Guidelines To Expand and

Improve Treatment

2004 Edition

Effective Prison

Mental Health Services Services

U.S. Department of Justice

National Institute of Corrections
U.S. Department of Justice

National Institute of Corrections

320 First Street, NW

Washington, DC 20534

Morris L. Thigpen

Director

Larry Solomon

Deputy Director

George M. Keiser

Chief, Community Corrections/Prisons Division

Madeline Ortiz

Project Manager

National Institute of Corrections

World Wide Web Site

http://www.nicic.org
EFFECTIVE PRISON

MENTAL HEALTH SERVICES

Guidelines To Expand and Improve Treatment

May 2004

NIC Accession Number 018604

Holly Hills, Ph.D.

Christine Siegfried, M.S.S.W.

Alan Ickowitz, Psy.D.
This report was funded by the National Institute of Corrections (NIC) under cooperative agreement 00P10GIN5 with the

National Mental Health Association. Points of view or opinions stated in this document are those of the authors and do

not necessarily reflect the official position or policies of the U.S. Department of Justice.
iii

FOREWORD

Since the early 1990s, an increasing number of adults

with mental illness have become involved with the

criminal justice system. State and federal prisons, in

particular, have undergone a dramatic transformation, housing a growing number of inmates with serious mental disorders. Complicating this situation is

the high proportion of mentally ill inmates who have

co-occurring substance use disorders.

Effective Prison Mental Health Services: Guidelines To

Expand and Improve Treatment presents historical,

legal, and ethical issues relevant to dealing with mental illness in the field of corrections.These issues include determining which inmates to treat and how

to treat them; managing inmate behavior and symptoms; adapting treatment regimens to special populations, including older inmates, women offenders, and

sex offenders; and using substance abuse services

and specialized mental health units effectively.

The manual examines in detail correctional health

care programs and suggests guidelines that contain

mechanisms for program implementation.These

include national standards, policies, procedures, planning methods, budget development, staffing patterns,

and monitoring and evaluation tools necessary for

a successful correctional health care program. Each

chapter of this manual grew out of a variety of

approaches to helping mentally ill inmates, incorporating the observations and recommendations of an

advisory group composed of mental health professionals and information gathered from written survey instruments, literature searches, and site visits

to correctional institutions.

With the appropriate treatment services in the criminal justice system, and connection to communitybased services upon release, these special inmate

populations could live successful, integrated lives

within their communities.

Morris L.Thigpen

Director

National Institute of Corrections
v

PREFACE AND

ACKNOWLEDGMENTS

As the country’s oldest and largest nonprofit organization that addresses all aspects of mental health

and mental illness, the National Mental Health

Association (NMHA) and its 340 affiliates work to

improve the mental health of all Americans, especially the 54 million people with mental disorders,

through advocacy, education, research, and service.

Effective Prison Mental Health Services: Guidelines To

Expand and Improve Treatment provides correctional

administrators and health directors information on

meeting the complicated needs of inmates with

mental health and co-occurring substance use

disorders.With appropriate treatment services

in the criminal justice system and connections to

community-based services on release, offenders

often can live successful lives integrated in their

communities without further run-ins with the law.

This document is designed for correctional administrators who have the authority to improve and expand mental health treatment options for people

serving time in jails or prisons.The authors offer

practical strategies and model service options available in some states to help reduce the difficulties

correctional staff encounter when working with

people with mental illnesses.A range of topics are

covered, including the scope of the problem, treatment options targeting co-occurring disorders, the

treatment of women offenders, and model program

approaches that can be implemented in other criminal justice facilities.

The authors involved in this publication and their

affiliations include Holly Hills, Ph.D., Department

of Mental Health Law and Policy, Louis de la Parte

Florida Mental Health Institute, University of South

Florida; Christine Siegfried, M.S.S.W., UCLA National

Center for Child Traumatic Stress; and Alan Ickowitz,

Psy.D., formerly of the Residential Substance Abuse

Treatment Program for Offenders with CoOccurring Disorders, Florida Department of

Corrections. NMHA staff involved include Charles

Ingoglia,Wendi Cook, Oscar Morgan, and Luanne

Southern.

A project of this nature would be impossible to conduct without extensive cooperation and assistance

from all who participated in the cooperative agreement. In particular, we would like to offer special

thanks to Dr. Susan Hunter. It was under Susan’s

leadership and guidance during her tenure as Chief

of the NIC Prisons Division that this project for

improving mental health treatment services for

offenders in the criminal justice system and providing avenues to community-based services on release

came to fruition.
vii

CONTENTS

FOREWORD ............................................................................................................................................................................iii

PREFACE AND ACKNOWLEDGMENTS ................................................................................................................................v

1. INTRODUCTION ................................................................................................................................................................1

Purpose of the Manual ......................................................................................................................................................1

Scope of the Problem ........................................................................................................................................................2

Challenges ............................................................................................................................................................................5

Benefits of Effective Mental Health Services ................................................................................................................8

Summary ............................................................................................................................................................................10

References ..........................................................................................................................................................................10

2. SCREENING AND ASSESSMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS ....................13

Problems in Screening and Assessment ......................................................................................................................14

National Standards and Guidelines for Mental Health Evaluations ......................................................................15

National Standards and Guidelines for Substance Abuse Evaluations ..................................................................17

Special Considerations Relevant to Screening and Assessment ............................................................................18

Methods and Tools for Screening and Assessment ..................................................................................................21

References ..........................................................................................................................................................................23

3. MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT......................................................................................25

Mental Health Treatment ................................................................................................................................................25

Substance Abuse Services ..............................................................................................................................................34

References ..........................................................................................................................................................................37

4. USE OF SECLUSION, SEGREGATION,AND RESTRAINTS ........................................................................................41

Mental Health Services in Segregation ........................................................................................................................41

Use of Seclusion and Restraints ....................................................................................................................................42

Mental Health Services in Supermax Prisons ............................................................................................................43

References ..........................................................................................................................................................................43
viii

5. SUICIDE PREVENTION ..................................................................................................................................................45

National Standards in Suicide Prevention ..................................................................................................................45

Federal Bureau of Prisons Five-Step Program for Suicide Prevention ................................................................49

Suicidal Gestures and Manipulations ............................................................................................................................50

References ..........................................................................................................................................................................51

6.TREATINGWOMEN OFFENDERS ................................................................................................................................53

Substance-Abusing Women Offenders ........................................................................................................................53

Women Offenders With Histories of Victimization ..................................................................................................54

Incarcerated Women and Their Children ....................................................................................................................54

Promising Practices for Women Offenders ................................................................................................................55

References ..........................................................................................................................................................................56

7. PSYCHOPHARMACOLOGICAL INTERVENTION FOR PSYCHIATRIC DISORDERS....................................................57

Candidates for Psychopharmacological Intervention ..............................................................................................57

Major Categories of Psychotropic Drugs ....................................................................................................................57

Effectiveness of Medications ..........................................................................................................................................58

Risks of Medication Use ..................................................................................................................................................59

Prescription and Delivery of Medications to Inmates ..............................................................................................60

Issues in Ethnopharmacology ........................................................................................................................................60

Bias in Prescribing Practices ..........................................................................................................................................61

Liability Issues in the Prescribing and Dispensing of Medication ..........................................................................61

Right To Refuse Medication ............................................................................................................................................62

Involuntary Medication of Inmates ..............................................................................................................................62

The Role of Pharmacotherapy in Reducing Suicide Risk ........................................................................................63

The Role of Pharmacotherapy in Addressing Violent or Aggressive Behavior ....................................................63

Continuity of Medication ................................................................................................................................................63

References ..........................................................................................................................................................................64

8.TRANSITIONAL SERVICES..............................................................................................................................................67

Assessment of Treatment Needs ..................................................................................................................................67

Reentering the Community ............................................................................................................................................68

Continuity of Care ............................................................................................................................................................68

Aftercare ............................................................................................................................................................................70

Conditions of Release ......................................................................................................................................................71

Legal Issues ........................................................................................................................................................................72

Positive Outcomes in Transitional Care ......................................................................................................................72

References ..........................................................................................................................................................................73

C ONTENTS
ix

9.TREATMENT OF SPECIAL POPULATIONS ..................................................................................................................75

Treatment of Persons With Mental Retardation or Developmental Disability ..................................................75

Treatment of Violent Offenders ....................................................................................................................................77

Treatment of Sex Offenders ..........................................................................................................................................78

Treatment of Older Adults ............................................................................................................................................79

References ..........................................................................................................................................................................81

10. PROFILES OF THREE STATES ....................................................................................................................................83

Maryland ..............................................................................................................................................................................83

Oregon ................................................................................................................................................................................84

Texas ....................................................................................................................................................................................86

Summary ............................................................................................................................................................................86

APPENDIX. INSTRUMENTS FOR SCREENING AND ASSESSMENT OF MENTAL HEALTH

AND SUBSTANCE ABUSE DISORDERS ............................................................................................................................87

C ONTENTS
1

Since the early 1990s, more and more adults with

serious mental illness have become involved in the

criminal justice system. Prisons, in particular, have

undergone a dramatic transformation, housing a

growing population of inmates with serious mental

disorders.The U.S. Department of Justice estimates

that 16 percent of all inmates in state prisons have a

mental illness (Ditton, 1999).

This enormous influx of persons with mental illness

into the prison system is most likely due to the following factors:

• The closing or downsizing of state psychiatric

hospitals.

• The lack of an adequate range of community support programs for people with serious mental disorders and the chronic underfunding of public

services.

• Restrictive insurance and managed care policies

that curtail access to more intensive services.

• The poverty and transient lifestyles of many people with serious mental illness, which bring them

into contact with police.

• The likelihood that adults with serious mental illness have a co-occurring substance abuse disorder (Sundram, 1999).

Correctional facilities historically have been unprepared to provide mental health services.They typically have not had the physical facilities, staff, staff

training, or clinical resources to meet the needs of

inmates with serious mental illness.Yet the courts

have made it abundantly clear that correctional facilities are legally and constitutionally required to provide adequate mental health services for the inmates

in their custody.

It is important for prison officials to understand the

severity and scope of mental illness in their populations and how to treat mental disorders effectively.

These issues have important implications for humane

and effective facility operation, maintaining safety for

inmates and staff, and avoiding litigation.

PURPOSE OF THE MANUAL

Individuals with mental illness pose special challenges

to every level of prison staff, from correctional officers to medical staff to administrators. Staff often

do not have the knowledge, training, and experience

they need to handle inmates with special needs

effectively.The sometimes conflicting goals of security and treatment create problems for staff as well as

inmates.

The purpose of this manual is to make available to

correctional professionals some of what is known

about effective mental health services and interventions for offenders in prisons who have a mental illness.The manual describes effective practices in a

number of key areas, including screening and assessment, case management, psychopharmacology, and

suicide prevention services, and discusses methods

for effectively organizing and managing in-prison

mental health services.The manual also presents an

overview of relevant standards and legal issues that

Chapter 1

INTRODUCTION
pertain to mental health services in prisons and

discusses the benefits of in-prison mental health

programs.

The manual can help correctional administrators

become aware of current research about effective

services and practices and thereby improve the

mental health care available in prisons. It promotes

the types of practices that reduce incidents of harm

and attempted harm, help inmates function in prison,

decrease inmates’ symptoms and prevent relapse,

and increase the well-being of both inmates and

staff. Practical guidelines and tools permit prison

officials and staff to assess the appropriateness and

effectiveness of their own and other in-prison mental health programs.

SCOPE OF THE PROBLEM

Definition of Serious Mental Illness 

Mental disorders vary significantly in their severity,

symptoms, causes, responsiveness to treatment,

course, duration, and degree to which they impair a

person’s functioning.There is little consensus about

the definitions of the terms mentally ill offender and

offender with serious mental illness. Some researchers

and practitioners refer to diagnosable major psychiatric disorders—i.e., schizophrenias, unipolar and

bipolar depressions, and organic syndromes with

psychotic features—as serious mental illness (Jemelka,

Trupin, and Childes, 1989). Others are less concerned with diagnosis and believe that “the degree

of discomfort and impairment and their duration are

important in deciding whether a mental disorder is

serious” (Cohen and Dvoskin, 1992).

The consent decree to Dunn v. Voinovich (1995), a

federal class action suit that alleged inadequate mental health treatment for Ohio’s prisoners, stated that

prisoners who meet criteria for a serious mental illness must have a “substantial disorder of thought or

mood which significantly impairs judgment, behavior,

capacity to recognize reality or cope with the ordinary demands of life within the prison environment.”

C HAPTER I

2

The illness must also be “manifested by substantial

pain or disability” (Pinta, 1999).

Types of Mental Disorders 

Mental disorders discussed in this manual include

the following:

• Schizophrenia.

• Bipolar disorder (also known as manic

depression).

• Major depression.

• Anxiety disorders.

• Personality disorders.

Schizophrenia is a group of mental disorders characterized by major disturbances in thought, perception, emotion, and behavior.Thinking is illogical and

usually includes delusional beliefs. Distorted perceptions may take the form of hallucinations; emotions

are flat or inappropriate. Schizophrenia impairs a

person’s ability to think, make judgments, reason,

respond emotionally, remember, communicate, interpret reality, and behave appropriately.As many as 5

percent of prison inmates may have schizophrenia

(National GAINS Center, 1997; Pinta, 1999), a rate

up to four times greater than the rate found in the

general population (approximately 1.3 percent) (U.S.

Department of Health and Human Services, 1999).

Bipolar disorder, or manic depression, is a mood disorder that includes a number of variations and subtypes. Generally, individuals with bipolar disorder

experience serious mood swings, episodes of mania

that alternate with episodes of deep depression.

Sometimes one mood or the other dominates.

Mania is characterized by an elevated, expansive, or

irritable mood, well beyond what would be considered normal or typical. Individuals may appear to

have an inflated sense of self-worth or grandiosity.

The person’s thoughts or speech may be very rapid

and difficult to follow. During manic episodes, people

generally display high levels of energy and little need

for sleep.Their judgment is usually poor and they
People with antisocial personality disorder frequently end up in the criminal justice system due to their

failure to conform to social norms and laws.These

individuals disregard the wishes, rights, and feelings

of others and are frequently deceitful and manipulative in order to gain personal profit or pleasure.

Adults with antisocial personality disorder appear

impulsive, irritable, and aggressive.They frequently

display a reckless disregard for the safety of themselves or others and show little remorse for the

consequences of their acts. In correctional settings,

many exhibit an arrogant and inflated self-appraisal

and a superficial charm. Estimates are that 30 to 50

percent of prison inmates have antisocial personality

disorder (Pinta, 1999).

Prevalence Rates 

In 1999, the Bureau of Justice Statistics reported

that more than 16 percent of state prison inmates

had a mental condition or had been hospitalized

overnight in a mental hospital (Ditton, 1999).Although this estimate is based on self-reporting by

inmates, it indicates the need for mental health services in state prisons.

Other studies have found that—

• 8 to 19 percent of prisoners have significant psychiatric or functional disabilities and an additional

15 to 20 percent of inmates will require some

form of psychiatric intervention during their

incarceration (Metzner, 1993).

• 8 to 12 percent of inmates at any given time suffer from a serious mental disorder, such as schizophrenia, bipolar disorder, and major depression

(DiCataldo, Greer, and Profit, 1995).

• The rate of serious mental illnesses among prisoners is three to five times the rate found in the

community (National GAINS Center, 1997).

These figures indicate that an extraordinarily high

number of state prison inmates have a mental disorder of some sort that requires treatment.

may behave recklessly in many areas. Mania often cooccurs with substance abuse, which can make diagnosis difficult. Bipolar disorder is thought to affect

up to 6 percent of the prison population (Pinta,

1999).

Major depression is a mood disorder that generally

occurs as an episode or series of episodes of very

severe depression. People suffering from major

depression may not only exhibit a depressed mood

but may appear to lose interest in life’s activities and

be lethargic or fatigued.They may have difficulty concentrating, focusing, remembering things, or making

simple decisions.They may see their situation as

hopeless and themselves as worthless. Major depression may also be accompanied by such psychotic

symptoms as delusions. Persons suffering from major

depression are at increased risk for suicide and may

be preoccupied with thoughts of death. Some studies show that depression may affect up to 9 percent

of the prison population (National GAINS Center,

1997; Pinta, 1999).

Anxiety disorders are a group of mental disorders

characterized by intense states of apprehension or

anxiety or by maladaptive behavior designed to

relieve anxiety.Anxiety disorders include generalized

anxiety and panic disorders, phobic and obsessivecompulsive disorders, social anxiety disorder, and

posttraumatic stress disorder. Generalized anxiety

disorder affects about 6 percent of the prison population, but posttraumatic stress disorder is more

common, particularly among women offenders

(National GAINS Center, 1997; Pinta, 1999).

Personality disorders are characterized by personality traits and patterns of behavior that begin in

adolescence or early adulthood, are inflexible, maladaptive, and persistent, and cause significant functional impairment or distress to individuals.They

include paranoid personality disorder, schizoid and

schizotypal disorder, antisocial personality disorder,

borderline personality disorder, histrionic personality

disorder, narcissistic personality disorder, avoidant

personality disorder, dependent personality disorder,

and obsessive-compulsive personality disorder.

3

INTRODUCTION
Because of head injuries, substance abuse, and other

afflictions to the brain, a significant number of inmates have subtle dementia that impedes their ability to make rational decisions and formulate plans

(Taylor, 2001).

Scope of Mental Health Treatment

in Prisons 

State prisons provided substantial mental health

services in 2000.According to the U.S. Department

of Justice (Beck and Maruschak, 2001), state public

and private adult correctional facilities reported

that—

• 95 percent provided mental health services to

their inmates.

• 78 percent screened inmates at intake.

• 79 percent conducted psychiatric assessments.

• 84 percent provided therapy or counseling by

mental health professionals.

• 83 percent distributed psychotropic medications

to inmates.

C HAPTER I

4

A 1999 review by Emil Pinta summarizes eight

prevalence studies that used rigorous sampling and

structured interview processes to determine prevalence rates of disorders among prison inmates. Pinta

found on average that 18 percent of inmates have

serious disorders such as schizophrenia, bipolar disorder, or major depression at some point in their

lives and 15 percent have current (within the past

year) disorders. In addition, approximately 19 percent of male and 30 percent of female adult prisoners have “broader definition” disorders that impair

their daily activities to a substantial degree (Pinta,

1999).

The National GAINS Center reports that 26 percent of the prison population exhibits active alcohol

abuse and dependence and 20 percent exhibits drug

abuse or dependence.About 13 percent of the

prison population has both a serious mental illness

and a co-occurring substance abuse disorder.Among

those diagnosed with schizophrenia, major affective

disorder, or antisocial personality disorder, the

prevalence of co-occurring substance abuse is 90

percent (National GAINS Center, 1997).

Functional Impairment 

Many major mental disorders are accompanied by

impaired functioning.That is, mental illness not only

affects a person’s thoughts, emotions, or behavior

but also affects his or her ability to adapt and carry

out such important functions as relating to others.

Mental disorders in prison are associated with high

degrees of disability scores on the Global Assessment of Functioning (GAF) scale (a measure of how

much a person’s mental problems interfere with

daily living). One study estimated 39 percent of

inmates with mood disorders and 35 percent with

anxiety disorders had severe impairment; another

56 percent with mood disorders and 15 percent

with anxiety disorders were moderately impaired

(Neighbors, 1987) (see “Examples of Substantial

Disability or Impairment in the Prison

Environment”).

Examples of Substantial Disability or

Impairment in the Prison Environment

• Hospitalization.

• Placement in a residential treatment unit or observation and crisis cell.

• An impaired ability to complete job assignments or

participate in programs.

• Significant impairment in the ability to relate to others.

• Threatened or attempted suicide.

• An ongoing need for mental health treatment and

psychotropic medication.
Ten percent of state inmates received psychotropic

medications in 2000, and 13 percent attended

mental health therapy or counseling (Beck and

Maruschak, 2001).

No studies have evaluated the quality or outcomes

of prison mental health services or compared treatment offered in specialized versus general correctional facilities. In 2000, however, two-thirds of all

inmates receiving therapy or medications were in

facilities that did not specialize in providing mental

health services (Beck and Maruschak, 2001), thus

illustrating how important it is that every confinement facility be prepared to identify, assess, and treat

inmates with mental illness.

CHALLENGES

The high numbers of people with serious mental

health problems entering prison present significant

challenges.Adults with mental illness often enter

prison with histories of chronic health problems,

unemployment, homelessness, transient behavior,

financial instability, and high-risk behaviors.Typically,

they do not have health coverage, and they lack the

supportive, positive, and enduring relationships that

contribute to emotional health and stability (McVey,

2001).While incarcerated, inmates with mental illness often need housing and services different from

those offered to other inmates.They may need extra

medical attention, treatment, medication, security,

suicide precautions, special programming, rehabilitative services, case management, or transition services. Due to their illness, they may need to be housed

in units with higher staffing ratios. Many prison officials find themselves balancing the needs of inmates

against the costs of the special services.

Many inmates with mental illness have difficulty

adapting to the structure, routine, and social milieu

of prisons. Some become overly passive, withdrawn,

and dependent (Jemelka,Trupin, and Childes, 1989).

Others act out their illness in antisocial ways.

Infractions are a primary indicator of prison adjustment and may ultimately affect classification and

release decisions. Judgments about what behaviors

are tolerable or are allowed as manifestations of illness, therefore, are important ones (Jemelka,Trupin,

and Childes, 1989). Prisons should avoid penalizing

inmates for infractions that are a direct result of

their mental disorder.

5

INTRODUCTION

Challenges in Caring for Inmates With

Mental Illness

• Determining whom and how to treat.

• Managing inmate behavior and symptoms.

• Recognizing the negative effects of the prison environment on mental health.

• Understanding inmates’ difficulties in adjusting to institutional life.

• Determining the need for special services.

Determining Whom and

HowToTreat 

Prison mental health programs typically emphasize

treatment for inmates with serious or acute mental

illness, those who are suicidal, and those with the

most dangerous or disruptive symptoms. Corrections agencies surveyed by the National Institute of

Corrections in 1999 reported devoting more mental

health resources (i.e., special housing, programming,

and management) to inmates who meet predetermined criteria of major mental illness than to those

who have lesser needs (LIS, Inc., 2001).A majority of

these agencies use formal assessments to determine

which inmates have a serious mental illness.Thus

inmates with major mental illnesses receive housing

and programming not available to inmates who have

less serious mental disorders.

But determining how to screen adults coming into

the prison system and how to identify emergent

mental health problems among inmates is challenging. For a variety of reasons, many adults with serious mental illness go to great lengths to hide their

illness from staff or other inmates. Some inmates

may not know they have a mental illness or be able

to convey information about their symptoms well to
others. Many adults have co-occurring substance

abuse disorders, head injuries, or developmental disorders that complicate their diagnosis and treatment. Prison staff must be trained to recognize the

signs of serious mental disorders and substance

abuse, monitor the entire prison population for signs

of emerging problems, and distinguish acute and serious conditions from less serious ones. Knowing

what types of treatment and programming are most

effective and how to deliver services in a timely,

humane, and efficient manner is also an ongoing

challenge for prison authorities.

Managing Inmate Behavior and

Symptoms 

Illnesses such as schizophrenia, schizoaffective disorder, and major depression may affect inmates’ ability

to care for themselves and to comply with certain

orders or procedures. People with major depression

or bipolar disorder may exhibit aggression or irritability. Paranoia may result in an inmate’s failure to

relate well to others. People with schizophrenia may

hear voices and have other problems that interfere

with their ability to follow directions and behave as

expected. In addition, mental illness can evoke fears,

hostile reactions, and negative responses from other

inmates and staff.

Several studies describe inmates with mental disorders as having a disruptive effect in a prison environment. One study found an elevated rate of incident

reports for subjects who rated positive on the schizophrenia scale during their first 90 days of incarceration (DiCataldo, Greer, and Profit, 1995).The Bureau

of Justice Statistics found that people with mental illness were twice as likely as other prisoners to be

involved in a fight (Ditton, 1999).

Prison administrators must often invest in increased

levels of staffing to house offenders with mental disorders safely and humanely.

C HAPTER I

6

Recognizing the Negative Effects

of the Prison Environment on

Mental Health 

Overcrowding, the lack of privacy, temperature and

noise levels, victimization, and other environmental

conditions in prisons can easily exacerbate the

symptoms of mental illness for some people. In fact,

the prison environment itself can contribute to

increased suicide and the inability of inmates with

serious mental illness to adjust. Environmental factors can also elicit significant adjustment reactions

from inmates who may not have had a previous diagnosis but who become ill while incarcerated.

Prisons are usually located far from an inmate’s

home.Visitation can be sporadic, and maintaining

community ties can be difficult for the inmate, the

inmate’s family, and service agencies.Additional stressors related to institutional life include—

• Poor living conditions.

• A lack of meaningful work.

• Violence and sexual exploitation.

• The weakening of the inmate’s usual affectional

ties.

• Forced inactivity (Schetky, 1998).

Finally, the stability of the prison community allows

inmate groups, gangs, and hierarchies to develop.

Some groups can be problematic or dangerous while

others are potentially supportive (Ortiz, 2000).

When turnover is low, inmate weaknesses and vulnerabilities surface quickly and are soon exploited.

Prisoners with mental illness are sometimes housed

in special sections to better protect them, but they

may still be mixed with others who exploit or victimize them.

The vulnerability of inmates with mental illness to

abuse by other inmates and their tendency to accumulate disciplinary sanctions for disruptive behavior
may more often result in placing offenders with

mental illness in protective segregation or isolation.

Segregated placements address some environmental

problems and create others.Administrative segregation, for example, can have substantial psychological

consequences for an inmate with depression or

schizophrenia (Reid, 2000). Isolation can increase

symptoms for many people. Placing inmates in higher

security settings may also limit their access to privileges, programs, work release assignments, and early

parole (DiCataldo, Greer, and Profit, 1995).

Understanding Inmates’ Difficulties

in Adjusting to Institutional Life 

The nature of serious mental illness can create

problems for an inmate’s ability to cope and adjust

to the prison environment. Offenders with mental

disorders generally have a more complicated adaptation to prison as measured by rule violations and

incidents of misconduct. Serious mental illnesses are

stress sensitive; changes in housing, staffing, and routine may bring about an adverse reaction. Prison

policies and practices such as the following can

cause special problems or inhibit the adaptation to

prison life for inmates with serious mental illness:

• Prohibiting inmates on psychoactive medications

from working in prison industries.

• Misunderstanding an inmate’s aberrant behavior,

which can turn a minor incident into a serious situation (Morgan, Edwards, and Faulkner, 1993).

Morgan, Edwards, and Faulkner (1993) compared the

adaptation to prison by individuals with schizophrenia with that of a control group. For all outcome

variables—number of infractions, number of lockups,

days in lockup, ability to obtain a job in prison, and

ability to obtain release from prison—the scores of

the group with schizophrenia were inferior to the

control group.

Additionally, that study found that—

• More inmates with schizophrenia remained in

prison and completed their entire sentence.

• Fewer inmates with schizophrenia obtained parole

or were placed on probation.

• Inmates with schizophrenia incurred more violent

infractions and were moved more often for medical or disciplinary reasons.

Inmates with schizophrenia do not adapt well and

are less able to successfully negotiate the complexity

of the prison environment (Morgan, Edwards, and

Faulkner, 1993).

Inmates with mental illness are less likely to earn

good time due to their behavior and are more likely

to stay longer in prison than other inmates with

similar offenses. In fact, 86 percent of severely mentally ill prisoners serve their full sentence (AIS

Health.com Managed Care Advisor, 2001).

Determining the Need for Special

Services 

Many adults with mental illness enter the prison system with histories of problems such as victimization,

co-occurring substance abuse, chronic health conditions, or violence. Many inmates with mental illness,

especially women, have histories of trauma and

abuse prior to entering prisons; others are victimized while incarcerated. Some adults have histories

of sexual offending.These subpopulations need specialized treatment services that may be costly to

start.

The high rates of exposure to psychological trauma

experienced by women offenders and the association found between trauma and psychiatric disorders suggest that prisons serving women need

programs to address exposure to trauma and its

aftermath (Jordan et al., 1996).

The prevalence of co-occurring substance abuse

and mental health disorders is especially high in the

prison population (about 13 percent). Research

shows that integrated treatment—that is, comprehensive and coordinated treatment for both disorders delivered in the same setting by cross-trained

staff—can be effective, but its startup costs can

be significant (National GAINS Center, 1997).

7

INTRODUCTION
Inmates with chronic mental illness pose special

challenges. Many prisons acknowledge the need for

chronic care programs or special needs housing

units within the correctional setting for inmates with

chronic mental illness who do not require inpatient

treatment but do require a therapeutic environment

due to their inability to function adequately within

the general population. Designing and staffing these

units is a challenge for prison authorities, but the

benefits can be significant. If designed appropriately,

these units can reduce serious rule infractions, suicide attempts, correctional discipline, seclusion, hospitalization, and the need for crisis intervention.

Geriatric inmates are one of the fastest growing segments of the prison population and one of the most

expensive to house and maintain, largely due to their

physical and mental impairments. Specially trained

staff may be needed to identify and treat geriatric

health and mental health problems and prevent suicide attempts (Maue, 2001).

Inmates with histories of violence and sexual offending and inmates with developmental disabilities also

deserve special consideration.These special subpopulations within the growing prison population may

require specialized mental health programming or

treatment services. Balancing the needs of these

inmates with the cost of providing effective rehabilitative services is an ongoing challenge for prison

authorities.

