|Segregation: Challenging the Status Quo|
|By Thomas White, PhD|
Dr. Dean Aufderheide’s recent CorrectCare article, Mental Illness in Administrative Segregation (Spring 2013), provided insightful recommendations about protecting yourself from lawsuits related to mentally ill inmates in segregation or special housing units. The risk management issues notwithstanding,it must be emphasized that this is not a new problem. For decades civil rights lawsuits involving mentally ill inmates in SHU have criticized the delivery of mental health services, most commonly citing excessive use of administrative segregation and the lack of timely and meaningful access to adequate care. Yet, despite decades of grappling with this seemingly straightforward issue, our use of long-term SHU to manage the mentally ill is growing and the lawsuits continue. It seems fair to ask why so little progress has been made. One obvious reason may be that we have not addressed some fundamental issues about providing services in SHU that have undermined even our most reasoned and well-intentioned efforts.
No Viable Housing Alternatives
As prison populations began growing several decades ago, administrators relied heavily on their SHUs to routinely manage and separate more and more problem inmates. For violent, predatory inmates who simply refuse to follow the rules, this was an effective strategy that may still be a viable and reasonable option. However, also caught up in this process were many mental ill inmates who were nonviolent but displayed unpredictable cycles of crisis and adjustment, causing them to “ping-pong” between the general population and SHU. As a result, many chronic, mentally ill inmates today spend months and sometimes years in long-term, single-cell isolation simply because our reliance on SHU has crowded out the development of other housing options for the mentally ill.
Limited Clinical Contact
As mentally ill populations grew, fulfilling even basic policy requirements in large, diverse SHUs became difficult, if not overwhelming, for clinicians. To maximize time and resources, a number of practices evolved to compensate for the demands of the 24/7, lockdown environment. Perhaps most prominent was the traditional SHU rounds. In every facility on most days, clinicians can be found walking the SHU range talking to inmates through the closed door of their cell. In fact, this practice is so universally accepted it has become the de facto standard of care for noncrisis SHU contacts. But despite its practicality, conducting interviews at the cellfront is obviously less than ideal because it offers little privacy and almost no meaningful interaction, and limits any useful therapeutic involvement.
Although it is efficient, this practice can have serious unintended consequences. Some high-risk inmates can and do go for long periods of time receiving little individual, one-on-one attention unless they experience psychotic episodes or engage in outbursts of violence or self-injury, or in some cases attempt suicide. At that point, everyone responds to the crisis. But even then, there are typically few permanent housing options available other than SHU, so the cycle starts again.
Recommendation for Breaking the Cycle
Given the industry’s stated recognition of these long-standing problems, the federal courts are becoming less tolerant about our inability to provide meaningful remedies and the issue has even spurred recent congressional hearings. This may be signaling an end to the status quo as well as new pressures to provide real, ongoing treatment to our growing mentally ill population. In an era of diminished funding, change must be accomplished without greatly expanded resources, but complicated problems do not necessarily require complicated or expensive solutions.
For example, to address the need for alternative housing, some units can be designated for inmates who need less restrictive housing than SHU. Such a unit would also serve as a transition point for inmates going to or being released from SHU to assess their stability and provide treatment.
For SHU itself, a greater mental health presence can be accomplished by assigning permanent clinical staff to the unit. This would enable clinicians to conduct more frequent and/or focused daily rounds for identified high-risk inmates. Other low-cost adaptations might include developing a “mental health range” in SHU to facilitate better access and rapport with inmates and allow more out-of-cell time for selected inmates. Another clinical improvement would be to ensure that adequate time and space are available to permit direct and private engagement with inmates.
Finally, it seems time to develop mechanisms for sharing management responsibility between security and mental health professionals to maximize continuity of care and minimize long-standing antitherapeutic criticisms.
A New Paradigm
Introducing even moderate, incremental change in any institution can be difficult and entails some degree of risk and the possibility of failure. But that should not prevent us from trying. The most fundamental challenge for most institutions will be a willingness to modify the self-justifying lockdown strategy we have relied on for years that hampers innovative treatment approaches for nonviolent mentally ill inmates. Nevertheless, to have a chance at success, such bold and deliberative action will be necessary and must come from the very top.
The purpose here is not to simply criticize the status quo or rehash old problems. Rather, it is to stimulate candid dialogue about ways to fix long-standing issues associated with housing mentally ill inmates in segregated housing, and to encourage practitioners and decision-makers alike to engage in that discussion sooner rather than later, before expensive and disruptive change is forced upon us by the courts.
Thomas White, PhD, is a principal with Training and Consulting Services, Shawnee Mission, KS. He retired as regional administrator of psychology services from the Federal Bureau of Prisons and now provides consulting, training and litigation support services in the public and private sectors. To reach him, visit www.SuicideConsultant.com
Reprinted with permission from the Winter 2014 issue of CorrectCare, the quarterly magazine of the National Commission on Correctional Health Care. All rights reserved.
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