|Are We All on the Treatment Team?|
|By Joe W. Hatcher, Ph.D., Professor of Psychology, and Matthew Breuer|
Working in a correctional setting has never been simple, for security or for health services staff. When population characteristics change, new challenges emerge, and over the last few decades an important dimension of the inmate population has changed. They are now much more likely to be mentally ill, and this fact has important implications for the inmates themselves and for the staff who deal with them.
The increased presence of the mentally in correctional institutions is the most recent result of the swinging pendulum of care for the mentally ill. Fifty years ago mental health treatment of the severely mentally ill occurred in an in-patient institution, and over a half million of the mentally ill lived in such institutions. Beginning in the 1960s, however, a process of “deinstitutionalization” began that has resulted in a reduction of that in-patient population to less than 80,000. The plan was that local community health centers would take up the treatment of the mentally ill, but for a variety of reasons, often related to cost, this has not worked out. Often poor and on the streets, many mentally ill have found their way into the criminal justice system. Our prisons have become the new mental institutions, with, according to some sources, over one million of the mentally ill currently behind bars.
How likely is any given inmate to be mentally ill? According to a 2006 Bureau of Justice Statistics report authored by James and Glaze (2006), approximately 45% of federal inmates, 56% of state inmates, and 64% of jail inmates displayed symptoms of a mental health problem. Other estimates cite somewhat lower numbers, though all agree that the number of mentally ill inmates is much higher than in the past. Rates of mental illness are considerably higher in female institutions, with a Wisconsin institution reporting that over 75% of their inmates have mental illness diagnoses. Types of mental illness range from psychotic disorders such as schizophrenia to depression and anxiety disorders, along with drug addiction and personality disorders such as antisocial personality, with some suggesting that post-traumatic stress disorder is also prevalent and often overlooked.
Prisons would not be described as a positive therapeutic environment for any inmate, but for the mentally ill the environment can be toxic. The lack of privacy, concerns about personal safety, and the general stress of incarceration can intensify many mental illness symptoms. Being seen for medical and psychological needs is not simple, as numbers of psychologists and psychiatrists have not kept up with the rise of the mentally ill inmate population. In Wisconsin, for example, numbers of psychology staff in male institutions would have to be increased by almost 50% to meet the standards set up by the American Association of Correctional Psychology. Psychology staff are often over-extended as a result, and inmates are not seen as often as best-practice standards would require.
For security staff, mentally ill inmates present two different problems. First, there are clear security concerns. Although mentally ill people in the national population are only slightly more likely to be violent than are the non-mentally ill, there are indications that this may operate differently inside correctional walls. For example, it was reported that in Wisconsin the mentally ill accounted for 90% of incidents of self-harm and 80% of the attacks on staff during a one year period starting in June of 2008. Mentally ill inmates who are not currently taking their medication are a special concern.
At the same time, mentally ill inmates do not fit the usual template for inmate misbehavior, which is that inmates know exactly what they are doing and, when breaking rules, can be held completely accountable for their actions. Mentally ill inmates may violate rules because they are confused and not thinking clearly, or because they are having trouble regulating emotions. In short, they may break rules simply because they are showing the symptoms of being mentally ill. Security staff, and psychology staff as well, may be prone to see malingering instead of mental illness, and this may result in punishment for behavior that is not necessarily under the complete control of the inmate.
One result of this is that mentally ill inmates tend to “sink” toward more restrictive environments, such as maximum security status and segregation, environments that are arguably even more destabilizing. This situation has led to a general consideration of whether segregation is appropriate for mentally ill inmates, and, if so, what can be done to make the situation less debilitating.
How can security staff and psychology staff deal more successfully with the problem of mentally ill inmates? First, they can become better informed as to the scope of the problem, perhaps by watching The New Asylums, a Public Broadcasting System documentary on the issue. Other suggestions have included more training concerning mental illness for security staff, allowing mental illness concerns to be brought up in disciplinary hearings, and hiring more treatment staff.
In the opinion of the first author, however, the most immediate need is for a better relationship and more cooperation between security and psychology staff. Security staff have far greater access to the everyday behavior of the inmate population than do psychology staff, so they have valuable information concerning behavior that may indicate symptoms of mental illness. Psychology staff know more about the particular issues facing individual inmates, and could provide valuable information to security staff about behaviors to expect from certain inmates without having to share diagnostic information, which can violate confidentiality guidelines.
The first author has worked in several different correctional institutions over the past few years and has seen a range of security staff/psychology staff relationships. In some institutions, the two types of staff rarely talked directly with each other, and there seemed to be a general lack of trust. At other institutions, conversations took part on a daily basis between security and psychology staff, and some problems were headed off before they became more serious. The broader solution to the problem of the mentally ill inmate will probably have to come from changes in social policy or sentencing guidelines concerning the mentally ill. Until those changes occur, however, we will need to work together to provide more secure and, yes, more humane environments for staff and for inmates. At this point, whether we like it or not, we are all on the treatment team.
Important information for this article was provided by the sources below:
Ill-equipped: U.S. Prisons and Offenders with Mental Illness. Human Rights Watch, 2003. Prison Is Revolving Door for Mentally Ill, Who Don't Get Needed Meds. Jessica VanEgeren, Capital Times (Madison, WI), june 10, 2009.
Doris J. James and Lauren E. Glazer. Mental Health Problems and Jail Inmates. Bureau of Justice Statistics Special Report, 2006
Editors Note: Joe Hatcher is a Professor of Psychology at Ripon College in Ripon, Wisconsin and work part-time in the Wisconsin Department of Corrections.
Matthew Breuer is a senior psychology major at Ripon College who plans a career working with the mentally ill.
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