Grief Interrupted: The Experience of Loss Among Incarcerated Women

Abstract

Incarcerated women face a number of stressors apart from the actual incarceration. Nearly half of all women in prison experience the death of a loved one during their incarceration. Our purpose for this study was to explore the experience of grief and loss among incarcerated women using a phenomenological method. Our study approach followed van Manen's method of phenomenology and Munhall's description of existential lifeworlds. Our analysis revealed four existential lifeworlds: temporality: frozen in time; spatiality: no place, no space to grieve; corporeality: buried emotions; and relationality: never alone, yet feeling so lonely. The findings generated from this study can help mental health providers as well as correctional professionals develop policies and programs that facilitate the grief process of incarcerated women within the confines of imprisonment.

The number of women in prison has increased by almost 800% in the last three decades (Greene, Pranis, & Frost, 2006). In 2008, there were almost 115,000 women who were imprisoned in state and federal institutions in the United States, representing an average annual increase of 3% between 2000 and 2007 (West, Sabol, & Cooper, 2010). Incarcerated women, most of whom have significant mental health and medical problems that predate their imprisonment, face a number of stressors apart from the actual incarceration (Keaveny & Zauszniewski, 1999). The death of a loved one is one stressor that nearly half of all women in prison experience during their incarceration. For incarcerated women, poor health coupled with limited social supports and restrictions posed by incarceration can have a significant impact on the grieving process. Because of the paucity of knowledge on an inmate's experience of loss in prison, the purpose of our phenomenological study was to explore the experience of loss of a loved one. Although grieving is a normal universal experience, grieving in prison is met with additional challenges, placing these women at high risk for unresolved or complicated grief. Understanding their experience has important implications for the women themselves, mental health and medical services, correctional staff, and the larger community of taxpayers who support the state correctional health system.

Evolution of the Study

Our study aim was to describe the experience of losing a loved one through death while incarcerated. Our research assumption was that much of the available data on grief and adaptation to loss did not fully address the effect of incarceration on the experience of loss. The first author's experience working with women in a maximum-security women's prison prompted the current study. The work involved implementing an exercise intervention program. As the women became comfortable with the researchers, they shared more personal aspects of their lives. This began with one of the participants discussing her mother's failing health and impending death. She expressed guilt, powerlessness, and lack of control. Her sharing led to other women sharing the pain of having a family member die during their incarceration. Another inmate whose mother had died had a picture of her mother taped to her uniform. The wrinkled photograph showed her mother smiling and surrounded by several generations of children. Next to the picture was taped a Mass card.¹ The woman tearfully related that her mother had died and she was unable to attend any of the funeral or memorial services because they were out of state. She was unsure of the cause of death because family members had only told her “bits and pieces” over the phone. Although family members sent her pictures of her mother taken in the casket, she said, “It doesn't look like her.” Placing the picture of her mother and the Mass card on her uniform was her way of remembering her mother and showing her respect for her life. This action also signaled to others, including other inmates, correctional staff, and health care professionals, that she was grieving. Together, these women expressed that grief work in prison is often done without the support of family and without being witness to the traditional rituals surrounding death. To meet the mental health needs of this vulnerable population, it is important to understand the experience of losing a loved one while incarcerated.

Justification and Significance

Although almost half of all women in prison report experiencing the death of a close friend or family member while incarcerated, scant data exist that elucidate the experience of grief and loss among women inmates. We chose to explore the phenomenon of loss using a phenomenological approach. We interviewed women incarcerated in a minimum-security prison located in the northeastern part of the United States. It is hoped that knowledge gained from this investigation will help correctional nursing staff, mental health professionals, and medical staff better anticipate the health needs of women during the difficult time of grieving. Findings from this investigation might also help departments of correction respond appropriately to inmates during their times of loss while still maintaining pertinent security protocols. Because loss of a loved one is a universal experience, findings from this work might help generate knowledge about the experience of loss among other populations of women who are left to grieve alone in similarly constrained situations, including women in the military, women in shelters, and women separated by migration.

