Better Off In Prison?
Better Off In Prison?
Ed Note: This article, originally published in Behavioral Healthcare (2010;30:26-29), has been chosen as a finalist for NIHCM Foundation’s Seventeenth Annual Health Care Journalism Awards. For the Behavioral Healthcare Web site and article, click here. For a related blog by Dr Moffic, see Wrestling With Evil in Prison Psychiatry.
When my clinic manager told me that prison may be the best place to practice psychiatry nowadays, I didn’t believe him. After all, prisons often seem like a world apart, often in isolated rural areas or in windowless, nondescript urban buildings.
Some mental health professionals feel that working in a prison is for second-rate clinicians who can’t get better work, as I once did, or that typical prisoners are sociopaths who cannot be treated successfully.
However, after working in prison psychiatry for six months now, I must say that my clinic manager may just be right, at least for this medium-security men’s prison in Wisconsin. There is much that the rest of our mental healthcare system, especially community mental health, can learn from what is in place in some prisons today.
Better access to care
Take access, for instance. Inadequate access for care has been a chronic problem in mental health, not only for the uninsured, but also for the minimally insured or those in tightly administered managed-care programs. As the current economic crisis reduces state Medicaid funding, more patients can’t find services and become progressively more dangerous, often ending up in jails or prison. This has been dubbed the “criminalization of mental illness.”
Once these individuals reach the prison system, however, access to mental healthcare is no longer a problem. In fact, access is easier for mental healthcare than for medical healthcare. There is no fee for mental healthcare, but there is a fee equivalent to a day’s work for non-emergency medical care. Mental health is a priority in prisons, in part because mental health conditions often connect to the behaviors that caused incarceration in the first place. Inmates identified as being “mentally ill” may also offer an alternative, and perhaps more acceptable, explanation to others regarding their criminal past.
Not only do prisoners who recognize they need mental healthcare have easy access, but those with undiagnosed mental health problems are more readily recognized by others because inmates are under constant observation. Of course, mental disorders can be viewed as an excuse for criminal behavior and a means of being “soft” toward prisoners, who are known to manipulate the system. Occasionally, this thinking results in an inmate with a mental health problem, such as impulsive ADHD behavior, ending up in the segregation unit instead of the psychiatrist’s office.
Access is especially important in prison due to the prevalence of mental health disorders. Up to 50 percent of inmates are thought to have some diagnosable psychiatric disorder, including alcohol and substance abuse disorders.
Safety and security
Of course, access is meaningless unless both clinicians and patients feel-and are-safe. Clinicians can and do get hurt, or worse: Wayne Fenton, MD, was killed in 2006 while assessing a paranoid psychotic patient in his empty, private practice office on a weekend.
Though infrequent, there have also been violent incidents in the community mental health centers where I have worked, both in the clinic and outside in the parking lot. When funds were available, we hired a security guard, but often we couldn’t afford it. I had assumed that working in a prison would be more risky, and I worried that my counter-transference of feelings of fear for my patients could limit my responsiveness to them.
However, security is the first priority of prisons, and, as it turns out, there hasn’t been a dangerous incident involving a healthcare clinician in more than 20 years. The prior psychiatrist warned me that deer jumping on the roadway are more dangerous to me than the inmates visiting the prison medical office.
Throughout my 35-year career, I’ve sought to find a practice setting where family practitioners, psychiatrists, and other mental healthcare clinicians work together. And, to my surprise, here it is-in prison!
The quality of all the staff seems equivalent to what I’ve known outside of prison. Among the psychiatrists in this Wisconsin system are two former department chairs of well-known medical schools. One is known for his work with the homeless, and the other for his work with aggressive behavior.
Our salary meets or exceeds that of facilities outside the prison system. Productivity standards are not excessive, as they sometimes are in community mental health settings.
