Topic:
CORRECTIONS; PRISONS AND PRISONERS; MENTAL HEALTH;
Location:
MENTAL HEALTH; PRISONS AND PRISONERS;

OLR Research Report


September 24, 2001

 

2001-R-0605

MENTAL HEALTH SERVICES AT CORRECTIONAL FACILITIES

By: Susan Price-Livingston, Associate Attorney

You asked about the availability of mental health treatment for, and the supervision of, Connecticut inmates with mental illnesses. (You also asked the same question about Connecticut inmates housed at the Wallens Ridge facility in Virginia. Although there were prisoners there when you made this request, they have since been removed, and we have not included Wallens Ridge in this report.)

SUMMARY

State and federal laws and constitutions mandate that the Department of Correction (DOC) provide mental health services to inmates who have been identified as needing them. Under a $70 million contract with the University of Connecticut Medical Center, approximately 650 full-time-equivalent mental health professionals, including psychiatrists, psychologists, social workers, psychiatric nurses, and counselors treat inmates at state correctional facilities. Services include psychiatric assessments; individual and group therapy; medication administration and monitoring; crisis intervention; and specialized treatment programs for sex offenders, people with dual diagnoses (i.e., mental health and substance abuse problems), and those with a history of self-mutilation. Dr. Brett Rayford, Psy.D. of DOC's Health Services Division reports that mental health services are offered at each DOC facility (although some offer more than others) and there are no waiting lists, except for those needing substance abuse treatment.

Intake workers screen people entering the DOC system to determine whether they are suicidal or require mental health services before releasing them into the general prison or jail population. Rayford indicated that the mental health screening process at jails (which house people awaiting trial and some serving sentences of two years or less) is probably less thorough than that done at DOC's Walker Reception Center (the intake center to which people beginning their prison terms are sent). He suggested that this is in part because of the relative instability of the jail population, where the average length of stay is about two weeks during which time prisoners are frequently moving between jail and the courts.

The type and length of services and mental health supervision an inmate gets depends on DOC's assessment of his mental health needs. The department assigns each inmate a mental health needs score at intake, and may adjust it upward or downward as his condition worsens or improves. DOC houses most people it identifies as having serious disorders at the Osborn, York, Manson, and Garner facilities, where comprehensive mental health services are available. (Garner has an intensive mental health unit for violent males with bipolar disorders or schizophrenia.) The department has guidelines for suicide prevention, use of restraints, and administration of psychotropic medication (drugs used to treat psychiatric illnesses), which apply to all facilities.

DOC also works with the Parole Board and Department of Mental Health and Addiction Services (DMHAS) to make referrals and arrange for community-based services before a mentally ill inmate is released. Preliminary data (based on only six months of tracking released inmates) suggests that recidivism rates for people who get these services are substantially lower than for the general prison population (5% compared to the national average of about 60%), reports Rayford.

INMATES RECEIVING TREATMENT

A July 2001 U.S. Bureau of Justice Statistics report shows that 2.3% (341 inmates) of the 16,984 inmates in Connecticut correctional facilities (jails, prisons, juvenile detention, and halfway houses and other community-based correction programs) on June 30, 2000 were receiving 24-hour mental health treatment. A much larger percentage, 17.8% (2,596) were receiving counseling or therapy; and 11.4% (1,659) were taking psychotropic medication. (Actual figures may be higher because no information was available for 2,407 Connecticut inmates who were incarcerated on that date.) Connecticut's treatment figures were above national averages (1.6%, 12.8%, and 9.7%, respectively).

INMATE NEEDS ASSESSMENT

DOC must assess the needs of pretrial inmates and all individuals sentenced to 60 days or more in the following areas: (1) medical, (2) mental health, (3) education, (4) substance abuse treatment, (5) vocational/work skill, (6) sex offense treatment, and (7) family/residence/community resource. Assessments must be completed during the first 30 days of incarceration (Objective Classification Manual, III.D).

