The role of the psychiatrist in evaluating a prison mental health system in litigation

Federal courts during the past 14 years have recognized that many prisons in the United States have provided constitutionally inadequate medical and psychiatric services. Our recent national survey indicates that at least 20 states have had at least one part of their correctional system included in a certified class action suit that alleged insufficient mental health services for inmates. This article reviews the role of the expert psychiatric witness during the phases of litigation that involve proposed remedial plans and compliance in implementing remedial plans. Available epidemiologic data about psychiatric disorders among prison inmates, standards for correctional mental health care, and various mental health system models are briefly reviewed. A comprehensive approach to evaluating proposed remedial plans and assessing issues of compliance with accepted plans is described. Special attention is directed toward psychiatric issues unique to a correctional system.     

HIV-infected prisoners: what mental health services are constitutionally mandated?

State and federal correctional facilities currently have approximately 23,000 inmates who are infected with human immunodeficiency virus (HIV). These inmates suffer from the same mental health disorders as uninfected inmates but are additionally subject to mental health problems uniquely related to their HIV infection. Many prison systems are struggling to provide minimal mental health care to uninfected inmates. How will prisoners address the additional mental health needs of the staggering number of inmates being diagnosed with AIDS and HIV? This article describes the type of mental health services that are constitutionally mandated and discusses whether and how prisons will have to respond to the distinct mental health issues related to HIV infection.     

The Swedish mental health system. Past, present, and future

In sum, the evolution, strengths, and weaknesses of the Swedish mental health system are quite similar to mental health systems in other Western countries; early reliance on stand-alone, state psychiatric hospitals, followed by deinstitutionalization and development of largely ambulatory, community mental health care. This evolution has been complicated in Sweden by the multiple levels and system components, the state, the county councils and the municipalities. Unlike the United States, but similar to Britain, community mental health care in Sweden is provided by two systems; treatment (and forensic services) by the county councils' mental health providers, and generic services by the municipalities' social welfare system. The resulting division of roles and responsibilities creates a strong need for collaboration and coordination of activities on behalf of consumers. It can also have the unintended disincentives to serving more difficult consumers. All these difficulties not withstanding, the Swedish mental health system has made major stride in providing quality, appropriate care.     

Current issues in state mental health forensic programs

The major current issues facing state and local forensic mental health programs are presented in this paper. Debates over forensic patients' rights and the insanity defense are discussed, together with many administrative problems such as the pros and cons of correctional versus mental health system program control and payment incentives for treatment. The authors cite the differing goals of correctional and mental health systems, i.e., security and treatment, as reasons for difficulties in developing needed collaboration. Guidelines are suggested to address such important issues as mixing civil with criminal patients, developing units for special populations, defining patients who can respond to treatment, and follow-up after discharge.     

Characteristics of homicide perpetrators among Italian forensic hospital inmates

OBJECTIVE: To identify distinctive clinical and social features of the psychiatric patients who committed homicide among inmates of Italian forensic hospitals. METHOD: Clinical and social characteristics of four cohorts of patients were compared: 64 inmates who committed or attempted homicide (Hs), their 64 matched controls from community services caseloads, 54 inmates who committed other crimes and their 54 matched controls from community services caseload. RESULTS: When compared with other inmates, patients who committed or attempted homicide showed less severe psychopathology (later onset of mental disorders, later contact with mental health services, lower disability scores) except for higher scores at BPRS "hostility" and "suspiciousness" factors; they also showed better premorbid adjustment (socioeconomic status, employment), and surprisingly better behavioural profile (fewer compulsory admissions, fewer previous criminal records, less substance abuse, less frequently in caseloads of community services). When compared with their matched controls, Hs had lower psychopathology, better adjustment, and a similar behavioural profile. CONCLUSIONS: Italian inmates of forensic hospitals who committed or attempted homicide have clinical features and personal histories which are far from the stereotype of the violent and dangerous psychiatric patients. The risk assessment procedures routinely performed in several countries may detect violent, but not homicidal behaviour.     

Redefining mental health law

Mental health law traditionally focuses on preserving the civil and constitutional rights of people labeled mentally ill. However, because of fundamental changes in the public mental health system. most people labeled mentally ill no longer reside in state psychiatric hospitals. As a result, the core policy issue in mental health today is assuring access to community based services, supports, and housing which enable people to live successfully in the community. Because of this different environment, the definition and scope of mental health law must be expanded dramatically if those interested in the subject are to continue to influence mental health policy. This article examines five contemporary mental health policy issues, including changes in reimbursement systems and the growth of the consumer and family movements, that illustrate the legal, policy, and research questions which will emerge in an expanded and redefined mental health law agenda. The author thanks Ingo Keilitz, Thomas Hafemeister, and Pamela Casey for their review of earlier drafts of this article.     

