No matter the community, jails are forced to manage offenders with mental health problems. Recent court rulings requiring the community standard of care have made it clear: jails need to provide adequate mental health services to those offenders in need.

Recently, Joel Dvoskin, Assistant Professor of Psychiatry fort he University of Arizona College of Medicine, spoke to attendees at the National Institute of Corrections Large Jail Network Winter meeting about the problems jails face.

He believes jail officials want to do the right thing for those afflicted with mental health issues inside their facilities and also knows that this can be difficult.

"What jailers and wardens need is clarity about what their duties are and [the] resources to carry out their duties. Theses people want to do a good job and in my experience when they don't it's either because the rules weren't clear or they didn't have enough resources," said Dvoskin.

He understands these challenges first hand after spending more than a decade in New York as the head of the state's Forensic Mental Health Services Department and then as acting commissioner of the state's Office of Mental Health.

Dvoskin said jails officials get frustrated because they see the mental health needs of the offenders who come into the jails, and know that they might be better served elsewhere.

"They get mad because they don't control their front door and public mental health systems have similarly had their budgets cut. It's a very difficult problem and it isn't that people aren't trying," he said.

Dvoskin believes that here are people trying to improve the situation, but it is "a big mountain to climb."

"Corrections administrators are struggling with how to do a dime program for a nickel," he said.

In his presentation to the large Jail Network, Dvoskin tried to provide some guidelines to jail administrators to assist them with this issue. Below is a summary of that presentation.

HOW DO YOU KNOW IF YOUR MENTAL HEALTH SERVICES ARE NOT WORKING?
* Your staff hates the shrinks.
* The shrinks hate your staff.
*You can't find the mental health staff. Access is crucial, so make access a part of
your expectation of mental health contractors.
* They can't get to you.
* Take a walk through Administrative Segregation. The more mentally ill inmates you
see, the worse you're doing. If most of your seg unit is made up of the mentally ill,
you will never win a lawsuit. You should also require your mental health staff to do
cell to cell visits every week.
* Ask staff and inmates about the referral system: "What would happen if...?" You
need a good referral system; be sure it works in terms of both screening and referral.
* There are delays in receiving medication. Write into your contract the time limits for
delivery of medication.
* There are delays in renewing prescriptions. If a psychotic inmate runs out of
medication, there is a risk to the safety of the inmate and staff.

HOW DO YOU KNOW IT'S WORKING?
* Mentally ill inmates who are out of control are brought up in the morning report-
because they are rare.
* The Mental Health Director is part of your management team.
* Community mental health agencies visit their clients in jail. The jail is part of the
community, and these agencies must provide services.
* Your captains drink coffee in the mental health office. This is a good sign of
interaction between mental health and corrections staff.
* The fewer surprises the better; you need to know about mentally ill inmates.
* You do cross training of both corrections and mental health staff.

AMERICAN PSYCHIATRIC ASSOCIATION GUIDELINES
* "Principles Governing the Delivery of Psychiatric Services in Jails and Prisons"-
Buy this American Psychiatric Association guide and use it to hold contractors
accountable.

LEGAL CONTEXT
* Estelle v. Gamble
* Bowring v. Godwin
* Ruiz v. Estelle
* Langley v. Coughlin
* Madrid v. Gomez
* Youngberg v. Romeo
* Turner v. Safely
* Also note Wakefield-the first case to cite a duty to provide aftercare. This is a 9th
Circuit Court case only, but it will become broader. There is a trend in the direction
of requiring aftercare.

LEGAL REQUIREMENTS FOR CORRECTIONAL HEALTH SERVICES - RUIZ CASE
Most large jails have attended to these requirements:
* Systematic screening and evaluation;
* Treatment that is more than mere seclusion or close supervision;
* Participation by trained mental health professionals;
* Accurate, complete, and confidential records;
* Safeguards against psychotropic medication prescribed in dangerous amounts
without adequate supervision, or otherwise inappropriately administered; and
* A suicide prevention program.
ACCESS TO MENTAL HEALTH CARE AND TREATMENT
* Adequate and appropriate access to care. If inmates can't get to care easily, it
doesn't matter how good it is.
* Access to care in segregation units. Mental health people should do rounds regularly.

