Annette Hanson, MD

 

In 2004, the federal government authorized $50 million for state initiatives to coordinate crime control efforts between the criminal justice and mental health systems. Some of that money was dedicated toward expansion of state mental health courts in an attempt to reduce the number of people with serious mental illness in jails and prisons.

Unlike traditional criminal courts, a mental health court is a nonadversarial problem-solving program that brings together all the stakeholders involved in a defendant’s criminal case and mental health care. A criminal defendant who agrees to participate in mental health court must participate in regular status hearings during which a judge reviews the defendant’s adherence to a court-imposed treatment plan and monitors his progress while on probation. The judge considers input from the prosecutor and the defense attorney, and also from the court’s social worker or case manager. A defendant who agrees to mental health court involvement is often placed on probation rather than sentenced to incarceration and is usually incarcerated for a shorter time pending trial.

As one would expect, freedom is a strong incentive to agree to mental health court conditions.

Although mental health courts have been in existence for 20 years, data about program efficacy have been mixed. Outcome studies have been hampered by lack of truly blind subject assignment, inadequate controls, and selection bias because many mental health courts exclude defendants charged with serious violent crimes or sex offenses. Also, mental health courts are voluntary programs with significant dropout rates. Nevertheless, proponents of mental health courts believe that they prevent crime, reduce violent offending, and serve to stabilize people with serious mental illness in the community.

In a study published recently in Psychiatric Services (2017 Aug 15. doi: 10.1176/appi.ps.201700107), researchers from North Carolina University, Raleigh, addressed the effect of mental health court involvement on criminal recidivism. Lowder et al. looked at 17 outcome studies of mental health court participants published between 2004 and 2015. These studies included 16,129 participants followed for a minimum of 1 year.

Most of the included studies defined recidivism as a new arrest. For the purpose of the meta-analysis, researchers also included any incarceration, conviction, or new charge. Each study also included a comparison group of defendants processed through usual criminal procedures. Included studies generally looked at reoffending in the year after entry into the program or in the year following exit from the program.

The meta-analysis found a small but significant reduction in criminal recidivism, although the degree of this effect varied considerably between studies, and the effect disappeared completely when only moderate and high-quality studies were considered.

These results should not surprise anyone. Crime is a complex human behavior mediated by more than just psychiatric issues. Poverty, stressful life events, and substance abuse all play a role. And as an outcome variable, an arrest is not a sensitive measure because many crimes go unreported. Defendants with lower rates of reoffending may simply have more forgiving victims; for people with mental illness, that victim is often a family member.

Fortunately, crime prevention is not the sole justification for mental health programs. There are also the intangible social benefits that aren’t measured in these studies – benefits like improved quality of life, restored relationships, and the ability to participate more fully in all the joys that life has to offer. For people with serious mental illness who graduate from mental health court, that’s the outcome that counts.
 

Dr. Hanson is a forensic psychiatrist and coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene and the Maryland Division of Correction.

 

In 2004, the federal government authorized $50 million for state initiatives to coordinate crime control efforts between the criminal justice and mental health systems. Some of that money was dedicated toward expansion of state mental health courts in an attempt to reduce the number of people with serious mental illness in jails and prisons.

Unlike traditional criminal courts, a mental health court is a nonadversarial problem-solving program that brings together all the stakeholders involved in a defendant’s criminal case and mental health care. A criminal defendant who agrees to participate in mental health court must participate in regular status hearings during which a judge reviews the defendant’s adherence to a court-imposed treatment plan and monitors his progress while on probation. The judge considers input from the prosecutor and the defense attorney, and also from the court’s social worker or case manager. A defendant who agrees to mental health court involvement is often placed on probation rather than sentenced to incarceration and is usually incarcerated for a shorter time pending trial.

As one would expect, freedom is a strong incentive to agree to mental health court conditions.

Although mental health courts have been in existence for 20 years, data about program efficacy have been mixed. Outcome studies have been hampered by lack of truly blind subject assignment, inadequate controls, and selection bias because many mental health courts exclude defendants charged with serious violent crimes or sex offenses. Also, mental health courts are voluntary programs with significant dropout rates. Nevertheless, proponents of mental health courts believe that they prevent crime, reduce violent offending, and serve to stabilize people with serious mental illness in the community.