Mayberry revisited: The characteristics and operations of America's small jails

Much attention has been focused on the problems of America's prisons and jails. Jail research and often jail litigation have centered on large county or municipal jails; often these resemble correctional systems and are so called. Yet many of the nation's 3041 counties are small, rural, and sparsely populated. In a 1982 survey conducted by the National Sheriffs' Association, 640 jails had bed space for 16 or fewer inmates. Many of these jails suffer from the same kinds of deficiencies as large jails, although these problems are not exacerbated by size. Most jails suffer from lack of adequate funding, but for small jails this is a particularly acute problem which affects all facets of operations.

Data from the 1983 National Jail Census and the 1982 National Sheriffs' Association survey are used to develop a profile of the overlooked but important small jail, defined for our purposes as a facility capable of housing ten or fewer inmates. This profile indicates that small jails are older, have less cell capacity, and provide fewer health and rehabilitation services than their larger counterparts. The national prevalence of small jails and some of their notable deficiencies suggest that alternatives to these facilities be considered.     

Emerging trends in correctional civil liability cases: a content analysis of federal court decisions of title 42 united states code section 1983: 1970–1994Publications received

This research analyzes the decisions of correctional civil liability cases litigated under Section 1983 for the years 1970 through 1994. The analysis provides an examination of 3,205 published United States federal court correctional liability cases brought against correctional personnel in penal and local jail facilities. Longitudinal trends, patterns, prevailing parties, common types of lawsuits filed, and damages and attorney fees awarded are discussed based on the content analysis classification scheme. The analysis revealed sixteen major correctional topic areas where prisoner litigation is likely. High liability issues in corrections are addressed and recommendations are presented.     

Preventing Suicide in Jails and Prisons: Suggestions from Experience with Psychiatric Inpatients

Abstract:  Both among psychiatric inpatients and inmates of prisons and jails, suicide is highly prevalent with alarming rates. In many countries, there has been a call for action to prevent such deaths and to educate staff in the early recognition of suicide risk. A careful MedLine search was used to identify relevant papers dealing with suicide prevention in psychiatric inpatients. This paper reviews this research and the policy recommendations that have been developed for psychiatric hospitals in order to reduce the incidence of suicide in their patients. Results derived from this search indicated that these policy recommendations can be applied to suicide prevention in correctional settings, and it is argued that suicide prevention programs in correctional settings can benefit from the research conducted and the policy recommendations for suicide prevention in psychiatric facilities. In conclusion, the best practices for preventing suicides in jail and prison settings should include the following elements: training programs, screening procedures, communication between staff, documentation, internal resources, and debriefing after a suicide.     

Estimating mental health needs and service utilization among prison inmates.

A sample of 3,684 inmates in the New York State prison system was surveyed in May 1986 to determine the prevalence of psychiatric and functional disability and service utilization. It was estimated that 5 percent had a severe psychiatric disability, and 10 percent had significant psychiatric disability. The higher the level of disability, the greater the proportion of inmates that had received mental health services in the last 30 days and in the last year. Still, 45 percent of the severe disability group had no service contacts in the last year. Patterns of utilization differed significantly by sex (a greater proportion of women received services) and by race (a greater proportion of whites received services). The clinical factors associated with receipt of services varied considerably between men and women.     

A Tale of Two Laws: The U.S. Congress Confronts Habeas Corpus Petitions and Section 1983 Lawsuits

