Why Are Inmates Dying?

In yesterday's New York Times there was a story by Erin Banco called Suicides Worry Experts at Big Jail in Capital. The story talks about four deaths at the DC jail this year and the general worrying trend of increasing correctional suicides nationally. The article speculates that the deaths may be attributed to lack of adequate mental health staffing or deficiencies in the jails' observation practices. Some of the people interviewed for the story linked the deaths to cutbacks in state mental health budgets.

Correctional suicide is an area that, as Dinah would put it, is a "Clink" thing---a topic I've been interested in for a number of years. I wrote about this three years ago in an article called Correctional Suicide: Has Progress Ended? In my article I pointed out that nationally we seemed to have hit a "floor" with regard to suicide prevention---rates had been declining consistently over the years until a recent plateau. I wrote about what I thought might be the cause of that plateau: the Prison Litigation Reform Act which limited prisoner access to the courts and circumscribed how far courts could intervene to improve prison and jail conditions,  as well as changes in the profile of the typical correctional suicide, and the increasing problem of gang violence and intimidation in corrections.

What was most striking for me then was the fact that correctional suicide studies are starting to show increasing numbers of inmates who die from suicide without any previous mental health history or history of suicide attempts. I coined the term for this phenomenon a "clean" suicide---one that could not have been picked up or prevented through currently accepted screening methods and referral protocols. The New York Times article didn't address this, but I couldn't help wondering if the deaths in the DC jail might fall into this category.

What I didn't mention in my earlier paper---because the numbers weren't out yet---was that the increase in jail and prison deaths may reflect a larger trend in rising national suicides. According to the CDC, the age-adjusted death rate for suicide has increased by 8.7 percent since 2000. The other new data comes from the recent Department of Justice report on inmate sexual victimization and abuse. According to this national survey, being a sex offender increases the by other inmates. The Washington Post has reported that three of the four DC jail deaths were by detainees who were charged with sex offenses.

The Times may be correct that cutbacks in state mental health budgets have had an effect, but this does not address the fact that for many states the funding for correctional health care comes out of the public safety budget rather than the health and mental hygiene budget. State cutbacks could still play a role, just not through the route the article suggests. States with privitized correctional health budgets would also have to be examined separately to look for contractual budget changes.

So those are my thoughts about the NYT correctional suicide story. I figured I'd better get this post up fast before Dinah nudges me to write about it. (Yeah I know, I'm supposed to be re-reading the book proposal but Dinah you know I had to blog about this.)

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 End of the Stories: Patient C

Patient C was held in the booking area in a cell by himself. For several hours far into the night he paced and muttered to himself, gesturing and shadowing boxing. The jail psychiatrist tried to pursuade the booking officers to help administer emergency medication but they refused, citing lack of man power and the amount of bureacratic paperwork that would have to be done in conjunction with any use of force incident. Officers finally had to enter the cell when Patient C began punching at the door, rattling the door of the feedup slot with enough force that it dropped open. Then he began punching the walls.

"OK guys," the jail psychiatrist said to the nearest officer and the duty lieutenant. "Now we've gotta do something."

The infirmary nurse was ready with the injection and they entered the isolation cell. Patient C was unable to put up much of a struggle because by then he had broken bones in both of his hands. Two hours later he was calm. Six hours later he was completely back to normal. He was able to give his history to the doctor on the next shift.

Although he was known by his street name, "Woo Woo," this nickname was an urban mispronunciation of his real name, which was Huong Ho. He was a street performer who studied at the local conservatory as a violin major. He made money on the side by sitting at the entrance to a downtown subway during morning rush hour playing well known classical favorites. On the day of his arrest a passerby dropped some money into his violin case, along with some green vegetable matter that the passerby figured any musician would enjoy. Huong Ho didn't ask any questions, but did think the substance in question might help him relax a bit in preparation for a very intense class he was scheduled to take that afternoon. Unfortunately, the weed wasn't what he thought it was. He blacked out. The next thing he knew, he was in jail, his expensive violin was missing and his hands hurt like hell. He looked scared, like he was about to cry.

