Current Issues in Correctional Psychiatry or (if you want to be cynical) …so what else is new? Jeffrey L. Metzner, M.D. Clinical Professor of Psychiatry University of Colorado School of Medicine

A new textbook…

Patients in State and County Hospitals 1979: 140,35563/100, : 140,35563/100, : 54,01520/100,000* 1997: 54,01520/100,000* Transinstitualization/criminalization hypothesis** Transinstitualization/criminalization hypothesis** *RW Manderscheid and MJ Henderson, eds. Mental Health United States 1998 and Mental health United States DHHS Pub. #(SMA) , Washington, DC: US Government Printing Office, 1990 and **Erickson, Rosenheck, Trestman, Ford, Desai. Risk of Incarceration between Cohorts of Veterans with and without Mental illness Discharged from Inpatient Units. Psychiatric Services: 59, , Feb

California (135,981), Texas (168,280), and the Federal system (201,697) together have 37% of all the prisoners in the nation. California (135,981), Texas (168,280), and the Federal system (201,697) together have 37% of all the prisoners in the nation. The 21 smallest jurisdictions accounted for 7.8% of the total population under jurisdiction at midyear Prisons (2013)

Prevalence rates of mental disorders Studies and clinical experience have consistently indicated that 8-19% of prison inmates have psychiatric disorders that result in significant functional impairments. Studies and clinical experience have consistently indicated that 8-19% of prison inmates have psychiatric disorders that result in significant functional impairments. Another 15-25% of inmates will require some form of psychiatric intervention during their incarceration. Another 15-25% of inmates will require some form of psychiatric intervention during their incarceration.

Right to treatment

Landmark cases Cooper v. Pate 278 U.S. 546 (1964) Cooper v. Pate 278 U.S. 546 (1964) Estelle v. Gamble 429 U.S. 97 (1976) Estelle v. Gamble 429 U.S. 97 (1976) Bowring v. Godwin 551 F.2d 44 (4 th Cir. 1977) Bowring v. Godwin 551 F.2d 44 (4 th Cir. 1977) Bell v. Wolfish 441 U.S. 520 (1979) Bell v. Wolfish 441 U.S. 520 (1979) Ruiz v. Estelle 503 F. Supp (S.D. Tex. 1980) Ruiz v. Estelle 503 F. Supp (S.D. Tex. 1980) Miller v. French (2000) (Prison litigation reform act) Miller v. French (2000) (Prison litigation reform act) Coleman v Brown & Plata v. Brown (131 S. Ct. 1910, 1923 (2011) Coleman v Brown & Plata v. Brown (131 S. Ct. 1910, 1923 (2011)

Three essential elements required to establish a constitutionally adequate correctional mental health system are as follows: Adequate physical resources regarding treatment program space and supplies; Adequate physical resources regarding treatment program space and supplies; Adequate human resources concerning numbers of properly trained and/or experienced mental health staff who will identify and/or provide treatment to inmates with serious mental illnesses; and Adequate human resources concerning numbers of properly trained and/or experienced mental health staff who will identify and/or provide treatment to inmates with serious mental illnesses; and

Adequate access for inmates to the physical and human resources within a reasonable period of time (Cohen 1993). Adequate access for inmates to the physical and human resources within a reasonable period of time (Cohen 1993). Cohen F: Captives’ legal right to mental health care. Law and Psychology Review. 1993; 17:1-39.

Standards and/or guidelines for correctional health care programs American Psychiatric Association American Psychiatric Association American Public Health Association American Public Health Association National Institute of Corrections, National Institute of Corrections, National Commission on Correctional Health Care National Commission on Correctional Health Care American Nurses Association American Nurses Association Association of Correctional Psychologists Association of Correctional Psychologists

Current issues in correctional psychiatry Mental health issues relevant to lockdown units (e.g., segregation, disciplinary, supermax, etc.). Mental health issues relevant to lockdown units (e.g., segregation, disciplinary, supermax, etc.). Mental health input into the disciplinary process. Mental health input into the disciplinary process.

Discharge plans for inmates with serious mental illness. Discharge plans for inmates with serious mental illness. Special Needs of Female Inmates Special Needs of Female Inmates Research ethics (see IOM report- Research ethics (see IOM report- Substance Abuse Treatment Substance Abuse Treatment

Segregation Housing Issues

Mentally ill prisoners in segregation Security housing unit (SHU) (“Supermax”) Security housing unit (SHU) (“Supermax”) Administrative segregation Administrative segregation Disciplinary (punitive) segregation Disciplinary (punitive) segregation Pre-hearing detention Pre-hearing detention Protective custody Protective custody Other? Other?

Types of segregation Disciplinary segregation, which is based upon what the inmate did, is typically ordered as punishment for an institutional infraction, and is often of relatively short duration. Disciplinary segregation, which is based upon what the inmate did, is typically ordered as punishment for an institutional infraction, and is often of relatively short duration. Administrative segregation is typically imposed based upon what the inmate will do. That is, administrative segregation is prospective in nature, and designed to protect other inmates from a danger believed to be posed by the inmate. Administrative segregation is typically imposed based upon what the inmate will do. That is, administrative segregation is prospective in nature, and designed to protect other inmates from a danger believed to be posed by the inmate.

It is often administrative segregation, a classification status, which has now commonly led to the imposition of long- term segregation. It is often administrative segregation, a classification status, which has now commonly led to the imposition of long- term segregation.

The use of supermax confinement is overutilized within correctional facilities in the United States. The use of this type of program, because of its extreme limitations on liberty and its potential for harm, should be reserved for cases in which there is no less restrictive way to remedy an unsafe situation.

The major problems relevant to the mentally ill in segregation involve issues related to the following: Definition of mental illness Definition of mental illness Duration of confinement in segregation Duration of confinement in segregation Conditions of confinement Conditions of confinement Clinical assessment of the above 3 factors Clinical assessment of the above 3 factors

American Psychiatric Position Statement Prolonged segregation of adult inmates with serious mental illness, with rare exceptions, should be avoided due to the potential for harm to such inmates. If an inmate with serious mental illness is placed in segregation, out-of-cell structured therapeutic activities (i.e., mental health/ psychiatric treatment) in appropriate programming space and adequate unstructured out-of- cell time should be permitted. Correctional mental health authorities should work closely with administrative custody staff to maximize access to clinically indicated programming and recreation for these individuals. Prolonged segregation of adult inmates with serious mental illness, with rare exceptions, should be avoided due to the potential for harm to such inmates. If an inmate with serious mental illness is placed in segregation, out-of-cell structured therapeutic activities (i.e., mental health/ psychiatric treatment) in appropriate programming space and adequate unstructured out-of- cell time should be permitted. Correctional mental health authorities should work closely with administrative custody staff to maximize access to clinically indicated programming and recreation for these individuals.

Segregation Housing More than half of prison suicides occur in segregation units Federal Bureau of Prisons Study ( )

Segregation Housing (cont.) Yet segregation accounts for less than 10% of prison beds

Zubek, Bayer, and Shephard: conceptualize segregation units to have three main characteristics: conceptualize segregation units to have three main characteristics: social isolation, social isolation, sensory deprivation, and sensory deprivation, and confinement. confinement.