The prison population
Despite the high level of security, everything is in place to provide competent treatment. Among the disorders that a prison psychiatrist sees are:
•Antisocial personality disorder, which is clearly associated with criminal behavior and a lack of remorse. Psychiatrists don’t see many cases outside of prison because patients with this disorder don’t feel they need help or manipulate their way out of treatment.
•Malingering, a diagnosis often associated with antisocial personality disorder in the DSM-IV, which I have never considered as often as I do now.
•Post-traumatic stress disorder (PTSD). I have found that a significant percentage of those thought to be primarily sociopathic often have an extensive history of trauma and a subsequent onset of post-traumatic stress disorder. The trauma is especially common in African-American males, who are heavily overrepresented in prison systems. One has to be careful here because it is so hard to be sure that reported trauma actually took place due to the possibility of fabrication and limited access to information from family and friends.
•Narcissistic personality disorder appears to be quite common among prisoners as well.
•A large group of prisoners also have the expected alcohol and substance abuse disorders, which are often at the root of their criminal behavior and subsequent imprisonment.
•Bipolar disorder. This is sometimes seen after prisoners get “clean” from substance abuse for the first time in many years. Manic behavior associated with bipolar disorder sometimes led to substance abuse as the individual attempted to self-medicate the mood swings.
•ADHD is overrepresented in prisoners, and is frequently seen in the core symptom of impulsivity. Another ADHD symptom-poor concentration at work and school-often contributes to subsequent crime.
•Schizophrenia. There seems to be a smaller, but still significant, percentage of the chronic and severely mentally ill inmates, including schizophrenics. In many cases, prisons have assumed the role once held by state hospitals, from which schizophrenic patients were discharged in the 1970s into often inadequate community-based treatment.
Besides the disorders that inmates have upon arrival, there are other disorders that tend to develop within the prison environment. Depressive disorders secondary to loss and separation from the outside world are common. Anxiety related to fears about prison life and the future are also common. Inmates traumatized by other inmates may experience PTSD or a triggering of memories of earlier trauma.
Treating inmate disorders
Several common challenges must be overcome before effective treatment can be provided. Prisoners tend to mistrust authority figures, including clinicians. Given that clinicians desire to help people and be healers, working with those who have done the opposite can elicit intense feelings such as antipathy or even horror. For clinicians, those feelings must be processed and accepted.
Nowadays, the application of psychotherapy is as limited in prison as it is outside. Medication is the mainstay of treatment, though any medications that can be abused or diverted to other prisoners are strictly limited. In Wisconsin many medications are prohibited, including benzodiazepines and stimulants. Seroquel, which I had not realized was subject to abuse, is another prohibited medication.
Given the high costs of housing and securing prisoners, states seek to control other costs, including medication. Thus, less expensive, generic medications are always preferred, as their usage has less suicide risks and fewer metabolic side effects.
For the treatment of those with substance abuse disorders, we have a four-month residential facility. Such settings are virtually unavailable nowadays outside of a prison, except for the very expensive celebrity rehab facilities.
The treatment of schizophrenic patients can be especially distressing in prison. Fortunately, the rest of the inmates tend to leave these “crazies” alone rather than victimize them. Some schizophrenic inmates don’t seem to mind staying in prison. One such patient said to me: “Doc, I like it here. I hope I don’t have to leave. I wouldn’t mind coming back if I do. I have a place to stay, three squares, and medical care.” Finding adequate community mental health resources for inmates who complete their sentences is perhaps our greatest challenge in planning discharges.
I find that some of the most difficult prisoners to treat are those with Adult ADHD, since the best ADHD medication has very limited availability due to its potential for abuse. Some have suggested that separate housing units be developed for such inmates. However, earlier diagnosis and better treatment options outside of prison can help reduce the impulsivity, substance abuse, or social exclusion that leads to criminal behavior in the first place.
Conclusions
So, are those with mental illness better off in prison? Given the various states of prisons in the U.S. and the world, ranging from the bare-bones barracks and occasional riots in California to the hotel-like settings and services in Austrian prisons, some patients are and some patients aren’t.