In a study published recently in Psychiatric Services (2017 Aug 15. doi: 10.1176/appi.ps.201700107), researchers from North Carolina University, Raleigh, addressed the effect of mental health court involvement on criminal recidivism. Lowder et al. looked at 17 outcome studies of mental health court participants published between 2004 and 2015. These studies included 16,129 participants followed for a minimum of 1 year.

Most of the included studies defined recidivism as a new arrest. For the purpose of the meta-analysis, researchers also included any incarceration, conviction, or new charge. Each study also included a comparison group of defendants processed through usual criminal procedures. Included studies generally looked at reoffending in the year after entry into the program or in the year following exit from the program.

The meta-analysis found a small but significant reduction in criminal recidivism, although the degree of this effect varied considerably between studies, and the effect disappeared completely when only moderate and high-quality studies were considered.

These results should not surprise anyone. Crime is a complex human behavior mediated by more than just psychiatric issues. Poverty, stressful life events, and substance abuse all play a role. And as an outcome variable, an arrest is not a sensitive measure because many crimes go unreported. Defendants with lower rates of reoffending may simply have more forgiving victims; for people with mental illness, that victim is often a family member.

Fortunately, crime prevention is not the sole justification for mental health programs. There are also the intangible social benefits that aren’t measured in these studies – benefits like improved quality of life, restored relationships, and the ability to participate more fully in all the joys that life has to offer. For people with serious mental illness who graduate from mental health court, that’s the outcome that counts.
 

Dr. Hanson is a forensic psychiatrist and coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene and the Maryland Division of Correction.

 

In 2004, the federal government authorized $50 million for state initiatives to coordinate crime control efforts between the criminal justice and mental health systems. Some of that money was dedicated toward expansion of state mental health courts in an attempt to reduce the number of people with serious mental illness in jails and prisons.

Unlike traditional criminal courts, a mental health court is a nonadversarial problem-solving program that brings together all the stakeholders involved in a defendant’s criminal case and mental health care. A criminal defendant who agrees to participate in mental health court must participate in regular status hearings during which a judge reviews the defendant’s adherence to a court-imposed treatment plan and monitors his progress while on probation. The judge considers input from the prosecutor and the defense attorney, and also from the court’s social worker or case manager. A defendant who agrees to mental health court involvement is often placed on probation rather than sentenced to incarceration and is usually incarcerated for a shorter time pending trial.

As one would expect, freedom is a strong incentive to agree to mental health court conditions.

Although mental health courts have been in existence for 20 years, data about program efficacy have been mixed. Outcome studies have been hampered by lack of truly blind subject assignment, inadequate controls, and selection bias because many mental health courts exclude defendants charged with serious violent crimes or sex offenses. Also, mental health courts are voluntary programs with significant dropout rates. Nevertheless, proponents of mental health courts believe that they prevent crime, reduce violent offending, and serve to stabilize people with serious mental illness in the community.

In a study published recently in Psychiatric Services (2017 Aug 15. doi: 10.1176/appi.ps.201700107), researchers from North Carolina University, Raleigh, addressed the effect of mental health court involvement on criminal recidivism. Lowder et al. looked at 17 outcome studies of mental health court participants published between 2004 and 2015. These studies included 16,129 participants followed for a minimum of 1 year.

Most of the included studies defined recidivism as a new arrest. For the purpose of the meta-analysis, researchers also included any incarceration, conviction, or new charge. Each study also included a comparison group of defendants processed through usual criminal procedures. Included studies generally looked at reoffending in the year after entry into the program or in the year following exit from the program.

The meta-analysis found a small but significant reduction in criminal recidivism, although the degree of this effect varied considerably between studies, and the effect disappeared completely when only moderate and high-quality studies were considered.

These results should not surprise anyone. Crime is a complex human behavior mediated by more than just psychiatric issues. Poverty, stressful life events, and substance abuse all play a role. And as an outcome variable, an arrest is not a sensitive measure because many crimes go unreported. Defendants with lower rates of reoffending may simply have more forgiving victims; for people with mental illness, that victim is often a family member.