Review of the Literature

Grief is a term commonly used to describe the emotional response to the loss of a loved one through death (Stroebe, Hansson, Schut, & Stroebe, 2008). Grieving involves a process of diverse psychological and physical elements, which occur differently among individuals (Stroebe et al., 2008). Mental health symptoms of grief include depression and anxiety, anger, suicidal ideation, and posttraumatic stress disorder (PTSD; Stroebe, Schut, & Stroebe, 2007). Although grief is an unavoidable and universal experience, for some the experience is much more intense, leading to what has been described as unresolved grief, protracted grief, traumatic grief, or complicated grief, and as having symptoms similar to PTSD (Complicated grief, 2006).

There is an abundance of research and theory in the distinct yet related areas of grief, death, mourning, and suffering. A common consensus that dominates the literature is that for individuals to achieve a resolution and experience a degree of acceptance, a state of peace with the loss must be reached (Cutcliffe, 1998). The work of Kubler-Ross and Kessler (2005) on the experience of death and dying lists five stages that characterize a normal grieving process: denial, anger, bargaining, depression, and acceptance. Bowlby (1980) described three phases of mourning as beginning with preoccupation with the lost person, followed by a second phase that focuses on the pain of the experience, and then a final phase of reorganization characterized by a return to normal functioning. In the reorganization phase, memories and experiences of the pain of loss might still occur with associations connected to the memory.

Gorle (2008) noted the importance of ceremonies, rites, signs, symbols, and rituals in assisting individuals to cope with crisis and change in the grieving process. Gorle illustrated his point, writing, “The act of sprinkling or shoveling earth onto the casket in the grave is a poignant ‘ceremony’ within the funeral ‘ritual’ that speaks to the finality of death. It is the action in and of itself that is the ‘ceremony’” (no page). Gorle also explained that rituals like funerals, wakes, and other services allow for the freedom of expression of feelings surrounding loss because of the death of a loved one, and that these rituals have the potential to assist in navigating the tasks and stages in the grieving process.

Not all individuals experience uncomplicated grief. Parkes and Weiss (1983) identified three patterns of abnormal grieving: unanticipated grief, complicated grief, and chronic grief. Raphael (1983) similarly highlighted three patterns of pathological grief: distorted grief; chronic grief; and absent, delayed, or inhibited grief. Parkes (1998) discussed the potential effect of unresolved grief in individuals who are prevented the experience of grief either by internal or external factors, like the incarcerated. These individuals are more likely to experience sleep disorders, depression, and hypochondriacal symptoms. Unresolved grief could result in a number of complicated grieving processes. Among them is disenfranchised grief. It is characterized by the inability to grieve because of external restrictions (Gilbert, 2007), and ultimately results in grief that is not allowed to be publicly expressed (Young, 2003). The resulting transitions lead the individual to perceive the loss as ambiguous or lacking a sense of clarity (Gilbert), which doubly complicates the grieving process.

The concept of suffering, as outlined by Morse (2001), encompasses two behavioral states: enduring and emotional suffering. The concept of suffering informs our work on grief in several ways. Enduring behaviors, which include suppressing emotions and focusing on the present, allow sufferers to survive, to live, and in some cases, to die. The second type of enduring, enduring to live, is voiced by those suffering as the need to “just get through the day.” This need to “pull it together” can be seen in many stages of the grief process as an individual “recognizes that he or she must function in order to survive or get through the situation” (Morse, p. 52). This functioning might include writing obituaries, making funeral arrangements, and comforting others. Although the trajectory of suffering is not linear in nature, behaviors associated with emotional suffering include releasing emotions and publically displaying suffering (crying, sobbing, moaning, and so forth). Morse postulated that emotional suffering is necessary for healing because it allows individuals to work through their suffering until they have “suffered enough” (p. 51). Subsequently, individuals slowly reformulate their future, set realistic goals, and move forward. For some individuals, however, the nature and context of their life and situation might require prolonged periods of endurance. As a result, they must internalize their emotions. Though their emotions are guarded and their suffering hidden from others, their suppressed energy might be released as angry outbursts, often directed at something unrelated to the actual cause of suffering.

Loss and Grief Among Incarcerated Women

Incarcerated women are disproportionately women of color, primarily from low-income families with fragmented family histories, and are survivors of sexual and/or physical abuse as children or adults (Browne, Miller, & Maguin, 1999; Greenfeld & Snell, 1999; Harlow, 1999). Almost half have high school degrees or passed the general educational development (GED) test, and most have limited vocational training or work experience. Many have significant substance abuse problems and mental health issues (Covington, 2007). The Bureau of Justice Statistics reported in 2006 that 73% of the women in state prisons and 75% of the women in local jails have symptoms of mental health disorders, compared to 12% reported among women in the general population (James & Glaze, 2006). Among the inmates who had mental health issues, three quarters also met the criteria for substance abuse and dependence (James & Glaze). All of these factors might further complicate the experience of grief and loss.