Fortunately, the only person he had hurt was himself. Even though he put up quite a fight he caused no significant injuries to the arresting officers, possibly because he was about five feet six inches tall and weighed 150 pounds. Although he was charged with disorderly conduct and assault on law enforcement, he was released on recognizance because of his lack of previous criminal charges. At trial he was granted probation before judgment.

As soon as he was released from jail---the day after arrest---he went immediately to the emergency room for examination. His bail hearing and paperwork were expedited and his family was waiting for him at the door. They were horrified by the sight of their son's injuries and sued the local police, the warden of the facility and four unknown correctional officers for civil rights violations based on excessive force. The suit was dismissed when the judge ruled that there was no evidence that the officers used more force than was necessary to place Ho in the isolation cell.

After several weeks of recovery Ho returned to the conservatory. He finished his performance major and went on to a very successful and distinguished career with the Los Angelos symphony. Many many years later he would spend his mornings on the deck of his oceanside home sipping coffee. The local surfers would see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient B

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. Here is what happened to Patient B:

Patient B was sent out to the emergency room where he took a swing at the ER doc examining him and later another one at the consulting psychiatrist there (the police grudgingly uncuffed Patient B so the nurse could take vital signs. The police warned them not to.) They started a detox protocol which sedated him but he remained disoriented. The ER doc called the consulting psychiatrist back (who was waiting for Patient B to sober up so he could do an evaluation). The ER doc insisted that the consulting psychiatrist admit the patient to the psychiatry service as soon as possible for detox. The psychiatrist explained that he could not assess the need for admission, if any, until the patient sobered up. The ER doc walked away muttering something quietly under his breath. Several hours later the patient was no longer combative, but he was also no longer responsive. The psychiatrist came by to see if Patient B was sober yet and found him obtunded with a single dilated pupil. Patient B was rushed to radiology for an MRI. His intracranial bleed was caught just in time. After an extended stay on the neurosurgery service he was discharged to a rehabilitation facility.

Meanwhile, the local state's attorney had an attempted murder on his hands. The victim, a local used car dealer, narrowly survived a knife attack when Patient B walked into his girlfriend's apartment and found the car dealer...um...checking the oil. The girlfriend was unharmed but told the police that Patient B was there in violation of a protective order she had taken out against him two weeks before. Given the serious nature of the charge and the political implications of domestic violence in general, the prosecutor refused to drop the charges even though he knew that Patient B was in the hospital. They held the bail review hearing at the patient's bedside. Patient B was held with a no bail status and a correctional officer was posted at the patient's bedside. Leg irons bound the patient to the bed as he recovered from his neurosurgery. His ex-girlfriend, learning that Patient B had been near death, had an immediate change of heart and got into a fight with the attending officer when she insisted she needed to be at the bedside as well. Hospital security was called when she refused to leave, and she was ultimately taken into custody for disorderly conduct.

Ultimately Patient B was seen by the psychiatry consult liaison service. He was found to have moderately severe short term memory impairments, abstraction problems with difficulty reasoning, expressive aphasia and profound apathy. And he could only walk with assistance. His public defender took one look at Patient B sitting in the wheelchair in court and he knew he would have to request a competency assessment. He also knew Patient B would be found incompetent to stand trial, but not dangerous due to his physical impairments.

Patient B dropped into legal purgatory. He was incompetent to stand trial but could not be admitted to a psychiatric hospital for restoration because he was not dangerous. Even the neurosurgeons couldn't predict how much, if any, of his mental faculties would be regained over the longterm. The state's attorney's office refused to drop the charges because of the seriousness of the offense. When the statutory limit of incompetence was reached, the judge threw out the charges but the state's attorney immediately reindicted the defendant, thus restarting the clock. The case was appealed to the highest court in the state and a final opinion is pending.

Meanwhile, many many years later Patient B spends a few minutes every morning sipping coffee on the front porch of the assisted living facility the nursing home released him to. He hasn't heard from his girlfriend in many years although he has vague fond memories of motorcycle road trips with her hugging him from behind. His housemates---a demented elderly professor of economics and a frail former teacher---see him on the porch and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person.

The End of the Stories: Patient A

Thank you to everybody who commented on my hypothetical jail patient scenarios in my post Send Them Away. I thought it was interesting that people with different professional backgrounds and levels of experience pretty much agreed on what to do, who to keep and who to send out.

