Social and independent living skills for psychiatric patients in a prison setting. Innovations and challenges

There is a tremendous need for mental health services in correctional settings. An innovative psychosocial rehabilitation program that emphasizes skills training has been implemented by a state mental health agency within a large state prison. Preliminary results indicate that the treatment is effective in teaching social and independent living skills to mentally ill inmates. However, durability of treatment effects ultimately depends on the ability to track and to provide follow-up services for inmates after they are discharged to the general prison facility or to parole settings. Recommendations for developing and implementing effective systems of delivering mental health services in prisons are offered.     

Gender differences in jail inmates' symptoms of mental illness,treatment history and treatment seeking

Background Rates of mental illness among prisoners are substantial, but little is known about the unique mental health needs of women in jail, those under pre‐trial custodial remand or serving short sentences. Aims To compare male and female jail inmates along a wide range of symptoms of mental illness using identical assessment methods, and to examine gender differences in treatment seeking before and during incarceration. Methods Soon after incarceration in a county jail, 360 male and 154 female pre‐trial and post‐trial inmates completed the Personality Assessment Inventory, a wide‐ranging measure of psychiatric symptoms. Treatment seeking information was taken from official jail records. Results Women were more likely to report clinically significant symptoms of anxiety, borderline personality features, somatic concerns and trauma‐related symptoms; however, trauma‐related symptoms and borderline features were also common among male inmates. Although both men and women reported high rates of drug‐related problems, alcohol‐related problems were twice as prevalent among male inmates. Female inmates were more likely to seek and be enrolled in jail‐based treatment; there were no differences in reported help seeking prior to incarceration. Conclusions Female jail inmates are especially in need of mental health services. Effective interventions for post‐traumatic stress disorder and borderline personality disorder are needed in jail settings for both male and female inmates during incarceration and upon release. Copyright © 2009 John Wiley & Sons, Ltd.     

Lifetime use of mental health and substance abuse treatment services by incarcerated women felons

OBJECTIVE: This study examined the lifetime use of alcohol, drug, and mental health treatment services by recently incarcerated women prison inmates. METHODS: A total of 805 women entering a North Carolina prison for new felony charges in 1991 and 1992 were interviewed in person shortly after incarceration. The women were assessed for psychiatric disorders and lifetime use of substance abuse and mental health treatment services. Rates of service use were analyzed by inmate characteristics and were compared with rates for a sample of women in the community in North Carolina. RESULTS: The majority of women inmates reported a history of using substance abuse services or mental health services or both. Those with psychiatric disorders and prison recidivists were the most likely to have used such services. Rates of service use were substantially higher for the inmates than for the women in the community, even when the effects of having a psychiatric or substance use disorder were controlled for. CONCLUSIONS: Many of the incarcerated women in the study met lifetime criteria for alcohol, drug, and mental health disorders that were significantly related to their use of substance abuse and mental health treatment services. The majority of the inmates met criteria for a current disorder despite past treatment. Further research is needed to help in developing programs to reduce women inmates' alcohol, drug, and mental health problems.     

A survey of mental disability among state prison inmates

To obtain a comprehensive picture of the levels of mental disability in the general state prison population in New York State, the authors gathered data on a random sample of inmates using a survey instrument adapted from the state's level-of-care surveys of the psychiatric population. The sample consisted of 3,332 inmates in the general prison population (9.4 percent) and 352 inmates in prison mental health units. The survey results showed that 8 percent of the state's prison inmates have severe psychiatric or functional disabilities that clearly warrant some type of mental health intervention, and another 16 percent have significant mental disabilities that require periodic services. The specific nature and extent of these disabilities need to be assessed before appropriate services can be developed.     

Treatment prospects for persons with severe mental illness in an urban county jail

OBJECTIVE: A retrospective study of inmates with severe mental illness in a large, urban county jail aimed to obtain information about their psychiatric and criminal histories and status, the psychiatric services they used while incarcerated, and the challenges they might present in psychiatric treatment after release. METHODS: The authors ascertained demographic characteristics, diagnoses, psychiatric and legal histories, and current psychiatric condition and treatment from jail psychiatric records of a random sample of 104 male inmates with mental illness and from electronic county mental health records and state records of criminal histories. RESULTS: Seventy-eight inmates (75%) were diagnosed as having a severe mental illness. Of these, 59 (76%) required inpatient care or its equivalent for part of their time in jail for the current offense. Of the inmates with severe mental illness, 92% had a history of nonadherence to medications before this arrest, 95% had prior arrests, 72% had prior arrests for violent crimes against persons, and 76% were known to have a history of substance abuse. CONCLUSIONS: A large percentage of persons with severe mental illness received their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. The persons with severe mental illness in this study would present a major challenge in treatment in any setting given their psychiatric and criminal histories. The resources of the mental health system need to be greatly expanded, with priority given to treating persons who are criminalized or who are in danger of becoming criminalized.     

