Psychiatric Annals

Mental Health Care in the Federal Bureau of Prisons 

A Theoretical Model for Assessment of Delivery of Mental Health Services in the Correctional Facility

James H Hilkey, PhD

Abstract

The interface between mental health professionals and the criminal justice system is ripe for confusion for the treatment provider. Problems of conflicted allegiances stemming from differing backgrounds and philosophies1 may be at the core of this conflict. Mental health practitioners trained in scientific disciplines and helping concerns are often viewed as visitors within the criminal justice system white correctional administrators and custody staff are typically considered the backbone of the system, or as Dílulío2 references, "the keepers." Monahan3 has described the principal role conflict and ethical dilemma of psychologists and psychiatrists in the criminal justice system to be whether to help the client, to further the system, or to serve what is perceived to be the best interests of society. Judge David Bazelon has referred to psychologists and psychiatrists in the criminal justice system as "little more than high priced janitors hired to sweep the problems of the system under the rug,"4 This confusion contributes to difficulty in fully utilizing the contributions these individuals can make to the criminal justice system, as well as to difficulties in recruiting qualified staff and retaining those already in the system.

Questions as to the utility of mental health professions in prisons, the lack of significant positive treatment outcomes,5 and the frustration inherent in living with these role conflicts have not, however, diminished the need for mental health services within the prison system. Courts are increasing requests for pretrial evaluations of defendants and are utilizing the expertise of mental health professionals to provide input in sentencing recommendations. Indications for treatment frequently accompany the convicted inmate to his place of confinement. Finally, deinstitutionalization of the mentally ill has resulted in the incarceration of a chronically disturbed offender group with significant treatment needs. These factors increase the demands for competent mental health staff, equipped to treat the special needs of offenders.

To serve the prison population effectively, mental health practitioners need a conceptual framework to help define their role, the system in which they will function, and the population they will serve. Abraham Maslow's theory of human motivation6 provides just such a framework when applied to the prison environment. Review of his theory can aid practitioners in matching their expertise to the demands of the prison environment.

Maslow's theory of human motivation details five levels of needs, which are arranged in a hierarchical modeKsee Figure). Physiological needs form the foundation of the hierarchy and must be satisfied before an individual can attend to any higher-ordered needs. Unmet needs serve as important organizers of human behavior and motivation. As these basic needs become chronically satisfied, they fall into the background and effectively lose their immediate function as organizers of behavior and the individual is then free to move to the next level.

Safety needs form the second level of Maslow's theory. These are described as the individual's attempt to create an environment that is stable, secure, and free from excessive fear. Clearly defined rules, a sense of law and order, and the ability to exist without fear from physical or psychological danger contribute to one's sense of safety. From the child's vantage point, safety is represented by a predictable schedule, consistency, and feelings of reassurance that all is in proper order. For the adult, safety may be symbolized by living in a secure neighborhood, adequate financial reserves, secure employment, or freedom from predatory assault. The individuai who perceives himself to be in an unsafe situation will marshal all available resources to instill a sense of security; little else is important.

If physiological and safety needs are essentially gratified, the individual is free to move to the third…

The interface between mental health professionals and the criminal justice system is ripe for confusion for the treatment provider. Problems of conflicted allegiances stemming from differing backgrounds and philosophies1 may be at the core of this conflict. Mental health practitioners trained in scientific disciplines and helping concerns are often viewed as visitors within the criminal justice system white correctional administrators and custody staff are typically considered the backbone of the system, or as Dílulío2 references, "the keepers." Monahan3 has described the principal role conflict and ethical dilemma of psychologists and psychiatrists in the criminal justice system to be whether to help the client, to further the system, or to serve what is perceived to be the best interests of society. Judge David Bazelon has referred to psychologists and psychiatrists in the criminal justice system as "little more than high priced janitors hired to sweep the problems of the system under the rug,"4 This confusion contributes to difficulty in fully utilizing the contributions these individuals can make to the criminal justice system, as well as to difficulties in recruiting qualified staff and retaining those already in the system.