Since people seemed to enjoy speculating on the back stories, I thought I'd supply the endings.

Patient A was kept in the jail and admitted to the infirmary. After a few days of medication he quickly got better and was able to tell you what happened since his last release. His mother tried to get him an appointment at the local mental health clinic shortly after he got home, but she was told there was a three month wait until the first available appointment and that she should call the police or take him to an emergency room if it was an emergency. After he ran out of his thirty day supply of release medication he went to the emergency room to get it renewed, but when he ran out of meds a second time he was told he could no longer get his meds renewed through the emergency room. It didn't really matter though since his benefits were cut off while he was in jail and he couldn't afford them anymore anyway.

His mental state went downhill quickly after that. His mother, the much-beloved Cookie Lady (as she was known in the neighborhood), didn't stand much of a chance. I'll spare you the details. As a well-trained forensic psychiatrist you know that ethical standards for correctional work forbid you from collecting forensic evidence in jail as a treating clinician, so you are circumspect about your documentation as it regards the current offense. Eventually, an outside forensic evaluation is done and Patient A becomes an insanity acquittee. He is transferred to a forensic hospital.

Immediately after the verdict, there is public uproar. The local newspaper publishes an opinion piece calling for reform of the public mental health system and looser standards for civil commitment and involuntary treatment. A state delegate proposes legislation for outpatient civil commitment. The governor organizes a task force to study the issue and the entire police force is required to undergo crisis intervention and mental health training. Mental health advocates decry Patient A's incarceration, loudly insist that jail couldn't help anybody, and accuse the jail (not you in particular, but the jail) of giving lousy, horrible, inadequate or nonexistent care. (Meanwhile, the somatic jail doc has diagnosed Patient A's new-onset diabetes and Patient A is getting a diagnostic workup for the lump that was discovered on his admission physical---it turned out to be benign. Because of patient confidentiality, none of this can be revealed to the public but you know it.) Meanwhile, on the newspaper internet discussion board some people express outrage that "that dangerous nut case" should have been sent to prison forever, given the electric chair, or made to undergo the same horrible acts he did to his mother. Patient A reads all about this in the newspaper delivered to his ward, and hears about it on the ward television news reports.

Years later, many years later, Patient A is quietly granted conditional release by a sympathetic judge, with the support of the local state's attorney. He goes to live back in his old neighborhood---now gentrified beyond recognition, where he spends a few minutes every morning sipping coffee at the corner Starbucks. His neighbors---a young attorney fresh out of law school, a music student at the local conservatory, and a young couple who work for the local newspaper, see him there and exchange casual greetings. They think he is a shy but likable guy, a quiet but kind person. They enjoy having him as a neighbor.

Send Them Away

I saw this story on my twitter feed, about a jail sheriff in Ohio who has instituted a policy to refuse to accept any detainees who are violent due to a mental illness. Some people are saying this is a great policy because it will keep people with psychiatric disorders from getting locked up. The sheriff was quick to add though that diverting people out to an emergency room was not an alternative to incarceration. Rather, it was a means of providing immediate care and stabilization to people who might need it.

What lead to this new policy? The article mentioned that budget cutbacks at the jail lead to a decrease in psychiatric coverage, from full time to less than part time. There was also an incident at the jail in which an inmate on the psychiatric infirmary died while struggling with correctional officers. (No details were mentioned about this incident, although some officers were criminally charged.)

I read this story with mixed emotions. On the one hand, I appreciated the need for emergency medical care for some newly arrested prisoners. On the other hand, I had a visceral response to the sheriff's statement: "We're not going to be a dumping ground for these people," said the sheriff. Apparently, he equates seriously mentally ill people with trash. That's the issue I have with this policy. It's not really about getting people the help they need, it's about NIMBY-ism (Not In My Back Yard), a way to turf the treatment of the seriously ill off on someone else. So the jail doesn't want to accept violent mentally ill people, and hospitals don't want to admit psychiatric patients with histories of violence. It seems that the most ill folks are destined to sift down through the institutional bureaucracies until they pool into some environmental equivalent of a Thunderdome.

