Psychiatric Services in Correctional Facilities (Third Edition)

This is a recent report of the American Psychiatric Association's Work Group to Revise the APA Guidelines on Psychiatric Services in Correctional Facilities. The third edition of Psychiatric Services in Correctional Facilities attempts to bridge the 15-year-gap between the second edition in 2001 and the present. Much has changed during this timeframe, including an increase in the population of incarcerated men from 1.2 to 2.2 million between 1989 and 2012 (preface). A survey of county jails indicates that 95 percent of confined individuals with serious mental illness and 75 percent reported a substantial increase in inmates with serious mental illness relative to 5 to 10 years ago.¹ The members of the Work Group who created these new Guidelines are notable in the field of forensic and correctional psychiatry. The book succeeds in providing essential information on psychiatric services in jails and prisons in a concise and organized manner, while placing them in a legal and constitutional framework.

The book is divided into three parts that are supplemented by 10 appendices. Part I examines basic legal concepts, including the right to treatment, adequate care, and treatment over objection. The authors appraise how inmates access treatment and the quality of the care delivered. The book unfortunately does not elaborate on treatment over objection in the context of The U.S. Supreme Court's decision in Washington v. Harper, 494 U.S. 210 (1990). Many jails and prisons do not offer this treatment option and would rather place an individual on a waiting list for state psychiatric hospitalization which may take a long time due to lack of available beds. As a result, inmates deteriorate and some, who have been adjudicated incompetent to proceed with trial, end up spending more time incarcerated than they should. Where does autonomy end and negligent service provision begin?

Under the section on confidentiality and privacy, some psychiatrists may find it controversial that the recommendations include limiting the involvement of the psychiatrist in the determination of whether an offender's mental disorder contributed to a behavioral infraction and that the psychiatrist should not comment on whether an inmate should be disciplined. The recommendation that because of the potential for conflicting roles, evaluating psychiatrists should not be the treating psychiatrist is unrealistic given the shortage of psychiatrists working in correctional settings. This section of the book also examines the mental health referral process, determining the level of care, ethics, hunger strikes, research, and administrative matters. A discussion about diversion, including pre- and post-booking, examines the unfortunate circumstances whereby an individual cannot be diverted.

Part two of the book gives a broad overview of the guidelines for psychiatric services in correctional facilities without mentioning limiting factors and how such factors can be overcome. The recommendation for a screening process within the first four hours of incarceration would be invaluable in triaging inmates for clinicians. A discussion that mentions the acute shortage of correctional psychiatrists and utilization of midlevel practitioners would have been useful but was not present. Similarly, although community re-entry and transfer planning was mentioned, there is no discussion of how staffing and ensuring privacy can obstruct these processes. A review of essential services that are needed for re-entry, including procurement of identification cards, prerelease classes, job assistance, and housing information would have been welcome. These services can facilitate re-entry into the society and reduce the risk of recidivism.

The authors examine specific treatments for conditions including substance use disorders, posttraumatic stress disorder, nonsuicidal self-injurious behavior, HIV, and hepatitis.

Service provisions for the special populations like individuals with intellectual disability, who are pregnant and who require hospice services are addressed. The authors discuss segregation, including its negative effects on inmates who have mental disorders, reducing seclusion and restraint by using de-escalation techniques and less restrictive alternatives, and how telepsychiatry can be used to bridge service delivery in communities where there is a shortage of psychiatrists. Despite laudable discussions on these specific treatment goals, there were again some notable omissions. There was no discussion of formulary restrictions and options for correctional psychiatrists in the face of such restrictions. The authors did not exhaust service options for newborns and their mothers beyond foster care or with relatives. Many studies have shown that such children are vulnerable to attachment disorders and newer initiatives including parenting classes for mothers and provision of nurseries and daycares can facilitate maternal–infant bonding.²

Finally, the appendices provide valuable information through position statements by the American Psychiatric and American Medical Associations. I was particularly interested in position statements relating to segregation of prisoners with mental illness, a prisoner with mental illness on death row, capital punishment, and the care of transgender and gender variant individuals in prisons and jails.

• © 2017 American Academy of Psychiatry and the Law