BENEFITS OF EFFECTIVE

MENTAL HEALTH SERVICES

Given the difficulties of serving offenders with mental health needs in the prison setting and the limited

human and financial resources available to devote to

this population, corrections practitioners and policymakers at times may question the wisdom of implementing significant prison-based mental health

services (see “Three Reasons for Providing Mental

Health Treatment in Correctional Settings”).

Treatment within a prison enables inmates to use

rehabilitative opportunities within the prison.There

C HAPTER I

8

is little doubt that treatment also reduces management and disciplinary problems as well as liability.

Almost all prisoners (95 percent) return to the

community.Therefore, providing holistic mental

health services to offenders in the prison contributes to the community’s health and safety

(Wilkinson, 2000).

Because many in-prison programs have never been

effectively evaluated, much more is to be learned

about which types of interventions are associated

with improved clinical outcomes, prevention of

relapse and recidivism, enhanced safety within the

institution, greater public protection, and overall cost

benefit. Many innovative, promising, and comprehensive approaches have not been formally evaluated.

Evidence exists for the effectiveness of interventions

in such key areas as treatment modalities, medications, and screening and assessment tools. For example, effective screening and assessment of mental

health problems has reduced management problems,

improved care, and reduced liability of correctional

institutions (Maue, 2001). Likewise, research indicates that cognitive skills training, intensive drug

treatment, residential treatment, prison education

and work programs, and sex offender treatment

interventions work (Gorzyck, 2001). On the whole,

cognitive-behavioral approaches that focus on

offenses and behaviors are more successful than

sanctions aimed at eliminating future misconduct

Three Reasons for Providing Mental

Health Treatment in Correctional

Settings

1. To reduce the disabling effects of serious mental illness and maximize each inmate’s ability to voluntarily

participate in correctional programs.

2. To decrease needless human suffering caused by

mental illness.

3. To help keep prison staff, inmates, volunteers, and

visitors safe.

Source: Cohen and Dvoskin (1992)
(Immarigeon, 2001).A cognitive-behavioral approach

to relapse prevention is used by a majority of aftercare drug treatment programs.

A number of studies have shown the effectiveness

of using the newer psychotropic medications versus

older medications to treat offenders with serious

mental illness in correctional settings. (Some of

these studies are discussed in chapter 7,“Psychopharmacological Intervention for Psychiatric

Disorders.”) Two treatment methods have shown

remarkable success: prison-based substance abuse

services and specialized mental health units.

Effectiveness of Substance Abuse

Services 

A significant amount of data shows the efficacy and

cost-effectiveness of prison-based substance abuse

services. A 1998 study by the Federal Bureau of

Prisons found that 3 percent of prisoners who

received drug treatment were rearrested in the 6

months after release, compared with 12 percent of

inmates who did not receive treatment (Curley,

1999).Although several types of substance abuse

services have been shown to be effective, therapeutic communities are generally acknowledged to be

the most effective for treating incarcerated offenders with significant addiction problems (Curley,

1999).

Since the early 1990s,Texas has initiated a number

of programs in its prisons and state jails, including an

intensive 9- to 12-month in-prison therapeutic community program.Their program includes 3 months of

aftercare in a community residential facility, followed

by 9 to 12 months of outpatient treatment while on

parole.At 12 months, 16 percent of inmates who

had completed the program had been rearrested,

compared with 30 percent who completed only one

component and 30 percent who were not treated

(Maxwell, 1999).

In a followup study of offenders admitted to treatment in the Substance Abuse Felony Punishment

(SAFP) program in 1993, the Texas Criminal Justice

Policy Council found that 10 percent of those who

completed treatment returned to prison within 1

year of release, compared with 26 percent who did

not complete treatment and 19 percent who received no treatment.The SAFP program is less

expensive than incarceration due to differences in

time the inmates serve in prison and the savings

associated with reduced recidivism. Based on the

cost of treatment and savings in recidivism, the study

found that for every dollar spent on treatment, the

state saved $1.85.This formula does not include the

savings in regular daily prison costs (Maxwell, 1999).

Effectiveness of Specialized Units 

The effectiveness of specialized mental health units

for the care of inmates with serious mental illness

who are unable to cope with participating in daily

activities with the general population but who are

not in need of hospital-level care has been demonstrated in numerous prison systems (Wilkinson,

2000).

One study analyzing the use of intermediate care

programs for inmates with psychiatric disorders

assessed whether inmates admitted to these programs reduced their disruptive and harmful behaviors and whether prison authorities used fewer

correctional restrictions and mental health services

to address those behaviors. Intermediate care programs provide an intermediate level of clinical and

rehabilitative services for inmates who need more

than the outpatient services offered by prison mental health units but do not require the intensive

inpatient services offered by the state’s central

forensic psychiatric center. In these therapeutic

communities, mentally ill inmates are sheltered from

being taunted, exploited, or assaulted by predatory

inmates in the general prison population. Inmates

receive such services as milieu therapy, individual and

group therapy, task and skills training, educational

instruction, vocational instruction, and crisis intervention.This specialized unit was indeed effective:

Significant reductions were found in very serious

rule infractions, suicide attempts, correctional

9

INTRODUCTION
discipline, and use of crisis care, seclusion, and hospitalization (Condelli, Dvoskin, and Holanchock, 1994).

Specialized mental health units generally reduce

the number of institutional crises and management

problems and improve the quality of life for impaired

inmates.These units have moderate costs, which are

more than offset by the decrease in the use of inpatient psychiatric care and improvements in institutional safety and security (Haddad, 1999).

SUMMARY

Today’s prisons face enormous challenges in finding

safe, effective, and affordable methods to identify and

treat the growing numbers of inmates who have

serious mental illness.Yet many are finding practices

and interventions that succeed both in reducing the

suffering and deterioration of inmates with various

disorders and in making prisons safer and easier to

manage.

This manual provides an overview of effective practices in a number of key areas, including screening

and assessment, case management, psychopharmacology, and suicide prevention. It also describes

treatment and programming approaches found

effective with special subpopulations within prison

settings, such as women and offenders with cooccurring mental health and substance abuse disorders. It outlines relevant standards and legal issues

that pertain to mental health services in prisons and

discusses some of the benefits of in-prison mental

health programs.

One goal of this manual is to alert correctional

administrators to the growing body of research

about effective services and practices and prompt

them to assess the appropriateness and effectiveness

of their own programs and services.These actions

can lead to improved outcomes and reduced recidivism among inmates in their care, reduced liability,

and safer places to work.

C HAPTER I

10

REFERENCES

AIS Health.com Managed Care Adviser (2001).

“Texas Considers Algorithm Project to Cut

Prison Mental Health Costs.” Reprinted from the

June 24 issue of Managed Care Week.Web site:

www.aishealth.com. Accessed August 2001.

Beck,A.J., and Maruschak, L.M. (2001). Mental Health

Treatment in State Prisons, 2000. Washington, DC: U.S.

Department of Justice, Bureau of Justice Statistics.

Condelli,W.A., Dvoskin, J.A., and Holanchock, H.

(1994). Intermediate Care Programs for Inmates

with Psychiatric Disorders, Bulletin of the American

Academy of Psychiatry and the Law, 22 (1), 63–70.

Cohen, F., and Dvoskin, J. (1992). Inmates with

Mental Disorders:A Guide to Law and Practice.

Mental and Physical Disability Law Reporter, 16,

339–346.

Curley, R. (1999).Treatment’s Last Frontier?:The

Criminal Justice System Is Trying to Build a Culture

of Compassion.Will It Promote Recovery? Behavioral

Healthcare Tomorrow, 8 (2), 10–15.

DiCataldo, F., Greer,A., and Profit,W.E. (1995).

Screening Prison Inmates for Mental Disorder:An

Examination of the Relationship Between Mental

Disorders and Prison Adjustment. Bulletin of the

American Academy of Psychiatry and the Law, 23 (4),

573–585.

Ditton, P.M. (1999). Mental Health and Treatment of

Inmates and Probationers. Washington, DC: U.S.

Department of Justice, Bureau of Justice Statistics.

Dunn v. Voinovich (1995). Case No. C1–93–0166 (S.D.

Ohio).

Gorzyck, J. (2001).What Works:A Commissioner’s

View. Offender Programs Report, 4 (5), 65.

Haddad, J. (1999).Treatment for Inmates With

Serious Mental Illness Who Require Specialized

Placement But Not Psychiatric Hospitalization.

Correctional Mental Health Report, 1 (4), 49, 59–62.
Immarigeon, R. (2001). Comprehensive Handbook

Addresses Risk Assessment, Offender Assessment,

and Treatment Context. Offender Programs Report, 5

(1), 7.

Jemelka, R.,Trupin, E., and Childes, J.A. (1989).The

Mentally Ill in Prisons:A Review. Hospital and Community Psychiatry, 40 (5), 481–491.

Jordan, B.K., Schlenger,W.E., Fairbank, J.A., and

Caddell, J.M. (1996). Prevalence of Psychiatric Disorders Among Incarcerated Women: II. Convicted

Felons Entering Prison. Archives of General Psychiatry,

53, 513–519.

LIS, Inc. (2001). Provision of Mental Health Care in

Prisons. Washington, DC: U.S. Department of Justice,

National Institute of Corrections Information

Center.

Maue, F.R. (2001).An Overview of Correctional

Mental Health Issues. Corrections Today, 63 (5), 8,

August.

Maxwell, J.C. (1999).The Texas Criminal Justice

Treatment Initiative. Offender Programs Report,

3 (2), 17.

McVey, C.C. (2001). Coordinating Effective Health

and Mental Health Continuity of Care. Corrections

Today, 63 (5), 58–62,August.

Metzner, J.L. (1993). Guidelines for Psychiatric

Services in Prisons. Criminal Behavior and Mental

Health, 3 (4), 252–267.

Morgan, D.W., Edwards,A.C., and Faulkner, L.R.

(1993).The Adaptation to Prison by Individuals with

Schizophrenia. Bulletin of the American Academy of

Psychiatry and the Law, 21 (4), 427–433.

National GAINS Center (1997). The Prevalence of Cooccurring Mental and Substance Abuse Disorders in the

Criminal Justice System. Just the Facts Series. Delmar,

NY: National GAINS Center.

Neighbors, H.W. (1987).The Prevalence of Mental

Disorder in Michigan Prisons. DIS Newsletter (8). St.

Louis:Washington University School of Medicine (as

cited in Pinta, 1999).

Ortiz, M. (2000). Managing Special Populations.

Corrections Today, 62 (7), 64–68, December.

Pinta, E.R. (1999).The Prevalence of Serious Mental

Disorders Among U.S. Prisoners. Correctional Mental

Health Report, 1 (3), 33.

Reid,W.H. (2000). Offenders with Special Needs.

Journal of Psychiatric Practice, 6 (5), 280–283.

Schetky, D.H. (1998). Mourning in Prison: Mission

Impossible? Journal of the American Academy of

Psychiatry and the Law, 26 (3), 383–391.

Sundram, C.J. (1999). Quality Assurance for Mental

Health Services in Correctional Facilities. Correctional

Mental Health Report, 1 (1), 5.

Taylor, E.R. (2001). Using Algorithms and Protocols

in Diagnosing and Treating Offenders with Mental

Health Disorders. Corrections Today, 63 (5), 80–83.

U.S. Department of Health and Human Services

(1999). Mental Health:A Report of the Surgeon General.

Rockville, MD: U.S. Department of Health and

Human Services, Substance Abuse and Mental Health

Services Administration, Center for Mental Health

Services.

Wilkinson, R.A. (2000). Mental Health Care for Ohio

State Prisoners:The View from the Director’s Office.

Retrieved December 26, 2002, from the Ohio

Department of Rehabilitation and Correction Web

site: http://www.drc.state. oh.us/web/articles/

article58.html.

11

INTRODUCTION
13

SCREENING AND ASSESSMENT

FOR MENTAL HEALTH AND

SUBSTANCE ABUSE DISORDERS

Chapter 2

The ever-increasing numbers of offenders with significant mental illness and substance abuse disorders

who enter prisons have made it essential for prison

administrators to put into place policies and procedures that will identify and treat these individuals.

Implementing effective screening and assessment

practices helps maintain an optimal level of safety

and security for staff, inmates, and the public.

Furthermore, adopting national screening and assessment guidelines minimizes the risk of legal action

against the facility.The process of identifying and

evaluating this subpopulation of inmates consistent

with national standards and guidelines is outlined

below.This process outline also includes information

on scheduling, staffing, and followup.

Offenders entering into the state prison system

should be screened for mental health and substance

abuse disorders for both clinical and legal reasons.

Screening and assessment for mental illness—

• Identify those at risk for injuring themselves and

others.

• Determine whether the inmate is capable of functioning in the prison.

• Determine whether the inmate should be transferred to a mental health facility.

• Determine whether the inmate can benefit from

treatment at the prison (Ogloff, Roesch, and Hart,

1993).

Standards for screening and assessment developed

by several national organizations suggest that, as

with other acute medical conditions, mental health

and substance abuse issues need to be identified

immediately on entry into a correctional facility.

Significant stressors encountered in adjusting to the

prison environment can be particularly problematic

for those who have a preexisting psychiatric condition.The sooner individuals can be identified, the

sooner treatment providers working in the correctional setting can intervene to help them adapt to

the environment.This helps the facility maximize

security, maintain its operational routine, and make

the prison safer for staff and inmates (Dvoskin and

Steadman, 1989).Adequate screening and followup

procedures help the offender with mental health or

substance abuse problems function better and have

the potential to reduce inmate suicide (NIC, 1995),

violence, and other predatory behaviors (Cohen and

Dvoskin, 1992).

The right of a prison inmate to receive screening

and treatment for mental health disorders has developed out of several legal precedents.The U.S.

Supreme Court established that it is unconstitutional

under the eighth amendment to show deliberate

indifference to the serious medical needs of prisoners (Estelle v. Gamble, 1976). In Bowring v. Godwin

(1977), a federal appeals court determined that the

right to medical treatment is not distinguishable

from the right to mental health treatment.The court

ruled that prisoners are entitled to psychological or

psychiatric treatment if a physician or other health

care provider concludes that the inmate has a serious mental disease or injury and that, without treatment, he or she would suffer some harm. Further,
the court determined that a correctional facility

must have a system for screening and evaluating

inmates to identify those who need mental health

treatment (Ruiz v. Estelle, 1980).

The U.S. Supreme Court ruled that inmates do not

have a constitutional right to rehabilitation from

drug addiction (Marshall v. United States, 1974), however, and a lower court, following this precedent,

held that it is not a violation of the eighth amendment if treatment for alcoholism is not provided

(Pace v. Fauver, 1979). However, in Palmigiano v.

Garrahy (1977), the court found that inadequate substance abuse screening procedures contributed to

inmate suicide and drug trafficking in Rhode Island

prisons. In addition, the absence of screening procedures to detect substance abuse symptoms has provided the grounds for unfavorable litigation against

correctional facilities (Peters, 1992). Given these

court decisions, prison administrators who ensure

that offenders are receiving appropriate levels of

assessment and treatment for mental health and

substance problems will not only be creating safer

facilities for staff and inmates, they will also be protecting themselves and their state institutions from

potential costly litigation.

Screening, a process of information gathering that

includes an interview, a review of existing records,

and the administration of specialized instruments

or tests, seeks to identify those inmates who may

require a particular intervention or treatment. It

should cast a large net that allows more false positives than false negatives (Ogloff, Roesch, and Hart,

1993; CSAT, 1994; Peters and Bartoi, 1997). Because

many offenders with existing mental health and substance abuse problems have already been identified

and treated while incarcerated in local jails, a review

of jail treatment records is extremely valuable.

Screenings should be completed on entry at reception centers or other permanent institutions, as well

as after transfer between institutions.A more elaborate and comprehensive evaluation or assessment

should take place for those identified by the screening process as likely to have one or more psychiatric

disorders.

C HAPTER 2

14

Assessment is the process of examination or evaluation following the screening that ascertains the specific nature and severity of the mental health and

substance abuse problems and their history and

course. It determines what type of intervention or

treatment is best for individuals identified as having

a mental health or substance abuse disorder by the

screening.The assessment provides the necessary

information for the planning and implementation of

appropriate treatment to best deal with the identified disorders. It should include a detailed interview

and record review and may involve the administration of other instruments or tests.Assessment interviews should—

• Include a complete mental status exam (which

focuses on the current presentation during the

assessment process itself).

• Describe the individual’s appearance, orientation,

behavior, thought quality, and thought content.

• Note the presence of severe psychiatric symptoms and self-reports of recent changes in

appetite, sleep, or sexual drive.

PROBLEMS IN SCREENING AND

ASSESSMENT

Most prison authorities acknowledge the wisdom

and legal necessity of screening and assessing inmates for mental health disorders. Determining how

to screen and the methods to use remains challenging. Mental health professionals who want to work in

prisons are in short supply and are generally used to

provide treatment, consultation, and training rather

than screening.The result is that prison staff, sometimes with limited training, must distinguish on a

daily basis inmates who are experiencing symptoms

of a serious mental illness from those who are

malingering or experiencing adjustment disorders.

A complicating factor is that many people with serious mental illness do not acknowledge they have it

or do not want other inmates or staff to know they

have it.An inmate’s outward expression of bizarre
thoughts or behavior or any loss of control may

result in being put on suicide watch, being given

medication, or being sent to administrative lockdown. In addition, prison inmates often exploit and

take advantage of other inmates’ weaknesses.As a

result, inmates may fail to report their symptoms,

and considerable time may pass before an inmate’s

mental illness is discovered and diagnosed.

Along with initial screening, ongoing methods are

needed to identify emergent mental health problems

among the inmate population. Some inmates do not

have a preexisting mental condition when they enter

prison but develop significant psychiatric problems

as a result of incarceration.The sooner these problems can be identified and treated, the sooner these

inmates can adjust and cope with their environment.

Consequently, it is important that all staff (e.g., correctional officers, teachers, classification) be trained

to identify symptoms of mental illness and that formal and informal mechanisms be in place for staff to

refer those identified with possible mental health

disorders to the appropriate health staff (Ogloff,

Roesch, and Hart, 1993).

Inmates with mental illness who stand out and

cause problems quickly get attention.Those who are

quietly psychotic or depressed are harder to recognize. Prison staff may not see them as a problem.

Counselors and nursing staff generally should be

aware of the entire inmate population in addition to

monitoring those known to have mental illness, substance abuse, mental retardation, or problems adapting (Reid, 2000a).

Suicide is an additional risk in correctional settings,

and mentally ill inmates are at particularly high risk.

Suicide is the third leading cause of death in prison

(Hayes, 1999), and almost all suicide attempts committed in prisons are by people diagnosed with

major psychiatric disorders (Bonner, 2000). Prison

officials must have ways to recognize inmates with

suicidal thoughts and behaviors at any time and

intervene quickly.

Malingering, or feigning illness to avoid work, is a fact

of life in the correctional setting. Malingering may

include exaggeration as well as complete fabrication

of symptoms (Reid, 2000b). Some argue that prisoners will feign mental illness to be admitted to a comfortable therapeutic unit or to remain in it longer

than necessary.They might even engage in self-injury

or suicidal gestures to obtain a secondary gain, such

as transfer to another location, a change in conditions of confinement, or special privileges.

Prison staff must exercise great caution in interpreting what is malingering or manipulative behavior.

Misdiagnosing these activities may end in unintended

death.There is a high incidence of borderline intelligence and mental retardation in the prison population.An inmate’s inability to think abstractly and lack

of verbal skills may inhibit his or her ability to put

common symptoms and feelings into words that

adequately convey a sense of what is happening.

Such inmates may be thought to be malingering

when they cannot explain what they are feeling. In

addition, some offenders may have been instructed

by other inmates to report outrageous symptoms to

health personnel—such as hearing voices—to get

treatment for legitimate problems such as depression (Taylor, 2001).

Finally, cultural differences also play a role in the

diagnostic process. It is not uncommon in some cultures for people to see visions, for example. It is the

professionals’ duty to sift through all the factors to

determine whether there is a legitimate problem

(Taylor, 2001).

NATIONAL STANDARDS AND

GUIDELINES FOR MENTAL

HEALTH EVALUATIONS

Numerous national organizations have promulgated

standards for correctional health care, including for

mental health screenings. Useful guidelines have been

developed by the American Psychiatric Association

(APA) and the National Commission on Correctional Health Care (NCCHC) (Metzner, 1993).

15

SCREENING AND ASSESSMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS
An APA task force report on psychiatric services in

jails and prisons (2000) recommends that a mental

health screening be conducted at the time of admission to the prison.This initial screening ensures that

any inmate who is mentally ill or developmentally

disabled and requires mental health intervention is

referred for appropriate mental health evaluation

(assessment) and housed in an appropriate level of

care.APA recommends that this initial screening

involves—

• Observation and structured inquiry with a set of

questions.

• Standard questions for all inmates.

• Questions that are administered at the time of

admission.

• A qualified mental health professional or trained

correctional officer to conduct the screening.

Following this initial screening,APA recommends a

more detailed, thorough, and structured intake mental health screening be—

• A part of the standard medical screening given to

all inmates.

• Conducted within 7 days of admission to the

prison.

• Administered by a qualified health care

professional.

APA’s guidelines also recommend that any inmate

identified by these screenings as having a mental illness or disability be referred to an appropriately

trained mental health professional for a more comprehensive mental health examination (i.e., assessment).This assessment should take place within 24

hours of receiving the referral from the screener.A

comprehensive assessment could, however, be initiated prior to the intake mental health screening by a

referral from other custodial staff or even from the

inmate.

C HAPTER 2

16

NCCHC (1999) also has developed standards for

two levels of mental health screenings in prisons.

The first is recommended to take place immediately

(within 2 hours) on arrival and to be completed by

qualified health care personnel. NCCHC interpretation of qualified health care personnel includes professionals or technical workers certified by their

state to support or supplement the functions of

physicians as long as they do not practice outside

their license, certification, or registration.

The second level of screening is a postadmission

mental health evaluation (closer to an assessment, as

defined above). It is recommended that this evaluation occur within 14 days of admission to the prison

and be completed only by qualified mental health

personnel. Qualified mental health personnel include

psychiatrists, physicians, psychologists, nurses, physician assistants, psychiatric social workers, and others

who are permitted by law to care for the mental

health needs of patients.This mental health evaluation should include a structured interview that

inquires into the inmate’s history and current

status regarding symptoms and other factors (see

“Elements of the Mental Health Evaluation”).

Elements of the Mental Health

Evaluation

• Psychiatric history, including hospitalizations and outpatient treatment.

• Current use of psychotropic medications, if any.

• Current suicidal ideation.

• History of suicidal behavior.

• Current and prior drug and alcohol usage.

• History of sex offenses.

• History of violent behavior.

• History of being victimized by criminal violence.

• History of special education placement.

• History of seizures or cerebral trauma.

• Emotional response to being incarcerated.

• Intelligence testing for mental retardation (required

by NCCHC guidelines (1999)).
NATIONAL STANDARDS AND

GUIDELINES FOR SUBSTANCE

ABUSE EVALUATIONS

The National Institute of Corrections (NIC) and the

Center for Substance Abuse Treatment (CSAT) recommend guidelines on screening for alcohol and

drug abuse in prison settings.

NIC’s Report of the National Task Force on Correctional Substance Abuse Strategies (NIC, 1991)

recommended that—

• The facility develop and implement a standardized

and comprehensive method to assess for alcohol

or drug abuse in its inmates.

• The assessment be done as early as possible after

entry.

• The assessment be done throughout incarceration

for all offenders.

• The assessment be documented in a cumulative

file.

CSAT (1994) suggests the following basic guidelines

for conducting substance abuse screenings with

offenders in the criminal justice system:

• Screening interviews should be conducted in

private.

• Screenings should be documented in written form

in a case file.

• Screenings should be seen as integral to, rather

than an adjunct to, other admission processes

when entering the facility.

• Screenings should be held at multiple points

because an inmate’s motivation and readiness to

admit to problems vary.

• Staff should be appropriately trained to conduct

screenings.

CSAT suggests that assessments be comprehensive

and holistic and recommend the most appropriate

treatment (CSAT, 1994).The assessment should—

• Use qualified human services professionals with

competence in alcohol or drug programs (e.g.,

licensed social workers, addictions counselors).

• Be conducted with a credentialed or certified

counselor in an alcohol or drug field.

• Review archival data including criminal justice and

treatment records.

• Assess the impact of alcohol and drug abuse on

marriage, family, employment, self-concept, and

other areas.

• Identify risk factors for continued alcohol and

drug abuse.

• Review medical/health findings.

• Review psychological test findings.

• Include educational and vocational background.

• Include suicide or other crisis risk assessment.

• Assess the inmate’s motivation and readiness for

treatment.

• Evaluate the inmate’s attitudes and behaviors during the assessment.

The assessment should also include a detailed history of the inmate’s patterns of alcohol and other drug

use, including—

• The onset of alcohol and drug use.

• Behaviors associated with alcohol and drug use

(e.g., using for sex, to go to work).

• The method of administration of the substance.

• The presence or absence of tolerance effects.

• The presence or absence of physical withdrawal

symptoms.

17

SCREENING AND ASSESSMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS
• Uncontrolled use, such as binges or overdoses.

• The use of alcohol and other drugs to selfmedicate painful or unpleasant emotions.

• Attempts to hide alcohol and drug use.

• Physical signs of alcohol and drug use (e.g., needle

tracks, emaciation).

• Positive drug test results.

• Previous attempts to stop alcohol and drug use.

• Family dysfunction relative to alcohol and drug

use.

SPECIAL CONSIDERATIONS

RELEVANT TO SCREENING

AND ASSESSMENT

Screening for Suicide 

A primary function of screening is to identify inmates who are at risk for suicide.This screening

typically occurs when a person enters a reception

center or the permanent institution. Inmates who

have co-occurring mental health and substance

abuse problems are at higher risk for suicide when

compared with inmates without such histories (NIC,

1995).A suicide screening should include a review of

records, an interview, and possible testing. Peters

and Bartoi (1997) recommend that the screening

inquire about—

• A history of prior suicidal gestures or attempts

and their seriousness.

• Current mental health symptoms.

• Current suicidal ideation.

• The relationship between suicidal behavior and

mental health symptoms.

If an inmate presents suicidal ideation, the screener

also should inquire about—

C HAPTER 2

18

• A current suicide plan (i.e., when, what method

will be used, its degree of lethality).

• The current level of hopelessness.

When an inmate has an active suicide plan that has a

high probability of causing significant harm or when

a significant level of hopelessness exists, steps should

be taken immediately to protect (but not isolate)

the person in a secure environment and start clinical

interventions.

Screening for Motivation and

Readiness for Treatment 

As with most organizations that provide treatment

for mental health and substance abuse disorders,

prisons generally have a limited amount of resources

and must maximize the efficacy of the treatment

they provide.To this end, it can be useful to screen

all inmates for their level of motivation to change

and their readiness to accept treatment. Researchers

have found that an individual’s level of motivation to

change can be an important predictor of treatment

compliance, treatment dropout, and treatment outcome (Lehman, 1996; Ries and Ellingson, 1990).

Screenings for motivation also can help providers

determine what type of treatment intervention to

provide.Treatment efficacy can be maximized when

treatment interventions can be matched to different

levels of readiness to change (Prochaska, DiClemente,

and Norcross, 1992; Osher and Kofoed, 1989).

Although several instruments have been developed

to screen for motivation and readiness, a few simple

interview questions, like those that follow, can provide important data:

• How serious do you think your mental health

problems are? 

• How important is it for you to receive treatment

for your mental health problems?

• How serious do you think your alcohol and drug

use problems are?
• How important is it for you to receive treatment

for your alcohol and drug problems?

• Do you want to change your alcohol or drug use?

• Have you tried to reduce your alcohol or drug

use? (Peters and Bartoi, 1997).

Questions such as these can give screeners an early

indication of the offender’s motivation for treatment

and help providers plan interventions as early as

possible on entry to the facility.

Co-occurring Disorders 

Screenings and assessments in criminal justice settings ought to address issues related to mental

health, substance abuse, and the interaction between

the two (Peters and Bartoi, 1997) (see “Information

To Gather To Assess for Co-occurring Disorders”).

The screening approach used to identify mental

health and substance abuse conditions should be

integrated; that is, if either a mental health or substance abuse disorder is detected, the other should

be immediately screened for as well.The prevalence

of co-occurring substance abuse and mental health

disorders is especially high in the prison population.

An estimated 13 percent of the prison population

has both a serious mental illness and a co-occurring

substance abuse disorder (National GAINS Center,

1997), and 23 to 56 percent of people in the general

population who have a diagnosable mental disorder

also have a substance abuse disorder (Regier et al.,

1990). Of the estimated 16 percent of state prison

inmates in 1996 identified as mentally ill, 59 percent

reported using alcohol or drugs at the time of their

offense and 34 percent had a history of alcohol

dependence (Bureau of Justice Statistics, 1999).

Ethnic, Cultural, and Gender

Considerations 

Ethnicity, culture, and gender play important roles in

an individual’s life and in the development of mental

health and substance abuse disorders, and screening

and assessment in correctional settings must take

this into account.According to the U.S. Surgeon

General’s report Mental Health: Culture, Race, and

Ethnicity (U.S. Department of Health and Human

Services, 2001), racial and ethnic minorities tend to

have less access to mental health care, be misdiagnosed, receive less care, and receive poorer quality

care than whites.African Americans represent nearly

half of all prisoners in state and federal facilities, but

19

SCREENING AND ASSESSMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS

Mental Health

• Acute mental health symptoms.

