My Patient Is Not A Peanut Butter Cup

On CBS news yesterday I saw this report about mentally ill people who end up in jail. The sheriff of the Cook County jail complained that psychiatric patients who don't take their medication become criminals and added, "We're not a mental health facility. These people should not be here.''

Simultaneously this week in the Baltimore Sun we have this story, where hospital workers complained because malingering criminals were being held at their facilities.

This week's news is a terrific example of what I call the Reese's Peanut Butter Cup problem of forensic patients. (I put up the old commercial for reference.) Each side is basically complaining that they have to provide care for someone. Nevermind that people can't be cleanly divided between the "mad" and the "bad," or that people who "only" have personality disorders can still die from those disorders. We waste a lot of time and energy arguing about who should be where and who should be doing what.

The bottom line is that we have to figure out how to deliver the right care to the patient regardless of the setting. Forensic patients require treatment as well as security. That sheriff needs to realize that his facility will always require a psychiatric infirmary and mental health services and that he's not going to be able to "clean house" off all the psych patients. Similarly, hospital workers can't write off every assaultive patient as being "just a sociopath."

We need to beef up hospital security so everyone, patients and staff alike, can feel safe. And jails need to be given enough mental health staff so the administrators won't feel like they're being overrun with chaos.

Getting rid of the patient is never the right answer to a health care system problem.

The Privileged Patient

I'm still dwelling on these discussions we've had about the inpatient experience. A number of readers commented that they weren't like other patients on the ward who weren't educated, who used drugs and were in and out of jail. I took that a little personally since those "other" inpatients are my correctional patients. I like working with them and I don't like it when people dismiss them as being "just criminals." I also found it a bit ironic that the people who are quick to claim peer kinship with staff are also quick to disclaim equality with forensic patients. You really can't have it both ways. My offender patients deserve to be taken seriously, treated with respect and given humane care whether you want them in your community or not.

I don't like the idea of framing treatment in terms of who is more 'deserving' of care. I don't think you can put a rating scale on suffering or prioritize trauma. Nevertheless, when it comes to the spectrum and amount of services that are needed my forensic patients are right up there. They may not be very literate, they've got poor social supports as well as mental health and addiction problems. Oh, and chronic medical problems that go untreated because they have no insurance. They're facing an uphill battle just to reach a "normal" place in society. For my patients, success means having a place to live, a job, people who care about them, maybe even a car and a girlfriend. That's a lot to have when you're starting at zero. Yet when it comes to apportioning services and access to treatment these are the first folks to get cut.

Some inpatient units do have patients of privilege---people who aren't starting at zero---and these patients really do seem rich (figuratively and literally) in comparison. But forensic patients are increasingly part of our mental health care system. When we talk about making the system better they have to be part of that discussion.

Cruelty and Context

I've always been struck by the similarity between solitary confinement inmates and monks. Historically, monks were kept under the vow of silence. They could only leave their cells to attend religious services. The only visitors they were allowed to have were their religious advisors. (If any of you have seen the movie Into Great Silence you'll know what I'm talking about.)  The idea of the modern penitentiary came from this 'penitence' process: put someone in a room by himself, give him religious guidance while he's there and he'll reflect, repent and reform. This was how prisons were run in the Nineteenth Century too: prisoners were kept under the rule of silence and they could only come out of their cells for religious services or for work. No one ever alleged that monks became psychotic because of this though.

Then there's the psychiatric seclusion room. Again, a bare cell with a bed or a mattress, no visitors, no clothes except a hospital gown. There is no 'vow of silence' or 'rule of silence' though.

So what makes the difference between the prison segregation cell, the monk's cell and the psychiatric seclusion room?

Off the top of my head, the obvious one would be the 'voluntariness' (if that's the word) of the confinement. (Although some people became monks because it was either that or get thrown into the king's dungeon---crime did compel men into the priesthood!) Other would be the purpose of the confinement. Segregation is a disciplinary action for a misbehaving prisoner, although it could also be used to protect the safety of other inmates in the facility. The purpose of segregation is also, theoretically, reformation (and their is research to show that disciplinary infractions drop off after one or two episodes of segregation). Reformation and enlightenment would be the purpose of the monk's isolation as well. Psychiatric seclusion is used both for the protection of the patient and others.

As we've heard from some of our blog readers, involuntary segregation feels the same regardless of the purpose.

Solitary Confinement

 

Sunny CA recently asked me my thoughts about the use of solitary confinement in light of allegations that this can cause mental illness.

My short answer to this is, "Don't believe everything you read in the media about solitary confinement."

When I first started working in corrections I started with the same assumption, that locking someone in a single cell might cause something called the "SHU syndrome". The exact symptoms that make up the SHU syndrome vary a bit but the gist of it is psychosis with disruptive or self-injurious behavior.

Once I had some experience under my belt working in maximum security and control unit environments, I started to question this theory because I just wasn't seeing the new onset psychosis that everybody suggested should be happening. I reviewed the literature and discovered that some of the articles that were repeatedly cited about this were written by psychiatrists who were plaintiff's experts in class action suits involving longterm segregation. I also found out that the articles describing SHU syndrome were no more than series of case report studies. In the classic Grassian article about solitary confinement, the author even admitted that he had to encourage the inmates to report their symptoms! And there were no well controlled studies about it. I did find a series of four papers in the British Medical Journal that did repeated measures of various psychological test batteries on inmates, and compaired scores against the subjects' accumulated incarceration history. These papers found no deleterious effects from confinement in general, but was not specific to segregated confinement. Another study from Canada (I think Wormith was the first author) found no negative effects, but this was a short term (just a few months) study.

The best designed research on the effects of longterm segregation was just published this past November. The University of Colorado researchers studied a few hundred inmates who were taken to disciplinary adjustment hearings and were at risk for longterm segreation. They compared those who were transferred to segregation with those who were returned to general population, and had an additional control group of inmates in the prison psychiatric hospital who also had disciplinary and behavioral problems. They compared the mentally ill inmates to the non-mentally ill inmates in all three settings over time (Ad Seg, Gen Pop and psych infirmary). They did testing every three months over the course of one year.