Fortunately, crime prevention is not the sole justification for mental health programs. There are also the intangible social benefits that aren’t measured in these studies – benefits like improved quality of life, restored relationships, and the ability to participate more fully in all the joys that life has to offer. For people with serious mental illness who graduate from mental health court, that’s the outcome that counts.
 

Dr. Hanson is a forensic psychiatrist and coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene and the Maryland Division of Correction.

On June 30, New Mexico became the latest state to throw out a challenge to a law banning physician-assisted suicide. In Morris v. Brandenburg, proponents of the right-to-die movement contended that medical aid in dying was a fundamental right, meaning that any law that restricted the right should be presumed to be invalid unless the state had a compelling reason for the restriction.

In a unanimous decision, the New Mexico Supreme Court held that there was no such right under that state’s constitution, and that even if the right had existed, the state had several compelling reasons to restrict it: to protect “the integrity and ethics of the medical profession”; to protect “vulnerable groups – including the poor, the elderly, and disabled persons – from the risk of subtle coercion and undue influence in end-of-life situations, including pressures associated with the substantial financial burden of end-of-life health care costs”; and to protect “against voluntary or involuntary euthanasia because if physician aid in dying is a constitutional right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication.”¹

Let me repeat that last point:

If aid in dying is a constitutional right, then medical euthanasia is inevitable. In other words, if a patient is too disabled to commit suicide on his or her own, a physician would be obligated to kill the patient.

Proponents will dismiss this last statement as alarmist and unfounded. They will point to a 20-year history of legalized aid in dying in Oregon, and insist there has never been a problem and no attempt to expand the practice to include euthanasia.

What they don’t mention is that such an attempt would be politically disastrous for the right-to-die movement. In 2015, 25 states and the District of Columbia considered legalization bills.² After careful consideration and debate, these bills failed in every state except California, and in that state it passed only because of an extraordinary and unusual legislative maneuver. The bill initially failed in regular session, but passed in special session when the California Medical Association (CMA) shifted to a neutral stance. That shift would never have happened had CMA members been aware of the legal inevitability of euthanasia. At this stage of the political process, the goal of the right-to-die movement is to get laws on the books in as many states as possible before pushing for more.

The New Mexico opinion echoes a similar decision issued this past May by a New York appellate court. The plaintiffs in that case were three terminally ill New Yorkers and five doctors, as well as two euthanasia advocacy groups. The arguments were virtually identical to those made in New Mexico, asserting a fundamental right to medical aid in dying based upon personal autonomy. They additionally sought an exception to New York criminal law, which defined assisted suicide as second-degree manslaughter. In Myers v. Schneiderman, the court observed that no appellate court had ever found medical aid in dying to be a fundamental right and that no new developments justified a change in this interpretation.³ While the court acknowledged some change in public opinion as reflected in telephone surveys, it correctly gave little weight to this argument: “Plaintiffs fail to allege whether those public polls reflect the opinion of people who are fully informed of the arguments espoused by those who caution against permitting aid-in-dying, such as those articulated in the New York State Task Force on Life and the Law.”

This task force issued the following recommendation in its 1994 report,⁴ “When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context”: “The Task Force members unanimously recommend that existing law should not be changed to permit assisted suicide or euthanasia. Legalizing assisted suicide and euthanasia would pose profound risks to many individuals who are ill and vulnerable. The Task Force members concluded that the potential dangers of this dramatic change in public policy would outweigh any benefit that might be achieved” (Chapter 6, p. 120).

The New York aid-in-dying bill did not progress out of committee by the time the session ended in June.

Lastly, both of these cases concluded that medical aid in dying was suicide. In Myers, Judge Angela M. Mazzarelli stated: “The word ‘suicide’ has a straightforward meaning, and a dictionary is hardly necessary … It is traditionally defined as ‘the act or instance of taking one’s own life voluntarily and intentionally.’ ... Whatever label one puts on the act that plaintiffs are asking us to permit, it unquestionably fits that literal description.”

 

Regardless of the label used – aid in dying, assisted suicide, or self-deliverance – it is not a civil right.