Actions by state prisoners have comprised a large and growing body of litigation in the U.S. federal courts over the past thirty years. State prisoners can challenge the validity of their state trial court convictions (habeas corpus petitions) and the constitutionality of the conditions of their confinement to state prisons and jails (Section 1983 lawsuits). Currently, one out of every five civil cases filed in the federal system is brought by a jail or prison inmate. When in the past did these cases begin to arise? What is the present trend? What does the future hold concerning the number of cases likely to be filed? These questions are at the heart of the current research. Care is needed in addressing these queries because it is neither easy nor obvious to know what propels the volume of litigation. Moreover, the future is especially difficult to predict in light of recent legislation adopted by the United States Congress to limit the number of habeas corpus petitions and the number of Section 1983 lawsuits filed each year. The unique contribution of the current research is threefold. First, an improved methodology is used to describe past patterns and to forecast future trends. Simply stated, prisoner litigation is hypothesized to be related to the number of prisoners. As the number of prisoners increases, the volume of litigation increases proportionately. What is not obvious about this relationship is that it has persisted over the past decades despite substantial changes in legal doctrines designed to affect the filing of the litigation. Second, the effects of two major congressional actions passed in 1996 to limit prisoner litigation are examined and assessed for their success in achieving their intended objectives. The first of these, the Antiterrorism and Effective Death Penalty Act, which sought to restrict habeas corpus petitions, is judged to have virtually no impact. The second piece of legislation, the Prisoner Litigation Reform Act, which sought to curtail lawsuits against correctional officials, appears to have lowered the volume of litigation in the short‐term, but has not disrupted the underlying link between the number of prisoners and the number of lawsuits. Finally, estimates are made of the future volume of litigation and the corresponding number of federal judges needed to resolve prisoner litigation. These estimates have the advantage of being based on significant statistical relationships and accounting for the effects of recent congressional action.     

Contemporary prison overcrowding: short-term fixes to a perpetual problem

Since the United States began using incarceration as its cornerstone of punishment for those who transgress the law, this method of discipline has been fraught with problems. One of the most ubiquitous problems found within correctional institutions are the conditions inmates are forced to live in particularly, when penal facilities are overcrowded. These conditions have led to extensive litigation, compelling the judicial system to change. Although overall conditions have improved, a perpetually increasing inmate population continues to plague correctional systems as costs continue to rise. As state budgets have become strained during the economic downturns, many states’ officials view less punitive measures as possible solutions to the excessive costs of administering punishment and overcrowded inmate populations. Due to facility overcrowding, several states have actually been placed under federal court order to reduce their inmate population in order to protect inmates’ constitutional rights. Although this has resulted in a change of policies to help alleviate prison overcrowding, there is little evidence these are anything more than short-term fixes to a problem with no end in sight.     

Medical school forensic psychiatry units in health care delivery facilities rather than criminal justice institutions: an alternative model

We have presented a model for developing forensic psychiatric treatment and teaching services of a medical school Department of Psychiatry, but where these services are the basic comprehensive health care delivery system for the entire community. These offer consultative and treatment services for adult and family court clinic, psychiatric forensic services, of forensic psychiatry open bed and medium security-type bed, as well as day hospital and outpatient services. All of these are sited in the normal health care delivery system of the university teaching hospitals and its patient treatment, teaching, and research facilities. Consultative services are offered on request to the criminal justice system, but the basic health care delivery system is controlled administratively by the ordinary university teaching hospital authorities and exists as a one of a kind unit at the Royal Ottawa Hospital. The Royal Ottawa Hospital is a private nonprofit hospital, with its own Board of Trustees, and is affiliated with the medical school, as part of a major university network. We believe it important to present this model for an overall forensic psychiatric service, in contradistinction to the more commonly established forensic psychiatric facilities in state mental hospitals, in a special facility for the criminally insane, or in a criminal justice system institution such as a penitentiary. We believe that our model for forensic psychiatric facilities has great advantages for the patient. Here the patient is treated in a specialized facility (as all psychiatric patients with specialized problems should be); but one which is a specialized forensic facility, within the range of specialized psychiatric facilities that are needed by an urban community.(ABSTRACT TRUNCATED AT 250 WORDS)     

A National Survey of Mental Health Services Available to Offenders with Mental Illness: Who Is Doing What?

The purpose of this study was to examine the national practices of psychotherapy services for male offenders with mental illness (OMI) in state correctional facilities. Participants consisted of 230 correctional mental health service providers from 165 state correctional facilities. Results indicated that mental health professionals provided a variety of services to OMI that can be conceptualized by six goals considered important in their work: mental illness recovery, emotions management, institutional functioning, re-entry, risk-need, and personal growth. Mental health professionals in this study generally viewed mental illness recovery, institutional functioning, and personal growth as significantly more important and spent more time focused on these goals than emotions management, re-entry, and risk-need. Mental health professionals tended to believe the services they provided were effective across four key treatment foci including mental illness, skill development, behavioral functioning, and criminogenic needs with more progress perceived in areas related to mental illness and skill development than their ability to effectively change behavioral functioning. Implications of these findings and directions for future research are discussed.     

