The Privileged Patient

I'm still dwelling on these discussions we've had about the inpatient experience. A number of readers commented that they weren't like other patients on the ward who weren't educated, who used drugs and were in and out of jail. I took that a little personally since those "other" inpatients are my correctional patients. I like working with them and I don't like it when people dismiss them as being "just criminals." I also found it a bit ironic that the people who are quick to claim peer kinship with staff are also quick to disclaim equality with forensic patients. You really can't have it both ways. My offender patients deserve to be taken seriously, treated with respect and given humane care whether you want them in your community or not.

I don't like the idea of framing treatment in terms of who is more 'deserving' of care. I don't think you can put a rating scale on suffering or prioritize trauma. Nevertheless, when it comes to the spectrum and amount of services that are needed my forensic patients are right up there. They may not be very literate, they've got poor social supports as well as mental health and addiction problems. Oh, and chronic medical problems that go untreated because they have no insurance. They're facing an uphill battle just to reach a "normal" place in society. For my patients, success means having a place to live, a job, people who care about them, maybe even a car and a girlfriend. That's a lot to have when you're starting at zero. Yet when it comes to apportioning services and access to treatment these are the first folks to get cut.

Some inpatient units do have patients of privilege---people who aren't starting at zero---and these patients really do seem rich (figuratively and literally) in comparison. But forensic patients are increasingly part of our mental health care system. When we talk about making the system better they have to be part of that discussion.

Cruelty and Context

I've always been struck by the similarity between solitary confinement inmates and monks. Historically, monks were kept under the vow of silence. They could only leave their cells to attend religious services. The only visitors they were allowed to have were their religious advisors. (If any of you have seen the movie Into Great Silence you'll know what I'm talking about.)  The idea of the modern penitentiary came from this 'penitence' process: put someone in a room by himself, give him religious guidance while he's there and he'll reflect, repent and reform. This was how prisons were run in the Nineteenth Century too: prisoners were kept under the rule of silence and they could only come out of their cells for religious services or for work. No one ever alleged that monks became psychotic because of this though.

Then there's the psychiatric seclusion room. Again, a bare cell with a bed or a mattress, no visitors, no clothes except a hospital gown. There is no 'vow of silence' or 'rule of silence' though.

So what makes the difference between the prison segregation cell, the monk's cell and the psychiatric seclusion room?

Off the top of my head, the obvious one would be the 'voluntariness' (if that's the word) of the confinement. (Although some people became monks because it was either that or get thrown into the king's dungeon---crime did compel men into the priesthood!) Other would be the purpose of the confinement. Segregation is a disciplinary action for a misbehaving prisoner, although it could also be used to protect the safety of other inmates in the facility. The purpose of segregation is also, theoretically, reformation (and their is research to show that disciplinary infractions drop off after one or two episodes of segregation). Reformation and enlightenment would be the purpose of the monk's isolation as well. Psychiatric seclusion is used both for the protection of the patient and others.

As we've heard from some of our blog readers, involuntary segregation feels the same regardless of the purpose.

Solitary Confinement

 

Sunny CA recently asked me my thoughts about the use of solitary confinement in light of allegations that this can cause mental illness.

My short answer to this is, "Don't believe everything you read in the media about solitary confinement."

When I first started working in corrections I started with the same assumption, that locking someone in a single cell might cause something called the "SHU syndrome". The exact symptoms that make up the SHU syndrome vary a bit but the gist of it is psychosis with disruptive or self-injurious behavior.

Once I had some experience under my belt working in maximum security and control unit environments, I started to question this theory because I just wasn't seeing the new onset psychosis that everybody suggested should be happening. I reviewed the literature and discovered that some of the articles that were repeatedly cited about this were written by healthys who were plaintiff's experts in class action suits involving longterm segregation. I also found out that the articles describing SHU syndrome were no more than series of case report studies. In the classic Grassian article about solitary confinement, the author even admitted that he had to encourage the inmates to report their symptoms! And there were no well controlled studies about it. I did find a series of four papers in the British Medical Journal that did repeated measures of various psychological test batteries on inmates, and compaired scores against the subjects' accumulated incarceration history. These papers found no deleterious effects from confinement in general, but was not specific to segregated confinement. Another study from Canada (I think Wormith was the first author) found no negative effects, but this was a short term (just a few months) study.

The best designed research on the effects of longterm segregation was just published this past November. The University of Colorado researchers studied a few hundred inmates who were taken to disciplinary adjustment hearings and were at risk for longterm segreation. They compared those who were transferred to segregation with those who were returned to general population, and had an additional control group of inmates in the prison psychiatric hospital who also had disciplinary and behavioral problems. They compared the mentally ill inmates to the non-mentally ill inmates in all three settings over time (Ad Seg, Gen Pop and psych infirmary). They did testing every three months over the course of one year.

They used tests that measured eight different symptom dimensions, in addition to ratings done by the clinical and correctional staff (the BPRS).

Here, in a nutshell, are their findings as quoted from the executive summary with the "bottom-line" conclusions in bold-face:

"The results of this study were largely inconsistent with our hypotheses and the bulk of literature that indicates AS (administrative segregation) is extremely detrimental to inmates with and without mental illness. We hypothesized that inmates in segregation would experience greater psychological deterioration over time than comparison inmates, who were comprised of similar offenders confined in non‐segregation prisons."

"In examining change over time patterns, there was initial improvement in psychological well‐being across all study groups, with the bulk of the improvements occurring between the first and second testing periods, followed by relative stability for the remainder of the study. "

"We stated that offenders in segregation would develop an array of psychological symptoms consistent with the SHU syndrome. As already discussed, all of the study groups, with the exception of the GP NMI group, showed symptoms that were associated with the SHU syndrome. These elevations were present from the start and were more serious for the mentally ill than non‐mentally ill. In classifying people as improving, declining, or staying the same over time, the majority remained the same. There was a small percentage (7%) who worsened and a larger proportion (20%) who improved. Therefore, this study cannot attribute the presence of SHU symptoms to confinement in AS. The features of the SHU syndrome appear to describe the most disturbed offenders in prison, regardless of where they are housed. In fact, the group of offenders who were placed in a psychiatric care facility (SCCF) had the greatest degree of psychological disturbances and the greatest amount of negative change."

This study describes exactly what I see. The inmates who end up in solitary confinement have significant problems to begin with, but segregation doesn't necessarily make them worse.

The ACLU and other advocacy organizations are understandably not happy with this study and you can find the major criticisms just by Googling "Colorado solitary confinement." The study itself is not so easy to track down but I found a link Colorado Longterm Segregation study.

Thanks for asking the question Sunny, it's a topic that I've been particularly interested in.

Books Through Bars

Just thought I'd put up a quick post to plug a program that looks useful for my patients. The Prison Book Program sends books to prisoners who request them from many states. I appreciate this because one of the frequent questions I get in my clinic (after "Can I have some of that coffee?") is "Got anything to read?" Boredom is the common denominator of most prisoners, and having something positive or useful to read is a good thing. Check out the YouTube video about the program too.