Inmates who may have mental health needs can be identified in the following ways:

1. DOC's intake health screening reveals past or current psychiatric treatment, suicide risk factors, or the inmate exhibits bizarre behavior;

2. a judge or other court officer has made a notation on the court order (mittimus) that accompanies the inmate to the facility;

3. community mental health providers, such as court diversion program personnel, case managers, or those who have evaluated the inmate's competence to stand trial, inform jail or prison staff of a person's mental illness;

4. the inmate discloses his mental condition himself; or

5. some other person—a family member, public defender, correction officer, or fellow inmate—provides the information.

When an inmate who may have mental health needs is identified, a staff referral is made to DOC's Mental Health Services Unit. Health workers screen referrals and identify inmates who need to be assessed immediately. Under the department's guidelines, situations requiring immediate assessment include reports of suicidality, agitated psychosis, a recent discharge from a psychiatric inpatient facility, or any other referral where the mental health staff is concerned that, because of mental illness, the inmate poses a significant, present danger to himself or others.

Mental health staff give next priority to referrals from DMHAS programs or community providers; they must evaluate all other referrals within five working days. Every inmate with a mental health needs score of 3 or higher (see below) must have an individualized treatment plan, which mental health staff develops and monitors.

Mental Health Needs

Under the classification manual, DOC must screen and assign a mental health needs (MH) score ranging from 1-5 to all people in its custody. DOC considers people given a score of 5 to be gravely ill, and those with a score of 1 as having no need for mental health services. Ratings of 3 or above must be based on a qualified mental health professional's assessment of the inmate; DOC permits qualified classification staff (who are not mental health practitioners) to assign MH-1 and –2 scores.

MH-5 Score. Inmates receiving this score have been assessed as severely impaired with an acute psychiatric condition such as major psychosis; suicidal thoughts, ideations, gestures, or attempts; major depression; or acute anxiety. DOC considers them potentially dangerous to themselves and others and unable to function in any setting other than a highly structured inpatient infirmary or mental health unit or hospital.

DOC services for people with this score include psychiatric evaluation and on-going support; psychotropic medication; and individual, group, or recreational therapy. DOC must assign or transfer them to facilities with intensive mental health services or, if their condition remains unstable, commit them to the Whiting Forensic Division of Connecticut Valley Hospital.

MH-4 Score. These individuals have been assessed as moderately impaired due to a sub-acute or chronic psychiatric or mental condition. Examples include (1) people with chronic schizophrenia or bipolar disorders who have frequent psychotic episodes and need medication and assistance with activities of daily living; (2) individuals with borderline personality disorders who have frequent suicidal gestures or episodes of self-mutilation, who, due to chronic mood instability and impulsiveness, require daily mental health staff contact and support; and (3) people with mental retardation who need help with activities of daily living and are prone to being preyed upon if housed with the general prison population.

DOC usually houses people with this score in structured environments where they have frequent contact with mental health staff. Other services may include an assignment to a specialized mental health housing area, psychiatric assessments, psychotropic medication, and individual or group therapy.

MH-3 Score. DOC has rated these inmates mildly to moderately impaired with a latent or chronic mental illness. Examples include (1) people with chronic schizophrenia or bipolar disorders who are compliant with medications, may have periodic psychotic episodes requiring hospitalization, yet are able to function in a general population setting; (2) people with major depression or a history of suicidal behavior who need supportive services, medication, or both and may also require periodic hospitalizations; and (3) inmates with personality disorders who need supportive services and crisis intervention to prevent self-mutilation or suicidal gestures.

DOC's guidelines require mental health staff to monitor inmates given this score. They may have difficulty functioning in a general population setting such as a large dormitory and periodically need on-site mental health services and intervention.

MH-2 Score. DOC considers individuals with this score to have minimal or intermittent mental health impairments. Examples include people with a history of treatment for adjustment, attention-deficit hyperactivity, conduct, eating, post-traumatic stress, or developmental disorders; depression; anxiety; phobias; or brief psychotic episodes who do not have current symptoms or need medication or follow-up services. The guidelines specify that DOC can house them in any correctional environment and provide them mental health services based on need.

MH-1 Score. DOC assigns this score to inmates with no known current or past history of mental illness. It does not provide them mental health services.

