Prison mental health services: results of a national survey of standards, resources, administrative structure, and litigation

The formation of adequate mental health systems within prisons has accelerated as a result of successful class action lawsuits. Our recent national survey questioned all state correctional departments about the existence of standards in each system, compliance with such standards, prevalence of class action lawsuits involving the issue of providing adequate mental health services for inmates, issues related to consent decrees, available mental health resources within the correctional system, and the administrative structure of the mental health system. Our purpose was to identify those factors correlated with certified class action lawsuits involving issues related to mental health services. Twenty-one states were involved in such litigation. Only the presence of psychiatric hospitals operated by the department of corrections correlated with the presence of certified class action lawsuits involving mental health services. Prison systems larger than 15,000 inmates were at higher risk for such litigation. Smaller systems having psychiatric hospitals run by the state mental health agency appeared to be at less risk for such litigation.     

Understanding how sexual offenders compare across psychiatric and correctional settings: examination of Canadian mentally ill sexual offenders

Abstract

Much of what is known about sexual offenders is based on correctional samples and then applied across settings based on the assumption that this group is homogeneous. In this study, 149 files were compared, including 108 cases from the forensic mental health system (FMH) and 41 cases from the correctional system (COR). Although many similarities were observed between the FMH and COR groups, the results also revealed important differences. The FMH group was characterised by more frequent hospitalisations, higher rates of major mental illness and single status. The COR group was characterised by a history of physical and sexual abuse, family history of addictions, more intrusive sexual offences and higher rates of offending. These results highlight different profiles for sexual offenders in forensic mental health and correctional settings and challenge us to consider the implications for assessment, treatment and risk management of this unique group of sexual offenders.     

Nonsexual boundary violations: sauce for the gander

Numerous articles in the mental health literature concern sexual contact between therapists and patients, which is explicitly prohibited by all four mental health professions' ethical codes. There is relatively little about nonsexual boundary violations, which are often covert and much more difficult to recognize (particularly in their early stages) than sexual violations; what little there is assumes that the clinician has the power in the relationship and uses that power for personal advantage. In this article the authors discuss the situation, rare in civil mental health facilities but common in correctional and forensic mental health facilities, in which personality-disordered patients manipulate and coerce clinicians to cross appropriate professional nonsexual boundaries for the patients' benefit; this reversal of the usual power dynamics between treaters and patients requires recognition of the role reversals present and requires different strategies for preventing such violations (hence "sauce for the gander").     

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.     

Psychological assessment of forensic psychiatric outpatients

The 1960s decrease in long-term residential mental health care resulted in former psychiatric patients being admitted to correctional and forensic psychiatric facilities. Although psychologists face challenges in managing and treating this displaced population, assessment data plays a pivotal role in the determination of appropriate aftercare for the mentally ill parolee. This article discusses the assessment protocol utilized by the Forensic Conditional Release Program (CONREP) in California, summarizes data from these patients, and uses case excerpts to illustrate the potential value of assessment with a forensic psychiatric (outpatient) population. Special emphasis is given to the use of the MMPI-2 and Rorschach.     

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)     

Mentally ill offenders in prison: the Belgian case

According to the EUPRIS-study on mental health in prisons (2007), available data on mental disorders in prison are scarce. Therefore, this study aims at summarizing and discussing the available knowledge on incarcerated mentally ill offenders concerning: (1) the screening and assessment for detecting mental health; (2) the psychiatric expertise in order to evaluate the mental status; and (3) the development and provision of forensic psychiatric treatment and care. These findings will be applied to the current situation in Belgium, which is a particularly interesting case. Belgium is currently facing difficulties concerning a large population of interned mentally ill offenders residing in correctional establishments.Implications with regard to the penal code, general or mental health legislation, screening, assessment, and treatment could deliver interesting viewpoints on how this problem could be tackled more effectively. Therefore, the findings will be discussed with reference to the international scientific and policy debate, focusing on ethical implications.     

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 multivariate analysis of sex offender recidivism

Sex offender recidivism risk is a multifaceted phenomenon requiring consideration across multiple risk factor domains. The impact of treatment involvement and subsequent recidivism is given limited attention in comparison to other forensic mental health issues. The present analysis is a retrospective study of sex offenders treated at a secure facility utilizing a cognitive-behavioral program matched with an untreated correctional sample. Variables studied included demographic, criminal history, offense related, and treatment progress. Recidivism was assessed through arrest data. Multivariate analysis suggests that recidivism is significantly related to quality of treatment involvement, offender demographics, offense characteristics, and criminal history. Successfully treated offenders were significantly less likely to subsequently reoffend. Recidivists were also significantly younger, less likely married, had engaged in more victim grooming or less violent offending behavior, and had significantly more prior property charges. The authors discuss the clinical and policy implications of the interrelationship between treatment involvement and recidivism.     

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.     

Forensic mental health law reform in Japan: from criminal warehousing to broad-spectrum specialist services?