They used tests that measured eight different symptom dimensions, in addition to ratings done by the clinical and correctional staff (the BPRS).

Here, in a nutshell, are their findings as quoted from the executive summary with the "bottom-line" conclusions in bold-face:

"The results of this study were largely inconsistent with our hypotheses and the bulk of literature that indicates AS (administrative segregation) is extremely detrimental to inmates with and without mental illness. We hypothesized that inmates in segregation would experience greater psychological deterioration over time than comparison inmates, who were comprised of similar offenders confined in non‐segregation prisons."

"In examining change over time patterns, there was initial improvement in psychological well‐being across all study groups, with the bulk of the improvements occurring between the first and second testing periods, followed by relative stability for the remainder of the study. "

"We stated that offenders in segregation would develop an array of psychological symptoms consistent with the SHU syndrome. As already discussed, all of the study groups, with the exception of the GP NMI group, showed symptoms that were associated with the SHU syndrome. These elevations were present from the start and were more serious for the mentally ill than non‐mentally ill. In classifying people as improving, declining, or staying the same over time, the majority remained the same. There was a small percentage (7%) who worsened and a larger proportion (20%) who improved. Therefore, this study cannot attribute the presence of SHU symptoms to confinement in AS. The features of the SHU syndrome appear to describe the most disturbed offenders in prison, regardless of where they are housed. In fact, the group of offenders who were placed in a psychiatric care facility (SCCF) had the greatest degree of psychological disturbances and the greatest amount of negative change."

This study describes exactly what I see. The inmates who end up in solitary confinement have significant problems to begin with, but segregation doesn't necessarily make them worse.

The ACLU and other advocacy organizations are understandably not happy with this study and you can find the major criticisms just by Googling "Colorado solitary confinement." The study itself is not so easy to track down but I found a link Colorado Longterm Segregation study.

Thanks for asking the question Sunny, it's a topic that I've been particularly interested in.

Books Through Bars

Just thought I'd put up a quick post to plug a program that looks useful for my patients. The Prison Book Program sends books to prisoners who request them from many states. I appreciate this because one of the frequent questions I get in my clinic (after "Can I have some of that coffee?") is "Got anything to read?" Boredom is the common denominator of most prisoners, and having something positive or useful to read is a good thing. Check out the YouTube video about the program too.

Are They Animals?

Here's a story about a supermax facility in Illinois. Apparently efforts are being made to improve mental health services to these control unit inmates, some of whom have been in
solitary confinement for up to ten years.

They're getting a lot of service: group and individual counselling, psychiatric treatment and recreational activities. And they've had some serious behavior problems---109 of the 247 inmates are there because they committed new criminal offenses while in prison, including
stabbing correctional officers and murder.

To me the story isn't interesting because of the mental health care issues or because of the nature of the inmates----that's pretty much old stuff to me. What I always think is fascinating are the comments left by the readers. Some people think the inmates are so mentally ill
that they shouldn't be locked up in spite of their repeated violent offenses. Others call them "animals" or worse, and want them all to be killed. Stories like this reveal more about the readers, and about society in general, than about the patients I treat or the system I
work in. As long as there is this level of hysteria and extremism we as a society have trouble addressing the needs of our offenders realistically.

Things We'll Never Know

I've been following the story of Maurice Clemmons, the suspect wanted for the killing of four police officers in Seattle. I don't have any connection to the case, but his story is familiar to me from thousands of inmates like him I've met over the years.

In addition to the media reports, I reviewed the parole and clemency documentation published here.

Here's what strikes me about the case:

Clemmons was a repeat offender who committed new crimes every few months until he turned eighteen. The longest break in his criminal activity was the eleven years that he was in the Arkansas prison system. We don't know what he was involved in before that because juvenile records are generally sealed.

He was already under court supervision when he was convicted of the robbery and theft that sent him to prison in 1990. Even though he was only about eighteen, the judge slammed him: over a hundred consecutive years for what (in Baltimore at least) would have been a ten year sentence, max. When he was first considered for parole, the board would have granted him parole only under one condition (a "firm" condition, as handwritten onto the parole document): that he leave the state. This was not your average offender.

He asked to have his sentence reconsidered, and was granted a reduction by a new judge who noted that she didn't understand why he had been given so much time. (There was no discussion of the reasoning behind this decision other than that the sentence seemed excessive. No discussion of his previous offenses or the nature of the index crimes.) The state's attorney's office opposed his parole each time it came up (then again, that's their job).

When he petitioned Governor Huckabee for a commutation he admitted that he had some initial adjustment problems (he didn't mention what they were, but I could make an educated guess) but added that since his mother died he was determined to turn his life around. He denied any history of alcohol or drug abuse or any history of psychiatric illness or treatment. According the Examiner.com web site, he never required mental health care during the eleven years in prison. When he got out and moved to Washington he was able to run his own landscaping business and get married. A pretty good start, even without therapy.

Prior to killing the police, Clemmons exhibited unusual behavior: claiming to be Jesus, to be able to fly, and forcing his family to undress. To put it modestly, this was a bit of a change for him. He might have been violent and antisocial in the past, but he was never known to be "crazy".

The general public will never know the full story behind the change in his mental state since he was killed by police. Had he survived, he likely would have received a thorough and detailed pretrial psychiatric evaluation for an insanity defense. Only then would we have found out if he really had a psychotic disorder or if he was psychotic due to PCP, Ecstacy or crack cocaine use.

Could any of this have been prevented? I don't know. Maybe, if his sentence hadn't been reduced, both he and the four police officers might be alive today. Then again, maybe he could have been killed (or murdered someone else) in prison. We'll never know.

Who Are You?

The DOC badge said his name was John X. Doe and that he was born on 1/1/81. The medical information system said his name was John Y. Doe and that he was born on 2/4/84. The legal information system said that John Y. Doe plead guilty to misdemeanor theft and was given six months. John X. Doe has an open robbery charge. John Y. Doe has been through the system three times and has always screened negatively for mental health issues and never needed psychiatric services. John X. Doe was in our forensic hospital for six months being restored to competency. The patient insists he's John X. Doe in spite of both information systems that link him through his DOC number.