Am I, and other clinicians like me, better off in prison? As of now, it certainly seems so. I not only can provide as high or higher quality treatment in the prison setting, but I’ve been challenged by situations that I’ve never encountered before and learned things I couldn’t have learned anywhere else.
Helping those who have hurt others can be the ultimate test for a healer. When my treatment is successful, I have the satisfaction of knowing that I may have reduced the typical 70 percent recidivism rate by motivating a former inmate to change his life’s course, perhaps in a way that saves the lives or property of other citizens. This feeling makes me wonder if most mental health clinicians or administrators wouldn’t be better off after spending a little time in prison.
Comparing prison psychiatry and community psychiatry
| Prison | Community |
Access to care | No insurance required; rapid access with little or no cost | Coverage required; significant waiting times are common |
Integrated primary/mental healthcare, with on-site psychiatrist | Sometimes available | Rarely available |
Productivity expectations | Generally appropriate | Sometimes excessive, especially under tightly managed plans |
Medication availability | Generally limited, includes only generics and medications with low abuse potential | Unlimited, based on prescriber’s preference, formulary provided in coverage, or patient ability to pay |
Substance abuse treatment | Long-term, residential treatment often available on site without long waits | Off-site residential treatment may require wait time and significant out-of-pocket costs |
Vulnerability to violent behavior | Extremely low due to high security, constant observation, and prior knowledge of violent patients’ histories | Varied, based on funding for on-site security, knowledge of patient history, office staffing, and layout |
Dr. Moffic's thoughtful commentary ignores one fundamental aspect of the physician-patient relationship. Need you guess? It is called "confidentiality."Already compromised in psychiatric practice, in no other setting (except perhaps the military) is it so problematic. During my own short stint in a max security facility in NY I observed what is currently a virtual necessity; a modified Miranda warning which preserves a vestige of reality: '"Whatever you say or do, may be used against you!"
www.smpsych.com
On a different issue from that of confidentiality, it was informally pointed out to me that I used too strong a term, "prohibit", to describe the availability of certain medications that are more readily abused or diverted in prison. At the very least, I should have wrote that they are "virtually prohibited"or strongly discouraged, or that there are exceptions to this principle, for indeed some patients in our Wisconsin prison system are on one of them. Maybe my mistake was a reflection of my own internal prohibition about using such medication anymore in prisons. They seem too risky and/or there are other options.
In fact, two years later after this blog was first written, confronting this issue in prison has made me even more sensitive to how such medications may be used or misused outside of prison, and how consequently I have been much more careful of prescribing them anywhere. For example, even though I am viewed as having some expertise in Adult Attention Deficit Disorder, I will not prescribe stimulants unless my diagnosis is confirmed by some sophisticated neuropsychological testing. The diversion of stimulants in colleges, and even the workplace, seems to be escalating so much that we are now debating whether such medications can be used as "neuroenhancers". But that ethical debate is for another time.
Dr Moffic made the following comment:
Thanks so much for this comment on the challenge of confidentality in prison systems. As I went back to review what I had written, you are absolutely right to point out that I had ignored an important clinical issue that might differ in prisons. Such feedback helps to make blogs so worthwhile to write.
If the commentor has time, it would be useful to let us know more of how observing a modified Miranda warning affected the clinical care. Also, was this something that was told had to be followed, and by whom?
In my particular setting, I was not told anything about this as I was first oriented to my medium-security state prison. What I learned over time is what could be described as a much broader interpretation of the Tarasoff decision, that if I found out anything that might endanger other inmates or correctional officers, that should be reported to security. Actually, all the inmates already know this, so they don't share information about sexual interactions with other inmates, smuggling of contraband, power plays, etc. I haven't discovered many instances where such withholding of information seems to adversely influence my treatment of the inmates. Usually, I still find out enough about their history (often through their criminal records), symptoms, and behavior to know how to proceed with medication, though with extra caution. On occasion, when behavior that they might have - but didn't - told me gets them in trouble, then I find out.
