Journal of Psychosocial Nursing and Mental Health Services

Psychopharmacology 

Challenges of Treating Mental Health Issues in Correctional Settings

Brenda G. Kucirka, PhD, PMHCNS-BC, CNE; Jeffery Ramirez, PhD, PMHNP, CARN-AP

Abstract

The current article explores the challenges of correctional nursing and provides implications for nursing practice and advocacy for optimal outcomes for incarcerated individuals with mental illness. The role of the nurse as advocate and educator is discussed. Opportunities for changing the conversation that addresses the criminalization of mental illness, stigma, and social policy is presented as a path forward. [Journal of Psychosocial Nursing and Mental Health Services, 57(7), 7–12.]

Abstract

The current article explores the challenges of correctional nursing and provides implications for nursing practice and advocacy for optimal outcomes for incarcerated individuals with mental illness. The role of the nurse as advocate and educator is discussed. Opportunities for changing the conversation that addresses the criminalization of mental illness, stigma, and social policy is presented as a path forward. [Journal of Psychosocial Nursing and Mental Health Services, 57(7), 7–12.]

Psychiatric–mental health nurses (PMHNs) practicing in the correctional system face significant challenges when providing care to incarcerated individuals who are exhibiting behavioral symptoms and those diagnosed with mental illness. Multisource data as well as conversations with nurses working in the correctional system highlight the ethical dilemma that occurs as they attempt to reconcile available treatment options with psychiatric–mental health best practice guidelines (Ellis & Alexander, 2017; Gorman, 2018; Mollard & Hudson, 2016), thus creating a cognitive dissonance that intensifies the sense of futility expressed by many who seek to provide care to individuals with mental illness in the correctional system.

Prisons and jails have become de facto mental health care institutions. This situation is an unintentional consequence of deinstitutionalization and lack of adequate access to care for individuals with mental illness (Bard, 2018; Sayers, Domino, Cuddeback, Barrett, & Morrissey, 2017; Segal, Frasso, & Sisti, 2018). As the number of available psychiatric treatment beds have decreased across the country, there has been a shift from hospitalization to incarceration of individuals with serious mental illness (SMI) and substance use disorders (Bard, 2018; Treatment Advocacy Center, 2016). This criminalization of mental illness has resulted in an overrepresentation of individuals with mental illness in the correctional system (Bard, 2018; Ellis & Alexander, 2017).

The focus of the current article is to describe the challenges nurses encounter when trying to provide mental health care and treatment in the correctional setting. Implications for nursing practice and advocacy that support optimal outcomes are discussed. Opportunities for changing the conversation that addresses the criminalization of mental illness, stigma, and social policy is presented as a path forward.

For the purposes of the current article, the term correctional nursing is used, which includes jails and prisons even though jails are short-term stays (i.e., typically <1 year) and prison terms are longer in duration. Jails and prisons have similar challenges in meeting the needs of individuals with mental illness in their custody.

Significance and Background

The passage of the Community Mental Health Act of 1963 forced many state hospitals to close their doors and discharge individuals with SMI to the community or streets (Torrey, 2014). More than 50 years later, individuals with mental illness are being housed in jails and prisons at record high numbers (Torrey, 2014). It is estimated that there are 400,000 incarcerated individuals who have a mental health disorder; of these individuals, 25% are diagnosed with a SMI (Allison, Bastiampillai, & Fuller, 2017; Hirschtritt & Binder, 2017). In 2016, the National Alliance on Mental Illness reported approximately 2 million individuals who experience mental health crises are more likely to have law enforcement be the first responders than mental health professionals. Furthermore, individuals with mental illness arrested for non-violent crimes and detained in jails do not receive the mental health care they need and spend a longer time in jail or prison than their counterparts without mental illness. The stress and trauma of the correctional environment often exacerbates their mental illness and for individuals who are undertreated, symptoms of paranoia and agitation may be heightened (Allison et al., 2017).

Challenges to Mental Health Care in Correctional Settings

Stigma

Individuals with mental illness who are arrested and have a criminal record are doubly stigmatized. They are stigmatized for their mental illness and are viewed as more dangerous and violent. In addition, they carry the stigma of being a criminal for committing a crime, which is often a minor crime, yet they are detained in jail to await their court date for longer periods of time then individuals without mental illness (Grohs, 2017). Furthermore, it has been established that individuals with mental illness are at higher risk of being violent when their mental illness is not properly treated. Individuals with mental illness in the criminal justice system also have the stigma of lower socioeconomic status, homelessness, and substance use disorders (Dhaliwal & Hirst, 2016).