• Suicidal thoughts and behavior.

• Other observable mental health

symptoms.

• The age of onset of mental health

symptoms.

• Prior treatment.

• Prior use of medications.

• Cognitive impairment.

• Recent trauma (e.g., sexual abuse,

physical abuse).

• Family history of mental illness.

Source: Peters and Bartoi (1997).

Information To Gather To Assess for Co-occurring Disorders

Substance Use

• Signs of acute intoxication.

• Signs of acute withdrawal.

• Signs of tolerance effects.

• Negative consequences as a result

of substance use.

• Age and pattern of first substance

use.

• Current patterns of use.

• Drugs of choice.

• Motivations for using.

• Treatment history.

• Family history of substance abuse.

Interaction Effects of Mental

Illness and Substance Abuse When

Both Are Present 

• The effects of one disorder on the

other.

• Patterns of symptom expression.

• Chronology of the two disorders.

• Motivations for treatment of each

condition.
incarcerated African Americans with mental illnesses

are less likely than whites to receive mental health

care. In addition, certain minority groups may

present mental health symptoms in ways that differ

from what clinicians expect, affecting the accuracy of

the information gathered at screening, which can

lead to difficulties in diagnostic and treatment planning. For example,African Americans are more likely

than whites to express psychiatric symptoms as

somatic complaints or symptoms (i.e., symptoms of

a physical illness) because physical problems may be

a more acceptable way of expressing suffering within

their community.

To address some of these issues, assessors and

treatment providers in correctional settings should

be trained to be culturally competent. Cultural competency requires both knowledge and skills about

the differences within and between various cultural

groups, especially their views on health, illness, treatment, and care. Culturally sensitive screenings and

assessments may show improved accuracy and can

result in more positive outcomes for the interventions they help to design. Cultural competence

avoids prejudgments or biases about others’ cultural

beliefs and customs and demonstrates respect for

their attitudes, beliefs, and behaviors (CSAT, 1999).

To improve cultural competency in correctional settings, CSAT (1995) recommends that correctional

staff be trained in cultural diversity and issues specific to the cultural groups they serve.This training

should include—

• Education about stereotypes and biases.

• How language and terminology perpetuate

stereotypes.

• Diversity within groups.

• How cultural beliefs relate to alcohol and drug

use and criminality.

• The effects of alcohol and drugs on women and

stereotypes about women who are alcohol or

drug abusers.

C HAPTER 2

20

• The effects of intolerance on gay men and lesbians

seeking treatment.

• The effects of biases about economically deprived

offenders.

During an assessment, staff should gather information about how the individual views his or her own

race, culture, subculture, and sexual orientation

(CSAT, 1994).The accuracy of the assessment depends in part on the assessor’s ability to be open

and not make assumptions about an individual’s selfconcept simply by virtue of his or her belonging to a

particular group. Inmates should be asked directly

what they feel and think about being a member of

their culture or group.

To improve competency in assessing minorities and

other ethnic or cultural groups, the assessor—

• May need to perform the evaluation in the language of the inmate.

• Must be sensitive to a client who may need to

communicate in street language.

• Should use language that is easily understood by

the inmate to engage him or her in the process.

• Should be aware of the importance of the inmate’s cultural identity and that his or her acculturation into the dominant culture may vary.

• Should not rely on presuppositions about what an

individual’s culture of origin means to him or her.

Screening and Assessment of

Women Offenders 

The screening and assessment of female inmates is

particularly significant given the growing numbers of

women in state prisons and the higher incidence of

mental illness and substance abuse disorders when

compared with male inmates (Bureau of Justice

Statistics, 1999). For example, an estimated 19 percent of female jail detainees are diagnosed with

schizophrenia, bipolar disorder, or major depression

compared with 9 percent of male detainees (Teplin,
1994;Teplin,Abram, and McClelland, 1996).A history

of prior physical or sexual abuse is reported by 30

percent of mentally ill male inmates and 78 percent

of female inmates (Bureau of Justice Statistics, 1999).

An often-cited study that randomly sampled nearly

1,300 detainees awaiting trial at the Cook County

Jail (Teplin,Abram, and McClelland, 1996) found the

following:

• More than 80 percent of women detainees suffered from one or more lifetime psychiatric

disorders.

• More than 70 percent of women offenders were

alcohol or drug dependent.

• 34 percent of women offenders suffered from

posttraumatic stress disorder (PTSD).

• Almost 17 percent of women detainees had experienced an episode of major depression in their

lives.

• As many as 14 percent of women detainees had a

depressive episode in the 6 months before arrest.

In the most comprehensive survey of women

offenders ever conducted in U.S. prisons, approximately 40 percent reported a history of physical or

sexual abuse (Bureau of Justice Statistics, 1994).

Female inmates were three times more likely than

male inmates to report past abuse and six times

more likely to report past sexual abuse. In one

California Department of Corrections study (Bloom,

Chesney-Lind, and Owen, 1994), 80 percent of

women offenders reported experiencing physical,

sexual, or emotional abuse.

Screening and assessment of women offenders,

therefore, need to be particularly sensitive to the

presence of mood symptoms (predominantly depression) and anxiety symptoms (predominantly

PTSD).The high prevalence rates of abuse and the

symptoms of PTSD that sometimes result make

adjustment difficult for these women. In addition,

leaving abused women offenders unidentified and

untreated can lead to serious management problems

for correctional staff.Women offenders with PTSD

may have problems directly associated with their history of abuse such as difficulty interacting with male

authority figures who remind them of their abusers,

being physically restrained, and being unclothed

(Veysey, 1998). In addition, symptoms associated with

PTSD, such as hypervigilance (constant scanning of

the environment for danger), an exaggerated startle

response (physical overreaction to loud noises or

sudden movements), phobias, auditory and visual

flashbacks, and anger/rage reactions, can have a significant impact on the way these women relate to

others and on the safety and the security of the

facility. Specialized instruments facilitate early and

accurate identification of these symptoms (see

appendix).

Women offenders also may feel inadequate as mothers, wives, and working women, which requires additional considerations for the screening process

(CSAT, 1994). CSAT recommends that staff assess

the following aspects of women offenders’ lives:

• Parenting skills.

• Prenatal care and birth control practices.

• Responsibilities for child care and the care of

other dependents.

• Roles within the family and how they relate to the

women’s cultural identity.

• A history of violence or rape.

• Employment and income history and how it

relates to hazardous and criminal behaviors (e.g.,

prostitution, selling drugs).

• Opportunities for education and intellectual

growth.

METHODS AND TOOLS FOR

SCREENING AND ASSESSMENT

Drug Testing 

Drug testing, urinalysis, and toxicology screening are

integral components of comprehensive screening

21

SCREENING AND ASSESSMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS
and assessment for substance abuse (Peters and

Bartoi, 1997).Although other methods of detection

can evaluate the presence of drugs and alcohol (e.g.,

hair analysis, sweat patches), they generally are not

used in correctional settings. Regular drug testing

can—

• Alert staff to the presence of inmate substance

abuse.

• Help detect relapse during treatment.

• Increase inmates’ motivation to remain abstinent.

• Reduce substance abuse in the facility.

Because most drugs and alcohol are detectable

through urinalysis for relatively short periods of

time, testing should be carried out frequently

throughout the period of incarceration. (For example, alcohol is eliminated from the body within several hours and cocaine within 72 hours.)

Drug testing should follow established procedures

or guidelines that promote reliability and validity of

results and should include—

C HAPTER 2

22

• Direct visual observation of the collection of the

urine sample where possible. Exceptions should

be made for “shy bladder.”

• A determination of water loading that might taint

a sample.

• The documentation of chain of custody for the

samples collected.

• The verification of drug testing results if they are

contested.

• Treating refusals to submit and tainted samples as

positive test results.

• Testing for major drugs of choice and alcohol

(usually a breath analysis).

• Testing for the most commonly used drugs in the

institution’s geographic area.

• Testing for the most common drugs in correctional settings, including marijuana, cocaine, opiates

(e.g., heroin), PCP, and amphetamines.

Screening for Co-occurring

Disorders

For mental health disorders

(choose one)

• Brief Symptom Inventory (BSI).

• Referral Decision Scale (RDS).

For substance abuse disorders

(choose one)

• TCU Drug Dependence Screen (DDS).

• Simple Screening Instrument (SSI).

• Alcohol Dependence Scale (ADS)

and Addiction Severity Index (ASI).

(drug use section)

This combined screening takes approximately

10 to 15 minutes to administer and score. If

additional time is available, also use the Beck

Depression Inventory (BDI) to obtain a more

detailed screening of depression.

Screening and Assessment Instruments

Screening for Motivation and

Readiness for Treatment

(choose one)

• Circumstances, Motivation,

Readiness, and Suitability Scale

(CMRS).

• Stages of Change Readiness and

Treatment Eagerness Scale

(SOCRATES).

• University of Rhode Island Change

Assessment (URICA) Scale.

Assessing Co-occurring

Disorders

For mental health disorders

(choose one)

• Minnesota Multiphasic Personality

Inventory–2 (MMPI–2).

• Millon Clinical Multiaxial

Inventory–III (MCMI–III).

• Personality Assessment Inventory

(PAI).

For substance abuse disorders

• Addiction Severity Index (ASI).

This combined assessment takes approximately

3 hours to administer and score.
Instruments for Interviewing and

Test Measures 

Peters and Bartoi (1997) examined many instruments and tests available to screen and assess 

co-occurring mental health and substance abuse disorders among inmates. Each instrument’s overall reliability and validity, as well as its validity for use in

criminal justice (versus community) settings, were

evaluated, along with costs, scoring procedures, and

training required for staff to administer the tool (see

their recommendations in “Screening Instruments”,

see p. 22). Instruments to screen for motivation and

readiness for treatment are also recommended by

Peters and Bartoi (1997).

When screenings indicate the presence of symptoms

of mental health/substance abuse disorders, an

assessment should follow to elucidate the specific

diagnosis, the history of each mental health and/or

substance abuse disorder, and a more thorough

understanding of their interaction.The assessment

also assists in developing an individualized treatment

plan to effectively treat the conditions.

REFERENCES

American Psychiatric Association (2000). Psychiatric

Services in Jails and Prisons, Second Edition.Washington, DC:American Psychiatric Press.

Bloom, B., Chesney-Lind, M., and Owen, B. (1994).

Women in California Prisons: Hidden Victims of the War

on Drugs. San Francisco: Center on Juvenile and

Criminal Justice.

Bonner, R.L. (2000). Correctional Suicide Prevention

in the Year 2000 and Beyond. Suicide and LifeThreatening Behavior, 30 (4), 370–376.

Bowring v. Godwin (1977). 551 F.2d 44 (4th Cir.).

Bureau of Justice Statistics (1994). Women in Prison.

Washington, DC: U.S. Department of Justice.

——— (1999). Mental Health and Treatment of

Inmates and Probationers. Washington, DC: U.S.

Department of Justice.

Center for Substance Abuse Treatment (1994).

Screening and Assessment for Alcohol and Other Drug

Abuse Among Adults in the Criminal Justice System.

Treatment Improvement Protocol Series 7 (DHHS

Publication No. (SMA) 00–3399). Rockville, MD: U.S.

Department of Health and Human Services.

——— (1995). Planning for Alcohol and Other Drug

Abuse Treatment for Adults in the Criminal Justice System. Treatment Improvement Protocol Series 17

(DHHS Publication No. (SMA) 95–3039). Rockville,

MD: U.S. Department of Health and Human Services.

——— (1999). Cultural Issues in Substance Abuse

Treatment. (DHHS Publication No. (SMA) 01–3612).

Rockville, MD: U.S. Department of Health and

Human Services.

Cohen, F., and Dvoskin, J.A. (1992). Inmates with

Mental Disorders:A Guide to Law and Practice.

Mental and Physical Disability Law Reporter, 16 (4),

462–470.

Dvoskin, J.A., and Steadman, H.J. (1989). Chronically

Mentally Ill Inmates:The Wrong Concept for the

Right Services. International Journal of Law and

Psychiatry, 12, 203–210.

Estelle v. Gamble (1976). 429 U.S. 97.

Hayes, L.M. (1999). Inmate Suicide:A Look at

Yesterday,Today, and Tomorrow. Correctional Mental

Health Report, 1 (1), 3.

Lehman,A.F. (1996). Heterogeneity of Person and

Place:Assessing Co-occurring Addictive and Mental

Disorders. American Journal of Orthopsychiatry, 66 (1),

32–41.

Marshall v. United States (1974). 414 U.S. 417.

Metzner, J.L. (1993). Guidelines for Psychiatric Services in Prisons. Criminal Behavior and Mental Health,

3(4), 252–267.

National Commission on Correctional Health Care

(1999). Correctional Mental Health Care: Standards and

Guidelines for Delivering Services. Chicago: National

Commission on Correctional Health Care.

23

SCREENING AND ASSESSMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS
National GAINS Center (1997). The Prevalence of Cooccurring Mental and Substance Abuse Disorders in the

Criminal Justice System. Just the Facts Series. Delmar,

NY:The National GAINS Center.

National Institute of Corrections (1991). Intervening

with Substance-Abusing Offenders:A Framework for

Action. Washington, DC: U.S. Department of Justice.

——— (1995). Prison Suicide:An Overview and Guide

to Prevention. Washington, DC: U.S. Department of

Justice.

Ogloff, J.R.P., Roesch, R., and Hart, S.D. (1993).

Screening,Assessment, and Identification of Services

for Mentally Ill Offenders. In Steadman, H.J., and

Cocozza, J.J. (Eds.), Providing Services for Offenders

with Mental Illness and Related Disorders in Prisons (pp.

9–26).Washington, DC: National Coalition for the

Mentally Ill in the Criminal Justice System.

Osher, R.C., and Kofoed, L.L. (1989).Treatment of

Patients with Psychiatric and Psychoactive Substance

Abuse Disorders. Hospital and Community Psychiatry,

40(10), 1025–1030.

Pace v. Fauver (1979). 479 F. Supp. 456 (D.N.J.).

Palmigiano v. Garrahy (1977). 443 F. Supp. 956 (D.R.I.).

Peters, R.H. (1992). Referral and Screening for Substance Abuse Treatment in Jails. Journal of Mental

Health Administration, 19 (1), 53–75.

Peters, R.H., and Bartoi, M.G. (1997). Screening and

Assessment of Co-Occurring Disorders in the Justice

System. Delmar, NY:The National GAINS Center.

Prochaska, J.O., DiClemente, C.C., and Norcross, J.C.

(1992). In Search of How People Change:Applications to Addictive Behaviors. American Psychologist,

47, 1102–1114.

Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z.,

Keith, S.J., Judd, L.L., and Goodwin, F.K. (1990).

Comorbidity of Mental Disorders with Alcohol and

C HAPTER 2

24

Other Drug Abuse: Results from the Epidemiologic

Catchment Area (ECA) Study. Journal of the American

Medical Association, 264, 2511–2518.

Reid,W.H. (2000a). Offenders With Special Needs.

Journal of Psychiatric Practice, 6 (5), 280–283.

——— (2000b). Malingering. Journal of Psychiatric

Practice, 6 (4), 226–228.

Ries, R., and Ellingson,T. (1990).A Pilot Assessment

at One Month of 17 Dual Diagnosis Patients.

Hospital and Community Psychiatry, 41 (11),

1230–1233.

Ruiz v. Estelle (1980). 503 F. Supp. 1265 (S.D.Tex.),

rev’d in part, 679 F. 2d 1115 (5th Cir. 1982), modified

in part, 688 F. 2d 566 (5th Cir. 1982).

Taylor, E.R. (2001). Using Algorithms and Protocols

in Diagnosing and Treating Offenders with Mental

Health Disorders. Corrections Today, 63 (5): 80–83,

August.

Teplin, L.A. (1994). Psychiatric and Substance Abuse

Disorders among Male Urban Jail Detainees. American Journal of Public Health, 84, 290–293.

Teplin, L.A.,Abram, K.M., and McClelland, G.M.

(1996). Prevalence of Psychiatric Disorders among

Incarcerated Women. Archives of General Psychiatry,

53, 505–512.

U.S. Department of Health and Human Services

(2001). Mental Health: Culture, Race, and Ethnicity—A

Supplement to Mental Health:A Report of the Surgeon

General. Rockville, MD: U.S. Department of Health

and Human Services, Substance Abuse and Mental

Health Services Administration, Center for Mental

Health Services.

Veysey, B. (1998). Specific Needs of Women Diagnosed

with Mental Illnesses in U.S. Jails. In Levin, B.L.,

Blanch,A.K., and Jennings,A. (Eds.) Women’s Mental

Health Services:A Public Perspective. Thousand Oaks,

CA: Sage Publications.
25

MENTAL HEALTH AND

SUBSTANCE ABUSE TREATMENT

Chapter 3

MENTAL HEALTH TREATMENT

A number of court rulings affirm that prison inmates

are entitled to mental health care equal to that available in the community.Yet, few if any prisons are able

to offer a comprehensive array of mental health

services for all inmates who may require or request

them. Limitations of mental health staff and resources force most prison officials to prioritize inmates with the most severe impairments and

dangerous and disruptive symptoms. Inmates with

adjustment disorders and less severe mental health

problems may wait lengthy periods for treatment or

get no treatment at all.

Ruiz v. Estelle (1980) established the minimum components needed to deliver adequate mental health

treatment in prison, including the use of trained

mental health professionals in sufficient numbers

to identify and treat inmates who are mentally ill

(Metzner, 1993). But determining who gets treatment, what types of treatment are appropriate and

in what amounts, who should deliver treatment, and

how treatment gets delivered are major decisions

for correctional administrators and their health administrators.These decisions have important ramifications for the health and safety of inmates and staff,

costs to the facility, and legal liability.

National Standards and Guidelines 

Although the courts do not mandate the use of any

particular mental health service delivery model, they

do expect correctional facilities to maintain policies

and procedures that will reduce needless suffering

and allow access to needed services (Cohen and

Dvoskin, 1992). Several national organizations have

created guidelines for the establishment of adequate

mental health systems in prisons and provide recommendations for treatment.

American Psychiatric Association. The American

Psychiatric Association (APA) (2000) guidelines recommend that a variety of biological and psychological therapies be available to treat mental health

disorders that significantly interfere with an inmate’s

ability to function in prison.Treatment should be

multidisciplinary, eclectic, and consistent with generally accepted mental health practices and institutional requirements.APA’s guidelines require the

following components to be available:

• A crisis intervention program with infirmary beds

available for short-term treatment (less than 10

days).

• An acute care program (inpatient treatment for

inmates with significant psychiatric symptoms that

interfere with their ability to care for themselves).

• A chronic care program (a special housing unit for

inmates with a chronic mental illness who do not

need acute inpatient care but cannot function

adequately within the general population).

• Outpatient treatment services.

• Consultation services (including consultation with

other prison officials and departments and the

training of officers and program staff).

• Discharge/transfer planning (including both

transfer to other institutions and release to the

community).
National Commission on Correctional Health

Care. APA’s guidelines were designed to be used in

conjunction with the standards developed by the

National Commission on Correctional Health Care

(NCCHC) (Anno, 2000). In addition to issues of care

and treatment, NCCHC standards address administrative and personnel issues, support services, special

needs and services, health records, and medical-legal

issues. Care and treatment issues stipulated by

NCCHC include the following:

• Inmates must be screened for mental health problems by a qualified health professional within 2

hours of admission.

• Inmates must be informed within 24 hours of

arrival of the types of mental health services

available and how to access them.

• Inmates must have a health appraisal within 7 days

of arrival that includes taking a history of any

prior mental health problems, hospitalizations,

psychotropic medications, suicide attempts, and

alcohol and other drug abuse.

• Inmates must receive a mental health evaluation

within 14 days of arrival that includes a complete

mental health history and current mental status

and screening for mental retardation and other

developmental disabilities.

• Treatment plans must be created for inmates who

are identified as having serious mental health

needs and who are developmentally disabled.

• Inmates should be seen by a qualified professional

within 48 hours of a request for nonemergency

mental health services (72 hours on a weekend).

• Prison procedures must address psychiatric emergencies and suicide attempts.

• Mental health treatment should occur in private

(except for high security risks) and with respect

for the offender’s dignity and feelings.

Metzner (1993) has integrated several sets of

national guidelines and recommends to organizations

developing a comprehensive mental health system

C HAPTER 3

26

that their policies and procedures address 13 issues

(see “Issues To Be Addressed in a Prison’s Comprehensive Mental Health System”).

Informed Consent and the Right To

Refuse Mental Health Treatment 

Although APA, NCCHC, and other guidelines exist

to ensure that offenders receive adequate mental

health treatment, the right of inmates to refuse mental health treatment also must be addressed by policies and procedures in prison settings.This right to

refuse treatment is inherent in the notion of informed consent, which NCCHC (1999) defines as

follows:

...the agreement by a patient to a treatment, examination, or procedure after the

patient receives the material facts about the

nature, consequences, and risks of the

Issues To Be Addressed in a Prison’s

Comprehensive Mental Health System

• A mission and goals.

• Administrative structure.

• Staffing (e.g., personnel, credentialing, job

descriptions).

• Reliable and valid methods for identifying inmates

with severe mental illness.

• Treatment programs available to inmates.

• Involuntary treatment, including the use of seclusion,

restraints, forced medications, and involuntary

hospitalizations.

• Medical/legal issues, including informed consent and

the right to refuse treatment.

• Confidentiality.

• Mental health record requirements.

• A quality assurance and improvement plan.

• The training of mental health staff regarding correctional and security issues.

• The formal training of correctional staff regarding

mental health issues.

• Research protocols involving human subjects.
MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT

proposed treatment, examination, or procedure, and the alternatives to it. (p. 113)

Informed consent, a familiar concept in community

health care, should become a standard part of mental health care in prisons, in accordance with each

state’s laws.

The right to refuse treatment in prisons usually

involves forced medications but can also involve

counseling or other less intrusive mental health

interventions.Although the federal courts have been

reluctant to recognize the broad right of offenders

with mental disorders to refuse treatment, they

allow for states to expand on this right, which a

number of state courts have done (Hafemeister,

1998). It is therefore critical that prison administrators create policies concerning the right of inmates

to refuse treatment that conform to court rulings of

the jurisdiction in which the facility is located (APA,

2000; NCCHC, 1999).

If an inmate invokes his or her right to refuse a

mental health intervention or treatment, NCCHC

recommends the following:

• The refusal should be in written form.

• The refusal should specify the condition for which

the treatment was offered.

• The refusal should specify the procedure that was

to be provided.

• The refusal should be made directly to health care

staff.

• The refusal of a specific treatment should not be

considered a “blanket” refusal for all treatments.

• A refusal at one point in time should not be considered a refusal for subsequent care.

• Health care staff should counsel an inmate against

refusing treatment when they consider the treatment to be in the inmate’s best interest.

There are exceptions to the need for informed consent.When, for example, mentally ill inmates pose an

imminent danger to themselves or others, they can

be treated despite their refusal.These exceptions

should be clearly delineated in written procedures.

Scope of Mental Health Treatment

in Prisons 

The National Institute of Corrections (NIC) conducted a survey of 49 state departments of corrections (DOCs), the Federal Bureau of Prisons, and

correctional agencies in Canada, Guam, and Puerto

Rico to study the range of services provided to

meet the mental health needs of inmates (NIC,

2001).The survey found that—

• Many state DOCs distinguish between inmates

with serious mental illness and inmates with other

mental health needs.

• Some DOCs provide mental health care to all

inmates with mental health needs, regardless of

the severity of their condition.

• Although all DOCs typically emphasize treatment

for those with significant mental illness, many provide treatment (usually counseling) for inmates

who have other mental health needs and who

request such services.

• Depending on the formal diagnosis or other mental health classification, an institution may vary the

type, level, and intensity of treatment (e.g., individual versus group, medication versus therapy, inpatient versus outpatient housing).

• Inmates who do not have an acute mental illness

will typically receive less than 1 hour per week of

mental health counseling.

• Most DOCs use formal criteria to determine

when inmates need to be housed in a special unit

or apart from the main population due to mental

health concerns.

• When inmates are acutely symptomatic, they are

typically housed in infirmary units or other settings that allow for close supervision by health

care staff.

27
• Some DOCs house mentally ill inmates who

require inpatient treatment in special units within

their prisons; some designate entire facilities to

house and treat them; others house them in outside hospitals run by other state agencies.

Most state correctional facilities use residential

treatment units designed to house inmates with

chronic mental illness separate from the general

inmate population and to provide a range of structured therapeutic interventions.These units are

often referred to as “transitional care units” or

“intermediate care units” because inmates function

at a level between those in the general population

and those in a hospital.This type of unit has been

shown both to dramatically improve the quality of

life for mentally ill inmates who are more vulnerable

to the predatory behaviors of other nonmentally ill

inmates and to make the prison more safe (Cohen

and Dvoskin, 1992). Inmates are placed temporarily

in these residential units, for example, when being

moved between inpatient hospitalization and the

open population.They are placed in such units permanently when their mental illness prohibits them

from ever being safe in the general population.These

therapeutic units should be self-contained and

equipped both to provide standard services and to

offer the treatment and programming necessary for

their special needs, such as individual and group

therapy, medication, and such recreational and vocational activities as art therapy and music therapy

when possible (Metzner et al., 1998).

Mental Health Treatment

Modalities 

In the community as well as in correctional settings,

four basic forms of clinical intervention are used to

treat mental health symptoms and the functional

impairments that result from mental health disorders: psychotropic medication, individual psychotherapy, group psychotherapy, and family intervention.

Psychotropic Medication. Medications are effective

and important treatment interventions within prison

settings (see chapter 7,“Psychopharmacological

C HAPTER 3

28

Intervention for Psychiatric Disorders” for more

detail). Generally, Metzner and colleagues (1998) recommend that—

• The use of psychotropic medications be consistent with community standards (i.e., according to

the same practice guidelines followed by health

care professionals when treating the general population in the community).

• All classes of psychotropic medications be available to inmates (although the availability of certain

medications that are often abused should be

limited).

• Psychotropic medications be dispensed by licensed

health care professionals, not by correctional officers or other inmates.

• Psychotropic medications be dispensed in single

doses.

• Psychotropic medications be prescribed only in

the context of an adequate clinical examination.

Individual Psychotherapy. Individual psychotherapy

often is not as available as other forms of treatment

within prisons because of limited resources. However, therapy can benefit the overall mental health

and coping ability of individuals with mental illness in

prison settings, and supportive individual psychotherapy for those with serious mental illness should be

available. In addition, when individual psychotherapy

can be provided to a larger population than inmates

with severe mental illness, other issues, such as the

inmate’s ability to safely adapt to the facility, can be

addressed. Common therapy issues in correctional

settings relate to feelings of helplessness and apathy

as a consequence of incarceration and attempts to

adapt to violence, intimidation, and sexual or financial exploitation (Metzner et al., 1998). Grief and loss

can be particularly difficult for offenders to deal with

when they learn of family members who have died

or broken off all contact with them. Research also

suggests that—

• Individual psychotherapy can be provided in outpatient, inpatient, or special treatment settings.
MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT

• Individual counseling should focus on psychoeducation and developing improved coping strategies.

• Cognitive-behavioral interventions are typically

the most beneficial to help inmates who deny and

externalize responsibility.

• Inmates with borderline personality disorder,

posttraumatic stress disorder, and dissociative disorders may benefit from longer term individual

psychotherapy (Metzner et al., 1998).

Group Psychotherapy. Group therapy is the most

often used treatment intervention in prison settings

in part because it is the most cost effective. Group

therapy can also be provided in outpatient, inpatient,

or special treatment settings and can help inmates—

• Realize they are not unique in having emotional

and mental health problems (Metzner et al.,

1998).

• Develop interpersonal and communication skills.

• Develop anger management skills.

• Learn how to cope with alcohol and substance

abuse.

• Learn about mental illness and psychotropic

medications.

Professionals from various disciplines (e.g., social

work, psychology, nursing) may be qualified to provide individual and group psychotherapy.These individuals, however, should possess the necessary

education, training, licensure, certification, and experience to qualify them.

Family Intervention. Although family therapy is not

regularly offered in state correctional settings, a

variety of studies have found that increased contact

between inmates and their families can contribute to

an inmate’s successful reintegration into the community after release (NIC, 2002). Prison programs and

family visitation can help to encourage healthier family relationships and develop a critical element in the

offender’s postrelease support system, which in turn

may lead to more successful reintegration and a

reduced risk for reoffending. Family involvement can

be especially helpful for offenders with mental illness

as transition issues for these inmates are often even

more complex and stressful.Treatment staff can

arrange for supervised family visits and psychoeducation can be provided to the family.These sessions

often yield important historical data that can make

prison interventions more successful interventions

and better prepare the inmate for release.

Mental Health Staffing 

Guidelines and standards from national organizations

such as the American Public Health Association

(APHA),APA, and NCCHC do not stipulate how

many or what type (i.e., from which discipline) of

mental health or substance abuse professionals

should be employed by each prison.They recommend only that there be qualified mental health professionals at sufficient levels to ensure that inmates

can receive the treatment equal to contemporary

standards of care (Metzner, 1993).Very little empirical data exist to help administrators select a particular staffing model for providing mental health

services to inmates (Rice and Harris, 1993; Dvoskin

and Patterson, 1998).The numbers and types of

mental health care providers required at any particular facility depend on the number of inmates being

treated, the particular needs of those inmates, and

the scope of services being offered (e.g., inpatient,

outpatient, special programs) (NCCHC, 1999). It is

recommended, however, that the professionals providing mental health and substance abuse services

meet the state licensure, certification, and registration requirements necessary to practice outside of

the prison setting so as not to compromise the

quality of care provided to inmates (NCCHC, 1999).