Mental Health Subcodes. DOC's inmate mental health needs assessments may also include one of the following subcodes:

● T=Temporary condition — a brief period of emotional instability, often of 60 days or less, which is correctable with treatment

● I=Improvable condition — may be stabilized with treatment and mental health intervention, psychotropic medication, or both

● P=Permanent condition — chronic and unlikely to substantially improve during incarceration even with intensive treatment services

● S=Suicidal ideation, gestures, or attempts

● R=Remission — mental health condition is in remission with improvement to the level of functioning in a general population housing unit and environment

IDENTIFYING AND MONITORING SUICIDAL INMATES

DOC Administrative Directive 8:14 specifies guidelines for staff training; screening, referral, and identification; risk assessment; emergency health measures; housing and monitoring standards; and administrative reviews of suicides. It requires all DOC facilities to have a written suicide prevention plan and to submit monthly statistical reports on inmate suicide attempts and use of prevention strategies to the Health Services director.

Staff Training

The guidelines require newly hired staff in jobs with direct inmate contact to complete eight hours of suicide prevention training before they are assigned to a facility. The training covers the signs of a potential suicide, reporting at-risk inmates, suicide intervention techniques, and administration of first aid and CPR. All direct contact staff must complete two hours of suicide prevention and emergency procedures training each year.

Screening, Referral, and Identification

Custody staff must ask about an inmate's potential for self-destructive or suicidal behavior upon any transfer from another authority's custody. They must immediately notify health services staff and complete a written report whenever they have information that suggests an inmate may be a suicide risk. Medical staff also screen new inmates before they are released into the general population for a history of suicide attempts or other indications of suicide risk.

All inmates coming into a facility who have an already-assigned mental health needs subcode of “S” or a history or any other indication of suicide potential are immediately referred for a mental health assessment. Intake staff can also initiate emergency suicide plan procedures when necessary (see below).

Mental health staff complete suicide risk assessment and mental health assessment forms for each inmate referred as potentially suicidal, notify appropriate custody and health services staff of the level of risk they assign, and recommend a management plan. Classification supervisors must be notified whenever an inmate gets an “S” subcode; these inmates must also be given mental health assessments every three months and whenever DOC places them in, or removes them from, restrictive housing.

Emergency Mental Health Intervention

DOC's administrative directive also requires each facility to have a written plan for responding to mental health emergencies. These plans must cover staff training and communication; emergency methods for handling a suicide in progress; administration of first aid and CPR; and the duties of first and subsequent responders, supervisors, and health services staff.

Staff members are directed to immediately notify their supervisors and Health Services whenever an inmate exhibits abnormal or self-destructive behavior or threatens suicide. After an assessment, a health services staff member may place an inmate appearing to be actively suicidal on one-on-one continuous observation or 15-minute watch. In emergency situations when no health services staff is present, the shift supervisor can also do this, so long as he notifies the facility's duty officer and on-call psychiatrist.

DOC must transfer inmates who licensed medical personnel determine are immediate suicide risks to designated DOC mental health level 5 infirmaries, a hospital emergency room, or a DMHAS or DCF-run mental health facility. If the facility where the emergency occurs does not have a level 5 infirmary, the shift supervisor must temporarily place the inmate in a cell or room that is safe, protrusion-free, and adequate for a potentially suicidal inmate. The cell or room must be searched, have a door that can be locked, allow for quick access and ease of observation, and have limited and secure furnishings. The inmate must undergo a strip and visual body cavity search before being placed there.

Staff must continuously observe him and document his condition every 15 minutes. They must offer fluids at least every two hours and provide bite-sized foods and liquids at meal times. Food and fluid intake/output and refusals must be documented.

One-on-One Continuous Observation (in Infirmary). Placement on one-on-one continuous observation in a level 5 infirmary requires a physician's order. When this is the case, in addition to the above requirements, qualified health services staff must assess the inmate's condition at least every two hours. His physician can order observation to be discontinued after evaluating him, or a registered nurse can do so based on the physician's telephone order. Continuous observation orders can be for no more than three hours at a time; longer observation periods require a new assessment and physician's order.

15-Minute Watch. When an inmate is on a 15-minute watch, assigned staff check for “living, breathing flesh” at irregular intervals ranging from five to 20 minutes apart. The same health assessment and discontinuation procedures apply as were described above.

