COMMENTARY

The Return of the Alienist

James L. Knoll IV, MD

Disclosures

May 10, 2013

In This Article

The Fruits of Alienation

Our humanistic calling -- our desire to save lives and relieve suffering -- was apparently too suspect and paternalistic. Now psychiatrists operate, to an extent, in handcuffs. On the subject of cuffs, what has this diminution of nefarious psychiatric authority brought us as a society? It has allowed many patients with mental illness to suffer untreated, delayed progress in the field, and created a serious public health issue that no one cares to acknowledge -- the shift of persons with severe mental illness into correctional institutions. Alas, health issues that are ignored invariably come back to call.

We have chosen, at great expense, effort, and misery, to recreate an entire mental health system inside prisons. The irony is that although there is no official, coordinated mental health system in free society, there is now a more sophisticated one behind prison walls. The correctional mental health system has come about as a result of very costly, time-consuming litigation. Whereas often no such system exists in the community, we now have an entire "continuum of care" in correctional facilities -- an array of services from inpatient, to intermediate care, to "outpatient" treatment in the general population of the prison.

Yet, there is much more related to mental health going on behind the walls. We now have research data showing that correctional facilities leave a permanent mark, mentally and physically, on inmates with severe mental illness.[12] By the time they reenter society, they are greatly disadvantaged in terms of a higher rate of recidivism, death, and an impaired ability to live successfully in the community.

Another recent trend -- a very slightly lowered level of incarceration, according to US Department of Justice statistics[13] -- has been driven largely by economic and not policy considerations. But as the overall prison population drops, the number of inmates with severe mental illness is not likely to decline substantially, if at all. In the near and intermediate term, prisons will increasingly resemble psychiatric facilities. In an age when it is no longer viewed as acceptable to execute persons with intellectual disabilities or severe mental illness, one would hope that this enlightened attitude might extend to declining to use prisons as our de facto mental health system. Lamentably, in 2013, this is not the case. Correctional facilities are now the most comprehensive continuum of mental healthcare services in the United States. Prisons, however, were never intended to be psychiatric hospitals, so they have had to quickly retrofit.

Although driven by litigation, the correctional system has made valiant and admirable attempts to transform itself into a more mental health-friendly system.[14] But places intended for punishment invariably institute punishment -- and in the case of persons with severe mental illness, missteps caused by their symptoms lead directly to punitive isolation.[15] Growing awareness of this problem led the American Psychiatric Association (APA) to issue a position statement in 2012 on segregation of prisoners with mental illness.[16] The APA's position is that "Prolonged segregation of adult inmates with serious mental illness, with rare exceptions, should be avoided due to the potential for harm to such inmates." The issue of the effects of prolonged solitary confinement (also called "punitive isolation") for inmates without severe mental illness is currently a contentious one; however, the clear consensus in forensic psychiatry is that the potential for psychiatric harm to inmates with severe mental illness is simply too great. Yet, the reality is that across the United States, it is not uncommon to find many persons with severe mental illness in punitive segregation.

The use of correctional facilities as psychiatric hospitals ultimately leads to the issue of discharge and discharge planning, as is required of psychiatric hospitals in the community. Until relatively recently, crafting an adequate mental health discharge plan was a wholly foreign concept to most jails and prisons. Upon release, many mentally ill persons did not have Medicaid; Supplemental Security Income; or referrals to housing or supportive services, such as case management or outpatient treatment.

Only 10 years ago, in the first class-action lawsuit challenging a city's practice of not providing discharge planning for its mentally ill inmates, the New York Supreme Court appeared to grasp the new role of correctional facilities as psychiatric facilities. In Brad H. et al. v City of New York et al.,[17] the court held that the city must provide intensive discharge planning for inmates with serious mental illness before they are released to the community. It is anticipated that other states will be influenced by this ruling and may implement similar services. This is timely, in that recent research finds that the circumstances surrounding reentry can be associated with significant morbidity and mortality.[18,19]

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