Ferszt (2002) succeeded in describing the lived experiences of inmates with regard to a loss. The investigator used qualitative methods based on in-depth interviews with three participants, and suggested that women who lost a loved one through death during their incarceration suffered unresolved grief and a lack of integration and resolution. Furthermore, she described the circumstances surrounding the experience of a loss by women in prison as marked by absence of support, relatives, and counseling; lack of time spent with the deceased as a consequence of incarceration; and prohibitions to attending the funeral. Gaps were also seen in the process of informing the inmate and creating provisions for a supportive environment for grieving. Uninhibited expression of grief was hindered by the fear of disciplinary action from supervisors.

Phenomenological Perspective

The process of uncomplicated grief has been well documented, with stages and tasks to facilitate the accommodation of the loss. Although opinion on the exact timeline for grieving varies among experts, it is a process that transitions from acute grief toward an integration of the loss and a return to the everyday world. From a phenomenological perspective, human behavior is understood as it occurs in the context of relationships to things, people, events, and situations, in what Merleau-Ponty (1989) referred to as embodiment (Boyd, 1993). Based on this concept, people are tied to their worlds, and perception is more than what is thought; it includes the mind and body. Thoughts, feelings, and emotions are deeply embedded in the individual's life, or lifeworld (Munhall, 2007). Thus, understanding the experience of loss for incarcerated women needs to take into count their lifeworlds, which include spatial, corporeal, temporal, and relational (Munhall). Spatial involves exploring the space or environment and its meaning related to the lived experience. Specifically, we understand the experience by taking into consideration the situated context. Corporeal or embodiment refers to experiencing the phenomenon as lived through one's body, which is described by Munhall as body intelligence. Temporal relates to the element of time and the perception of time as it relates to the phenomenon. Relational is the connection to self and others in the world. Finally, each of these lifeworlds is connected and overlaps.

Methods

We obtained approval from both the university institutional review board (IRB) and the Department of Corrections Research Division in October, 2005, and placed a flyer asking for participants in the dayroom of the prison. The flyer was written at the Flesch-Kincaid Grade level 4.5 (passive sentences = 0%; Flesch reading ease = 85.7; Flesch, 1948). Women who were interested in the study gave their name to the registered nurse located in the health services unit of the prison. The first author contacted the women who were interested in participating, described the study, and obtained informed consent. Because of the high rate of illiteracy in prison populations, the informed consent document was read aloud to all potential participants. Women who spoke and understood English but did not read and write were enrolled in a study by “making their mark” on the consent document (Food and Drug Administration, 2001).

Many of the participants were aware that in addition to the first author's role at the university, she also practiced as a nurse practitioner in the facility. The first author was aware of the power differential between herself and the inmates, and attempted to “create a welcoming, nonthreatening environment” (Karnieli-Miller, Strier, & Pessach, 2009, p. 280), as well as diffuse any perceived coercion using several strategies. First, the flyers describing the study were not posted near the health services unit. Second, as noted, women interested in participating did not give their name to the first author, but rather to the registered nurse in the health services unit. During the course of the informed consent, as well as during the actual interview, participants were provided an opportunity to ask questions. Furthermore, they were informed that participation in the investigation would have no impact on their sentence length, sentence structure, parole, or their access to health services. No incentives to participate, including money or time out of work or other prison groups/programs, were given. Participants were advised that they were free to end the interview at any point in time without fear of reprisal. They were made aware that the first author was a mandated reporter and would report to the designated medical/mental health professional any indication of suicidal or homicidal ideation. Last, participants were informed that the function of the interview was investigatory in nature, and that to receive mental health care or counseling they should seek immediate care through the registered nurse located in the health services unit.