While the sheriff may be reacting to a budget cut, remember that legislatures don't dictate line-item cost cutting. That's up to the facility administration. So when the sheriff sat down with his new reduced budget, what made him cut the psychiatric hours? Do you think there may be some problem with priorities here?

In my experience people spend too much time arguing over who belongs where. People with mental illness require the right treatment, at the right time, regardless of their physical location. The real solution is to have adequate mental health staff in place and to have custody staff trained to work with them. The facility needs to have policies in place to give emergency medication, adequate safe and humane housing and staff skilled in verbal de-escalation, not to mention adequate mental health coverage.  This particular jail has hired an outside consultant who will undoubtedly consider and review all these things. The main point of my post being: The solution to a health care problem should never be to get rid of the patient.

But let's assume for the moment he's acting with good intentions and walk this policy through it's logical outcomes. The biggest challenge---and this is not a small barrier---is that custody will not know when violence is due to mental illness. Even clinicians can have trouble telling if someone is drunk or high on crack or psychotic or just really really pissed.

I'd like to invite our readers to participate in a little practical exercise. Read these scenarios and tell me what you think. Although these are clinical questions you don't have to be a clinician to answer. I'd like to give the general public a chance to think like a forensic doctor.


Clinical Scenario:

You are a forensic psychiatrist working full time in a medium-sized local detention center (a jail). Each of the following patients are brought to you on the same day, and you have to make the call to send the patient out to an emergency room for further evaluation and treatment or keep them in the facility. Remember that none of them have been booked or formally charged yet (they are so 'out of it' that they are brought directly to you rather than getting charged first). If you send them to an emergency room you will get a basic set of lab work done but no further workup is guaranteed. There is also the chance that the arresting officer may decide not to press charges after all, so that he can drop the patient off in the emergency room and get back to the streets. On the other hand, if you keep the patient in the detention center you run the risk of missing a serious physical condition that could leave the patient dead in his cell overnight. Here we go:

Hypothetical Patients:

Patient A: Patient A is brought to the jail by the police covered in blood. He is thought disordered, incoherent and talking about angels and demons. He believes he is in heaven and thinks that satellites have been tracking his movements throughout the city. He is homeless and has no known family or friends. This is his tenth incarceration in five years and his presentation today is consistent with all the other times that he has been locked up. From previous jail treatment records you know that he responds quickly to low doses of medication and will require only a week or ten days of admission to the jail infirmary. When well he has a good relationship with you and always reminds staff when his medication order is about to expire. Even now, he knows who you are and appears significantly relieved to know you are there to start his treatment promptly. The arresting officers, who don't know any of this, warn you as you escort him into your office (in a waist chain and handcuffs), "Careful doc, you don't want to know what he just did to his mother." All of Patient A's previous incarcerations were for non-violent offenses like drug possession and minor thefts.

Patient B: Patient B is brought to the jail by the police covered in blood. He smells of alcohol and has an open bleeding gash on the back of his head. The arresting officer tells you that this is the third time in two months he has arrested Patient B for public intoxication and misdemeanor assault. You have never met Patient B before and have no old records. Patient B is disoriented, hallucinating and talking about angels and demons. As the arresting officer escorts him into your office (in a waist chain and handcuffs), he warns you, "Careful doc, you don't want to know what he just did to the other guy."

Patient C: Patient C is brought to the jail by the police covered in blood. He is angry, swearing and wrestling with both the police and the correctional officers in the booking area. You are unable to get close enough to him to ask questions and when asked questions by the booking officer he responds only with profanity. He has no obvious open wounds or signs of trauma. The arresting officers don't need to warn you about anything. You know enough to stand waaaay back. The only thing you know about him is his reported name, which may or may not be an alias. The officers know him only by his street name, "Woo Woo." He isn't cooperative enough to verify his identity through fingerprints so you can find no old records.

Question:

Which of these patients would you send out to an emergency room from the jail, and which would you keep and treat in house? Why? Discuss.

(This topic is a classic problem in forensic work. It was the subject of one of my earliest blog posts entitled Hot Potatoes.)

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.

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.

