Psychiatric Annals

Mental Health Care in the Federal Bureau of Prisons 

The Prison Forensic Unit: Training Ground

Sally C Johnson, MD

Abstract

The impact of law, both criminal and civil, frames almost every aspect of prison psychiatry. Within this legally defined framework one finds a wealth of psychopathological and psychiatric dilemmas. The groundwork for learning general psychiatry, exposure to a wide variety of mental disorders of varying degrees of severity, and responsiveness to treatment is easily laid out. But perhaps just as important, a prison psychiatric facility can also serve as an ideal place to develop the skills and breadth of experience needed to practice criminal forensic psychiatry.

All of psychiatry within the Federal Bureau of Prisons (BOP) can, in a way, be considered forensic psychiatry. Transfer of prisoners from general prison facilities to psychiatric units no longer happens without attention to inmates' rights to avoid the potential stigma of being labeled mentally ill.1 Inmates on prison psychiatric units are not treated without informed consent and even the most disturbed, who are committed for treatment by law, must have their mental competency to make decisions about medical care adjudicated.2 While some inmates protest staff efforts to treat them, others sue for wrongful discharge or demand attention to their right to treatment. Individuals charged with federal crimes are sent to prison psychiatric units for evaluation of their mental competency to stand trial or their criminal responsibility at the time of the alleged offense. Those found not competent to stand trial or not criminally responsible are evaluated as to their dangerousness and may be detained for extended periods if determined to pose a risk to others or the property of others. Trying to facilitate placement of menially disturbed individuals into state facilities so as to comply with the letter and spirit of the law has become part of the routine of the psychiatric unit.

It is becoming increasingly clear that forensic psychiatrists are more than general psychiatrists who happen to be asked legal questions. Forensic psychiatry, now an accepted subspecialty, has changed and expanded over its more than 170 years of identified existence. However, there are still frequent episodes of general psychiatrists being paraded before the public who unwittingly at best, or knowingly at worst, present themselves as forensic experts. Even within the subspecialty it is becoming increasingly difficult for the forensic psychiatrist to remain truly expert with the entire spectrum of problems and questions in the field and still keep current with the wealth of information being added to the psychiatric profession. Dietz has suggested that forensic experts narrow their focus to a subset of four branches of the discipline; criminal behavior, mental disability, forensic child psychiatry, or legal aspects of psychiatric practice.3 The prison psychiatric unit naturally lends itself to training in criminal behavior, although it does not entirely exclude exposure to any of the other areas.

For years a stigma has remained attached to prison psychiatry, psychiatrists, and (though less directly) to forensic psychiatrists in prisons. Prison psychiatry has long been viewed as, at best, trying to keep up with the psychiatry practiced in other settings.4·5 Prison psychiatrists are often described as having mediocre skills and are discounted because of their large workload, long hours, poor pay, or even because they work in settings that are "hardly optimal environments for rehabilitation."0

Prison forensic psychiatrists, who were established to serve as impartial experts to the court, historically have been perceived as conducting evaluations under limited circumstances, spending less than adequate time with the defendant, not having access to sufficient collateral material, and becoming disgruntled with their work because it is viewed as routine.7 This is contrasted to private forensic experts who supposedly are "much more apt to regard the (forensic) examination situation…

The impact of law, both criminal and civil, frames almost every aspect of prison psychiatry. Within this legally defined framework one finds a wealth of psychopathological and psychiatric dilemmas. The groundwork for learning general psychiatry, exposure to a wide variety of mental disorders of varying degrees of severity, and responsiveness to treatment is easily laid out. But perhaps just as important, a prison psychiatric facility can also serve as an ideal place to develop the skills and breadth of experience needed to practice criminal forensic psychiatry.

