The Prison Rape Elimination Act and Correctional Psychiatrists

History

For years, inmate sexual assault was described by some as inevitable and “the extra punishment anyone sentenced to prison can expect.”² Although there was some discussion of inmate welfare, no agenda or effort translated these concerns into policy until 1994. At that time, the Supreme Court ruled that prisons that fail to protect inmates from sexual assault were in violation of the Eighth Amendment, which forbids cruel and unusual punishment (Farmer v. Brennan, 1994).³ Human Rights Watch⁴ and Amnesty International⁵ issued reports describing the extent of sexual abuse of female inmates. The advocacy group that would become Stop Prisoner Rape (SPR), cofounded by Russell Smith and prison rape survivor Stephen Donaldson, released a prisoner rape education program. The media were integral to bringing attention to prison rape, reporting findings published in academia. Public awareness grew that prison rape has downstream public health consequences. Victims can become infected with HIV/AIDS and then return to their communities of origin when released. Despite this growing attention, correctional systems made little apparent effort to address or eliminate rape. Some argue that it was the resistance of correctional systems that provided the necessary pressure for Congress to pass the Prison Rape Elimination Act (PREA) of 2003.² PREA in turn created the National Prison Rape Elimination Commission (NPREC), a bipartisan group that met from July 2004 through August 2009. The NPREC was charged with reporting on the nature and causes of prison rape and with recommending national standards to the U.S. Attorney General for reducing its occurrence. The NPREC released its final report in June, 2009⁶ in the form of a four-volume set of standards for adult prisons and jails (with supplemental standards for immigration detainees),⁷ juvenile facilities,⁸ lockups,⁹ and community corrections.¹⁰

Inmates With Mental Illness at Risk

Research has consistently found that at any given time in the United States, there are more mentally ill individuals in jails and prisons than in psychiatric facilities.¹¹ In the NPREC standards, inmates with mental illness were specifically identified as an at-risk group for sexual assault; consistent estimates suggest that 12 to 13 percent of prison rape allegations involve an inmate with mental illness or intellectual limitations, eight times the proportion of the general inmate population.⁶ The importance of a coordinated response at the facility level was clearly described, going beyond actions taken in response to an incident of sexual abuse to include a genuine culture change intended to eliminate prison and jail sexual assault.

Although the NPREC created standards, PREA designated the National Institute of Corrections (NIC) as the agency responsible for training and technical assistance and for serving as a national information clearinghouse. The National Institute of Justice (NIJ) was similarly tasked to provide research-based evidence to improve knowledge, practice, and policy addressing sexual violence in prisons.¹

Specialized Training

Specific to mental health professionals, the NPREC standards, NIC training, and related documents identify the need for specialized training for mental health and medical professionals in screening, prevention planning, allegation management, and investigation of prison rape. At the time of intake screening, pursuant to § 115.41,¹² if an inmate affirms experiencing or perpetrating prior sexual victimization in the community or facility, that inmate is to be offered a follow-up meeting with a medical or mental health practitioner within 14 days of intake. Although the language of the standards refers generally to “mental health practitioner,” the explicit role of the psychiatrist is not identified. Psychiatrists should look at this opportunity to shape the curriculum in their facility or system to assure that it is extensive, authoritative, and effectively conveys the needed knowledge and skill base. Further, the unique role of the psychiatrist may be defined in terms of diagnosis, management, and treatment of a prison rape victim, at a minimum.

Stress Disorder Diagnoses

“Rape trauma syndrome,” a term initially coined in the 1970s, is a state characterized by an acute phase of disorientation, followed by reorganization and resolution (Ref. 13, p 9). This term has been adopted formally as a nursing diagnosis.¹⁴

DSM-5 now devotes an entire chapter, “Trauma and Stressor Related Disorders,” to these disorders (Ref. 15 pp 265–290). Although DSM-5 provides guidance, the rape victim most likely will not present as delineated in the manual. As the inmate's manifestation of symptoms is not linear, it is imperative that the correctional psychiatrist recognize that an inmate can manifest symptoms subsequent to sexual trauma at any point throughout the incarceration.¹³ Moreover, an inmate with pre-existing mental illness who becomes a victim of sexual assault may present with primary illness exacerbation and additional signs and symptoms of a secondary illness. For example, the stressor criterion (Criterion A) for acute stress disorder (ASD) in DSM-5 requires specific identification of direct experience, indirect experience, or witnessed traumatic events. Individuals may now meet diagnostic criteria in DSM-5 for ASD if any 9 of 14 listed symptoms are present.¹⁵ Although DSM-5 attempts to take into account the many ways in which an individual suffering with ASD or posttraumatic stress disorder (PTSD) may present, incarcerated patients have even more heterogeneous symptoms and functional impairment.

Increased Suicide Risk

Victims of sexual assault are at a significantly higher risk for suicide, given the common sequelae of increased fear, stress, and anxiety. The risk is especially high in men, as higher percentages of men than women experience distress about their sex-role reputations.^2,16 The research of Struckman-Johnson¹⁶ in Midwestern prisons document suicidal ideation among inmate victims of sexual assault, both male and female. Responses affirming sexual coercion were reported by both sexes in prisons that were overcrowded, and assaults were alleged to have originated both from staff and from other inmates. When assessing a victim, psychiatrists should inquire specifically about suicidal ideation immediately after an assault, as that is the time of highest risk. However, given the potential for delayed symptom manifestation, careful assessment of suicidal ideation should be conducted at each subsequent interaction thereafter.

