Psychiatric Annals

Psychiatry in Correctional Systems

Francis A J Tyce, MD

Abstract

1. Howard, J. The State of the Prisons in England and Wales and an Account of Some Foreign Prisons. London: William Eyres, 1777.

2. Howard. J . An Account of the Principal Lazarettos in Europe, etc. London: William Eyres, 1789.

3. Coleman. L. Prisons; The crime of treatment. Psychiatr Opin. 2:3 (June, 1974).

4. Buerre de Brismont. The criminal Insane of England. Am. J. Psychiatry 27, 284.

5. Dix, D. L. Soliciting a state hospital for the insane. Submitted to the Legislature of Pennsylvania, Philadelphia, February 3, 1845. Isaac Ashmeaü. printer.

6. Wilson. D. P. My Six Convicts. New York: Rinehart & Company, 1951, p. 35.

7. Mueller, G. O W, Medical services in prison: Lessons from two surveys. CIBA Foundation Symposium 16 (1973), 6-7.

8. Halleck, S. American psychiatry and the criminal: A historical review, int. J. Psychiatry 6 (1968), 185-207.

9. McCartney. J. L. Intensive psychiatric study ot prisons; receiving routine in classification clinic Elmira Reformatory. Am. J. Psychiatry 13 (1934), 1183-1203.

10. Bruckner, D. J. In the Los Angeles Times. Quoted in tnePrison Mirror. Stillwater. Minn., Vol. 88, No. 14. July. 1975.

11. Gray, W. J. Grendon and the English prison: Medical service. CIBA Foundation Symposium 16 (1973), 131 .

12. Fully, G. Penitentiary medicine in France CIBA Foundation Symposium 16 (1973), 79.

13. Directory of the American Correctional Association. College Park: University of Maryland Press, 1975.

14. Press Release, November 17, 1976. Washington, D.C.: U.S. Department of Justice, Law Enforcement Administration Association.

15. Corrections, The Challenge of Crime in a Free Society. Report by the President's Commission on Law Enforcement and the Administration of Justice. Washington, D.C.: Government Printing Office, 1967, ch. Vl.

16. Corrections Magazine 2:3 (March, 1976), 10.

17. Trudel. R. Report of the National Criminal Justice Reference Service. December 31. 1974. Washington, D.C: Law Enforcement Administration Association.

18. Attorney General's First Annual Report. Federal Law Enforcement and Criminal Justice Activities Administration. Washington. D.C. : Government Printing Office, 1973. Quoted in Shervington, W. Psychiatr. Ann. 4:3 (March, 1974), 43.

19. Speed, D. Medical Office, H.M. Prison, Bristol CIBA Foundation Symposium 16 (1973), 46.

20. Mitford, J. Kind and Unusual Punishment: The Prison Business. New York: Alfred A. Knopf, 1973, p. 9.

21. Halleck, S. L. Rehabilitation of criminal offenders - A reassessment of the concept. Psychiatr. Ann. 4:3 (March, 1974), 61-85.

22. Rundle, F. Prisons: The crime of no treatment. Psychiatr. Opin. 2:3 (June. 1974). 17,

23. Nagel, W. G. The New Red Barn: A Critical Look at the Modern American Prison. New York: The American Foundation, 1973, pp. 129-139.

24. Martinson, R., Lipton, D., and Wi/ks, J. The Effectiveness of Correctional Treatment: A Survey of Treatment Evaluation Studies. New York: Praeger, 1975.

25. Jacobson. J., and Wirt. R. MMPI profiles associated with outcomes of group psychotherapy with prisoners. In Butcher. J. N. (ed.). Research Developments and Clinical Applications. New York: McGraw-Hill, 1969.

26. Kassenbaum, G., Ward, D., and Wilner, D. Prison Treatment on Parole and Survival: An Empirical Assessment. New York: John Wiley & Sons, 1971 .

27. Rubin, S. Psychiatry and the prison: A negative report. Int. J. Psychiatry 6 (1968). 218.

28. Keve, P. W. Prison Life and Human Worth. Minneapolis: University of Minnesota Press, 1974, pp. 182-186.

29. Keve. P. W. The need for community rehabilitation for legal offenders. Hosp. Community Psychiatry (March, 1971).

30. Tyce, F. A. P.O. RT. of Olmsted County, Minnesota. Hosp. Community Psychiatry (March, 1971), 22-26.

31 . Andennaes, J. Punishment and Deterrence. Ann Arbor: University of Michigan Press, 1974.