Questions as to the utility of mental health professions in prisons, the lack of significant positive treatment outcomes,5 and the frustration inherent in living with these role conflicts have not, however, diminished the need for mental health services within the prison system. Courts are increasing requests for pretrial evaluations of defendants and are utilizing the expertise of mental health professionals to provide input in sentencing recommendations. Indications for treatment frequently accompany the convicted inmate to his place of confinement. Finally, deinstitutionalization of the mentally ill has resulted in the incarceration of a chronically disturbed offender group with significant treatment needs. These factors increase the demands for competent mental health staff, equipped to treat the special needs of offenders.

To serve the prison population effectively, mental health practitioners need a conceptual framework to help define their role, the system in which they will function, and the population they will serve. Abraham Maslow's theory of human motivation6 provides just such a framework when applied to the prison environment. Review of his theory can aid practitioners in matching their expertise to the demands of the prison environment.

Maslow's theory of human motivation details five levels of needs, which are arranged in a hierarchical modeKsee Figure). Physiological needs form the foundation of the hierarchy and must be satisfied before an individual can attend to any higher-ordered needs. Unmet needs serve as important organizers of human behavior and motivation. As these basic needs become chronically satisfied, they fall into the background and effectively lose their immediate function as organizers of behavior and the individual is then free to move to the next level.

Safety needs form the second level of Maslow's theory. These are described as the individual's attempt to create an environment that is stable, secure, and free from excessive fear. Clearly defined rules, a sense of law and order, and the ability to exist without fear from physical or psychological danger contribute to one's sense of safety. From the child's vantage point, safety is represented by a predictable schedule, consistency, and feelings of reassurance that all is in proper order. For the adult, safety may be symbolized by living in a secure neighborhood, adequate financial reserves, secure employment, or freedom from predatory assault. The individuai who perceives himself to be in an unsafe situation will marshal all available resources to instill a sense of security; little else is important.

If physiological and safety needs are essentially gratified, the individual is free to move to the third level: the need to belong, to experience affection, and to be loved. Individuals at this level sharply feel the loss of a loved one and are particularly sensitive to any kind of ostracism or rejection. Motivated by the need for human contact, they seek groups that address their need to belong and affirm their value as human beings. The absence of these opportunities contributes to psychological maladjustment. Ideally, meaningful acceptance into a group begets feelings of self-worth and opens the door to the next level in Maslow's hierarchy: needs for esteem.

Maslow states that esteem is represented by an individual's genuine evaluation of himself as confident, self-assured, and valuable to others as well as to one's self. Esteem may be a desire for strength, achievement, adequacy, or confidence. It may also be represented by a desire for appreciation, dignity, status, or fame. Thwarting these needs produces feelings of inferiority, weakness, and helplessness. Once these needs are sufficiently met, the individual may move to fulfillment of the final but least clearly defined level, that of need for self-actualization.

Masfow defines self-actuaíization as the freedom to pursue ultimate goals that are essentially unencumbered by issues at the lower levels of the model. These may be heavily influenced by issues of aesthetics.

Maslow's theory can be directly applied to the model prison environment. It can serve to explain some of the complexities and define some of the issues of role and purpose for both those who live and those who work in a correctional environment.

It is more often the exception in contemporary times in our society that basic physiological needs of prisoners are not met. In the past two decades there has been increasing attention to adequate provision of prisoners' basic needs. External review and audit organizations such as the American Psychiatric Association, the American Correctional Association, and the loint Commission on Accreditation of Hospitals, in establishing standards of acceptable care for jails and prisons, have addressed the issue of adequate living conditions. In some troubled systems, courts have ordered that more humane conditions be established to include provision of adequate physical space, an acceptable level of nutrition, adequate medical care, and routine exercise.7

While there are few prison environments today that do not address basic physiological needs, there are many more prisons that function inadequately at Maslow's second level concerning needs for safety. Though plagued by serious problems of overcrowding in prisons, courts continue to compete for space for sentenced inmates. Administrators work overtime to accommodate record numbers of inmates in already overcrowded facilities. Deteriorating physical plants often fail to provide appropriate segregation of predatory groups of prisoners. The public, while demanding that criminals be taken off the streets, is reluctant to pay the increasingly high costs for construction and staffing of new facilities. Administrators are required to balance the demands of a difficult population in a safe, humane environment wiih the perhaps unrealistic demands to protect the public's safety. Officials who are limited in their ability to create a safe environment may see a decline in their ability to maintain good staff morale. This has the corresponding effect of deteriorating attention to rules and regulations, and inconsistent discipline is likely to follow.

