Criminal Justice Section
Criminal Justice Magazine
Volume 16, Issue 3
Henry C. Weinstein
Psychiatric Services in Jails and Prisons
A Task Force Report of the American Psychiatric Association
Published by the American Psychiatric Association Task Force to Revise the APA Guidelines on Psychiatric Services in Jails and Prisons; 2d ed. (2000); paperback; 77 pp.; $19; available online at www.amazon.com.
Reviewed by Henry C. Weinstein, M.D .
Let me begin with a disclaimer: I am not an impartial reviewer. I was the chairperson of the American Psychiatric Association’s task forces that wrote both the first and second editions of this book. And although I will try to be objective, it should surprise no one that I think this book is a necessary resource for anyone involved in or concerned with jails and prisons.
Of the two million inmates incarcerated in the United States it is estimated that 8 percent are actively psychotic and 20 percent are in need of mental health care. The legal context of providing psychiatric services in jails and prisons is unique in that in no other setting are these services constitutionally guaranteed. With this in mind, the book espouses a core concept that the fundamental policy goal for correctional mental health care is "to provide the same level of mental health services to each patient in the criminal justice process that should be available in the community." Note that this policy goal is deliberately higher than the community standard that is called for in many legal contexts.
The book’s guidelines state that "timely and effective access to mental health treatment is the hallmark of adequate mental health care." To determine whether these guidelines are met, mental health service delivery systems must be analyzed to ensure that there are no unreasonable barriers to patients’ receiving appropriate services. Examples of such barriers include instituting or allowing disincentives that would deter patients from seeking care; interfering with the prompt transmittal of a patient’s oral or written request for care; unreasonable delays before patients are seen by mental health staff or outside consultants; charging fees that prevent or deter patients from seeking care; and punishing an inmate for seeking or refusing care.
The book has three major sections. The first section is "The Principles Governing the Delivery of Psychiatric Services in Jails and Prisons." It discusses the general principles that apply to all types of correctional facilities, and includes brief essays that cover, in detail, critical topics such as legal context; access to mental health care and treatment; quality of care, education, and training; cultural awareness; informed consent; confidentiality; suicide prevention; ethical issues; research; administration issues; interprofessional relationships; psychiatric services in and out of court; and alternatives to incarceration.
The second section is devoted to the guidelines themselves, which set out, again in detail, the actual services that should be provided. They include the identification at various stages of confinement of the mentally ill inmates; the processes of screening and referral that include receiving screening and referral, intake screening and referral, post-classification referral; and various types of assessments such as brief mental health assessments, comprehensive mental health evaluations, and various mental health treatments, and discharge planning.
The third section is "Special Applications of the Principles and Guidelines." It applies the principles and guidelines in the first two sections to particular patient populations and further elaborates on special services that should be provided to meet the needs of these patients, including inmates with substance abuse disorders, inmates with other co-occurring disorders, inmates with HIV/AIDS, women inmates, youth in adult correctional facilities, geriatric inmates, and inmates with mental retardation or developmental disabilities.
Material in each section illustrates how the guidelines are applied. In the first section, under "Access to Mental Health Care," there is a detailed discussion of segregation units in jails and prisons. A segregation area is defined as "any unit which confines inmates to their cell 23 or more hours per day." Inmates may be isolated not only for disciplinary reasons, but also for administrative or protective reasons. And in jails and prisons that don’t have adequate mental health services, inmates with mental illness often find their way into segregation housing unnecessarily when their mental illnesses prevent them from understanding or adhering to correctional rules.
These guidelines emphasize that when an inmate is segregated, for any reason, the responsibility to address serious mental health needs remains in effect. Indeed, because of the stressful nature of segregation, facilities must make special efforts to assess and address mental health treatment needs in these settings.
• that no inmate should be placed in segregation solely because he or she exhibits symptoms of mental illness unless there is an immediate and serious danger for which there is no other reasonable alternative;
• that the facility remains responsible for meeting all of the serious medical and psychiatric needs of the inmate—segregation status notwithstanding;
• inmates who are in current, severe psychiatric crisis, including but not limited to acute psychosis and suicidal depression, should be removed from segregation until such time as they are psychologically able to tolerate that setting;
• inmates who are known to have serious mental health needs, especially those with a known history of serious and persistent mental illness, when housed in segregation, must be assessed on a regular basis by qualified mental health practitioners, to identify and respond to emerging crises;
• institutions should provide for regular "rounds" by a qualified mental health clinician in all segregated housing areas. During these rounds, each inmate should be visited briefly to assess any emerging problem. The clinician should also communicate with security staff in order to identify any inmate who appears to be showing signs of mental deterioration or psychological problems.
In the second section, the guidelines are applied to the topic of discharge planning. Policymakers are beginning to understand that one way to avoid the "revolving door" for the mentally ill offender is to make efforts to ensure follow-up mental health treatment in the community. The guidelines state that adequate discharge planning include specific assessments of the mentally ill inmate, appointments to be arranged, notifications, staff responsibilities, and linkages to community-based services. In addition, discharge planning may include help with obtaining necessary financial benefits (e.g., Medicaid) and housing (due to the high incidence of homelessness in the jail population) placements. It should also take into account the benefits of the so-called "assertive community therapy" model for persons requiring a very structured and comprehensive discharge plan. And, finally, this section notes the important potential role of the family.
Women inmates are one of the special populations covered in the third section of the book. In the article, "Female Offenders: An Introduction," Professor Myrna Raeder opened a special issue of this magazine that focused on women offenders. (16 (1) Crim. Just. 4 (Spring 2001).) She wrote that "it is important to note that an unusually high percentage of incarcerated women suffer from various mental illnesses." As a matter of fact, studies have shown that women inmates have two times the incidence of mental illness than men inmates. Moreover, their mental illnesses are by and large, different. Severely mentally ill male inmates are more likely to suffer from schizophrenia and bipolar disorders whereas women are more likely to suffer from depression. In the book’s third section on special populations the special mental health needs of women inmates are dealt with in detail, including the fact that many have been abused, and that many have very young children.
Finally, it’s important to note that, as our task force recognized, during the past decade, the first edition of these guidelines "lighted the way for those seeking to navigate the perilous shoals of providing psychiatric services in jails and prisons." In addition we noted how "these guidelines have been used and cited extensively in many contexts. They have been used in educational contexts for the teaching and training of correctional mental health professionals, cited as a reference for certifying examinations, used for planning and improving mental health services in jails and prisons, and frequently quoted in litigation. They also have been used by surveyors and monitors of correctional facilities." It was our intention that this second edition would continue the good and necessary work.
Dr. Henry C. Weinstein is a member of the ABA Criminal Justice Section and its Corrections and Sentencing Committee. He is clinical professor of psychiatry and director of the program in psychiatry and the law at the New York University School of Medicine Center and the Bellevue Hospital Center.