32. Tyce, F. A. Public hospitals as social restoration centers. Hosp. Community Psychiatry (March, 1969).

TABLE…

The talk that is the basis for this article was originally given at the Mayo Clinic at the Symposium honoring Dr. Howard P. Rome on October 30, 1976. It has been incorporated into the new International Encyclopedia of Psychiatry, Psychology, Psychoanalysis & Neurology and appears here through the courtesy of Benjamin B. Wolman, M.D., editor-in-chief. ®1977, International Encyclopedia of Psychiatry, Psychology, Psychoanalysis & Neurology, 10 West 66th St., New York, N.Y. 10023.

"if it were the wish and aim of the magistrates to effect the destruction - present and future - of young delinquents, they could not devise a more efficient method than to confine them so long in our prisons."

John Howard wrote that 200 years ago,1,2 but it might just as well have been said today. As Lee Coleman described the prisoner's world in 1974, "Were it our goal to systematically destroy human beings, we could have come up with no more clever scheme than this nightmare of powerlessness . "3

There is no more dismal chapter in man's history than that recording the effect of the systems society has developed and still uses to deal with its criminals. (When I say "criminals," I refer only to the 2 per cent of those who get caught and end up in the system; 98 per cent get away with it.)

A comparison of the correctional system that existed 200 years ago with that of today may help to identify some of the problems and indicate what we must do if we are to effect any worthwhile change. Over the past 200 years only a few significant changes in the system have been effected by medicine or psychiatry; it is time to ask why. Does the problem lie within the nature of the correctional system itself? If so, what fundamental changes should be made?

According to Howard's report on the state of prisons in England and Wales in 1777, the prisons were filled with felons and lunatics. Debtors made up half of the prison population; they were confined until they could pay their debts (although there was some pressure to keep them from being confined too long, since their creditors had to pay for the cost of their confinement!). It was not until 1816 that the English parliament decided that the criminally insane should be housed in a special institution.4*

Progress was slower in the United States. As late as 1845, Dorothea Dix could tell the Pennsylvania Legislature that "the insane will be found in jails and penitentiaries."5 Howard had advocated in 1777 that young offenders be separated from hardened criminals, men be separated from women, debtors from felons.1 But in some states as recently as 1930, prisoners were still being confined together without regard to sex, age, or criminal charge. Chains, shackles, flogging as a punishment for minor infraction of rules, complete silence, and permanent isolation were all common features of American prisons.6

What about physicians in prisons? In 1775, the king of England had ordered that "an experienced surgeon or apothecary be appointed to every gaol, a man of repute in his profession."1 In its Standard Minimum Rules for the treatment of prisoners, approved in 1955, the United Nations mandated that "at every institution there shall be available the services of at least one qualified medical officer who should have some knowledge of psychiatry."7 A survey in 1969 showed that 10 of the 31 nations reporting were in partial compliance, and 20 maintained they were in full compliance.7

As psychiatry developed during the early part of this century, many had high hopes that it could provide real solutions to the problem of criminal behavior. In a masterful review, Seymour Halleck has documented 100 events in the history of American psychiatry and the criminal.8 He reports that psychiatrists working in the criminal system were held in high esteem during the 1920s and 1930s. But their prestige began to decline in the late 1930s, reflecting "an unwillingness of the younger generation of American psychiatrists to engage in the problems of the offender."

