Comprehensive geriatric programs in a time of shrinking resources: "True Grit" revisited.
"OK, group! Listen up! We want to do a patriotic number for our World War II vets. Any suggestions?"
This was part of the inmate banter at a recent "True Grit" gathering celebrating the lives of elderly inmate veterans in this humanistic geriatric inmate program. The Senior Structured Living Program at the Northern Nevada Correctional Center (NNCC), better known as True Grit, was described in a Corrections Today article three years ago. (1) The Nevada Department of Correction (NDOC) defines structured living as "a comprehensive program of structured physical, mental, psychological and spiritual programs, which have a set routine and within which the inmate is required to participate, to the best of his abilities, on a regular and on-going basis."(2) Since that article was published, the program has expanded from 55 members to 120. There have been a number of structural modifications to True Grit, including eliminations of activities or functions that did not work and additions of others that did. There also has been a significant positive learning curve, with inmates, correctional staff, psychological and medical staff, and administration all being involved as stakeholders in a program that was unknown in Nevada six years ago.
Inmates older than 50 comprise about 10 percent of prison populations. (3) In 2007, the Nevada Department of Corrections reported that the proportion of state inmates age 65 and older was 3.6 percent. (4) As the population in the state's correctional system ages, the number of geriatric inmates will continue to increase. This is why the leadership of NDOC developed True Grit in 2004. It was established at NNCC primarily because the department's Regional Medical Facility is there, and most of the elderly inmates have one or more medical conditions. It is an all-male program because there are very few women over age 60 incarcerated in Nevada. To be admitted to the program, participants must be age 60 or older; referred by a case-worker; have a positive history of institutional adjustment; and be willing to abide by and comply with the program's rules. The men in True Grit range in age from 60 to 91, with the majority being in their late seventies.
True Grit is a structured living program that has rules and regulations designed to empower elderly inmates to live as healthfully as possible. By means of activities designed to enhance both cognitive and physical life skills, True Grit attempts to ensure that geriatric inmates contribute to their own well-being while at the same time enhancing the overall sociocultural environment of the institution. All of this comes at a price.
Nevada, like many other states and jurisdictions, has been severely affected by the current economic downturn. Revenues coming into the state coffers have diminished significantly. Thus, the level of financial support that can be supplied to various correctional programs must be curtailed. How will it be possible to enhance a new and successful program when resources are diminishing? Nevada's Legislature meets only once every two years; it is in session in 2009. Therefore, all budgets for the 2010-2011 fiscal years were carved in stone by the middle of 2009. New programs will not receive funding, and many established programs will be cut back or eliminated altogether. How can True Grit survive?
The answer is volunteerism. True Grit has grown and flourished because of volunteerism and donations from various organizations and individuals. The psychologist who oversees the program is funded by the state for a separate function, so her salary is not attributed to True Grit. The inmates would be inmates wherever they were housed, so there is no additional expense in terms of inmate housing or other costs. Thankfully, the vitality of the program has attracted the attention of several volunteers from a variety of different areas. Approximately 55 percent of the men in True Grit are military veterans; of this number, more than 60 percent are from the Vietnam era, but there are a number of World War II and Korean War veterans, as well. This proportion of veterans is significant enough that the program director has become involved with the University Veterans Coalition at the University of Nevada, Reno. Through this interaction, volunteers have become involved with the incarcerated veterans and have explored ways to establish reentry programs for veterans, as well as to enhance interaction between the elderly veterans and those housed in other areas. The Vietnam Veterans of America has an active chapter at NNCC, and both inmate veterans and volunteers from other VVA chapters interact with the geriatric veterans in an increasingly significant way. Also, a program that was established by the U.S. Department of Veterans Affairs, called Vet-to-Vet, has now come on the yard, with volunteers from the University Veterans Coalition and the community facilitating peer process groups among the elderly veterans at NNCC.
