Chapter 14 Mental Health Chapter Objectives Outline issues inherent in the provision of mental health care in the correctional setting. Understand when inmate participation in mental health care and treatment can be required. Explore the right to privacy with regard to mental health records. Introduction Provision of mental health services is a necessary and complex part of any correctional operation.  Attention to planning and implementation of services to meet the mental health needs of population greatly contribute to a smooth running facility; inattention can lead to problems, negative publicity and litigation.  Correctional administrators must know the standards for care of mentally ill offenders.  Process for care of the mentally ill has changed significantly over the past fifty years. With the advent of psychopharmacology and focused therapies most people suffering from mental illness may be managed in outpatient settings. Introduction The management of most mentally ill patients as outpatients has resulted in the deinstitutionalization of people needing care.  However, the lack of community resources and existing support systems has led to the inadequate treatment of some mentally ill persons and has resulted in their placement in the criminal justice system. Current data reflect more mentally ill persons in jails and prisons than in community mental institutions.  About half of the inmate population has been diagnosed with a mental health problem with approximately 16% diagnosed with serious mental illness. The Diagnostic and Statistical Manual of Mental Disorders Most commonly used classification system of mental illness and defects.  A mental disorder is a: “clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability.”  Major mental disorders include diagnosis of: schizophrenia, major depression, or bipolar disorder. Many inmates demonstrate personality dysfunction and meet criteria for Antisocial Personality Disorder and other personality disorders, which remain difficult to treat. Guidelines and Standards The responsibility for provision of care to those who are denied the ability to choose their own care because of confinement has been defined in the Courts and standards of several organizations published to review. The current standard of care requires basic and clinically relevant care. Problems arise when care falls below accepted standards and may result in deliberate indifference. Deliberate indifference can be evidenced by: lack of access, failure to follow through with care, insufficient provision of staff resources, and poor outcomes due to negligent care. Guidelines and Standards Several organizations have established minimum guidelines for the treatment of mentally ill in correctional environments: a. American Correctional Association (ACA) b. American Medical Association (AMA) c. American Public He.

1. Chapter 14
Mental Health
Chapter Objectives
Outline issues inherent in the provision of mental health care in
the correctional setting.
Understand when inmate participation in mental health care and
treatment can be required.
Explore the right to privacy with regard to mental health
records.
Introduction
Provision of mental health services is a necessary and complex
part of any correctional operation.
Attention to planning and implementation of services to meet
the mental health needs of population greatly contribute to a
smooth running facility; inattention can lead to problems,
negative publicity and litigation.
Correctional administrators must know the standards for care of
mentally ill offenders.
Process for care of the mentally ill has changed significantly
over the past fifty years. With the advent of
psychopharmacology and focused therapies most people
suffering from mental illness may be managed in outpatient
settings.
Introduction
The management of most mentally ill patients as outpatients has
resulted in the deinstitutionalization of people needing care.
However, the lack of community resources and existing support

2. systems has led to the inadequate treatment of some mentally ill
persons and has resulted in their placement in the criminal
justice system.
Current data reflect more mentally ill persons in jails and
prisons than in community mental institutions.
About half of the inmate population has been diagnosed with a
mental health problem with approximately 16% diagnosed with
serious mental illness.
The Diagnostic and Statistical Manual of Mental Disorders
Most commonly used classification system of mental illness and
defects.
A mental disorder is a: “clinically significant behavioral or
psychological syndrome or pattern that occurs in an individual
and that is associated with present distress or disability.”
Major mental disorders include diagnosis of: schizophrenia,
major depression, or bipolar disorder.
Many inmates demonstrate personality dysfunction and meet
criteria for Antisocial Personality Disorder and other
personality disorders, which remain difficult to treat.
Guidelines and Standards
The responsibility for provision of care to those who are denied
the ability to choose their own care because of confinement has
been defined in the Courts and standards of several
organizations published to review.
The current standard of care requires basic and clinically
relevant care. Problems arise when care falls below accepted
standards and may result in deliberate indifference.
Deliberate indifference can be evidenced by: lack of access,
failure to follow through with care, insufficient provision of
staff resources, and poor outcomes due to negligent care.