We invited women to participate in an audiotaped interview if they had served at least 3 months of their current sentence in prison, and had experienced the death of a loved one (as defined by the participant) during their current confinement. Loved ones included but were not limited to friends, family members, partners, and children. Women who had lost more than one loved one while incarcerated were able to discuss whichever loss was/losses were the most significant to them. Although the length of time since the death was noted, no participants were excluded based on how recently the loss was experienced. Because the investigation was qualitative in nature, thus requiring ongoing dialogue between the participant and the first author (who speaks English), only women who spoke English were included in the investigation. Women who had suffered a miscarriage as their only loss during incarceration were ineligible. Women who had suffered the death of a pet were not included.

The women who participated in the study were asked to describe the experience of losing a loved one while incarcerated. Specifically, the interview was opened with the following prompt: “Please tell me, in your own words, about the experience of losing your (mother, grandmother, and so forth) while you were incarcerated.” The word “loss” was chosen because it reflected the common vernacular used by women at the study site (i.e., “I lost my mom”). Every attempt was made to allow the participant to continue speaking without interruption. However, probing questions were used if clarification was needed, or if the participant needed prompting. These in-depth interviews lasted between 1 and 2 hours. Interviews were audiotaped and transcribed verbatim. The third author took notes during the interviews, recoding each participant's body language and emotions (such as crying). Written field notes were recorded after each interview was conducted, identifying relevant concepts and ideas that were beginning to emerge.

Data Analysis

The second author's expertise in phenomenology was instrumental in guiding the analysis of the data. As stated by van Manen (1990), phenomenology aims at a deeper understanding of the nature or meaning of our everyday experiences. “Meaning is found in the transaction between the individual and a situation” (Munhall, 2007, p. 162). We approached this study using van Manen's method of phenomenology, with four concurrent processes involving eleven steps. The first process, turning to the nature of the lived experience, involved orienting to the phenomenon, formulating the phenomenological question, and explicating assumptions and preunderstandings. Using purposive sampling, 15 incarcerated women who had experienced the loss of a loved one agreed to be interviewed. The second process, the existential investigation, involved exploring the phenomenon. We paid specific attention to Munhall's description of the four existential lifeworlds in the data analysis: temporality, spatiality, corporeality, and relationality. Work by Hentz (2002) was also used in the development of themes and the organization of the existential lifeworlds. The third process, phenomenological reflection, relates to the thematic analysis, a process of reflecting on the lived experience of these women. Our aim was to uncover the essence of the experience for each participant, as well as the common themes. We explored how words were used, common patterns of experiences, and the essential themes related to the experience. The fourth process was phenomenological writing that involved creating the phenomenological descriptions to sensitize the reader to the “deeper significance or structure of the lived experience being described” (Munhall, p. 162; van Manen).

Findings

A total of 15 women responded to the flyer. The age range of the 15 participants was 23 to 67 years (M = 39, SD = 11.5). Among the respondents, 3 were African American, 4 were Hispanic, and 8 were White. The length of their current sentence that had already been served ranged from 4 months to 11 years (M = 4.1, SD = 3.7). The themes we uncovered have been organized around the four existential lifeworlds: temporality, spatiality, corporeality, and relationality.

Temporality: Frozen in Time

The grieving process for these women appeared to be suspended in time. For some it had been years since the loss, but they felt that they could not really grieve the loss until they were out of prison. Women spoke of not having closure because they did not participate in the funerals or see the gravesite. Although they all acknowledged that the death was real, there was an element of disbelief, a sense that it was not real until they could actually see it for themselves. As one women expressed,

So I think I was still in shock. It was only a year and I don't think I have dealt with it yet. Like I have to go home and see, go to the cemetery and see for myself. I think that's what I need. I am not in denial that she is dead because I know she is dead. It's just seeing it that I think will be the moment that I will probably break down.

Women expressed that the time to grieve would be when they returned home. Grieving would be a process that they would be going through alone, because all of their family members had already finished their grieving. Indeed, the timeline for grieving was suspended while incarcerated. One woman expressed how she would be completely alone in her grieving:

I could not grieve them the way you'd normally do if you were on the outside. Like pay your respects, go to the family's house and stuff like that, and it's hard because like when I go home, it's been months since this happened. I don't feel like going to the family's house now and me rehashing the pain for them, because they've already gone through the process.