Stigmatization and lack of validation or recognition of one's humanity in the correctional setting results in a sense of demoralization among incarcerated individuals (Jacobs & Giordano, 2018). There is a perception among many correctional officers and prison staff that all incarcerated individuals are manipulative, discounting the impact of trauma and mental illness on behavior. Psychiatric symptoms are often viewed as feigned and treated with harsh punishment, which includes the use of solitary confinement, segregation in restrictive housing units, and physical and psychological abuse (Bard, 2018; Galanek, 2013). This lack of knowledge regarding mental illness coupled with interactions that are not trauma informed can result in increased severity of illness and exacerbation of psychiatric symptoms (Mollard & Hudson, 2016).

In addition, self-stigma may prevent individuals with mental health issues from seeking treatment. The fear of appearing weak or becoming a victim may cause some to deny their illness, whereas others may simply be unaware that the symptoms they are experiencing are related to mental illness. Screening for mental health issues and obtaining a medical history would help identify individuals in need of treatment who do not actively seek treatment (Burns, 2011; Kolodziejczak & Sinclair, 2018).

Barriers to Treatment

Limited resources, including time, staff, and restrictive formularies, create challenges and barriers to effective mental health treatment (Burns, 2011; Ellis & Alexander, 2018; Kolodziejczak & Sinclair, 2018). Large caseloads with limited time allotted for individual treatment beyond assessment and prescribing psychotropic medications is not congruent with best practice. The potential for establishing a therapeutic rapport is lost when nurses are forced to medicate and move on.

The practice of medicating without providing psychotherapy may be less time intensive; however, it does not meet best practice guidelines (Kolodziejczak & Sinclair, 2018). Although this practice is seen as using limited resources most efficiently, it is not using them most effectively.

When correctional staffing is short or movement is restricted, treatment does not occur, leading to inconsistent treatment. Medications are not consistently dispensed and individuals without overt symptoms or disruptive behaviors are not identified as needing mental health treatment. Conversely, individuals with disruptive behaviors unrelated to mental illness may be identified as having a mental illness. Over-diagnosing and under-diagnosing are barriers to treatment (Kolodziejczak & Sinclair, 2018). Time may be spent with individuals who do not need treatment but want medication and know how to manipulate the system, whereas those who would benefit from psychotropic medications are not screened or treated.

Limited formularies and restrictive prescribing policies as well as delays in starting medication contribute to ineffective or poorly managed pharmacotherapy. Substitutions and arbitrary medication changes may precipitate decompensation (Jacobs & Giordano, 2018; Watson, 2016). Failure to effectively manage symptoms in turn impacts the well-being and safety of incarcerated individuals with mental illness as well as the general prison population. This is an ethical issue that cannot be ignored. It is cruel, inhumane, and unethical to fail to address symptoms. Furthermore, it places individuals with mental illness at risk of being victimized and further traumatized.

Care and Custody

Prison structure and culture do not align with nursing ideals of caring and compassion. Historically, the purpose of prison was to provide containment and punishment for accused criminals. Safety and security are the priority with treatment viewed as a privilege rather than a necessity. The imperative of order and control takes precedence over establishing a therapeutic rapport and providing therapeutic interventions (Segal et al., 2018). For example, when a prison is in lock down, movement is suspended; thus, treatment does not occur. Lack of consistency in treatment due to the overarching mandate for control and order in the institution results in unmet mental health needs.

The prison environment is often devoid of caring. Dehumanization and oppression are used to keep inmates in line. The correctional milieu is not congruent with the therapeutic milieu. Although the correctional milieu offers containment, it does not offer the structure (consistency), support, involvement, and validation associated with the therapeutic milieu (Gunderson, 1978) where healing can occur. Many correctional officers resent when nurses extend compassion and caring, asserting that prison is for punishment, not care (Ellis & Alexander, 2017). Correctional officers have the authority to make decisions regarding priority for care and need based on their assessment of the situation without an understanding of the nature of the problem, psychodynamics, or psychopathology. The inability of correctional officers to differentiate between volitional acting out and symptoms of mental illness creates a barrier for incarcerated individuals to access care (Gorman, 2018; Segal et al., 2018).

Nursing promotes a caring paradigm and is not typically focused on custody and security issues. Due to lack of focus on custody and emphasis on care, PMHNs can have philosophical and ethical conflicts with correctional officers related to the competing forces of nursing care and custodial control (Dhaliwal & Hirst, 2016; Ellis & Alexander, 2017). Nurses are challenged to straddle the chasm between custody and care. The requirement of adhering to the restrictive, oppressive policies of the correctional system while staying true to nursing ethical principles of treating patients/clients with respect, dignity, and compassion and protecting human rights can create moral distress (Lazzari et al., 2019). Nurses must rely on creative problem solving, thinking outside the box, to work effectively within the system. It is important for nurses to gain an understanding of the role of correctional officers so that they can partner with them for optimal outcomes. Correctional officers can provide structure and help incarcerated individuals learn prosocial behaviors by holding them accountable to the rules. Nurses can broaden the perspective of correctional officers through education and compassion to help correctional officers understand mental illness, behaviors, and how to communicate therapeutically. Ultimately, by drawing on each other's strengths, nurses and correctional officers can forge a positive working alliance to address the mental health care needs of incarcerated individuals.