SERVICE COMPONENTS
*Intake screening at booking. Every single inmate should be screened for suicide risk
and serious mental health needs. About one-third to one-fourth will screen positive
and should be evaluated.
* Evaluation following initial screening. Evaluation should be followed by
recommendations for treatment. Approximately 15% are likely to need mental
health services.
* Assessment of competency to stand trial. This may be done by the jail or outside the
jail. If you determine incompetence, notify the attorney of a question of the inmate's
ability to stand trial.
* Use of psychotropic medications. There are studies showing that more expensive
medications are more effective in the long run.
* Substance abuse counseling. This is not a constitutional right. However, if
someone has a co-occurring disorder, you must treat him or her.
* Psychological therapy. There is a question of how much a jail must require, but this
is a clinical judgment issue.
* External hospitalization. You must be able to transfer those you cannot stabilize.
* Case management. This is not a legal requirement, but it is a good way to do
business.
* Discharge planning. This is increasingly viewed as a legal requirement. Failure to
provide aftercare can be negligence.

QUALITY OF CARE
* Fundamental policy goal: to provide the same level of mental health services to each
patient in the criminal justice process as should be available in the community.
* Communication psychology model-Jail environments are examined and modified
to minimize negative impacts and promote pro-social living. Think of the jail as a
community and of mental health services as serving the community.
* An adequate number of trained staff must be present in every jail. There is no exact
number required, but the APA says a jail psychologist should have a caseload of 75-
100 inmates. Fifteen percent of inmates are likely to be on psychotropic
medications.

CULTURAL AWARENESS
* Positive attitudes are usually developed after exposure to and awareness of other
belief systems.
* Tolerance for diverse populations
* Empathy for the minority experience-Blacks and Hispanics are typically less often
served by the mental health system.
* Understanding ethnocentric bias and its effects
* Cultural competence may be asking too much; most people will settle for respect. Be
open to other cultures.

CONFIDENTIALITY
* Situations where confidentiality is not applicable:
* Patient is self-injurious or suicidal;
* Patient is assaultive or homicidal; or
* Patient presents a risk of escape or creation of disorder within the facility.
* You can only promise to be discreet; confidentiality is not possible.

SUICIDE PREVENTION
Essential elements of a suicide prevention program include:
* How to recognize danger signs-Special stressors of inmates and their effects
(including noise and extremes of temperature)
* Effective and well-understood referral system-Ask staff to use their own judgment;
if they think something is wrong with someone, do a referral. Err on the side of
caution.
* Communication between staff members on needs and risks presented by suicidal
inmate
* Debriefing in the event of a completed suicide. It is usually best to make the
debriefing inviting, but not mandatory.
* Be careful about a punitive response to suicidality; locking someone down is not a
good idea.
* Policy and procedural guidelines-NY State has a Jail Suicide Prevention Manual,
which is free.
* Suicide prevention intake screening guidelines
* A training program for jail and lockup officers in suicide prevention
* Training for mental health personnel

REASONS FOR MENTAL HEALTH SERVICES
* Alleviate unnecessary suffering;
* Alleviate symptoms of mental disorders that interfere with an inmate's ability to
function in the surrounding environment;
* Make the institution safer; and
* Meet legal requirements.

MENTAL HEALTH TREATMENT
* Referral for Mental Health Treatment
* Mental Health Evaluations
* Provide Therapeutic Milieu-This doesn't have to be formal group therapy
* Discharge Planning-This can be simple, such as an appointment with a community
mental health center and a three-day supply of medications.
* Individual or group psychotherapy or supportive counseling
* Crisis intervention

INTERPROFESSIONAL RELATIONSHIPS
* Cooperation of all participating professionals-psychiatrists, psychologist, nurses,
correctional counselors, correctional officers
* Whatever the model of supervision utilized, the practical aspects of supervision must
be within the appropriate expertise of the supervisor. For example, someone
supervising nurses should have nursing experience.