Treatment of Antisocial Personality

Disorder 

Some clinicians consider antisocial personality disorder to be untreatable (Maier and Fulton, 1998), and

many DOCs will not provide treatment for it when

it is the only presenting problem. Some research has

29
shown, however, that certain treatments can be

effective in reducing antisocial behaviors (Gacono

et al., 2000).The most frequently used interventions

recommended for the treatment of antisocial personality disorder in prison are based on cognitivebehavioral strategies and social learning principles.

One widely used cognitive-behavioral approach to

treat antisocial personality disorder focuses on getting the inmate to accept responsibility for his or

her behavior (Yochelson and Samenow, 1976).This

approach relies on psychoeducation and skills-building

interventions to help inmates identify their distortions and errors in thinking.Treatment focuses on

teaching inmates the relationship between these

criminal thinking errors and their criminal (i.e., irresponsible) behavior. If thinking errors are eliminated,

the expectation is that prosocial behaviors are more

likely. Inmates correct their thinking errors through

daily journal writing that details their thinking process and group therapy where they can be directly

confronted about their criminal thinking patterns

and the resulting behaviors.

Therapeutic communities, based on a social learning

model, are used to treat antisocial personality disorder (De Leon, 1985). Inmates in these specialized

communities are taught that they are residents or

family members and that they must follow the rules

of the community, submit to the authority of the

group, and suffer sanctions imposed by the group

when they violate the community’s principles and

values.Therapeutic communities are not routinely

created in prison settings for the primary treatment

of antisocial personality disorder, however.They are

generally used for the treatment of alcohol or drug

abuse disorders, but they can help to mitigate the

antisocial personality traits of offenders because

they emphasize prosocial values.

Treatment Planning 

Regardless of the specific treatment or setting

where services are delivered, an individualized treatment plan is essential to the provision of prisonbased mental health services.The plan includes a

C HAPTER 3

30

series of written statements that address key components of the inmate’s mental health issues and

treatment (Metzner et al., 1998).A treatment plan

should include—

• An objective description of the problems the

inmate faces as a result of mental illness.

• An objective description of short- and long-term

goals of treatment.

• The types of therapeutic interventions that will be

used to achieve those goals and how often they

will be delivered.

• The providers who will deliver the treatment.

Treatment plans also can address interventions or

activities to be provided by nonmental health staff

that can be critical in helping inmates with mental

illness function adequately and provide relief from

symptoms.These interventions and activities may

include attending school or vocational programs,

recreational activities, family visits, and work assignments (Metzner et al., 1998).

Crisis Intervention Services 

Offenders who require long-term mental health interventions and treatment are generally seen in residential units or at outpatient clinics.There are times,

however, when emergency interventions for crisis

situations must be provided to inmates who may or

may not be receiving mental health services on a

regular basis. Crisis intervention is needed when

inmates’ mental illnesses make them dangerous to

themselves or others or leave them unable to adequately care for themselves. Most often, this is the

result of an acute suicidal depression or an acute

exacerbation of psychosis (Cohen and Dvoskin,

1992).

On these occasions, the success of the crisis intervention in preventing further psychiatric decompensation (the appearance or exacerbation of a mental

disorder due to the failure of defense mechanisms)

and in protecting the inmate and others depends

on the timely response by staff and the ability to
provide the necessary services, including access 

to—

• Mental health screening and assessment.

• Psychotropic medications.

• Supportive psychotherapy.

• Crisis stabilization beds.

Long-term mental health treatment may or may not

follow these crisis intervention services.At times, it

is a crisis situation that first brings an inmate into

contact with mental health staff.This may be true for

several reasons: the inmate’s initial screening and

assessment did not reveal mental illness, the inmate’s

mental illness was in remission prior to the crisis, or

the illness developed while incarcerated (Cohen and

Dvoskin, 1992).When a crisis provides mental health

staff with the opportunity to determine that a mental health disorder exists, the inmate should be referred to the appropriate level of ongoing services

and treatment (e.g., outpatient, residential, hospital).

Long-term followup is generally not required for

inmates who return to their previous level of functioning after the crisis is resolved and for whom no

significant mental illness is assessed to be present.

However, one or two followup appointments with

mental health staff may be judicious simply to ensure

that the inmate can maintain the level of functioning

he or she had prior to the crisis.

State prisons can meet the legal requirement of

providing psychiatric hospital treatment for inmates

who need extensive inpatient care using one of

these three models:

• A prison psychiatric hospital, which is run by the

mental health staff who work for the prison.

• An entire prison facility that serves as a psychiatric hospital designated to house and treat mentally ill offenders, which is run by mental health

staff who work for the corrections authority.

• Outside hospitals usually run by other state agencies to which inmates are transferred until they

can return to prison.

When deciding which model to use to treat inmates

who require extensive inpatient care, administrators

should consider which has the best funding, resources, continuity of care, and timely access to

required services (Hafemeister, 1998).The benefits

of using the first option, small psychiatric hospitals

within the prison (Maier and Fulton, 1998), include

the following:

• Less entrenched in excessive security.

• A greater level of trust.

• Better staff communication.

• Better opportunities for specialized treatment.

Case Management 

A good deal of variability exists in the systems

prisons use to deliver mental health services

(Goldstrom, Manderscheid, and Rudolph, 1992; NIC,

2001).The particular model a state department of

corrections uses often depends on such factors as

the size and location of the system and the quality

of the relationship between the DOC and the state’s

mental health department. One key component of

the system should be case management, a process

designed to effectively monitor and provide services

to offenders with mental illness (Jemelka, Rahman,

and Trupin, 1993).

Case management was first developed in the 1960s

and 1970s as a way to help those with mental illness

access the social and health services they need to

function on a day-to-day basis in the community

(Chamberlain and Rapp, 1991).At least five variations

on case management have since been described, all

based on the involvement of a professional who

works closely with clients with mental illness to broker (and sometimes directly provide) a multitude of

services the client may require.The traditional functions performed by case managers working with

adults with mental illness are listed in “Typical Tasks

Performed by Case Managers.”

In correctional settings, case managers may be

assigned to inmates who have mental health

31

MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
disorders, alcohol or drug abuse disorders, or both

(co-occurring disorders). In a prison, the community

comprises the general, or open, population housing

units and the various departments and programs

that deliver services to the offenders.The case manager may need to broker between both correctional

administrative systems (e.g., security, classification,

housing) and treatment-oriented services and programs (e.g., education, vocation, health/medical, mental health, and alcohol and drug abuse services).

At one time, this brokering of services was the sum

total of a case manager’s job. Increasingly, it has been

recognized that interventions with inmates who

have mental illness need more intense involvement

and that the relationship between the case manager

and client should be emphasized (Chamberlain and

Rapp, 1991). Case managers in a recent National

Institute of Justice (NIJ) document (1999) reported

that informal counseling with their clients was a vital

component in their relationship. Further, with appropriate education and training, case managers also can

provide treatment in the form of counseling and

psychotherapy.

Case managers employed by state prisons may come

from a variety of backgrounds and disciplines. Some

facilities use trained mental health staff as case managers, while others rely on classification staff to fulfill

the function.The use of case managers who also are

trained mental health professionals provides services

that meet or exceed most of the legal, correctional,

C HAPTER 3

32

and professional standards established for the provision of mental health services. Requiring that case

managers be properly trained mental health professionals also is consistent with national guidelines

that recommend that the training and competence

of the qualified mental health personnel employed in

correctional facilities be equal to community standards (APA, 2000; NCCHC, 1999).

To avoid a conflict of roles, clinicians who provide

mental health treatment in forensic settings should

not also provide correctional services (Metzner et

al., 1998). Jemelka, Rahman, and Trupin (1993) provide guidance on effective case management:

Mentally ill offenders are best managed by

an identified mental health case manager

who is responsible for activating and monitoring a continuum of treatment and classification services to a caseload of mentally ill

offenders.The purpose of this approach is

to monitor each offender’s individualized

mental health treatment plan, and to regularly evaluate the adequacy and appropriateness of the plan, making modifications

where necessary. Effective case management

will ensure consistency of service delivery,

and will monitor mentally ill offenders’

progress, including changes in levels of functioning and treatment needs. (p. 15)

Prison-based case managers who work with offenders with mental illness perform the following

activities:

• Create and monitor an individualized service

plan or treatment plan that provides a detailed

account of the inmate’s multiple intervention

needs.

• Assess the inmate’s programming needs and refer

the inmate to programs as appropriate.

• Meet regularly with the inmate to monitor and

assess his or her psychiatric functioning and evaluate for decompensation.

• Provide counseling and psychotherapy.

Typical Tasks Performed by Case

Managers

• Assessment of the offender’s needs.

• Planning services to meet the needs identified through

assessment.

• Advocating for the offender’s needs.

• Linking offenders to the services identified by service

planning.

• Monitoring the offender’s progress in achieving the

objectives detailed in the service plan.
• Refer the inmate to other mental health and medical staff as needed.

• Act as a liaison between classification, security,

and health services.

• Provide information to security and classification

staff to help them in their decisions regarding

such issues as an inmate’s housing and

responsibilities.

• Communicate with various institutional staff who

have contact with the inmate to help monitor his

or her level of functioning.

• Plan for aftercare upon discharge from the prison

and release back to the community.

• Communicate with the probation or parole

agency.

Inmates with mental illness often fall through the

cracks when they return to the community. Case

managers can be instrumental in helping them obtain

the services they need to best function outside the

institution.APA guidelines (2000) emphasize this

type of discharge and aftercare planning for offenders with mental illness to ensure continuity of care

when they are released to the community and being

transferred to another institution.

Case managers are responsible for the following

aspects of discharge and aftercare planning:

• Arranging appointments at mental health agencies

in the community for inmates who require mental

health treatment upon release.

• Arranging for the continuation of psychotropic

medications.

• Making other types of referrals, such as vocational

rehabilitation, substance abuse services, self-help

groups, and financial assistance.

• Helping inmates apply for public assistance and

other benefits in preparation for release.

• Notifying staff at other facilities about the mental

health needs of transferring inmates.

Staff Training 

Prison-based case managers working with inmates

with mental illness should possess, at a minimum, the

skills needed by any successful prison staff member,

including correctional officers (Rice and Harris,

1993).

Studies suggest that staff who are most likely to succeed with correctional or mentally

disordered offender populations are those

who use authority to enforce rules but in a

nonconfrontational manner, who model

prosocial (and anticriminal) attitudes and

behaviors, and who are at the same time

empathic and interpersonally skilled.

(p. 110)

Line correctional staff assigned to work with

inmates with mental illness are best prepared for

this role if they receive the same training as direct

care workers in psychiatric hospitals (Hafemeister,

1998). Correctional officers can be highly effective

when they are trained to—

• Understand that simply listening and talking to

mentally ill inmates may resolve crises.

• Understand that frequent contact by staff, even

brief contacts, can help calm confused and anxious

inmates.

• Provide accurate information about the institution

and how to access mental health services to

inmates.

• Observe and record inmate behavior.

• Receive and relay inmate requests for assistance

from mental health staff.

• Consult with mental health staff about mental

issues.

• Monitor inmates who take psychotropic medications for compliance and side effects.

• Identify the early signs and symptoms of mental

illness and implement suicide prevention

(Hafemeister, 1998).

33

MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
Basic training for all correctional staff should therefore include the following information:

• How to recognize the early signs and symptoms

of serious mental illness and suicide.

• The nature and effects of psychotropic

medications.

• The mental health services available in the prison.

• How and when to make referrals to mental health

services (Cohen and Dvoskin, 1992).

Case managers should demonstrate the ability to—

• Establish rapport with inmates.

• Educate inmates about the institution and its

mental health services.

• Link inmates to other services and departments.

• Link inmates to community services on release.

• Prepare treatment plans.

SUBSTANCE ABUSE SERVICES

Reports from state and federal prisons indicate that

as many as 80 percent of criminal offenders have an

alcohol or drug abuse problem (NIC, 1991).

In 1991, a report of the NIC national task force on

correctional substance abuse strategies recommended the following:

• Institutions should provide a range of services,

from drug education to intensive residential programs, for substance-abusing offenders.

• Services should include assessment, self-help

groups, drug education and information, counseling, comprehensive drug treatment, and intensive

therapeutic communities.

• Frequent and random urinalysis should be

employed in conjunction with all treatment

approaches as a strong deterrent to relapse for

drug-dependent offenders.

C HAPTER 3

34

• Continuity of care is an important concern as

offenders move through the system.

• Drug education should be provided to all offenders.The possibility of spreading acquired immune

deficiency syndrome (AIDS) through intravenous

drug use should be emphasized (NIC, 1991, p.8).

In addition, NIC recommends that prison-based

alcohol and drug treatment includes the following

components:

• An integrated staffing approach to delivering

treatment.

• The cooperation of treatment and security staff

to ensure program effectiveness.

• The sensitivity of treatment staff to security

concerns.

• The education of security staff about substance

abuse issues.

• The participation of community treatment and

supervision agencies in mutual training and support activities.

• Incentives and sanctions to increase offenders’

motivation for treatment to be included in all

correctional substance abuse programs (see

“Coerced Treatment for Substance Abuse

Disorders”).

Coerced Treatment for Substance

Abuse Disorders

Although some clinicians and researchers argue against

coerced alcohol or drug treatment on philosophical,

constitutional, or clinical grounds, others believe that

without external motivation or coercion, many chronic

addicts would not enter treatment (CSAT, 1995).

Limited empirical evidence suggests that coercion does

not lessen treatment effectiveness and, further, that legal

pressure may increase admission rates into programs

and promote treatment retention (Simpson and Friend,

1988;Anglin, Brecht, and Maddahian, 1989; De Leon,

1988).
• The increased availability of self-help groups as an

adjunct to treatment and as an integral part of

aftercare (e.g.,Alcoholics Anonymous, Narcotics

Anonymous).

• Targeted treatment programs for special needs

populations (e.g., women, pregnant women, HIVpositive inmates, sex offenders, elderly inmates,

inmates with mental illness, minorities).

• Education and treatment for relapse prevention.

• Enhanced prerelease treatment programming.

Three interventions and services recommended by

NIC—therapeutic communities, relapse prevention,

and self-help support groups—are explained in further detail.

Therapeutic Communities 

Therapeutic communities provide a comprehensive

set of treatment interventions within a residential

environment where inmates are usually segregated

from the general population for 6 to 24 months.The

therapeutic community philosophy, based on a social

learning model, teaches that alcohol and drug abuse

are disorders of the entire person.The main goal is

a total change in the inmate’s lifestyle that includes

not only abstinence from alcohol and drug use but

also the development of prosocial attitudes, values,

and behaviors (CSAT, 1995).Therapeutic communities provide a comprehensive set of rehabilitation

services for offenders and are generally reserved for

the chronic alcohol and drug abuser. Some research

suggests that, with appropriate followup on release,

inmates treated in prison therapeutic communities

have lower rates of reincarceration (Simpson,

Wexler, and Inciardi, 1999). In addition, research suggests that treating alcohol- and drug-abusing inmates

in prison therapeutic communities has a positive

impact on prison management by reducing the number of disciplinary infractions committed by the

inmates and thereby reducing prison management

costs (Wexler and Lipton, 1991; Prendergast,

Farabee, and Cartier, 2001).

Relapse Prevention Skills 

Relapse prevention, rooted in social learning principles, explains relapse to alcohol and drug use as the

result of a predictable series of cognitive and behavioral events (Hills, 2000).The offender is taught to

identify his or her particular triggers and high-risk

situations that can set into motion the gradual process of relapse (CSAT, 1993).After the triggers are

identified, the inmate is taught how to avoid or overcome them through increased self-awareness,

strengthened resistance, and positive coping strategies. Relapse prevention skills learned while incarcerated can be particularly helpful on release from

prison, when offenders often are faced with limited

community or family supports and significant deficits

in educational and vocational skills and opportunities.

Self-Help Groups 

Self-help groups such as Alcoholics Anonymous,

Narcotics Anonymous, and Dual Recovery Anonymous often play an integral role in prison-based substance abuse programs and, like relapse prevention

skills, they are often an important part of an inmate’s

postrelease planning. Support groups are not a formal treatment intervention and are led by inmates’

peers in prison, just as they would be in a community setting. (In correctional settings, staff may be present to monitor or supervise.)

Self-help groups are appealing to correctional program administers because they can be used as an

adjunct to both outpatient and residential/therapeutic community prison-based programs.The NIC task

force report (1991) states that:

Groups like Alcoholics Anonymous (AA)

and Narcotics Anonymous (NA) for offenders can support the effort to intervene in

substance abuse by communicating strength

and hope to offenders, who are often pessimistic about their future.These groups

provide an alternative to a drug-involved

system of relationships and can serve as an

“adopted family” in which prosocial values

and behaviors are supported. (p. 15)

35

MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
Because traditional 12-step self-help groups are

organized around a spiritual philosophy, it is important that organizations offer alternative self-help

groups for inmates who might reject participation in

them.The SMART Recovery model, for example, is

based on the principles of Rational Emotive Behavior

Therapy (REBT) (Ellis and Velten, 1992). SMART

Recovery groups are led by peers, and members

learn how to maintain and increase their motivation

to quit, handle urges without acting on them, develop new ways of coping with problems, and create a

healthy, balanced lifestyle.

CO-OCCURRING DISORDERS

Of the 16 percent of state prison inmates with a

mental illness, 59 percent reported using alcohol or

drugs at the time of their offense, and 34 percent

have a history of alcohol dependence (Bureau of

Justice Statistics, 1999).Although the terms “dual

diagnosis” and “co-occurring disorders” refer to a

spectrum of individuals who have more than one

disorder, for the purposes of this discussion, inmates

with co-occurring disorders are those who have a

severe and persistent mental illness and a substance

use disorder.

Inmates with severe and persistent mental illnesses

who require alcohol or drug treatment in correctional settings are often excluded from the programs

that serve the alcohol or drug dependent inmate

(Hills, 2000). Programs sometimes exclude those

who are taking psychotropic medications, and some

inmates’ mental illnesses are exacerbated by substance abuse programs that use highly confrontational treatment methods.The Center for Substance

Abuse Treatment (1994) has, therefore, recommended that this special population receive treatment

separately from other offenders. Service needs also

may be addressed, however, with crossover services

or overlay programming when the development of

independent and segregated programs is not possible (Hills, 2000).

The Federal Bureau of Prisons, Guam, Puerto Rico,

the Correctional Service of Canada, and 37 state

C HAPTER 3

36

DOCs offer specialized services for inmates who

have co-occurring disorders (NIC, 2001).Three

models of treatment are commonly used for the

delivery of service to inmates with co-occurring disorders: parallel, sequential, or integrated treatment.

Parallel Treatment

In a parallel approach, the inmate receives mental

health services from one or a team of clinicians to

deal with the mental disorder and receives substance abuse treatment from another professional.

The offender might be in a substance abuse program

while also being carried on the caseload of a mental

health provider.A case manager coordinates the two

treatments by scheduling the sessions, attending the

groups, and meeting with the treatment teams.

Sequential Treatment

Alternatively, an offender can be treated for mental

health and substance abuse disorders sequentially;

that is, the inmate receives treatment for one problem before the other is addressed. For example, a

person might be told by a mental health professional

that psychotherapy or psychotropic medications are

not appropriate until a substance abuse counselor

has been seen and the addiction is under control.

Similarly, the substance abuse professional or treatment program might refer the inmate to the mental

health department to have symptoms of anxiety

or depression stabilized before treatment of the

inmate’s addiction or abuse could begin. In criminal

justice settings, the sequential approach is most

commonly used (Hills, 2000).

Both the parallel and sequential treatment approaches may be adequate for offenders with less severe

co-occurring disorders, but they are not the treatment of choice for inmates with severe and persistent mental illness.

Integrated Treatment

In 1997, the National Advisory Council of the U.S.

Substance Abuse and Mental Health Services
Administration (SAMHSA) recommended that treatment for co-occurring disorders be integrated and

that—

. . . the delivery of mental health and 

substance-related treatment and rehabilitation should be reorganized to provide

integrated services that are responsive to

the unique, complex interactivity of cooccurring disorders. (p. 23) 

This integrated model calls for a single professional

or team of professionals trained in both mental

health and substance abuse to provide comprehensive treatment that addresses both disorders simultaneously.The inmate with a dual diagnosis has the

opportunity to develop a trusting, therapeutic relationship with a single individual or team and can

learn how to effectively deal with multiple conditions and their often complex interaction with each

other.

An integrated treatment approach has numerous

advantages; offenders—

• Are more likely to receive a consistent explanation of their conditions.

• Are less likely to receive contradictory or conflicting treatment strategies.

• Can expect greater continuity of care over time.

• Can expect treatment interventions to be specifically tailored for them based on their progress in

the recovery process.

Hills (2000) recommends the following key principles be incorporated in corrections-based treatment

programs for offenders with co-occurring disorders:

• Services should follow the integrated model.

• Both disorders should be treated as primary in

importance.

• Individual programming should address the severity of symptoms and skill deficits.

• Psychopharmacological interventions should be

used when appropriate.

• Phases of intervention should be tailored to the

particular setting (e.g., prison-based treatment

should take into account the length of the

sentence).

• The treatment continuum must extend into the

community.

• Support and self-help groups are critical in successful reintegration to the community.

REFERENCES

American Psychiatric Association (2000). Psychiatric

Services in Jails and Prisons, Second Edition.Washington, DC:American Psychiatric Press.

Anglin, M.D., Brecht, M.L., and Maddahian, E. (1989).

Pretreatment Characteristics and Treatment Performance of Legally Coerced Versus Voluntary

Methadone Maintenance Admissions. Criminology, 27,

537–557.

Anno, B.J. (2000). National Correctional Health

Standards. In Ashford, J.B., Sales, B.D., and Reid,W.H.

(Eds.), Treating Adult and Juvenile Offenders With Special

Needs (pp. 81–96).Washington, DC:American

Psychological Association.

Bureau of Justice Statistics (1999). Mental Health and

Treatment of Inmates and Probationers. Washington,

DC: U.S. Department of Justice.

Center for Substance Abuse Treatment (1993).

Relapse Prevention and the Substance Abusing Criminal

Offender. Technical Assistance Publication Series 8,

Criminal Justice Subseries,Volume 1 (DHHS Publication No. (SMA) 99–3284). Rockville, MD: U.S.

Department of Health and Human Services.

——— (1994). Assessment and Treatment of Patients

with Coexisting Mental Illness and Other Drug Abuse.

Treatment Improvement Protocol Series 9 (DHHS

Publication No. (SMA) 95–3061). Rockville, MD: U.S.

Department of Health and Human Services.

37

MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
——— (1995). Planning for Alcohol and Other Drug

Abuse Treatment for Adults in the Criminal Justice

System. Treatment Improvement Protocol Series 17

(DHHS Publication No. (SMA) 95–3039). Rockville,

MD: U.S. Department of Health and Human Services.

Chamberlain, R., and Rapp, C.A. (1991).A Decade of

Case Management:A Methodological Review of Outcome Research. Community Mental Health Journal, 27

(3), 171–187.

Cohen, F., and Dvoskin, J.A. (1992). Inmates with

Mental Disorders:A Guide to Law and Practice.

Mental and Physical Disability Law Reporter, 16 (4),

462–470.

De Leon, G. (1985).The Therapeutic Community:

Status and Evolution. The International Journal of

Addictions, 20, 823–844.

——— (1988). Legal Pressure in Therapeutic Communities. In Leukefeld, C.G., and Tims, F.M. (Eds.),

Compulsory Treatment of Drug Abuse: Research and

Clinical Practice. NIDA Research Monograph 86:

Rockville, MD: U.S. Department of Health and

Human Services.

Dvoskin, J.A., and Patterson, R.F. (1998).Administration of Treatment Programs for Offenders with

Mental Disorders. In Wettstein, R.M. (Ed.), Treatment

of Offenders with Mental Disorders (pp. 1–43). New

York:The Guilford Press.

Ellis,A., and Velten, E. (1992). When AA Doesn’t Work

for You: Rational Steps to Quitting Alcohol. Fort Lee, NJ:

Barricade Books.

Gacono, C.B., Nieberding, R.J., Owen,A., Rubel, J., and

Bodholdt, R. (2000).Treating Conduct Disorder,Antisocial, and Psychopathic Personalities. In Ashford, J.B.,

Sales, B.D., and Reid,W.H. (Eds.), Treating Adult and

Juvenile Offenders With Special Needs (pp. 81–96).

Washington, DC:American Psychological

Association.

Goldstrom, I.D., Manderscheid, R.W., and Rudolph,

L.A. (1992). Mental Health Services in State Adult

C HAPTER 3

38

Correctional Facilities. In Manderscheid, R.W., and

Sonnenschein, M. (Eds.), Mental Health, United States.

Washington, DC: U.S. Department of Health and

Human Services.

Hafemeister,T.L. (1998). Legal Aspects of the Treatment of Offenders with Mental Disorders. In

Wettstein, R.M. (Ed.), Treatment of Offenders with

Mental Disorders (pp. 44–125). New York:The

Guilford Press.

Hills, H.A. (2000). Creating Effective Treatment Programs for Persons with Co-Occurring Disorders in the

Justice System. Delmar, NY:The National GAINS

Center.

Jemelka, R.P., Rahman, S., and Trupin, E.W. (1993).

Prison Mental Health:An Overview. In Steadman,

H.J., and Cocozza, J.J. (Eds.), Providing Services for

Offenders with Mental Illness and Related Disorders in

Prisons. Washington, DC:The National Coalition for

the Mentally Ill in the Criminal Justice System.

Maier, G.J., and Fulton, L. (1998). Inpatient Treatment

of the Mentally Disordered Offender. In Wettstein,

R.M. (Ed.), Treatment of Offenders with Mental Disorders (pp. 126–201). New York:The Guilford Press.

Metzner, J.L. (1993). Guidelines for Psychiatric

Services in Prisons. Criminal Behavior and Mental

Health, 3 (4), 252–267.

Metzner, J.L., Cohen, F., Grossman, L.S., and

Wettstein, R.M. (1998).Treatment in Jails and

Prisons. In Wettstein, R.M. (Ed.), Treatment of

Offenders with Mental Disorders (pp. 211–264). New

York:The Guilford Press.

National Commission on Correctional Health Care

(1997). Standards for Health Services in Prisons.

Chicago: National Commission on Correctional

Health Care.

——— (1999). Correctional Mental Health Care:

Standards and Guidelines for Delivering Services.

Chicago: National Commission on Correctional

Health Care.
National Institute of Corrections (1991). Intervening

with Substance-Abusing Offenders:A Framework for

Action. Washington, DC: U.S. Department of Justice.

——— (2001). Provision of Mental Health Care in

Prisons. Washington, DC: U.S. Department of Justice.

——— (2002). Services for Families of Prison Inmates.

Longmont, CO: U.S. Department of Justice.

National Institute of Justice (1999). Case Management

in the Criminal Justice System. Washington, DC: U.S.

Department of Justice.

Prendergast, M., Farabee, D., and Cartier, J. (2001).

The Impact of In-Prison Therapeutic Community

Programs on Prison Management. Journal of Offender

Rehabilitation, 32 (3), 63–78.

Rice, M.E., and Harris, G.T. (1993).Treatment for

Prisoners with Mental Disorders. In Steadman, H.J.,

and Cocozza, J.J. (Eds.), Providing Services for Offenders

with Mental Illness and Related Disorders in Prisons.

Washington, DC:The National Coalition for the

Mentally Ill in the Criminal Justice System.

Ruiz v. Estelle (1980). 503 F. Supp. 1265 (S.D.Tex.),

rev’d in part, 679 F. 2d 1115 (5th Cir. 1982), modified

in part, 688 F. 2d 566 (5th Cir. 1982).

SAMHSA National Advisory Council (1997). Improving Services for Individuals at Risk of, or with, Cooccurring Substance-Related and Mental Health

Disorders. Rockville, MD: U.S. Department of Health

and Human Services.

Simpson, D.D., and Friend, J. (1988). Legal Status and

Long-Term Outcomes for Addicts in the DARP

Follow-up Project. In Leukefeld, C.G., and Tims, F.M.

(Eds.), Compulsory Treatment of Drug Abuse: Research

and Clinical Practice. NIDA Research Monograph 86,

Rockville, MD: U.S. Department of Health and

Human Services.

Simpson, D.D.,Wexler, H.K., and Inciardi, J.A. (Eds.)

(1999). Drug Treatment Outcomes for Correctional

Settings (Special Issue, Parts 1 and 2). Prison Journal,

79 (3, 4), 291–445.

Wexler, H.K., and Lipton, D.D. (1991). Project

REFORM: Developing a Drug Abuse Treatment

Strategy for Corrections. Journal of Drug Issues, 21,

469–490.

Yochelson, S., and Samenow, S. (1976). The Criminal

Personality,Volume 1:A Profile for Change. New York:

Jason Aronson.