Resources

1. http://www.nmcompcomm.us/nmcases/nmsc/slips/SC35,478.pdf

2. https://www.deathwithdignity.org/assisted-dying-chronology/

3. http://www.nycourts.gov/reporter/3dseries/2016/2016_03457.htm

4. https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

On June 30, New Mexico became the latest state to throw out a challenge to a law banning physician-assisted suicide. In Morris v. Brandenburg, proponents of the right-to-die movement contended that medical aid in dying was a fundamental right, meaning that any law that restricted the right should be presumed to be invalid unless the state had a compelling reason for the restriction.

In a unanimous decision, the New Mexico Supreme Court held that there was no such right under that state’s constitution, and that even if the right had existed, the state had several compelling reasons to restrict it: to protect “the integrity and ethics of the medical profession”; to protect “vulnerable groups – including the poor, the elderly, and disabled persons – from the risk of subtle coercion and undue influence in end-of-life situations, including pressures associated with the substantial financial burden of end-of-life health care costs”; and to protect “against voluntary or involuntary euthanasia because if physician aid in dying is a constitutional right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication.”¹

Let me repeat that last point:

If aid in dying is a constitutional right, then medical euthanasia is inevitable. In other words, if a patient is too disabled to commit suicide on his or her own, a physician would be obligated to kill the patient.

Proponents will dismiss this last statement as alarmist and unfounded. They will point to a 20-year history of legalized aid in dying in Oregon, and insist there has never been a problem and no attempt to expand the practice to include euthanasia.

What they don’t mention is that such an attempt would be politically disastrous for the right-to-die movement. In 2015, 25 states and the District of Columbia considered legalization bills.² After careful consideration and debate, these bills failed in every state except California, and in that state it passed only because of an extraordinary and unusual legislative maneuver. The bill initially failed in regular session, but passed in special session when the California Medical Association (CMA) shifted to a neutral stance. That shift would never have happened had CMA members been aware of the legal inevitability of euthanasia. At this stage of the political process, the goal of the right-to-die movement is to get laws on the books in as many states as possible before pushing for more.

The New Mexico opinion echoes a similar decision issued this past May by a New York appellate court. The plaintiffs in that case were three terminally ill New Yorkers and five doctors, as well as two euthanasia advocacy groups. The arguments were virtually identical to those made in New Mexico, asserting a fundamental right to medical aid in dying based upon personal autonomy. They additionally sought an exception to New York criminal law, which defined assisted suicide as second-degree manslaughter. In Myers v. Schneiderman, the court observed that no appellate court had ever found medical aid in dying to be a fundamental right and that no new developments justified a change in this interpretation.³ While the court acknowledged some change in public opinion as reflected in telephone surveys, it correctly gave little weight to this argument: “Plaintiffs fail to allege whether those public polls reflect the opinion of people who are fully informed of the arguments espoused by those who caution against permitting aid-in-dying, such as those articulated in the New York State Task Force on Life and the Law.”

This task force issued the following recommendation in its 1994 report,⁴ “When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context”: “The Task Force members unanimously recommend that existing law should not be changed to permit assisted suicide or euthanasia. Legalizing assisted suicide and euthanasia would pose profound risks to many individuals who are ill and vulnerable. The Task Force members concluded that the potential dangers of this dramatic change in public policy would outweigh any benefit that might be achieved” (Chapter 6, p. 120).

The New York aid-in-dying bill did not progress out of committee by the time the session ended in June.

Lastly, both of these cases concluded that medical aid in dying was suicide. In Myers, Judge Angela M. Mazzarelli stated: “The word ‘suicide’ has a straightforward meaning, and a dictionary is hardly necessary … It is traditionally defined as ‘the act or instance of taking one’s own life voluntarily and intentionally.’ ... Whatever label one puts on the act that plaintiffs are asking us to permit, it unquestionably fits that literal description.”

 

Regardless of the label used – aid in dying, assisted suicide, or self-deliverance – it is not a civil right.

