Psychiatrists who work with inmates with serious mental illness should be aware of the potential problems that can occur when these individuals are transferred to psychiatric hospitals for treatment and then returned to jail or prison. Such problems can result in substandard or compromised care.
This was the message delivered by a correctional psychiatrist who spoke at the annual meeting of the American Academy of Psychiatry and the Law in October.
“When inmates are transferred from the correctional setting to the hospital, communication often breaks down,” noted James Knoll, M.D., director of forensic psychiatry and an associate professor of psychiatry at the SUNY Upstate Medical University.
Knoll cited research conducted by Jeffrey Metzner, M.D., indicating that anywhere from 8 percent to 19 percent of people who are incarcerated have a psychiatric illness resulting in significant functional disability, and 15 percent to 20 percent of prisoners require psychiatric intervention during incarceration.
Inmates may be moved to a psychiatric hospital for intensive treatment or for an assessment of dangerousness, for instance. In addition, when prison staff feel frustrated or burned out due to an inmate's repeated acts of self-harm, hospital staff can sometimes be helpful in reducing risk of self-harm and mitigating the frustration of the prison staff.
Knoll pointed out that correctional facilities and hospitals need to have a sense of what the other is capable of providing to inmates during the transition. “It's important to understand the fantasies the jail may have about what the hospital can do and vice versa,” he told attendees.
In many cases, prisons do not have the level of staff training or staff availability to conduct assessments or intensive treatment, he added. They may also not provide group therapy or certain types of psychotherapy. “It is important for hospital staff to understand this” when treating inmates who are going to be transferred back to prison, said Knoll.
He noted that it is not uncommon for prison inmates to be transferred to hospitals late in the day when on-call staff may be working and don't know about the inmates' psychiatric history.
Psychiatrists treating inmates who will be transferred back to prison should also be aware that hospitals and prisons often have different medication formularies, with those of prisons usually being more restrictive.
“If you are a treating physician in a hospital, it's probably not a good idea to start inmates on medications they won't be able to obtain when they are back in prison,” Knoll noted.
In addition, he cautioned meeting attendees who work with inmates in hospitals to be on guard for countertransference toward inmates transferred from correctional facilities.
Hospital clinicians “may be affected by the nature of a person's criminal offense and have less empathy toward drug offenders and violent offenders,” which can negatively impact the quality of the patient's assessment and treatment.
Supervision, training, and staff support can go a long way toward helping mental health staff to deal with these feelings, Knoll said. ▪