School-based mental health services in the united states: History,current models and needs

Children's mental health needs continue to be largely unmet, even when community services are provided. On-site mental health services in schools address unmet needs by improving access to, and relevance of services. As schools have increasingly been mandated to serve the needs of all children (including those who are emotionally disturbed) general health and mental health services have been increasingly placed in them. Although the provision of basic health care in schools began in the early part of the century, the concept of providing comprehensive services, in which mental health services are integrated into primary medical care, has only been implemented recently. We review the background of school-based mental health services, compare various models of service delivery, and highlight issues important to the future development and advancement of these services.     

Treatment of offenders with mental disorders: focusing on prison psychiatry

Forensic mental health services exist in a nebulous space at the intersection of two different systems-criminal justice and mental health-and the entanglement of these systems poses intricate problems for psychiatrists. This article discusses the present circumstances of forensic mental health services in Japan, focusing on trends in prison psychiatry. In the traditional Japanese system, offenders with mental disorders were treated within general psychiatry as involuntarily admitted patients, or within the prison system as mentally ill inmates. As a consequence of recent legal reform, however, this situation has radically changed. The Medical Treatment and Supervision Act of 2005 aimed to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their reintegration into society. Under the new system, a person who commits a serious criminal offense in a state of insanity or diminished capacity shall be referred by the public prosecutor to the district court; following a treatment order of the court, the person shall be treated in psychiatric facilities established by the law. While the new system is expected to play a role in the context of specialist forensic psychiatry, its distinction from general psychiatry remains unclear. For example, persons who commit serious crimes, such as assault, in an acute psychotic state are occasionally admitted to general psychiatric hospitals, even if they meet the criteria for a treatment order under the Medical Treatment and Supervision Act. The relationship between prison psychiatry and specialist forensic psychiatry is still more problematic. Compared to the intensive, rehabilitation-oriented care provided under the Medical Treatment and Supervision Act, mental health services in penal institutions have a number of disadvantages, and it is unlikely that mentally ill prisoners have benefited from the recent progress in forensic psychiatry. Statistics show that the number of sentenced prisoners with mental disorders has steadily increased during the last decade. Although a majority of these individuals are substance abusers, the number of patients with schizophrenia who are unable to serve a sentence due to severe illness is not insignificant. Although patients are sometimes transferred to medical prisons, a substantial number of inmates with mental disorders remain in general prisons, most of which lack adequate medical staff. Accordingly, the growing number of mentally ill inmates is imposing a heavy burden on the penal administration system. Provisions of the Mental Health and Welfare Act pertaining to general psychiatry are not applicable to patients in penal institutions. The Psychiatric Review Board established in each prefecture does not intervene in the management of these facilities. As a result, legal safeguards against the violation of patients' rights are not sufficiently guaranteed in penal institutions. There are no legal provisions for transferring patients with severe mental disorders from prisons to psychiatric hospitals. Once sentenced to imprisonment, offenders with mental disorders are treated almost exclusively within the prison system. This situation is particularly serious in the case of patients with long-term sentences. In addition, the continued availability of psychiatric care after discharge from prison, which is crucial for preventing relapse of illness and recidivism, is not assured. When a mentally ill inmate is discharged, the head of the institution is required to report the discharge to the prefectural governor, in accordance with the Mental Health and Welfare Act. Recently, although the number of such reports has sharply increased, in actuality many of the persons reported are not admitted to hospitals because they do not meet the criteria for involuntary admission, and the provisions of the Medical Treatment and Supervision Act do not apply to them. In conclusion, more attention should be paid to the reform of prison psychiatry. Coordination of the separate functions of general psychiatry, specialist forensic psychiatry, and prison psychiatry is also important.     