I've never treated either of these guys before, have no old records of my own and have no way of knowing if they're actually one and the same person who just lies about different things at different times. Someone just shoot me now.

So is John Doe someone with no previous psychiatric history who is malingering now because he's facing a serious felony charge? Or is he a chronically mentally ill person who is going to relapse if I don't put him on meds? (And relapse in a big way if it required a six month hospitalization.)

Oh yeah, one more thing---he won't answer any questions other than to confirm his middle name and birthdate (which may be a lie). When I try to do a mental status examination he sits there and stares at me.

Gawd, ya gotta love this work.

Any suggestions?

Life After Homicide

Is there life after homicide? No, I obviously don't mean for the victims---I mean for the killers.

This is a question that struck me after one of my patients, a convicted murderer who violated his parole, said to me: "I don't feel good about the fact that I'm a killer."

For some reason that statement just struck me and I'm not sure why. Of course someone would feel bad about killing. Sociopaths don't, but most normal non-sociopathic killers do. I think it hit me because my patient's offense had happened over a decade before and he had done well on parole since his release. He was really sad about what he had done and was trying to make things better.

The fact of the matter is that all killers aren't the same. You have the barfight killers, the enraged jealous lover killers, the cold and calculating hit man killers, the child abuse killers, the sadistic serial killers, the drunk driver killers, the school shooting killers, the newborn infant hidden pregnancy killers, the "teenager who kills his entire family" killers and so on and so on. Everybody's different. Ever since the middle ages and the old English common law, killings have been broken down into different categories of murder and manslaughter so that killers would be punished in accordance with the type of killing they're guilty of.

But back to my patient. The question that came to me was, "How do you handle the guilt of being a killer?"

Is it like dealing with grief in the bereaved, where you never really expect someone to just 'get over' something? Is it something you just have to learn to live with? Do you tell the patient that they're now obligated to live the rest of their lives paying their debt to society? Is there a point where the guilt should end? Or is the person really obligated to spend the rest of their life beating himself with a knotted cord? What good does that do?

It's a matter of public record that the Emmy Award-winning actor Charles Dutton was an inmate in our correctional system back in the 1970's for killing someone. To my knowledge he's never been in trouble since then, he's turned his life around, and he's contributed a lot to society since he's gotten out. Most killers don't put their pasts behind them quite so successfully. In my experience a killer who successfully has turned his life around is someone who gets out, has a job, has a place to live, has people who love him and who doesn't commit too many more crimes. It's a bit much to expect someone to never get in trouble again---life is weird, circumstances happen beyond your control and bad reputations throw a long shadow---but at least it shouldn't be another violent offense.

As all of my patients know, it's better to make a life than take a life. It's just a lot tougher to make a life.

I'll Show You

Working with violent patients has its challenges. The main one is when they actually do become violent. When they act up, smash things or assault someone there is a quick need to coordinate interventions between security and mental health staff. Of course, safety is the primary goal. Nothing therapeutic can happen until the patient regains control of himself, or someone else gets him under control.

After that, we get him. Violence is actually pretty rare in my facility---a credit to the quality of the correctional staff---but occasionally it does happen.

The only reason I'm writing a blog post about it is because the management of violent patients gets tricky when you're the one they're violent toward. It can be a challenge to continue working with a patient who has threatened you or, god forbid, actually committed violence against you. I've never been decked by a prisoner but I know colleagues who have been. Bless them, they came back to work the next day too.

The question is, what happens next? I don't have the option of firing a patient from my practice and the patient doesn't have the option of switching physicians. For better or worse, we're stuck with each other.

I've put together some general principles about how to manage this situation. Here they are:

1. Safety first

This is obvious, but I'll say it and get it out of the way. Make sure he's cuffed, in leg irons and a waist chain. Custody may forget this in between appointments, so remind them to cuff him the next time he comes down. Have an officer standing outside the office door. If for some wierd reason you don't want him cuffed, have someone sitting in the room with you during the appointment. Bodies count, and it can't hurt to have someone to call for backup if you don't have a security alarm in your office. Confidentiality? Doesn't count here. In cases of imminent dangerousness, there is no confidentiality.

2. Be upfront

Don't pretend that there is a therapeutic rapport when there isn't one. Bring the issue out into the open by saying out loud what the patient is thinking: "You're probably not too happy about seeing me again but we both know you need treatment." It's also OK for you to acknowledge, out loud, that you're going to have a hard time treating someone who threatens you or hurts you.

3. Use timeouts

You and the patient both may need to take timeouts. If the patient starts to get angry, call attention to it and give him a chance to pull himself together. He may not realize how he's coming across. If he continues to escalate, terminate the appointment. In the parlance of the medical progress note, the phrase "appointment terminated for safety reasons" is another way of saying "I let the guy go back to his cell because he was about to swing on me". If you do this, make sure the patient knows you will continue trying to see him and treat him. He may want to run from you, but you can't abandon him. Sometimes that is enough to impress the patient that you're committed to helping and may engage him in treatment.

You need to take a break too if you find yourself getting angry in return. You need to be impartial and calm in order to give the inmate a fair and thorough clinical evaluation.

4. Remember noise is just noise

An angry prisoner will be loud. He might swear. He will complain (a lot). That's all OK. Let it happen, knowing that eventually he will run out of energy. As long as he's not moving toward you or throwing things or physically out of control, it's OK. Don't be intimidated by noise. When he does calm down, quietly ask permission to make a treatment recommendation. There's a chance he might listen once he's had a chance to vent and be listened to.

5. Work on awareness

Like I said before, in all likelihood the inmate is not going to have any awareness of how he's coming across either in volume or in the intimidation factor. When custody starts peeking in the office to make sure everything is alright, you can carefully point this out to the patient and explain that people are concerned because of how he's behaving. That might be enough to trigger insight.

So that's what I do, for what it's worth. Sometimes it helps, sometimes it doesn't. But at least it's worth a try.