Only a few women were permitted to leave the prison to attend their loved one's viewing. One woman whose son died was given 15 minutes at the funeral home to see her son's body. For her it was not enough time to bring closure and begin grieving:

I saw him there to say goodbye. I think that maybe if they had given me a few extra minutes…. I just need to have some kind of closure so that we can move on. People need more than 15 minutes. The 15 minutes is cruel. Fifteen minutes is, just isn't long enough, unless you are like some kind of dangerous psycho escapee, you know, someone who is a real threat. But you know they wouldn't even let you go if you were like that. People need more time than 15 minutes. So I think I'm not going to start grieving until I leave here. When I can go to the cemetery. It's going to be strange to go home after all this time.

Spatiality: No Place, No Space to Grieve

For these women, prison was not the place to grieve, and there was no personal space for grieving. There is no privacy in prison. Participants voiced that there were always people around but not ones who really cared. Women spoke of the lack of privacy, and that many of them were told in front of other inmates that their loved one had died. Women yearned for a place where they could be alone to grieve without others witnessing their distress, and for most, facing the reality of the loss and being able to grieve was associated with being out of prison and at home. The lack of privacy and having no space was recounted by one of the women:

Right in front of everybody. They made me call in front of everybody. It was horrible. The experience just sucked. I used the admissions phone and there was new people coming in and there were officers everywhere. And the officers, they didn't even really give a shit. They were just looking at me like just another day.

Some women expressed that they were not in their real life, that they were “out of sight” and “out of mind,” and that their grieving would begin when they got back home. Prison was no place to grieve:

It just doesn't seem real because I am not in my real life right now. I'm not in the environment I'm [normally] in. I'm not in the state of mind that I'm normally in at home. I'm not in a routine that I'm [normally] in. I am stuck away locked up. Nothing here is normal.

Even when women were given a physical space to meet with loved ones, the space was not considered the place to express loss or sadness. One woman recounted her experience of visiting with her father in the prison visiting room shortly after her mother had been buried. She said,

My father came to visit me the next week, he just buried my mother. I said, “My dad's coming. My mother just passed last week and he just buried her. Could we maybe sit in the corner over there by ourselves?” Because I knew we were going to cry. They said, “No.” So we had to sit in this visiting room with all these people hugging and crying and trying to do it quietly.

During the interview, one woman discussed how comforting and peaceful it was in the private interview space, stating,

I wish I had someplace to go where I could just be. Just not be stressed by outside factors, a roommate who doesn't want to have you in the room. I just wish I had somewhere where I could just go and get some peace. I wish that I could just stay in this room. Just sleep on the floor under that chair. That's how I feel. I am just so desperately tired and so desperately in need of something. In need of peace. I can't get a bit of peace.

Corporeality: Buried Emotions

One comes to more fully understand an experience through the body's experience of the phenomenon. Munhall (2007) described it as the starting point of meaning. These women experienced an acute response to loss, followed by an urgent need to block their emotional responses. Many of the women shared that it was too risky to show their feelings, because being emotional and crying in front of other inmates made them look weak and vulnerable. Excess displays of emotion could be interpreted by correctional officers as being a potential suicide risk. Women did not want to be locked up in a room for suicide precautions, so they concealed the expression of emotions and in doing so also blocked their grieving.

Denying the body its expression contributed to the suspension of the grieving process for these women. They were not in denial of the loss, but they indeed denied themselves the experience of expressing their grief. The emotional expression was controlled, but the emotional pain and anguish were buried deep inside. For these women the pain of the loss lived in their bodies. Merleau-Ponty (1989) wrote, “[the] haunting of the present by a particular past experience is possible because we all carry our past with us insofar as its structures have become ‘sedimented’ in our habitual body” (p. 33). Thus, these women carried their unresolved grief. The following story was a common one among these women. It illustrates the initial response to loss and then the control of emotions:

So when my mother told me, I just broke down in pieces…. It was a lot of emotions. I think that it just was very devastating…. I could not stop crying. I mean I was constantly crying…. I couldn't drink water. I couldn't eat. I am always trying to be in control of my feelings and not let them overwhelm me because of the long time I have to do here, and I was always scared to get put in one of those rooms, you know, because they think you're going to do something to yourself, and I always try to be okay. Everything is okay. I talk to myself and try to handle my feelings. People never see me crying that often. I wanted to die because I couldn't handle the pain. I felt that the pain was so bad…. People cannot express their true feelings. I wanted to cry and cry and cry, but I couldn't cry the way I wanted to because I was scared I was going to be put in a room with no clothes on and have somebody look at me 24/7 [24 hours a day, 7 days a week].