Resources

1. http://www.nmcompcomm.us/nmcases/nmsc/slips/SC35,478.pdf

2. https://www.deathwithdignity.org/assisted-dying-chronology/

3. http://www.nycourts.gov/reporter/3dseries/2016/2016_03457.htm

4. https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

On June 30, New Mexico became the latest state to throw out a challenge to a law banning physician-assisted suicide. In Morris v. Brandenburg, proponents of the right-to-die movement contended that medical aid in dying was a fundamental right, meaning that any law that restricted the right should be presumed to be invalid unless the state had a compelling reason for the restriction.

In a unanimous decision, the New Mexico Supreme Court held that there was no such right under that state’s constitution, and that even if the right had existed, the state had several compelling reasons to restrict it: to protect “the integrity and ethics of the medical profession”; to protect “vulnerable groups – including the poor, the elderly, and disabled persons – from the risk of subtle coercion and undue influence in end-of-life situations, including pressures associated with the substantial financial burden of end-of-life health care costs”; and to protect “against voluntary or involuntary euthanasia because if physician aid in dying is a constitutional right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication.”¹

Let me repeat that last point:

If aid in dying is a constitutional right, then medical euthanasia is inevitable. In other words, if a patient is too disabled to commit suicide on his or her own, a physician would be obligated to kill the patient.

Proponents will dismiss this last statement as alarmist and unfounded. They will point to a 20-year history of legalized aid in dying in Oregon, and insist there has never been a problem and no attempt to expand the practice to include euthanasia.

What they don’t mention is that such an attempt would be politically disastrous for the right-to-die movement. In 2015, 25 states and the District of Columbia considered legalization bills.² After careful consideration and debate, these bills failed in every state except California, and in that state it passed only because of an extraordinary and unusual legislative maneuver. The bill initially failed in regular session, but passed in special session when the California Medical Association (CMA) shifted to a neutral stance. That shift would never have happened had CMA members been aware of the legal inevitability of euthanasia. At this stage of the political process, the goal of the right-to-die movement is to get laws on the books in as many states as possible before pushing for more.

The New Mexico opinion echoes a similar decision issued this past May by a New York appellate court. The plaintiffs in that case were three terminally ill New Yorkers and five doctors, as well as two euthanasia advocacy groups. The arguments were virtually identical to those made in New Mexico, asserting a fundamental right to medical aid in dying based upon personal autonomy. They additionally sought an exception to New York criminal law, which defined assisted suicide as second-degree manslaughter. In Myers v. Schneiderman, the court observed that no appellate court had ever found medical aid in dying to be a fundamental right and that no new developments justified a change in this interpretation.³ While the court acknowledged some change in public opinion as reflected in telephone surveys, it correctly gave little weight to this argument: “Plaintiffs fail to allege whether those public polls reflect the opinion of people who are fully informed of the arguments espoused by those who caution against permitting aid-in-dying, such as those articulated in the New York State Task Force on Life and the Law.”

This task force issued the following recommendation in its 1994 report,⁴ “When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context”: “The Task Force members unanimously recommend that existing law should not be changed to permit assisted suicide or euthanasia. Legalizing assisted suicide and euthanasia would pose profound risks to many individuals who are ill and vulnerable. The Task Force members concluded that the potential dangers of this dramatic change in public policy would outweigh any benefit that might be achieved” (Chapter 6, p. 120).

The New York aid-in-dying bill did not progress out of committee by the time the session ended in June.

Lastly, both of these cases concluded that medical aid in dying was suicide. In Myers, Judge Angela M. Mazzarelli stated: “The word ‘suicide’ has a straightforward meaning, and a dictionary is hardly necessary … It is traditionally defined as ‘the act or instance of taking one’s own life voluntarily and intentionally.’ ... Whatever label one puts on the act that plaintiffs are asking us to permit, it unquestionably fits that literal description.”

 

Regardless of the label used – aid in dying, assisted suicide, or self-deliverance – it is not a civil right.