The Year In Homicide

There has been a lot of stories in the news lately about homicides committed in hospitals. Just out of curiosity, I went to the Bureau of Labor Statistics web site and pulled some data from their Census of Fatal Occupational Injuries. It confirmed what I suspected, that homicides of workers in hospitals have increased at twice the rate as correctional facilities, where worker homicides have remained stable. Here's the graph I was able to make from the BLS data:


OK, I'm in a hurry and the graph is small and fuzzy. I'll try again later, but the upshot is that the red bars (hospital murders) are up to 6 and 7 homicides per year while the blue bars (correctional facility murders) have remained stable at about 3 per year. This is only for the employees who have been murdered, not all murder victims. When I get a chance I'll go to the Bureau of Justice Statistics and see if I can find data for all murder vicitms in hospitals versus correctional facilities, not just employee victims.

When we consider the cost and repercussions of increased hospital security, think about this trend. We people wonder if it's safe to be a forensic psychiatrist in corrections, I will bring out these numbers. It does seem to be safer to work in prison than in a hospital.

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.

Who Is A Criminal?

I'll admit this seems like an odd question with an obvious answer. Most people would say that a criminal is anyone convicted of a crime. However, there is a difference between someone who has merely been convicted of a single crime and someone with a pattern of criminal behavior. Repetitive criminals may be psychopaths or sociopaths. Fictional characters like Hannibal Lechter or Tony Soprano are good examples of sociopathic or psychopathic personalities.

It might be a bit disconcerting to know that people like this actually exist and that they've been around for a long time. In 1837 an English psychiatrist named James Pritchard wrote a book entitled Treatise on Insanity in which he described people who lacked the ability to form attachments to others and who were unable to experience normal human affection or emotions. These individuals had little regard for the feelings or rights of others, however they didn't have the hallucinations or impaired cognitive functioning that was seen in other psychiatric disorders. Dr. Pritchard coined the term 'moral insanity' to describe this disorder, which he felt was a defect in area of the brain responsible for moral reasoning. Around this time the American Journal of Insanity (which later became the American Journal of Psychiatry) published several individual case studies of homicide offenders, all of which were entitled "A Case of Homicidal Insanity". They were all essentially just case descriptions of murderers. The letters to the editor of the journal following these case studies debated the validity of 'moral insanity' as a mental illness. The difficulty was that the term 'insanity' implied that from a legal standpoint the criminal should not be held responsible or punished for his behavior. Eventually the term 'moral insanity' was dropped in favor of the term 'psychopath', a term proposed by a Nineteenth Century German psychiatrist.

More recently, the term 'sociopath' has been used instead of 'psychopath'. This latest change happened because people were getting confused by the 'psycho' part of the psychopathy label---psychopathy doesn't mean that the criminal is psychotic. Actually, neither sociopathy nor psychopathy are actual 'official' psychiatric diagnoses in that they can't be found in the Diagnostic and Statistical Manual (DSM). The DSM uses the term antisocial personality disorder (ASPD). Patients with antisocial personality disorder have difficulty with lying, impulsivity, repeated criminal acts, and impulsivity or irresponsibility. The majority of people with ASPD are not psychopaths. Psychopaths represent a minority of severely disordered people who lack emotional attachments or responsiveness. They are narcissistic and are unable to learn from experience. They lack empathy or remorse and are cold, cruel, callous people. This callousness is what distinguishes psychopathy from antisocial personality disorder.

There are a lot of people with antisocial personality disorder---about 3% of the United States population or nine million people. The exact prevalence of psychopathy may never be known because psychopaths usually only come to the attention of clinicians when they are caught committing crimes or when those around them coerce them into treatment. The most skillful psychopaths may not come to the attention of the law and may function successfully as politicians, religious leaders or heads of large corporations.

A screening tool for psychopathy was developed in the 1980's and has been widely used in research and forensic practice. Scores on the Hare Psychopathy Check List-Revised (PCLR-R) have been found to be useful for predicting violence and criminal recidivism. Psychopaths identified by the PCLR-R are being studied through functional neuroimaging in order to identify the physical basis for the disorder. These studies have shown that in psychopaths the part of the brain responsible for processing emotions works differently than in normal people. They also have different physiologic responses to emotion.