As I contemplate this issue, I'm not sure if such alteration in confidentiality is better or worse for psychiatric patients in prison. I think the bigger challenge, both inside and outside of prison, is to get through all the reservations (conscious and unconscious defenses, distrust of authority, etc.) that prevents sharing of useful information. The psychoanalysts have had a term for this, establishing a "holding environment" where the patient feels safe enough to convey disturbing information about themselves. I have to conclude that such an environment is harder to establish in prison.
Steven Moffic, M.D.
Prisons and nursing homes are the new psychiatric treatment facilities. I still prefer private practice to the latter.
Thanks to Steve for writing about an area of psychiatry that has a relatively low profile. Such first-person accounts of prison work can help to make this area of psychiatry more accessible to those who might be interested to take on this work.
Steve has already pointed out in an earlier post that the article uses the word "prohibit" to describe the availability of certain medications with the Wisconsin prison system and this may have been too strong a term. Actually, medications such as benzodiazepines, stimulants and Seroquel are available, but their use is significantly restricted by a pre-approval process that involves medication algorithms and evaluates medical necessity. For a variety of reasons, the threshold for using these medications is different in a prison environment.
I did work in the New York State Prisions. I remember a kind hearted psychiatrist who approached the prisoner' s cell near the bars and the prisioner grabed him by his tie and almost choked him to death. The psychiatrist believed he was safe because he was a good guy. One must never be alone with a "dangerous mental prisioner you never know when they will go of and you don't know if they are dangerous or or mental. Be careful, think of yourself first and career later. S.W. M.D.
I have worked part time in a prison in on the east coast for the last 4 years. The other half is my private practice. A significant part of the psychiatric staff is pieced together with part timers who, like me just come in 2 or 3 times a week, so there is a lot of cross coverage of inmates when their usual psychiatrist is not in that day. When I first got here I found it very interesting. I actually work for the state medical school that has the contract with the Dept of Corrections to supply psychiatric and medical care to the prison system. Over the 4 years it has been increasingly difficult to work here. With budget cuts we have lost staff so case loads get larger. Recently we just found out the pay structure is no longer that great as we lost a psychiatrist to the state psychiatric hospital located in the same city. She is only out of residency training about 2 years but she said she would get about $23,000 more at the hospital and a better retirement plan. Rules are strict here. No personal phone calls, no internet use that is not directly related to your work in the prison. No longer being that attractive, we are always short staffed. Only about 1/2 of the psychiatric staff are up to par. In my department we don't get our own offices. Most patients are seen at their cell door. There are only certain times during the day we can travel to the housing units. Lately we have been told there may be a plan to replace us by nurse practitioners, but my partner is a nurse practitioner who told me that they just lowered the salary to $55/hr which no one will take.
I appreciate your insightful article. Correctional Medicine and Psychiatry is under-explored as a career. As a physician in the federal prison system, I feel that we have an excellent chance to serve a medically underserved population of people, to educate them about drugs/alcohol/psychiatric illnesses, and then provide appropriate medical care. Many of these folks want to get back on track and be productive citizens again after there release. The old joke goes...how many psychiatrists do you need to change a lightbulb-just one, but only if it wants to change.
Yes, this is a populations that needs our expertise, but the ability to provide that does vary immensely across the states. Even in the best of circumstances, the challenge is also to be compassionate, but very careful about being fooled and in danger. I was told three things not to do when I started; do not wear a necktie, do not shake hands, and do not let the patient sit closer to the door.
Regarding the advice you were given, to "not let the patient sit closer to the door," I came to the opposite conclusion. After working in the Massachusetts Treatment Center for Sexually Dangerous Offenders for nine years and evaluating men there for more than 25 years, I always let the patient sit closer to the door.
The last thing I want is an enraged patient who is fed up with me and/or therapy and/or an evaluation I am doing who has to come toward me in order to get out of the room. If a patient is going to be violent and he is more powerful than the psychiatrist, being closer to the door isn't going to help much.