Therapeutic Rapport

The crux of psychiatric–mental health nursing is the nurse–patient relationship. However, in the correctional setting, it becomes the nurse–inmate relationship. This setting brings a different level of complexity to the relationship. Working with individuals with mental illness in correctional settings requires nurses to be mindful of the relationship, environment, and correctional rules and regulations. Nurses need to have knowledge in psychiatric–mental health nursing and the criminal justice system (Ellis & Alexander, 2017). The reality that there are individuals with antisocial personality disorder and traits that will exploit the caring intentions of nurses for personal gain and to receive medication cannot be discounted. As all behavior has meaning, nurses must hone their ability to discriminate among intentional manipulation, criminal intent, and psychopathology.

Nurses must provide the same quality and evidence-based care regardless of the incarcerated individual's criminal offense. Providing this care can be difficult when nurses are made aware of the criminal acts of an individual, especially if they have a personal history of victimization. Correctional nurses must remain nonjudgmental and cognizant of their preconceived judgments to prevent fracturing therapeutic rapport (Dhaliwal & Hirst, 2016).

To build a therapeutic relationship within the correctional environment, nurses will need to identify their personal views, biases toward certain populations, and assumptions about individuals who are incarcerated (Dhaliwal & Hirst, 2016; Ellis & Alexander, 2017). If nurses are unable to identify these critical aspects of developing self-awareness and reflective practice, this can become a barrier to providing quality mental health care or achieving a therapeutic relationship.

Another element of promoting a therapeutic relationship requires healthy boundaries. One must be vigilant for transference and countertransference in the nurse–inmate relationship. Failure to recognize these dynamics may lead to boundary blurring, crossing, and the potential for exploitation (Peternelj-Taylor & Yonge, 2003). Nurses are educated and trained to be caring and nurturing, seeking to establish a therapeutic connection. The correctional setting does not share this philosophy; correctional officers are trained to maintain order and control. This training promotes a harsh, non-therapeutic environment where caring and sensitivity are viewed as weakness and a liability. There are strict restrictions on any type of touching or disclosing personal information. Having firm boundaries prevents nurses from being manipulated or intimidated by an inmate (Dhaliwal & Hirst, 2016). It is important to note that the manner in which one sets boundaries must always be respectful.

Implications for Practice

PMHNs must establish strategies to navigate the challenges of correctional nursing. Establishing strategies can be accomplished through collaboration with correctional institutions to develop programs that provide training and education to correctional officers and prison staff regarding mental health and mental illness and therapeutic communication (Melnikov, Elyan, Schor, Kigli, & Kagan, 2017). Teaching correctional officers and staff about mental health, mental illness, and therapeutic communication is essential in supporting the well-being of individuals who are incarcerated. Education can be used to decrease stigmatization by increasing awareness of the experience and impact of mental illness. Education supports the development of empathy through shifting perspectives and developing contextual awareness (Segal, 2011).

The correctional setting can be a traumatic experience, and for those who have a history of trauma, it can be a source of retraumatization. Providing education on trauma and trauma-informed care using the 4Es Model of Trauma-Informed Care provides a framework to expand understanding of trauma and the impact of trauma. The components of the 4Es model are educate, empathize, explain, and empower (Mollard & Hudson, 2016). These principles are used to inform interventions and interactions to support improved well-being for individuals who have experienced trauma.

Barriers to treatment can be addressed through advocacy for policies that support access to care and alternatives to incarceration, such as jail diversion programs for individuals with SMI (Ellis & Alexander, 2018; Sayers et al., 2017). Collaborative relationships can be cultivated with prison administrators to develop treatment models that support best practice guidelines. Nurses should become familiar with prison formularies and prescribing procedures and restrictions. Nurses can also advocate for expanding prison formularies using evidence-based protocols and policies that allow for off-formulary prescribing when indicated on a case-by-case basis (Burns, 2011).

Conclusion

PMHNs can and should be leaders in shaping social policies through advocacy. Nurses can advocate for prison reform and policies that are proactive in nature, such as access to mental health care in the community. By meeting and educating legislators about mental health issues, PMHNs can inform policy makers to support policies and initiatives that address access to care and mental illness in the correctional system. Advocating for increased access to care is a powerful strategy that supports individuals with mental illness and their families. Placing an emphasis on education, primary prevention, and case finding has the potential to decrease the prevalence of incarceration of individuals with SMI and substance use disorders (Allison et al., 2017; Bard, 2018).

