The Violent Mentally Ill

There's been lots in the news lately about forensic hospitals and the management of violence by psychiatric patients. Here's a short list:

1. Beyond the Gates of Gomorrah

A new book by Dr. Stephen Seager, a tell-all about his work in a California forensic hospital.

2. Broadmoor

A very rare documentary filmed within the walls of a British forensic hospital. In two parts, all on YouTube:

Ep 1 http://youtu.be/bNifHcZV_4Y  Ep 2 http://youtu.be/QNlGxWe-z6s 

3. Clinical Psychiatry News

My recent column, a review of new California guidelines for the treatment and management of inpatient violence. 
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Note from Dinah: the birds have nothing to do with the post, but I don't like it when Clink is too lazy to add a graphic.  Aren't they cute? 

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 Trauma Recovery Movement: Where Did It Come From?

For anybody who's interested, you can follow along with me as I learn about this stuff. I put the tape measure pic up because I'm learning about trauma treatment and outcome measures.

I was curious about SAMSHA's National Center for Trauma-Informed Care so I did a little background reading based on material I found on their web site. (And if there's anybody reading involved in this who would like to jump in and provide more information, please do. Shrink Rap also allows guest posts!)

It appears that this arose out of a SAMSHA initiative to encourage study of innovative program delivery systems. It was recognized that certain groups of people had severe and overlapping treatment issues. In other words, there were women with high levels of childhood abuse, adult violence, mental health issues and substance abuse. They wanted to figure out how to best provide treatment to these folks and they theorized that the key link or ingredient, a "cause" if you will, was the trauma history.

A two-phase, multisite study was designed to look at this problem. (1) In the second phase, nine cities were selected to participate. They enrolled thousands of women in a variety of treatment settings. The women all had one or more of the three issues: trauma history, substance abuse and mental health problems. One key fault is that there was a non-random assignment of the patients: they were allowed to self-select the "intervention" versus "usual care" condition. Both the trauma and usual care groups provided mental health and substance abuse counselling. The trauma group was additionally provided a women-only therapy group that employed one of four trauma treatment recovery models. The usual care group provided some additional not clearly specified intervention (I didn't have time to read in detail, it sounded like a generic social skills group).

The results were difficult to interpret because it turned out that two of the nine sites had significantly different study subjects. They had to break out certain sites from the rest to analyze the data. However, when pooled two interesting findings came out: the first was that a program that integrated all services (mental health, substance abuse and trauma/generic) was better than a program that offered disjunctive services. The second finding was that the more core services the patient used, there was a slight but significantly worse outcome. (2)

Outcomes were measured at six and twelve months. Overall mental health scores were measured using the Global Severity Index (GSI) and the Brief Symptom Inventory (BSI). Mental health status was improved more when services where combined, even when there was no change in addiction severity. Traumatic symptoms also improved.

What I take away from this is: integrated treatment is better.

That doesn't surprise me. Maryland is reorganizing it's public health services to reflect this, and the Affordable Care Act also recognizes this. There's also been at least one study (I've got it pinned on my pInterest board) which showed that integrated care post-release can decrease felony recidivism.

But improvement with integrated care does not prove that the treatment effect comes from treating the trauma. I think that's the mistake. This model can be useful for anyone with complicated co-occurring conditions, male or female, traumatized or not.

OK, I'll shut up now. What's new with you, Dinah?



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1. McHugo, et al. Women, Co-occurring disorders, and Violence Study: Evaluation design and study population. Journal of Substance Abuse Treatment 28: 91-107, 2005

2. Morrissey et. al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services 56: 1213-1222, 2005

What I Learned Part 1

Those of you who have been reading the blog for a while know that every year I blog and live-tweet from the American Academy of Psychiatry and Law conference. This year we are hosted in Montreal, the land of fine dining and the most beautiful language in the world. Thus, the foodie picture. When I fly back I will be carrying extra baggage and I don't mean my luggage.