Women spoke about the lack of concern when someone experienced a death of a loved one. They discussed how they needed to control their expression of grief for fear that they would be seen as weak by the other inmates. They described the need to “put up a wall” to be able to deal with things. They became immune to feeling. Showing too much emotion, they believed, placed them at risk for being locked up for suicide precautions. As one women stated,

If you cry too much or if they see that you're having a hard time maybe adapting, they'll put you back behind the wall, and I don't want that to happen. So I continue to try to pick myself up every morning. I try to preoccupy my mind…. I really do not want to be around people. My biggest thing is that I just have to stay out of my room because if they see me isolating and crying too much they will ship me back over there.

In addition to sadness, women spoke of anger—“feeling so damn mad”—as an emotion that needed to be buried inside and controlled, even hidden from mental health providers. The desire to physically act out their anger was tempered by the fear of getting “locked up.” One woman who did seek mental health care shortly after learning that her father had died, said,

All they cared about was whether I was going to hurt myself or anybody else, and once I said “No,” they went, “Well there's really nothing we can do,” and I got pissed and I said, “Well then, what the hell did you call me down here for?” “Well, we have to check.” I was so damn mad I wanted to kick her. You didn't call down to see if maybe you needed to talk? Take something to rest? Anything? Would you like a journal to write down how you feel? There was nothing there.

Relationality: Never Alone, Yet Feeling So Lonely

The relational lifeworld is the world in which we find ourselves in relation to others (Munhall, 2007). It is also how one relates to one's self, how we define ourselves and how we are defined by those around us. The concept of self takes on new meaning after entering prison. As one woman recounted, “You are an inmate. They don't see you as human.” Expressions of kindness, empathy, and compassion were rare; they were but a memory for many women. These women also expressed how they needed to be different while in prison, that they could not be their true selves. They needed to keep their emotions to themselves, knowing that they could not trust anyone. With families distant, and for many inaccessible, women lacked the comfort and support they so desperately needed to help them through the grieving process. Painfully absent was the comfort of human touch. Women spoke about how they felt they needed to be held and comforted when they learned of their loss. The following comments speak to the experience of being alone and losing a part of oneself:

You don't have nobody to reach out to. You're completely alone. It's bad for anybody to have to go through this even on the outside, but at least you got family, you got loved ones out there that you can be around. In here, you don't have nobody. You don't have nobody to hold you, to talk to, or anything like that.

I know these women are different when they're out of here, but while in here, they're not our friends, and I can't trust anybody with my feelings. That's a big thing and any woman will tell you that. You become somebody else when you come in here, just to protect yourself because we're so sensitive that it's easy to be hurt…. So we build these walls in all different aspects and trust is a big one here. I want to interact, I want closeness. It just doesn't happen here. I protect myself here and there, but I'm not going to harden up because that's just not who I am.

Prison is a setting in which one can never be alone; it is a setting that is inherently structured to limit the development of relationships that foster human connection. Opportunities to show kindness and compassion are few and often ignored. One woman noted how she was informed that her aunt, who had served as her guardian for most of her life, had passed away. She said,

The sergeant just called me. I was out on the sidewalk. She didn't tell me in a building or anything. “Oh by the way, your aunt passed away.” It was so cold. They're so cold. So that was so cold and she was mean. I could have fallen on the ground when she told me. That was cold.

For many of the women, emotional distance was amplified by physical distance from family and friends. Without some physical connection at the time of loss, women were left with writing letters to express “the worst situation you'd want to be in.” As one woman noted,

There was absolutely nothing I could do. Write and call. But you need hugs and to see a person's face. A lot of families are closer by. But my oldest daughter lives like five hours from here…. And a letter is nice but it just doesn't do it.