3. Guidelines and Standards
Several organizations have established minimum guidelines for
the treatment of mentally ill in correctional environments:
a. American Correctional Association (ACA)
b. American Medical Association (AMA)
c. American Public Health Association (APHA)
d. American Psychiatric Association (APA)
e. The Joint Commission on Accreditation of Health
Care Organizations
f. National Commission on Correctional Health Care
(NCCHC)
g. National Institute of Corrections (NIC)
Standards and Guidelines
The importance of external review and accreditation should not
be understated, and although there is considerable overlap of
the intent in the standards, the degree of fit varies greatly. For
example ACA looks at issues more broadly, while the Joint
Commission is very specific.
Successful accreditation provides support for the correctional
system when questions arise about the adequacy of care.
Access to Care
The 1980 court case Ruiz v. Estelle, 503 F.Supp. 1265 (1980),
the Court focused on six issues which address the minimum
standards for mental health care in a correctional environment.
a system to ensure mental health screening
provision of treatment while inmates are in segregation or
special housing units

4. training of mental health staff to ensure individualized
treatment
maintenance of an accurate and confidential medical record
system
presence of an effective suicide prevention program
monitoring to assure appropriate use of psychotropic
medication
These same issues remain relevant and essential today.
Screening
Mental health care begins at the screening stage when the
offender arrives at an institution.
Inmates should be screened promptly upon arrival and before
they are placed in a housing situation without direct staff
observation.
The primary goal of screening is to identify emergent and
urgent problems.
While screening forms and tools may be standardized, the
screening should be individualized to each offender
Screening
Proper mental health intake screening will determine the type
and immediacy of need for other mental health services.
Inmates requiring further assessment need to be housed in an
area with staff availability and observation.
Further assessment may include: additional interviews, record
collection and review, physical examination, laboratory studies,
drug screening, continued observation and occasionally
psychological testing.
Treatment

5. Treatment needs can be met in a variety of settings:
Outpatient
Inpatient
Transitional
Treatment
While the concepts of outpatient and inpatient care is generally
understood, transitional care represents inmates with similar
problems being housed together in a general population unit
with special programs in an attempt to integrate the offenders
into the general population of a correctional system. They are
designed to:
stabilize symptoms in a sheltered environment
improve coping skills to allow inmate to be housed or returned
to general population
helping the inmate to better adapt to the general prison
environment
Inpatient Hospitalization
Admission to an inpatient psychiatric hospital may be voluntary
or involuntary and may be to a facility in the community or a
prison psychiatric hospital. When there is an offender who
requires by does not volunteer for admission, there is an
administrative due process or judicial review concerning the
need for hospitalization.
Inpatient Hospitalization
Reasons for inpatient hospitalization include:
Presence of severe or disruptive psychiatric symptoms
Inability of the system to handle the inmate in a less restrictive
environment

6. Court orders for inmate inpatient evaluation or commitment
Assessed risk of imminent danger to self or others
Treatment Related to Diagnosis
All mental health treatment interventions are related to
diagnosis.
Treatment may be delivered by various members of the mental
health treatment team. Clear documentation of an
individualized treatment plan should be placed in the inmate’s
medical record. All members of the team may handle different
diagnosis and defects. For example, a counselor may take lead
on the diagnosis of mild depression, while medical staff
(psychiatrist) would take care of psychosis.
Because of the relapsing nature and chronicity of some mental
disorders discharge planning and follow-up care in the
community is critical. The cornerstone of successful discharge
planning remains sound diagnostic assessment.
Crisis Intervention
Crisis intervention includes interventions aimed at reducing
acute mental distress.
Frequency crisis present as suicidal ideation, suicide attempts
or directed aggression.
Suicide prevention programs include adequate training of staff
in the identification of signs and symptoms of suicide risk.
Issues Arising from Confinement
Some individuals enter the criminal justice system while
mentally ill.
Others develop new symptoms or illness once in custody. The
stress of being in the criminal justice system itself can create or
exacerbate symptoms or illness.