Stanton and Schwartz8 nàte the need for a predictable social norm from which the individual can differentiate himself. A safe, coherent social environment is an absolute necessity for elementary ego integrity. If the correctional environment is unsafe or perceived so by inmates, they often resort to less civilized responses to protect themselves. Some may isolate themselves from their peers while others band together or barter for protection they believe is unavailable from prison officials.

Unsafe conditions not only define the role and behavior of prisoners, but also that of staff. Roles of mental health practitioners at this level involve little more than classification and diagnosis. This role was particularly prevalent in the late I9th and early 20th centuries, with the rise of the medical model in American corrections.9 Psychiatrists' primary contributions were little more than attempts to control and separate troublemakers. Caseloads were large and treatment was only a symbolic goal.9 Present roles closely simulate those in early conditions whenever prison populations increase and safety is jeopardized. The clinician who enters a correctional facility that is struggling to provide acceptable levels of safety quickly becomes aware that many of the problems stem from the unsafe environment. Primary treatment becomes almost exclusively crisis intervention.10 Not onJy are proactive treatment needs obscured by attempts to create a safe environment, but staff may also mimic behaviors similar to those witnessed in their charges: they may react to threatened safety by remaining emotionally distant from inmates, seeing inmates as adversaries, and attempting to define boundaries between disciplines. All these actions contribute to poor staff morale and ineffective delivery of services.

Issues of threatened safety stem not only from the realities of overcrowded, understaffed prisons, but they are also active in the attitudes of those who are charged with prisoner care. Seymour Halleck, in his book Psychiatry and the Dilemma of Crime11 states:

Influenced by a humanistic tradition which argues for (he dignity and worth of each individual and finding increasing enlightenment as to the changeability of man's nature, modern sociely does have some wish to provide better treatment for all its deviant citizens. Friendly attitudes toward law violatore, however, do not come easily. The criminal has wronged us, and our concern for his rehabilitation is also accompanied by our urge to punish him. This ambivalent attitude has led to a number of compromises in our treatment of offenders. Among them is an increased willingness to call upon psychiatrists to find arbitrary linkages between mental illness and criminality.

In addition to the physical environment requiring attention to issues of safety, the psychological and aititudinal concerns of staff and inmates must be addressed as well. Education of staff must occur on a conceptual as well as a clinical levei. Safety for all can be greatly enhanced if people understand clinical realities, such as that the agitated paranoid inmate is terror stricken and attempting to protect himself, rather than simply "bad" and gaining pleasure from harming others.

As an individual who feels safe becomes able to attend to needs for belonging, he can, if he chooses, begin to develop a sense of himself without the distraction of constant fearfulness. Energy previously devoted to physical protection is freed for more affiliative activities. Maintenance of rigid prohibition against association with staff dissolves. The reliance on unwritten anti-staff, anti-administration attitudes referred to as the "convict code" also diminishes. Instead, inmates are free to accept assistance from, and in many cases develop therapeutic relationships with, staff. In the safe environment, prosocial groupings and inmate activities become much more evident; the need to belong to prison protection gangs loses power.

Correspondingly, inmates at this level become not only increasingly sensitized to their personal needs of belonging, but also to failed membership in social groups, particularly family. Rather than mental health practitioners occupying their time helping to "keep the Hd on," they can spend more of their resources in facilitating the belonging needs of the inmates. Understanding needs for affiliation and the press to psychologically understand past failure creates a unique opportunity for group treatment. The role and purpose of all staff is radically different in the safe and humane environment as compared with those focusing on establishing basic safety needs. With safety conditions well established, the expertise, of the menta! health practitioner much more closely matches the needs of the inmate population with a better fit between treatment and problem. With this melding, positive motivation for effective therapy is heightened for both staff and inmates.

