Current Issues in Correctional Psychiatry

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Current Issues in Correctional Psychiatry

• or (if you want to be cynical) so what else is
  new?
• Jeffrey L. Metzner, M.D.
• Clinical Professor of Psychiatry
• University of Colorado School of Medicine

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A new textbook
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Patients in State and County Hospitals

• 1979 140,355 63/100,000
• 1997 54,015 20/100,000
• Transinstitualization/criminalization
  hypothesis
• RW Manderscheid and MJ Henderson, eds. Mental
  Health United States 1998 and Mental health
  United States 2000. DHHS Pub. (SMA) 99-3285,
  Washington, DC US Government Printing Office,
  1990 and 2001.
• Erickson, Rosenheck, Trestman, Ford, Desai.
  Risk of Incarceration between Cohorts of Veterans
  with and without Mental illness Discharged from
  Inpatient Units. Psychiatric Services
  59,178-183, Feb. 2008.

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Prisons (2013)

• California (135,981), Texas (168,280), and the
  Federal system (201,697) together have 37 of all
  the prisoners in the nation.
• The 21 smallest jurisdictions accounted for 7.8
  of the total population under jurisdiction at
  midyear 2006.

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Prevalence rates of mental disorders

• Studies and clinical experience have consistently
  indicated that 8-19 of prison inmates have
  psychiatric disorders that result in significant
  functional impairments.
• Another 15-25 of inmates will require some form
  of psychiatric intervention during their
  incarceration.

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Right to treatment
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Landmark cases

• Cooper v. Pate 278 U.S. 546 (1964)
• Estelle v. Gamble 429 U.S. 97 (1976)
• Bowring v. Godwin 551 F.2d 44 (4th Cir. 1977)
• Bell v. Wolfish 441 U.S. 520 (1979)
• Ruiz v. Estelle 503 F. Supp. 1265 (S.D. Tex.
  1980)
• Miller v. French (2000) (Prison litigation reform
  act)
• Coleman v Brown Plata v. Brown (131 S. Ct.
  1910, 1923 (2011)

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Three essential elements required to establish a
constitutionally adequate correctional mental
health system are as follows

• Adequate physical resources regarding treatment
  program space and supplies
• Adequate human resources concerning numbers of
  properly trained and/or experienced mental
  health staff who will identify and/or provide
  treatment to inmates with serious mental
  illnesses and

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• Adequate access for inmates to the physical and
  human resources within a reasonable period of
  time (Cohen 1993).
• Cohen F Captives legal right to mental health
  care. Law and Psychology Review. 1993 171-39.

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Standards and/or guidelines for correctional
health care programs

• American Psychiatric Association
• American Public Health Association
• National Institute of Corrections,
• National Commission on Correctional Health Care
• American Nurses Association
• Association of Correctional Psychologists

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Current issues in correctional psychiatry

• Mental health issues relevant to lockdown units
  (e.g., segregation, disciplinary, supermax,
  etc.).
• Mental health input into the disciplinary
  process.

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• Discharge plans for inmates with serious mental
  illness.
• Special Needs of Female Inmates
• Research ethics (see IOM report-http//books.nap.e
  du/catalog/11692.html)
• Substance Abuse Treatment

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Segregation Housing Issues
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Mentally ill prisoners in segregation

• Security housing unit (SHU) (Supermax)
• Administrative segregation
• Disciplinary (punitive) segregation
• Pre-hearing detention
• Protective custody
• Other?

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Types of segregation

• Disciplinary segregation, which is based upon
  what the inmate did, is typically ordered as
  punishment for an institutional infraction, and
  is often of relatively short duration.
• Administrative segregation is typically imposed
  based upon what the inmate will do. That is,
  administrative segregation is prospective in
  nature, and designed to protect other inmates
  from a danger believed to be posed by the inmate.
  

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• It is often administrative segregation, a
  classification status, which has now commonly led
  to the imposition of long-term segregation.

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• The use of supermax confinement is overutilized
  within correctional facilities in the United
  States. The use of this type of program, because
  of its extreme limitations on liberty and its
  potential for harm, should be reserved for cases
  in which there is no less restrictive way to
  remedy an unsafe situation.

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The major problems relevant to the mentally ill
in segregation involve issues related to the
following

• Definition of mental illness
• Duration of confinement in segregation
• Conditions of confinement
• Clinical assessment of the above 3 factors

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American Psychiatric Position Statement

• Prolonged segregation of adult inmates with
  serious mental illness, with rare exceptions,
  should be avoided due to the potential for harm
  to such inmates. If an inmate with serious mental
  illness is placed in segregation, out-of-cell
  structured therapeutic activities (i.e., mental
  health/ psychiatric treatment) in appropriate
  programming space and adequate unstructured
  out-of-cell time should be permitted.
  Correctional mental health authorities should
  work closely with administrative custody staff to
  maximize access to clinically indicated
  programming and recreation for these individuals.

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Segregation Housing

• More than half of prison suicides occur in
  segregation units

Federal Bureau of Prisons Study (1983-1997)
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Segregation Housing (cont.)

• Yet segregation accounts for less than 10 of
  prison beds

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Zubek, Bayer, and Shephard

• conceptualize segregation units to have three
  main characteristics
• social isolation,
• sensory deprivation, and
• confinement.