A prison can be likened to a walled city, confining its citizens within its walls by exercise of military style rule. At best it represents a benevolent type of dictatorship; at worst it rages in turmoil spilling onto the pages of the daily newspaper. Although the city, by design, is separate from the outside world, it cannot escape society's influence and review. Social policies and problems ultimately influence the population within the walls and the conditions of confinement. When rehabilitation is in vogue, money is heaped on educational and vocational programs. When it is not in vogue, we become frightened of innovative programming, risk taking is discouraged, and more individuals are locked up for longer periods, allegedly to better protect society.
Assuming control of an individual's freedom, as is done in any closed institution, carries with it grave responsibilities. Among these are provision of basic services and treatment of uncomfortable deviance from the norm, be it biological, psychological, or social. What services are to be considered basic and what degree of deviance from the norm is viewed as requiring treatment also fluctuate in response to external social factors. Whether convicted inmates experience feast or famine in regard to basic services and programming, a significant percentage of them (comparatively greater than in other settings) will demonstrate overt psychiatric symptomatology and will directly or indirectly demand mental health services during the course of their confinement. In addition, there is a paucity of secure settings outside of prison psychiatric units which can evaluate and acutely treat potentially mad and bad individuals. Thus, at the pretrial and presentencing stages, those who demonstrate mentally disordered behavior, either currently or historically, will in all likeiihood be sent to a prison facility for further study. How, where, and by whom are the demands of each of these subgroups to be met?
For more than 50 years, the Federal Bureau of Prisons has attempted to meet the needs of those mentally disordered offenders who have entered its doors. Both civil service and public health professionals have established and operated psychiatric hospitals that are currently evaluating and treating approximately 600 individuals. There are three regional psychiatric referral centers for male offenders: Butner, NC; Springfield, Mo; and Rochester, Minn. There is one center for female offenders in Lexington, Ky. Each center operates within a prison facility; two (Springfield and Rochester) also house the Bureau's principal medical facilities.
Each facility is composed of a forensic service that conducts pretrial and presentencing evaluations for the court; an acute inpatient treatment component that treats primarily psychotic and affectively disordered patients; and an aftercare or outpatient component that follows chronic or recovering patients or individuals with primarily characterological disorders. Some special treatment programs, such as those dealing with drug rehabilitation, are located at the major psychiatric centers. Additionally, short term therapy, crisis intervention, and some group therapy is conducted by staff within other federal prison institutions.
Providing therapy in a prison setting is in and of itself a challenge. Disciplinary actions may interfere with treatment or be used as resistance to treatment. Inmates quickly learn they can avoid dealing directly with a problem, whether it is internal, interpersonal, or environmental, by simply acting out and receiving a disciplinary action or transfer. Aspects of the "inmate code," which encourages silence rather than sharing information with staff may inhibit therapy or put the therapist in a difficult position if the information regards a potential danger within the prison. Conversely there may be distinct advantages for the inmate to be in therapy, such as better living conditions or time away from work while attending sessions. Whether to focus therapy on how to deal with life outside of a prison or how to adjust to life in a prison is a question that is continually raised. There is usually minimal family or other outside support available to help in the therapeutic process. This encourages other inmates and staff to assume the role of a large extended family - a role from which it is difficult for the inmate to escape.
There are some distinct advantages and disadvantages to treating certain types of psychiatric patients within the prison setting. Treatment of schizophrenia in prison utilizes the limit setting already established as part of the prison environment to help the patient monitor his dysfunctional behavior. Social settings to prevent isolation and varied work experiences are readily available. Medication can be monitored on a daily basis. The average stay in prison is long enough to allow the patient to develop an extended view of his illness. This is helpful in educating the inmate about his disease and his capacity for functioning both with and without psychotropic medication. One disadvantage is that the prison environment can be a dangerous place and may augment already existing paranoia. Actively psychotic patients are also more vulnerable to the manipulations and predatory behavior of the better functioning, more character disordered individuals.
The borderline inmate may have a heyday in prison. Lack of cohesion between treatment and custody staff may allow these inmates to split staff. Different approaches utilized to deal with disruptive behavior by correctional and therapeutic staff may enable borderline inmates to avoid treatment interventions. In reality, however, there is little difference between good correctional practice and good therapeutic practice with these patients. It is possible for the prison setting to establish limits necessary for some borderlines to learn more socially acceptable ways of dealing with stress.
The antisocial personality disordered inmate presents a unique treatment challenge. Limit setting may ensure a calm treatment environment but may not help the individual develop his own internal control system. The inmate is readily available for therapy for a longer period, but secondary gain may be the predominant motivating factor for the therapy. One has to hope that a therapeutic alliance develops and over time the secondary gain issues diminish and the therapeutic process becomes dominant.
Some innovative concepts in patient care and management have developed within the prison system. For example, at the Federal Correctional Institution in Butner, NC, psychiatric patients are mainstreamed with the general prison population in areas such as recreation, eating, work assignments, and education. This is facilitated by holding ihe mental health inmate accountable for his actions on a day to day basis to the largest extent possible. Encouraging the mental health inmate to live in a more "normal" milieu works against some aspects of institutionalization common to many psychiatric hospitals. It also encourages closer interaction between mental health and correctional staff. Work is considered part of the treatment program for all convicted inmates. Levels of jobs are available so that even the partially compensated inmate can work. Education about illness and treatment modalities is also carefully done for both inmates and staff. Treatment focuses on symptom management on the part of the inmate, especially where the symptoms are chronic and not entirely responsive to medication control. All staff, including correctional officers, secretaries, and counselors, are taught to deal with seriously disturbed inmates. The goal is to allow both inmates and staff to feel respected and in control of their living or working situation.
Staff within the Bureau of Prisons have worked hard to produce mental health services that are humane, effective, and comprehensive. Efforts are now being made ?? consider how we can continue to provide these services to a rapidly expanding prison population. The following articles, all by Federal Bureau of Prisons' mental health staff, and the comments by |. Michael Quintan, Director of the Federal Bureau of Prisons and the Hon. Harry A. Blackmun, Associate Justice of the United States Supreme Court, discuss several interesting aspects of our mental health programs and services. It is our hope that together they will provide a glimpse into the fascinating world of prison psychiatry.