The poster session this morning was quite crowded and I wasn't able to get near most of them, but I did see a lot about legal and clinical implications of synthetic marijuana. Forty-one states have laws criminalizing sale and use of these new chemicals which go by a variety of street names. Effects on mental state can be extreme, including disorganized and violent behavior and hallucinations. So far there are no known longterm clinical effects associated with its use, however. Intoxication has been used in criminal defenses to mitigate culpability (although not generally successful as the basis for an insanity defense) and in states where the substances are still legal courts are struggling to figure out how it should play into a mental state defense.

Dr. Charles Scott gave an outstanding presidential address entitled "Believing Doesn't Make It So: Forensic Education and the Search for Truth." He discussed the evolving---and higher---expectations for forensic evidence, including psychiatric testimony, and how this should inform forensic training and practice.

The next session was a very nice (if I do say so myself) panel presentation about civil commitment of mentally ill offenders following release from prison. California has a mandatory civil commitment law which requires transfer of certain violent offenders with serious mental disorders to a psychiatric hospital at the end of incarceration. Legal challenges to this law were discussed and compared to the New Jersey system, which uses a non-mandatory administrative procedure instead. Finally, these procedures were compared to the state of Maryland where there is no established transfer policy but a wide degree of consultation and collaboration between the correctional and mental health systems, which in many cases obviates a need for hospital transfer.

[At this point in the day I stepped out for lunch and came back four courses later. Oh my, the food was amazing.]

The afternoon session was a very practical panel presentation about who should get access to forensic reports and the implications of HIPAA on evaluee access to protected health information in the report. Historically forensic reports were considered legal work products rather than medical documents, and as such an evaluee did not necessarily have a right to get a copy of or read the report. Under HIPAA some types of reports---such as a disability evaluation or fitness for duty evaluation---might be considered to be protected health information which an evaluee has a right to access. This is an evolving area, however. And under HIPAA, evaluees do not have a right to reports generated for civil, criminal or administrative hearings. This isn't a settled issue and there was good audience discussion.

The evening session was a mock trial which presented the new DSM 5 proposed criteria for hebephilia. The limitations and implications of the new criteria were discussed, which appeared to rely heavily upon an assessment of the victim's Tanner stage. The issue was presented in the context of a fictional sex offender civil commitment hearing, with three mock experts: one for the state, one for the defense, and one independent court-appointed expert. A strong case was made against inclusion when the defense expert testified that the new criteria could result in an 80 percent increase in false positive diagnoses.

So that was the first day. More to come so stay tuned. Live-tweets can be followed at: www.twitter.com/clinkshrink. [For those concerned about speakers' informed consent for social media coverage, all presenters are advised at abstract submission that sessions are recorded and they know that sessions may be covered by the media.]

The High Cost of (No) SuperMax

Recently NPR featured a story on All Things Considered about the state of Illinois closing its SuperMax prison in Tamms. The story talked about the fact that the prison cost twice as much as other prisons to run, in spite of the fact it housed only 200 prisoners. It mentioned human rights organizations that felt control unit prisons or "SuperMax" facilities were environments that inflicted cruel and unusual punishment. The story implied that longterm solitary confinement caused mental illness and that such prisons did nothing to improve safety in the correctional system.


Wow, I wonder which correctional system they were working in.


I work in a system that at one time had one of the highest internal homicide rates in the country. (Internal homicide refers to murders committed within prison, by prisoners.) I have worked in a control unit prison, and I can tell you that the average citizen can't comprehend the level of depravity shown by some of the inmates there. I'm talking about prisoners who have long histories of violence, dating back to elementary school years. When the New York Times ran a story recently about nine-year-old psychopaths, the first people I thought of were some of my SuperMax inmates.


In my correctional system you have to work to end up in a control unit prison. Beds are few, they are expensive, and they aren't given out like candy. SuperMax inmates are people who are repetitively assaultive to their peers or staff, who repeatedly destroy property or set fires, or who actually kill someone at a lower level of security. Single incidents short of murder are rarely enough to warrant a high security transfer.


