Depression, Substance Abuse High Among Incarcerated Youths

MISSING THE DIAGNOSIS

I worked as a substance abuse counselor in a Maryland jail for three years
and later as a licensed psychologist in adult Maryland correctional
facilities for several years, working exclusively with youths sentenced as
adults.

Dawn Miller's report of the high rate of mental problems among incarcerated
youths is in line with my experience. Two additional observations: youth
substance abuse in prison is underreported, especially by those inmates who
continue regular or occasional use in prison or those who have buddies
doing so.

The best chance of knowing the true picture is through counseling
relationships.

During working therapy, substance abuse reporting increases, compared to
what inmates report on questionnaires or brief interviews. Why? Youthful
inmates generally do not trust health-care professionals or others with
information they fear will result in further scrutiny or charges, unless it
will benefit them - for instance, if they think it will transfer them to a
better treatment situation and contribute to earlier release. Therefore, I
think the substance abuse rate would be considerably higher than what the
federal government study reported.

Another point I would make is that dysthymic disorder, a long-term
low-intensity depression, is very common among youthful - and older -
offenders. Two reasons explain why this is underidentified: First, youthful
offenders frequently do not identify long-term depression when they have it
because they have become ego-syntonoic, which means they've been down so
long it seems normal to them.

Secondly, many professionals miss the diagnosis not only because the youths
report they are fine, but because depression in youths often lacks the
display or report of being sad, which most persons regard as the hallmark
of depression.

Youths may be irritable, touchy, resentful, spiteful or belligerent
instead. These manifestations of depression (blended with personality
traits and attitudes) often engender negative reactions in professionals
that throw them off the diagnostic track.

Especially when combined with substance use and/or prior trauma, many of
these youths experience alexithymia, the numbing of emotional experience,
so that they are disconnected from experiencing and expressing their own
feelings. They cannot report feelings. The clinician is therefore left to
make inferences about the uncooperative youth's angry depressed mood.

Also, in the past, professionals used to take an either-or perspective
regarding acting-out youth. The youths either had an externalizing disorder
(e.g. acting aggressively, as in conduct disorder) or an internalizing
disorder (e.g. depression). Research and experience confirms that youths
often have both. They can rob someone on the street and also be depressed -
even though to most of us, aggressive behavior and depression don't seem to
mix well.

Many of these youths often display a below-normal capacity for empathic
regard for others, even though they often express deep concern and loyalty
for their own mothers, a touching feature that does not erase their
aggressive actions elsewhere to someone else's mother or child. Both the
aggressive behavior and the depression must be treated.

Despite their many common experiences before prison, youth inmates are
individuals, especially regarding their degree of empathic capacity and
responsiveness to treatment. Early release is no favor to them or to us
when they have not demonstrated a capacity to change and have no new place,
education, job training, routine and well-monitored, semi-structured living
arrangement to which they can return.

One of our studies indicated that a high percentage of re-offenders came
from the same four zip codes of an urban area. Youths' pre-incarceration
environments are the training grounds that lead to prison. Returning them
there retrains them to recycle. Treatment starts in prison, but if it ends
there without the other features I mentioned, it is often - though not
always - like a Band-Aid for an internal hemorrhage.