Newsworthy Deaths

So for the second time in as many days we have another story about a wealthy, high-flying businessman who commits suicide. Yesterday it was a German industrialist, today it was a Chicago real estate auctioneer.

I'm not sure what makes these suicides more newsworthy than the death of one of my neighbors a couple years ago that didn't make the newspaper, or the hundreds of other suicide deaths that happen every month in this country, but there it is on CNN. Maybe it's a media comment on the state of the economy. Maybe it's the shock value of a successful or wealthy person just throwing it all away and giving up. Maybe it's a morality tale that materialism doesn't lead to happiness. Regardless, the stories draw eyeballs just for the schadenfreude of watching someone fall from a high place.

In our local newspaper there were stories about other recent suicides: a Pennsylvania politician who was also an accused serial rapist and a school teacher who was accused of assaulting a student. The New York Times recently had an in-depth story about the Fort Meade scientist who committed suicide under the stress of the FBI anthrax investigation. These are deaths at the other end of the social spectrum, involving people who might generate a lot less sympathy than the businessmen. In other situations like this I've heard people suggest that the accused 'had it coming' or even express relief that money wouldn't be wasted on a trial.

Does it really matter? The impact of suicide on the spouses, family, co-workers, friends and neighbors doesn't depend on the deceased's social status. And I cringe at the implication that perhaps suicide prevention may not be quite as crucial for people who are less deserving than others.

A pedophile patient of mine thought it was important that I believe he was innocent, as if I'd give him worse care because of his offense. I finally shocked him by telling him, "It doesn't matter if you did it or didn't do it, you still deserve to be healthy."

I really hope that someday society will believe that.

Noah's Ark (Bring On The New Fish)

One of our readers asked me to comment on how psychiatrists who work in corrections keep from becoming 'hardened' to their patients when so many of them are 'lying jerks' (anonymous reader's words, not mine).

The question was weirdly relevant this week.

I came back from a week off to find that our entire department was flooded. A three inch pipe (clean water, fortunately) broke over the weekend and left a five inch layer of water over our entire floor. It leaked from the third floor tier all the way through to the first floor entrance. I don't even want to think about how many gallons that was.

The water had been vacuumed by the time I came in but the smell hit me immediately. There are no words to describe this. Employees came in, took a sniff, and immediately turned around to leave. I had no idea carpets and paper could mildew so fast.

So back to Anonymous's question: How do you keep from becoming hardened?

The short answer is: It's demoralization you have to watch out for, not insensitivity.

Psychiatrists become psychiatrists because they like their patients, and generally I do. Every psychiatrist has an occasional patient who conceals information, is deceptive or sometimes unpleasant. This goes with the territory and isn't limited to forensic work. It's part of being human and most human beings don't reveal everything about themselves immediately, or at least not the unseemly bits. I don't take patient deception personally. It's part of the job. It's possible to lose one's naivety without becoming jaded or cynical.

The real challenge can be to keep up your morale (or at least not undermine your co-workers' morale) in the face of repeated broken pipes and flooded offices, uncontrolled air conditioning (or no heat), disappearing resources and quality assurance administrators who believe a new form is the answer to every problem. Demoralization is the death by a thousand cuts, more subtle and deadly than any nasty cursing sociopath.

My advice to the 'new fish' in the field is to be careful who you associate with and listen to. It may be nice to have a co-worker to vent to, but if all the two of you are doing is venting then there's a problem. Disgruntlement is contagious and the more you listen the more it feeds. Find the cheerful co-worker (there always is one, the polly anna who sees a broken pipe as a chance to clean out the office) and hang out with that person once in a while. Take a break and spend some time planning your next vacation. Hug someone you care about. Kiss your dog. If I were Dinah, I'd eat a hot fudge sundae. (Oh wait, I do that anyway.) Know that this aggravation, too, will pass. Then aggravation will happen again. Then pass. Then...well...you get it. Eventually you, the new fish, will be advising others how not to become 'hardened'.

And now I finally get that chance to go clean out my office...

Clink Responds

In my post “Who Is A Criminal?” one anonymous commenter posted a link to a newspaper story about a former musician who died of benzodiazepine withdrawal in a Cleveland jail. The anonymous commenter wondered what I thought about the story.

Over the course of the years it's not unusual for people to send me links, both on and off the blog, to stories about horrible things that have happened in a jail or prison and to ask my opinion about it. The link usually comes in an email with the subject heading, "Can you believe this???" or "Does this really happen???" The expectation seems to be that I'm supposed to either share their outrage or else defend some obviously horrible outcome.

I do neither, mainly because I don't know anything particular about the case in the media. I do know that the full story never gets reported because facility administrators and staff are bound by confidentiality (or by their attorneys) so the only information public hears about is the horrible stuff.

That being said, Anonymous Commenter followed up the comment with a few specific good questions that I'm answering here.

The Anonymous Questions are:

1. Is what happened to Sean Levert a symptom, in your view, of a tendency by prison administrators to treat psychiatric illnesses as not 'real' -- or was it an exception to the norm?

Clink responds: I can't comment on the Levert case specifically since I don't know the facts of the case. Most prison officials and correctional officers I've worked with don't have any trouble acknowledging that psychosis is a real illness. Sometimes they (and my patients) aren't always up to date regarding information about the medical nature of clinical depression and I've educated people about that.

2. The new Cuyahoga jail policy includes weaning prisoners off benzodiazepines. What's your take on this -- considering that these are relatively short-term prisoners, is it appropriate for a clink shrink to change the drug therapy? Is it appropriate for a shrink to go along with a policy designed, it would seem, less on therapeutic reasons than on convenience to the prison?

