Coping With Mental Health Issues

Correctional facilities in the U.S. have become the nation’s default mental health providers. This has been a trend for the past 50 years: a result of what is called “deinstitutionalizing,” and the numbers are sobering. According to the 2012 study “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals 2005–2010” published by the Treatment Advocacy Center, the number of psychiatric hospital beds shrank by 14% between 2005 and 2010 alone. It is currently at the same level as it was in 1850, which was the beginning of the movement to provide better mental health care in hospitals to the seriously mentally ill.
The numbers are telling. Nearly one in five inmates has some form of mental illness, according to Sharen Barboza, Ph.D, CCHP-MH, director of Clinical Operations at Mental Health at MHM Services, Inc., a Vienna, Va.-based provider of behavioral health and medical services in correctional facilities. One of the problems, she notes, is that correctional facilities were not constructed as treatment facilities. Treating mental illness has been incidental and something that has been thrust into the correctional milieu. Imagine, she says, if an unanticipated 20% of the prison population needed wheelchair access.
Constitutionally, corrections facilities are required to provide “medically necessary” treatment or to treat “serious” conditions. Despite that, there are myriad mental health disorders, only a small percentage of them are considered “serious.” That still means that 14% to 20% of inmates suffer from a serious mental illness (SMI) such as schizophrenia, bipolar disorder, major mood disorders, and borderline personality disorders. That percentage is even higher in jails. Between 2005 and 2010, the trend was for more states to reduce the number of psychiatric beds. During that time, 13 states closed 25% or more of their total state hospital beds. Minnesota and New Mexico closed more than 50%, and Michigan and North Carolina just under 50%. The number of psychiatric hospital bed closures has reduced the number to 28% of what is considered “necessary for minimally adequate inpatient psychiatric services.” (The Treatment Advocacy Center called for a moratorium on further closings until a sufficient number of beds are available in community facilities.) As a result of these closings, people with chronic or acute mental conditions are gravitating to emergency rooms, prisons, and jails.
Regardless of the difference between what is and what should be, the question remains for those employed in the correctional setting: What do we do about it? Three mental health providers from different organizations weigh in.
Barboza of MHM offers her suggestions for how to cope with the situation. One is to enlist the help of the experts. She suggests that a facility’s management incorporate the mental health staff in regards to discussions about segregation, housing options and service options. The other is “training, training, training.” For one, not all correctional officers are trained to recognize the symptoms that present in mental illness.
Many inmates with m
ental health conditions struggle with prison life. They may misinterpret the meaning of an action or have difficulty moving quickly or following multi-layered instructions such as being given a to-do list of four tasks and are able to complete only two or three. The smooth operation of the facility is disrupted by this group of inmates who have difficulty functioning.
On top of that, Barboza furthers, there is a subset of officers who did not set out to have mental health careers, are not schooled in the subject, and might themselves misinterpret the meaning of an action to be one of misbehavior. Officers, says Barboza, should be trained in areas such as crisis intervention and mental health first aid. She compares this tactic with the fact that many or most are trained in CPR.
Mental health professionals also require training. Correctional facilities are controlled environments and schedules change on a moment’s notice. Things get cancelled, moved, and locked down, which requires a special set of skills to train providers to thrive in such as environment. Malingerers will try to take advantage and scam and fraud to get what they want, and that and other institutional behavior will need to be recognized. While she stresses that training should include administration as well, she adds, “You get more bang for the buck by training the line staff.”
Birmingham, Ala.-based NaphCare’s philosophy, says Dr. Steven Bonner, Chief Medical Officer, MD, is to be aggressive with identification and management from the start. NaphCare, “a comprehensive medical and mental health service provider concentrating 100% in partnering with corrections agencies around the country” utilizes the “Proactive Care Model,” which is conducted upon arrival. An inmate is screened during booking using TechCare, an electronic operating system that screens for mental health issues, suicidality, and detox requirements. If they are found to be suicidal, their safety is ensured and the mental health team and security are notified. If an inmate requires detox, he or she may be placed in into a “standardized detox protocol.”