Mental Health Commitments. If the inmate remains a high suicide risk and it appears that his condition cannot be stabilized at a DOC infirmary, mental health staff must arrange for him to be committed to a licensed inpatient psychiatric facility (e.g., Whiting Forensic Institute).

Suicide Reviews

Whenever an inmate commits suicide, DOC guidelines direct facilities to conduct a comprehensive clinical and administrative review. It must include the conclusions reached by an administrative investigation and recommendations for improvements to prevent future occurrences.

USE OF RESTRAINTS

DOC policy specifies that physical restraints can be used only in situations that are “directly proportionate” to the presence of imminent physical danger to the inmate, others, or the environment. Only soft restraints are allowed, and then only when supported by a doctor's order or an order from the on-call psychiatrist within one hour of restraint being initiated if no health services staff was on-site when the emergency arose.

Restrained inmates are to be placed face-up on a mattress positioned on top of a bed frame. Arm and leg restraints must be applied in a manner that minimizes physical discomfort. The guidelines mandate the following physical checks at the indicated intervals:

1. circulation — every 15 minutes

2. respiration — every 15 minutes

3. pulse — every 30 minutes

4. blood pressure — every 60 minutes

5. temperature — every 120 minutes

Restraints must be totally or serially removed and each limb moved to full range of motion and assessed for trauma, blood circulation, and/or diminished nerve sensation at least every two hours. They must be immediately removed if the inmate's physical condition worsens, contraindicating restraints. In such circumstances, his physician must be notified immediately.

Inmates in restraints must also be fed and monitored in accordance with the one-on-one continuous observation standards (see above). Each facility must send the Health Services director a monthly statistical report of all physical restraints applied for mental health reasons.

ADMINISTRATION OF PSYCHOTROPIC DRUGS

DOC guidelines generally prohibit the use of psychotropic medication unless an inmate gives written consent to this treatment. When it is prescribed, a physician or registered nurse must examine the inmate within one week of the medication being initiated, changed, or discontinued. The inmate's medical record must include each dose offered and whether he took or refused it. A physician or advanced practice nurse must also examine him monthly for side effects and to determine whether the medication continues to be effective. Each facility is required to train staff on and monitor inmates taking psychotropic drugs to guard against heat exhaustion.

On release, DOC may give inmates up to a two-week supply of their medications and instructions on how to take them.

Involuntary Medication of Inmates

DOC guidelines allow specified health staff to administer psychotropic drugs to inmates without their consent when there is a mental health emergency and the health or safety of the inmate, staff, or others may be jeopardized if this is not done. In such cases, DOC staff must have first tried less restrictive or intrusive measures or have been notified by the inmate's treating physician that such efforts would be inadequate. Males can be involuntarily medicated without a hearing for up to 72 hours. Females may be so medicated for up to 24 hours.

If the inmate's physician recommends that the medication be given for a longer period of time, a three-person panel of clinicians must hold a hearing. The panel members, none of whom can be involved in the inmate's current treatment or diagnosis, must review the prescribing physician's findings and interview the inmate. The inmate has an assigned representative and can call witnesses and cross-examine DOC's witnesses.

The panel can approve the continuation of the medication, overriding the inmate's objection, if they unanimously agree that the inmate meets the criteria for a mental health emergency or that his condition will rapidly deteriorate to the point of constituting a mental health emergency if the medication is discontinued.

DOC MENTAL HEALTH PROGRAMS

In addition to the above mental health treatment and supervision protocols, DOC's Program Development Unit designates the following as mental health programs:

PROGRAM

FACILITY

DESCRIPTION

Arts and Crafts

Garner

Allows inmates assigned to mental health units to exhibit or develop artistic talent in a structured, therapeutic environment

Creative Therapy

York

Focuses on developing interpersonal skills in women housed in the Inpatient Mental Health Unit

Dialectical Behavior Therapy

York

A cognitive-behavioral/relaxation treatment approach for women with a history of self abuse (e.g., self-mutilation) housed in the Social Rehabilitation Unit

Gardening/Activity Program

Garner and Osborn

Gardening program for mentally ill inmates to help them interact with staff and one another and allow staff to monitor and assist them with personal hygiene, grooming, and appropriate interpersonal behavior; priority given to inmates recently discharged from inpatient treatment

