Social and economic demands, along with the broadening of mental health service delivery systems over the past two decades, have resulted in an influx of paraprofesstonal staff into traditionally professional mental health treatment settings such as local mental health centers, psychiatric and medical hospitals, counseling centers, halfway nouses, and prisons. Two major factors, however, continue to promote and maintain the employment of paraprofessionals in these settings: the limited availability of trained clinicians and the administratively attractive cost-effectiveness of hiring paraprofessionals rather than professionals.1,2 Research clearly supports the clinical effectiveness of nonprofessionals making therapeutic interventions. Several studies have found that paraprofessionals or lay individuals often perform as well, relative to clinical outcome measures, as professionals and that they sometimes perform more effectively.3·4 These findings have generally been attributed to motivational factors, personal attributes, and the identification of the paraprofessional with a specific population due to shared demographics.5
Limitations of paraprofessional staff have also been noted. Although they are often able to successfully implement components of treatment plans due to their unique attributes and experientially based knowledge, ihey rarely are qualified to choose, assess, or modify such plans. They may also be less sensitive to the ethical and legal issues involved in delivery of mental health services than are professional staff. For these reasons, paraprofessionals in mental health settings are trained and supervised by professional clinicians to ensure quality patient care within acceptable standards of practice. Given this guidance and supervision, they can be viewed as viable extenders of mental health services.5
Nowhere is the understanding and appreciation of the clinical effectiveness of paraprofessionals more important Io professional staff than in prisons. Prisons invariably have too few identified clinicians to adequately meet the needs of the ever increasing population, but they frequently have a wealth of potential paraprofessionals, eg, correctional staff. A review of the literature indicates that some attention has been given to the helping role of correctional workers6*"; however, formal mental health service delivery has been viewed solely as the responsibility of the clinical staff.12-'4 Nevertheless, in order to provide the highest possible standard of care, professionals cannot ignore the potential benefits of effectively integrating nonclinical correctional personnel into the mental health service delivery and treatment structure in prisons. This article will describe the unique characteristics of the prison environment, staffing patterns, and staff roles that both promote and hinder the effective utilization of correctional staff as paraprofessionals and will propose a model of clinically-oriented training that takes these factors into account.
Recent changes in the management of mentally disturbed offenders have provided a greater opportunity for correctional personnel to function in paraprofessional clinical roles. The historical precedent has been that prisoners exhibiting mental disorders were generally transferred out of prison to hospital settings, but the current trend in both state and federal prison systems is to provide in-house treatment within specialized mental health units. Accordingly, there has been a significant increase in the number of prison units designated to care for mentally disordered offenders. 1^-16 These units can be viewed as existing within a societal framework considerably different from that of nonprison mental health facilities,
Despite the clinical mission of providing treatment, there is the omnipresent and essentially superceding correctional mission of maintaining the custody of the inmates and the security of the environment. The dual missions of the units readily facilitate the arbitrary distinction between correctional and clinical staff members and reinforce a general perception by each group that their duties are mutually exclusive. Administratively separate lines of supervision further reinforce this division. Despite these structural factors, closer inspection of actual staff division within the units reflects that significant overlap exists. Correctional staff are clearly involved in counseling and educational interactions with patients as a result of their custody, management, and supervisory functions. Clinical staff are concerned with maintaining a secure environment in order to effectively treat their patients.
