Corrections Psychiatry: Needles in a Haystack
Identifying treatable mentally ill detainees.
Posted Jul 24, 2018
Finding needles in a haystack. Separating the wheat from the chaff. The nature of corrections work is identifying individuals who suffer from a treatable mental illness and implementing the optimal treatment in suboptimal circumstances.
For three years I worked in a psychiatric hospital run by the department of corrections. That the DOC administered the facility is not unusual. The presence of pre-trial detainees in the same units as those already convicted of crimes made it unique. Men who’d been arrested by police and suspected to be laboring under a mental illness would be transferred to the DOC hospital for evaluation before they were indicted or convicted of any crime. Housed in units behind layers of fencing, barbed wire, and the ubiquitous control measures of any corrections facility, they were incarcerated for an evaluation period of around one to two months.
I was to expeditiously commence treatment for mental illness while the appointed evaluators (psychologists or designated psychiatrists) made recommendations to the court concerning disposition. For some, their “crimes” were obviously the product of mental illness and they would be transferred to state hospitals outside the criminal justice system.
The hospital served other functions. It housed men found incompetent to stand trial (deemed unable to sufficiently understand the legal process and assist in their defense) or those not criminally responsible for their actions. Both were remanded to the hospital for indeterminate periods until either restored to competence or no longer a threat to society. The concept of not guilty by reason of insanity is fraught with societal complexity.
Lastly, the hospital accepted referrals from other DOC facilities for evaluation of mental health concerns. Most of the facilities employed psychiatrists who saw patients in what would be akin to an outpatient setting. Like in the outside world, if an individual required more acute stabilization they would be sent to our facility. That often meant an inmate threatening suicide.
We were a maximum-security prison, but during the day if an inmate were in general population he could eat in the cafeteria, spend time in the gym, hang out in the yard. All under the watchful eyes of the COs (corrections officers) with restricted movement, but still a far cry from isolation. Those in Supermax could be in lockdown for 23 hours with only an hour to pace in a small, fenced-in area. You can see the incentive for threatening suicide or engaging in self-injurious behavior; they were transferred to our facility and possibly general population.
Many of those I attended to had severe mental illness, some with concomitant criminality. Working with the antisocial personality (common in prison, as you might imagine) was difficult; adding severe mental illness to that base model is like throwing gasoline on a burning tire. It challenged my ability to see through personality to deeper issues and to utilize treatments that could considerably improve outcomes.
An unexpected benefit was the time available to me. In today’s insurance world, lengths of stay are kept low; it’s rare to implement a treatment and observe the full course of recovery. On many occasions, because of the time available for observation at the prison hospital, I identified an illness, initiated medication, and had the satisfaction of watching the person return to their baseline. Sometimes that meant altering the course of their incarceration and putting them on a path to a more stable life.