Even housing in a control unit prison is not a guarantee of safety: control unit prisoners have continued to run gangs and even to kill in spite of that high security environment.


And now advocacy groups want these facilities closed, and these prisoners turned loose upon their peers in lower security settings. Frankly, if I were a parent of a medium security inmate I would be very concerned about that.


Then there is the allegation of mental deterioration. I've ranted...er, written...about this topic a few times before here on Shrink Rap and also on Clinical Psychiatry News. Briefly, what advocacy groups don't mention---and their expert consultants also sometimes overlook---is that control unit prisoners are a very disturbed group to begin with, even prior to transfer to the facility. They have severe personality disorders which press the limits of our psychiatric diagnostic criteria. They have maladaptive learned behaviors that seem bizarre to the outsider but serve a clear, logical purpose to those familiar with the correctional environment. In spite of this, recent research has shown that solitary confinement can actually improve rather than worsen this psychological disturbance.


Let's assume for a minute that longterm solitary confinement did have detrimental effects for most prisoners, just for the sake of argument. Most systems do have psychological services in place to address this. Prisoners eligible for longterm solitary can be screened for pre-existing psychiatric conditions, and those conditions can be treated with medication, counselling and behavior management even in a control unit environment. Most SuperMax facilities have policies that require regular rounds on segregation inmates, and psychological services are available.


Abolition of an entire facility is an extreme response to a theoretical problem. The violence posed by control unit inmates, unfortunately, is not theoretical.

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 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.)

This Week In The News

There are a lot of stories in the news lately that have a forensic connection: the disgruntled noncustodial father who blew up his house (and kids), Madonna's stalker who eloped from a psychiatric hospital, a recent legal decision out of Georgia about assisted suicide, and an inmate with gender identity disorder who may be the first to get a state-sponsored sex change operation.


Where to begin, where to begin?


The Georgia decision has personal relevance since it means one of our retired local doctors won't face murder charges for offering advice and encouragement from a distance to someone who died of suicide there. The Georgia Supreme Court decided that the law banning suicide in that state was unconstitutional since it barred mere conversation about the issue separate from any act of aiding a suicide. As such, it was an unlawful infringement on free speech. It's hard to believe that it's been five years already since the first time I've blogged about this topic and fifteen years since the US Supreme Court said it was OK to ban it. Over half the country has laws against it now, but I don't know how many, if any, could be at risk because of the issue with the Georgia statute.


The story about the inmate with gender identity disorder (found thanks to my friend Lorry Schoenly's twitter feed---thanks Lorry! please follow her) also interests me because it's an emerging issue in the treatment rights of prisoners. Specifically, prisoners with gender identity disorder. We've talked about gender identity disorder before on podcasts number 20 and 21 (which included an interview with Dr. Chris Kraft about evaluation and treatment), respectively. I blogged about the history of right to treatment for prisoners here, but there's been one significant change since that 2006 blog post: courts have decided that gender identity disorder does constitute a serious mental disorder which requires treatment. What the courts are arguing about now is whether that right to treatment includes sex change operations. The state of Wisconsin passed a law to ban use of health care funds for this, but that law was overturned as unconstitutional. Prisons are required to continue hormone therapy if it was being prescribed prior to incarceration, though.


Separate from the issue of treatment, GID prisoners don't have a right to dress in opposite sex clothing or to have access to makeup. They don't have a right to be housed in a facility consistent with their gender identity. (Female prisoners sued, and won, cases alleging invasion of privacy when male-to-female GID inmates were housed in a female correctional facility.)


So that's where we are on the GID inmate front. Regarding the Madonna stalker, well, I have some personal experiences with psychotic stalkers but since I don't blog about specific patients that story will go untold.


That leaves the child murder story. Ugh. No thanks. I've seen these cases, they're awful, I'd rather not dwell on them. I'm taking a personal pass.

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.