Treatment

The goals of treatment for individuals with a diagnosis of ASD or PTSD include reducing the severity of ASD or PTSD symptoms, preventing or treating trauma-related comorbid conditions that may be present or emerge, improving adaptive functioning and restoring a psychological sense of safety and trust. Patients assessed within hours or days after an acute trauma may present with overwhelming physiological and emotional symptoms (e.g., insomnia, agitation, emotional pain, and dissociation). Pharmacotherapy may be the first-line intervention for acutely traumatized patients whose degree of distress prevents new verbal learning or nonpharmacological treatment strategies.

In the jail or prison system, it is not atypical that victims of sexual abuse have great difficulty in making the decision to come forward and report the incident. During this initial phase, when life has been suddenly disrupted by an external event, the victims may be left feeling confused, anxious, and upset, with a compromised sense of self and autonomy. It is while in this state that the inmate is expected to report the assault, talk to multiple officials, undergo the gathering of physical evidence, and so forth. In the community, the traumatically assaulted individual might rely on a support system, and subsequently remove himself from the location of the crime and the aggressor. Moving to a safer location has historically not been possible during incarceration. PREA now mandates that the victim be provided with a victim advocate from a rape crisis center as soon as possible. The facility has the responsibility to place the victim in a safe environment, with involuntary segregated housing as last resort (for no more than 24 hours), while finding a safe nonpunitive location for the victim. However, although the victim may now feel safe, the reality is that the inmate has been separated from any routines and support systems formed during incarceration.

As part of PREA, mental health care practitioners are to receive training in detecting signs of sexual abuse and sexual harassment, in preserving physical signs of sexual abuse, in responding effectively and professionally to victims of sexual abuse and sexual harassment, and in reporting allegations or suspicions of sexual abuse and sexual harassment. Although it is atypical, it is possible that the psychiatrist is either the first responsible individual on the scene or the person to whom the victim first discloses the assault. Hence, within the correctional setting, in addition to training on identification of signs and symptoms of sexual abuse and harassment, practitioners also have to be trained in preserving physical evidence.

Research has not consistently identified patient- or trauma-specific factors that predict the development of ASD or interventions that will alter the evolution of ASD into PTSD. Effective treatments for the symptoms of ASD or PTSD encompass psychopharmacology, psychotherapy, and psychoeducation. With an acute trauma, the timing and nature of the first mental health contact may vary. Although some individuals who have been sexually assaulted are able to benefit from supportive and psychological interventions, some victims may exhibit hysteria, sadness, anger, and hostility, whereas others may demonstrate no emotion at all. They may be numb or in shock or have difficulty expressing themselves. Others may not be comfortable expressing emotion and therefore may appear totally calm, composed, and quiet. Any of these reactions may be observed. One should not expect a sexual abuse victim to act in a particular way.¹³

Although the formal assessment may be postponed, it is imperative that the victim be assessed for dangerousness to self or others. In evaluations that occur shortly after exposure to the traumatic event, the initial clinical response generally consists of supportive psychiatric care and assessment.^17,18

By definition, ASD occurs within four weeks of the trauma and lasts for a minimum of three days.¹⁵ Consequently, it can be diagnosed through four weeks after the traumatic event. If symptoms meeting the criteria are present one month subsequent to the traumatic episode, PTSD is the appropriate diagnosis. Because diagnostic assessment may occur at any time after a traumatic event, the clinician must bear these essential distinctions in mind when evaluating the trauma-exposed individual. Although it has been hypothesized that pharmacological treatment soon after trauma exposure may prevent the development of ASD and PTSD, existing evidence is limited and preliminary.¹⁹ Thus, no specific pharmacological interventions are currently recommended to prevent the development of ASD or PTSD in at-risk individuals. Further, exposure to previous trauma may modify vulnerability to subsequent trauma. For example, a victim may have become convinced at the time of a prior traumatic incident that the best way to get over it is just to act normal; thus, showering, grooming, eating and attempting to seem “okay” may influence the development of PTSD and complicate treatment and recovery.^13,15,20

In the short- and long-term after an incident, victims may become depressed or anxious. In someone with a preexisting mental illness, this stressor may exacerbate symptoms that had been controlled. A victim with bipolar disorder may begin to manifest symptoms of mania, including less need for sleep, an increase in goal-directed activities, and elevated or irritable mood.^15,19 An inmate with a preexisting mental illness may also exhibit signs or symptoms of a separate disorder altogether. Further, a victim with a previous diagnosis of PTSD may experience a relapse.¹⁹ The correctional psychiatrist should identify the patient's symptoms and decide how best to treat them.

Over the weeks after the sexual abuse, victims should be followed up by the mental health team as they will most likely exhibit a range of emotions, including fear of being alone or being around others, and significant changes in pursuit of activities that they enjoyed before the abuse. They may also exhibit retraumatization in response to triggers in the environment in the form of shock, denial, humiliation, self-doubt, guilt, shame, self-blame, depression, self-hatred or anger in the form of a desire for revenge, or suicidal thoughts.^19,20,21