All of psychiatry within the Federal Bureau of Prisons (BOP) can, in a way, be considered forensic psychiatry. Transfer of prisoners from general prison facilities to psychiatric units no longer happens without attention to inmates' rights to avoid the potential stigma of being labeled mentally ill.1 Inmates on prison psychiatric units are not treated without informed consent and even the most disturbed, who are committed for treatment by law, must have their mental competency to make decisions about medical care adjudicated.2 While some inmates protest staff efforts to treat them, others sue for wrongful discharge or demand attention to their right to treatment. Individuals charged with federal crimes are sent to prison psychiatric units for evaluation of their mental competency to stand trial or their criminal responsibility at the time of the alleged offense. Those found not competent to stand trial or not criminally responsible are evaluated as to their dangerousness and may be detained for extended periods if determined to pose a risk to others or the property of others. Trying to facilitate placement of menially disturbed individuals into state facilities so as to comply with the letter and spirit of the law has become part of the routine of the psychiatric unit.

It is becoming increasingly clear that forensic psychiatrists are more than general psychiatrists who happen to be asked legal questions. Forensic psychiatry, now an accepted subspecialty, has changed and expanded over its more than 170 years of identified existence. However, there are still frequent episodes of general psychiatrists being paraded before the public who unwittingly at best, or knowingly at worst, present themselves as forensic experts. Even within the subspecialty it is becoming increasingly difficult for the forensic psychiatrist to remain truly expert with the entire spectrum of problems and questions in the field and still keep current with the wealth of information being added to the psychiatric profession. Dietz has suggested that forensic experts narrow their focus to a subset of four branches of the discipline; criminal behavior, mental disability, forensic child psychiatry, or legal aspects of psychiatric practice.3 The prison psychiatric unit naturally lends itself to training in criminal behavior, although it does not entirely exclude exposure to any of the other areas.

For years a stigma has remained attached to prison psychiatry, psychiatrists, and (though less directly) to forensic psychiatrists in prisons. Prison psychiatry has long been viewed as, at best, trying to keep up with the psychiatry practiced in other settings.4·5 Prison psychiatrists are often described as having mediocre skills and are discounted because of their large workload, long hours, poor pay, or even because they work in settings that are "hardly optimal environments for rehabilitation."0

Prison forensic psychiatrists, who were established to serve as impartial experts to the court, historically have been perceived as conducting evaluations under limited circumstances, spending less than adequate time with the defendant, not having access to sufficient collateral material, and becoming disgruntled with their work because it is viewed as routine.7 This is contrasted to private forensic experts who supposedly are "much more apt to regard the (forensic) examination situation as a highly challenging task to which (they) devote considerable time and effort with or without adequate remuneration."7

In contrast to this view, forensic psychiatric work within the federal prison system today supports a description antithetical to that outlined above. BOP professionals conducting forensic evaluations for federal courts do so in four referral centers across the country. The evaluations are completed by experienced clinicians in accredited inpatient psychiatric facilities. Sufficient time, ranging up to 120 days, is provided by law to complete the evaluations. All patients are psychiatrically and medically evaluated. Psychological testing is completed and collateral information is obtained and reviewed. Comprehensive reports are written in understandable terms and are supplied to the court, prosecutor, and defense counsel. The results are also discussed with the defendant. Evaluations typically go beyond simply rendering opinions to legal questions and address diagnosis, prognosis, treatment needs, and treatment rendered. Evaluators consult with all parties involved and testify as often for the defense as for the prosecution. Clinical and written work is continuously reviewed and discussed by the forensic team and supervised by the director of the forensic service.

Because the federal prison population is expected to double by 1992, mental health forensic services within the BOP must continue to improve to adequately meet the increased needs. Changes in federal law affecting mentally disordered offenders and new sentencing guidelines have resulted in increased public awareness of the type and quality of the services rendered. Cases originating within the federal system are currently bringing questions that plague psychiatry as a whole to JegaJ consideration, such as when involuntary treatment can and should be implemented and how to resolve the plight of sòme of the more chronically mentally ill.

The upgrading of forensic services within the BOP, coupled with the types of problems and issues encountered in the prison psychiatric setting, highlight the advantages of utilizing federal prison psychiatric units as training sites for psychiatric residents and other clinicians interested in developing a subspecialty in criminal forensic psychiatry.