Podcast 64: Brain Freeze

Happy Holidays, everyone.  We taped this a few weeks ago, but Shrinky Podcasts always make for good holiday chatter.   Today we talk about 
1) Brain Freeze-- inspired by a Well article in the NYTimes for 11/10 on Rick Perry's Brain Freeze.  You'll note that in this podcast, Dinah reads Roy's mind, and no has brain freeze from eating cold ice cream.  We kind of ramble, and so what else is new?  We talk about memory and attention and learning and Dinah explains why men don't take out the garbage during football games.  Clink talks about the scientific phenomena of "brain overload."

2) Siri-- ah, we did this podcast right after I got my new iPhone and it was new and exciting and I was working on an article on Siri and the Psychiatrist.  We ask Siri where we can buy a duck and when the world will end.  Apparently we have 5 billion years.  And Sigourney Weaver was 62 years, 1 month, and 5 days old at the time we recorded.


3) Prison Food-- inspired by a lawsuit in which a prisoner contends that the soy-based food being served in prison is 'cruel and unusual punishment' which caused him cramps. Clink talks about how prison food is handled.  She also talks about nutrient rich Nutraloaf that can be eaten without utensils and she discusses an NPR story which includes the recipe for anyone who would like to try nutraloaf. 


If you'd like to try it:
Special Management Meal
Yield - Three Loaves

• 6 slices whole wheat bread, finely chopped
• 4 ounces imitation cheddar cheese, finely grated
• 4 ounces raw carrots, finely grated
• 12 ounces spinach, canned, drained
• 2 cups dried Great Northern Beans, soaked,
cooked and drained
• 4 tablespoons vegetable oil
• 6 ounces potato flakes, dehydrated
• 6 ounces tomato paste
• 8 ounces powdered skim milk
• 4 ounces raisins

From Clink: You mispelled nutraloaf. Don't worry, I fixed it. Also, by pure coincidence today's correctional nursing topic on Lorry Schoenley's Blogtalk radio show was all about managing food allergies in corrections. For those of you who want to know what happens to inmates with peanut allergies, here it is directly from someone in the know.

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An Anniversary to Forget

Over at Shrink Rap News on the Clinical Psychiatry News web page I've posted my latest rant about the Stanford prison experiment in recognition of its fortieth anniversary. Commenting over there is a nuisance, thus the post here. Pardon the inconvenience.

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.

Budgets, Crime and What Happened to Stephanie

From the New York Times today we have a story entitled, "A Schizophrenic, A Slain Worker, Troubling Questions," a horrible story about a mentally ill man who killed a social worker in his group home. The story highlights the defendant's longstanding history of violence with several assaults in his past. He once fractured his stepfather's skull and his first criminal offense involved slashing and robbing a homeless man. (On another post on this blog Rob wondered why the charges were dismissed in that case; from experience I can tell you it's probably because the victim and only witness was homeless and couldn't be located several months later when the defendant came to trial.) The defendant, Deshawn Chappell, also used drugs while suffering from schizophrenia. Before the murder he reportedly stopped taking his depot neuroleptic and was symptomatic. The news story also suggested that he knew he was committing a crime: he got rid of the body, disposed of the car and changed out of his bloody clothes. Nevertheless, he was sufficiently symptomatic to be found incompetent to stand trial and was committed to a forensic hospital for treatment and restoration. At his competency hearing the victim's family thought that the defendant was malingering his symptoms, while the victim's fiance was distraught enough that he tried to attack Chappell in the courtroom. The point of the Times article appears to be an effort to link the crime to cuts in the Massachusetts mental health budget.

So what do I think about this story? (As Dinah would say, this is a 'Clink' thing.)

About the crime itself I have little to say. There's nothing that out-of-the-ordinary or unusual about this as a forensic case. I have no opinion about his legal sanity since I know nothing other than what's presented in the media (and I've had enough of my own cases covered in the media myself to take what I read with a large grain of salt!). Frankly, these kind of cases happen every day as you could tell by following the Psychiatry and the Law twitter feed.

Why does this story, of all the potential psychotic killer stories, showing up in the New York Times, and why is it showing up now?