It is important to mentor new nurses and prepare future nurses to serve this population and address this social justice issue. Nursing education should include content on correctional nursing in the curriculum in didactic and clinical courses. Discussions on mass incarceration and social justice will increase awareness of the needs of incarcerated individuals. This awareness has the potential to transform care for incarcerated individuals, families with a history of incarceration, and formerly incarcerated individuals.

As advocates for social justice, nurses need to engage in a dialogue to generate ideas and strategies to support access to care for those with mental illness in correctional institutions. So many of us working in psychiatric–mental health nursing are passionate about our service. We need to harness that passion and call on our colleagues in other specialties to join us in this much needed fight to help shape future health care policy changes.

Although correctional nursing has many challenges, it also has rewards. Nurses make a significant difference in the lives of incarcerated individuals by bringing compassion into a setting where kindness and validation are scarce. Establishing work-life balance and practicing self-care is essential for those who work in corrections to decrease the potential for vicarious trauma (Osofsky, Putnam, & Lederman, 2008). Nurses can join a peer supervision group to provide a forum for debriefing, address issues of countertransference, share experiences, and seek validation.

References

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Section Editor's Note

Kucirka and Ramirez cogently described the challenges of treating inmates in jails and prisons in the United States. The absolute right to community standard health care for this population was established by Estille v Gamble in 1976 and reaffirmed by Brown v Plata in 2011. Prescribing psychotropic medications poses challenges in that assessments require an honest and cooperative interview with the client; however, individuals who are being held against their will would likely have a vested interest in presenting in a self-protective manner. They may over- or under-report symptoms for a variety of reasons, including to obtain protective housing, to shield against impending punishment for rule infractions, to relieve boredom, or for fear due to environmental conditions (Simpson, 2016). Medication-seeking is common, especially for selective medications that have sedating and/or stimulating qualities. Thus, many drugs are unavailable on formularies, even though they may be appropriate in community settings for treatment of symptoms experienced by inmates. Stimulants for attention-deficit/hyperactivity disorder are rarely available for treating this diagnosed condition; treatment is limited to environmental strategies of structure and boundary setting. In addition, benzodiazepine agents are usually restricted due to their high risk for abuse and diversion.

Other commonly abused medications include bupropion (Wellbutrin®) and venlafaxine (Effexor®) due to stimulant-like effects. Gabapentin (Neurontin®) can be used for sedation and is easily crushed and snorted for added effect or may be diverted for barter among other inmates. Quetiapine (Seroquel®) is often requested by inmates at higher doses than necessary to withdraw and relax from environmental stresses, and to a lesser extent, other serotonin-dopamine antagonists, such as aripiprazole (Abilify®), olanzapine (Zyprexa®), and risperidone (Risperdal®), are also requested. Therefore, dopamine antagonists, such as haloperidol (Haldol®) and fluphenazine (Prolixin®), are more likely to be offered on the formulary with consequential burden and risk of extrapyramidal effects and tardive dyskinesia (Del Paggio, 2012).

However, as Kucirka and Ramirez note, a high percentage of inmates have previous medical, psychiatric, and substance use diagnoses that need to be addressed. The correctional setting is a highly stressful place that inmates view as threatening and adding to their pre-existing mental health conditions. The National Commission on Correctional Health Care (2018) and the American Correctional Association (2017) have published standards for health care services that focus on quality delivery of medical and mental health services within correctional systems (American Academy of Psychiatry and the Law, 2018). These standards provide guidelines for prescribing and providing alternative psychotherapeutic services for individuals with mental health and substance use disorders.

So how do advanced practice psychiatric nurses (APPNs) provide humane care for inmate patients in jails and prisons? Although these patients have fewer options in selecting their APPNs or therapists, negotiating treatment plans, or seeking alternative treatments, they can still collaborate in their treatment. It is a challenge for APPNs to maintain appropriate boundaries and compassion for these patients, yet there are rewards in collaborative care. Services can be provided in small groups as well as individual modalities. Helping these patients learn coping, problem-solving, and interpersonal skills can fill the gaps in limitations of medications. Lithium, an often underused medication for those at risk for suicide and treatment-resistant depression, can be beneficial for inmates as an alternative to stimulating antidepressant agents. Another often overlooked effective alternative to sedatives and hypnotics is the development of sleep hygiene practices amenable to jail and prison environments. Mental health nursing in correctional settings can be rewarding and exciting, allowing for creative ways of providing care for a vulnerable population.

References

Barbara J. Limandri, PhD, PMHNP, BC

Authors

Dr. Kucirka is Assistant Professor, Widener University School of Nursing, Chester, Pennsylvania; and Dr. Ramirez is Associate Professor, Gonzaga University, Spokane, Washington.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Brenda G. Kucirka, PhD, PMHCNS-BC, CN, Assistant Professor, Widener University School of Nursing, One University Place, Founders Hall 319, Chester, PA 19013; e-mail: bkucirka@widener.edu.

10.3928/02793695-20190612-02

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