39

MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT
41

USE OF SECLUSION,

SEGREGATION, AND RESTRAINTS

Chapter 4

Finding safe, humane, and nonpunitive methods for

handling inmates who are experiencing the symptoms of mental illness is an ongoing challenge for

prison administrators.The nature of serious mental

illness may create major problems for managing the

behavior of these inmates. Some symptoms of serious mental illness may result in inmates’ committing

disciplinary infractions. Prison administrators must

work to maintain order in their facilities but must

also work to avoid penalizing inmates with mental

illness for behavior that results directly from their

illness. Inmates with mental disorders who do not

fully comprehend the rules or who are unable to

control their behavior often get into trouble and are

punished even when they clearly have diminished

responsibility, comprehension, or self-control (Faiver,

1998).

The American Psychiatric Association (APA) has

expressed concern that inmates who have difficulty

understanding or adhering to institutional rules as a

result of their mental illness will find their way into

segregation units unnecessarily in prisons with inadequate mental health services (APA, 2000).This concern is heightened when it comes to supermax

facilities, as inmates could spend years in segregation

in those units. Solitary confinement or extended

segregation may cause extreme stress for a mentally

ill person and can promote decompensation and

exacerbate the illness (Faiver, 1998).

MENTAL HEALTH SERVICES IN

SEGREGATION

As do other inmates, offenders with mental illness

violate institutional rules and commit infractions that

would normally result in discipline, including segregation and confinement.Although administrators must

ensure that such behaviors trigger appropriate consequences (lest inmates deduce that having a mental

illness excuses disciplinary violations), caution must

also be taken because segregation for mentally ill

offenders can severely exacerbate their psychiatric

symptoms. Segregation may be so anxiety provoking

for some that they may go to extreme lengths to

avoid it, including threatening or attempting suicide

(Hafemeister, 1998). Given that offenders with mental illness will at times be placed in administrative or

disciplinary segregation, mental health staff should be

readily available onsite to identify inmates who are

experiencing significant psychological problems and

to provide an adequate level of services.

National Commission on Correctional Health Care

(NCCHC) standards specifically stipulate that health

care must continue to be made available to inmates

in segregation (Anno, 2000). Routine checks (rounds)

must be made by health staff at least three times a

week for inmates in administrative segregation and

daily for inmates in disciplinary segregation.Although

the NCCHC standards do not address the frequency with which mental health staff should visit

inmates in segregation, the APA has recommended

that they make the rounds of segregated inmates at

least weekly to check their mental status (Anno,

2000;APA, 2000).Anyone needing further evaluation

or treatment should be referred for followup interventions and seen in an appropriate clinical setting.

APA (2000) recommends that, when inmates are

in segregation for any reason, mental health staff

should make a special effort to assess and address

serious mental health needs because of the stressful
nature of segregated housing (see “Meeting Mental

Health Needs in Segregated Housing”).

C HAPTER 4

42

health and mental health staff, NCCHC standards

stipulate certain requirements (Anno, 2000):

• The facility must have written policies and procedures governing their use.

• Only soft restraints may be employed.

• Only a physician or other health provider permitted by law may order restraints or seclusion.

• Health staff may only use restraints or seclusion

as part of a treatment regime and not for disciplinary or custody reasons.

• Any single order for restraints or seclusion cannot exceed 12 hours.

• Inmates in restraints or seclusion must be

checked at least every 15 minutes.

APA recommends that staff consider that many inmates, especially women, may have suffered from a

history of abuse and trauma and may be retraumatized when secluded and restrained (APA, 2000).

They recommend that the treatment team work

together with the inmate to use other methods to

manage behavior, for example,“much of the behavior

that may seem to require restraints may be deescalated by ‘talking the person down’ and understanding what is really going on” (p. 53).

APA recommends that correctional facilities follow

their state mental health laws and professional practice guidelines when they determine their policies

on medical and psychiatric seclusion.

The new ACA standards for health care (ACA,

2001) also stipulate that correctional institutions

have policies and procedures that address the use of

restraints for psychiatric reasons.These policies and

procedures must include the conditions under which

restraints may be applied, the types of restraints

allowed, the staff qualified to decide when they are

to be used because less restrictive measures would

not be successful, the length of time they can be

applied, documentation of efforts for less restrictive

alternatives as soon as possible, and an after-incident

Meeting Mental Health Needs in

Segregated Housing

• Inmates should not be confined in segregated housing

units solely because they exhibit symptoms of mental

illness.

• Segregated inmates must continue to receive any mental health services that mental health staff determine

essential.

• Inmates in current, severe psychiatric crisis, including

but not limited to acute psychosis and suicidal depression, should be removed from segregation until they

are able to psychologically tolerate segregation.

• Inmates who have been identified as having serious

mental health needs, especially those with severe and

persistent mental illness, must be assessed regularly by

mental health staff to identify and respond to any

crises as soon as possible.

Unlike the NCCHC and American Correctional

Association (ACA) guidelines,APA specifically recommends that mental health staff conduct regularly

scheduled rounds in all segregation units and have

contact with every inmate.APA also states that mental health staff need to communicate with security

staff to help identify offenders who show signs of

decompensation.

USE OF SECLUSION AND

RESTRAINTS

Both seclusion and mechanical devices that restrain

are used at times to protect mentally ill offenders

from harming themselves and others. Because of the

high potential for misuse of these devices (i.e., to

control or punish an inmate rather than as a therapeutic intervention), specific and well-articulated

policies and procedures must be in place to govern

who can use them and under what conditions.When

restraints are used for therapeutic interventions by
review.Although ACA guidelines state that all of

these issues must be addressed, the specific details

are left up to the organization to determine.

MENTAL HEALTH SERVICES IN

SUPERMAX PRISONS

Supermax prisons are either freestanding facilities

or distinct units within facilities that are designed

to manage inmates who are violent or seriously disruptive. Because these inmates are a threat to the

security of the facility and the safety of others, their

behavior is controlled by separation, restricted

movement, and limited access to staff and other

inmates (NIC, 1999). In most of these facilities, programming, such as education, substance abuse treatment, anger management, and vocational training, is

generally limited to video broadcasts and written

correspondence. However, some facilities allow services to be delivered at the cell front, and some even

allow small groups of inmates to gather in classroom

settings close to the housing units.

In some states and jurisdictions, inmates with mental

illness are excluded from supermax facilities; in others, they are not. Some supermax facilities have designated segregated units to house offenders with

mental illness, while others provide mental health

services within the main facility.

Many professionals believe the following NIC recommendations (1999):

Insofar as possible, mentally ill inmates

should be excluded from extended control

facilities. Each inmate being considered for

such a facility should have a mental health

evaluation.Although some mentally ill

offenders are assaultive and require control

measures, much of the regime common to

extended control facilities may be unnecessary, and even counterproductive, for this

population. (p. 12)

The isolation and deprivation in supermax prisons

and their potential for inducing mental health problems has led many mental health professionals to

oppose their use altogether. It is recommended that,

at a minimum, mental health staff regularly visit all

inmates in these facilities to determine their mental

status and screen for signs of mental illness.Treatment for those who require it must be made available either at the supermax itself or elsewhere and

should follow the policies and procedures for comprehensive mental health care that would be provided to any other inmate in any other correctional

facility.

REFERENCES

American Correctional Association (2001). Performance Based Health Care Standards: Field Test Version.

Lanham, MD:American Correctional Association.

American Psychiatric Association (2000). Psychiatric

Services in Jails and Prisons, Second Edition.Washington, DC:American Psychiatric Press.

Anno, B.J. (2000). National Correctional Health

Standards. In Ashford, J.B., Sales, B.D., and Reid,W.H.

(Eds.), Treating Adult and Juvenile Offenders With Special

Needs (pp. 81–96).Washington, DC:American

Psychological Association.

Faiver, K.L. (Ed.) (1998). Health Care Management

Issues in Corrections. Lanham, MD:American Correctional Association.

Hafemeister,T.L. (1998). Legal Aspects of the

Treatment of Offenders with Mental Disorders. In

Wettstein, R.M. (Ed.), Treatment of Offenders with

Mental Disorders (pp. 44–125). New York:The

Guilford Press.

National Institute of Corrections (1999). Supermax

Prisons: Overview and General Considerations.

Washington, DC: U.S. Department of Justice.

43

USE OF SECLUSION, SEGREGATION, AND RESTRAINTS
45

SUICIDE PREVENTION

Chapter 5

Perhaps nothing is more tragic and unsettling for

prison staff and inmates than the suicide of an inmate.This event can shake an institution and leave

doubts, fears, anxiety, recrimination, and anger in the

minds of both staff and inmates for a considerable

length of time. It is important for prison administrators to adopt the most effective standards and procedures to prevent suicides and manage suicidal

inmates. Staff must be equipped to identify inmates

who are at risk so they can intervene and prevent

this tragedy.

Suicide remains a leading cause of death for prison

inmates, ranking third among all deaths that occur in

prisons (Bureau of Justice Statistics, 1993). However,

since the 1960s significant advancements have been

made in the prevention of suicide in U.S. correctional facilities (Lester and Danto, 1993). Prison Suicide:An

Overview and Guide to Prevention (NIC, 1995) contains

the most current data on prison suicide and its prevention, including a report on a 10-year survey of

prison suicides conducted by the National Center

on Institutions and Alternatives (NCIA) from 1984

through 1993. Important findings of this survey

include the following:

• Suicides in prisons occurred at the rate of 21 per

100,000 inmates per year.

• Suicides in the general population occurred at the

rate of 12.2 per 100,000 people per year.

• Suicides in jails occurred at the rate of 107 per

100,000 inmates per year.

• Prison suicide rates gradually and steadily declined

throughout the country from 1985 through 1993.

Hayes (NIC, 1995) reviewed local, state, and federal

studies on prison suicides and found common characteristics among prison inmates who successfully

completed suicides (see “Risk Factors for Prison

Suicides”).

The number of male inmates who successfully complete suicide greatly outnumbers the number of

females who do so. For example, throughout the

Federal Bureau of Prisons system, 43 inmates committed suicide from 1988 to 1992 (White and

Schimmel, 1995).All 43 were male, despite that the

number of females in federal prisons had increased

to more than 7 percent of the total prison population during that period. In jails, male offenders committed 95 percent of suicides (Hayes and Rowan,

1988).

NATIONAL STANDARDS IN

SUICIDE PREVENTION

Because suicide remains a leading cause of death

for prison inmates, suicide prevention is generally

addressed as a separate issue in most national correctional standards.Although prisons are not required by law to follow them, these standards help

institutions minimize their legal liability (NIC, 1995).
American Correctional Association 

The American Correctional Association (ACA) has

developed the most widely recognized suicide prevention standards (Bonner, 2000).These standards

require the following:

• A written policy and procedures to ensure that all

special management inmates are directly observed

at least every 30 minutes.

• More frequent observation for inmates who are

violent or have a mental illness than for inmates

who are not violent and do not have mental

illness.

• Continual observation for actively suicidal

inmates.

• A written suicide prevention and intervention

program approved by a qualified medical or mental health professional.

• Training for all correctional staff in the suicide

prevention and intervention program.

• Intake screening, identification, and supervision of

inmates who may be prone to suicide.

C HAPTER 5

46

National Commission on

Correctional Health Care 

Like ACA, National Commission on Correctional

Health Care (NCCHC) standards (1999) require a

written suicide prevention plan. NCCHC also suggests 11 essential components for such a program:

• Identification. Initial screening should include

observation and interview data related to an

inmate’s potential suicide risk.

• Training. All staff should be trained to recognize

verbal and behavioral cues that indicate suicide

risk.

• Assessment. A qualified mental health professional should designate the inmate’s level of suicide

risk.

• Monitoring. The facility should develop a procedure for monitoring at-risk inmates that includes

regular and documented supervision.

• Housing. Suicidal inmates should not be isolated

unless under constant supervision.When constant

supervision cannot be maintained, the inmate

should be housed with another inmate or in a

dormitory and checked every 10–15 minutes.

• Referral. Procedures should be developed for

referring inmates who are at risk for suicide or

have attempted suicide to mental health staff.

• Communication. Effective communication must

take place between correctional and health staff

about an inmate’s status.

• Intervention. Staff should develop procedures on

how to handle a suicide attempt in progress (e.g.,

first aid measures and how to cut down a hanging

inmate).

• Notification. Procedures for notifying family,

prison administrators, and other outside authorities regarding potential, attempted, or completed

suicides should be developed.

Risk Factors for Prison Suicides

• The presence of significant mental illness.

• A prior history of suicide attempts.

• Having a lengthy sentence (20 years or more).

• Being 31 to 40 years of age (which is older than the

age of most jail inmates who successfully complete

suicides).

• Having institutional problems (e.g., being in protective

custody).

• Being housed in a segregated or isolated housing unit.

• Being male.
• Reporting. Staff should document in detail all

potential, attempted, or completed suicides.

• Review. The facility should perform administrative

and medical reviews of completed suicides.

NCCHC also provides recommendations for the

assessment, housing, and observation of suicidal

inmates through a level system that allows for a

more individualized approach to the problem of suicidal potential and behavior:

• Level 1. Inmates who have recently attempted

suicide should be observed continuously in a safe

and protected room.

• Level 2. Inmates at high risk for suicide based

on current mental status and history should be

placed in a safe and protected room and observed

every 5–10 minutes.

• Level 3. Inmates at moderate risk (e.g., coming off

level 1 or 2) should be observed by staff every 10

minutes when awake and every 30 minutes when

asleep.

• Level 4. Inmates who have a significant risk history and could become severely depressed or suicidal should be observed every 30 minutes when

awake or asleep.

National Center on Institutions and

Alternatives 

NCIA integrated the ACA and NCCHC standards

and generated its list of the most critical features of

any comprehensive suicide prevention program

(NIC, 1995):

• Staff training.

• Intake screening and assessment.

• Housing.

• Levels of supervision.

• Intervention.

• Administrative review.

NCIA assessed how each state department of corrections (DOC) addressed these critical areas and

cited model examples of each.

Staff Training. The need for proper training for all

staff to recognize potential inmate suicides and

respond appropriately is emphasized in the national

standards of both ACA and NCCHC.

The key to any suicide prevention program is properly trained correctional staff, who form the backbone of any prison facility.Very few suicides are

prevented by mental health, medical, or other professional staff because suicides usually are attempted

in inmate housing units during late evenings and on

weekends when inmates are outside the purview of

program staff (NIC, 1995).

NCIA’s analysis cited the Nevada Department of

Corrections as a model organization that meets this

particular standard. Nevada’s policies stipulate both

preservice training for all new employees, which

teaches the identification and referral to mental

health services of suicidal inmates, and an annual

inservice training for current employees provided by

mental health staff on advanced issues in suicide prevention. Nevada’s procedure also specifies that this

advanced training be provided annually for all staff

including custody, program, and medical staff and that

it cover—

• Signs and symptoms of a potentially suicidal

inmate.

• Risk factors in evaluating a potentially suicidal

inmate.

• The management of potentially suicidal inmates.

• The levels of suicide prevention.

• The administrative review of mental health issues.

Intake Screening and Assessment. Both ACA and

NCCHC recommend that all inmates entering a

correctional institution be screened and assessed for

the potential for suicide.

The best assurance against suicide is screening all

new inmates and continually monitoring individuals

47

SUICIDE PREVENTION
found to be at risk throughout the critical first

hours of incarceration (Atlas, 1989).

NCIA highlights the following Connecticut Department of Correction (Connecticut DOC) procedures

for screening and assessment:

• Health services staff screen all inmates for obvious and subtle signs of the potential for suicide

within 24 hours of admission to the facility.

• Any indication of potential suicide results in an

immediate referral to mental health staff, who

administer a suicide intake screening form.

• Mental health staff recommend appropriate followup, including housing and other referrals.

• Guidelines on suicidal risk are provided to staff to

help them identify potentially suicidal inmates.

• All staff are educated to take seriously all suicide

threats or attempts and all reports regarding a

potentially suicidal inmate, even when the information comes from other inmates.

Housing. One of the most important and consistent

findings in suicide prevention research is the strong

correlation between segregation and successful

suicide.

Overwhelmingly consistent research shows that isolation should be avoided whenever possible. NIC has

stated,“Whether its use is disciplinary or observational, isolation can pose a special threat to inmates

who have limited abilities to cope with frustration”

(NIC, 1995, p. 7).

National standards are consistent: potentially suicidal

inmates are to be housed in the general population

or in a mental health or medical unit located close

to staff whenever possible. Housing for potentially

suicidal inmates should be designed to maximize

staff interaction with them, and physical restraints

and removal of their clothing should only be a last

resort when there is imminent danger of selfdestructive behavior. In addition, housing should be

tailored to suit the level of an inmate’s suicide risk.

NCIA cited the Virginia Department of Corrections

C HAPTER 5

48

as meeting this standard because its policy for suicide prevention addresses these issues in an unambiguous manner.

Levels of Supervision. National standards support

two levels of supervision for suicidal inmates: close

observation, for inmates who have expressed suicidal ideation or have had a recent history of selfdestructive behavior, and constant observation, for

inmates who are threatening to or have engaged in

an act of suicide. Inmates under close observation

must be directly observed at least every 15 minutes,

while those under constant observation must be

observed continuously. NCIA cited the Connecticut

DOC’s suicide prevention policy for its specific language on how to implement observation procedures

(see “Connecticut Suicide Prevention Policy on

Observation”).

Intervention. The promptness with which staff respond to a suicide attempt and the actions taken are

critical factors in determining whether the victim

Connecticut Suicide Prevention Policy

on Observation 

Close Observation

• A 15-minute watch is used for inmates who have

expressed suicidal thoughts but who are not actively

suicidal at the present time.

• Officers must physically observe the inmate in staggered intervals at least every 15 minutes.

• An officer should enter the cell if necessary to determine the inmate’s status.A TV monitoring system cannot be used as a substitute but can supplement

observation.

Constant Observation

• Continuous one-to-one observation is used for

inmates threatening or engaging in suicidal behaviors.

• Officers must maintain a clear and unobstructed view

of the inmate at all times.

• The officer must document the suicide watch on an

Observation, Seclusion, and Restraint Checklist Form.

• TV monitors may be used as a supplemental tool but

not a substitute.
will survive. National standards on intervention generally agree that—

• All staff who have contact with inmates should be

trained in CPR and first aid procedures.

• Any staff member who discovers an inmate engaging in a suicide attempt must alert other staff,

who should call for medical personnel and begin

first aid and/or CPR.

• Staff must never presume an inmate is dead and

must initiate and maintain lifesaving procedures

until the arrival of medical staff (NIC, 1995).

The Louisiana Department of Public Safety and

Corrections meets this standard; its procedures stipulate in detail the responsibilities and duties of the

first and second officer on the scene, as well as the

role of the supervisor and medical personnel.The

department’s procedures also state the type of

equipment that must be immediately available to all

officers on duty in the event that they must respond

to a suicidal inmate.

Administrative Review. National guidelines from

ACA and NCCHC recommend that the following

steps be taken after a suicide:

• A critical review of the circumstances surrounding

the event.

• A critical review of the facility’s relevant

procedures.

• A synopsis of the relevant training received by the

staff who were involved.

• A review of the mental health and medical services provided to the victim.

• Recommendations for changes in policy and procedure, staff training, physical plant, and medical

and mental health services as a result of the

incident.

The Pennsylvania Department of Corrections’ policy

on administrative review serves as a model because

it stipulates who will order the review, who will

carry it out, how and why it will be conducted, what

information should be kept confidential, and what

information should be shared with correctional staff

for training purposes.

When an inmate takes his or her own life, the impact on corrections staff and other inmates can be

dramatic (NIC, 1995):

One of the most tragic, debilitating events

that can happen to a prison is an inmate

suicide. It will shake your structure.The initial response is always—“What happened?

Who was making the rounds? Did the inmate need mental health services?” (p. 40)

In the aftermath of a successful suicide, correctional

staff from all departments can be emotionally and

psychologically affected. In addition to experiencing

grief over the loss of the inmate, staff can become

preoccupied with thoughts of what could have been

done to prevent the death and also can become

anxious and fearful regarding the assigning of blame

or responsibility. Inmates may respond with increased anxiety and begin to lose trust in the staff

to keep them safe.When inmates begin to blame

staff and act out their anxiety and anger, management problems can result. Staff debriefing and referrals to mental health counselors for both inmates

and staff should be encouraged to help them cope

with the event.

FEDERAL BUREAU OF

PRISONS FIVE-STEP

PROGRAM FOR SUICIDE

PREVENTION

The Federal Bureau of Prisons (FBOP) has used a

five-step suicide prevention program since 1982,

which includes—

1. The initial screening of all inmates for suicidal

potential.

2. Criteria for the treatment and housing of suicidal

inmates.

49

SUICIDE PREVENTION
3. Standardized recordkeeping, followup procedures,

and collection of data relevant to suicides.

4. Staff training.

5. Periodic reviews and audits.

After the first 10 years of the program, FBOP inmate suicides decreased by 43 percent (White and

Schimmel, 1995).Although a direct causal link between the implementation of the program and the

reduction in suicides cannot be proved, it is logical

to deduce a correlation.The authors believe that the

written policy providing clear guidelines and unambiguous procedures was a key factor in this success.

In addition, the National Institute of Corrections

(1995) supports the FBOP program, stating the

following:

While all aspects of FBOP’s program might

not be applicable in a particular setting, its

basic structure provides the essential components of a responsive, professionally managed suicide prevention program that

merits consideration by other correctional

facilities and systems. (p. 56)

SUICIDAL GESTURES AND

MANIPULATIONS

Prison administrators and correctional staff must

differentiate those inmates who are genuinely distressed to the point where suicide has become a

legitimate option in their minds from inmates who

threaten suicide or make suicidal gestures (e.g.,

superficial cuts to wrists) to effect some change in

their situation. Inmates may make such threats to

receive attention and preferential treatment from

staff, to be transferred to a medical unit or another

prison, to avoid a transfer or court appearance, to

maintain a facade of serious mental illness, and to

gain the sympathy of family.

C HAPTER 5

50

Regardless of the motivation, it is a serious mistake

for prison officials to ignore inmates and their parasuicidal (intentionally self-harmful) behaviors for fear

of reinforcing the manipulation. Further, it is even

more egregious for inmates to be punished and isolated as a consequence. It is common for inmates

who manipulate their situation by these threats or

gestures to escalate their behavior in an attempt to

achieve their goal and, in so doing, to die either accidentally or by miscalculating how the staff will

respond (NIC, 1995).

Some clinicians believe it is meaningless to attempt

to distinguish between manipulative and nonmanipulative suicide attempts (Haycock, 1992). In this view,

there is no reliable basis by which to make this judgment and death can result in either case.Therefore,

all inmates who express suicidal or parasuicidal intention or behavior should be treated according to

the institution’s suicide prevention protocols.

However, other forensic clinicians attempt to make

this distinction and recommend different interventions accordingly (Haycock, 1989). For those inmates

assessed to be genuinely suicidal, close supervision,

social support, and access to psychosocial resources

are recommended (NIC, 1995). For those believed

to be manipulating for secondary gain, interventions

should combine close supervision and behavioral

management techniques to modify the behavior.

In the final analysis, all correctional staff share the

responsibility for preventing inmate suicide. Inmate

suicides are tragic events (Bonner, 2000) in which—

Fundamentally, the suicidal inmate suffers

from a hopeless state of mind whereby

emotional relief, future outcome, and reasons for living do not exist for the individual. (p. 375)

The challenge for correctional administrators is to

provide staff the training and resources that put

them in the best possible situation to help at-risk

and hopeless inmates whenever possible and prevent

this type of tragedy from occurring.
REFERENCES

Atlas, R. (1989). Reducing the Opportunity for Inmate Suicide:A Design Guide. Psychiatric Quarterly,

60 (2), 161–171.

Bonner, R.L. (2000). Correctional Suicide Prevention

in the Year 2000 and Beyond. Suicide and LifeThreatening Behavior, 30 (4), 370–376.

Bureau of Justice Statistics (1993). Correctional

Populations in the United States, 1991. Washington,

DC: U.S. Department of Justice.

Haycock, J. (1989). Manipulation and Suicide

Attempts in Jails and Prisons. Psychiatric Quarterly, 60

(1), 85–98.

——— (1992). Listening to “Attention Seekers”:The

Clinical Management of People Threatening Suicide.

Jail Suicide Update, 4 (4), 8–11.

Hayes, L.M., and Rowan, J.R. (1988). National Study of

Jail Suicides: Seven Years Later. Alexandria,VA: National

Center on Institutions and Alternatives. Sponsored

by National Institute of Corrections, U.S.

Department of Justice.

Lester, D., and Danto, B.L. (1993). Suicide Behind Bars:

Prediction and Prevention. Philadelphia, PA: Charles

Press.

National Commission on Correctional Health Care

(1999). Standards and Guidelines for Delivering Services.

Chicago: National Commission on Correctional

Health Care.

National Institute of Corrections (1995). Prison

Suicide:An Overview and Guide to Prevention. Washington, DC: U.S. Department of Justice.

White,T., and Schimmel, D. (1995). Suicide Prevention in Federal Prisons:A Successful Five Step Program. In Hayes, L.M. (Project Director), Prison Suicide:

An Overview and Guide to Prevention. Mansfield, MA:

National Center for Institution and Alternatives.

51

SUICIDE PREVENTION
The characteristics of women offenders differ from

those of men.The increase in the number of women

in the justice system ought to bring with it more

attention to their unique needs.Yet, there has been

little movement to redesign services to be gender

specific.This chapter highlights the unique needs of

women inmates and describes several promising

practices to meet them.

The number of women in prison is on the rise;

some research indicates that, between the years

1984 and 1999, their numbers increased by 273 percent (Gilliard and Beck, 1996).Women offenders are

a diverse group. Many of them are ethnic minorities,

have had significant academic or educational difficulties, are survivors of child maltreatment or domestic

violence, and have histories of substance abuse. In

addition, many suffer from a sexually transmitted

disease or other chronic health condition. Many

women’s involvement in the justice system exacerbates the difficulties they face due to their traumatic

histories.The often punitive culture within the justice system may trigger a reliving of past traumatic

events, which may cause them to present with symptoms associated with posttraumatic stress disorder.

According to the Bureau of Justice Statistics

(Greenfield and Snell, 1999) women in prison tend

to be unemployed at the time of arrest; high school

graduates, recipients of a GED, or enrolled in college; and never married. More than 46 percent are

African-American, 36 percent are white, and 14 percent are Hispanic. More than 75 percent of women

have minor children, and 6 percent are pregnant

53

when they enter prison and in almost all cases are

abruptly separated from their children after giving

birth. Black and white offenders accounted for nearly equal proportions of women committing robbery,

aggravated robbery, and aggravated assault.

Women inmates represent about 10 percent of the

total criminal justice population and have higher

rates of mental illness than men (Gilliard and Beck,

1996).Women involved in the criminal justice system

are more likely than men to enter because of drugrelated charges.According to the Bureau of Justice

Statistics, almost half of the women in prison reported committing their offense under the influence of

drugs or alcohol.

SUBSTANCE-ABUSING

WOMEN OFFENDERS

Substance abuse offenses are increasing at greater

rates for women than for men within the correctional population.The ethnicity of women who are

involved in the criminal justice system and who have

histories of substance abuse is significant. For example, 60 percent of substance-abusing women in California state prisons in 1994 were women of color,

including 31 percent African American, 25 percent

Latina, and 3 percent Native American. Health risks

are very high for women offenders, regardless of

ethnicity (Taylor, 1996). In addition, women offenders

with histories of drug addiction reportedly have low

self-esteem and are isolated, anxious, depressed, and

cut off from their feelings.

Chapter 6

TREATING WOMEN OFFENDERS
Treatment implications for women offenders who

are substance abusers include the following:

• Women who are substance abusers have specific

medical, vocational, psychosocial, educational,

transportation, and childcare needs.

• Women who are substance abusers have experienced female gender socialization, which limits

their skills in identifying and asserting their personal needs. Many women come from families

with a high incidence of mental illness, suicide,

substance abuse, and violence. Others are victims

of incest, rape, and physical abuse.

• Many women who are substance abusers suffer

from low self-esteem, depression, anxiety, isolation, and detachment, which suggests that interventions should be designed to build on women’s

strengths.

WOMEN OFFENDERS WITH

HISTORIES OF VICTIMIZATION

On average, half of women in prison report histories

of physical or sexual abuse at some point in their

lives (Greenfield and Snell, 1999). Seventy-three percent of those who reported having an emotional

condition had been sexually or physically abused.

Women who have been abused may have difficulty

dealing with restraints, seclusion, and searches, which

they may perceive as dangerous or threatening and

which may result in retraumatization.

Many women offenders are passive, dependent, and

subservient to men.They feel powerless, rarely

assume responsibility for their lives, and frequently

come under the control of men, usually other

offenders. Many report physical battery and psychological abuse by husbands and partners. Dependency,

low self-esteem, high levels of anxiety, limited interpersonal and resource networks, and difficulty negotiating with others are consistently reported to be

more common in drug-dependent women than in

men with similar drug problems (Taylor, 1996).

C HAPTER 6

54

Many women with histories of trauma have been

diagnosed with co-occurring mental health and substance abuse disorders.Treatment methodologies

must focus on both the residual effects of the trauma and the women’s subsequent mental health and

substance abuse issues.This integration of approaches will enable a path to health and recovery.

INCARCERATED WOMEN AND

THEIR CHILDREN

The majority of women in prisons are mothers.The

Bureau of Justice Statistics (Greenfield and Snell,

1999) reported that more than 75 percent of

women in prisons had children under the age of 18.

African American and Latina women were more likely than white women to have children under age 18.