Because New York is trying to "beef up" their assisted outpatient treatment law, of course. And the Times has come out in favor of it. They've had other articles in the paper promoting assisted outpatient treatment.

Now, I'm all in favor of advocating for improved mental health services as well as adequate training and reimbursement for well-qualified mental health staff. I just wish they wouldn't feed into the fear and public stereotyping of seriously mentally ill people to do it. That's my first reaction to this piece.

My second reaction is in response to this quote:

"The first time Mr. Chappell secured a state hospital bed — and the treatment that comes with it — was when he ended up behind bars."

And the observation by Chappell's mother:

"In 2007, Mr. Chappell, sentenced to a year in jail but required to serve only three months, ended up at the prison psychiatric hospital. When his mother visited him there, she said, she was heartened to see the effects of an enforced medication regimen. “This was the son I raised,” she said. “He talked about going back to school and getting a college degree.”

I'm going to link back to those quotes the next time I hear somebody comment that "locking people up doesn't do any good." There are some people---fortunately relatively few---who can only be treated in a secure environment because they are just too repetitively assaultive to be treated anywhere else. That's what forensic hospitals and prisons are for.

When A Thick Skin Helps

I had to follow up on Dinah's post "What Makes A Good Therapist." (Note to Dinah: I put the punctuation inside the quotation mark. I'm getting better!)

While I agree that empathy is important, it strikes me that so many times psychiatrists are also called upon to be able to tolerate a lot of negative stuff: anger, resentment, bitterness and the general nastiness that can come along with helping people sort out the awful historical relationships in their lives. Once upon a time there was a fantastic psychiatrist blogger by the name of Shiny Happy Person who suggested that in order to become a psychiatrist people should have to pass the "F-You Test." In other words, you have to be able to handle people screaming and cursing at you. Somebody is going to suggest that only happens with my patients because I treat criminals, but I know this happens with non-criminal patients too.

How do you balance empathy with a thick skin? It gets tricky. If you genuinely care about your patients and want them to get better then it would be nice if they weren't nasty to you in return. But if nastiness does happen, it's your job as a psychiatrist to not let it bother you or interfere in treatment. This is particularly true in forensic work when patients can regularly place blame on others (or on you!) for what goes on in their lives. And when a correctional patient makes demands or threats in order to get something inappropriate from you, a thick skin must be replaced with Kevlar. For the patient's own good, you have to have the toughness to do the right thing to avoid harm. (Eg. "I know you'd really like to have some Elavil for sleep, but since you're over 40 and have coronary artery disease and hepatitis C and have attempted suicide by pill overdose twice and have no recent EKG or liver function test results in your record, I really can't give that to you.")

Prisoner advocates criticize correctional health care providers for being cold or unempathic, but I think they are misinterpreting a necessary and appropriate line that a good correctional clinician has to walk. I just thought I'd bring it up because this is also sometimes necessary for non-forensic psychiatrists as well.

The Gulag

Dinah is away this week so Roy and I are filling in. Here's a quick blog post (more to come). I stumbled over the Center for History and New Media web site this morning and found a video tour of an old Soviet gulag. In addition to the video, there's an accompanying audio tour (in Russian, with an English text translation). The camp is better than most, from what I gathered from the description, because it eventually housed formerly high-ranking prisoners. The thing that struck me most was this comment by the tour guide, about transfers out of the gulag to other facilities:

"If one could leave a camp or a jail, a mental institution meant a life sentence, because the effect of mind-altering drugs could not be reversed."

I wonder how many tourists have gone away from that tour thinking that psychiatrists are equivalent to political persecutors. I've seen this attitude about psychiatric medications reflected in some legal opinions here in the United States as well, thankfully in cases a couple decades old, but present nonetheless---the idea that psychiatric medications are "mind-altering" rather than "mind-correcting."

Of course, there are people who have been hurt by psychiatric medications or who feel that they have been permanently damaged by them and I'm not dismissing or ignoring those experiences. I was just struck by the international nature of the stigma about meds.

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.

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.