Although the other women in the prison meant well, relationships with these women were not able to replace the sense of human connection and connection to the lost loved one that so many women needed. Prison relationships were just not the same. Lack of trust resulted in relationships of both limited depth and limited potential:

Your family can't hug you. You have complete strangers that don't even have a clue about who died hugging you and I mean, you want a hug, but it's just not the same. I'm not close to anybody. I have wicked trust issues…. I'm close to one certain girl here. I talk to her about all my stuff, but I don't give her my all because I don't know. That unknown is the scariest part of any part of your life. Only when I feel like I can trust you with every bit of my life will I talk to you. All these women they're going to leave and you'll never see them again. It's not like I'm gonna call up another inmate and say, “Let's hang out,” because if they're in jail, they obviously have issues and I have issues. Two “sick-ees” don't make a “well-ee,” you know what I mean?

Relationships with mental health providers were viewed by many as “useless,” and as one woman noted, “I don't really feel like she's listening to me or has an opinion.” Indeed, women voiced that getting appointments with mental health providers was difficult, and were angered that the main concern of the providers related to suicide risk:

Who the hell would I talk to about that here? They'll ask you, “Do you want to speak to somebody?” But I mean, why do you want to speak to someone that half the time it's like a hassle to get them to talk to you? And then it's like, “Okay, are you going to hurt yourself? Okay, do you want meds [medication]?” I don't know. That's not what I need.

Discussion

The accounts the women provided resonated with what Morse (2001) described as “enduring to live,” because prison was not a safe place for them to suffer, release their emotions, or lose control. Demonstrating what Morse described as “tast[ing] emotional suffering” (p. 52), many participants found, at least for a brief moment, a safe space to move from enduring to actually expressing emotional suffering. In fact, almost every woman who participated in the study expressed some form of emotional release (crying, sobbing, and so forth), often at the start of the interview. Participants found comfort in sharing their experiences in the study. For most of the women it was the first time since their loss that they had really talked about it. They also shared how that felt, and that it was the first time they had encountered someone who really cared, listened, and understood their experience and needs. As one woman described, “I am glad that you are doing this. It's a tough crowd around here. It felt good to talk about it, too.” During this investigation, the women had control over when and if they displayed their emotions. They signed up voluntarily, knew when and where the interview would take place, and some even brought Mass cards and pictures to touch and share during the interview. As one woman noted, “I knew I was going to get upset, but I have been looking forward to talking about this with you.”

The mental health needs of these women, by their own accounts, were not addressed, placing them at increased risk for complicated grief and an increase in psychiatric symptoms. These data support accounts from other incarcerated women, and support the need for a change in institutional protocols when an inmate loses a loved one. In response to the distrust of and limited access to mental health services in prison, incarcerated women deal with the loss by suppressing and hiding their grief. Indeed, it is unclear if the majority of women returned to enduring the suffering after completing the interview. According to Morse (2001), flipping between enduring and emotional suffering is largely based on “energy level, context, and available support” (p. 52).

Women in this study expressed a desire to help other women who had experienced a loss during incarceration, and there was overwhelming interest in a support group for women who had lost a loved one while incarcerated. The typical distrust toward other inmates was not extended to other women experiencing a loss; the desire for a support group was expressed by almost all of the women in the study. The women clearly expressed that they needed compassion and support during their time of loss. They also needed privacy within the constraints of the prison environment. Mental health services are needed that provide support beyond medication management or emergency evaluation for suicide/homicide risk. Most women inmates are convicted of nonviolent, drug-related crimes, and are not “hardened criminals.” They just want to be treated “like a human being.” Indeed, if facilitating the grieving process—even for individuals who have committed the most heinous of crimes—can result in improved public safety and a better institutional milieu, might this be an important component of social justice, both for the perpetrators and their victims (Waldram, 2007)?

Understanding the effect of the experience of grief on this large, vulnerable population has important implications for the women themselves, mental health and medical services, correctional staff, and the larger community. Women are released back into their communities with little transitional support or access to services that address their substance abuse and mental health issues (Bloom & Covington, 2008). Unresolved grief can complicate this transitional process. To decrease the impact on incarcerated women, their families, and communities, it would be beneficial to facilitate the grieving process prior to release.

Facilitating proper grieving and allowing for healing is a goal in itself, but it can also help to create a path to seek help with other mental health issues, substance abuse, and past physical and sexual abuse. Treatment for any or all of these issues can help these women, their families, their communities, and the larger community of taxpayers by reducing substance abuse and the resulting crimes. As one woman said, “Hopefully … for the time that I'm here I can express myself like this to you and get it out, so that it's not something that I want to cover up with drugs and alcohol again when I get out of here.” Our study findings support previous accounts of women's experiences of grief during incarceration (Ferszt, 2002). They also offer new insight into the specific attitudes of incarcerated women toward mental health services when dealing with a crisis. The results can be used by mental health providers and prison staff to facilitate the grieving process for women inmates. By resolving some of their grief, women might be less likely to utilize unhealthy coping mechanisms such as drugs or alcohol upon their return to the community.