Since the 1980s Japan has undergone a number of mental health law reforms culminating in the 2005 forensic law. This added to its enactments on involuntary commitment, long-term aged care and substitute decision making, bringing Japan into focus as an industrialized state now possessed of a full package of civil and forensic provisions. This article seeks to demonstrate that the new forensic law cannot achieve its own stated goals without seeking to put into place financial and administrative supports aimed to integrate the myriad of patient populations that will be inevitably affected by the new forensic system. In order to avoid the widespread syndrome that has already been experienced internationally of warehousing mentally ill offenders in jails, it is critical that the Japanese government develop effective and culturally sensitive techniques for dealing with low risk populations through a diversionary process. Furthermore, although the legislation addresses serious crimes, it is imperative that policies be put into place to avoid directing young offenders, violent patients from the general hospital system, the developmentally handicapped, already convicted persons found in hospital settings and problematic cases in the correctional system, to the new forensic units established by the legislation. It is only though contemplating unintended outcomes of the legislation that the Japanese government will be able to avoid the ongoing stigmatization and prolonged institutionalization of mentally ill populations. Despite apparent cultural differences internationally vetted human rights requirements must be properly protected, not only in the forensic context, but throughout the mental health system at large. The coordination of services and the development of specialty training are necessary conditions for the realization of improved and humane conditions for mentally ill persons in Japan.     

Prevalence of Criminal Thinking among State Prison Inmates with Serious Mental Illness

To examine the prevalence of criminal thinking in mentally disordered offenders, incarcerated male (n = 265) and female (n = 149) offenders completed measures of psychiatric functioning and criminal thinking. Results indicated 92% of the participants were diagnosed with a serious mental illness, and mentally disordered offenders produced criminal thinking scores on the Psychological Inventory of Criminal Thinking Styles (PICTS) and Criminal Sentiments Scale-Modified (CSS-M) similar to that of non-mentally ill offenders. Collectively, results indicated the clinical presentation of mentally disordered offenders is similar to that of psychiatric patients and criminals. Implications are discussed with specific focus on the need for mental health professionals to treat co-occurring issues of mental illness and criminality in correctional mental health treatment programs.     

Mental health performance measurement in corrections

Correctional facilities have become, by default, one of the largest providers of mental health care for patients with serious mental illness. In its 2002 Report to Congress, the National Commission on Correctional Health Care has reported that most facilities do not provide quality mental health care, nor do they conform to nationally accepted guidelines for mental health screening and treatment. This article describes the product of a consensus panel of correctional health care experts, charged to develop performance measures, based on nationally accepted standards, for selected elements of psychiatric treatment behind bars, aimed to improve the quality of care. Performance measures were developed for medication adherence, suicide prevention, mental health treatment planning, and sleep medication usage.     

A tale of two cultures: examining patient-centered care in a forensic mental health hospital

Several questions remain unanswered regarding the extent to which the principles and practices of patient-centered care are achievable in the context of a forensic mental health hospital. This study examined patient-centered care from the perspectives of patients and providers in a forensic mental health hospital. Patient-centered care was assessed using several measures of complementary constructs. Interviews were conducted with 30 patients and surveys were completed by 28 service providers in a forensic mental health hospital. Patients and providers shared similar views of the therapeutic milieu and recovery orientation of services; however, providers were more likely to perceive the hospital as being potentially unsafe. Overall, the findings indicated that characteristics of patient-centered care may be found within a forensic mental health hospital. The principles of patient-centered care can be integrated into service delivery in forensic mental health hospitals, though special attention to providers' perceptions of safety is needed.     

Why call someone by what we don't want them to be? The ethics of labeling in forensic/correctional psychology

Labeling a person by their past behavior or a criminal conviction is commonplace throughout forensic and correctional psychology. Labels including ‘offender’ and ‘sex offender’ infiltrate academic writing and conference presentations, names of professional organizations and treatment programmes and, at times, traverse therapeutic work. That such labels are frequently used and rarely advocated against suggests that helping professionals either (i) don't recognize labeling as an ethical issue, or (ii) don't consider it their role to challenge. The current paper aims to encourage critical reflection on the use of labels in forensic and correctional psychology. Key concerns are illustrated through a focus on labels commonly assigned to individuals who have sexually abused, where labeling is especially prolific. The scope of labeling is reviewed, and implications for rehabilitation and reintegration discussed. Next, an analysis of the ethics of labeling individuals on the basis of criminal convictions, past behavior or psychological phenomena is presented. It is argued that the use of such labels contradict core ethical principles including beneficence and nonmaleficence, respect for the dignity of all persons, and responsibilities to society. A de-labelling movement for forensic/correctional psychology and related fields is proposed.     