Guidelines for psychiatric services in prisons

Recent prevalence studies have found that 8–19% of prison inmates have significant psychiatric or functional disabilities. Efforts to establish adequate mental health systems in prisons within the USA were accelerated during the late 1970s as a result of successful class action lawsuits. These efforts have been assisted by the development of standards for correctional health care programmes by a variety of national organisations. This paper describes a framework for establishing an adequate mental health system within a prison. Basic principles for delivery of psychiatric services in prisons, administrative models for such services, guidelines for correctional based psychiatric treatment, and issues unique for correctional mental systems are reviewed.     

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in‐reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial (“disability”) are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic services.     

Rates of sexual victimization in prison for inmates with and without mental disorders

OBJECTIVE: This study estimated the rates of sexual victimization among prison inmates with and without a mental disorder. METHODS: The study sampled inmates aged 18 or older in 13 prisons within a single mid-Atlantic state prison system (12 facilities for men and one for women). A total of 7,528 inmates completed the survey instrument, which was administered by audio-computer-assisted technology. Of the 6,964 male respondents, 58.5% were African American, 16.2% were non-Hispanic white, 19.8% were Hispanic, and 5.5% were of another race or ethnicity. Of the 564 female respondents, 48.4% were African American, 30.9% were non-Hispanic white, 14.4% were Hispanic, and 7.3% were of another race or ethnicity. Mental disorder was based on self-reported previous mental health treatment for particular mental disorders. Sexual victimization was measured by using questions adapted from the National Violence Against Women and Men surveys. RESULTS: Approximately one in 12 male inmates with a mental disorder reported at least one incident of sexual victimization by another inmate over a six-month period, compared with one in 33 male inmates without a mental disorder. Among those with a mental disorder, sexual victimization was three times as high among female inmates (23.4%) as among male inmates (8.3%). African-American and Hispanic inmates with a mental disorder, independent of gender, reported higher rates of sexual victimization than their non-Hispanic white counterparts. CONCLUSIONS: Prisons are hazardous places. Steps must be taken to protect inmates from predators inside prison, to screen them for posttraumatic stress disorder, to provide trauma-related treatment, and to keep them safe.     

What do children and young people want from mental health services?

PURPOSE OF REVIEW: The purpose of this paper is to review the literature reporting on children and young people's views on child and adolescent mental health services. RECENT FINDINGS: The review demonstrates that there is limited research exploring the views of children and young people regarding mental health services. Despite its limitations, the research available shows that young people, their parents and healthcare providers often have different expectations of services. Young people want accessible services staffed by those they are able to trust and who demonstrate an ability to listen; above all, young people want to be involved in the decisions made about them. SUMMARY: To date, children and young people have not been actively engaged or involved in service development. This is an evolving field and we need to ensure that existing evidence is taken into account as well as investigating further the views of young people. Child and adolescent mental health services need to consider how we serve young people, particularly children, whose perspectives may differ from those of their parents.     

The organization and management of community mental health services

Development of Community Mental Health Centers has revealed the need for more effective administrative mechanisms for planning, developing, and controlling mental health services and for involving effectively the local community in this process. The public health model of primary, secondary, and tertiary prevention was used as a basis for planning and developing mental health services in two settings. The resulting organizations proved effective in providing qualitative mental health services and in developing effective work groups throughout the organization to take responsibility for program. Experience with this model supports specialization of state hospitals into rehabilitation facilities and their close integration with programs in the communities they serve. It is proposed that this will require state hospital programs becoming the responsibility of local communities.     

Growth of mental health services in state adult correctional facilities, 1988 to 2000

OBJECTIVE: This study examined trends in the availability and use of mental health services in state adult correctional facilities. METHODS: Results from the 1988 Inventory of Mental Health Services in State Adult Correctional Facilities of the Center for Mental Health Services were compared with those from the 2000 Census of State and Federal Adult Correctional Facilities survey of the Bureau of Justice Statistics. The two surveys were chosen because they occurred more than a decade apart, had a reasonable amount of data, and could be made comparable. RESULTS: This analysis used data from 757 state adult correctional facilities that were sampled in 1988. The number of such facilities increased to 1,097 in 2000, a 44.9 percent increase. A dramatic increase was also seen in the prison population, from 505,712 in 1988 to 1,084,625 in 2000, a 114.5 percent increase. Mental health services were offered in significantly more facilities in 2000 than in 1988. However, the relative percentage of facilities that offered mental health services decreased overall. Simultaneously, the percentage of inmates who used these services increased overall. CONCLUSIONS: The growth in prison facilities and the growth in prisoner populations are outstripping the more meager growth in mental health services. These results suggest that mental health services are becoming less available to the prison population, and service populations are becoming more concentrated in the facilities that do offer such services.     

