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Mental Health Programs: Addressing the Unfunded Mandate

Posted on: Friday, 14 October 2005, 03:01 CDT

By White, Thomas W; Gillespie, Elizabeth

The October 2005 edition of Corrections Today featured a series of articles about one of the fastest growing and most vexing problems facing correctional administrators today: managing mentally ill offenders. Given the generally accepted high-risk nature of mentally ill offenders, almost every nationally recognized organization, including the American Correctional Association,1 the American Psychiatric Association,2 the National Commission on Correctional Health Care3 and the American Jail Association, have developed standards and/or support standards that call for written policies and procedures governing the treatment of the mentally ill. Although these standards are neither state nor federally mandated, they have, nevertheless, been instrumental in creating the framework that guides policy development in most state and local facilities and all federal correctional facilities.

However, because these guidelines are drawn quite broadly, they do not ensure standardization from state to state, even when written policy exists. Consequently, the resulting mental health programs are often very different in focus, implementation strategy and staffing patterns. Thus, even though most correctional systems today have some type of mental health policy in place, it is impossible to predict the components of any given program or the extent to which it is actually effective in meeting the needs of mentally ill offenders.

Scope of the Problem

Even with the impetus provided by professional standards, the management of the mentally ill in jails and prisons has been driven primarily by the courts, such as in the cases Madrid v. Gomez and Ruiz v. Estelle. The increased level of judicial scrutiny and oversight can be attributed to many social and political factors, but the most significant reason has been the sheer number of mentally ill offenders in federal, state and local custody. Although exact statistics are elusive, the Bureau of Justice Statistics reports that there are about 600,000 to 700,000 mentally ill offenders admitted to jails each year, and about 16 percent of the nearly 2 million prison inmates in the United States are also diagnosed with some form of mental illness. The rate of severe mental illness has also been bound to be greater in prison than in the community.4 Many of these offenders also have co-occurring substance abuse problems as well.5 The increase in mentally ill offenders can be attributed, in large part, to funding reductions for community-based social service programs and inpatient psychiatric hospitals, leaving many mentally ill people without access to treatment. Those with mental illness who committed crimes have been more likely to be arrested,6 and eventually they have found themselves in custody. However, being in custody has not diminished their need for mental health treatment. Rather, it only shifted the demand for treatment from the community to the criminal justice system.7

In fact, many experts argue that the criminal justice system is now the last-resort provider for many hard-to-serve clients and is fast becoming the de facto mental health treatment resource for the nation's poor and disadvantaged.8 However, correctional administrators, unlike community providers, cannot shift responsibility for treating these offenders. Due to constitutional requirements to provide adequate medical care, they have a legal duty to provide the services or face the very real threat of court intervention and sanctions. It does not help that these new responsibilities have come at a time when corrections at local, state and federal levels are experiencing decreases in their own levels of funding.

An Unfunded Mandate

In essence, correctional systems across the nation are being asked to fulfill what amounts to an enormous unfunded mandate. They are being told to provide mental health programming in addition to maintaining security and custody. Their primary security mission is often seen as an incompatible role to mental health programming, particularly at current funding levels. Most prisons and jails are not and have never been structured to deal with these unique, high- maintenance offenders. Historically, prisons have been structured to manage the 80 percent of offenders who are not mentally ill and who represent a realistic threat of violence or escape. As such, it is often difficult for managers to initiate the type of institution flexibility that can accommodate the needs of the mentally ill, while still fulfilling the prison's basic mission of incapacitation and deterrence, which society expects and demands.

The problem, of course, is that without sufficiently flexible policies and procedures, mentally ill offenders experience more difficulties in prison and jails, which can worsen their mental illnesses. For example, because they experience increased adjustment problems,10 offenders with mental illness often bounce back and forth between the general population and special housing units, sometimes experiencing long periods of time in segregated housing. After several failed attempts at adjustment, many are transferred to higher security institutions where there are more staff and more behavioral controls. As they move up the security structure, inmates with mental illness have limited access to institution privileges" and consume even larger portions of the available correctional resources. To make matters worse, inpatient psychiatric bed space is often more scarce for offenders in prison and jail systems than in the community. Consequently, only the most psychotic inmates can be transferred from regular institutions to inpatient settings, leaving many sub-acute inmates to remain in institutions with less-than- optimal treatment conditions and a small number of professional mental health treatment providers.

Unintended Consequences

The unintended consequence of this all too common scenario of moving offenders up the security ladder is that it often does deprive the mentally ill of adequate treatment, despite the best intentions of institution managers. In too many instances, mentally ill offenders do not have sufficient opportunities to remain in open population or receive treatment other than periodic reviews and psychiatric medication. Under these circumstances, their psychological conditions can quickly deteriorate12 and can lead to increased risks of suicide, violence or psychotic episodes.13 In fact, many completed suicides occur in segregation and are committed by offenders with mental illness.14 Should these adverse incidents occur in sufficient numbers, the likelihood of further court intervention also increases, closing the circle of action and reaction between the court and the correctional system. The resulting litigation and court oversight can often create tremendous upheavals in the prison or jail system and can require much more costly interventions than would have been needed if more moderate but adequate remedies had been initiated earlier in the process.