Community In‐Reach Through Jail Reentry: Findings from a Quasi‐Experimental Design

Offenders face a number of significant challenges upon reentry into the community, including securing employment, locating housing, and accessing adequate substance abuse and mental health treatment. These and related issues, if neglected, only bolster rising recidivism rates which have prompted renewed interest in rehabilitation initiatives such as inmate reentry. Many jurisdictions have implemented programs designed to improve offenders' success after prison, but jail reentry programs are far less common. This study examined the effectiveness of one such program, the Auglaize County (OH) Transition (ACT) Program. Using a quasiexperimental design, recidivism was measured a year after release to determine if participation in the ACT Program was predictive of successful reentry. Findings suggest that program participation is strongly related to outcome success as was criminal history. Implications for correctional policy and suggestions for additional jail reentry research are considered.     

DBT in an outpatient forensic setting

Literature shows that effective treatment of borderline personality disorder (BPD) has become possible. However, borderline patients in forensic psychiatry do not seem to benefit from this development. In forensic psychiatry, prevention of criminal recidivism is the main focus of treatment, not core borderline problems like parasuicidal and self-destructive behavior. A dialectical behavioral treatment program for BPD was implemented in an outpatient forensic clinic in The Netherlands. Sociodemographic, clinical, and treatment data were collected from ten male, and nineteen female forensic BPD patients, and compared with corresponding data from fifty-eight non-forensic BPD patients. The results show that it is possible to implement dialectical behavior therapy in an outpatient forensic clinic. The data indicate that the exclusion of forensic patients, and especially female forensic patients, from evidence-based treatment is unjustified given the highly comparable clinical and etiological characteristics they share with female BPD patients from general mental health settings.     

A qualitative exploration of the experience of restorative approaches in a forensic mental health setting

Restorative justice (RJ) is an intervention gaining worldwide recognition in criminal justice systems and other settings. There is a growing evidence base demonstrating positive outcomes in a number of domains, but we found no previous research focussed upon the use of RJ in a forensic mental health setting. This study used a constructivist grounded theory analysis of semi-structured interviews to explore and develop a deeper understanding of RJ practices interventions in such a setting. Ten participants including RJ facilitators, patients and mental health staff took part in research interviews. Restorative interventions were found to be congruent with models of mental health and offender recovery. Processing emotions, developing thinking and coherent narrative, and immediacy are found to be key components of the intervention. The emergent model highlights the role of containment and a high level of facilitator skill when working with a complex, vulnerable and potentially unstable client group.     

Medication noncompliance in schizophrenia: codification and update

Risk of relapse and recidivism makes the failure to take antipsychotic medication as prescribed a significant issue in forensic psychiatry. This question may arise in such contexts as the setting of bail, plea bargaining, the insanity defense, and sentencing. We have reviewed the literature on medication noncompliance in schizophrenia and present here the results, organized by topics relevant for the work of forensic mental health experts. Reported rates of noncompliance vary widely, reflecting major differences in the populations studied and the methods used as well as the complexities involved in defining noncompliant behavior. A noncompliance rate of 50 percent has been attributed globally to chronic patients, both medical and psychiatric. The tendency of significant factors to interact precludes a simple typology of noncompliance. However, environmental security and supportiveness correlate positively with adherence; whereas anxiety, paranoia, grandiosity, depression, and side effects correlate negatively. Clinicians' assessments of whether medication is being taken have proven to be unreliable. Although monitoring by chemical measurement, particularly a radioreceptor assay for urine samples, can be useful, depot injection ensures that prescribed medication is being taken. Less invasive means of promoting compliance are described; psychodynamic and ethical issues to be considered in the monitoring and promotion of compliance over extended time periods are presented. We also probe the link between medication noncompliance and behavioral relapse. The time between default and relapse is most often measured in weeks. Whether due to medication withdrawal or not, the relapse pattern of each individual tends to repeat, allowing its recognition before recidivism occurs. Restarting medication at this stage, especially with a dosage increase, is usually effective. In sum, the forensic mental health expert can now readily use a large and diverse literature to assist with a variety of significant issues.     

The Criminogenic,Clinical, and Social Problems of Forensic and Civil Psychiatric Patients

Forensic psychiatric patients consume an increasing proportion of mental health resources in Canada and the United States. To inform mental health policy and practice, we compared the criminogenic, clinical, and social problems of forensic patients to those of civilly committed psychiatric patients in two Canadian studies. We predicted that forensic patients would score higher on criminogenic problems and lower on clinical and social problems than civil patients in two studies: one comparing 83 forensic and 189 civil inpatients on a clinician-completed form, the Resident Assessment Instrument--Mental Health, at an urban mental health center, and the second comparing 423 forensic and 178 civil patients assessed at different times using the Patient Problem Survey. The two studies were quite similar in their findings, despite differences in their samples, measures, and data collection methods. In both studies, forensic patients were similar to or lower than civil psychiatric patients in all criminogenic, clinical, and social problems. We conclude that forensic mental health services would benefit greatly by drawing from knowledge accumulated in the general psychiatric literature. This finding also supports the idea that many forensic patients can be appropriately diverted to nonforensic mental health services.