The majority of women under correctional supervision have minor children; two-thirds of women in

state prison and one-half of those in federal prison

had children in their care prior to their incarceration

(Greenfield and Snell, 1999).

More than 1.3 million minor children are offspring of

women under correctional sanction, and more than

250,000 of these children have mothers who are

serving time in prison or jail (Greenfield and Snell,

1999).Women bear more physical, financial, and

emotional responsibility for their children than do

men and, as a result, separation from children during

incarceration is particularly traumatic. Contact with

children and families is sporadic. Institutional visits

are few, and children often are afraid to go to prison

to visit their mothers.The predominant form of

communication between mothers and their children,

when it occurs, is by telephone.

Due to the limited number of gender-specific correctional facilities, women are ordinarily much farther away from home and family than the average

male prisoner.This increased distance causes substantial transportation problems for children of prisoners and as a result deprives women prisoners of

contact with their children.
Acknowledging Women’s Roles as

Parents 

Treatment provided to mothers with co-occurring

disorders and histories of violence should acknowledge their roles as parents and incorporate maternal

themes within individual and group therapies.

Opportunities should be provided for regular, ongoing contact between mothers and their children.

Strengthening Parenting Skills 

Education and parental support can improve a mother’s parenting skills. During incarceration, correctional systems should provide ongoing parenting skills

education and training to mothers to prepare them

for family reunification after their release.

Parenting education, according to the SAMHSA

study, should consider the following issues:

• Mothers may have inappropriate expectations for

their children’s behavior.They can improve their

parenting skills by becoming aware of their children’s developmental issues.

• Mothers may have lapses in empathy for children

because they are absorbed with pressures in their

own lives.When they are supported, mothers are

able to better pay attention to their children’s

needs.

• Mothers may “reverse roles,” causing them to

look at their children for fulfillment of their own

needs. Developing satisfying relationships with

other adults may ease a mother’s need to turn to

her children for emotional sustenance.

• Some mothers use corporal punishment because

they are not aware of alternatives. Providing them

with other strategies increases their ability to

manage their children’s behavior.

SAMHSA also recommends that attention should be

paid to mothers’ struggles with issues of shame and

guilt, which can exacerbate their mental health

problems.

PROMISING PRACTICES FOR

WOMEN OFFENDERS

Due to the prevalence of co-occurring substance

abuse and mental health disorders among women

victims of violence, the federal Substance Abuse and

Mental Health Services Administration (SAMHSA)

conducted the Women, Co-Occurring Disorders and

Violence Study in partnership with its Center for

Mental Health Services, Center for Substance Abuse

Treatment, and Center for Substance Abuse Prevention.The study’s goal was to identify promising practices for the treatment of women with co-occurring

disorders who also have histories of violence.Although the study did not address treatment during

incarceration, the attributes of successful treatments

that address the specific needs of women with both

co-occurring disorders and histories of violence can

and should be applied to all systems that provide

intervention to women, including the justice system.

The SAMHSA study reported that treatment for

women with co-occurring conditions and histories

of violence works best when it contains the following four components:

• Focus on each individual woman’s strengths.

• Acknowledge a woman’s role as a parent.

• Improve interactions between the parent and

child.

• Use a comprehensive approach to coordinate

specific types of treatment for the mother and

her children.

Focusing on Strengths 

A woman with co-occurring disorders and a history

of victimization has within her certain strengths that

should be acknowledged and addressed during treatment: devotion to her children and strong motivation to protect them; compassion and empathy

toward children vulnerable to loss, grief, and pain;

and enormous courage and perseverance.

55

TREATING WOMEN OFFENDERS
REFERENCES

Browne,A.B., Miller, B., and Maguin, E. (1999). Prevalence and Severity of Lifetime Physical and Sexual

Victimization Among Incarcerated Women. International Journal of Law and Psychiatry, 22, 301–322.

Gilliard, D.K., and Beck,A.J. (1996). Prison and Jail

Inmates, 1995. Bureau of Justice Statistics Bulletin.

Washington, DC: U.S. Department of Justice, Bureau

of Justice Statistics.August. NCJ 161132.

Greenfield, L.A., and Snell,T.L. (1999). Women

Offenders. Bureau of Justice Statistics Special Report.

Washington, DC: U.S. Department of Justice, Bureau

of Justice Statistics. December. NCJ 175688.

Taylor, S.D. (1996).Women Offenders and Reeentry

Issues. Journal of Psychoactive Drugs, 28 (1), 85–93.

C HAPTER 6

56

Using a Comprehensive Treatment

Approach 

The SAMHSA study recommends that the following

should be considered to provide women with cooccurring disorders and histories of violence the

treatment that addresses their unique needs:

• Issues of trauma, mental illness, and substance

abuse should be interwoven to better integrate

treatment.

• Treatment should be tailored to the developmental needs of each woman and the age of her

children.

• Issues relating to historical involvement with

other systems should be addressed; for example,

custody, previous mental health and substance

abuse treatment, and primary health history.

The overarching justification for integrating issues of

parenting, mental illness, trauma, substance abuse,

and violence into treatment is to improve outcomes

for incarcerated women and their children. It is

assumed that when mothers’ needs are addressed,

their children, consequently, will be affected. If the

issues of substance abuse, mental illness, cooccurring disorders, trauma and violence, and 

maternal-child relationships are addressed during

incarceration, there may be increased opportunities

for women to be successfully integrated into their

communities and reunited with their families.
57

PSYCHOPHARMACOLOGICAL

INTERVENTION FOR PSYCHIATRIC

DISORDERS

Chapter 7

Numerous medications were discovered in the second half of the 20th century that can diminish the

symptoms experienced due to major mental illness.

In the 1950s, drugs were accidentally discovered

to be effective; today, drugs are “designed” by

altering their chemical structures to produce newgeneration medications that are more effective and

have fewer side effects.

The use of medication to ameliorate symptoms of

mental illness is an essential component of prison-

(and community-) based mental health treatment.

Their use in prison must be closely monitored because inmates have been reported to be overmedicated in some cases as a management strategy.

Some inmates may seek out medication in the belief

that it will give them a “high.” Although some psychotropic medications do result in mood changes

or elevations, the vast majority offer no such experience. Folklore about their effects persist, however,

and can lead to bartering and hoarding of certain

medications by inmates. Close monitoring is essential in any case.

Although psychotropic medications are important

in the treatment of severe and persistent mental

illness, comprehensive mental health treatment involves additional components.These other interventions may vary depending on the inmate’s diagnostic

presentation, but they typically include individual or

group psychotherapy that focuses on acquiring psychosocial and daily living skills (see chapter 3,

“Mental Health and Substance Abuse Treatment”).

CANDIDATES FOR

PSYCHOPHARMACOLOGICAL

INTERVENTION

In the prison population, persons with severe and

persistent mental health disorders are often treated

with psychotropic medications. Medications may also

be used to treat a range of less severe mental health

disorders or to reduce cravings associated with

addictions. Medications help inmates stay calm, feel

less angry or anxious, sleep better, and manage

stress.

MAJOR CATEGORIES OF

PSYCHOTROPIC DRUGS

Pharmacotherapies that act similarly are grouped

into the following broad categories:

• Antidepressant agents should be used to treat

severe forms of major depression and bipolar

(depression + mania) disorder. Drugs in this category include tricyclic and selective serotonin

reuptake inhibitors (SSRIs).

• Antipsychotic agents are used most commonly

to treat forms of schizophrenia. Some of the

newer generation medications are called atypical

antipsychotics.

• Antianxiety agents are used in instances of significant presentation of anxiety symptoms that affect

functionality. Some drugs in this category are not
allowed in correctional settings due to their

potential for abuse.

• Mood stabilizers, or antimanic agents, can act to

modulate symptoms of mania and aggressive impulses in patients with other disorders. Drugs in

this category include valproic acid and divalproex

sodium.

If all individuals diagnosed with a severe and persistent mental health disorder were on medication, no

more than 15 percent of the total census of a prison

would be prescribed medications from the categories described above. If rates of prescription exceed 25 percent of the total institutional population,

it is likely that medication is being used for management or in response to inmate requests—not for

symptoms that indicate a diagnosable mental illness

(Maier and Fulton, 1998).

EFFECTIVENESS OF

MEDICATIONS

A number of studies have shown the benefits of

using psychotropic medications, particularly the

newer ones, in correctional settings.

Clozapine, resperidone, and olanzapine, called atypical antipsychotic agents, are effective in forensic

populations (Maier, 1992).An increasing body of evidence has found them to be “more efficacious in

treating schizophrenic pathology than typical antipsychotics” (Baillargeon and Contreras, 2001: 51).

Quetiapine (brand name Seroquel) is likewise receiving increased attention in correctional settings for

the management of psychotic symptoms.Atypical

antipsychotic medications typically are well tolerated

and safer to use than some of the older medications.

Other studies done with corrections populations

around the use of atypical antipsychotic medications

have found the following:

• The noncompliance rate for inmates taking typical

antipsychotics can be nearly double that for atypical antipsychotics (Roskes, 2000).

C HAPTER 7

58

• Atypical antipsychotics are more cost effective or

cost neutral than typical neuroleptics (Roskes,

2000).

• Atypicals carry a greatly diminished risk for movement disorders, thus lessening the need for sideeffect medications, which have abuse potential in

correctional settings (Burns, 2000).

• Atypicals have demonstrated their efficacy in

decreasing hostility and aggression, which leads

to a decreased use of seclusion and physical

restraints, less expressed hostility and aggression,

decreased inmate-on-inmate assaults and potential

injuries, and improved ability to manage inmates

(Burns, 2000).

• Clozapine, in particular, has been shown to reduce

the risk of suicide in patients with schizophrenia

(Burns, 2000).

A number of studies have shown the following benefits of using the newer antidepressants over older

medications:

• Fewer and less severe side effects.

• Fewer deaths, especially suicide, associated with

overdoses.

• Enhanced inmate compliance with taking medication, which leads to greater treatment success.

• Less potential to be valued by inmates as drugs of

abuse (Metzner, 1999).

Some correctional mental health care systems

restrict newer antidepressant medications and atypical antipsychotics from prison formularies for cost

reasons, but this activity is often self-defeating. Many

inmates find the side effects of older antidepressants

so unpleasant that they discontinue taking the medications.This often leads to increased suffering and

increased use of more expensive services, such as

inpatient hospitalization or infirmary services. Because of the increased risk of suicide or lethality

from overdose when using older antidepressants

exclusively as frontline treatment, prisons risk

increased liability when they try to save money by
offering cheaper but less effective medications.

Finally, newer antidepressants and antipsychotics

have become the accepted standard of care for civilian populations. Medications offered in correctional

settings should be consistent with those available in

the community.

RISKS OF MEDICATION USE

All medications, no matter how safe, carry the

potential for side effects (see “Typical Side Effects of

Psychotropic Medications”).This is, in part, why the

American Psychiatric Association (APA) recommends that psychiatrists have the ability to prescribe

all psychotropic medications.APA also recommends

that medications be distributed by qualified medical

personnel and that 24-hour nursing coverage be

available wherever persons with acute psychiatric

problems are held.

must be done with each individual to determine

whether to continue the drug or try another. Many

persons with psychiatric disorders discontinue or

refuse to take medications when they experience

unpleasant side effects.

Some psychotropic medications are not well suited

for correctional settings because they require more

comprehensive medical monitoring.The following

drugs can be prescribed only when laboratory facilities are available to regularly assess blood levels and

possible side effects:

• Lithium carbonate.

• Clozapine.

• Medroxyprogesterone.

• Anticonvulsants.

In addition, adjustments and refinements to medication protocols can take 6 months or more with

close monitoring of symptom changes. In inmate

populations living in stressful circumstances, it may

take even longer to bring symptoms under control.

Prison authorities must address and accommodate

issues of movement within the institution, access to

medical staff, and the requirements of dosing schedules. Inadequate access to medical supervision while

on medication can lead to inmates experiencing

unpleasant or even dangerous side effects.

Inmates taking antipsychotic medications can experience difficulties with regulating their body temperature during hot weather.Those taking low-potency

medications, such as clozapine or chlorpromazine,

are much more likely to suffer from heatstroke;

death can occur in otherwise healthy young men.

Inmates taking these medications should have access

to plenty of fluids and air-conditioned spaces during

periods of hot weather (Diamond, 1998).

The use of certain medications in correctional settings should be limited due to their potential for

abuse, which can include— 

• The misuse of these medications by inmates with

substance use disorders.

59

PSYCHOPHARMACOLOGICAL INTERVENTION FOR PSYCHIATRIC DISORDERS

Typical Side Effects of Psychotropic

Medications

• Akasthesia: feeling restless, jittery, fidgety.

• Akinesia: feeling slowed-down, having no “mental

energy.” 

• Anticholinergic effects: dry mouth, blurry vision, trouble urinating, constipation, memory difficulties, confusion, hallucinations.

• Tardive dyskinesia: writhing movements of the hands,

mouth, tongue.

• Sexual/menstrual effects: loss of drive, cessation of

menses.

• Tremors: typically in the hands.

• Weight gain.

Source: Diamond, 1998.

Because most people taking these medications report some side effects, their use must be closely

monitored. In some instances, additional medications

are prescribed to reduce side effects.A cost-benefit

analysis that measures the degree to which side

effects are bothersome versus the drug’s benefit
• Overuse to induce sleep.

• Bartering or selling for their effect on mood or

cognition (perception of a “high”).

• Their potential for lethal use by persons who may

be suicidal.

Drugs with a potential for abuse include all

sedatives–hypnotics, benzodiazepines, and stimulant

drugs.

PRESCRIPTION AND DELIVERY

OF MEDICATIONS TO INMATES

The use of medications in a correctional facility

should be consistent with use in the community; that

is— 

• Their prescription should occur only in the context of an adequate psychiatric evaluation.

• They should be dispensed by licensed health care

professionals, not officers or inmates.

• Their inappropriate use includes excessive dosing

or polypharmacy with the goal of inmate behavior

control or population management.

As inmates near release, some institutions use selfmedication programs, sometimes called keep-onperson strategies, which allow inmates to take

personal responsibility for their medication and dosing schedule. Procedures and allowable medications

vary by institution and are typically established collaboratively by the administration and psychiatric

medical staff.

NCCHC prison standards (1997) outline recommendations for the storage and distribution of pharmaceuticals.These include— 

• Maximum security storage for DEA-controlled

substances, syringes, and other items that have

potential for abuse.

• Maintaining control of medications under appropriate staff members and in a clean, safe, and dry

environment.

C HAPTER 7

60

• A review of storage and dosing methods by a

pharmacist at least quarterly if no pharmacist is

onsite.

• The use of medications only when clinically indicated and not for disciplinary reasons.

For cost-control purposes, some institutions use a

sealed, prepackaged unit dosing schedule in which

unused medications can be returned to the pharmacy if a prescription is changed or the inmate is released. In general, oversight of who is prescribing,

delivering, storing, and accessing psychotropic medications is essential. Prison psychiatrists must have

a manageable caseload to be able to appropriately

oversee inmates’ use of and response to medications.Although it is difficult to make recommendations about caseload issues in many areas of mental

health treatment,“something of a consensus has

been reached” with regard to caseloads for psychiatrists serving persons on psychotropic medications

(APA, 2000): In prisons, one full-time psychiatrist

should not serve more than 150 patients on psychotropic medications.

ISSUES IN

ETHNOPHARMACOLOGY

Recent years have witnessed an increased focus on

how ethnic and cultural influences can alter an individual’s response to medication. Differences can

arise from genetic, psychosocial, or environmental

causes.Variations in response to medications have

been attributed to these ethnic and cultural factors:

• Dietary differences.

• Metabolic rates.

• Adherence to medication regimens.

• The simultaneous use of alternative and traditional healing practices with pharmacological therapy.

Most of the ethnic variation in drug metabolism is

related to the reduced activity of drug-metabolizing

enzymes, which can result in higher amounts of

medication in the blood and increased side effects
(U.S. Department of Health and Human Services,

2001).A recent study by Ruiz et al. (1999) concluded that Hispanic patients need lower doses of

neuroleptic medications than African Americans and

whites to treat their schizophrenia.

Help-seeking behavior and responsiveness to treatment can be influenced by cultural factors. Language

issues can also influence compliance with dosing

strategies. In addition, persons affiliated with certain

ethnic groups may use alternative herbal remedies,

which can interact with prescribed medications.

More research is needed to identify these issues and

offer comprehensive guidelines for those prescribing

across a range of ethnic groups.

BIAS IN PRESCRIBING

PRACTICES

Some studies have revealed that minority inmates

are less likely to receive mental health treatment

than are white inmates (Steadman, Holohean, and

Dvoskin, 1991). In their study examining prescribing

practices related to antipsychotic medications in the

Texas prison system, Baillargeon and Contreras

(2001) found that “blacks were prescribed atypical

antipsychotic agents less frequently than whites or

Hispanics” (p. 52).This is of particular concern, as

Trestman (2001) notes, because— 

• Minorities are disproportionately incarcerated,

and a disproportion of those are African

American.

• African Americans are more susceptible to the

development of tardive dyskinesia or dystonia

than are diagnostically similar members of other

ethnic groups.

It is unclear, based on the data from Baillargeon and

Contreras’ (2001) investigation, whether the apparent racial bias that exists in their sample reflects an

“ongoing bias that may exist in the community regarding diagnosis and/or treatment” (Trestman, 2001,

p. 55).

The use of prescribing guidelines or decision algorithms may help to reduce biases in practice.To the

extent that the use of these algorithms standardizes

practice, they are likely to improve decisionmaking

(Trestman, 2001).

LIABILITY ISSUES IN THE

PRESCRIBING AND

DISPENSING OF MEDICATION

A comprehensive review by Vaughn (1997) assesses

the potential for civil liability against prison officials

under Title 42 of the United States Code, section

1983, for failure to provide appropriate medication.

The article reviews the financial costs associated

with supplying medications to inmates and the simultaneous pressure that administrators face to reduce

costs and it concludes that— 

[P]rison administrators who attempt to

reduce health care expenditures by supplying inmates with inefficacious medication

ultimately may cost their jurisdictions more

money in legal fees and civil litigation than

in medication if their cost-cutting attempts

amount to deliberate indifference to the

serious medical needs of inmates. (p. 318) 

In his review,Vaughn points out that civil liability can

be incurred when— 

• Prison officials fail to follow standard medical

procedures.

• Prison officials declare that budget issues have

prevented them from efficacious and more expensive medications.

• Contraindicated medications are supplied.

• Medications are not delivered in a timely fashion.

• Medications are prescribed or withheld for nonmedical reasons.

• Medications are prescribed to control or punish

inmates.

61

PSYCHOPHARMACOLOGICAL INTERVENTION FOR PSYCHIATRIC DISORDERS
Case law demonstrates support of prison administrators in disagreements about the type, dosage, or

strength of medications prescribed (Vaughn, 1997).

RIGHT TO REFUSE

MEDICATION

Prisoners have a right to refuse treatment, including

medication, and do so for many of the same reasons

that patients in community settings or hospitals do;

they— 

• Do not like the medication’s side effects.

• Do not believe the medication is effective for

their symptoms.

• Do not believe they are ill.

• Try to gain leverage over staff to bargain over

unrelated issues.

• Are confused about giving consent for treatment.

• Wish to assert their legal rights.

The relationship the physician has with the offenderpatient likely sets the tone for the patient’s acceptance of medication recommendations. Physicians

should try to get the informed consent of the inmate to the treatment after the inmate has received

information about its nature, consequences, and

risks. NCCHC (1999) recommends that signed

consent be obtained when there is some risk to

a patient associated with the treatment.

Many courts have considered the right to refuse

treatment.When asked to rule on requiring medication,“judges rule for medication in almost 100% of

cases” (Wettstein, 1998, p. 146).

Most clinicians favor the review of all treatment

decisions by an independent clinical review board

for inmates that accept or refuse treatment.This

increases clinical safeguards and decreases malpractice liability exposure (Wettstein, 1998).

C HAPTER 7

62

INVOLUNTARY MEDICATION

OF INMATES

Forced medication of adult inmates is allowed under

NCCHC standards in an emergency situation that

contains an imminent threat to the inmate or others

and when other interventions have been attempted.

To act in an emergency situation, policies and procedures must be in place that specify the following:

• The requirement of authorization by a physician.

• The anticipated duration of the regimen.

• Where, when, and how the procedures may be

used.

• A description of when less restrictive alternatives

may be initiated (NCCHC, 1997).

In nonemergency situations, case law has been less

clear about the individual’s right to refuse treatment,

especially psychopharmacological intervention. In

Vitek v. Jones (1980), the U.S. Supreme Court ruled

that prisoners are entitled to procedural protection

if they refuse a treatment recommendation. In this

case, the Court concluded that the inmate should

have received prior written notification that a transfer was being considered, been given time and help

to prepare for a hearing, and been afforded the

opportunity to cross-examine those testifying

against him.The Court also concluded that the decision should have been made by an independent

decisionmaker. In Washington v. Harper (1990), the

Supreme Court overturned a state opinion that

prisoners should have a right to a judicial hearing

when involuntary medication is involved. In this decision, the Court did not want to question the skill

or ethics of those prescribing the medication but

rather weighed in to protect the state’s interests

regarding protecting the institution’s officers, other

staff, and other prisoners. Here the Court allowed

that the medication could be forcibly administered

“if the inmate is dangerous to himself or others and

. . . it is in the inmate’s medical interest” (Haney and

Specter, 2001, p. 60).
THE ROLE OF

PHARMACOTHERAPY IN

REDUCING SUICIDE RISK

Most disorders or circumstances that increase suicide risk are common in incarcerated populations

(e.g., substance dependence along with a history of

impulsivity or violence; current life stress that may

overwhelm an at-risk person) (Ivanoff and Hayes,

2001). Individuals with mental illness also can

demonstrate suicidal thoughts, impulses, and, sometimes, overt behaviors. No studies have verified the

efficacy of psychosocial or psychopharmacological

treatments to reduce suicidal behavior in jail or

prison populations.Although depression and substance abuse can be associated with suicidal behavior, other conditions can be associated with

increased risk, including— 

• Acute agitation or anxiety.

• The experience of command hallucinations.

• Unmanageable psychotic or manic episodes.

• Paranoid delusions (Silverman et al., 1998).

Some studies have found medication to be successful

in reducing impulsivity and, therefore, apparently reducing acts of self-harm.The medications used in

these investigations have included carbamazepine,

lithium, and propranolol (Conacher, 1997).

THE ROLE OF

PHARMACOTHERAPY IN

ADDRESSING VIOLENT OR

AGGRESSIVE BEHAVIOR

No psychopharmacological intervention has been

developed specifically for the treatment of violence

or violent impulses. Some researchers believe that

the majority of violent offenders would neither “require nor benefit from” medication for their violent

impulses (Serin and Preston, 2001, p. 256). However,

the following medications have shown some beneficial effects:

• Antidepressants have been used with some success in modulating violence in the context of such

mental illnesses as depression, dementia, schizophrenia, and personality disorders.

• Lithium may have similar effects in similar populations but may increase aggression in persons with

temporal lobe epilepsy and other organic mental

disorders.

• The sedating effects of antipsychotic agents can

reduce violence associated with delusions or hallucinations but should not be used for long-term

management of aggression.They also can lower

seizure threshold.

• Antianxiety agents are often used to manage agitation or violent behavior that is associated with

alcohol withdrawal, acute psychosis, mania, or

episodic temper outbursts.They are not considered to be useful long term because confusion,

memory problems, depression, and dependency

on the substance can result.

• Antihypertensive agents (typically beta blockers)

may reduce aggressiveness in children and adolescents with explosive disorders as well as adults

with a range of organic brain syndromes.

• New-generation antipsychotic agents (e.g.,

clozapine, risperidone, olanzapine, sertindole,

and quetiapine) may reduce aggression and

violence in persons with psychosis (Salekin

and Rogers, 2001).

CONTINUITY OF MEDICATION

As with all forms of intervention for health disorders, psychopharmacological interventions should

be administered as they were when the person was

receiving care in the community, if that precedent

exists.The NCCHC position paper on continuity of

care (1999) states that inmate health care should be

considered part of the health care continuum that

extends before, during, and after a person’s period

of incarceration—both for the individual’s protection

and that of the community as a whole. Inmates who

63

PSYCHOPHARMACOLOGICAL INTERVENTION FOR PSYCHIATRIC DISORDERS
require continued health care should have a prerelease plan developed and an appropriate health care

provider identified prior to their release. Institutions

vary widely on practices regarding continuity of

medication from the institution to the community,

providing 3 to 30 days of medication to inmates at

the time of their release. No formal policy exists in

the national standards with regard to a recommended or required strategy. Issues regarding the continuity of care are discussed in other chapters.

REFERENCES

American Psychiatric Association (2000). Psychiatric

Services in Jails and Prisons, Second Edition.Washington, DC:American Psychiatric Press.

Baillargeon, J., and Contreras, S.A. (2001).Antipsychotic Prescribing Patterns in the Texas Prison

System. The Journal of the American Academy of

Psychiatry and the Law, 29, 48–53.

Burns, K.A. (2000). Use of Atypical Antipsychotic

Medications in Correctional Settings. Correctional

Mental Health Report, 2 (1), 1.

Conacher, G.N. (1997). Pharmacological Approaches

to Impulsive and Aggressive Behavior. In Webster,

C.D., and Jackson, M.A. (Eds.), Impulsivity:Theory,

Assessment, and Treatment (pp. 394–408). New York:

The Guilford Press.

Diamond, R. (1998). Instant Psychopharmacology:A

Guide for the Nonmedical Mental Health Professional.

New York: W.W. Norton & Co.

Haney, C., and Specter, D. (2001).Treatment Rights

in Uncertain Times. In Alford, J.B., Sales, B.D.,

and Reid,W.H. (Eds.), Treating Adult and Juvenile

Offenders with Special Needs. Washington, DC:

American Psychological Association.

C HAPTER 7

64

Ivanoff,A., and Hayes, L. (2001). Preventing, Managing,

and Treating Suicidal Actions in High-Risk Offenders.

In Alford, J.B., Sales, B.D., and Reid,W.H. (Eds.),

Treating Adult and Juvenile Offenders with Special

Needs. Washington, DC:American Psychological

Association.

Maier, G.J. (1992).The Impact of Clozapine on 25

Forensic Patients. Bulletin of the American Academy of

Psychiatry and the Law, 20, 297–307.

Maier, G.J., and Fulton, L. (1998). Inpatient Treatment

of Offenders with Mental Disorders. In Wettstein, E.

(Ed.), Treatment of Offenders with Mental Disorders.

New York:The Guilford Press.

Metzner, J.L. (1999). Judging the Cost-Effectiveness of

Atypical Antidepressants: Price Is Only One Factor.

Correctional Mental Health Report, 1 (2), 1.

National Commission on Correctional Health

Care (1997). Standards for Health Services in Prisons.

Chicago: National Commission on Correctional

Health Care.

——— (1999). Correctional Mental Health Care:

Standards and Guidelines for Delivering Services.

Chicago: National Commission on Correctional

Health Care.

Roskes, E. (2000).Treatment Compliance with

Atypical Psychotropic Medications. Correctional

Mental Health Report, 2 (1), 1.

Ruiz, P.,Varner, R.V., Small, D.R., and Johnson, B.A.

(1999). Ethnic Differences in the Neuroleptic Treatment of Schizophrenia. Psychiatric Quarterly, 70,

163–172.

Salekin, R., and Rogers, R. (2001).Treating Patients

Found Not Guilty by Reason of Insanity. In Alford,

J.B., Sales, B.D., and Reid,W.H. (Eds.), Treating Adult

and Juvenile Offenders with Special Needs. Washington,

DC:American Psychological Association.
Serin, R., and Preston, D. (2001). Managing and

Treating Violent Offenders. In Alford, J.B., Sales, B.D.,

and Reid,W.H. (Eds.), Treating Adult and Juvenile

Offenders with Special Needs. Washington, DC:

American Psychological Association.

Silverman, M., Bongar, B., Berman,A., Maris, R., Harris,

E., and Packman,W. (1998). Inpatient Standards of

Care and the Suicidal Patient: Part II.An Integration

with Clinical Risk Management. In Bongar, B.,

Berman,A., Maris, R., Harris, E., and Packman,W.

(Eds.), Risk Management with Suicidal Patients (pp.

83–109). New York:The Guilford Press.

Steadman, H.J., Holohean, E.J., and Dvoskin, J. (1991).

Estimating Mental Health Needs and Service Utilization among Prison Inmates. Bulletin of the American

Academy of Psychiatry and the Law, 19, 297–307.

Trestman, R.L. (2001). Commentary:Antipsychotic

Prescribing Practices in the Texas Prison System. The

Journal of the American Academy of Psychiatry and the

Law, 29, 54–57.

U.S. Department of Health and Human Services

(2001). Mental Health: Culture, Race, and Ethnicity—A

Supplement to Mental Health:A Report of the Surgeon

General. Rockville, MD: U.S. Department of Health

and Human Services, Substance Abuse and Mental

Health Services Administration, Center for Mental

Health Services.

Vaughn, M.S. (1997). Civil Liability Against Prison

Officials for Prescribing and Dispensing Medication

and Drugs to Prison Inmates. The Journal of Legal

Medicine, 18, 315–344.

Vitek v. Jones (1980). 445 U.S. 480.

Washington v. Harper (1990). 494 U.S. 210.