Unrecognized Problems

In fairness, it is hard for high-level managers to judge the efficacy of their programs because they are typically far removed from institutions where the programs are actually implemented. It is only in the aftermath of a completed suicide or other highly visible events that a mental health program's effectiveness comes under intense scrutiny. If problems are discovered at that point, it is often too late. Therefore, a major dilemma facing correctional administrators is how to appraise the effectiveness of their most high-risk, high-visibility programs before they are faced with obvious problems and potential litigation.

Policy Review

Since it is impossible to fix problems unless they are known to exist, the first step toward more effective mental health treatment is a top-to-bottom assessment of the department's current program. It is obviously preferable to do this before problems arise, but even in the midst of controversy, it is still necessary. The assessment begins with an objective review of policy to determine if it provides adequate direction, oversight and accountability. The fact that a policy exists is no guarantee that it provides any meaningful direction or accountability. Frankly, this is because policies are often written in such general terms that they allow wide variability in their actual application. While some flexibility for institution managers is desirable, too much ambiguity often results in inconsistency, defusion of responsibility and unpredictable levels of care. Multiplied across several institutions, these inequalities easily create hard-to-justify variations in the delivery of care.

Quality Control

While good policy is essential, it is of little value without meaningful oversight. To paraphrase President Reagan's famous quote, administrators should trust staff to comply with policy, but verify they are doing it. Even the best, most conscientious employees may cut corners under pressure, and without regular oversight, periodic corner-cutting can become standard practice. Eventually, squares become circles. To extend the analogy, the administrators who think they have a square mental health program may be very surprised to find many circles of many sizes that theycannot defend if problems arise.

Adequate oversight of mental health programs occurs on several levels and is defined differently at each level. At the central office or department level, it means having, at a minimum, one identified position as a director or coordinator of mental health services. This person should be a mental health professional who is qualified by training and experience in the delivery of mental health treatment and programs. Corrections professionals, physicians or other nonpsychiatric health care professionals are not typically qualified to fill this type of position but may have administrative supervision over it. In addition to general oversight of all mental health programs, the mental health director should serve as the department's subject matter expert and have ty for formulating and revising existing departmental policy. However the most important factor for success is the development of standardized, quality control mechanisms or audits to ensure policy compliance at all levels. This should typically entail regular reports and record- keeping requirements as well as periodic visits to each institutional program to conduct an in-depth review of policies and procedures. Any deficiencies should be routinely reported to administrators with the power to take needed corrective actions, and follow-up should ensure that deficiencies are addressed.

At the institutional level, oversight means identifying one mental health professional to be responsible for implementing all aspects of the mental health policy. The institution professional should be capable of providing direct supervision of treatment providers and able to assess the quality of treatment being offered to offenders. There should also be direct administrative supervision of the institution professional to ensure that basic policy requirements are being fulfilled on a daily basis. Administrative supervision in conjunction with audits conducted by the central office director should ensure a relatively high degree of certainty that broad policy requirements are being adequately maintained.

Inpatient Services

Finally, there must be adequate inpatient treatment facilities to ensure that offenders with severe mental illness receive intensive treatment when institution resources are exhausted. At a minimum, this should consist of sufficient access to traditional mental health providers such as psychiatrists, psychologists, social workers, psychiatric nurses, and vocational and recreation professionals. Provision of these services can be accomplished in a variety of ways, as indicated in the National Institute of Corrections publication titled Mental Health Services: Guidelines to Expand and Improve Treatment. Individual systems may develop their own hospitals, open treatment units within prisons, use existing state mental health facilities or personnel, or they may contract bed space as needed from outside the system. The development of transitional care facilities that offer services and staffing that fall between what is available in the inpatient hospitals and standard institutions can also be a very cost-effective way to maximize services.

Cost Effectiveness

By this point, reader may be shaking their heads and asking how they can pay for these expensive changes. In fact, it may be easier and less expensive than it seems. For example, is it possible to find one position in the entire department of corrections to convert to a mental health director? If the answer is yes, and it probably is, then several important program initiatives become immediately available, simply by creating this position. The first is the development of more detailed policy that provides better direction, oversight and accountability for all mental health programs. The second is the development of audit review standards as well as the implementation of actual audits. Next, the coordination of programs and training brought about by this position will increase consistency of operations and ensure better continuity of care throughout the system. Finally, clear policy direction coupled with an identified mental health provider at the institution level will similarly ensure greater consistency and accountability in each institution.

Thus, by increasing the central office staff by one position and redefining the responsibilities of some institution providers, it is possible for almost any correctional system to immediately increase its ability to better coordinate programs, increase consistency and accountability, and ensure far more continuity of care for its mentally ill offenders. Although not a total solution for some agencies, these relatively simple and inexpensive administrative changes would address the most common problems facing many correctional systems.