SERVICE DELIVERY ISSUES
* Who pays for the service?
* Who controls the units of service?
* Who delivers services?
* Where are services to be delivered?
* Who evaluates and sets the standards for services delivered?
* Who receives services?
* What services are to be offered?

SUBSTANCE USE DISORDERS
* A positive mental screening for substance intoxication should trigger an immediate
mental health screening for the presence of depressed mood and/or suicidal ideas.
* Most completed suicides occur within 24-48 hours after admission and are carried
out by inmates who are intoxicated or experiencing withdrawal symptoms.

CO-OCCURING DISORDERS
* Treatment of mental health and substance abuse simultaneously. This needs to be
combined for those with both disorders.
* Each disorder is treated as primary.
* Psychosocial problems and skill deficiencies must be addressed through assessment
and consultation.
* Medication should be prescribed with caution.
* Intervention should be designed for the particular setting.
* Treatment services must be extended to the community.
* Treatment should be integrated with self-help groups and support networks.

SPECIAL POPULATIONS AND THEIR CLINICAL NEEDS
* Combat veterans-adult
* Combat veterans II-victims of child abuse
* Women-have a great deal in common and have special needs
* Segregation and protective custody
* Cutters
* Cognitive deficits-people with retardation and head injuries
* Misfits-not mentally ill, but a management problem. In extraordinarily tough
cases, you can get a state hospital to take such an inmate.

WOMEN
* The prevalence of mental illness among women is twice that of men. The difference
seems to be in rates of depression, anxiety, and trauma spectrum disorders.
* Up to 70% report a history of sexual abuse either as a child or as an adult.
* Clinical and corrections staff should receive basic training in gender-specific issues.
* Women are more likely to be the custodial parent for their children and have greater
concerns about them.
* A free phone is important, as it allows them to talk to their children.

YOUTH IN CORRECTIONAL FACILITIES
* Many of these young prisoners have experienced severe abuse and neglect, trauma-related anxiety, and depression.
* Those who are small are likely targets of sexual aggression.
* The high prevalence of neuropathology and learning disorders requires access to
neurological and neuropsychological evaluations and treatments.

MENTAL RETARDATION/DEVELOPMENTAL DISABILITY
* Screening must include mechanisms to assess intellectual functioning and questions
about participating in special education programs, as well as head injury or seizure
disorder.
* Since the mentally retarded are often ridiculed, some facilities may choose to create
segregated housing for their protection. Find ways to protect them sensibly.
* Prevalence is usually about 1% of the population.

GERIATRICS AND RELATED ISSUES
* Terminal illness (The terminally ill are "old" by definition.)
* Hospice inside a prison
* Compassionate release
* Funding issues

PREVENTING SUICIDE-NEW YORK RESULTS
* For the first 10 years following implementation of this program, despite a 100%
increase in jail census, there was a 150% decrease in jail suicides.
* "If this ain't science, it'll do until science comes along."
* Privacy can be a barrier to success. New York has a One-Page Information Sharing
law. There is a requirement to share basic information between corrections and
community mental health agencies.

HAVE REASONABLE GOALS
* Fluctuation of suicide rates. This is natural. If there are very few suicides in your
jail, you are doing a great job.
* There is no such thing as a suicide-proof jail or prison. You are engaged in a
constant battle.
* Jails versus prisons. Jails are becoming more like prisons.
* "Change the Odds"-Enough of a mission statement.
* Treat suicide as a crisis.
* More options = fewer deaths. Everyone who is suicidal wants both to die and to
live. Make it hard enough for them to kill themselves that they have time for their
protective mechanisms to kick in.

SUICIDE PREVENTION
* Prevention spans the duration of incarceration.
* Responsibility begins with observations of transporting/detaining officers, and it
may not even conclude upon release.
* Note relevant personal data: background and mental health history, criminal record,
and behavior and appearance.