Clink responds: Correctional psychiatrists don't prescribe based on length of time in jail because we don't have any way of knowing who the short-timers are. We don't generally know trial dates, pretrial hearing dates, parole or probation hearing dates or mandatory release dates. Regarding prescribing practices, I blogged about this quite a while ago in my post "Change Is Good" so I won't be completely repetitive here. The short story is that there are valid clinical reasons to change someone's medicine that have nothing to do with cost or policy. Medication needs change depending on the environment. Someone with diabetes will need less insulin in a hospital because he'll be getting a controlled diabetic diet and won't have access to off-diet goodies. Prisoners will need less (and sometimes no) medication once they are abstinent from drugs and alcohol in a controlled environment. Sometimes the free society treatment is being provided by a non-psychiatrist and it just frankly doesn't make sense or is inadequate. There are too many hypothetical possibilities to cover them all, but those are the most common reasons why I change medications. The other thing to be aware of---and this is a bit different from free society medicine---is that you're not prescribing for an individual, you're prescribing for an institution. Anything you give to one inmate will eventually end up in the hands of another. For example, if you use tricyclic antidepressants liberally as a sleeping pill you will eventually have an institution filled with medication that is potentially lethal in overdose. Or that can be bad for someone with liver disease (and lots of my folks have hepaitits). There are valid institutional reasons for certain prescribing policies.

3. If a prisoner comes in with a current diagnosis, how much weight do you give that in determining your treatment? Do you defer to the previous doctor, or consider yourself to be starting from scratch?

Clink responds: It depends upon who gave the current diagnosis. First of all, most of my patients weren't getting treatment prior to incarceration. And for those who say they were in treatment, in the majority of cases that treatment can't be confirmed. I once scrupulously collected records for my patients for about four months, when I was new to corrections. Eventually I found that record collection was a futile activity for three reasons: 1. Most of my releases were returned with the comment 'unable to locate patient'---ie., they were never in treatment like they said they were, 2. The records gave me information I already knew from taking a history, and 3. The information I needed wasn't in the documentation because the discharge summary was dictated by a ward social worker or nurse (and only signed by the psychiatrist) and didn't contain the basis for the diagnosis. So, regarding the weight given to previous diagnosis: If I know the doctor and trust their clinical skills I give significant weight to that. If I've never heard of the person before, or if the patient is completely new to me (never seen during previous incarceration) then I start from scratch. If anything the patient tells me suggests that his clinical circumstances have changed, or if he doesn't seem to be responding to appropriate treatment, I restart from scratch. If there's something about the clinical picture that is inconsistent, I rethink the diagnosis. Clinical circumstances change over time, symptoms can change over time, new information can appear or develop so you just keep an open mind. A psychiatry professor I respect once said (on this podcast) that "A good clinician is someone who makes prudent decisions based on insufficient information". In other words, no clinician every has an entirely complete database to work from so you do the best you can with what you've got.

OK, I hope that answers the Anonymous Questioner. Those were good questions.

From The L.A. Times

Usually we pick our post topics off the New York Times, but here's a couple stories from the LA Times that caught my eye today:

Report urges more sleep for medical residents

The National Institute of Medicine has officially encouraged medical training programs to place 16 hour limits on the length of shifts that doctors in training can work. The report produced by NIM also recommends that any resident required to work longer than a sixteen hour shift be required to take a five hour nap before continuing.

So now the biological functions of physicians are being regulated by accrediting bodies and other professional organizations. Imagine the stress: "Sleep, gosh darn it! Sleep or we'll lose our accreditation!"

I totally agree that doctors need a decent amount of sleep in order to be any good to their patients, themselves and their families. I just think it's weird that hospitals have to be forced to acknowledge the biological needs of their doctors.

Another interesting story in the LA Times is a three part series entitled Through Prison Glass. It's a story about a woman, who also happens to be an attorney, who met and married a prison inmate while he was incarcerated in Pelican Bay. Pelican Bay is California's control unit prison (also known as a SuperMax facility). The prisoner in this story is alleged to be a leader of the Aryan Brotherhood and is in SuperMax for a murder conspiracy and other crimes committed inside prison walls.

I think it's an interesting story because I'm always curious about the psychology of women who marry convicted criminals whom they've never even known outside prison. You can read the second part of the series here.

My Last Day

As I was leaving prison today I noticed a man standing on the corner. He was wearing nice pants and a dress shirt. He had a knapsack thrown over one shoulder and was wearing sunglasses while talking on a cell phone. I didn't think anything of it until he looked over and saw me and yelled, "Doc! Hey doc! Remember me? You helped me, you really did. I'd hug you but I know that wouldn't be appropriate."

Frankly, I didn't recognize him at first. I knew who he was after he called my name, but just to see him standing there, well, the context was quite different and he looked very very different from his appearance in prison.

Anyway, he was doing great. He had a place to live, a job, was going to AA regularly, staying clean. He was waiting for his ride to pick him up for AA. His phone rang and he picked it up. "It's my ride," he said. He told his ride: "Hey, guess what? I'm standing here with the doc who saved my life!" His ride pulled up, and the driver immediately started waving and hollering at me too. My patient said, "You remember him? You saved his life too." I had seen the driver maybe twice, just a few days after he had been arrested. I remembered him, remembered that he had never been in trouble before, was facing serious charges and was pretty upset. Then the driver quoted to me, word for word, something I had said to him four years before that had helped him get through incarceration.

As they were driving off they pointed to me and said, "You keep doing what you're doing. You keep helping people."

I don't have any trouble admitting that I choked up a bit and by the time I got back to my car I was in tears.

You see, today was my last day as a fulltime prison doc. After about fifteen years I've decided that for my own sanity I'd need to cut back to part time and go back to doing another job I've always enjoyed doing (more about that later). This was quite the experience to have as I'm going, literally, out the door. It's the experience I'll remember the next time I hear someone knocking docs who do med checks instead of psychotherapy, or saying that prison doesn't help anybody.

It's good to remember that sometimes there are happy endings.

Leave Me Alone: Does SHU Syndrome Exist?

[Note: This is the second in a two part series discussing the effects of longterm segregation. The first part in the series can be read here.]

When you read legal opinions or listen to professionals talk about the psychiatric effects of longterm segregation you will sometimes hear them refer to something called the "SHU syndrome". The "SHU" stands for Special Housing Unit, another name for a control unit prison or a tier in a regular prison where inmates are kept in longterm segregation.