Resources

1. http://www.nmcompcomm.us/nmcases/nmsc/slips/SC35,478.pdf

2. https://www.deathwithdignity.org/assisted-dying-chronology/

3. http://www.nycourts.gov/reporter/3dseries/2016/2016_03457.htm

4. https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In 2005, the American Psychological Association formed a task force to address the role of psychologists in the interrogation of Central Intelligence Agency and Department of Defense detainees. The task force was formed at the request of psychologists consulting with both entities and their supervisors to address the ethics of psychologist involvement in shaping interrogation practices. The task force concluded that psychologist participation was allowed in order to ensure that the process was “safe, legal, ethical, and effective.” The Presidential Task Force on Psychological Ethics and National Security (PENS) report drew immediate objection from within the organization and triggered a member-initiated movement to rescind the findings. Members alleged that those involved in the creation of the PENS report had conflicts of interest and that the task force was heavily weighted with psychologists who were already consulting with national security organizations.

These concerns were substantiated in a book entitled Pay Any Price: Greed, Power, and Endless War (New York: Houghton Mifflin Harcourt, 2014) by New York Times reporter James Risen. In the spirit of the Watergate investigation, Risen “followed the money” as it flowed from the U.S. government to national security and defense agencies, and into the pockets of select psychologists who took active roles in harsh interrogation techniques.

Armed with this new evidence, the American Psychological Association initiated an independent investigation of the association’s role in November 2014. The results of that investigation were published recently in a 542-page report synopsized by James Risen in the New York Times. Also known as the Hoffman report, it confirmed numerous conflicts of interest between psychologists involved in the 2005 revision of the ethics guidelines, and both the C.I.A. and the D.O.D. The full implications of the Hoffman report remain to be seen, but the history and process of this problem are informative.

Both the American Medical Association and the American Psychiatric Association have position statements against participation in interrogation and torture. In 2006, the American Psychiatric Association issued a position statement in which it held that “that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person.” The American Medical Association similarly codified a prohibition against participation in interrogation in its ethical guidelines: “Physicians must oppose and must not participate in torture for any reason. Participation in torture includes, but is not limited to, providing or withholding any services, substances, or knowledge to facilitate the practice of torture. Physicians must not be present when torture is used or threatened.” Members who become aware of the practices are called upon to report them and to adhere to professional ethical standards.

But before psychiatry congratulates itself for its moral fortitude, we would do well to remember that the Department of Homeland Security’s Office of University Programs awarded $39 million to 12 academic institutions in 2011, to create “centers of excellence” related to cybersecurity, counterintelligence measures, disaster preparedness, prevention of terrorism, and research into the sociologic and psychological causes of radicalization. All mental health professionals should ensure that any research-related national security issues abide by international, ethical, and humanitarian standards, and should refrain from areas of investigation that target vulnerable individuals or groups.

The Hoffman report reminds us that everything that is legal is not necessarily ethical. It highlights the necessity of bright line standards over issues related to essential human rights and well-being. For these concerns, we should value internal challenge and dissent, and we must continually ask ourselves if we are on the right path. We must also create and protect avenues for our members who discover and report violations, even if this protection is given to the detriment of our organization. The purpose of a professional organization is to ensure the quality and integrity of its members and to protect the public from those members who fall short in either domain. As professionals, we are each responsible for ensuring that our organization carries out these duties.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In 2005, the American Psychological Association formed a task force to address the role of psychologists in the interrogation of Central Intelligence Agency and Department of Defense detainees. The task force was formed at the request of psychologists consulting with both entities and their supervisors to address the ethics of psychologist involvement in shaping interrogation practices. The task force concluded that psychologist participation was allowed in order to ensure that the process was “safe, legal, ethical, and effective.” The Presidential Task Force on Psychological Ethics and National Security (PENS) report drew immediate objection from within the organization and triggered a member-initiated movement to rescind the findings. Members alleged that those involved in the creation of the PENS report had conflicts of interest and that the task force was heavily weighted with psychologists who were already consulting with national security organizations.

These concerns were substantiated in a book entitled Pay Any Price: Greed, Power, and Endless War (New York: Houghton Mifflin Harcourt, 2014) by New York Times reporter James Risen. In the spirit of the Watergate investigation, Risen “followed the money” as it flowed from the U.S. government to national security and defense agencies, and into the pockets of select psychologists who took active roles in harsh interrogation techniques.