On several occasions, my patients did storm out of the room and, because they were closer to the door, away from me.
Thanks for a well written article. Here in the Gulf countries one comes across in the Ministry of Health Service either visits to the prison by the doctor on fixed days or the patients are brought to the ER for follow up. The most stressful part for expatriate Psychiatrists is an almost absent security and the threatening use of language and behaviour to obtain benzodiazepines by the prisoners as the accompanying lower ranked soldiers on duty are least interested in the security aspect of their presence and the majority of criminals brought insist on drugs of their choice especially benzodiazepines and fake symptoms of epilepsy and generally carry with them prescriptions from their past visits to private doctors who are at times for a variety of reasons under pressure to prescribe such drugs for varying intervals either to appease them or just get rid of them hoping that they are seeing the last of them. and during the next follow up it may not be their turn in the ER! .Contrary to this wishful expectation as well as lack of administrative support each is left to fend for himself..Unrestricted visits due to improper appointment system,force of violence and self harm keeps on bringing the patients again and again for refills for various pretexts from lost medicines to need more stronger medicines and so on. Over time the more hardened prisoners use multiple refills without supervision to run their fiefdoms within the prison and recruit new prisoners to simulate symptoms to access sedatives for expanding their business in the prison.Such prisoners are a real danger to the doctor and it is my experience that one needs to insist on having enough security, and not to allow the prisoner unlimited access to drugs by reporting him in writing to the prison authorities for some control as verbal messages are lost the moment they are delivered! BY ALL MEANS SAFEGAURD YOUR PERSONAL SAFETY IF YOU COME TO WORK IN THE MIDDLE EAST.
Correctional psychiatry has been the most meaningful, challenging, interesting work I've done thus far. I especially enjoyed working with fresh alcoholics and addicts.
Unfortunately, in working for a for-profit company (which, I felt, did a decent job), politics around money could get very heated.
I have been, and still am a lean prescriber. In the correctional environment, that made me less popular among inmates.
Rubber stamp diagnosis does not number among my skills. Thus, a number of indignant inmates with highly atypical "psychotic"presentations left my office in a fury after finding their long supply of marketable pills was in jeopardy, long fed by previous successions of rubber stamped "schizophrenia" diagnoses.
Generally, I'm a diagnostic skeptic, especially in a correctional environment, in which collateral information and time can be brought powerfully to bear upon determining the presence/absence of serious mental illness. I also believe strongly that psychiatrists should be judicious in their attempts to ameliorate human misery with pills.
And those in a correctional environment who clamor loudest for meds ... often need them the least.
Mix some disgruntled inmate patients with some disgruntled community providers who want their contracts back ... and newspaper articles and lawsuits began to sprout, to later be swept away by summary judgments after many sleepless nights.
I now work in a state forensic hospital, a sad symptom of a dysfunctional mental health care system. Many with serious mental illnesses must now commit crimes to receive adequate services.
Funny ... no lawsuits or newspaper articles for the past three years at this institution. I must have become a better shrink! ;-)
As one who has worked in correctional mental health care for over a dozen years I too appreciate this insigful article that sheds light on what we do. We have a very important role in the American mental health care system, as most of our patients do return home to their families and their communities. We do an excellent job in caring for what is arguably the most difficult group of patients that one would encounter anywhere. Working in an environment that is "security first", and dealing with the negative attitudes of some security staff towards the inmate/patient and mental health services (thankfully this is evolving for the better) is an additional challenge. I applaud the effort to enlighten and educate. As we like to say here---there is never a dull or routine day behind the bars!!!!
Kudos to Dr. Moffic on this enlightening piece, which calls attention not only to health care in prisons, but also to the lack of available care for many on the "outside". I hope all psychiatrists will work toward a system of publicly-funded, universal insurance coverage, such as the plan proposed by Physicians for a National Health Program (www.pnhp.org).
Best regards, Ron Pies MD