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Outline issues inherent in the provision of mental health care in the correctional setting.
Understand when inmate participation in mental health care and treatment can be required.
Explore the right to privacy with regard to mental health records.
Provision of mental health services is a necessary and complex part of any correctional operation.
Attention to planning and implementation of services to meet the mental health needs of population greatly contribute to a smooth running facility; inattention can lead to problems, negative publicity and litigation.
Correctional administrators must know the standards for care of mentally ill offenders.
Process for care of the mentally ill has changed significantly over the past fifty years. With the advent of psychopharmacology and focused therapies most people suffering from mental illness may be managed in outpatient settings.
The management of most mentally ill patients as outpatients has resulted in the deinstitutionalization of people needing care.
However, the lack of community resources and existing support systems has led to the inadequate treatment of some mentally ill persons and has resulted in their placement in the criminal justice system.
Current data reflect more mentally ill persons in jails and prisons than in community mental institutions.
About half of the inmate population has been diagnosed with a mental health problem with approximately 16% diagnosed with serious mental illness.
The Diagnostic and Statistical Manual of Mental Disorders
Most commonly used classification system of mental illness and defects.
A mental disorder is a: “clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability.”
Major mental disorders include diagnosis of: schizophrenia, major depression, or bipolar disorder.
Many inmates demonstrate personality dysfunction and meet criteria for Antisocial Personality Disorder and other personality disorders, which remain difficult to treat.
Guidelines and Standards
The responsibility for provision of care to those who are denied the ability to choose their own care because of confinement has been defined in the Courts and standards of several organizations published to review.
The current standard of care requires basic and clinically relevant care. Problems arise when care falls below accepted standards and may result in deliberate indifference.
Deliberate indifference can be evidenced by: lack of access, failure to follow through with care, insufficient provision of staff resources, and poor outcomes due to negligent care.
Guidelines and Standards
Several organizations have established minimum guidelines for the treatment of mentally ill in correctional environments:
a. American Correctional Association (ACA)
b. American Medical Association (AMA)
c. American Public Health Association (APHA)
d. American Psychiatric Association (APA)
e. The Joint Commission on Accreditation of Health Care Organizations
f. National Commission on Correctional Health Care (NCCHC)
g. National Institute of Corrections (NIC)
Standards and Guidelines
The importance of external review and accreditation should not be understated, and although there is considerable overlap of the intent in the standards, the degree of fit varies greatly. For example ACA looks at issues more broadly, while the Joint Commission is very specific.
Successful accreditation provides support for the correctional system when questions arise about the adequacy of care.
Access to Care
The 1980 court case Ruiz v. Estelle, 503 F.Supp. 1265 (1980), the Court focused on six issues which address the minimum standards for mental health care in a correctional environment.
a system to ensure mental health screening
provision of treatment while inmates are in segregation or special housing units
training of mental health staff to ensure individualized treatment
maintenance of an accurate and confidential medical record system
presence of an effective suicide prevention program
monitoring to assure appropriate use of psychotropic medication
These same issues remain relevant and essential today.
Mental health care begins at the screening stage when the offender arrives at an institution.
Inmates should be screened promptly upon arrival and before they are placed in a housing situation without direct staff observation.
The primary goal of screening is to identify emergent and urgent problems.
While screening forms and tools may be standardized, the screening should be individualized to each offender
Proper mental health intake screening will determine the type and immediacy of need for other mental health services.
Inmates requiring further assessment need to be housed in an area with staff availability and observation.
Further assessment may include: additional interviews, record collection and review, physical examination, laboratory studies, drug screening, continued observation and occasionally psychological testing.
Treatment needs can be met in a variety of settings:
While the concepts of outpatient and inpatient care is generally understood, transitional care represents inmates with similar problems being housed together in a general population unit with special programs in an attempt to integrate the offenders into the general population of a correctional system. They are designed to:
stabilize symptoms in a sheltered environment
improve coping skills to allow inmate to be housed or returned to general population
helping the inmate to better adapt to the general prison environment
Admission to an inpatient psychiatric hospital may be voluntary or involuntary and may be to a facility in the community or a prison psychiatric hospital. When there is an offender who requires by does not volunteer for admission, there is an administrative due process or judicial review concerning the need for hospitalization.
Reasons for inpatient hospitalization include:
Presence of severe or disruptive psychiatric symptoms
Inability of the system to handle the inmate in a less restrictive environment
Court orders for inmate inpatient evaluation or commitment
Assessed risk of imminent danger to self or others
Treatment Related to Diagnosis
All mental health treatment interventions are related to diagnosis.
