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Better off in prison?

February 1, 2010
by H. Steven Moffic, MD
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A psychiatrist gains new insight on the state of behavioral healthcare after joining the staff at a Wisconsin prison

When my clinic manager told me that prison may be the best place to practice psychiatry nowadays, I didn't believe him. After all, prisons often seem like a world apart, often in isolated rural areas or in windowless, nondescript urban buildings.

Some mental health professionals feel that working in a prison is for second-rate clinicians who can't get better work, as I once did, or that typical prisoners are sociopaths who cannot be treated successfully.

However, after working in prison psychiatry for six months now, I must say that my clinic manager may just be right, at least for this medium-security men's prison in Wisconsin. There is much that the rest of our mental healthcare system, especially community mental health, can learn from what is in place in some prisons today.

Better access to care

Take access, for instance. Inadequate access for care has been a chronic problem in mental health, not only for the uninsured, but also for the minimally insured or those in tightly administered managed-care programs. As the current economic crisis reduces state Medicaid funding, more patients can't find services and become progressively more dangerous, often ending up in jails or prison. This has been dubbed the “criminalization of mental illness.”

Once these individuals reach the prison system, however, access to mental healthcare is no longer a problem. In fact, access is easier for mental healthcare than for medical healthcare. There is no fee for mental healthcare, but there is a fee equivalent to a day's work for non-emergency medical care. Mental health is a priority in prisons, in part because mental health conditions often connect to the behaviors that caused incarceration in the first place. Inmates identified as being “mentally ill” may also offer an alternative, and perhaps more acceptable, explanation to others regarding their criminal past.

Not only do prisoners who recognize they need mental healthcare have easy access, but those with undiagnosed mental health problems are more readily recognized by others because inmates are under constant observation. Of course, mental disorders can be viewed as an excuse for criminal behavior and a means of being “soft” toward prisoners, who are known to manipulate the system. Occasionally, this thinking results in an inmate with a mental health problem, such as impulsive ADHD behavior, ending up in the segregation unit instead of the psychiatrist's office.

Access is especially important in prison due to the prevalence of mental health disorders. Up to 50 percent of inmates are thought to have some diagnosable psychiatric disorder, including alcohol and substance abuse disorders.

Safety and security

Of course, access is meaningless unless both clinicians and patients feel-and are-safe. Clinicians can and do get hurt, or worse: Wayne Fenton, MD, was killed in 2006 while assessing a paranoid psychotic patient in his empty, private practice office on a weekend.
Though infrequent, there have also been violent incidents in the community mental health centers where I have worked, both in the clinic and outside in the parking lot. When funds were available, we hired a security guard, but often we couldn't afford it. I had assumed that working in a prison would be more risky, and I worried that my counter-transference of feelings of fear for my patients could limit my responsiveness to them.

However, security is the first priority of prisons, and, as it turns out, there hasn't been a dangerous incident involving a healthcare clinician in more than 20 years. The prior psychiatrist warned me that deer jumping on the roadway are more dangerous to me than the inmates visiting the prison medical office.

Throughout my 35-year career, I've sought to find a practice setting where family practitioners, psychiatrists, and other mental healthcare clinicians work together. And, to my surprise, here it is-in prison!

The quality of all the staff seems equivalent to what I've known outside of prison. Among the psychiatrists in this Wisconsin system are two former department chairs of well-known medical schools. One is known for his work with the homeless, and the other for his work with aggressive behavior.

Our salary meets or exceeds that of facilities outside the prison system. Productivity standards are not excessive, as they sometimes are in community mental health settings.

The prison population

Despite the high level of security, everything is in place to provide competent treatment. Among the disorders that a prison psychiatrist sees are:

  • Antisocial personality disorder, which is clearly associated with criminal behavior and a lack of remorse. Psychiatrists don't see many cases outside of prison because patients with this disorder don't feel they need help or manipulate their way out of treatment.

  • Malingering, a diagnosis often associated with antisocial personality disorder in the DSM-IV, which I have never considered as often as I do now.

  • Post-traumatic stress disorder (PTSD). I have found that a significant percentage of those thought to be primarily sociopathic often have an extensive history of trauma and a subsequent onset of post-traumatic stress disorder. The trauma is especially common in African-American males, who are heavily overrepresented in prison systems. One has to be careful here because it is so hard to be sure that reported trauma actually took place due to the possibility of fabrication and limited access to information from family and friends.

  • Narcissistic personality disorder appears to be quite common among prisoners as well.

  • A large group of prisoners also have the expected alcohol and substance abuse disorders, which are often at the root of their criminal behavior and subsequent imprisonment.