In addition to organizational issues, another major influence limiting effective clinical intervention by correctional personnel is professional role conflict based upon the dual mission of mental health units within correctional facilities. The primary professional goals of clinical and correctional staff are disparate and can encourage frustration. Conflict regarding the management of inmates can result from the varying self-perceived roles of each group. Notably, these types of role issues are not restricted to situations involving only clinical and correctional staff; they also exist within strictly clinical, multidisciplinary settings. Research in the area of role identification has shown that there are attitude differences among various professional disciplines based on training, and members of different disciplines often assess program and treatment efficacy from entirely different viewpoints. Further, administrators bring their own expectations to these settings and often have a perceptual framework at variance with the direct service providers.17
One of the most positive developments in recent years regarding the dichotomy between custody staff and clinicians has been the formulation and adoption of professional standards for the correctional field, which is beginning to serve as a framework of conflict resolution. Many federal and state facilities now operate under the auspices of the American Correctional Association (ACA) or are attempting to gain such certification. In addition to standards and guidelines pertaining to the general prison population involving inmate rights, classification, work programs, academic and education services, social services, prerelease and placement planning, the ACA standards also outline specific requirements for the treatment of mentally disturbed inmates that are applicable to all correctional staff, including clinicians. The American Public Health Association, American Association of Correctional Psychologists, Federal Bureau of Prisons, and numerous other governmental, social, and health organizations have developed criteria for the management and treatment of these offenders. Although these organizations and groups represent diverse perspectives from both the correctional and mental health fields, inspection of their standards and guidelines reveals a common concern in providing comprehensive treatment for the mentally ill offender during incarceration. 18
The similarity of these current standards across groups serves as an example of cohesiveness for staff in mental health prison units, wherein correctional and clinical personnel can realize both discrete and common professional goals. This interface can provide specific support for correctional staff to maximize clinical assets and opportunities.
CLINICAL OVERLAP OF STAFFING PATTERNS
Despite the setting demands and role issues already described, similarities in functions between clinical and correctional staff have also been made apparent. This congruence can actually provide a basis for proactive interfacing of clinical assets. Specificity of existing clinical resources can be achieved through detailed description of staffing patterns within prison mental health units.
The clearly defined clinjcal staff in prison mental health units is virtually the same as within other mental health settings. Typically, it consists of psychiatrists, psychologists, and psychiatric nurses. Some units employ vocational rehabilitation specialists and occupational or recreational therapists. Clinical staff perform the same duties in prison as in any other clinical setting; each discipline functions within its respective area of specialization. Administratively, clinicians are usually supervised by a clinical director or other equivalent upper program management personnel.
Psychiatric social workers are the one professional group critical to most mental health service delivery systems that is omitted in the usual list of clinical staff within a correctional facility. This reflects a historical difference between clinical and correctional models. In the vast majority of nonprison mental health settings, social workers specializing in psychiatric issues are integral members of the clinical team. They take detailed social histories, serve as a liaison between the clinical team and family members, provide direct counseling, and establish continuity of treatment and social services support for the patient upon release,
Prisons tend to place individuals with social work training or interest into a case management track. They are responsible for documenting background information on the inmates and handling procedural and legal issues in each individual's case. They monitor the rights of incarcerated inmates and serve as a liaison between the prison and the courts or parole commission. Case managers also coordinate inmates' discharge from the institution, regardless of whether this involves placement in a halfway house, direct release to the community, or transfer to another prison.
Not only is there a functional difference between the correctional case manager and the psychiatric social worker, but there are also other salient distinctions. Correctional case managers are generally not required to have a specific degree in social work (although many now have such credentials) and their positions have frequently been viewed by both line staff and administration simply as stepping stones to midlevel management. There has been a subsequent carry over of this philosophy into many of the mental health units. While case management is clearly the nearest conceptually similar position to that of a psychiatric social worker, the individuals filling these positions are typically correctionally oriented and often have little experience dealing with the specific needs of psychiatric populations. Nevertheless, case managers working in mental health units quickly find themselves assuming many responsibilities of psychiatric social workers whether they have the training and interest in doing so or not.
Informal counseling demands are higher and more difficult in mental health prison units than in general population units due to the cognitive and affective limitations of the patients. Simple discussion of information and issues pertaining to an individual's case can absorb much time and require significant effort on the part of a case manager. Additionally, case managers must often integrate psychiatric histories into their social assessments and then include current mental status and treatment considerations into discharge planning. Finally, case managers in mental health units are often faced with cases that may be legally more complex than those of other convicted offenders. Their caseloads frequently include preirial or presentence detainees who are committed to the units for forensic evaluations. Special procedures for management of these individuals are generally mandated by law and administrative policy and place extra demands on the case managers in terms of ensuring that these procedures are followed and documented.