Experience of psychiatric residents working on the forensic service at the Federal Correctional Institution in Burner, NC over the last 10 years has shown that all too often psychiatric residents finish their training with an inflated sense of skills and knowledge base. During their three or four years of training they have seldom faced the same kind of rigorous questioning of their diagnoses, formulations, and prognoses thai they previously may have faced on medical student rounds, let alone what they ultimately could face in a courtroom. Often their assessments, the adequacy of their evaluation process, their use of resources, and explanation of their findings, either verbally or in writing, are not carefully critiqued. They have not learned the potential power of their decisions or conclusions. Rarely have they developed a working understanding of even basic concepts such as informed consent or have had to justify why they used a particular treatment. They take actions such as committing a patient to a state hospital without any insight into the outcome and consequences of their decisions. They have been taught to deal with the patient occasionally in relation to the family and only rarely in relation to society. Clinical decisions are made on narrow data bases without questioning thai different conclusions could be reached if more information was considered or if the information was considered in a different way. Finally, they simply may not know the limitations of their knowledge and are often willing to attribute cause and effect relationships to pieces of historical information or make unrealistic predictions about future behavior.

On the forensic unit, the resident's work with individual defendants is put "under the microscope." This is done to prepare for possible court appearances but more importantly it is an educational experience for the resident. The extent of their knowledge about diagnoses, assessment techniques, and the treatment process quickly becomes cleat. Residents can become painfully acquainted with the limitations of the field of psychiatry and the psychiatric literature, and with the frustration of finding no good solution to a clinical situation. They are helped to develop a basic legal knowledge of criminal law and procedure. They are encouraged to interact with associated agencies, attorneys, and other prison professionals such as criminologisls, wardens, and security officers.

The external demands, as specifically outlined in the court orders authorizing commitment, require that the resident plan and complete the assessment process in a timely fashion. This involves obtaining and learning to utilize extensive collateral information that may well conflict with the resident's perception of the defendant and with the defendant's own account of his situation. Residents experience the embarrassment of being conned and learn much about severe character pathology. Perhaps most importantly, residents are required to write out the entire evaluation process in understandable terms in the format of a Forensic Evaluation to the Court. This can then be reviewed in depth and revised until it accurately captures the essence of the case and the evaluation process and clearly explains any conclusions.

The resident learns that forensic evaluations being conducted on the unit differ both objectively and subjectively in some ways from routine psychiatric evaluations done in other psychiatric settings. Ii is not uncommon for clinicians who are trained in these differences to realize that attention to some of these points may be beneficial in other settings.

Within the forensic evaluation, after review of appropriate court orders and requests, the evaluator establishes the goals for the evaluation process. These include establishing diagnoses, determining responses to the questions of the court, rendering a formulation of the legal issues at hand, and making treatment or management recommendations. These goals are not generated by the defendant (patient) as they would be in a more traditional setting. Efforts of the defendant to change these goals, to avoid addressing them, or to thwart them must be identified and explained. This often leads to significantly more confrontation within the interview setting than the resident has previously utilized. The evaluator also sets limits on the evaluation process that may be in response to external as well as clinically perceived individual factors of the defendant.

The evaluation itself is not voluntary in the usual sense of the word: it is court ordered, even if the patient/ defendant requested il or agreed to it. Frequently the evaluation entails foci not specifically anticipated by the defendant yet it cannot be curtailed or cancelled simply at the defendant's request.

In addition, there is limited confidentiality to be offered to the defendant in this type of setting.8 The limitations, including the extent of intended disclosure and purposes of thai disclosure, musí be clarified with the defendant at the beginning of the evaluation process. This actually provides less of a problem than might be expected in a clinical sense in that most defendants disclose sufficient information to allow the evaluation process to be completed and collateral information is routinely utilized. A parallel problem arises for the clinician in monitoring personal discussion of the case with other professionals or the media. Frequently the resident is flattered by and unaccustomed to the public's curiosity about crime, especially violent criminal behavior. The resident learns that one does not become famous through association with infamous people.