There is a genetic component to both ASPD and psychopathy as shown by adoption and twin studies. One large twin study has shown that for severe psychopaths as much as two-thirds of psychopathy can be attributed to genetics rather than environmental influences. For ASPD, the condition originates in childhood. A study done in the 1960's followed children from a mental health center who were referred for evaluation of their behavior problems. The study found that over fifteen years, one-third of the children with conduct disorder grew up to have antisocial personality disorder.

Can psychopaths be treated?

This is a tough question to answer. Psychopaths don't generally seek treatment voluntarily because they aren't bothered by their condition. They must be coerced into treatment or persuaded to participate by engaging their self-interest. For example, by emphasizing that treatment is a condition of parole and is necessary to stay out of jail or prison. Since psychopaths have difficulty learning from consequences, several treatment attempts may be necessary. The treatment must be designed to have open lines of communication between others involved in the psychopath's life in order to ensure truthfulness. There must be clear, consistent and firm boundaries between the patient and the therapist. Psychopaths with a high risk of violent behavior should only be treated in a secure and structured setting like a correctional facility. Psychopaths and people with ASPD are at increased risk of developing other psychiatric conditions such as mood disorders and substance abuse. Medication may be indicated for treatment of these co-existing conditions.

There is no evidence that psychopathy or ASPD can be cured. The goal of treatment is to minimize the impact of the conditions on others and on the patient. For example, one goal of treatment might be to minimize the risk of accidental injury by teaching the patient to recognize situations that trigger dangerous risk-taking behavior. Violence is another focus of treatment with psychopaths; violent behavior can be managed with administrative disciplinary procedures within the correctional facility or through the use of medication.

Specific treatment goals should be set up collaboratively with the patient so that expectations and treatment parameters are clear. The patient's self-identified treatment goal may also reveal his level of insight. When I asked one of my prisoners what he was working on in therapy, his answer was telling. "The truth," he said. "Telling the truth, it's something I've been working on for a while."

It's a beginning.

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.

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.

The 4H Club

When I took a medical history from one of my patients he told me, "I belong to the 4H club: hepatitis, HIV, herpes and hemorrhoids."

In medicine you see the term "comorbidity" used quite a bit. It basically just means that a patient has more than one medical problem happening all at once. It isn't specific to any particular combination of illnesses. In forensic psychiatry it usually means mental illness combined with substance abuse, combined with personality disorders. In the correctional world you can add a few extra layers of pathology by throwing in the medical diseases: hepatitis, HIV, head trauma, diabetes and other stuff, like the 4H list given to me today by one of my patients. (On the positive side, he had no history of closed head trauma.)

Practically speaking, what this means for treatment is that everything is going to be a little more complicated. You have to think about how the personality disorder will color the patient's reaction to your care, how the head trauma will affect his ability to understand what you say to him, and what the co-existing medical conditions will do to your choice of psychopharmacology. That can be a challenge. (OK, so the hemorrhoids in today's patient didn't really complicate the pharmacology. At least not until they invent rectal psychotropics.)

Working in a correctional environment actually helps when you're dealing with some of these multiply co-morbid cases. The structured environment gives some predictability and stability to their lives. It takes away some degree of stress in that they don't have to think about where their next meal is coming from. The clear rules and expectations set boundaries for containing the maladaptive behaviors. And while drugs and alcohol certainly do exist in jails and prisons, there's a lower likelihood that the patient will be using inside the walls than in free society. Finally, the patient has access to medical care that he might not otherwise have in the streets so the co-existing medical conditions are less likely to hinder treatment. My job would be much harder if I were treating these folks in free society.

Then again, in free society I'd have a desk and a telephone. And modern ventilation. And office supplies. And an office. Clerical support. A fax machine. Ample parking space. Unlocked restrooms. A vermin-free place to eat. And...

Oh, never mind.

Sanitized For Your Protection

When I was in medical school they taught us that epidemics of infectious diseases were particularly likely to break out in public institutions like schools, colleges, correctional facilities, dormitories and military barracks. When you consider all the infectious illnesses a person could catch in prison---methicillin-resistant staph or drug resistant tuberculosis or hepatitis or HIV---I guess the common cold is pretty benign. Nevertheless, I take precautions to keep from getting sick and to keep it from spreading to others.