A profile of mentally disordered offenders admitted to inpatient psychiatric services in the United States

This research note presents data about mentally disordered offenders (MDOs) treated in inpatient psychiatric services. Data are derived from 1980 admission surveys by the Survey and Reports Branch, National Institute of Mental Health (NIMH). These data report for the first time inpatient services provided to MDOs by non-Federal general and private hospitals. A total of 31,773 MDOs were admitted, with 85% going to state and county mental hospitals. The largest group, including admissions for evaluation, was ISTs (58%), followed by mentally disordered prisoners (32%), NGRIs (8%), and MDSOs (3%). Women and whites tended to be overrepresented among MDOs as compared to prison and jail inmates. Clear diagnostic differences by legal status were found, with schizophrenia predominant among NGRIs (81%) and alcohol and drug abuse disorders more frequent among ISTs. Overall, state and county hospitals in both 1967 and 1980 were the primary locus of care for mentally disordered offenders.     

Private regulation in mental health

General hospitals are increasingly important sources of care for chronic and acute mental patients. Joint Commission on Accreditation of Hospitals (JCAH) standards for staffing in general hospitals require the same degree of physician supervision and control for all services, including mental health. This paper considers the economic impact of JCAH standards on the practice of psychologists in hospitals. The “voluntariness” of the standards is assessed and the evidence that these standards foster economic protectionism is considered. We conclude that in light of the demonstrated capability of nonphysician professionals, methods of quality control appropriate for physician health care in general hospitals should be reconsidered as these instutions diversify into mental health services.     

Inmate Attitudes Toward Treatment: Mental Health Service Utilization and Treatment Effects

This study examined inmate attitudes toward treatment, mental health treatment utilization, and treatment effects that maximize treatment effectiveness. Participants consisted of 278 incarcerated male adult offenders from the Kansas Department of Corrections. Multiple linear regression analysis indicated that inmate attitudes toward treatment were predictive of the number of mental health treatment sessions (dosage) inmates received. Hierarchical linear regression analyses indicated positive help-seeking attitudes were associated with institutional behavior (decreased number and severity of disciplinary infractions) and scores on a measure assessing risk for future criminal behavior; however, the amount of mental health treatment an inmate received (treatment dosage) was associated with problematic institutional behavior (i.e., increased severity and number of disciplinary infractions). These results indicated that treatment dosage and behavioral outcomes were impacted by inmate attitudes toward treatment. As a result, correctional psychologists may be better able to predict which inmates will receive the most benefit from services. Implications of these findings for practitioners and policy makers are discussed.     

The Prevalence of Mental Illness Among Inmates in a Rural State

A limited number of recent empirical studies suggest that inmates suffer from high rates of serious mental illness. Different explanations are offered depending on the type of institution: jail or prison. The literature is based largely on urban samples and does not offer comparisons of rates across types of institution within a single study. The present study examined a random sample of 213 jail and prison inmates in a rural state using the Diagnostic Interview Schedule (III-R). Among jail inmates there was little evidence of high rates of serious mental illness, suggesting the criminalization of mental illness may not be as evident in rural settings as urban areas. Among prison inmates, however, high rates of mental disorders were found, supporting previous findings in urban and rural jurisdictions. Implications of the findings are discussed in the context of a consolidated correctional system.     

The Correctional Experiences of Youth in Adult and Juvenile Prisons

This article analyzes data from interviews with inmates to examine the correctional experiences of young men incarcerated through criminal (adult) courts in a large Northeastern state. The sample (N = 95) includes respondents from five correctional institutions; some of these inmates have been sentenced to adult department of corrections facilities, and some to juvenile facilities operated by the state's children's services bureau. Relative to the adult facilities, the juvenile facilities are smaller, have much lower inmate‐to‐staff ratios, and they place greater emphasis (in their official guidelines) on treatment, counseling, education, and mentoring of inmates. As a result, one might expect juvenile‐facility inmates to report a relatively more supportive, mentoring‐focused style of staff–inmate interactions than adult‐facility inmates. Yet surprisingly, inmates in adult facilities report better access to education and treatment/counseling services offered in their facilities.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); mental health services--DoD. Final rule

This final rule is to reform CHAMPUS quality of care standards and reimbursement methods for inpatient mental health services. The rule updates existing standards for residential treatment centers (RTCs) and establishes new standards for approval as CHAMPUS-authorized providers for substance use disorder rehabilitation facilities (SUDRFs) and partial hospitalization programs (PHPs); implements recommendations of the Comptroller General of the United States that DoD establish cost-based reimbursement methods for psychiatric hospitals and residential treatment facilities; adopts another Comptroller General recommendation that DoD remove the current incentive for the use of inpatient mental health care; and eliminates payments to residential treatment centers for days in which the patient is on a leave of absence.