Correctional Psychiatry I - Tx Flashcards
Benjamin Rush
American psychiatrist, penologist, founded APA, established hard labor as method of punishing convicted criminals
Walnut Street Jail (2)
First correctional institution in US (1790). Introduced “Pennsylvania System” as putting severe offenders in solitary confinement for reflection/repent
Reformatory Model
Established late 1800s. Recommended educational/training programs with indeterminate sentencing to help develop self-respect
Progressive Era/Rehabilitative Institution (time, what it was, aim)
Begun early 1900s, then dominated 1950-1970. Medical model to understand/treat deviant behavior. Searched for alternatives and reintegration.
Trend For Last 40 years
Skepticism about rehabilitation. Harder sentencing/release and more determinate sentencing
Incarceration Trends for Last 10-20 years
Rates have generally been decreasing
4 Purposes of Punishment
Deterrence
Incapacitation
Rehabilitation
Retribution
Discretionary vs. Mandatory Parole
D: When parole board has authority to release prisoners based on statutory/administrative determination of eligibility
M: Determinate sentencing statutes, inmates conditionally released after serving specific portion of sentence
2 Components of MH Diversion
- Screening/evaluation of defined groups for presence of mental disorder
- Negotiation with prosecutors, attorneys, CMH providers, courts to produce MH dispo instead of jail
2 Types of Diversion Programs
Prebooking - involves police, then emergency MH responses
Postbooking
3 Types of Postbook Diversion
- Dismissal of charges w/ agreement to participate in set services
- Deferred prosecution w/ reqs for tx participation
- Post-sentence relase where probation conditions involve MH/SA tx
4 Types of Confinement Facilities
Lockups
Jails
Prisons
Supermax
Lockups
Initial site from arrest to arraignment. Most common type, < 48 hours gen
Jails
Locally operated, confine before or after adjudication, and/or those sentenced to =< 1 year
Additional 5 Functions of Jails
- Readmit probation/parole/bailbond violators/absconders
- Temporarily detain juveniles before xfer to appropriate juvenile authorities
- Hold MI persons pending appropriate xfer to MH facilities
- Xfer inmates to Federal, State or other authorities
- Hold individuals for military, protective custody, contempt, or for courts as witnesses
Prisons
Long-term confineent, run by state or feds, holds for > 1 year
Prison Classification
Sorts prisoners into facility security level and inmate custody category
Facility Security Level
Nature/number of physical design barriers to prevent escape/ctrl behavior
Inmate Custody Category
Degree of staff necessary to ensure adequate control of inmate
Supermax (and aka)
Freestanding facility (or distinct unit) that provides secure control of inmates designated as violent or seriously disruptive behavior
AKA Security Housing Unit or SHU
2 Components of MH Problems Reported by Prisoners
Serious psychological distress (SPD) within 30 days prior to interview
History of having MH problem
6 SPD Items
Within last 30 days, how often felt:
Nervous
Hopeless
Restless/fidgety
So depressed nothing could cheer them up
Everything was an effort
Worthless
Having a MH Problem 7 Possibilities
Asked have you ever been told by MH prof that you had:
1. Manic depression/BPAD/mania
2. Depressive d/o
3. Schizophrenia/psychotic d/o
4. PTSD
5. Anxiety d/o such as PD or OCD
6. PD such as BPD/ASPD
7. Any other mental or emotional condition
Estimates of SMI in US Inmates
15-25%
Most Common Dx in Both M and F Offenders in Correctional Setting
Substance Abuse
Rate of ASPD in Male Offenders
Approx 50%
Setting with Most Suicides
Lockup
Most Common Suicide Method in All Settings
Hanging
Age Distribution of Jail Suicides
Bimodal: < 18 and > 55
Jail Suicide Timing 4 Findings
- Evenly distributed over first few days through several months
- Many occurred during waking hours
- Most not under influence of ETOH/drugs
- Many occurred in close proximity to court hearing
Leading Cause of Death in Jails
Suicide (almost 30% of all deaths) (2nd leading in prisons, 7%)
Jail Suicide Racial Breakdown
Whites most common (3x more than Hispanic and 5x than Black)
Types of Offenders Most Likely for Suicide
Violent offenders (kidnapping highest, then rape, homicide) - 5x more common than drug
11 Common Causes for Litigation 2/2 Suicide
- Inadequate MH/psych eval
- Failure to consider obvious/substantial RFs
- Failure to place on SPs upon recognizing
- Failure to communicate action to providers/staff
- Failure to adequately monitor on suicide watch/maintain log
- D/c suicide watch despite prior knowledge/cont’d risk
- Failure to follow policies/procedures
- Failure to provide staff training
- Abrupt d/c of meds on pt w/ previous behaviors
- Grossly inadequate tx or lack of general procedures/staff/etc creating “grossly inadequate healthcare system”
- Repeated delayed/denied medical tx
Security Threat Group (STG)
2+ inmates acting together who prose threat to security of staff/inmates and/or disruptive to programs/facility system
I.e., gangs
Homicide Rate in State Prisons
5 per 100,000 (2% of all deaths)
Prison Litigation Reform Act (what it is)
Permits prison/jail to alleviate constitutional violation caused by overcrowding, can release prisoners
Prison Litigation Reform Act 3 Reqs
-District court must determine overcrowding is “primary cause” of constitutional violations
-No other relief would be sufficient
-3-judge panel must review and consider impact on public safety/operation of CJS
Brown v. Plata (SCOTUS 2011) FOTC
2 class action lawsuits saying CA prison system violated 8th A due to deprivation of adequate healthcare
(CA system eventually placed into receivership bc state unable to fix system)
Brown v. Plata (SCOTUS 2011) Initial Panel Ruling
3-Judge Panel (Prison Litigation Reform Act) said overcrowding primary cause, set cap at 137.5% design capacity, ordered state to reduce by 40,000 over 2 years. Ruling appealed to SCOTUS.