In 1934 there were 48 full-time and 35 parttime psychiatrists working in prisons in the United States, according to the McCartney survey.9 According to current reports, there are no more than 50 full-time psychiatrists working among the 250,000 convicted offenders in state and federal prisons.10

SCOPE OF THE INSTITUTIONAL PROBLEM

Mueller has estimated that 10 million people throughout the world are being held in some sort of captivity.7 Comparative statistics are difficult to come by, since each nation has a different method of reporting. The United Kingdom has 111 prisons and borstals, with an average daily population of over 38,000 and 100,000 admissions a year11 (Table 1). France, with a population slightly greater than that of the United Kingdom, has 180 prisons of different sizes, a daily penitentiary population of 35,000, and 100,000 admissions a year.12

Table

TABLE 1PRISONS IN THE U.S., FRANCE, AND THE UNITED KINGDOM

TABLE 1

PRISONS IN THE U.S., FRANCE, AND THE UNITED KINGDOM

On an average day in the United States, there are 1.6 million offenders under correctional authority.16 About one-fourth of them are in jail or prison (Table 2); of these, some 250,000 are serving lengthy sentences in state or federal prisons (Table 3). Possibly 50,000 juveniles are now being detained in the United States. As the President's Commission on Law Enforcement and the Administration of Justice has noted, the corrections systems in the United States handle some 2.5 million admissions annually.15 And they spend more than $1.7 billion in doing so.18

Table

TABLE 2DISTRIBUTION OF PRISONERS IN THE UNITED STATES

TABLE 2

DISTRIBUTION OF PRISONERS IN THE UNITED STATES

Table

TABLE 3CORRECTIONAL FACILITIES IN THE UNITED STATES, FEDERAL AND STATE

TABLE 3

CORRECTIONAL FACILITIES IN THE UNITED STATES, FEDERAL AND STATE

Who are these prisoners? In England, Dr. Dorothy Speed has described the prison population as being composed of "roughly 10 per cent mad, 15 per cent bad, and 75 per cent sad."19 In the United States those who have become prison inmates "are predominantly black, young, unemployed, from large cities." Those who become guards "are overwhelmingly white, middle-aged, from small rural towns."20

To assume that psychiatry is having any meaningful effect on a system this large and complex is a delusion.

The problem lies not only in the size of the prison systems but also in the reality of the institutional experience today.2' A prison now consists of two disparate cultures - that of the guards and that of the inmates. Each has its own ethic. There is no mixing or crossing over; anyone who attempts to do this is dealt with summarily by his peers.

Recently a third group has been injected into the system - the mental health workers. This has invited disaster. The inmates have viewed the mental health workers as staff and have consequently mistrusted them. And when mental health workers have attempted to identify with inmates, the staff has viewed them as troublemakers and managed to get rid of them.22

Nagel has described various new treatment techniques used by mental health workers in some of the 100 correctional institutions he has visited in the '70s and has described his own experiences at Bordentown in 1959 and I960.23 He reports that despite the intensive treatment given by the mental health workers, they were unable to appreciably change the recidivist rate. Martinson and colleagues have come to a similar conclusion. Reviewing 231 accepted studies of correctional treatment that have been published since 1945, they found that little of this treatment noticeably affected the recidivist rate.24 Other longitudinal studies confirm these findings.25,26

What are we to conclude from these comparisons? The mass of evidence indicates that prisons really have not changed very much in the past 200 years. Prisons then and now house the poor, the minority groups, and the incompetent. They also house the violent, the mentally ill, the sexual offenders, the drug addicts and other psychologically disturbed human beings, and socially incompetent nondangerous people.*

The evidence suggests that psychiatric contributions to the prison system - the terminal point of the criminal justice system - have been small and ineffective. They have been ineffective in affecting both inmate recidivism and institutional attitudes. Since this is true, we must seriously consider Rubin's question: "Why work toward pouring more psychiatric help into prisons when most of the inmates need not, and should not, be there?"27

Seven out of every 10 of our prison inmates do not need maximum security and could be handled elsewhere, according to the consensus of many penologists.28,29 How do we prevent this 70 per cent of our prison population from getting into prison? What alternative situations are needed? Can psychiatry relate more effectively to some of these alternatives than it has to the present system?

The problem with the prison system and the route to it from the community is, as 1 see it, that it is a mechanistic system that fails to see the people caught up in it as potentially responsible human beings. At varying points within the system are small groups of living subsystems, where people struggle manfully to make the thing work. If the present system is not working - and it is not working successfully - alternative methods of correction must be found.**

AN ALTERNATIVE CORRECTIONAL PROGRAM

At present the route into the correctional system is apprehension, arrest, hearing, collection of evidence, trial, and disposition. There are four alternatives: dismissal (in which case no issue exists), fine or probation (in either of which cases the individual remains free in his community and is not started on the institutional route), and imprisonment (Table 4). 1 am not concerned here with the first three cases, only with the fourth - the person who gets caught up into the institutional system. I would like to propose an alternative correctional program for these people, who are now being sentenced to correctional institutions whether they are adults or juveniles, men or women.