7. Know stressors include involvement in the legal system,
separation from existing community support systems, peer
problems in the institution, loss of control and individual
decision making. Further incarceration may disrupt activities of
normal living and limit access to stress reducing activities.
Privacy
Correctional health-care providers are confronted with issues of
patient privacy and confidentiality. Medical and mental health
information can be shared with other medical providers;
however, there are strict restrictions on other release of health
care information.
Inmates have the right to obtain copies of their medical records
unless their health care providers deem such review would be
detrimental to the inmate’s health.
Legal Requirements
Hospitalization in a psychiatric facility (even in a prison) is
voluntary unless the level of impairment is so severe the patient
presents a clear risk of harm to themselves or others.
Each state and the federal government, by statute, outline how a
person can be involuntary hospitalized for psychiatric care.
Psychiatric hospitalization does not necessarily grant the care
provider authority to treat.
To treat, the inmate must give informed consent to a specific
treatment, unless the situation has been deemed an emergency
or treatment has been authorized by the court.
Dual Roles of Clinical Staff

8. Clinical staff may feel caught between their roles as providers
and correctional workers.
Inmate patients are to be notified of the security restrictions
which are present. They need to be advised that information
which might lead to the harm of the patient, others, or concerns
about property destruction which could harm others will be
disclosed.
Special Treatment Procedures
Use of special treatment procedures, such as seclusion or
restraint requires close attention.
The goal should be to keep inmate patients in these most
restrictive situations for the minimum amount of time to ensure
their safe management.
Inmates in seclusion require enhanced staff observation and
monitoring, including continuous monitoring if the inmate is
viewed as suicidal.
Inmates must be regularly checked by medical personnel to
ensure they are medically stable and circulation has not been
compromised. Correctional staff ensures toileting, meals, and
repositioning is accomplished. Both health-care providers and
correctional staff share responsibility.
Medications
Medication is a frequent, costly, and potentially high-risk
function within the correctional environment.
Pharmacotherapy is a mainstay of current mental health
treatment but can present problems in a correctional
environment.
Establishing clear and widely understood prescription
guidelines is useful in managing the use of psychiatry

9. medication, controlling costs and preventing abuse.
Medications should be kept to a minimum except for the
treatment of clearly documented medical or psychiatric
conditions
Medications
Medication compliance should be closely monitored.
Polypharmacy, the use of multiple medications from the same or
similar class of drugs should be avoided.
Having the same provider prescribe helps to decrease
medication seeking behavior. Every effort should be to have
one prescriber manage an individual’s medication.
Personality Disorders and Malingering
The diagnosis of antisocial personality disorder is based almost
exclusively on the basis of historical information. This
diagnosis is demonstrated by a pattern of disregard for others,
breaking the law and lying, as well as impulsive, irresponsible
and aggressive behavior. This disorder is difficult to treat.
Malingering is a conscious behavior that involves falsely
claiming or misrepresenting symptoms. Malingering is a
diagnosis of exclusion, only after psychopathology is ruled out.
The Integration of Care
The success of any mental health care is related to the adequacy
of general medical services. Medical illnesses often present
with psychiatric symptoms. A significant number of psychiatric
patients in the correctional environment have concurrent
medical illnesses.

10. Each inmate admission to a psychiatric hospital requires a
complete physical examination with extensive laboratory studies
to rule our organic causes for presented symptoms.
Conclusion
Staffing correctional health care and mental health programs
can be a difficult task. Few clinicians are trained to work in
correctional environments. Most clinicians enter the field by
accident. The provision of adequate care constantly competes
with maintaining adequate security.
Ironically, many clinicians are realizing that correctional
environments may be one of the last public strongholds for the
adequate care of seriously and chronically mentally ill patients.
The environment with the absence of third-party payers, and the
impact of externally imposed motivation to change create a
unique setting for the provision of mental health care.