COMPONENTS OF AN EFFECTIVE SUICIDE RISK MANAGEMENT PROGRAM
* Screening/Referral - Forms are for screening.
* Crisis Intervention
* Supervision Routine
* Special Watches
* Mental Health Observation Housing
* Inpatient Hospitalization
* Scheduled Mental Health Treatment
* Staff Communication
* Training
* Debriefing

COMPONENTS OF EFFECTIVE SCREENING
* At the "Front Door"
* Trained Staff
* Documentation
* Low Threshold-Staff must refer when in doubt.
* Standardization

FACILITY-WIDE INVOLVEMENT
* All-inclusive Training Policy-(for everyone in the facility)
* Officers/Security Staff
* Nursing/Counseling Staff
* Simple, Clearly-Defined Referral Mechanism
* Must include avenue of referral during regular business hours, evenings/third
shift, and weekends/holidays.

SUICIDE PRECAUTIONS: HOUSING OPTIONS
* Special Watches
* 15 minute and 1:1
*Mental Health Observation Calls
* Suicide Dormitory
* Hospitalization

BASIC SUICIDE RISK ASSESSMENT
* Is the person considering suicide?
* How do they plan to commit suicide?
* Method
* Time
* Location
* Do they have the means to carry out the plan?
* Why are they still alive? - Protective factors are very important, so they need to be
identified.

ASSESSING LEVEL OF RISK
*Admitted Suicidal Intent
* Detailed Plan
* Means to Carry Out the Plan
* Feeling of Peace/Resolution
* Attending to Personal Effects (goodbye letters, distribution of belongings)
* History of Suicide Attempts

FOLLOW-UP EVALUATIONS
* Facility Mental Health Staff
* Case Managers
* Therapists
* Counselors
* Nursing Staff
* Psychologists
* Psychiatrists

TREATMENT
* Inpatient vs. Outpatient Treatment

"MANIPULATION" SUICIDAL GESTURES
* Self-mutilation;
* Personality disorder;
* Staff issues-frustration, anger, and modification of response. Help your staff
understand that these gestures are not about them.

JAIL STRESSORS
* Fears, both reasonable and unreasonable, of:
* Assault
* Rape
* Abandonment-by family and lawyers
*Loss of housing and employment
*Crowding in holding tanks
*Odors
* Delays in mental health care
* Bad neighbors
* Sounds and silences
* Extremes of temperature
* The Rumor Mill
* Coercive environment
* Forced association
* Intoxication
* Withdrawal

CRIMINAL JUSTICE STRESSORS BEYOND THE JAIL OR PRISON WALLS
* Personal loss
* Isolation
* Problems with family
* Loss of social support
* Physical illness
* Dates of personal significance
* Mental illness
* Substance abuse

MYTHS AND MISCONCEPTIONS
* "If someone talks about committing suicide, they don't really mean it..."
* "Asking about suicide might give someone the idea..."
* "He was really down, but today he's in a great mood. Everything must be O.K.
now..."

SUICIDE: THE DECISION PROCESS
* Building of stressors
* Feelings of hopelessness
* Consideration of self-harm
* Desire to escape
* Ambivalence
* Decision to act
* Planning
* Agitation
* Peacefulness

PHYSICAL PLANT ISSUES
* High-Risk/Lockdown Areas-Most suicides occur in high-risk areas and at high-risk
times.
* General Population Areas
* Work/Recreation Areas

DOCUMENTATION
* Critical to effective care
* Clearly explain what you did and why
* "What" was happening
* "How" you elected to proceed
* "Why" you made that decision
* Clearly explain what you did not do and why

QUALITY ASSURANCE
* Consultation-the importance of second opinions
* Utilization Review-looking for outliers

WORKING TOGETHER TO SAVE LIVES
* Interdisciplinary Communication-Security, Programs, Medical, Mental Health Staff
* Mutual Respect-Interests and goals are not mutually exclusive
* Open and Active Discourse

For additional information, contact Dr. Joel Dvoskin, 3911 E. Ina Road, Tucson, AZ (520) 577-3051; joelthed@aol.com