Recent developments in antitrust: challenges to medical autonomy

Once exemptions from antitrust scrutiny were removed, economic arguments have proved effective in dissolving the hegemony formerly held by psychiatrists over the provision of mental health services. A growing number of courts, legislatures, and insurance companies have been persuaded by psychologists that they can provide at least comparable services at lower costs than psychiatrists. The fact that psychotherapy is less obviously a "medical" procedure than surgery or other physical treatments has facilitated the establishment of the psychologists' position. After these gains, there are indications that other mental health providers will follow the paths established by psychologists. Cost-containment efforts in the mental health care industry, particularly through health maintenance organizations, have already led to increased utilization of nondoctoral providers for initial screening services, and psychiatrists have even filed countersuits alleging restraint of their trade through the exclusive use of lower-cost providers (State Medical Society of Wisconsin v. Schweiker et al., 1982). With the clear message from many courts and legislatures that profession will no longer serve to distinguish among mental health providers, it appears that the validity of psychiatrists' assertions that independent practice by nonmedical mental health professionals will result in lower quality of care for patients will be tested in the marketplace, with peer review and tort litigation serving as the barometer by which that quality will be measured. And, as other nonmedical professionals establish their credentials through licensure and recognition by consumers, we can expect that they will also seek recognition of their capacities to provide (and be reimbursed for) professional services through the courts. With this greater access to consumers of mental health care will also come, of course, greater public scrutiny and greater risk of malpractice liability.     

On the Role of Correctional Officers in Prison Mental Health

This article discusses the role of correctional line staff in treatment of prison inmates with serious mental illness. The authors assert that many roles and duties traditionally attributed to clinicians can and often should be performed not only by mental health professionals, but by line staff such as correctional officers and nurses. Moreover, the optimal climate for effective treatment is one in which mental health professionals and line staff work collaboratively, especially since line staff alone are in contact with inmates 24 hours per day. The specific activities which comprise mental health treatment in prison are described as: 1) counseling and psychotherapy-talking with inmates, 2) consultation-talking about inmates, 3) special housing, activities, and behavioral programs, and 4) medication. Case examples demonstrate how correctional officers, nurses, and other line staff perform each of these activities. Recognition and nurturance of these activities will improve the quality of services and reduce stress on staff and inmates alike. Consultation with line staff, joint training, and use of multi-disciplinary treatment teams are advocated as methods of reaching these goals.     

Development of an innovative child and youth mental health training and services delivery project.

In 1989 North Carolina began funding a mental health demonstration training and services project to serve severely emotionally disturbed children and youth in the community. During the first two years of this state-university collaboration, consultation and direct services provided by faculty and student trainees have been linked to preexisting services at a mental health center serving three counties. The project has met initial goals of developing new and expanded services, building relationships with other agencies, and integrating university and mental health center staff. More formal process and outcome evaluations are under way. Areas of probable long-standing concern include the need for more cordial working relationships with other agencies and for more participation of parents in treatment and education programs.     

Standards of care for area mental health services

A provisional set of standards of care was derived from a quality assurance strand of a wider research project, which reported the development of evaluation strategies for area integrated mental health services (AIMHS). In contrast to most published standards, they apply to all facets of care in a comprehensive catchment area mental health service, whether clinical or functional, community or hospital based, urban or rural, or managed by the public, private or voluntary sectors. We review briefly existing sets of standards of mental health services and report the process of development of standards of care, each with sub-sets of performance indicators and examples. While the AIMHS standards and a companion quality assurance manual are still undergoing refinement, they offer a guide for mental health professionals to the provision of services, and a checklist to service-users of services that should be available to them at every stage of care in a mental health system.     

A study of offenses committed by psychotic inmates in a county jail

Following deinstitutionalization, several studies have documented an increase in the number of mentally ill inmates in prisons. The authors reviewed all referrals to a mental health clinic in a county prison and categorized each case as psychotic or nonpsychotic. The psychotic inmates were four times more likely to have been incarcerated for less serious charges such as disorderly conduct and threats, and they committed fewer sex offenses, property crimes, and drug offenses than nonpsychotic inmates. The authors conclude that the increased number of mentally ill prison inmates does not reflect a greater incidence of serious criminal activity in this group but an increase in the criminalization of psychotic behavior.     

Jail incarceration, homelessness, and mental health: a national study

OBJECTIVE: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. METHODS: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. RESULTS: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. CONCLUSIONS: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.