The commonly accepted definition of "syndrome" is a constellation of signs and symptoms that are common to all sufferers of a disease. Syndromes are validated by showing that the particular syndrome can distinguish between people who have the disease versus those who don't, and can distinguish one disease from others.

The SHU syndrome has had a variety of symptoms attributed to it, but they generally include some type of altered mental state, specifically changes in mood and cognition or orientation. It is presumed to be caused by the conditions of confinement in segregation. One of the earliest descriptions, and the one that probably gets cited most often by correctional experts and the judiciary, is in a 1983 article by Grassian, The psychopathological effects of solitary confinement. He interviewed fourteen segregation inmates who had been confined from eleven days to ten months. These inmates reported heightened sensory acuity, affective disturbance (particularly anxiety), difficulty with concentration and memory, as well as illusions and misperceptions. All symptoms reportedly resolved within hours of release from segregated confinement. It should be noted however that all the subjects in this study were inmates who had filed a class action Eighth Amendment suit based upon their condition of solitary confinement. The author himself noted that he was required to “actively encourage disclosure of information” in order to obtain symptom reports, because the subjects initially denied problems. This aspect of the study is rarely (make that never) cited in legal opinions.

I could post a series of studies, using small sample sizes of actual prisoners, to detail things people have done to see if segregation actually does cause physiologic changes or changes in psychiatric symptoms, but that would basically end up being a tedious listing of article summaries (a big reason why my book chapter on the effects of segregation was never finished---I even bored myself!). The bottom line is that studies using control groups showed either no significant differences with controls, or only minor differences that disappeared quickly after removal from segregation.

If anyone really really wants me to post the draft of a book chapter I could but I'm not sure my co-bloggers would forgive me.

**********

Grassian, Psychopathological effects of solitary confinement, American Journal of Psychiatry 140: 1450-1454, 1983.

Leave Me Alone: The Science Of Solitary Confinement

Solitary confinement, or segregation, is used for several reasons. Inmates are put into segregation as a disciplinary measure for doing things like threatening or fighting with officers, escaping, destroying state property or setting fires. Segregation is used for medical reasons for inmates who may have infectious diseases (like tuberculosis) or who are refusing evaluation for infectious diseases. Segregation is used for protective custody if the inmate is a juvenile or if there are reasons to believe the inmate's safety might be at risk in regular housing (also called general population). Finally, there are also mental health reasons for putting someone in segregation. Inmates who are new to the facility, who are frightened and need time to adjust, or who have had a recent trauma or loss may temporarily be put by themselves to give them a quiet place to deal with whatever is going on.

In free society segregation is used for therapeutic reasons too, although the terminology changes. On an inpatient unit "segregation" becomes "seclusion" even though the physical conditions may be identical, or very similar to, the physical environment in a prison. Seclusion rooms and segregation cells are usually bare with minimal comforts. The patient (or inmate) is deprived of access to outside resources and supports, with no regular recreation or entertainment. The food is, well, institutional food is institutional food.

The only real difference is that in free society when someone is put in seclusion there must be a clinical evaluation that finds an indication for using this intervention, usually unpredictability or evidence that the patient may be a danger to himself or others. The indication is documented and the patient is usually also observed at regular intervals. The order for seclusion must be rewritten at regular intervals and the basis for continued seclusion documented in the patient's chart. The patient must be allowed periodic freedom from restraint (if physically restrained) and access to hygiene and toileting facilities. Seclusion must end when the clinical indication for it is over.

In a correctional facility segregation does not have to be based on clinical need, and most often it's not used for mental health reasons. Segregation is usually used for security and disciplinary reasons, in which case it's called "disciplinary lockdown". The length of confinement is predetermined, usually a few days to a few weeks. If the inmate is really really bad (has killed other inmates or correctional officers) or presents an extreme security risk (repeated escapes or organizing riots) the segregation may last for months or even years. Inmates have a lot to lose by being placed in lockdown for this long, so correctional facilities have due process protections in place to provide them with a chance to challenge their confinement. The legal steps used to place an inmate in lockdown are very similar to the process used for civil commitment in free society: the inmate is given a notice that documents the alleged behavior leading to the lockdown, he is given a hearing before an independent factfinder with a chance to present evidence and confront witnesses, and he's given an opportunity to appeal the results of the disciplinary hearing. He is also allowed to be given less restrictive sanctions, like loss of privileges or cell restriction in general population. If all else fails, the inmate has the right to appeal the administrative hearing officer's decision to a court in free society.

So, now that you have this background I'll come to the real reason I want to talk about longterm segregation:

Inmate advocates allege that longterm segregation drives prisoners crazy. Whether you know it or not, millions of taxpayer dollars are spent every year litigating the use of longterm segregation. Specialized correctional facilities, known as control unit prisons, were invented specifically for inmates who require segregation for months or years. Class action suits filed by the American Civil Liberties Union and other advocacy organizations allege that this causes psychiatric deterioration and psychosis, with some groups calling for closure of all control unit prisons.

But is this true?

The fact of the matter is that despite all the money we've spent regulating the use of control unit prisons and monitoring inmates who are on segregation, the data are sketchy. Epidemiologic studies have shown that the prevalence of psychiatric disorders among prisoners increases with each increase in security level---in other words you find more psychiatric patients in maximum security than in minimum security---but this does not prove that high security causes psychiatric disorder. In all likelihood, inmates with aggressive or disruptive behavior, such as those found in maximum security, are more likely to be diagnosed with a psychiatric illness. Aggressive antisocial or borderline inmates often are also concurrently diagnosed with bipolar disorder. Conversely, inmates with psychiatric disorders are less likely to be classified to lower security levels where on-site psychiatry services may not be available. The epidemiologic findings are an artifact of the classification process and a reflection of our limited diagnostic schema.

I did a PubMed search (I'm big on these lately for some reason) using the terms "administrative segregation", "longterm segregation", "control unit prison" and "solitary confinement". There are only about 20 significant articles on this topic going back 45 years---not exactly an overwhelming body of literature. Only four of the nineteen are controlled studies with data, while the majority are descriptive, theoretical or speculative in nature.