Wettstein, R.M. (Ed.) (1998). Treatment of Offenders

with Mental Disorders. New York:The Guilford Press.

65

PSYCHOPHARMACOLOGICAL INTERVENTION FOR PSYCHIATRIC DISORDERS
67

TRANSITIONAL SERVICES

Chapter 8

On any given day, many individuals transition into

and out of U.S. jails and prisons.They may be

transferred— 

• From a jail to a prison.

• From a jail to a reception center to a prison.

• From one prison to another prison.

• From one unit to another unit within a prison.

• From a prison to a community hospital.

• From a prison to the community.

For inmates with mental illness, these transitions

can be very stressful and, without good planning,

can lead to exacerbation of their symptoms.

Most of the discussion in this area has focused on

the needs of offenders who leave prison and return

to the community—and yet, in most places, this

transition does not go as well as it could.The reasons for this are multifaceted.The remote location

of many prisons, the paucity of affordable housing

and other services in local communities, procedural

barriers to applying for assistance, and the lack of

integration between prisons and parole systems all

frustrate efforts to ensure a meaningful and seamless

transition for inmates with mental health and substance use problems (McVey, 2001).

Transition from one prison unit to another or from

one prison facility to another is likewise stressful for

inmates and needs careful planning to be done well

and avoid discontinuity.

ASSESSMENT OF TREATMENT

NEEDS

Inmates being moved from one institution to another should have a health screening to determine if

they pose a health or safety threat to themselves

or others.According to National Commission on

Correctional Health Care (NCCHC) prison standards, all inmates who are transferred within the

system, return from furlough, or have an “established health record for their current incarceration”

(NCCHC, 1999, p. 58) should be evaluated by a

qualified health care professional within 12 hours of

their arrival to ensure continuity of care. Further,

signs in the intake area should instruct inmates on

how to access care for their immediate health

needs.The screening should determine at a minimum whether the offender— 

• Is on medications.

• Is being treated for a medical or dental problem.

• Has any medical or dental complaints.

The screening also provides the opportunity to

assess the individual’s general appearance and behavior and determine whether he or she has any physical deformities or displays evidence of abuse or

trauma (ACA, 2001).The NCCHC standards (1999)

also state that allergies, current treatment plans,

pending appointments for diagnostic work, and specialty instructions for transport should be included

in transfer reports and forms.Additionally, mental

health screens should assess for the presence of
current suicidal ideation, a history of suicidal behavior, and a history of mental health or substance

abuse treatment.The NCCHC prison standards

offer examples of summary transfer forms

(NCCHC, 1999). Details about what might be covered in a comprehensive assessment are discussed

in chapter 2,“Screening and Assessment for Mental

Health and Substance Abuse Disorders.” 

REENTERING THE

COMMUNITY

More than 90 percent of prisoners will return to

the community. Most will not be under continued

supervision, depending on the probation, parole, or

community control system in place.Although the

concept of transition or reentry services is not new,

it has received more attention in recent years.

A successful reentry is the result of thorough

assessment and planning. Discharge planning begins

when the person is identified as having a mental

health or substance use disorder and continues

throughout the person’s institutional treatment period.An appropriate referral to community-based

services can be achieved only if the individual has

been accurately and comprehensively assessed (U.S.

Department of Justice, Corrections Program Office,

2001).

A community support plan that matches an individual’s strengths, weaknesses, and treatment needs

with available resources is needed to reintegrate

mentally ill offenders into the community (Jemelka,

Trupin, and Childes, 1989). It is very important to

involve the following stakeholders in discussions

about the reentry process:

• The offender.

• Mental health and/or substance abuse treatment

providers.

• Medicaid representative.

• Labor, employment, and vocational services’

representatives.

C HAPTER 8

68

• Faith-based community organizations’

representatives.

• Recreational organizations’ representatives.

Additionally, no aftercare plan will work unless the

offender “buys in” to it.Years of institutionalization

can make people feel passive or unable to take control of or give direction to their lives. Prison can

offer those who have never successfully managed

their mental illness an opportunity to learn how to

manage and take responsibility for their illness.This

should also be an explicit component of treatment

programs for individuals who have a history of significant criminal behavior that is interactive with

their symptoms of mental illness or substance use

disorder.

CONTINUITY OF CARE

Ensuring continuity of care for offenders with mental

illness is a significant challenge for prison officials.As

a rule, community providers and prison officials do

not communicate or exchange records when a person enters the prison system or during incarceration, and individuals are released directly to the

community with little or no transition planning or

information exchange.This lack of continuity and

communication works considerable hardships on

offenders with mental illness. Not only are many

offenders overwhelmed by the transition from a

highly structured environment to a less structured

one with little or no support, but important treatment gains made during incarceration can be undermined or lost.Without good coordination between

institutional and community programs, the offender’s

disorder, anxiety, or both are likely to weaken the

gains made in treatment and trigger a relapse (Field,

1998).

Continuity of care is “required from admission to

transfer or discharge” from the facility (ACA, 2001).

This includes sharing appropriate information with

community-based mental health or substance abuse

service providers. One of the challenges facing discharge planners in institutional settings is the lack of
TRANSITIONAL SERVICES

services available to the offender in their home

community.Another is the disjointed nature of the

service system.All agencies involved should acknowledge their responsibility in ensuring continuity of

care. In some locations, an interagency, multidisciplinary team designs a coordinated system of case

management for released offenders (McVey, 2001).

Although a number of states and communities have

developed continuity of care programs for prison

inmates, few communities offer comprehensive services that integrate care for co-occurring mental illness and substance use disorder. See “Maryland’s

Shelter Plus Care Housing Program” for an example

of a program that does integrate services.

One of the most significant issues facing people with

serious mental illness when they are released from

prison is their ability to continue their psychotropic

medication. Not having medications on their release

or transfer can pose a significant stressor for individuals leaving correctional institutions. Courts have

ruled that the state must provide an outgoing

prisoner who continues to require psychotropic

medication with a supply sufficient to ensure the

availability of the medication during the time reasonably necessary to consult a doctor and obtain a new

supply (Wakefield v. Thompson, 1999).

In a survey of prisons with capacities of more than

1,000 (67 percent reporting),Veysey and Schacht

(2001) found that 25 percent of prisons offer prescriptions and 33 percent offer a 14- or 30-day supply of medication. Institutions must review their

69

In 1992, the Maryland Mental Hygiene

Administration (MHA) developed the

Maryland Community Criminal Justice

Treatment Program (MCCJTP)

through a collaborative partnership

with local corrections officials, local

government leaders, and representatives from the private sector. MCCJTP

brings treatment and criminal justice

professionals together to screen

inmates with mental illness while they

are confined in local jails and detention centers, prepare individualized

treatment and aftercare plans, and

provide followup in the community

after their release.

MHA expanded the scope of its services in 1995 to include the Shelter

Plus Care Housing Program.This program, which is sponsored by the U.S.

Department of Housing and Urban

Development (HUD), provides tenant

or sponsor-based rental assistance to

homeless persons with disabilities.

Eligible participants include individuals

who are incarcerated in local detention centers or are on probation and

parole for misdemeanors and nonviolent felonies, are homeless, and have a

Maryland’s Shelter Plus Care Housing Program

mental illness.The program assists

homeless individuals who are preparing to leave MCCJTP facilities or are

in the community on the intensive

caseloads of probation and parole

agencies in 21 Maryland counties.

Case managers help program participants apply for entitlements, locate

housing, negotiate leases, budget their

money, link to services, monitor supportive services involvement, and

maintain their homes.

In 2002, 92 percent of those who

participated in the Shelter Plus Care

Housing Program maintained permanent housing and 87 percent maintained or increased their income. Only

6 percent were reincarcerated for

criminal offenses, 1.5 percent were

hospitalized for psychiatric treatment,

and 1 percent returned to

homelessness.

For more information about

Maryland’s Shelter Plus Care Housing

Program, contact—

Marian Bland, Director

Shelter Plus Care Housing and 

Homeless Program

Maryland Mental Hygiene 

Administration

8450 Dorsey Run Road

Jessup, MD 20794-1000

E-mail: blandm@dhmh.state.md.us

Staff from MHA’s Division of Special

Populations have provided onsite

technical assistance to several states.

For information about technical assistance, contact—

Joan Gillece, Clinical Director

Division of Special Populations

Maryland Mental Hygiene 

Administration

8450 Dorsey Run Road

Jessup, MD 20794-1000

E-mail: Gillecej@dhmh.state.md.us

For more information about the

Shelter Plus Care Housing Program

nationally, visit

http://www.hud.gov/offices/cpd/

homeless/programs/splusc/index.cfm.

Source: U.S. Department of Justice,

Corrections Program Office,

Proceedings of the National Corrections

Conference on Mental Illness, Boston,

MA, July 18–20, 2001.
C HAPTER 8

70

policies to ensure continuity of care in this important dimension of mental health treatment.

AFTERCARE

The term “aftercare” carries with it a range of interpretations. In this manual, it means creating a continuum of care pertaining to mental health and

substance abuse services as an inmate is released to

the community.Aftercare also includes referral and

engagement in a range of community services needed by the individual to successfully reintegrate into

the community, including:

• Case management.

• Supported housing.

• Supported employment.

• Relapse prevention services.

Since the 1970s, the concept of aftercare as a rehabilitative tool for all offenders has shifted to

addressing those populations of individuals who

need specialized rehabilitation services on release,

including:

• Sex offenders.

• Individuals with severe mental illness.

• Individuals with mental retardation.

• Individuals with substance use disorders.

• Violent offenders.

According to Ashford, Sales, and LeCroy (2001), it is

assumed that these individuals have “distinct need

configurations that influence their relapse potential

and likelihood of making a positive adjustment to

the community” (p. 375).

Persons with mental illness leaving prison have the

same needs for care as patients leaving a state hospital, including case management, day treatment, medication services, and housing (Jemelka,Trupin, and

Childes, 1989).The need for posttreatment release

supervision and coordination between mental health

and correctional authorities is a central issue in reintegrating offenders with serious mental illness into

the community for several reasons:

• On release from prison, offenders with a mental

illness find few opportunities in the community

for treatment, employment, housing, and social

services. Reluctance to serve offenders with mental illness can be found in virtually all areas of

community-based care (Jemelka,Trupin, and

Childes, 1989).

• Offenders with mental illness usually have difficulties planning for housing, employment, medical,

mental health, substance abuse, and social service

needs.Their cognitive and social skills may be

impaired, and family and appropriate social supports in the community are often lacking.

• Offenders with serious mental illness are unlikely,

without support, to be effective self-advocates in

negotiating the complex system of care (Jemelka,

Trupin, and Childes, 1989).

• Release to the community in a decompensated

mental state, combined with the unavailability of

housing, jobs, and community mental health and

dual diagnosis treatment, puts these individuals at

risk for homelessness, psychiatric hospitalization,

and reincarceration (American Association of

Community Psychiatry, 2001).

It is easy to suggest to inmates that they should

refrain from using drugs or maintain stable housing

and another thing entirely to help them in those

endeavors. Institutions must make efforts to— 

• Provide and coordinate with community members

for the needed services.

• Negotiate entry for persons perceived as less

than desirable.

• Help people connect with housing, case management, treatment programs, and other followup

care.

• Avoid middle-of-the-night releases.
TRANSITIONAL SERVICES

71

• Discontinue unanticipated releases from mental

health units to the community.

• Discontinue anonymous referrals to community

programs and providers.

Institutions should also consider stepdown programming, including transitions to work-release programs,

halfway houses, and increasingly less restrictive

environments.

Components of Aftercare 

Case management strategies have been developed

since the 1960s to help people move successfully

from hospitals to community treatment settings.The

role of the case manager is to identify, recommend,

and, in most cases, facilitate the referral of individuals

to services that will help them maintain stability in

their functioning. Case managers work to ensure

continuity of care through a series of steps,

including— 

• Assessment of need.

• Development of a case plan.

• Referral and linkage to available services.

• Monitoring of continued services.

• Evaluation as to whether services are achieving

the intended goals.

In the correctional system, case managers often

function purely as brokers of service because many

are not trained mental health professionals. Some

observers contend that case managers should not

only facilitate the receipt of services but also use

their relationship with the person to encourage

compliance with rules and treatment and to provide

support. Alternatives to “brokerage” models have

focused on helping individuals— 

• Obtain material resources.

• Develop coping skills to deal with everyday

stressors.

• Develop support systems.

• Disentangle themselves from negative relationships.

• Learn to relate appropriately to community members, including police, service providers, support

persons, and family members.

Educational or Vocational

Transitions and Aftercare 

In some settings, transitional services involving

offenders with disabilities may refer specifically to

the transfer of students in special education and the

movement of their educational records within the

justice system or between the justice system and

the community. Even in this context, transitional

services have been referred to as the “most neglected component of correctional educational programs” (Rutherford, Griller-Clark, and Anderson,

2001, p. 237).

As it relates to educational or vocational services,

transition should include the following aspects:

• Interagency communication and coordination.

• Joint planning around program placement.

• Records transfer.

• Transitional (prerelease) programs that include

independent living, social, and vocational skills

(Coffey and Gemignani, 1994).

The transition involved in vocational planning may

include a focus on postrelease employment, continued vocational training or education, and independent living.

CONDITIONS OF RELEASE

The goals of transitional services are to ensure

continuity of treatment and reduce recidivism.

Numerous reports have suggested that the intensity

of supervision and services provided following

release is an important factor in reintegrating individuals into their communities (Edens, Peters, and

Hills, 1997; Dvoskin and Steadman, 1994).
The following conditions of release might be imposed for some special needs offenders or offenders

with mental illness:

• The acquisition of stable employment.

• The acquisition of stable housing.

• Prohibitions against associating with known

criminals.

• Prohibitions against possessing weapons.

• Involvement in mental health treatment, including

medication compliance.

• Abstinence from drugs.

• Involvement in case management (Edens and

Otto, 2001).

Former incentives and sanctions to participate in

treatment and maintain prosocial behavior may not

be as strong in the community as they were in the

institution.Without incentives, especially to continue

sobriety and a crime-free lifestyle, offenders may

revert to old patterns of behavior (Field, 1998).

If an individual continues to be monitored, a return

to substance use or noncompliance with treatment

or medication regimens likely will be detected.This

monitoring, rather than being punitive, can offer

the offender the opportunity for reengagement in

community-based services rather than reentry into

the justice system.This is especially true if a range

of options is considered in response to infractions,

including increased supervision, hospital commitments, day fines, or brief jail sentences rather than

revocation of parole (Edens and Otto, 2001).

LEGAL ISSUES

Significant case law exists regarding the release or

monitoring of offenders with mental illness who are

returned to the community and who subsequently

harm someone.The issue of a duty to warn has

come into play in these cases.The courts have

C HAPTER 8

72

generally considered the mental health professional’s

amount of prior contact with the offender, the degree to which the offender’s acts are deemed foreseeable, the offender’s previous history of reckless

or violent behavior, and the degree to which the

offender’s mental health has deteriorated. Despite

the considerable burden these interpretations can

have on mental health professionals, the courts

appear to be looking for greater assurance that

“placement . . . back into the community will not

result in the recurrence of violent or harmful behavior by the offenders” (Hafemeister, 1998, p. 98).

Many states have enacted legislation to immunize

persons and institutions from liability when a person

released to the community harms someone. Overall,

if professionals can demonstrate that they acted

within “professional standards,” they will not incur

liability. How that standard is determined, however,

can be a complex and challenging task.

POSITIVE OUTCOMES IN

TRANSITIONAL CARE

An obvious goal of transitional care is to ensure

that a person’s treatment goes on as seamlessly as

possible.To foster this, treatment providers within

an institution or agency and partners in the community need to establish referral relationships through

which clear and consistent information can be conveyed. Persons with complex, multiple disorders cannot be expected to negotiate complicated treatment

systems and effectively communicate their treatment

history and future service needs.Treatment providers must act as their agents to provide the continuity of care that is essential to stabilize symptoms.

Having to repeat their entire treatment history to a

new set of providers each time they are transferred

is frustrating (and defeating) to clients with mental

illness.Although transfers are inevitable, they can

be done effectively with appropriate planning and

understanding of the stressful nature of the experience combined, typically, with the offender’s treatment ambivalence.
TRANSITIONAL SERVICES

73

REFERENCES

American Association of Community Psychiatry

(2001). Position Statement of AACP on Persons with

Mental Illness Behind Bars.Web site: www.comm.

psych.pitt.edu/finds/mibb.html.Accessed May 1, 2002.

American Correctional Association (2001).

Performance-Based Health Care Standards: Field

Test Version.August. Lanham, MD:American

Correctional Association.

Ashford, J., Sales, B. and LeCroy, C. (2001).Aftercare

and Recidivism Prevention. In Ashford, J.B., Sales, B.D.

and Reid,W.H. (Eds.), Treating Adult and Juvenile

Offenders With Special Needs. Washington, DC:

American Psychological Association.

Coffey, O.D., and Gemignani, M.G. (1994). Effective

Practices in Juvenile Correctional Education:A Study of

the Literature and Research, 1980–1992. Washington,

DC: National Office for Social Responsibility.

Dvoskin, J., and Steadman, H. (1994). Using Intensive

Case Management to Reduce Violence by Mentally Ill

Persons in the Community. Hospital and Community

Psychiatry, 45, 679–684.

Edens, J., and Otto, R. (2001). Release Decision

Making and Planning. In Ashford, J.B., Sales, B.D., and

Reid,W. H. (Eds.), Treating Adult and Juvenile Offenders

With Special Needs. Washington, DC:American

Psychological Association.

Edens, J., Peters, R., and Hills, H. (1997).Treating

Prison Inmates with Co-Occurring Disorders:An

Integrative Review of Existing Programs. Behavioral

Sciences and the Law, 15, 439–457.

Field, G. (1998). From the Institution to the Community. Corrections Today, 60 (5), 94–97, October.

Hafemeister,T.L. (1998). Legal Aspects of the Treatment of Offenders with Mental Disorders. In

Wettstein, R.M. (Ed.), Treatment of Offenders with

Mental Disorders. New York:The Guilford Press.

Jemelka, R.,Trupin, E., and Childes, J.A. (1989).The

Mentally Ill in Prisons:A Review. Hospital and Community Psychiatry, 40 (5), 481–491.

McVey, C.C. (2001). Coordinating Effective Health

and Mental Health Continuity of Care. Corrections

Today, 63 (5), 58–62,August.

National Commission on Correctional Health

Care (1997). Standards for Health Services in Prisons.

Chicago: National Commission on Correctional

Health Care.

——— (1999). Correctional Mental Health Care:

Standards and Guidelines for Delivering Services.

Chicago: National Commission on Correctional

Health Care.

Rutherford, R.B., Griller-Clark, H.M., and Anderson,

C.W. (2001).Treating Offenders with Educational

Disabilities. In Ashford, J.B., Sales, B.D., and Reid,W.H.

(Eds.), Treating Adult and Juvenile Offenders With Special

Needs. Washington, DC:American Psychological

Association.

U.S. Department of Justice, Corrections Program

Office (2001). Proceedings of the National Correctional

Conference on Mental Illness. Boston, MA, July 18–20.

Washington, DC: U.S. Department of Justice.

Veysey, B., and Schacht, L. (2001). Statistical Research

Presentation, Proceedings of the National Corrections Conference on Mental Illness, Boston, MA,

July 18–20.

Wakefield v. Thompson (1999) 177 F.3d 1160 (9th Cir.).
75

TREATMENT OF

SPECIAL POPULATIONS

Chapter 9

Several subpopulations within the prison are often

referred to as “special populations” because they

require a level of care or specialized services not

required by other groups.These groups sometimes

include adults with serious mental health disorders,

as well as offenders with mental retardation, violent

offenders, sex offenders, and geriatric offenders.

TREATMENT OF PERSONS

WITH MENTAL RETARDATION

OR DEVELOPMENTAL

DISABILITY

Individuals with mental retardation have “significantly

subaverage intellectual functioning” and other indicators of impaired functioning that occurred prior to

the age of 18.Although intelligence quotient (IQ)

scores are an indicator, most clinicians would agree

that assessing the need for special services requires

gathering information about an individual’s levels of

adaptive behaviors, social maturity and development,

and communication skills. Histories of those requiring specialized services often reveal that they had

significant behavioral problems throughout childhood and may have received specialized residential

treatment and/or schooling. It is also likely that they

were raised in an environment that did not allow for

much skill building, as other members of their family

may also be of limited ability (Day and Berney, 2001).

Estimates suggest that individuals with mental retardation are overrepresented in prison—at rates two

to three times greater than those found in the community (2–3 percent in the community versus up to

10 percent in prisons) (Gardner, Graeber, and

Machkovitz, 1998). Prevalence estimates regarding

rates of offenders meeting criteria for mental

retardation are controversial, however, because of

both test measurement issues (e.g., using groupadministered tests) and sociocultural variables that

may affect test scores (e.g., misrepresenting those

from impoverished backgrounds as being impaired).

Many more individuals in prison systems are considered to have “borderline” retardation. Some of these

individuals (with IQ scores in the 70–85 range) may

be best served in the context of mental retardation

services and others may do well in mainstream arenas; this decision depends on the evaluation of the

pattern of need of the individual at the time

(Gardner, Graeber, and Machkovitz, 1998).

Offenses that bring individuals with mental retardation into custody (and into treatment) may include

the following:

• Sex offenses related to poor impulse control, sexual naivete, and a lack of normal sexual outlets.

• Arson offenses related to impaired communication and emotional expression and as a response

to stress.

• Property offenses related to low frustration tolerance, exposure to delinquent peers, and disturbed

family environments (Day and Berney, 2001).

Much of the research about offenders with mental

retardation has looked at male offenders. Different

issues generally bring women offenders into care:

promiscuity, behavior problems, and self-neglect.
Some research has shown that women in this group

tend to have histories of self-mutilation and grossly

disturbed family histories (Day and Berney, 2001).

An estimated 40 to 70 percent of individuals with

mental retardation also meet criteria for a psychiatric disorder (APA, 2000). Because of their often

limited language skills, it is difficult to determine the

type of disorder they may have (e.g., anxiety, depression). In the context of their limited ability to generate enough information to make an accurate

diagnosis, the prescription of psychotropic medication is more often focused on behaviors or observable symptoms.

Prison staff may experience challenges with these

clients for a variety of reasons. Inmates with mental

retardation may experience one or more of the

following:

• Difficulty in comprehending and responding to

instructions.This can be counteracted by using

clear, simple language and giving the person adequate time to respond.

• Low frustration tolerance.This may lead to

excited behaviors or inappropriate verbalizations/ speech. Persons who can calmly redirect

the individual may need to intervene.

• Impulsivity. Difficulty controlling impulsive behaviors and positive or negative affect may cause the

individual to behave impulsively (APA, 2000).

When violence occurs, it may be the result of limited communication skills, a sense of being threatened,

misinterpreted social cues, or flawed concrete logic

(believing that acting in a violent fashion was the

only reasonable solution to the situation) (Day and

Berney, 2001).

A comprehensive assessment must first be done to

treat some of the factors that led to the criminality

of the person with mental retardation.This assessment should include intelligence and personality

testing, investigation of educational attainments, and

level of adaptive behavior. Genetic testing should be

used to identify specific genotypic abnormalities, and

C HAPTER 9

76

EEGs can determine the presence of brain damage

or epilepsy.To assess the likelihood of reoffense, the

offense pattern or cycle should be analyzed for frustration tolerance, impulsivity, emotional reactions,

and the person’s understanding of the offense.

Prison staff must take extra care to make certain

that inmates with mental retardation are not

ridiculed or preyed on by other offenders. Inmates

with mental retardation should be observed frequently so that these issues may be addressed. Some

prison systems have established special programs for

inmates with mental retardation (see “Sample State

Programs Serving Inmates With Mental

Retardation”).

Sample State Programs Serving

Inmates With Mental Retardation

The Center for Intensive Treatment (CIT), operated

by the New York Office of Mental Retardation and

Developmental Disabilities, is a highly structured residential program within a secure setting. Most residents

have histories of assaultive and aggressive behaviors and

many were found not to be criminally responsible for

their actions due to their mental retardation.The unit

has a 14-foot inward curving fence and a card-reading

locking system that provides access to various areas of

the facility, depending on the resident’s level of independence (Gardner, Graeber, and Machkovitz, 1998).

Treatment goals include improving decisionmaking and

vocational training through a mentoring program with

maintenance staff.

Resulting from a class action lawsuit, a program for

offenders with mental retardation was initiated by the

state of Texas.This specialized program provides offenders with adequate housing and work conditions, appropriate discipline, and protection from other offenders.

Staff working in these specialized units are trained to

“ensure sensitivity” to the individual’s needs (Gardner,

Graeber, and Machkovitz, 1998).

Treatment Programs for Offenders

With Mental Retardation 

Although some offenders with mental retardation

may come to prison,“the majority . . . can be
managed in the community supported by social, probation, and specialist psychiatric services” (Day and

Berney, 2001, p. 206).Within prisons, programs for

offenders with mental retardation typically focus on

building social skills and educational training.Token

economy systems reward desirable behaviors, and

unwanted behaviors result in loss of tokens and

“timeouts” or seclusion (in response to violent

behaviors).These programs usually offer structured

training programs and operate with higher staffing

ratios and multidisciplinary teams that include nursing staff.

Focused Treatment Interventions 

Sex Offenses. Rates of sex offenses among offenders who have mental retardation are four to six

times greater than among the general offender population (Day, 1993). Many of these offenses stem

from offenders’ limited information about sexual

relationships and courtship skills. Persons who have

mental retardation need basic sex education but also

need to be informed about laws and social codes

related to sexual behaviors.Treatment regimens that

involve learning arousal control skills, cognitive restructuring, group therapy, anger management, and

social skills training—in various combinations—have

been effective with individuals whose intelligence

scores range from 55 to 85 (Day and Berney, 2001).

These treatments also can be used with persons

with mental retardation who have committed sexual

offenses.

Antiandrogen drugs are used in some programs to

reduce the sex drive and facilitate engagement in a

behavior management program.Although their use

is contraindicated in some patients with medical illnesses, they can be effective in reducing deviant impulses and fantasies. Use of this class of drug should

be discussed in detail with the individual and his parent or guardian; written consent should be obtained.

Fire Setting. Fire setting is also overrepresented in

the population of offenders with mental retardation.

Fire setters may benefit from therapies that help

them evaluate antecedents to fire setting and teach

skills to reduce stress and improve coping.These

individuals should be closely monitored, housed in

lower stress living environments, and searched

frequently.

Control of Anger or Violence. Anger management

techniques such as relaxation training and the use of

cognitive self-statements (“calm down”) have been

used successfully in offenders with retardation.

Psychopharmacological agents can be effective but

must be used judiciously because they can have

adverse effects, especially in individuals with underlying brain disorders. Neuroleptics, antiepileptics, lithium, and beta-adrenergic blockers can be effective in

reducing episodic violence. Due to historical reports

of overprescription, however, all use of these medications for violence reduction should be carefully

monitored for adverse side effects and initiated at

small dosage levels (Day and Berney, 2001).

National Commission on Correctional Health Care

(NCCHC) prison standards (1997) require that

prison administrators and treating clinicians communicate about individuals with special needs, including

those with developmental disabilities, regarding

special housing considerations, work or program

assignments, and admissions and transfers from institutions (NCCHC, 1999).These standards also caution that security staff need orientation and training

regarding the impairments in thinking (e.g., concrete

thinking, slowness) that characterize individuals with

mental retardation.

TREATMENT OF VIOLENT

OFFENDERS

The Centers for Disease Control and Prevention

and NCCHC have declared that violence is a “public

health problem” and that correctional institutions

must play a role in addressing violence among their

populations (see “Stemming Violence Among

Inmates”).

Strategies for the treatment of violence are increasingly specific, depending on the individual’s pattern

of violence.Tolan and Guerra (1994) describe four

77

TREATMENT OF SPECIAL POPULATIONS
common patterns (with prevalence estimates among

adolescent violent offenders):

• Situational, related to environmental cues and

social factors (25 percent).

• Relationship, involving interpersonal conflict and

social/psychological factors (25 percent).

• Predatory, goal-oriented violence that may be

related to gang activity (5 percent).

• Psychopathological, reflecting repetitive violence

across settings; may be due to neuropsychological

deficits (1 percent).

Findings based on interventions from the conduct

disorder literature suggest that interventions should

emphasize skills acquisition and be delivered over

the long term to solidify and sustain gains (Kazdin,

1993). Persons who are true psychopaths (a very

small proportion of the offender population) may

not benefit from treatment.

Therapies for aggression fall into several categories:

• Psychopharmacological, although “no medication

has been developed or approved specifically for

treating violent behavior” (Serin and Preston,

2001, p. 255).

C HAPTER 9

78

• Psychological, including behavior modification,

social skills training, anger management, problem

solving, empathy, and perspective taking.

• Self-regulation techniques, including relaxation,

stress inoculation, and arousal reduction.

• Cognitive-processing strategies, including modifying appraisals and expectations, generating alternative solutions, and redirecting “criminal thinking.” 

Despite the range of available interventions, little

technology currently exists to help match offenders

with the “correct” prescription of care. Even if this

did exist, issues of staff resources and the ability to

offer multiple and varied programs would pose a significant challenge to correctional authorities.

TREATMENT OF SEX

OFFENDERS

Almost all incarcerated sex offenders fall into one of

two groups: rapists, most commonly men who have

assaulted adult women, and child molesters, men

who have committed “hands-on” offenses against

prepubertal children. Persons with lesser offenses

such as exhibitionism, voyeurism, and indecent exposure are typically not seen in institutional programs

but are treated in community-based settings.

