My Work as a Psychologist in Prison

I have received some email inquiries from my blog readers asking for more information about my job as a psychologist working in a prison. I thought that I would try and answer them here.

I presently work with some of our most challenging inmate-patients — those who are a danger to themselves, others or gravely disabled. This means that all of my current patients:

1. Have active suicidal ideation, intent or plans
2. Have homicidal ideation, intent or plans to hurt others, or
3. As a result of a mental disorder, are not making using of food, clothing, shelter, or other activities of daily living even though all of those items are made available.

My daily routine involves completing rounds, seeing each of these patients and determining whether or not their level of care should be stepped down or if they should be discharged and returned to the hands of custody officers. In conjunction with my team, I also determine whether or not the condition is severe or chronic enough to warrant a referral to the Department of Mental Health.

At this level of care, some interesting things happen. It is not unusual for a patient to be observed smearing or throwing his feces, to spit on, yell at, or threaten mental and medical healthcare staff. The other day, my patient successfully demonstrated how his voices could help him get out of his handcuffs. Mind you, he was handcuffed for safety concerns only — I usually have them in my office uncuffed.

Below are some of my recent clinical responsibilities.

Mental Health Screening: Each inmate entering the state's prison system receives a quick mental health screening. This is a quick assessment designed to evaluate for major mental health disorders such as Bipolar Disorder, Schizophrenia and Major Depressive Disorder. The inmate is then given a screener for potential developmental delays. This is important because inmates with limited cognitive functioning are at increased risk for victimization. They may also need a staff member to assist them with hearings, daily grooming, following directions and/or writing.

Emergency Duty: There are plenty of emergencies in prison. Psychologists and psychiatrists are on call to respond to mental health crises. These may entail calls for suicidal ideation, homicidal ideation, grave disability, victimization, rape, major depression, mania, panic attacks, grief, breakups or death of a loved one. In addition, there is a strong prison culture part of which demands that there is "no crying in prison." Inmates are only "allowed" to cry when their mom dies. Crying at any other time puts them at risk for harm by other inmates. Custody officers will refer an inmate as an emergency if he is caught crying or exhibiting other unusual or nonconforming behavior such as using racial slurs at targeted groups, poor hygiene, urinating in a common area, etc.

Psychological Intakes: Inmates who are referred to mental health receive an intake evaluation to determine whether or not they have a diagnosis needing treatment. These intakes are very similar to those used in community mental health or private practice. If necessary, a treatment plan is created and referrals are provided.

Therapy: Individual and group therapy is available to inmates using mental health services. Many inmates suffer from hard to treat personality disorders, particularly Antisocial, Narcissistic, and Borderline Personality Disorders. Many more are coping with drug addiction and polysubstance dependence. Some younger inmates or first-time offenders suffer from adjustment disorder. We see a variety of other disorders, particularly Bipolar I and II, Schizophrenia (Paranoid and Disorganized types), Schizoaffective Disorder, Generalized Anxiety Disorder, Substance-Induced Psychotic Disorders, and Major Depression. Personally, I conduct both individual and group therapy. I also still facilitate a group for inmates serving life in prison.

Court-Ordered Assessments: I have conducted court-ordered assessments from time to time. These assignments are from Judges seeking a psychologist's opinion as to a defendant's sentence — in short, a recommendation for prison or probation. Other court-ordered assessments seek recommendations for conditions of parole, i.e. Alcoholics Anonymous, therapy or parental visitation issues. A full psychological report is produced and submitted to the court.

See Inside the Fence for an account of my first day as a prison psychologist and Clarice Meets Hannibal for some insight into my interactions with inmate-patients.