Once an inmate is identified as having mental health issues, NaphCare’s mental health team has regular appointments with them. “A more stable mental health inmate poses far fewer issues for corrections,” says Dr. Bonner. NaphCare also sets up the inmate with follow-up appointments at local mental health facilities so upon release they may maintain their treatment. (Recidivism for mentally ill people is higher than other inmates. A study found that in Los Angeles County Jail, 90% of inmates with mental health problems were repeat offenders, and nearly a third of those had been incarcerated more than 10 times. ) “This service model has been quite successful in identifying and addressing inmates with mental health issues. The result for our patients and partners has been improved care and less negative outcomes.”
Bonner’s advice to correctional management likewise involves training and interaction. “Our recommendations would be for corrections to work closely with their mental health care provider and be a part of the process. If all parties involved are aware of the at-risk inmates, then you maximize your ability to intervene before a bad event. Making sure corrections officers have some basic mental health training is also very helpful in educating them on the warning signs of an inmate who is at-risk.”
Mark Fleming, Ph.D., regional vice president for Behavioral Health at Corizon, a Brentwood, Tenn.-based provider of correctional healthcare to over 537 correctional facilities, offers his recommendations to correctional management that can help ensure a successful behavioral health program: The first, he concurs, is to recruit, train and retain good staff.
Facilities should also follow nationally accepted guidelines prescribed by organizations such as the American Correctional Association (ACA) and the National Commission on Correctional Healthcare (NCCHC). The Standards were developed by experts in the fields of health, law and corrections and “lay the foundation for constitutionally acceptable health services systems.” The Standards can be found on NCCHC’s website.
He furthers that management should “utilize empirically validated treatment models and best practice approaches that have been shown to be effective in a correctional population” as well as “a multi-disciplinary team approach in delivering behavioral health to those in a correctional environment.”
His other suggestion for management is to incorporate a strong Continuous Quality Improvement (CQI) program into the system that tracks the work being done in the area of mental health. CQI, according to the NCCHC is to “improve health care by identifying problems, implementing and monitoring corrective action and studying its effectiveness.”
Some solutions might be found or burdens alleviated as a result of the Patient Protection and Affordable Care Act (PPACA). Barboza points out that the Act may provide funding for inmates that may not previously have been available. It allows community providers the knowledge that quality clinical work exists in corrections. It requires correctional providers to align with community providers, and may open a dialogue between corrections and the community. “I hope that PPACA will provide for much-needed access to MH care in the community.  We have never fully supported parity for MH services in our country, and PPACA may start to change that.  If it does, all people can be provided with the services they need in the community and hopefully stop the development of symptoms and behavior that result in interactions with law enforcement and can result in incarceration.”
Bonner of NaphCare also considers that the PPACA might have a dramatic effect on the issue of mental health in corrections. One of the biggest problems of mental health corrections, he says, is discharge planning. There are so few community service providers that it might be months before an inmate can get an appointment, and over that time he or she would be far less likely to maintain medications, stability, and sobriety, which in turn increases the likelihood of recidivism. In states opting for Medicare expansion, many inmates will qualify for benefits. This will provide them with a payer source, and it is much easier find referrals and providers when there is a payer source.
Barboza, Bonner and Fleming all agree that having a discharge plan in place can have a significant impact once an inmate has been released and actively pursue tactics to strengthen the process. NaphCare has the technology to interface with Medicare programs to assist in this. MHM has partnered with Centene, a “Medicaid management company to provide services in correctional settings through Centurion—a unique blending of community and correctional resources to help support the move toward PPACA.” Says Fleming of the Act, “The reentry process for inmates with severe mental illness and other mental health diagnoses will change how we create treatment plans in the correctional facilities as well as how we create a reentry transition plan to ensure a seamless continuity of care in the community.” 
For more information, contact NaphCare at, 1.800.834.2420, or e-mail; MHM at or 1.800.416.3649; Corizon at or 1.800.729.0069.