Most sex offenders are given DSM–IV (Diagnostic

and Statistical Manual of Mental Disorders, Fourth

Edition) (APA, 1994) diagnoses of sexual sadism or

pedophilia. Most would also receive a diagnosis of

antisocial personality disorder, though this is not typically a specific focus of mental health treatment.

Most sex offenders do not have a concurrent diagnosis of serious mental illness (e.g., schizophrenia or

bipolar disorder). It is recommended that the small

group of sex offenders who do have a major mental

illness receive mental health services to stabilize the

symptoms of this disorder before being referred for

specialized treatment of their sexual behavior (Rice,

Harris, and Quinsey, 2001).

Stemming Violence Among Inmates

The National Commission on Correctional Health Care

recommends that prisons take the following actions:

• Incorporate violence risk assessment into all intake

assessments.

• Refer individuals with violent histories to treatments

that are provided by adequately trained staff and that

take a biopsychosocial approach.

• Establish guidelines for violence prevention, including

awareness of nonphysical methods for controlling disruptive behaviors.

• Work with community providers to ensure continuity

of care once the offender is released.

Source: National Commission on Correctional Health

Care, 1999.
Categories of treatment for sex offenders include

the following:

• Nonbehavioral psychotherapy.

• Surgical and pharmacological treatments.

• Cognitive and behavioral psychotherapy (Rice,

Harris, and Quinsey, 2001).

Nonbehavioral psychotherapy (unstructured group

or individual counseling) has not been validated

empirically to reduce the likelihood of reoffending.

Some research suggests, in fact, the opposite: that

those treated with these strategies are more likely

to reoffend (Rice, Harris, and Quinsey, 2001).

Surgical castration has been evaluated in Germany

and Denmark, but based on the evidence from these

investigations, it remains difficult to recommend this

procedure.

Psychopharmacologic interventions have been used

much more commonly in North America. Drugs that

reduce circulating testosterone (cyproterone acetate

and medroxyprogesterone acetate (MPA)) evoke

fewer ethical concerns because their effects can be

completely reversed when the drugs are withdrawn.

Individuals prescribed these drugs report a reduction in sexual interest, sex drive, sexual fantasies, and

masturbation; no information on reduction of reoffending has been reported, however. Both drugs have

side effects that make them undesirable, including

loss of body hair, headaches, depression, gastrointestinal problems, weight gain, and fatigue.

Most investigations on the effectiveness of pharmacological interventions reported large numbers of

dropouts. Reviews conclude that few sex offenders

will agree to take medications such as MPA, and

fewer still will stay on them over the long term.

Some evidence suggests that those who stay on the

medication and receive additional treatment may

reoffend at lower rates. Some researchers believe,

however, that these individuals are the most highly

motivated members of the group, and that this

therefore is not fairly testing the effects of the drug

(Rice, Harris, and Quinsey, 2001).

Behavioral therapies typically link aversive events to

deviant fantasies through covert sensitization or

operant conditioning. Other elements of treatment

often include—

• Training in social competence.

• Anger management.

• Sex education.

• Victim awareness and empathy.

• Family therapy.

• Other counseling.

Although diverse interventions have been developed

and implemented, most have not been completely

and correctly evaluated to test their effectiveness.

This leads some researchers to conclude that “the

efficacy of treatments for child molesters and rapists

remains to be demonstrated” (Rice, Harris, and

Quinsey, 2001, p. 305).

Despite this pessimistic conclusion, many programs

operate and continue to investigate interventions in

an effort to reduce reoffending. Special consideration, therefore, must be given to sex offenders in

maintaining confidentiality about their mental health

treatment. Identification as a sex offender is recognized as putting an individual at increased risk for

violence within an institution (APA, 2000).

TREATMENT OF OLDER

ADULTS

The National Institute of Corrections (NIC) uses

the term “geriatric” for inmates who are 50 years of

age or older.This fairly liberal categorization is suggested because of the higher “biological age” of the

inmate population due to higher rates of smoking,

poor nutrition, lower socioeconomic status, and limited access to prior health care (APA, 2000).The

high-risk behaviors inmates commonly engage in

have resulted in appraised medical ages 5 to 10

years older than their chronological ages (McVey,

2001).

79

TREATMENT OF SPECIAL POPULATIONS
Longer sentences and increased curtailment of

parole have made older offenders the fastest growing population in state prisons (Ortiz, 2000). Older

offenders are also the most expensive group to

house and maintain, largely due to their physical and

mental impairments. Data from several sources suggest that the cost of medical care for elderly prisoners is almost three times the average cost for the

general population (Faiver, 1998).

Specific concerns related to the mental health treatment of older adults include diagnostic issues associated with the common co-occurrence of physical

health disorders. Issues of polypharmacy have to be

closely evaluated in populations being treated simultaneously for multiple physical and mental health

disorders.

Other important issues in the treatment of older

adult inmate populations include their—

• Physical vulnerabilities when housed with aggressive, younger adults.

• Potential lack of connection to other inmates.

• Greater rates of successful suicides.

• Increased risk for death during their term of

incarceration.

• Greater difficulty in adapting to prison (APA,

2000).

All these vulnerabilities can exacerbate underlying

psychiatric disorders.

Hopelessness and despair are common as older

male and female offenders gradually lose contact

with their families and face long prison sentences.

Elderly offenders’ losses progress slowly over time,

contributing to grief. Specially trained staff may be

needed in prison settings to identify and treat geriatric health and mental health problems and to prevent suicide attempts.Treatment of both mental

health and substance abuse problems must be individualized to meet the needs of these offenders

(Maue, 2001).

C HAPTER 9

80

Because many have aged out of the workforce, this

population has special programming needs and

significant issues regarding discharge planning, sexoffender counseling, long-term housing, medical

costs for chronic conditions, and hospice care.

Community Reintegration for

Older Adults 

Discharge planning is important for older offenders

who have any likelihood of being returned to the

community.The planning should focus on—

• Medicare and Medicaid enrollment.

• Reinstatement of veterans’ benefits.

• Securing community mental health treatment.

• Obtaining housing.

• Obtaining employment.

• Applying for public assistance.

• Renewing family ties (Faiver, 1998).

Older discharged prisoners usually face substantial

difficulties on reentry to the community.As a group,

older offenders frequently experience depression,

isolation, and loneliness, all of which contribute to

difficult community reintegration (McVey, 2001).

Prior prison experience is strongly associated with

the probability of homelessness for the elderly, and

discharge planning is vital to prevent this.

Specialized Facilities and Units

for Older Adults 

Younger inmates often take advantage of and abuse

inmates who are old and weak.Younger, more active

prisoners may get annoyed or irritated by older inmates who share the same housing and activity

space.As physical limitations and confusion begin to

appear in older inmates, some systems have found it

helpful to arrange separate living units with special

programming. Many studies suggest that older inmates be housed separately and have specialized
gender-responsive programs for their protection and

well-being that provide them with a sense of community and belonging (Ortiz, 2000).

NIC’s 1997 national survey on special issues in

prison medical services found that most state corrections agencies provided specialized medical care

to elderly inmates at several facilities but many have

consolidated medical care for elderly inmates at one

or more main sites.The most common approaches

to provide specialized medical care for elderly inmates include chronic care clinics, preventive care,

and increased frequency of physical examinations.

More than half of the corrections agencies reported

the availability of special nutrition and dietary care,

special housing, and the use of inmate aides to provide nonmedical assistance (e.g., reading, pushing

wheelchairs). Other services included physical therapy, special visitation policies, and special recreation

or work opportunities. Some had 24-hour physician

access and delivery of medications to reduce ambulation (LIS, Inc., 1997).

Elderly, Disabled, and Terminally

Ill Inmates 

NCCHC describes the elderly population as those

who may need help addressing issues associated

with death and dying, depression, and memory

impairments (NCCHC, 1999). Elderly and disabled

inmates require special accommodations for their

deteriorating physical and mental conditions, increased supervision and protection, and more frequent escort to health care services (Faiver, 1998).

The frail elderly’s difficulties with accomplishing

activities of daily living can overwhelm available staff

in many mental health or substance abuse treatment

programs. Some states have developed secure

extended-care facilities or nursing homes for elderly

inmates.

Faiver (1998) suggests that a specialized program for

elderly and handicapped inmates could include such

services as—

• Preventive health activities to decrease medical

costs.

• A diet appropriate to elderly individuals.

• Enhanced creative therapy programs.

• Self-help programming, community service, and

work opportunities.

• Sex-offender counseling and therapy.

• Life-coping skills for maturing adults.

• Assistance with activities of daily living and personal care needs related to Alzheimer’s disease,

arthritis, diabetes, cardiovascular and respiratory

problems, loss of eyesight and hearing, and other

chronic or acute debilitating conditions.

• Worship and religious counseling.

• A hospice program for terminally ill residents.

• Nursing care.

• Discharge and reentry planning.

As inmates become disabled or terminally ill, many

will no longer represent a real threat or danger to

society, and consideration should be given to seeking

approval from the parole board or the Governor for

compassionate release. For those who cannot be

released, humane environments, hospice, and palliative care options should be prepared for the terminally ill.A social work component is essential for a

prison facility specializing in the elderly.

REFERENCES

American Psychiatric Association (1994). Diagnostic

and Statistical Manual of Mental Disorders. Fourth

Edition.Washington, DC:American Psychiatric Press.

——— (2000). Psychiatric Services in Jails and Prisons.

Second Edition.Washington, DC:American

Psychiatric Press.

Day, K. (1993). Crime and Mental Retardation:A

Review. In Howells, K., and Hollin, C.R. (Eds.), Clinical

Approaches to the Mentally Disordered Offenders.

Chichester, UK: John Wiley.

81

TREATMENT OF SPECIAL POPULATIONS
C HAPTER 9

82

Day, K., and Berney,T. (2001).Treatment and Care for

Offenders with Mental Retardation. In Ashford, J.B.,

Sales, B.D., and Reid,W.H. (Eds.), Treating Adult and

Juvenile Offenders With Special Needs. Washington,

DC:American Psychological Association.

Faiver, K.L. (1998). Health Care Management Issues in

Corrections. Lanham, MD:American Correctional

Association.

Gardner,W., Graeber, J., and Machkovitz, S. (1998).

Treatment of Offenders with Mental Retardation.

In Wettstein, R.M. (Ed.), Treatment of Offenders With

Mental Disorders. New York:The Guilford Press.

Kazdin,A. (1993).Treatment of Conduct Disorder:

Progress and Directions in Psychotherapy Research.

Development and Psychopathology, 5, 277–310.

LIS, Inc. (1997). Prison Medical Care: Special Needs

Populations and Cost Control. Longmont, CO: U.S.

Department of Justice, National Institute of Corrections Information Center. September.

Maue, F.R. (2001).An Overview of Correctional

Mental Health Issues. Corrections Today, 63 (5), 8,

August.

McVey, C.C. (2001). Coordinating Effective Health

and Mental Health Continuity of Care. Corrections

Today, 63 (5), 58–62,August.

National Commission on Correctional Health

Care (1997). Standards for Health Services in Prisons.

Chicago: National Commission on Correctional

Health Care.

——— (1999). Correctional Mental Health Care:

Standards and Guidelines for Delivering Services.

Chicago: National Commission on Correctional

Health Care.

Ortiz, M. (2000). Managing Special Populations. Corrections Today, 62 (7), 64–68, December.

Rice, M., Harris, G., and Quinsey,V. (2001). Research

on the Treatment of Adult Sex Offenders. In Ashford,

J.B., Sales, B.D. , and Reid,W.H. (Eds.), Treating Adult

and Juvenile Offenders with Special Needs. Washington,

DC:American Psychological Association.

Serin, R., and Preston, D. (2001). Managing and

Treating Violent Offenders. In Ashford, J.B., Sales,

B.D., and Reid,W.H. (Eds.), Treating Adult and Juvenile

Offenders With Special Needs. Washington, DC:

American Psychological Association.

Tolan, P., and Guerra, N. (1994). What Works in Reducing Adolescent Violence:An Empirical Review of the

Field. Boulder, CO: Center for the Study and Prevention of Violence, Institute for Behavioral Sciences,

University of Colorado, Boulder.
83

PROFILES OF THREE STATES

Chapter 10

This chapter highlights successful programs for

offenders with mental illness in Maryland, Oregon,

and Texas and presents a brief history of each program, a description of its key features, and a discussion of its unique characteristics and future plans.

MARYLAND

In the early 1990s, correctional officials’ mounting

concerns about the growing number of individuals

with mental illnesses revolving in and out of the

Maryland correctional system and the lack of sufficient trained staff prompted the establishment of a

Governor’s task force to examine the problem and

recommend a coordinated approach by the behavioral health and criminal justice systems.The Maryland Department of Health and Mental Hygiene,

Mental Hygiene Administration (DHMH/MHA) allocated $50,000 in each of four counties as seed

money to establish the Jail Mental Health Program.

These dollars funded case management services to

help identify offenders with mental illness, enhance

communication between mental health and corrections staff, and reduce disruption associated with

offenders with mental illness.

The success of the pilots led DHMH/MHA to expand the program’s array of services and implement

it throughout the state.The primary goals of the

program, now known as the Maryland Community

Criminal Justice Treatment Program, are to meet

the comprehensive needs of this population, reduce

recidivism to state psychiatric hospitals and the

criminal justice system, and reduce homelessness.

Key Program Features 

Each participating jurisdiction is required to develop

an advisory board that includes representatives of

organizations that serve ex-offenders in the community, such as mental health, alcohol and drug abuse,

public defender, judicial, parole and probation, law

enforcement, social service, and consumer and advocacy agencies.To receive funding, each advisory

board must develop a memorandum of agreement

that defines the specific services each agency will

provide.The program focuses on individuals 18 years

of age or older who have a serious mental illness.

The individual also may have a co-occurring disorder

such as substance abuse or HIV/AIDS, be homeless

or deaf, or a combination of these. DHMH/MHA

provides a total of $1.5 million annually for case

management and psychiatric services that begin in

the correctional system.All individuals who meet the

criteria for medical need are offered an array of

services through DHMH/MHA managed care feefor-service system. Local governments, detention

centers, and agencies also have provided funds.

Approximately 4,500 individuals were served during

Maryland’s fiscal year 2001.

On incarceration, offenders receive a comprehensive

screening and assessment for mental illness and substance abuse, and crisis intervention services are

provided as necessary. Medication may be prescribed

following a medical evaluation.An individual treatment plan is developed, and the indicated therapies

are begun as soon as possible.A program designed

to help women offenders with substance-abuse

problems and the effects of traumatic life
C HAPTER 10

84

experiences is available in 8 of the 24 jurisdictions.

Plans are under way to expand the number of sites

and provide similar services to men.

The services provided during prebooking and incarceration lay the foundation for discharge planning.

In 1995, DHMH/MHA received a $5.5 million housing grant from the U.S. Department of Housing and

Urban Development to provide rental assistance to

parolees and probationers who are homeless or in

danger of being reincarcerated. In total, 407 individuals, including children and families, have been housed

through this program.The recidivism rate of those

in the program has been less than 4 percent.

DHMH/MHA has been innovative in blending federal, state, local, and private funds to underwrite program costs.

Unique Characteristics 

The following guiding principles have contributed to

the program’s success:

• Offenders with mental illness are part of the community and deserve treatment and community

services.

• Public safety issues are paramount in the service

delivery system.

• Holistic and coordinated treatment is most effective and efficient.

• Local jurisdictions should have autonomy in program implementation, within state guidelines.

• All public service providers should contribute

their share of services and resources to helping

offenders with mental illness.

Other areas identified as key to the program’s success include the following:

• Intensive case management.

• Program flexibility.

• Community partnerships.

• Strong advocacy.

• Blended funding.

• An individualized continuum of care.

• Monthly monitoring of supportive services.

Future Plans 

In addition to expanding its services to include more

trauma services for men, the Maryland program will

provide services to pregnant and postpartum incarcerated women and their infants.These services are

designed to enhance the environmental, ecological,

and institutional health and growth of mothers and

their infants. Clinical interventions will strengthen

the bond between mothers and their babies.

OREGON

Until the mid-1990s, the Oregon State Hospital provided most of the mental health services for people

with mental illness incarcerated in the criminal justice system in Willamette Valley, Oregon.As the

number of incarcerations increased, prison facilities

were established beyond Willamette Valley to meet

the increased need for prison cells.As a result, the

arrangement with the state hospital became progressively less effective.To improve the situation, the

Oregon Department of Corrections designed its

own program to treat people with mental illnesses

incarcerated in the prison system.The number of

people receiving mental health services in the prison

increased from 1,050 in 1997 to 2,018 people in

2002.

Key Program Features 

The Oregon Department of Corrections established

a system of mental health services based on outreach case management.The service system enabled

case managers who work in the prisons to meet

with offenders throughout the institution instead of

being restricted to scheduled office appointments.

These informal visits take place in the cell block,

recreation yard, and hallways and allow for interactions between the mental health provider and the

offender without the need for an appointment and

outside the confines of a doctor’s office.
This design has additional advantages for both providers and offenders. It enables mental health providers to watch offenders interact in their everyday

environments. Correctional officers can inform the

mental health professionals of any problems they

may have noticed. In addition, these interactions

allow for early identification of and intervention for

offenders with mental illnesses.

Two principles guide mental health services within

the institution: services are prioritized to serve

offenders with the most severe and persistent mental illnesses and the staff responds rapidly to that

population.To determine eligibility, staff identify people with special health needs through a general

health screening and the Personality Assessment

Instrument (PAI). Nurses assess each person entering the Oregon Department of Corrections within

the first hour of intake.This general health needs

screening frames the individual’s incarceration/transition plan, which follows him or her throughout the

entire term of incarceration.Within 48 hours of

intake, each person must complete a PAI, which provides more thorough information than the general

health screening.

Individuals identified as having a mental illness receive a face-to-face mental health evaluation within 2

weeks of intake. If an emergency occurs, face-to-face

assessments can be done very quickly.

Unique Characteristics 

The Oregon Department of Corrections offers the

following services to meet the needs of people with

serious and persistent mental illnesses within their

institutions:

• 62 crisis/residential beds.

• 70 day treatment beds.

• 208 dual-diagnosis treatment beds.

• Individual and group treatment (offered to 410

individuals).

• Case management and medication management

(offered to 2,018 individuals).

• A stepdown program to prepare individuals to

live within the general prison population.

• A co-occurring disorders program.

• A transitional program to help individuals obtain

housing, medication, and support services prior to

release.

Program staff work collaboratively with the state

mental health authority on various projects on a

regular basis. Staff also work with mental health

advocates at their request to increase access to

treatment services for people in the criminal justice

system.

Challenges 

The Oregon Department of Corrections has

worked through the following challenges:

• The number of people with mental illnesses

entering the criminal justice system is increasing.

• The severity of the mental illnesses of people who

enter the criminal justice system is increasing.

• Space to meet with people in a neutral, private

setting in prisons is limited. Space constraints hinder the growth of such programs as self-help

groups.

• The cost of medication continues to increase.

• Recruiting mental health staff in rural areas where

new prisons are being constructed is difficult.

The program is working to overcome these challenges to ensure that offenders who need mental

health treatment can be served expediently and

effectively.

Measures of Success 

Even before case management outreach services

were implemented, 60 percent of people with mental illnesses incarcerated in the criminal justice system received mental health services.With the new

structure, fewer people with mental illnesses are

segregated from other inmates, which reduces the

85

PROFILES OF THREE STATES
C HAPTER 10

personal deterioration that comes from long-term

isolation. Oregon’s in-prison mental health services

are cost effective and have generated more participation in prison education and work programs by

offenders with mental illness than offenders without

mental illness.

TEXAS

The mission of the Correctional Health Care/Mental

Health Services Program of the Texas Department

of Criminal Justice is to provide public and institutional safety, promote positive change in offender

behavior, and reintegrate offenders into society

through the provision of health care.To accomplish

this mission, the 550-bed John Montford Unit in

Lubbock,Texas, was established to provide a full

range of inpatient psychiatric services to offenders

with mental illness in the state correctional system.

Offenders throughout the state are referred to

Montford to receive individualized treatment in a

safe environment.

Key Program Features 

The Montford psychiatric hospital meets the needs

of offenders in the state criminal justice system by

offering a range of services at varying intensities.

Offenders referred to Montford are first transferred

to the crisis management unit, where they receive a

psychiatric evaluation, psychological evaluation, and,

if necessary, physical evaluation. Initial goals are to

resolve any immediate crises and decide what services best meet each person’s needs.

When offenders are admitted to Montford, they are

transferred from crisis management to acute care,

where they stay 10 to 14 days for additional evaluation and development of an individual treatment plan

based on the medical model.As individuals stabilize,

they are given increased privileges, individual treatment plans are adjusted, referrals are made to various groups offered by the staff, and offenders are

evaluated to determine their educational needs.

86

If hospitalization is required after acute care, offenders are transferred to a subacute care program.This

program follows a biopsychosocial model that emphasizes group therapy. Individuals are closely monitored to determine their response to medications,

and treatment plans are refined.The average length

of stay in a subacute care unit is 90 to 180 days.

Unique Characteristics 

The Montford Unit provides the following psychiatric services:

• 550 psychiatric beds.

• 400 trusty camp beds.

• A 48-bed general medical and surgical unit.

• Geriatric services.

• Nontraditional therapies, such as art therapy,

music therapy, occupational therapy, and recreational therapy.

• A trusty camp, gardens for the Lubbock food

bank, housing, stables, and roads located on 120

acres.

Challenges and Future Plans 

Staff at the John Montford Unit continue to develop

programs to meet the many needs of people who

use their services, such as a program for people with

serious character disorders.They are also considering a program for people with co-occurring psychiatric and substance use disorders.

SUMMARY

Incarceration can be very traumatic for individuals

who have a mental illness.The programs highlighted

in this chapter illustrate that mental health programs

designed to divert individuals from the criminal justice system, provide appropriate services while they

are incarcerated, and help them reenter the community can have positive effects on the quality of their

lives.
APPENDIX. INSTRUMENTS FOR SCREENING

AND ASSESSMENT OF MENTAL HEALTH AND

SUBSTANCE ABUSE DISORDERS

Appendix
INSTRUMENTS FOR

SCREENING AND ASSESSMENT

Brief Symptom Inventory. This is a short form (53

items) for another instrument, the Symptom Checklist 90–Revised (SCL–90–R). It provides both global

indices of psychopathology and specific psychiatric

symptom dimensions (Derogatis and Melisaratos,

1983).

Referral Decision Scale. This self-administered, 14-

item instrument specifically identifies the mental

health problems of individuals entering jails (Teplin

and Schwartz, 1989).

TCU Drug Dependence Screen. This instrument

provides diagnosable symptoms of substance use

and includes 19 items. It is in the public domain and

therefore available at no cost (Simpson, 1993).

Simple Screening Instrument. This instrument

examines five areas related to drug and alcohol

dependence. It is in the public domain and therefore

available at no cost (Center for Substance Abuse

Treatment, 1994).

Alcohol Dependence Scale. This 25-item instrument screens for symptoms of alcohol dependence

and was derived from the larger 147-item Alcohol

Use Inventory (AUI) via factor analysis (Skinner and

Horn, 1984).

Addiction Severity Index. Developed by the

National Institute on Drug Abuse (NIDA), this is

the most widely used instrument for measuring

substance abuse. Its structured interview examines

seven areas of functioning commonly affected by

substance abuse. It is in the public domain and

therefore available at no cost (McLellan et al., 1980,

1992).

Minnesota Multiphasic Personality Inventory–2

(MMPI–2). The MMPI–2 is a restandardized version

of the MMPI.This 567-item self-report measure provides scores on 10 clinical scales, 10 supplementary

scales, and 4 validity scales (Hathaway and McKinley,

1989).

Millon Clinical Multiaxial Inventory–III. This selfreport instrument yields scores on clinical syndromes and validity scales (Millon, 1983 and 1992).

Personality Assessment Inventory. This self-report

instrument contains 344 items and yields scores on

22 clinical scales (Morey, 1991).

Stages of Change Readiness and Treatment

Eagerness Scale (SOCRATES). This instrument has

two forms (one for alcohol use and one for drug

use), with 19 items each. Subscale scores indicate

which stage of change the individual is in. It is in the

public domain and therefore available at no cost

(Miller and Tonigan, 1996).

University of Rhode Island Change Assessment

(URICA) Scale. This instrument does not require

clinical training to administer and, like SOCRATES,

subscale scores indicate which stage of change the

individual is in (McConnaughy, Prochaska, and Velicer,

1983; DiClemente and Hughes, 1990).

Appendix

INSTRUMENTS FOR SCREENING AND

ASSESSMENT OF MENTAL HEALTH AND

SUBSTANCE ABUSE DISORDERS

89
INSTRUMENTS FOR ASSESSING

TRAUMA

The Traumatic Antecedent Questionnaire (TAQ).

This widely used instrument measures lifetime experiences of trauma in 10 areas, e.g., physical, sexual,

witnessing trauma (Herman, Perry, and Van der Kolk,

1989).

The Dissociative Experiences Scale (DES). This

self-report measure examines several areas of dissociative phenomena (e.g., amnesia, identity alterations,

and spontaneous trance states) that are often sequelae of trauma (Bernstein and Putnam, 1986).

Clinician-Administered PTSD Scale (CAPS). This

clinician-administered scale provides an accurate

diagnosis of posttraumatic stress disorder (Blake et

al., 1995).

Trauma Symptom Checklist 40. This 40-item, selfreport instrument evaluates symptoms in adults that

may have arisen from trauma experienced as a child

or adult.The instrument contains six subscales, and

items are rated on a 4-point scale and cover frequency over the previous 2 months (Briere, 1996).

REFERENCES

Bernstein, E.M., and Putnam, F.W. (1986). Development, Reliability, and Validity of a Dissociative Scale.

Journal of Nervous and Mental Disease, 174, 727–735.

Blake, D.,Weathers, F., Nagy, L., Kaloupek, D.,

Gusman, F., Charney, D., and Keane,T. (1995).The

Development of a Clinician-Administered PTSD

Scale. Journal of Traumatic Stress, 8 (1), 75–90.

Briere, J. (1996). Psychometric Review of the

Trauma Symptom Checklist–40, in Stamm, B.H. (Ed.),

Measurement of Stress,Trauma, and Adaptation.

Lutherville, MD: Sidran Press.

Center for Substance Abuse Treatment (1994).

Simple Screening Instruments for Outreach for Alcohol

and Other Drug Abuse and Infectious Diseases. Treatment Improvement Protocol (TIP) Series, No. 11.

Rockville, MD: U.S. Department of Health and

Human Services.

APPENDIX

90

Derogatis, L.R., and Melisaratos, N. (1983).The Brief

Symptom Inventory:An Introductory Report. Psychological Medicine, 13, 595–605.

DiClemente, C.C., and Hughes, S.O. (1990). Stages of

Change Profiles in Outpatient Alcoholism Treatment.

Journal of Substance Abuse, 2, 217–235.

Hathaway, S.R., and McKinley, J.C. (1989). Minnesota

Multiphasic Personality Inventory–2. Minneapolis: University of Minnesota Press.

Herman, J.L., Perry, J.C., and Van der Kolk, B.A.

(1989). Childhood Trauma in Borderline Personality

Disorder. American Journal of Psychiatry, 146, 490–495.

McConnaughy, E.A., Prochaska, J.O., and Velicer,

W.F. (1983). Stages of Change in Psychotherapy:

Measurement and Sample Profiles. Psychotherapy:

Theory, Research, and Practice, 20 (3), 368–375.

McLellan,A.T., Luborsky, L.,Woody, G.E., and O’Brien,

C.P. (1980).An Improved Diagnostic Evaluation

Instrument for Substance Abuse Patients:The

Addiction Severity Index. Journal of Mental and

Nervous Disease, 168 (1), 26–33.

McLellan,A.T., Kushner, H., Metzger, D., Peters, R.H.,

Smith, I., Grissom, G., Pettinati, H., and Argeriou, M.

(1992).The Fifth Edition of the Addiction Severity

Index. Journal of Substance Abuse Treatment, 9,

199–213.

Miller,W.R., and Tonigan, J.S. (1996).Assessing

Drinkers’ Motivation for Change:The Stages of

Change Readiness and Treatment Eagerness Scale

(SOCRATES), Psychology of Addictive Behaviors, 10,

81–89.

Millon,T. (1983). Millon Clinical Multiaxial Inventory:

Third Edition. Minneapolis, MN: Interpretive Scoring

Systems.

——— (1992). Millon Clinical Multiaxial Inventory: I

and II. Journal of Counseling and Development, 70 (3),

421–426.

Morey, L.C. (1991). The Personality Assessment Inventory: Professional Manual. Odessa, FL: Personality

Assessment Resources.
Teplin, L.A., and Schwartz, H. (1989). Screening for

Severe Mental Disorder in Jails. Law and Human

Behavior, 13 (1), 1–18.

Simpson, D.D. (1993). TCU Forms Manual: Drug Abuse

Treatment for AIDS-Risk Reduction (DATAR). Fort

Worth,TX:Texas Christian University, Institute of

Behavioral Research.

Skinner, H.A., and Horn, J.L. (1984). Alcohol Dependence Scale: User’s Guide. Toronto:Addiction

Research Foundation.

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INSTRUMENTS FOR SCREENING AND ASSESSMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS