Implementing Residential Treatment for Prison Inmates With Mental ...

Implementing Residential Treatment for Prison Inmates With Mental Illness Frederica W. O’Connor, David Lovell, and Linda Brown There is evidence that mentally ill offenders (MIOs) in prisons commit more infractions, serve longer sentences, and are more likely to be victimized than inmates who are not mentally ill. Humanistic and prison management interests are served if intervention programs minimize symptoms and promote coping and other functional skills. A collaborative agreement was established between Washington State Department of Corrections and a consortium of University of Washington faculty to mutually develop a prison-based program of clinical management and psychoeducation for MIOs. The resulting program is described, along with rationale, planning processes, implementation, and initial evaluation. Most aspects of the planned program are in place. Clinical and behavioral progress by inmates following program participation has been documented. Issues concerning treatment program implementation in prisons are discussed. Copyright 2002, Elsevier Science (USA). All rights reserved.

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LTHOUGH ESTIMATES of the prevalence of mental illness in prison populations vary because of differing definitions and assessment methods, available evidence indicates that it is higher than in the community. One review of multiple studies concluded that 10% to 15% of prison populations “have a major DSM-III-R thought disorder or mood disorder and need the services usually associated with severe or chronic mental illness” (Jemelka, Trupin & Chiles, 1989, pp. 483484; Lamb & Weinberger, 1998). Similarly a Canadian assessment of 495 randomly selected inmates revealed a six-months prevalence rate of 15.7% for major mental illnesses (Hodgins & Cote, 1990). Thus a significant minority of prison inmates are affected by a mental illness.

From the School of Nursing, University of Washington, Seattle, WA Address reprint requests to Frederica W. O’Connor, RN, PhD, Psychosocial and Community Health — Box 357263, University of Washington, Seattle, WA 981957263. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-9417/02/1605-0006$35.00/0 doi:10.1053/apnu.2002.36236

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In this article we briefly review characteristics and experiences of inmates with mental illness and enumerate potential benefits of psychoeducational treatment programs in prisons. We then describe the development and implementation of a treatment program that resulted from a collaborative agreement between the Washington State Department of Corrections and a consortium of University of Washington faculty from Psychosocial and Community Health Nursing, Community Psychiatry, Anthropology, Public Policy, and Social Work. An important aspect of this program is that it was envisioned, developed, and implemented through the joint efforts of an interdisciplinary university team and prison-based Department of Corrections staff. We reflect on this process from the vantage point of 6 years into the program. For our purposes, the term mentally ill offenders (or MIOs) refers to people in prisons with significant symptom levels or functional impairment resulting from a diagnosable mental illness, usually schizophrenia, unipolar or bipolar depression, or organic syndromes with psychotic features. Substance abuse or antisocial personality disorder often co-occur with other mental illness in incarcerated populations (DiCataldo, Greer, & Profit, 1995).

Archives of Psychiatric Nursing, Vol. XVI, No. 5 (October), 2002: pp 232-238

RESIDENTIAL TREATMENT FOR MENTALLY ILL INMATES

DIFFERENCES BETWEEN MENTALLY ILL AND NONMENTALLY ILL INMATES

Differences in prison conduct have been found between inmates with and without mental illness. One study reported that inmates with mental illness committed five times more staff assaults and other major offenses (infractions) than inmates without mental illness (McShane, 1989), and another study reported one and a half times as many infractions per 100 inmates annually, a significantly higher proportion of which were categorized as violent (Morgan, Edwards, & Faulkner, 1993). Prisoners admitted to the program described here had previously committed infractions at three times the rate found among general population inmates (Lovell & Jemelka, 1996; Lovell & Jemelka, 1998). Infractions by MIOs may at times result from psychiatric symptoms or inadequate coping skills. Inmates with mental illness have been identified as dependent, attention-seeking, deficient in social skills, and unable or unwilling to adhere to informal inmate norms (Morrison, 1991). Prisons maintain order through a profusion of rules and sanctions. Inmate relationships are often tense and may be ruthlessly competitive (Adams, 1992). Thus, the complexity of life on general population units may exceed the capabilities of inmates with mental illness. It is generally regarded that inmates with mental illness receive longer sentences and also serve a higher proportion of their sentences than do other inmates (Feder, 1991; Morgan, Edwards, & Faulkner, 1993). Indeed, the median sentence among inmates admitted to the treatment program is 5.7 years, substantially longer than the average sentence (just under 4 years) for all Washington felony offenders sentenced to prison in 1996 (Lovell, Allen, Johnson, & Jemelka, 2001; Sentencing Guidelines Commission, 1996). Inmates with mental illness also serve more of their sentences because they fail to accrue as much “good time,” which is earned when an inmate serves time without being infracted for rule violations. It follows that programs oriented toward stabilizing symptoms and developing coping and other social and living skills should provide numerous benefits. Cohen and Dvoskin (1992) cite the following potential benefits: reduction in human suffering; increased safety for inmates, staff, and visitors; and probably shorter incarcerations. Fur-

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thermore, if a program that stabilizes MIOs can be sustained, some portion of the financial investment in the program is likely to be offset by lowered costs elsewhere. For example, among New York State MIOs transferred to an intermediate care program, there were significant reductions in serious rules infractions, suicide attempts, and use of three higher-cost services: crisis care, seclusion, and hospitalization (Condelli, Dvoskin, & Holanchuck, 1994). THE WASHINGTON STATE PROGRAM

Our program is the result of a mandate from the state legislature, which was concerned about the management of inmates with mental illness in the state’s prisons. Services already in place were routine screening for mental illness during the reception of all male inmates, acute care units in two prisons, and several special needs units. Outpatient mental health services were available at all state prisons. Missing from this continuum was an intermediate option to systematically develop MIOs’ skills in collaborating with staff to manage their symptoms and adjustment to life in prison. A central focus of the collaboration then became the design, implementation, and evaluation of a residential psychosocial skills program sited in a male medium security prison. The principal treatment component occupies a 75-bed unit that uses a direct supervision model, a design in which inmates and correctional staff mingle in a large central area of the prison unit during most of the day. A 22-bed unit in an adjacent high security building serves as the admissions and acute care unit. New admits are usually transferred to the principal treatment unit within 2 weeks. Referrals come from general population, from other prisons, and from the state Prison Reception Center. Appropriate candidates are inmates whose symptoms appear likely to stabilize sufficiently for participation in group classes and who appear likely to benefit within 6 to 18 months, after which transfer out of the program is anticipated. Prison administrators and university faculty began planning the program about 1 year before the arrival of the first inmates. General decisions were made about unit philosophy, treatment programming, and staffing. Minor remodeling was undertaken to establish teaching-learning areas in the central area of the unit and to alter fixtures that could readily be used in a suicide attempt.

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Several months before the unit opened, staff that would be assuming leadership roles were hired. Committees of new staff, professional and managerial personnel from other prison units, prison administrators, and university faculty were formed to develop policies and procedures for the program and for integrating it with general prison operations. Workgroups also developed the program of mutually supportive elements to help inmates gain control of their symptoms and learn skills that would allow them to live more successfully in general population settings: ● ● ● ● ●

A staffing plan that supports inmates’ efforts to learn new skills; A low stress milieu that encourages effective behavior; Conscientious diagnosis and treatment planning; Participation in classes that develop skills and the confidence to use them; Guided transition to the next living environment.

The description of these elements in the next section will be followed by a discussion of the issues encountered in trying to implement them in a prison setting. DESIGN OF THE THERAPEUTIC PROGRAM

Staffing and Administration Any prison living unit requires staff to monitor the behavior of inmates, provide security for residents and staff, and perform “classification” tasks such as tracking inmate custody levels, programming, and progress towards release. Although there are no generally accepted numerical standards for prison mental health staffing, courts have established core objectives for prison mental health programs that provide a basis for assessing a staffing plan (Metzner, Cohen, Grossman, & Wettstein, 1998). These include conducting mental health assessments to establish diagnosis, level of function, and psychoeducational needs; dispensing and monitoring medications; making medical and psychiatric intervention available around the clock; meeting and developing individual treatment plans; and providing counseling or programming beyond medications. Because of this program’s particular mission, the final requirement means that staffing must be sufficient to offer a psychoeducational

curriculum that keeps inmates actively engaged in learning new skills. The staffing plan represented a compromise between the planners’ recommendations and the Department of Corrections’ budget limits. Staff were recruited from both the community and the correctional system on the basis of expressed interest in working with the mentally ill offender population. During interviews, applicants were rated on their ability to recognize potential contributions of mental illness to aberrant behavior in a correctional setting and to formulate responses that acknowledge both the requirements of security and the vulnerability associated with mental illness. The mental health program is directed by a correctional mental health program manager, and daily operations are coordinated by a correctional mental health unit supervisor. Staff for the 2-unit, 97-bed program includes one full-time psychiatrist, two clinical psychologists, one psychiatric nurse practitioner, nine registered nurses, and 31 correctional mental health counselors, distributed across three classification levels. Milieu Symptom and behavioral stability are promoted by a milieu comprised largely of vulnerable inmates, minimizing the incidence of serious predatory threats. This milieu is designed to enhance the effectiveness of the treatment program. Important features of a living environment congruent with the needs of MIOs are predictability, freedom from violence, opportunity for privacy, and a minimum of environmental irritants — a secure place in which challenges and stressors are matched to the vulnerabilities and impaired capabilities of the population (Seymour, 1977; Toch, 1993). These milieu ideals are supported by architectural, interpersonal, and programmatic features. On the principal treatment unit, inmates live in two-man rooms that offer visual and auditory privacy from the unit’s large central core. Each inmate carries the key to his room. Disruptive behavior is minimized by transferring back to the 22-bed acute care unit any inmate experiencing acute decompensation or sustained behavioral disruptiveness. To reduce isolation and stigmatization, inmates from the principal treatment unit are in contact with inmates and corrections officers


from other areas of the prison in the dining room, the outdoor exercise area, and on work details. Each inmate is assigned to a correctional mental health counselor (CMHC) for classification counseling, a security function that was expanded to include primary responsibility for directing an individualized treatment plan. On-unit staff offices permit regular informal contact between inmates and their counselors, which allows for early recognition and response to problems. Staff nurses administer medication and address psychiatric and general health concerns. Thus, a culture of physical and psychosocial safety is maintained by frontline staff. Weekly community meetings provide a forum for addressing group living problems. Staff meet weekly to discuss program issues, and they are expected to develop interdisciplinary, individualized treatment plans. Diagnosis and Treatment Planning Careful attention to symptoms and medications is critical to improving the behavior and quality of life of inmates with mental illness. The psychiatrist and two psychologists establish psychiatric diagnoses. Medication management is provided by the psychiatrist and a psychiatric nurse practitioner. An interdisciplinary group is expected to develop a preliminary treatment plan when inmates are admitted to the program and to formally update it after 2 weeks and thereafter at 90-day intervals. Skill Development The goal of the program is to develop and foster effective social and living skills. The expectation is that, if sufficiently encouraged, these skills will be used in daily life on the unit. Prior prison interventions have shown adoption and continued use of new skills among inmates with mental illness (MacKain & Streveler, 1990; Melville & Brown, 1987). Our program is loosely formatted on an academic model. Although flexibility and individualization are anticipated each time a course is taught, classes are based on course outlines. When course content has been taught, a course concludes and subsequently restarts with a new group of inmates (although inmates can take the course a second time). Eight to 12 inmates participate in a class at any given time. Course offerings fall into the following categories:

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Social-Interpersonal Skills: Interpersonal selfawareness, verbal and nonverbal communication, written communication, anger management Health and Self Management: Symptoms of mental illness, medication knowledge, hygiene, and physical and dental health, stress management Living Skills: Managing prison and community life Management of Drugs and Alcohol: Drug and alcohol education and relapse prevention with a specific focus on mental illness Recreation and Leisure: Use of leisure time, socialization, creative arts, fitness Transition Preparation: Classes and case management efforts to support transfer to general population, camp or work release, or a community placement; skill application in new setting.

Classes are typically led by a senior correctional mental health counselor, a nurse, or a psychologist, although one popular class was designed and established by an entry-level correctional mental health counselor. Teaching strategies vary, but the theory of psychoeducational programming suggests that methods be matched to the attentional, thought processing, memory, educational, and sometimes intellectual limitations of many MIOs. Active-directive teaching approaches, including role-playing, are emphasized in light of the behavioral as well as informational and attitudinal requirements of most topics. Positive reinforcement is used liberally in response to demonstration of newly learned skills. To encourage everyday use of skills, the practical advantages of using new behaviors are reviewed frequently and opportunities for skill use in the natural milieu are discussed. See Anthony and Liberman (1992) for elaboration of the philosophy and principles of psychosocial rehabilitation. IMPLEMENTATION OF THE PROGRAM

Acceptance by the Prison The rehabilitation program has integrated itself well into the larger institution. This welcome result may be attributed to a variety of factors: the regular presence of program inmates along with general population inmates in most prison activities, the practice of using the host institution as an initial

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discharge destination for many program graduates, the contributions of program personnel to training seminars for staff in other areas of the institution who also work with inmates who have mental illness, and the commitment of the institution’s administration to the success of the program. Since the history of corrections is replete with innovative programs that failed because of a lack of fit between the operations of the treatment unit and those of the larger institution, the program’s success in this regard is as noteworthy as it was essential. Acceptance of a program by the surrounding institution, of course, is no guarantee that it will remain faithful to its mission. We describe below the obstacles encountered in the areas of clinical focus, program administration, and continuity of care. Implementation of Clinical Components It was our observation that individual treatment plans were often completed in a generic or perfunctory manner. Rarely did they reflect interdisciplinary assessment of difficult behavior and the clinical posture (with respect to issues of manipulation, past trauma, need for support, and so on) most likely to be productive with the inmate. Review of treatment logs indicates that the psychiatrist, nurses, and case managers responsible for clinical management were paying careful attention to symptoms, medications, responses, and behavior. Thus gaps in treatment plans did not show lack of attention by individual staff members to the particular needs of participants. Rather, they reflected that staff members were not coming together routinely to discuss and reach consensus on the clinical approach to be taken. After the first 2 years, our reviews identified decreased participation in psychoeducational classes. We believe this was because of competing demands on staff time. When absences occurred among the front-line staff responsible for maintaining security on the unit, the senior counselors had to fill in, resulting in canceled classes. Senior counseling staff are also responsible for routine classification reviews— custody-level calculations, risk assessment forms, and the like—required for all inmates. The effort devoted to routine prison housekeeping functions detracts from the time and energy available for the psychoeducational program.


Despite these difficulties, the commitment of the staff to the goals of the program has been maintained, reinforced by the unmistakable difference in atmosphere between the mental health unit and normal correctional settings. Interviews with inmates who have left the program for other prison units indicate that most of them perceive the staff as helpful and available (Lovell, Johnson, Jemelka, Harris, & Allen, 2001). These interviews, as well as conversations with staff, indicate that the establishment of a supportive milieu has been a clear success of the program. Inmates feel safer and behave better. Those who are interested in working with staff to improve management of their symptoms and use of effective functional skills respond readily to the program milieu. Participants with a strong adherence to an inmate subculture sometimes do not appreciate the individualized involvement of staff in their lives. Program Administration The vicissitudes of the program included several changes of program manager, damaging conflicts among key clinical staff, and several periods of high staff turnover in which vacancies inhibited program delivery. One factor in the turnover in was the failure of the Department, at the outset, to hire a strong manager with both clinical and administrative credentials. Ensuing conflicts among subordinate staff resulted from competition over who would fill the vacuum and what direction the program would take. In addition, many of the initial senior correctional mental health counselors were hired from outside of corrections; all of these staff eventually left for other settings. Several core clinicians — the psychiatrist, the unit manager, the supervising nurse, and several veteran counselors – remained stable. Two years ago, in a change of executive priorities, funding for the collaboration was shifted to other areas; clinical consultations and systematic reviews of program implementation and participant outcomes were ended. Nonetheless, clinical staff report that classes and treatment conferences have been reestablished. It is noteworthy that the latest program manager has advanced clinical training and experience as well as the ability to protect the program administratively. He read our critical reports on program implementation and appeared to take our recommendations seriously.