Grief and Loss

York

Facilitated support group

Growth and Empowerment

York

Weekly group for women in the Inpatient Mental Health Unit; topics include relationships, dealing with feelings, self-esteem, abuse, recovery, and communication skills

Gym Recreation

Garner

Exercise program, including basketball, football, and baseball for inmates assigned to mental health housing units

Medication Compliance

Garner

Encourages inmates assigned to mental health housing units to take their medication

Mental Health Support

Garner

Co-led by mental health and community volunteers, focuses on self-help for dealing with depression and bipolar illnesses

Occupational Therapy—Therapeutic Recreation

York

Discussion, structured activities (such as arts and crafts), and audio/visual presentations for women assigned to the Inpatient Mental Health Unit

Post Traumatic Stress

Garner

Using relaxation techniques, group discussion, and conflict resolution, assists inmates deal with past life traumas that affect their present lives

Post-Traumatic Stress Disorder Group

York

For women living in the Social Rehabilitation Unit with a Post-Traumatic Stress Disorder diagnosis; prior Dialectical Behavioral Therapy training required

Psychiatric Symptoms

Garner

Helps inmates to understand and recognize the signs and symptoms of their illnesses and various interventions available

Relationship Skills

York

Explores interpersonal relationship and communication styles and how self-esteem and –image affect relationship choices

Sex Offender

Brooklyn, Cheshire, Garner, MacDougall, Manson, Osborn, and York

Teaches inmates who have committed sexual assaults about the nature of the act and helps them develop a relapse prevention strategy, improve the quality of interpersonal relationships, better manage anger, and develop victim empathy

Therapeutic Community Meeting

Garner

Group setting where inmates assigned to mental health housing discuss issues of concern using problem solving skills and conflict resolution

Therapeutic Writing

Garner

Structured writing group designed to promote positive coping skills, increase self-esteem, and alleviate the impact of stressful life events in inmates assigned to mental health housing units

Training in Relaxation and Stress Reduction

York

Teaches inmates with mental health needs a variety of techniques to reduce stress and induce relaxation

Women and Depression

York

Support group for inmates with a history of depression

Source: State of Connecticut Department of Correction Compendium of Programs and Services, rev. 9/2000

PRE-RELEASE TRANSITION TO COMMUNITY SERVICES

An interagency mental health referral plan requires DOC, in most cases, to make referrals to DMHAS six months before the scheduled minimum (earliest possible) release date of sentenced adults who:

1. have a mental health needs score of 4 or 5;

2. meet the DMHAS target population definition (see below) and will need community mental health treatment or medication after release;

3. the Parole Board has granted parole contingent on the development of an acceptable community mental health plan; or

4. DOC wants DMHAS to consider for its community-based programs.

The referral goes to the DMHAS district forensic coordinator for the town where the inmate will live after release, or if this is unknown, the coordinator for the town of his last known residence. The coordinator screens referrals to determine whether they fall within DMHAS's target population, namely, people who have:

1. a diagnosis of a severe mental illness, including schizophrenia, manic depression, major depression, or schizoaffective disorder;

2. been hospitalized for psychiatric treatment in a DMHAS or other psychiatric inpatient setting one or more times in the past three years, received community-based psychiatric services funded or operated by DMHAS within the past year, or both; or

3. had a DOC mental health needs score of 4 or 5 within the past year or received psychiatric outpatient treatment or psychotropic medication in a correctional facility within the past six months.

People with private health insurance and those whose primary diagnosis is sexual deviancy, alcohol or drug abuse or dependence, or mental retardation without an additional major psychiatric disorder are not eligible for DMHAS prison-release services.

The coordinator forwards appropriate referrals to one of DMHAS's local mental health authorities (there are 15 of these throughout the state), which assigns a case manager and conducts an in-person evaluation of the inmate. Under the interagency agreement, this evaluation must be done within three weeks of the local authority's receipt of the referral. The local staff then works with DOC and the inmate to arrange wraparound services and ensure that they are in place by the time he is released. The forensic coordinator tracks and monitors local referrals to insure that appropriate linkages are made.

SP-L:ts