Because the men in True Grit are entering the final phase of their lives, and because many are serving sentences that imply imprisonment for life, even if it is a simple 10-year sentence, the issues of death and dying have taken on a strong focus at NNCC. Volunteers have been enlisted from several different worldviews to assist, enable and educate these older inmates in regard to end-of-life issues. There is no formal hospice program available within the Nevada DOC, as can be found in Louisiana and California, but administrative empathy with the issue, as well as volunteers who adjust their schedules to support dying inmates, make for an environment that simulates a hospice setting. A retired lay minister from a mainstream Protestant denomination has conducted an ongoing series of classes concerned with aging, death and dying, while a pastor from a different mainstream denomination regularly visits men who are in the Regional Medical Facility, located within the NNCC campus. End-of-life spiritual care is provided by yet another ordained volunteer. Among the more than 250 men who are or have been in True Grit, 25 have died in prison during the past four years. These spiritual volunteers provide the aging survivors with a sense of spiritual security that would not be there if it were not for the program. Recently, a group of volunteers from an organization called Kairos held a weekend spiritual retreat inside the institution that added more meaning to these men's lives. Although Kairos functions separately from True Grit, a significant number of the elderly members participated in the retreat.
Doo-wop, country and rock music go a long way toward adding momentary pleasure to the lives of the elderly inmates. Within True Grit there are a number of professional musicians and a larger number of gifted amateurs. Using donated musical instruments, sheet music and other supplies, the men of True Grit have developed several musical groups that perform for the program and in other venues on a regular basis. Working with each other and with minimal program guidance, the True Grit inmates have established a 20-voice choir (including several in wheelchairs), a seven-member doo-wop group, a country ensemble, and a senior pop group. It may seem incongruous to hear a group of inmates belting out Lee Greenwood's lyrics, "I'm proud to be an American, Where at least I know I'm free," but the mental freedom that they achieve by creating something within themselves is truly a meaningful experience.
Creativity in other areas is also a part of the maintenance of good physical and mental health within True Grit. From the beginning, the men have been engaged in latch hook rug-making, crocheting, painting, jigsaw puzzle making, beading and other crafts. All of the craft material is either donated by various nonprofit organizations or purchased with donated funds. A prime example of the quality of workmanship that is turned out by the program is the 5-by-8-foot crocheted afghan entitled "The Eagle Weeps," which recently won Best in Show at the Nevada State Fair. This piece of work included 75,000 stitches and was accomplished by a single member of True Grit. It now hangs in the Nevada State Legislature Building and will eventually be donated to the Nevada Veterans Hospice in Reno. Other crafts include three-dimensional puzzles that are donated to various offices within the DOC when completed.
How is this therapeutic? Clearly, it provides a sense of accomplishment and self-worth within the men who are doing the work, but it serve other ends as well. One inmate, suffering from moderate-to-severe Parkinson's disease, stated that latch hooking reduced his tremors and eased his difficulty talking. A Native American inmate, who is accomplished at beading, uses his talent not only to create beautiful works, but also now teaches classes in beading to other inmates, both within True Grit and in other areas of the prison. The Arthritis Foundation of America notes that activities using fine-touch movements tend to slow the onset of osteoarthritis. And the mental health aspect of being productive and accomplishing something worthwhile is evident in these men who take great pride in their work.
Maintaining physical fitness is also a significant part of True Grit. Several times each week the men participate in physical activity that ranges from mild to moderate. In the spring and summer, wheelchair softball or tennis are the sports of choice, while fall and winter see the men playing wheelchair basketball or participating in various movement activities in the gym. The men who are wheelchair-bound are encouraged to do even the most minimal movements. All of the equipment, including tennis rackets, balls and gloves, has been donated.