Coordination of Care Most program graduates who go to general population can be found either in the host institution or in another institution with a treatment program for sex offenders. These settings are supportive, and program alumni are doing well in them. Routine transfer and classification procedures are designed chiefly to match inmates to beds at the appropriate security levels in the state-wide system. No system-wide process prevents abrupt termination of rehabilitative treatment for inmates with mental illness or keeps them from being transferred to hostile environments, and we witnessed several postprogram failures because of this factor. Despite this limitation, there is evidence that the program is fulfilling its intended role in the Department’s mental health system (Lovell, Allen, et al., 2001). Most inmates show lower levels of psychiatric disturbance following program participation. After transfer to other prison settings, most have been able to manage themselves in general population units with reduced infractions and greater participation in work and school. About 30% of program inmates, however, have proved themselves difficult to manage in every prison setting, including during program participation. It is conceivable that greater attention to the clinical planning, delivery, and placement issues described above would improve the system’s ability to cope with this high-maintenance minority of mentally ill prisoners. REFLECTIONS

The university and correctional participants who developed the program confronted two sources of conflict: between academics and practitioners, and between treatment and security. Our experience so far shows that both issues can be negotiated successfully, but also suggests that continuing vigilance is required to support a collaborative treatment program in a prison setting. The conflict between security and treatment is a shibboleth in correctional practice; like most cliche´ s it both reflects and distorts reality, and it raises issues beyond the scope of this report. In our program experience, however, there were few instances when staff lined up on different sides of an issue—for example, whether or not to segregate an inmate or where to transfer him— because one choice served his clinical needs and the other met

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the institution’s security requirements. The common feature of the program obstacles mentioned above is not the incompatibility of clinical and security considerations. Rather, there are certain things that must be done—floor security, counts, classification reviews, completion of official forms— because they are part and parcel of the functioning of a prison and will be officially monitored. There are other things that are desirable, but don’t absolutely have to happen: back-up staffing for training sessions, treatment team meetings on hectic days, psychoeducational classes when staffing is short, and case conferences with colleagues in other institutions. Given these pressures, the level of continuing attention to the clinical needs of program inmates is a remarkable achievement. In large part this is because of innovations that were built into the program when it was designed: the full-time psychiatrist, counselors’ offices on the unit, the CMHC series, and the psychoeducational model. Because of these features, the unit has a different “look and feel” from other correctional settings, and both staff and inmates have seen it as a milieu that supports and rewards their efforts. The university partners’ understanding of research and experience with rehabilitative methods in other contexts were critical to program design. The responsibility for making the program happen, however, rests with the correctional partners. Despite several bumps in the road, relationships between correctional and university collaborators became more comfortable and collegial as we gained experience with each other. This development is caused in part by mere familiarity, but also reflects the fact that a central core of staff are committed to the program’s mission and have seen the university participants as allies. Because the university did not control staffing and treatment protocols, the program represents a compromise. Although staffing is thinner than the University of Washington proposed, it compares well with comparable units in other states and allows far greater staff availability than inmates find in general population. Although prison operational requirements took precedence over research protocols in program design, we have been able to conduct informative studies on inmates with mental illness, correctional program issues, and outcomes.

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Although the collaboration has worked, the security of the relationship cannot be taken for granted. Washington State’s financial crisis, for example, has placed the Department’s contractual relationship with the University in mortal jeopardy. But the program carries on, which surely would not have happened if the university were responsible for running it. Nor would the program have achieved needed levels of cooperation from other areas of the correctional system if it were seen only as the university’s program. In the long run, the program’s continuing success will depend on the extent to which institutional and departmental administrators see the program’s accomplishments as theirs. ACKNOWLEDGMENT The authors appreciatively acknowledge the helpful comments of Kathy Kroening, MN, on an earlier draft of this article and also acknowledge numerous and diverse contributions from correctional and university collaborators to the work described here. This program was developed and implemented under the auspices of a Washington State Department of Corrections/ University of Washington Collaboration Contract.

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