My concept calls for four levels of descent into the correctional process. The first three - community correction centers, local jails, and regional rehabilitation centers - would be under community control. The fourth, the maximumsecurity prison, would be under state control (Table 5).

Table

TABLE 4THE EXISTING CORRECTIONAL SYSTEM

TABLE 4

THE EXISTING CORRECTIONAL SYSTEM

Table

TABLE 5AN ALTERNATIVE CORRECTIONAL PROGRAM OPTIONS OPEN TO THE JUDGE

TABLE 5

AN ALTERNATIVE CORRECTIONAL PROGRAM OPTIONS OPEN TO THE JUDGE

All four of these alternatives would be available to the judge in sentencing. And movement laterally in the system would be possible, according to the offender's conduct. That is, he could progress from the local jail to the community correctional center. Or he could move backward.

Let me discuss some of the features of each of these centers.

Community correction centers. Some community-based, community-directed, community-supported correctional centers for the criminal offender already exist28*30 as alternatives to prison in some communities. In Rochester, New York, the Probation Offenders Rehabilitation and Training program has been in existence for more than six years. During that period it has admitted more than 200 men, most of whom had originally been committed to prison.

What are the advantages of such a center? For one thing, all community resources are available - including psychiatry - for the rehabilitation of the community-based offender. But apart from this, two great differences separate such a facility from the prison. In the community correction center, the offenders are responsible for each other. They provide the security. Second, in all his contacts outside the institution, the offender is seen as a normal human being. He is treated as a responsible person; nothing distinguishes him as an offender. Were he to have been placed in a prison instead, he would be viewed at all times as a criminal.

How effective can such a center be? Well, the Rochester program reduced commitments to adult institutions by 70 per cent, and no juveniles at all were being sent to any institution.30 The 70 per cent reduction in adult commitment is interesting, since it coincides with the conviction of Keve and others that 70 per cent of those in adult prisons do not need to be there. 28,29

The community correction center should serve the geographic area served by the local courts and judges; in my opinion, its population base should not exceed 150,000. It should be governed by a board of directors, and the board should be responsible for developing group homes within the community for both male and female juvenile offenders. These juvenile offenders would attend the local schools and utilize all other helping agencies available in the community.

The local jail. This serves a population at least double that of the community correctional center (300,000, ideally) and is also under local control. It should not draw offenders from more than a 30-mile radius, although it could serve a number of community correction facilities within that area.

This is the facility that holds people awaiting trial who are unable to post bail. I believe those who are too poor to post bail should be guaranteed a trial within two weeks. If this were done, it would force judges to set bail within limits the person could afford, or else it would force the community to provide more judges, night courts, and weekend courts so that the requirement could be met.

In addition, the local jail holds offenders who have been sentenced to it, providing both individual and public deterrence against antisocial acts.31 Sentences here should be short - usually six months and never more than a year.

Offenders sentenced to the local jail live in the community and work at their regular jobs during the day; they are jailed at night and on weekends. In this way the check passer, the embezzler, and similar offenders could continue to support their families, pay for their room and board in jail, make restitution to their victims, and provide a visible demonstration of the moral influence of law enforcement.

A third function of the local jail is to provide short-term correctional opportunities for offenders in the community correction centers who have shown by their contact that they need it. This is the "lateral movement" within the system mentioned above.

The regional rehabilitation center. This facility serves a statewide region (more or less, depending on the population density) with a population base of perhaps 2 million.

The regional rehabilitation center would be located on its own campus and be divided into three areas: an open area, an area of minimum security, and an area of maximum security. (Offenders would be held in maximum security only for short periods; if prolonged maximum security were indicated, the offender would be sent to the fourth level of entry, the state prison.)

With its campus setting, the regional rehabilitation center could provide an array of services for male, female, adult, and juvenile offenders who could not be controlled in the local jails or community centers. It would also house those whose offenses were such that they would not be eligible for commitment to the local or community institutions.