Speaking of wheelchairs, a good, sturdy nonmotorized wheelchair costs somewhere between $250 and $1,000, depending on the manufacturer. Wheelchairs do not survive long in a prison environment because of the uneven terrain and other physical factors. Fifteen men in the True Grit program require wheelchairs permanently, while another few need them from time to time. Through donations from a community service organization in Reno called C.A.R.E. Chest, more than 50 wheelchairs have been given to NNCC. These have been distributed not only to those in True Grit who need them, but also to other inmates not in the program. C.A.R.E. Chest has also donated substantial amounts of durable medical equipment to NNCC, including continuous positive airway pressure (CPAP) machines, oxygen generators, walkers, crutches and shower chairs.
One aspect of True Grit that always has tails wagging is the pet therapy program, which is run by volunteers. The women of the Intermountain Dog Therapy organization bring pet therapy dogs ranging in size from small cocker spaniels to huge Leonbergers into the prison on a regular basis simply to be petted. This is soothing for the inmates. With tears in his eyes, one elderly inmate remarked, "I haven't petted a dog for 30 years!" The only group that enjoys these sessions more than the inmates is the dogs. They strain eagerly at the leash and vocalize loudly as they move through the yard and into the True Grit housing.
Other aspects of True Grit that require no funding from the state include discharge planning for reentry (always a problem for the sex offenders in the program), which has been carried out by nonprofit volunteer organizations such as My Journey Home, Ridge House and LZ Ridge (for Vietnam veterans). Wellness and life skills programs, such as the "Caged Cuisine" microwave cookbook and the "Unchained Verse" poetry manual (written entirely by the inmates), enhance the men's daily lives. Correctional programs that target criminogenic factors are also a significant part of True Grit. Violent offenders are enrolled in victim awareness psychoeducational modules, while sex offenders take a four-section course modeled after the correctional program used by the Naval Consolidated Brig in Miramar, Calif. There are also programs in anger management, relationship skills and substance abuse. While program administrators do not keep any hard numbers on cost savings, the senior physician at NNCC reports that since the advent of True Grit, the number of sick call visits by elderly inmates has decreased significantly, as has the volume of psychotropic medications administered.
A relationship has been established between True Grit and the gerontology section of the School of Social Work at the University of Nevada, Reno, which has resulted in more volunteers being available for various interactions with the inmates. Faculty from the university will conduct an evaluation of True Grit in conjunction with subject matter experts in the field of gerontology to determine what the next steps should be in furthering the humanistic care of geriatric inmates. Nonstate funding avenues, such as federal or private grants, are being explored with a view toward establishing an internship program within True Grit.
None of this volunteerism would be possible without the active support of prison administration, unit case management teams and uniformed officers. Without their professionalism and cooperation, particularly in terms of permitting volunteers to enter the prison and allowing donated materials to be used by the geriatric inmates, the program would not exist in its present form.
The success of this structured living program for geriatric inmates, operating on a negligible budget, should encourage others in the field of correctional health care to find a paradigm within their own jurisdictions that will enable them to provide humane and humanistic physical and mental health care to aging inmates. The geriatric inmate population will only continue to increase. True Grit provides a model, however imperfect, that suggests ways and means to enable correctional health care staff and administrative staff to provide the care that these elderly inmates should have. The impact of the graying American population base will increasingly make itself felt throughout all segments of society, so correctional systems need to be prepared.
(1) Harrison, M.T. 2006. "True Grit": An innovative program for elderly inmates. Corrections Today, 68(7):44-49.
(2) Hubert, T.P., M.T. Harrison and W.O. Harrison. 2009. "True Grit": An innovative humanistic living program for a geriatric population. Paper presented at the National Commission on Correctional Health Care national conference, 6 April in Las Vegas.
(3) Aday, R.H. 2003. Aging prisoners: Crisis in American corrections. Westport, Conn.: Praeger.
(4) Livingston, A. 2007. A brief description of age characteristics of select populations. Statistics and Planning Section, Nevada Department of Corrections.
Mary T. Harrison is a psychologist II at Northern Nevada Correctional Center. Jim Benedetti is the warden at NNCC.
This afghan, "The Eagle Weeps," was created with all donated material. It was given to the Veterans Administration Hospice Program in Reno, Nev., after being exhibited at the Nevada State Fair in August.