In addition to case managers, there is another correctionally based staff position in most prisons that can be described as semi -clinical: the correctional counselor. These counselors are members of the custody or security staff who, while required to attend to daily personal and business needs of the inmates (monitoring telephone, mail, and visiting privileges), also function as a source of advice and support for inmates. As with case managers, correctional counselors are generally promoted from the line staff ranks and usually do not have any mental health training in their background or education. They may or may not be specifically interested in counseling duties, but may be attracted to their jobs by other factors such as work schedules, pay, or promotion potential. Nevertheless, most receive some basic counseling training while employed in a counselor position. In general population units the clinical aspects of a correctional counselor's job may vary from a minimal role as a referral agent to professional staff, to an active involvement in supervised delivery of formal counseling programs, such as social skills groups. Within mental health units, the same special demands that automatically increase the clinical aspects of the case manager's position are operative relative to correctional counselors; the patients by virtue of their mental illness or legal situations often demand more individualized attention from the correctional counselor and precipitate different management and control procedures than are seen in general inmate populations.
Line officers work within a more clearly defined custodial position than do other unit staff, with their major duties primarily limited to areas of security and control. Despite the fact that their position is conceptually further from a clinical one than other correctional unit staff, these staff members typically spend more time in observation and direct interaction with patients than any other correctional or clinical personnel, thereby giving them more opportunity for informal counseling and intervention. Correctional officers typically receive only limited organizational training in skills such as observation, communication, and crisis intervention although these duties comprise a major portion of their work within specialized treatment units.
Finally, prisons that are structured by the Unit Management Model may also employ an administrator within the mental health unit who is primarily responsible for the overall running of the unit and directly supervises case managers, correctional counselors, and office personnel. A similar, intermediate management position also typically exists within prison systems that have a more centralized staffing model than unit management.
As described above, there is a significant lack of specific clinical training for most correctional staff. Several legal and professional organizations' standards emphasize consultation between correctional and clinical staff in working with mentally disturbed offenders, but practically no guidelines for staff training models are delineated. Despite recommendations for education of general custody staff in the identification of signs and symptoms of mental illness and mental retardation and in the assessment of emergency situations, virtually no attention is given to the unique training needs of correctional staff functioning as clinical paraprofessionals within mental health units.18 Therefore, while correctional staff are often qualified to serve as referral agents to mental health care providers and have many opportunities for clinical intervention, they rarely receive adequate training in service delivery methods for the mentally ill. It is proposed here that administrators within correctional mental health facilities have the responsibility to require such training and clinical staff have the responsibility for development, implementation, and assessment of specialized training programs. It appears that this is a logical first step in ensuring the maximization of correctional staff assets in direct service delivery. The following set of specific training recommendations can serve as a basic outline for program development.
Training programs must involve several core criteria: assessment of assets and needs; development of training strategies based upon the assessment; implementation of the strategies; and evaluation of the effectiveness of the strategies. In terms of assessment, the education, credentials, experience, motivation, and personal attributes of the correctional staff must be identified. Since there can be considerable variation in these factors among the staff members, formal assessment procedures such as direct questionnaires and rating scales can be useful in supplying statistical information upon which to tailor specific training to specific individual or group needs. The assessment process should also include the identification of clinical staff assets in particular areas in order to aid program developers in matching trainer to trainees.
The development of particular training methodologies should be based upon the data collected in the assessment phase; however, the most effective training forum, the multidisciplinary team with both clinical and correctional personnel, may already exist within the majority of prison mental health units. The emphasis of the multidisciplinary team should be on the formulation and dissemination of individual treatment plans, including discussion of the rationale for these and the appropriate interventions to be performed by both clinicians and correctional staff. Adjunct training methods can include in-service seminars and presentations, preparation of training and educational manuals, and supportive continuing education for correctional staff outside the institutional environment.
Finally, in order to evaluate the effectiveness of the training strategies for correctional personnel, each program should incorporate ongoing methods of monitoring and assessment. Potential areas of outcome measurement are the correctional staff's actual performance of clinical services, their self-perceived roles, and their degree of job satisfaction.
Prison mental health units provide a natural setting for utilization of correctional staff as clinical paraprofessionals; however, the effectiveness of clinical intervention is often restricted due to perceived goal and role conflicts between correctional and clinical staff, and is further limited by inadequate support and development for specialized clinical training for correctional staff. This article suggested that there is a significant degree of congruency between the goals and roles of both correctional and clinical staff within these specialized units. The development of more formalized clinical training programs can increase the effectiveness of clinical service delivery and reinforce the similarities between the two service groups.
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