Services for offenders at the regional centers would be provided both on and off campus. Those in open and minimum- security units would use community resources - vocational rehabilitation, special education, on-the-job training, work assignments. All who worked would be paid. The offenders would pay for their room and board; those with families would support them. All would be expected to pay restitution to the victim when this is indicated.

The same type of rehabilitative services would be provided on campus for those in the minimum-security units who could not be trusted and for those in maximum security. Again, if the offender worked and was paid, there would be requirements of restitution to the victim and family support.

The rehabilitation center should be located in the city that has the most resources in the region. College campuses, state hospitals, and similar institutions now on the brink of closure might well provide sites.32 Control would be vested in a board of directors appointed from citizens living within the region.

So far we have been talking about the 70 per cent of offenders who do not need to be in prisons. In all three of the facilities described, all medical and psychiatric services would be provided by the community and in the community. Insofar as rehabilitative services are concerned, the offender should be free to refuse these and opt only to serve his sentence. If he elected to decline rehabilitative services, his sentence would be served in the local jail if it were for a year or less and in the state prison if it were for longer than a year.

For those who opted for rehabilitative services, movement laterally within the complex could be expected as a consequence of their behavior.

The state maximum-security prison. This is the fourth and ultimate level of descent into the correctional system. It should contain only about 30 per cent of the offenders now being imprisoned in such institutions. That 30 per cent, obviously, consists of those from whom the community must be protected.

Here security is the first priority. Medical attention, humane housing, and whatever rehabilitative and recreational services are feasible would be provided - but only secondarily to the provision of maximum security.

The maximum-security prison would house those whose crimes are heinous - the professional criminal, the violent and aggressive offender, the chronic repeater of grave criminal acts. They would receive maximum sentences and serve them. Indeterminate sentencing would be abolished. The question of parole would not arise, although movement up from the state prison to the regional rehabilitation center, the local jail, and the community correction center would be possible.

CONCLUSION

I am convinced that no effective psychiatric intervention exists or can exist in our present correctional system. The absence of psychiatry from the system is not due to a lack of effort, either in the past or at present, on the part of health workers; rather, it is the result of the basic antitherapeutic nature of the correctional system.

So, rather than trying to attract psychiatric, mental health, and rehabilitative professionals into our present system, I suggest we spend our efforts on attempting to change the system itself.

In the model I have described, the first three levels of entry into the correctional system are under community control. Entry into any of the levels can be effected directly by the courts or by the offender himself as his conduct warrants movement upward or downward. All psychiatric, medical, and rehabilitation services are provided in the community for levels 1 and 2. The same services are provided in the community for offenders in level 3 who are competent to use them; they will be provided on campus for those who are not yet ready to move into the community.

Restitution to the victim - currently the most neglected person in the "justice" system - is seen as an important part of rehabilitation in this model.

Psychiatric intervention is also a major part of the model, with the community provided with all the major sources of rehabilitation it can generate for criminal offenders in the areas of mental illness, drug addiction, sexual offenses, and personal psychopathology who are sentenced to one of the three lower levels.

Release from level 4 - the state prison - would come only at the expiration of the sentence imposed. Release from levels 1, 2, and 3 could also come at the expiration of the sentence imposed; but if the model lives up to my expectations, it could come from a combined decision made by the staff, the offender himself, and his fellow offenders.

BIBLIOGRAPHY

1. Howard, J. The State of the Prisons in England and Wales and an Account of Some Foreign Prisons. London: William Eyres, 1777.

2. Howard. J . An Account of the Principal Lazarettos in Europe, etc. London: William Eyres, 1789.

3. Coleman. L. Prisons; The crime of treatment. Psychiatr Opin. 2:3 (June, 1974).

4. Buerre de Brismont. The criminal Insane of England. Am. J. Psychiatry 27, 284.

5. Dix, D. L. Soliciting a state hospital for the insane. Submitted to the Legislature of Pennsylvania, Philadelphia, February 3, 1845. Isaac Ashmeaü. printer.