Outsourcing Services

The final issue, inpatient services, may be a more formidable task, depending on what is already available. However, regardless of the existing system, considerable savings as well as increases in patient care can typically be gained by outsourcing specific professional services for specified periods of time, with very measurable goals to achieve. Perhaps the most obvious example would be contracting psychiatric services on an hourly basis for routine medication management for compliant offenders. Therapy services could also be contracted on a session-by-session basis to provide drug treatment, sex offender classes or group therapy. Similar strategies can be employed for education programs, recreation and occupational therapy. The use of consultants or part-time employees directly under the supervision of full-time institution staff ensures that offenders receive sufficient programming at minimum cost.

Transitional Care Programs

A frequently overlooked option to improve the quality of mental health care is the development of transitional care programs as either stand-alone facilities or units located within individual prisons. Often, mentally ill offenders are overclassified due to their poor institution adjustment and find themselves in costly high- security institutions that far exceed their true custodial needs. Developing small therapeutic units within several prisons of varying security levels can provide sheltered environments in appropriate security settings. A few specially trained and motivated staff under the nominal oversight of institution mental health professionals can provide daily supervision of these units. Combined with some contracted treatment services, transitional units lessen the need for costly inpatient services, facilitate better institution adjustment and reduce confinement in segregation, thereby lowering the potential for psychotic episodes, violence or suicide.

It can be relatively simple and very cost effective to develop quality services for mentally ill offenders. Because correctional systems differ considerably, some of these recommendations may be beneficial for some and not for others. Nevertheless, the process of building a quality mental health delivery system begins with a thorough assessment of current policies and programs to identify any existing weaknesses or deficiencies. If conducted objectively, this assessment should not only uncover weaknesses but should also give administrators a road map for correcting problems. Also, by establishing adequate quality control procedures and oversight mechanisms, managers can ensure continued policy compliance in the future. Most important, these procedures will ensure adequate treatment is provided to the offenders in their care.

Unilaterally exposing potential problems may sound counterintuitive to some administrators. However, it is far better in the long run for the system, and for the administrators themselves, to proactively acknowledge and correct deficiencies before they become crises that will set in motion costly and unnecessary litigation. Although correctional practitioners have not asked to become de facto mental health providers, they, nevertheless, have little choice but to accept these new roles as both an opportunity and challenge. In the final analysis, corrections must be willing to fulfill this new mission with the motivation, determination and perseverance that has characterized the profession's acceptance of previous challenges.

ENDNOTES

1 American Correctional Association. 1990. Standards for adult correctional institutions, third edition. Laurel, Md.

2 American Psychiatric Association. 2000. Psychiatric services in jails and prisons, second edition. Washington, D.C.

3 National Commission on Correctional Health Care. 1997. Standards for health care in prisons, third edition. Chicago.

4 Hills, H., C. Siegfried and A. Ickowitz. 2004. Effective prison mental health services: Guidelines to expand and improve treatment. U.S. Department of Justice, National Institute of Corrections.

5 Sundram, C.J. 1999. Quality assurance for mental health services in correctional facilities. Correctional Mental Health Report, 1(1):5.

6 Tiplin, L.A., 2000. Keeping the peace: Police discretion and mentally ill persons. National Institute of Justice Journal, July. Washington, D.C.

7 Council of State Governments. June, 2002. Criminal justice/ mental health consensus project. N.Y. Council of State Governments, Eastern Regional Office.

8 Baselon, D.L. 2003. Criminalization of people with mental illness: The role of mental health courts in systems of reform. Jail Suicide/Mental Health Update, 12(1):2.

9 Morgan, D.W., A.C. Edwards and L.R. Faulkner. 1993. The adaption to prison by individuals with schizophrenia. Bulletin of the American Academy of Psychiatry and the Law, 21(4):427-433.

10 DiCataldo, F., A. Greer and W.E. Profit. 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 an\d treatment of inmates and probationers. Washington, D.C.: Department of Justice: Bureau of Justice Statistics.

11 DiCataldo, F., A. Greer and W. Profit. 1995.

12 Reid, W.H. 2000. Offenders with special needs. Journal of Psychiatric Practice, 6(5):280-283.

13 Kupers, T. 1999. Prison madness: The mental health crisis behind bars and what we must do about it. San Francisco: Jossey- Bass Inc.

14 White, T.W., D.J. Schimmel and R. Frickey. 2002. A comprehensive analysis of suicide in federal prisons: A fifteen year review. Journal of Correctional Health Care, 9(3):331.

15 Cohen, F. and J. Dvoskin. 1992. Inmates with mental disorders: A guide to law and practice (part 1). Mental and Physical Disability Law Reporter, 16:339-346.

Thomas W. White, Ph.D., is a principal with Training and Consulting Services (www.suicideconsultant.com) in Kansas City, Kan. Elizabeth Gillespie is the director of the Shawnee County Department of Corrections in Topeka, Kan., and is responsible for adult and juvenile detention.

Copyright American Correctional Association, Incorporated Oct 2005

Source: Corrections Today

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