Contrast this with the court's view of the psychological effects of control unit prisons, as outlined in David Fahti's law review article "The Common Law of Supermax Litigation" (Pace Law Review Vol. 24:675, 2005):

"Federal courts continue to recognize as established fact that isolated confinement inflicts serious psychological harm on many prisoners."

And in one case cited in the article:

"The effect of prolonged isolation on inmates has been repeatedly confirmed in medical and scientific studies".

The medical articles cited in these legal cases are few, and are usually 20 years or more out of date. They point to the effects of social isolation and sensory deprivation, a line of research popular in the 1960's when research into brainwashing was de rigueur for psychologists. Unfortunately, because most of these cases are settled by consent decree and rarely go to trial, this lack of scientific scrutiny is left unchallenged. The result is that courts are mandating that certain inmates be removed from segregation based on the presence or abscence of an Axis I DSM diagnosis, disregarding the inmate's behavior and adjustment in previous facilities. In one case a court mandated that any inmate with a "serious personality disorder" be removed from a control unit prison---I imagine that must have pretty much emptied out the place.

I agree with the courts that control unit prisons should practice humane care under safe and reasonably comfortable conditions. It should be done because it's the right thing to do but you shouldn't misrepresent or distort scientific evidence to justify it.

*********

I had trouble saving the link to the combined search, so I'll just post the references:

1: Arrigo BA, Bullock JL.
The Psychological Effects of Solitary Confinement on Prisoners in Supermax Units:
Reviewing What We Know and Recommending What Should Change.
Int J Offender Ther Comp Criminol. 2007 Nov 19. [Epub ahead of print]
PMID: 18025074 [PubMed - as supplied by publisher]

2: Cloyes KG.
Prisoners signify: a political discourse analysis of mental illness in a prison
control unit.
Nurs Inq. 2007 Sep;14(3):202-11.
PMID: 17718746 [PubMed - indexed for MEDLINE]

3: Doncliff B.
Solitary confinement in mental health nursing.
Qld Nurse. 2007 Jun;26(3):7. No abstract available.
PMID: 17624037 [PubMed - indexed for MEDLINE]

4: Way BB, Sawyer DA, Barboza S, Nash R.
Inmate suicide and time spent in special disciplinary housing in New York State
prison.
Psychiatr Serv. 2007 Apr;58(4):558-60.
PMID: 17412861 [PubMed - indexed for MEDLINE]

5: Andersen HS.
Mental health in prison populations. A review--with special emphasis on a study
of Danish prisoners on remand.
Acta Psychiatr Scand Suppl. 2004;(424):5-59. Review.
PMID: 15447785 [PubMed - indexed for MEDLINE]

6: Andersen HS, Sestoft D, Lillebaek T, Gabrielsen G, Hemmingsen R.
A longitudinal study of prisoners on remand: repeated measures of psychopathology
in the initial phase of solitary versus nonsolitary confinement.
Int J Law Psychiatry. 2003 Mar-Apr;26(2):165-77. No abstract available.
PMID: 12581753 [PubMed - indexed for MEDLINE]

7: Andersen HS, Sestoft D, Lillebaek T.
Ganser syndrome after solitary confinement in prison: a short review and a case
report.
Nord J Psychiatry. 2001;55(3):199-201.
PMID: 11827615 [PubMed - indexed for MEDLINE]

8: Andersen HS, Sestoft D, Lillebaek T, Gabrielsen G, Hemmingsen R, Kramp P.
A longitudinal study of prisoners on remand: psychiatric prevalence, incidence
and psychopathology in solitary vs. non-solitary confinement.
Acta Psychiatr Scand. 2000 Jul;102(1):19-25.
PMID: 10892605 [PubMed - indexed for MEDLINE]

9: Gore SM.
Suicide in prisons. Reflection of the communities served, or exacerbated risk?
Br J Psychiatry. 1999 Jul;175:50-5.
PMID: 10621768 [PubMed - indexed for MEDLINE]

10: Sestoft DM, Andersen HS, Lillebaek T, Gabrielsen G.
Impact of solitary confinement on hospitalization among Danish prisoners in
custody.
Int J Law Psychiatry. 1998 Winter;21(1):99-108. No abstract available.
PMID: 9526719 [PubMed - indexed for MEDLINE]

11: Farrell GA, Dares G.
Seclusion or solitary confinement: therapeutic or punitive treatment?
Aust N Z J Ment Health Nurs. 1996 Dec;5(4):171-9. Review.
PMID: 9079314 [PubMed - indexed for MEDLINE]

12: Grassian S, Friedman N.
Effects of sensory deprivation in psychiatric seclusion and solitary confinement.
Int J Law Psychiatry. 1986;8(1):49-65. No abstract available.
PMID: 3940165 [PubMed - indexed for MEDLINE]

13: Suedfeld P.
Measuring the effects of solitary confinement.
Am J Psychiatry. 1984 Oct;141(10):1306-8. No abstract available.
PMID: 6486277 [PubMed - indexed for MEDLINE]

14: Grassian S.
Psychopathological effects of solitary confinement.
Am J Psychiatry. 1983 Nov;140(11):1450-4.
PMID: 6624990 [PubMed - indexed for MEDLINE]

15: Volkart R, Rothenfluh T, Kobelt W, Dittrich A, Ernst K.
[Solitary confinement as risk factor for psychiatric hospitalization]
Psychiatr Clin (Basel). 1983;16(5-6):365-77. German.
PMID: 6647886 [PubMed - indexed for MEDLINE]

16: Kaufman E.
The violation of psychiatric standards of care in prisons.
Am J Psychiatry. 1980 May;137(5):566-70.
PMID: 7369400 [PubMed - indexed for MEDLINE]

17: Maclay DT.
Letter: Solitary confinement in control units.
Lancet. 1975 Aug 30;2(7931):408. No abstract available.
PMID: 51211 [PubMed - indexed for MEDLINE]