6. Wilson. D. P. My Six Convicts. New York: Rinehart & Company, 1951, p. 35.

7. Mueller, G. O W, Medical services in prison: Lessons from two surveys. CIBA Foundation Symposium 16 (1973), 6-7.

8. Halleck, S. American psychiatry and the criminal: A historical review, int. J. Psychiatry 6 (1968), 185-207.

9. McCartney. J. L. Intensive psychiatric study ot prisons; receiving routine in classification clinic Elmira Reformatory. Am. J. Psychiatry 13 (1934), 1183-1203.

10. Bruckner, D. J. In the Los Angeles Times. Quoted in tnePrison Mirror. Stillwater. Minn., Vol. 88, No. 14. July. 1975.

11. Gray, W. J. Grendon and the English prison: Medical service. CIBA Foundation Symposium 16 (1973), 131 .

12. Fully, G. Penitentiary medicine in France CIBA Foundation Symposium 16 (1973), 79.

13. Directory of the American Correctional Association. College Park: University of Maryland Press, 1975.

14. Press Release, November 17, 1976. Washington, D.C.: U.S. Department of Justice, Law Enforcement Administration Association.

15. Corrections, The Challenge of Crime in a Free Society. Report by the President's Commission on Law Enforcement and the Administration of Justice. Washington, D.C.: Government Printing Office, 1967, ch. Vl.

16. Corrections Magazine 2:3 (March, 1976), 10.

17. Trudel. R. Report of the National Criminal Justice Reference Service. December 31. 1974. Washington, D.C: Law Enforcement Administration Association.

18. Attorney General's First Annual Report. Federal Law Enforcement and Criminal Justice Activities Administration. Washington. D.C. : Government Printing Office, 1973. Quoted in Shervington, W. Psychiatr. Ann. 4:3 (March, 1974), 43.

19. Speed, D. Medical Office, H.M. Prison, Bristol CIBA Foundation Symposium 16 (1973), 46.

20. Mitford, J. Kind and Unusual Punishment: The Prison Business. New York: Alfred A. Knopf, 1973, p. 9.

21. Halleck, S. L. Rehabilitation of criminal offenders - A reassessment of the concept. Psychiatr. Ann. 4:3 (March, 1974), 61-85.

22. Rundle, F. Prisons: The crime of no treatment. Psychiatr. Opin. 2:3 (June. 1974). 17,

23. Nagel, W. G. The New Red Barn: A Critical Look at the Modern American Prison. New York: The American Foundation, 1973, pp. 129-139.

24. Martinson, R., Lipton, D., and Wi/ks, J. The Effectiveness of Correctional Treatment: A Survey of Treatment Evaluation Studies. New York: Praeger, 1975.

25. Jacobson. J., and Wirt. R. MMPI profiles associated with outcomes of group psychotherapy with prisoners. In Butcher. J. N. (ed.). Research Developments and Clinical Applications. New York: McGraw-Hill, 1969.

26. Kassenbaum, G., Ward, D., and Wilner, D. Prison Treatment on Parole and Survival: An Empirical Assessment. New York: John Wiley & Sons, 1971 .

27. Rubin, S. Psychiatry and the prison: A negative report. Int. J. Psychiatry 6 (1968). 218.

28. Keve, P. W. Prison Life and Human Worth. Minneapolis: University of Minnesota Press, 1974, pp. 182-186.

29. Keve. P. W. The need for community rehabilitation for legal offenders. Hosp. Community Psychiatry (March, 1971).

30. Tyce, F. A. P.O. RT. of Olmsted County, Minnesota. Hosp. Community Psychiatry (March, 1971), 22-26.

31 . Andennaes, J. Punishment and Deterrence. Ann Arbor: University of Michigan Press, 1974.

32. Tyce, F. A. Public hospitals as social restoration centers. Hosp. Community Psychiatry (March, 1969).

TABLE 1

PRISONS IN THE U.S., FRANCE, AND THE UNITED KINGDOM

TABLE 2

DISTRIBUTION OF PRISONERS IN THE UNITED STATES

TABLE 3

CORRECTIONAL FACILITIES IN THE UNITED STATES, FEDERAL AND STATE

TABLE 4

THE EXISTING CORRECTIONAL SYSTEM

TABLE 5

AN ALTERNATIVE CORRECTIONAL PROGRAM OPTIONS OPEN TO THE JUDGE

10.3928/0048-5713-19770601-05

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