Brown v. Plata (SCOTUS 2011) SCOTUS Ruling
Court-mandated pop limit necessary to remedy violation of prisoner’s const rights (primary cause and no other relief would remedy)
Brown v. Plata (SCOTUS 2011) Scalia 2 Dissent Points
Called it “most radical injunction” by SCOTUS in hx
1. Individual claims of unconst tx did not extend to all inmates
2. Most inmates that would benefit from this decision not part of Coleman or Plata (2 class-action suit groups) class
% Inmate UDS Positive
10%
Ganser Syndrome (what it is/etiology and 4 components)
Constellation of sx in prisoners that appear to be attempt to exhibit own generic concept of MI, unclear if malingering/fictitious d/o/dissociative d/o
1. Approximate answers (eg 2+2 = 5, elephant has 5 legs)
2. Clouding of consciousness
3. Somatic conversion (particularly sensory sx)
4. Hallx
Ganser Syndrome Pathognomonic Sx
Approximate answers (but also seen in malingering)
Inmates Malingering % of Suspected
66%
2 Triggers of Litigation re: Isolation/Segregation
- Wanton infliction of pain
- Denying basic human needs
Self-Harm in Isolation
Massive increase. (NY only 7.3% inmates experienced, but 53.3% acts of self-harm in this group)
Sexual Victimization by Inmates v. Staff
58% inmates 42% staff
Prison Rape Elimination Act of 2003
Calls of gathering national stats of problem of prison rape and developing guidelines for states about how to address
HIV/AIDS rate in Prisons
Approx 1%
Most Common Infectious Ds Reported in Prisoners
HCV (10%)
Privilege/Confidentiality in Correctional Settings
Still apply, however countervailing demands of security
7 Correctional Situations Where Might Suspend Confidentiality
- Suicidal
- Homicidal
- Presenting reasonably clear danger to self/others, either by conduct or statements
- Reasonably clear risk of escape/creating internal d/o or riot
- Receiving psych meds or is noncompliant
- Requiring xfer to special unit for acute episodes
- Requiring xfer to tx facility outside jail/prison
Dual Agency (Dual Loyalty)
Situations where psychiatrist subject to > 1 authority or potentially >1 moral principle
3 Disclosures MHP Should Make to Prisoners Due to Possible Dual Agency
- His/her agency
- Purposes of encounter
- Uses to which information will be put
National Commission on Correctional Health (NCCHC) Guidelines on Health Personnel and Forensics
Prohibit health personnel from collecting certain info for forensic purposes
Parole Boards and Confidentiality
In many states, parole boards (by statute) have access to health records, including MH evals/notes
Percentages of Psych Tx/Meds in Prisons
12% of state prison inmates receive psych tx, 15% psych meds
Constitutional Right to SUD Tx (2)
- When viewed as a status condition, no right to SUD “rehabilitation”
- In situations of “disease,” such as active w/d, then right to tx
Constitutional Right to ID Rehabilitation
None
APA Task Force (2016) Fundamental Policy Goal for Correctional MH Care
“provide same level of MH services that should be available in the community”
APA Task Force (2016) 3 Basic Services That Should Be Provided
- Screening/referral/evaluation
- Treatment
- Community tx
Most Important Service Element in Correctional MH Health (& possible case)
Screening
(Ruiz v. Estelle (1990)?)
3 Recidivism Rates (& more likely offenders)
3y: 68%
6y: 79%
9y: 83%
Property offenders more likely to be arrested for a new crime compared to drug and violent offenders
Mentally Disordered Offender (MDO)
Individually who has been formally judged by judicial system as both G of a crime and emotionally disturbed. NOT include those whose MI hasn’t been reocgnized by court.