The evaluation is frequently completed by utilizing the team approach. The clinician must learn how to utilize information and observations from a variety of clinical and nonclinical staff. Opinions, motives, and skills may be questioned by any of the staff and the clinician quickly learns there is no room for narcissism or control issues here.

An adequate rotation on the forensic service can give the resident a crash course on the extremes of how mental illness impacts on human behavior. It allows the clinician to confront the breadth of human conduct and unfortunately identifies that not all terrible, bizarre, or frightening behavior can be explained in psychiatric terms. The evaluator must learn to extend respect to the individual being evaluated without justifying or excusing the behavior and without rationalizing with the defendant.

Residents must come to grips with the fact that they cannot believe everything a defendant tells them, nor can they always accurately assess the rationale behind what is said by the defendant. The motivation for fabrication or omission of pertinent information ranges from fear or shame to depression or the simple wish to continue criminal behavior. Nobody is always right in his assessment, and experiencing that teaches a valuable lesson to the potential criminal expert.

Finally, the more one practices within this subspecialty, the more evident becomes the need to establish norms for behavior, competence, responsibility, and dangerousness. There are no clear lines between the absence or presence of these conditions. The skill required to adequately and accurately render opinions including or excluding a defendant from any one of these categories comes from working with, evaluating, and re-evaluating individuals on both sides of the issue. By attempting to understand how those individuals were placed in particular groups by the court, other experts, or themselves, and by re interviewing and re-evaluating cases post conviction, the clinician can gradually assess the validity and reliability of his own assessment process for any individual case. Without this experienee, it is questionable as to whether one can truly function as a criminal forensic expert.

The prison forensic service also benefits from establishing training and maintaining programs. Assuming training functions supports more organization in service delivery and assessment procedures. The responsibilities associated with training demand moving away from a crisis intervention mode of operation. Time must be spent in direct supervision and group reviews. There is more impetus to keep up with the literature and progress in the field. Training programs also foster a greater emphasis on documentation and study of what is occurring on the unit and thus the quantity and quality of the clinical research on the unit is enhanced. Staff respond to the challenge of teaching and express better job satisfaction, despite the additional burden associated with having trainees on the unit, the need to escort individuals without full security clearance, and the need to juggle already limited office and treatment space. Training programs also serve directly and indirectly as a recruiting source for new staff. Without direct exposure to a prison service most clinicians fail to even consider working on one.

It is not expected that the majority of clinicians completing a training experience on the prison service will opt for full time careers in prison or forensic psychiatry. However, some portion may offer part time services to institutions or integrate some criminal forensic work into their practices. They will undoubtedly develop a more educated perspective on crime and a more realistic and perhaps more practical understanding of the interrelationship of socially deviant behavior and psychopathology. Ultimately, it is hoped they will more credibly meet society's need for expert criminal forensic psychiatric testimony.

REFERENCES

1 . Vitek v iunes, 445 US.

2. Vniled Stales v Charters. 829 F2d 479 (4th Cir. 1987).

3. Dietz PE: The Forensic Psychiatrist of the Future. Bull Am Acad Psychiatry Law 1987; 15(31:217-227.

4. Roth LH; Correctional psychiatry, in Curran Wi, McGarry AL, Petty CS (eds): Modern Legal Medicine Psychiatry and Forensic Science. Philadelphia, FA Devis. 1980.

5. Goldfarb RL, Singer LR: After Conviction, a Review of the American Correction System. New York, Simon and Schuster, 1973.

6. Goldfarb R: fails: The Ultimale Ghetto. New York, Anchor Books, 1973.

7. Benard L, Diamond MD: The fallacy of the impartial expert. Archives of Criminal Psychodynanmy. Spring 1959; 3(2):221-236.

8. Applebaum PS: Confidentiality in the forensic evaluation. Int f Law Psychiatry 1984; 7;285-300.

10.3928/0048-5713-19881201-08

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