Limitations

Given the state of the science, our investigation was necessarily qualitative in nature. As such, our sample size was limited, and this in turn limits the ability to show causal relationships. As noted previously, because the first author was also employed as a nurse practitioner at the facility, participants might have felt obligated in some way to volunteer for the study. It is also possible that participants might have believed that their answers could negatively impact them and might, therefore, have provided socially desirable responses. However, we employed several strategies in an effort to minimize perceived coercion as a result of the obvious power differential. Another limitation of the study is that the demographics of the participants are not representative of the national profile of women inmates. Selection bias was also possible because of the voluntary nature of recruitment.

Recommendations

Research

Future research is needed in other prisons of various security levels and in various geographic locations to explore the experience of loss among persons in prison. Additionally, although we chose the word loss to convey the experience of the death of a loved one, rephrasing the question to include simply the “death of someone you know/knew” might generate different findings. For example, the death of a past abuser/perpetrator might result in different reactions, including relief, anger over not being able to confront the abuser before their death, grief over the loss of closure, and guilt over being thankful that the abuser is dead (Violence Against Women Net, 2010). For some women, the death of their abuser might result in memories, both old and new, and flashbacks of their victimization. Our study has raised additional researchable questions: What is the grieving experience of these women after they leave prison? What is the long-term impact of suspended grief on mental health? On physical health? And what is the impact of supportive interventions on grieving? Although this work focused on women who were incarcerated, the experience of loss is universal. Other environments and situations, though not intended to be punitive or prison-like in nature, might also impose limits on the expression of grief. For example, women serving in the military, women in shelters, or women who migrate away from their home countries might feel similar constraints on their ability to express their grief; future research should address grief in the context of these extraordinary situations.

Practice

In light of practice, we hope that the knowledge gained from this study will help nurses, mental health providers, and medical staff anticipate inmates' needs when losing a loved one. Offering inmates the opportunity to provide feedback to the medical and corrections staff is a rare occurrence. Based on the results of this study, we suggest that prison facilities provide grief counseling to women who have lost a loved one. This counseling could take the form of a support group, as requested by the majority of the women in this study. There is evidence that group therapy is beneficial for women in creating connection to others (Bloom & Covington, 2008), which is precisely what these women inmates lacked. A support group for grieving women could be a cost-efficient intervention in an environment of scarce resources. Other therapeutic modalities, such as art therapy (Ferszt, Hayes, DeFedele, & Horn, 2004) or participation in groups that address psychosocial and spiritual well-being (Ferszt, Salgado, DeFedele, & Leveillee, 2009), might also be useful.

Policy

Other recommendations include providing training in grief work and basic counseling topics for correctional professionals, and implementing protocols regarding the delivery of notification of a death to an inmate. It is clear that many people in general, regardless of the setting, might be uneasy discussing death with someone grieving. We suspect this discussion must be especially conflicting for correctional officers, because they must balance their institutional responsibilities with their desire to help ease another human being's suffering. Policy changes that could improve inmates' experiences with grief and loss include allowing for semiprivate visitation and/or telephone communication when an inmate has recently lost a loved one. Creating a protocol surrounding the death of a loved one would be beneficial to the incarcerated women, corrections professionals, medical staff, and the families of the inmates.

Biographies

Holly M. Harner, PhD, MPH, CRNP, is a postdoctoral fellow in the Center for Health Equity Research at the University of Pennsylvania School of Nursing in Philadelphia, Pennsylvania, USA.

Patricia M. Hentz, EdD, CRNP, is a practice associate professor and program director of the Advanced Practice Psychiatric Mental Health Nursing Program at the University of Pennsylvania School of Nursing in Philadelphia, Pennsylvania, USA.

Maria Carmela Evangelista, MSN, APRN-BC, is a faculty nurse practitioner/clinical instructor at Columbia University School of Nursing, New York, New York, USA.