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Handbook of Correctional Mental Health

Jessica P. Byrne, M.D.

I am a veteran of the world of correctional psychiatry, having worked part-time for 7 years at a large county jail. Indeed, the world of correctional mental health differs from other clinical-care settings in a multitude of ways and poses extraordinary philosophical and practical challenges. The Handbook of Correctional Mental Health, edited by Charles L. Scott and Joan B. Gerbasi, attempts to both guide clinicians through these challenges and to provide a general introduction to major issues in the field of correctional mental health.

The twin goals of this ambitious volume, along with its cross-disciplinary and multiple authorship, create both its strengths and its weaknesses. Some of the chapters are written in textbook style, filled with the kind of data that might be helpful in preparing for the forensic psychiatry specialty board exam. Other chapters include thought-provoking clinical vignettes and evocative reflections on working in a correctional setting.

Some chapters are tough-minded and pragmatic; others express deep empathy for inmates with mental illness. The authors’ professional backgrounds include not only psychiatry, but also psychology, social work, and law, and so the chapters are rather inconsistent in tone and orientation.

For a psychiatrist practicing in a correctional setting, some chapters are particularly interesting and helpful. Kenneth Appelbaum’s discussion of "Practicing Psychiatry in a Correctional Culture" is refreshingly honest in its acknowledgment of real-life problems and the difficulty of resolving them. He explains the special potential for legal liability in correctional psychiatry, stemming from both ordinary malpractice suits (which arise with disturbing frequency in this environment) and potential constitutional violations (which involve access to the federal court system). He astutely observes that, in contrast to what outsiders might imagine, the risk of litigation far exceeds that of assault in the correctional mental-health setting. He acknowledges the common difficulties of high caseloads, underfunding, restricted formularies, and conflicts between clinicians and security staff, but stresses the importance of compassion and professionalism.

Appelbaum and Gary Beven (in his chapter "Offenders With Mental Illnesses in Maximum- and Supermaximum-Security Settings") both emphasize the special problem of disruptive or self-injurious behavior in inmates with mental illness (including both Axis I and Axis II disorders).

One example from my own clinical experience may typify the "vicious cycle of futility" that often occurs in such situations and give the reader without correctional experience some sense of the particular difficulties of correctional psychiatry: I was asked to evaluate a man in his late twenties who had been incarcerated for several weeks on a parole violation for a non-violent offense. He had a history of polysubstance abuse and had been diagnosed with an anxiety disorder and borderline personality disorder by previous psychiatrists. During a brief previous incarceration in the recent past, he had been identified by security and nursing staff as a "troublemaker" because of his angry outbursts. At the beginning of this incarceration, he told nursing staff that he had been taking Xanax (both prescribed and illegally obtained) to control his anxiety. According to protocols developed by medical and nursing personnel at the jail, he was not given any benzodiazepines (because he showed no objective signs of withdrawal), nor was he referred for further mental-health evaluation after his initial screening (by a hostile and punitive nurse). Predictably, he reacted with increasing levels of rage and behavioral dyscontrol. He made repeated contact with medical and nursing staff, claiming to have inserted a paper clip into his abdomen and complaining of abdominal pain. He was labeled as a "manipulator" whose statements should be discounted, and relevant imaging studies were not requested (stemming both from cynicism and financial constraint requirements).

Eventually, his agitation reached a point where he was considered unmanageable by the medical and nursing staff and was referred to me for consultation. I found him to be profoundly suicidal and entirely credible in his expressions of physical pain and emotional despair, and I recommended that he be sent to a local hospital for medical evaluation. Unfortunately, despite my best efforts to educate and negotiate with the medical staff, this recommendation was ignored, and the patient suffered a bowel perforation shortly thereafter that required emergency surgery at the local hospital. When he eventually returned to the jail, he was angrier than ever at the nursing and correctional staff, who responded by verbally humiliating him—and then, of course, he inserted another paper clip into his abdomen.

Clearly, this type of psychiatric work presents extraordinary difficulties. As Beven wisely writes, the philosophical issues (e.g., staff indifference) and resource limitations of correctional practice can combine to produce a terrible "compromised professionalism" that must be vigorously resisted. It is to this book’s credit that it not only explores the problems of correctional mental health, but grants positive recognition to the many clinicians who strive to provide good care within a flawed system, and even attempt to improve that system from within.

FOOTNOTES

 
Dr. Byrne practices psychiatry in Bala Cynwyd, PA. She is also a Clinical Assistant Professor at Drexel University School of Medicine, Philadelphia, PA.

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