18: Gendreau P, Freedman NL, Wilde GJ, Scott GD.
Changes in EEG alpha frequency and evoked response latency during solitary
confinement.
J Abnorm Psychol. 1972 Feb;79(1):54-9. No abstract available.
PMID: 5060981 [PubMed - indexed for MEDLINE]

19: WALTERS RH, CALLAGAN JE, NEWMAN AF.
Effect of solitary confinement on prisoners.
Am J Psychiatry. 1963 Feb;119:771-3. No abstract available.
PMID: 13998703 [PubMed - indexed for MEDLINE]

20: van WULFFTEN PALTHE P.
Fluctuations in level of consciousness caused by reduced sensorial stimulation
and by limited motility in solitary confinement.
Psychiatr Neurol Neurochir. 1962 Nov-Dec;65:377-401. No abstract available.
PMID: 14002046 [PubMed - indexed for MEDLINE]

How To Say Goodbye

In a few weeks I will be less of a ClinkShrink than I currently am. I'll still be a ClinkShrink, I'll just be doing it in fewer prisons. It feels odd to schedule my patients for followup knowing that I will no longer be there for their followup appointment. I am faced with the question of how to say goodbye to my patients, some of whom I've treated over multiple incarcerations in the last fifteen years.

Patients come in and out of my life fairly quickly. With a caseload of at least 150 patients or so, there's no way I can specifically remember each one. Often they disappear without warning, released to parole or transferred to other facilities. Sometimes I read about them in the newspapers later, either arrested or killed. That bothers me. I used to think that inmates didn't get attached to prison doctors because they move quickly through the system and see someone new at each pretrial facility. Generally though once they get into the sentenced side of the system, the prison side, this settles down and you have a chance to develop some longterm relationships. And the longer you work in the system the more inmates you get to know. Dinah thinks that when you're 'only' doing med checks the therapeutic relationship isn't important, but I can tell you it is. I'm going to miss (not all, but many) of these guys. If it matters to me, I'd be willing to bet it's going to matter to (not all, but many) of my patients.

The patients it will matter to are the ones who ask for me by name when they get arrested, the ones who insist on getting on the phone to say 'hi' when the nurse pages me for medication orders, the ones who honk and wave when they drive by me on the street, or run up to me in the recreation yard to tell me how they're doing. These are the patients who prove to me that kindness and a good rapport counts, even when you're 'only' doing med checks.

So I've been saying goodbye this week, not without a fair amount of guilt. Eventually I will be replaced but not right away, not for the full amount of time, and likely by someone with little or no correctional experience. I have sympathetic anxiety pains for the new clinician who has no clue what he's walking into, as well as for the inmate who sees the new face and has to start all over again.

But starting over is what the correctional experience is all about, for patients and sometimes also for physicians.

Fight Club

OK, so Dinah inspired me with her "You're The Psychiatrist...." post. She does do this fairly regularly. She stumbled into an Ultimate Fighting event and came out wondering, "Why do people do this?"

I'll tell you why. I have some experience with fighters, both as a psychiatrist who works with violent people and as someone who has hung around black belts for about twenty years.

It's about competition, it's about adrenaline and excitement, it's about taking risks and not being afraid of the consequences. (I'm tempted to say 'it's a guy thing', but besides being a sexist comment it would also happen to be an untrue statement. At some of the martial arts competitions I've been to I can tell you there are a substantial number of women competing nowadays. And you should see their tattoos!) So it's a sport, although I have to say there's sometimes a fine blurred line between a sport and a crime. If there are rules, if there's a professional organization sponsoring the event, if you have to pay to get in and you get some kind of formal training, then it's a sport.

Then there are crimes. People who fight---without rules and without sports equipment----sometimes do it because they enjoy it. It releases tension, gets rid of pent up emotion, and sometimes it settles problems (whether it's a good way to settle problems is obviously a whole different question). Among prisoners the challenge is to see how "good" you are at it or to establish dominance and defend your turf. It's to enforce gang rules or to punish rulebreakers. Among the younger inmates (also called "hoppers" in prison slang, after hip-hop) the idea is that fighting is protective; by being willing to 'step out' you'll be less vulnerable and it will keep people away from you. Younger inmates also will prove themselves by going up against much bigger prisoners or correctional officers. (The much bigger, more experienced correctional officers can usually see this coming and can 'talk them down' or persuade them that it's really not a good thing to do.)

So that's what my experience has been and what I can say about the motivation of fighters. Street fighters eventually grow up or burn out. They figure out they won't always be the biggest baddest person on the block and that injuries accumulate over time. Then there's the rare person who never figures it out, and they stay locked up. One prisoner I met had been in a coma for several weeks as result of a street fight. I asked him what he had learned from the experience. His response:

"Next time I bring a gun."

Oy.

A New Use For Gangs

(A BGF tattoo)

I found a new use for prison gangs today. It was completely unexpected.

The patient was a very large, somewhat scarey-looking guy with a history of bipolar disorder. When manic (and psychotic) he got violent. He was transferred back to my facility for refusing to take his meds in a lower security setting. I forget what happened there, but he just wasn't doing well. Back in my facility he was among his associates from the Black Guerilla Family, a well-known prison gang. They respected his size and definitely didn't want him getting sick. They made sure he went down from the tier to the pill line to get his medication.

You'd never guess he had a mental illness when he was well. He was still big and scarey-looking, but he was also articulate. He talked about being able to haul someone into a shower and "mess him up" without guilt or remorse. He talked about staying vigilant, knowing that being part of the BGF made him a target for other gangs. He talked about being bothered by the fact that his violence and lack of conscience didn't bother him. He talked about "wearing a mask" and passing as normal. I could have listened to him forever, and it would have made a good documentary about sociopathy.

But anyway, back to the gang. In psychiatry you hear a lot about the importance of social networks and family support and how this can prevent relapse for people with psychotic disorders. What you don't always think about is how a prison gang can serve this same function. The BGF helped keep my patient well.

He finished the appointment by asking how I was doing and if I was OK, which I thought was rather interesting. It was a bit like Tony Soprano, someone who could execute a guy without batting an eye, being concerned about the ducks in his pool. And I was the duck.