Given a physiologically complete, physically safe, and socially affiliatative environment, prisons can facilitate the development of a genuine sense of esteem among inmates. Proper modeling and professional guidance from well trained, sensitive staff can facilitate this end. With group psychotherapy, quality educational programs, and vocational training opportunities, inmates can grow to develop previously untapped potentials. Just as it is unlikely that a child will emerge as a competent proactive member of society without parental guidance tempered with an equitable system of discipline, we cannot expect an inmate to emerge from even the best run prisons without the "parental" influence of a well trained and psychologically sensitive staff. Many familiar with prisons comment on the differences between the chronological and developmental ages of inmates, and are impressed with the repetitive nature of their self-destructive behaviors. Needs to belong are most clearly satisfied in prison. Recognizing the need for both belonging and esteem opens unique treatment opportunities for the mental health practitioner in prisons that are not often experienced in other settings.

Though less often accomplished, it is conceivable thai the final two stages of Maslow's hierarchical model could be met in the prison environment: those of love and selfactualization. It is plausible that inmates with basic satisfaction of lower level needs could develop the increased capacity for empathy thai many would consider the ultimate goal of psychological treatment. The self-actualized individual will have outgrown both the needs for mental health intervention and the confines represented by the prison environment.

Historically there have been examples of correctional facilities that have fostered the philosophy of maintaining both safe and humane environments, such as the Federal Correctional Institution in Butner, NC. This institution was dedicated in 1976 and modeled after the concepts of Norval Morris, detailed in his book. The Future of Imprisonment.12 His thesis detailed steps for increased inmate responsibility and the provision of genuine choices. He and others2 clearly acknowledged the necessity of safety needs being met prior to implementation of issues of genuine choice or the idea of prison as a constitutional government. The Butner environment encourages the philosophy of inmate responsibility in a setting of safe and humane interactions between staff and inmates. The prison compound is an open setting with security at the perimeter, which contributes to a community feeling as opposed to the close custodial confinement associated with more typical prisons. Not unlike the community, there are few mandatory programs although a wide variety of activities are made available to the inmates.

This model allows the Butner environment to manage a large number of previously disruptive inmates with much less custodial supervision than previously required, mainstream a large psychiatric population into a general prison population, and recruit competent menial health professionals with a low degree of staff turnover. While far from the ideal, the philosophical as well as the operational routine of the Butner facility points with some encouragement to the potential for positive outcome.

FIGUREMaslow's Theory of Human Motivation

FIGURE

Maslow's Theory of Human Motivation

Maslow's model and the example cited above clearly speak to the fact that safe and humane correctional environments can and have been created. As lower level needs are satisfied, an ideal climate for treatment and rehabilitation is created affording unique opportunities for mental health practitioners. Despite the tremendous needs for serious treatment programs in prisons, the needs have heretofore been unmatched with commitments to make rehabilitation work. With an absence of a rehabilitation model, prisons are left with little more than a containment model that provides little help to those offenders troubled with emotional disorders.

BEFEREHCES

1 . Brodsky S: Psychologists in the Criminal fustice System. Urbana, IL. University of Illinois Press. 1973.

2. Dilulio I |r: Governing Prison: A Comparative Study of Correctional Managemen J. Ncw York. The Free Press. 1987.

3. Monahanl: Who is the Client: The Ethics of Psychological Intervention in the Criminal fustice System. Washington, DC, American Psychological Association, 1980.

4. Bazelon D: Psychologists in corrections - Are they doing good for the offender well for themselves, in Brodsky S (ed ) : Psychologists in the Criminal Justice System. Urbana. IL, University of Illinois Press, 1973.

5. Palmer T: Martinson Revisited, loumalof Research in Crime and Delinquency 1975; 12:133-152.

6. Masíow A: Motivation and Personality. ed 2. New York. Harper and Row, 1970.

7. Sadoff R: Legal issues in the Care of Psychiatric Patients. New York, Springer Publishing Company, 1982.

8. Stanton A, Schwanz M: The Mental Hospital: A Study of Institutional Participation in Psychiatrie Illness and Treatment. New York. Basic Books. 1954.

9. Roth man D: Conscience and Convenience. Boston. Little, Brown, and Co. 1980.

10. MODS R: Evaluating Treatment Environments:A Social Ecological Approach. New York, |ohn Wiley and Sons. 1974.

11. Halleck S: Psychiatry and the Oilemmas of Crime. Berkeley. CA. University of California, 1971.

12. Morris N: The Future of Imprisonment. Chicago, University oí Chicago Press, 1974.

10.3928/0048-5713-19881201-07

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