Treatment may be delivered by various members of the mental health treatment team. Clear documentation of an individualized treatment plan should be placed in the inmate’s medical record. All members of the team may handle different diagnosis and defects. For example, a counselor may take lead on the diagnosis of mild depression, while medical staff (psychiatrist) would take care of psychosis.
Because of the relapsing nature and chronicity of some mental disorders discharge planning and follow-up care in the community is critical. The cornerstone of successful discharge planning remains sound diagnostic assessment.
Crisis intervention includes interventions aimed at reducing acute mental distress.
Frequency crisis present as suicidal ideation, suicide attempts or directed aggression.
Suicide prevention programs include adequate training of staff in the identification of signs and symptoms of suicide risk.
Issues Arising from Confinement
Some individuals enter the criminal justice system while mentally ill.
Others develop new symptoms or illness once in custody. The stress of being in the criminal justice system itself can create or exacerbate symptoms or illness.
Know stressors include involvement in the legal system, separation from existing community support systems, peer problems in the institution, loss of control and individual decision making. Further incarceration may disrupt activities of normal living and limit access to stress reducing activities.
Correctional health-care providers are confronted with issues of patient privacy and confidentiality. Medical and mental health information can be shared with other medical providers; however, there are strict restrictions on other release of health care information.
Inmates have the right to obtain copies of their medical records unless their health care providers deem such review would be detrimental to the inmate’s health.
Hospitalization in a psychiatric facility (even in a prison) is voluntary unless the level of impairment is so severe the patient presents a clear risk of harm to themselves or others.
Each state and the federal government, by statute, outline how a person can be involuntary hospitalized for psychiatric care.
Psychiatric hospitalization does not necessarily grant the care provider authority to treat.
To treat, the inmate must give informed consent to a specific treatment, unless the situation has been deemed an emergency or treatment has been authorized by the court.
Dual Roles of Clinical Staff
Clinical staff may feel caught between their roles as providers and correctional workers.
Inmate patients are to be notified of the security restrictions which are present. They need to be advised that information which might lead to the harm of the patient, others, or concerns about property destruction which could harm others will be disclosed.
Special Treatment Procedures
Use of special treatment procedures, such as seclusion or restraint requires close attention.
The goal should be to keep inmate patients in these most restrictive situations for the minimum amount of time to ensure their safe management.
Inmates in seclusion require enhanced staff observation and monitoring, including continuous monitoring if the inmate is viewed as suicidal.
Inmates must be regularly checked by medical personnel to ensure they are medically stable and circulation has not been compromised. Correctional staff ensures toileting, meals, and repositioning is accomplished. Both health-care providers and correctional staff share responsibility.
Medication is a frequent, costly, and potentially high-risk function within the correctional environment.
Pharmacotherapy is a mainstay of current mental health treatment but can present problems in a correctional environment.
Establishing clear and widely understood prescription guidelines is useful in managing the use of psychiatry medication, controlling costs and preventing abuse.
Medications should be kept to a minimum except for the treatment of clearly documented medical or psychiatric conditions
Medication compliance should be closely monitored.
Polypharmacy, the use of multiple medications from the same or similar class of drugs should be avoided.
Having the same provider prescribe helps to decrease medication seeking behavior. Every effort should be to have one prescriber manage an individual’s medication.
Personality Disorders and Malingering
The diagnosis of antisocial personality disorder is based almost exclusively on the basis of historical information. This diagnosis is demonstrated by a pattern of disregard for others, breaking the law and lying, as well as impulsive, irresponsible and aggressive behavior. This disorder is difficult to treat.
Malingering is a conscious behavior that involves falsely claiming or misrepresenting symptoms. Malingering is a diagnosis of exclusion, only after psychopathology is ruled out.
The Integration of Care
The success of any mental health care is related to the adequacy of general medical services. Medical illnesses often present with psychiatric symptoms. A significant number of psychiatric patients in the correctional environment have concurrent medical illnesses.
Each inmate admission to a psychiatric hospital requires a complete physical examination with extensive laboratory studies to rule our organic causes for presented symptoms.
Staffing correctional health care and mental health programs can be a difficult task. Few clinicians are trained to work in correctional environments. Most clinicians enter the field by accident. The provision of adequate care constantly competes with maintaining adequate security.
Ironically, many clinicians are realizing that correctional environments may be one of the last public strongholds for the adequate care of seriously and chronically mentally ill patients.
The environment with the absence of third-party payers, and the impact of externally imposed motivation to change create a unique setting for the provision of mental health care.
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