am! This is a clinic, not a restaurant!”

Action: The nurse snapped, “I’m really busy right now. I’ll get to you as soon as I can.”

DANGER! Connection can be lost in these steps.

Feelings: The nurse was feeling stressed, angry, and guilty.

Needs: Because her needs for: understanding, ease/efficiency, kindness

Feelings and Needs in NVC Empathy

The Language of NVC EmpathyA 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

Developing your empathic skill - Listen first

Listen for the feelings and needs behind what the person is saying

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?

What does this have to do with resolving someone’s

clinical problem???

EVERYTHING! (Here’s why.)

Listening with empathy

Find a partnerTake turns speaking and listeningWhen the speaker is finished, the

listener repeats what she/he thinks the speaker was saying

Try some empathy guessesListeners: notice what your mind is

doing as you are listening.

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?

Questions? Concerns?

Questions?Concerns?Comments?Compliments?

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