Armed with this new evidence, the American Psychological Association initiated an independent investigation of the association’s role in November 2014. The results of that investigation were published recently in a 542-page report synopsized by James Risen in the New York Times. Also known as the Hoffman report, it confirmed numerous conflicts of interest between psychologists involved in the 2005 revision of the ethics guidelines, and both the C.I.A. and the D.O.D. The full implications of the Hoffman report remain to be seen, but the history and process of this problem are informative.

Both the American Medical Association and the American Psychiatric Association have position statements against participation in interrogation and torture. In 2006, the American Psychiatric Association issued a position statement in which it held that “that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person.” The American Medical Association similarly codified a prohibition against participation in interrogation in its ethical guidelines: “Physicians must oppose and must not participate in torture for any reason. Participation in torture includes, but is not limited to, providing or withholding any services, substances, or knowledge to facilitate the practice of torture. Physicians must not be present when torture is used or threatened.” Members who become aware of the practices are called upon to report them and to adhere to professional ethical standards.

But before psychiatry congratulates itself for its moral fortitude, we would do well to remember that the Department of Homeland Security’s Office of University Programs awarded $39 million to 12 academic institutions in 2011, to create “centers of excellence” related to cybersecurity, counterintelligence measures, disaster preparedness, prevention of terrorism, and research into the sociologic and psychological causes of radicalization. All mental health professionals should ensure that any research-related national security issues abide by international, ethical, and humanitarian standards, and should refrain from areas of investigation that target vulnerable individuals or groups.

The Hoffman report reminds us that everything that is legal is not necessarily ethical. It highlights the necessity of bright line standards over issues related to essential human rights and well-being. For these concerns, we should value internal challenge and dissent, and we must continually ask ourselves if we are on the right path. We must also create and protect avenues for our members who discover and report violations, even if this protection is given to the detriment of our organization. The purpose of a professional organization is to ensure the quality and integrity of its members and to protect the public from those members who fall short in either domain. As professionals, we are each responsible for ensuring that our organization carries out these duties.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In 2005, the American Psychological Association formed a task force to address the role of psychologists in the interrogation of Central Intelligence Agency and Department of Defense detainees. The task force was formed at the request of psychologists consulting with both entities and their supervisors to address the ethics of psychologist involvement in shaping interrogation practices. The task force concluded that psychologist participation was allowed in order to ensure that the process was “safe, legal, ethical, and effective.” The Presidential Task Force on Psychological Ethics and National Security (PENS) report drew immediate objection from within the organization and triggered a member-initiated movement to rescind the findings. Members alleged that those involved in the creation of the PENS report had conflicts of interest and that the task force was heavily weighted with psychologists who were already consulting with national security organizations.

These concerns were substantiated in a book entitled Pay Any Price: Greed, Power, and Endless War (New York: Houghton Mifflin Harcourt, 2014) by New York Times reporter James Risen. In the spirit of the Watergate investigation, Risen “followed the money” as it flowed from the U.S. government to national security and defense agencies, and into the pockets of select psychologists who took active roles in harsh interrogation techniques.

Armed with this new evidence, the American Psychological Association initiated an independent investigation of the association’s role in November 2014. The results of that investigation were published recently in a 542-page report synopsized by James Risen in the New York Times. Also known as the Hoffman report, it confirmed numerous conflicts of interest between psychologists involved in the 2005 revision of the ethics guidelines, and both the C.I.A. and the D.O.D. The full implications of the Hoffman report remain to be seen, but the history and process of this problem are informative.

Both the American Medical Association and the American Psychiatric Association have position statements against participation in interrogation and torture. In 2006, the American Psychiatric Association issued a position statement in which it held that “that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person.” The American Medical Association similarly codified a prohibition against participation in interrogation in its ethical guidelines: “Physicians must oppose and must not participate in torture for any reason. Participation in torture includes, but is not limited to, providing or withholding any services, substances, or knowledge to facilitate the practice of torture. Physicians must not be present when torture is used or threatened.” Members who become aware of the practices are called upon to report them and to adhere to professional ethical standards.