This actually isn't as easy as it sounds. Alcohol-based hand sanitizers are contraband and I have to provide my own kleenexes (Puffs only, thank you, with lotion). There is soap in the bathroom, if you have a key to get into the bathroom. I keep a can of Lysol by my desk. When I see an inmate who has a partcularly nasty cold I run down the hallway spraying doorknobs and swabbing them down with tissues in the hopes that even if I don't prevent the cold completely maybe I can at least minimize the viral load a bit. I make look a bit paranoid doing it, but it seems to work. I can't remember the last time I had a cold (although my pneumonia last January was particularly nasty).

I wish all infectious agents were that easy to control within the institution. Demoralization is the most infectious agent of all, and the toughest to treat once an outbreak starts. I wish Lysol would work for that.

Violent Mood Swings

"My mood is swinging."

When I see this as a chief complaint in a progress note I know what I'm going to read next: a diagnosis of bipolar disorder, not otherwise specified, and an order for the mood stabilizer du jour. What I will not (usually) see is a description of what mood states the patient is "swinging" between, the duration of those mood states or a list of associated symptoms. This isn't specific to correctional work in that I've also seen documentation like this in discharge summaries I've received from hospitals.

I'm familiar with the various "flavors" or subtypes of bipolar disorder that have been hypothesized, but the guys I treat don't fall into a clearcut diagnostic category (unless you count personality disorders) and sometimes there are cases that really push the boundaries between an Axis I and an Axis II problem. I see this a lot when I'm dealing with inmates with a history of institutional violence.

People who do research on violence struggle over how to define or characterize violent acts. You'll see references to predatory violence versus instrumental violence versus opportunistic violence versus impulsive aggression. The nuances elude me, other than to say that the one consistent thing seems to be the degree of planning (or lack thereof) involved in the act.

Before deciding to throw meds at the problem, I'll usually do an assessment to clarify whether or not violence really is an issue. You'd be surprised the number of guys who self-identify temper as an issue, but when you take their histories they've actually held it together quite well. Someone who only has one ticket (infraction) for fighting in a year of incarceration really can't be considered to have too much of a problem with violence. In cases like that I'll ask more questions to figure out exactly why the patient thinks it's a problem; more often than not, they're troubled by the fact that they merely have violent thoughts. In that case the inmate has unrealistic expectations of what a medication can do for their problem.

Other questions I ask are:

* who are you fighting with, inmates or officers or both?
The choice or level of discrimination reflects the degree of control over the violence.

* have you gotten into fights that you haven't had tickets for?
If the answer is yes, this usually means that the patient and his/her opponent plans the fight to avoid detection by custody, another situation where medication is unlikely to be of benefit.

* do you fight when you're sober and clean?
By far the most common precipitant for violence is substance abuse, either in the facility or in free society.

* do you have a bad temper even when you're not depressed?
Clinical depression can decrease frustration tolerance for prisoners. This is often the factor that causes them to seek treatment when they wouldn't even think of seeing a shrink on the outside. Treating the underlying depression fixes the temper problem.

* tell me about some of the situations you've gotten mad in recently
Often there's a good reason for it. Medication is unlikely to help you keep from getting mad when you've got people cursing at you or threatening you. Normal anger exists for a reason and medication will not keep someone from ever getting angry over things that would anger anyone.

So once I've done all this I'll decide whether or not the violence issue is one that might benefit from medication. I'll make it clear in my note that violence is the target symptom and I won't try to stretch a diagnosis to justify a treatment plan.

I think all classes of pharmacologic agents have been used to treat violence at one time or another, but most recently mood stabilizers have shown the most utility for aggression associated with personality disorders. Lithium has been used for this since the original studies in the 1970's, when it was found to cut the violent infraction rate in prisoners by about half. (Interestingly, some of this subjects also discontinued the medication on their own because they didn't "feel" it working, even when it was.) Valproic acid, carbamazepine and now the atypical antipsychotics have all been used for this. SSRI's can have an interesting pro-apathy (if that's a word) effect in some people, giving them the ability to "shrug off" experiences that they normally would have gotten upset about. Regardless, the goal is to lengthen the patient's fuse and give them time to think before they act.

As one patient of mine put it: "The medication doesn't lengthen my fuse. It gives me a fuse."