But before psychiatry congratulates itself for its moral fortitude, we would do well to remember that the Department of Homeland Security’s Office of University Programs awarded $39 million to 12 academic institutions in 2011, to create “centers of excellence” related to cybersecurity, counterintelligence measures, disaster preparedness, prevention of terrorism, and research into the sociologic and psychological causes of radicalization. All mental health professionals should ensure that any research-related national security issues abide by international, ethical, and humanitarian standards, and should refrain from areas of investigation that target vulnerable individuals or groups.

The Hoffman report reminds us that everything that is legal is not necessarily ethical. It highlights the necessity of bright line standards over issues related to essential human rights and well-being. For these concerns, we should value internal challenge and dissent, and we must continually ask ourselves if we are on the right path. We must also create and protect avenues for our members who discover and report violations, even if this protection is given to the detriment of our organization. The purpose of a professional organization is to ensure the quality and integrity of its members and to protect the public from those members who fall short in either domain. As professionals, we are each responsible for ensuring that our organization carries out these duties.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, bills aimed at allowing for physician-assisted suicide – also referred to as “Death With Dignity” laws – have been introduced in New Jersey, the District of Columbia, Maryland, Colorado, California, and Hawaii. Debates over the issue of end-of-life care are contentious and distressing, often accompanied by the tearful testimony of those who have cared for a family member throughout a long terminal illness. It’s hard to listen to these stories and not be moved personally, and to draw upon one’s own life experience with bereavement after a loved one’s suicide or disease.

For psychiatrists, the challenge is to think about assisted suicide not in terms of what we would want for ourselves, but what is best for our patients and the medical profession. Proponents argue that respect for patient autonomy should take priority, even if by respecting autonomy the end result is death. Opponents believe that by granting a request to die to a few people, many more vulnerable people may be abused or harmed inadvertently.

In my opinion, after extensive review of the bills and the effects of existing laws in Oregon and Washington, there are too many problems with assisted-suicide laws to safeguard or regulate this practice effectively.

The chief issue is that there is no mandate for any mental health evaluation for any qualified patient who requests assisted suicide. The primary physician and consulting physicians who certify competence may refer to a psychiatrist or psychologist, but this is only if there is a suspicion of incapacity. In Oregon, where this has been legal for 18 years, less than 5% of patients are referred for a competency assessment by a mental health professional although as many as 25% of terminally ill individuals may be suffering from clinical depression. In Oregon, individuals with HIV are 18 times more likely to die of assisted suicide than natural illness, which is particularly concerning given that HIV is known to affect the brain, and is associated with an increased risk of clinical depression and mania. The law allows a qualified patient to bar physicians from contacting or notifying family, which would make a psychiatrist’s competency assessment difficult if not impossible when the patient is suffering from a condition like dementia and can’t give a history himself.

The assisted-suicide process contains no mechanism to challenge the adequacy of the nonpsychiatrist’s assessment of capacity and noncoercion. There is no mechanism for judicial oversight, no mechanism to allow an interested party to raise the question of incompetence, and no existing standard of care for the assessment of capacity in this situation. Some bills protect the identity of the physicians and the patient, or bar medical records from subpoena or discovery, which would make any investigation for civil or criminal purposes difficult. In Oregon, 18 physicians were referred for board investigation, but none were sanctioned because the law required no more than “good faith” compliance with procedures – essentially only a requirement that the proper forms be filled out and filed promptly. This level of review is clearly inadequate when the process involves the death of an individual.

Some evidence suggests that having a physician-assisted law on the books may affect suicide rates in the general population. In Oregon, the suicide rate has risen out of proportion to the rest of the country, even excluding assisted-suicide deaths. (All laws require that assisted deaths be reported as a death from natural illness rather than suicide.) No formal study has been made of this issue, but there should be some provision to review and suspend the practice if this turns out to be the case.

All existing assisted-suicide laws recommend but do not require that a death be attended. Thus, despite the intent of the law, there is no way to ensure that the suicide is actually voluntary once the lethal medication is in hand. The law allows a physician to dispense medications to facilitate the ingestion of pentobarbital. This is necessary, because some patients have been unable to ingest the volume of liquid necessary to take the whole dose and have regurgitated the medication. Allowing premedication with an antiemetic is sometimes necessary. In theory, this aspect of the law could allow a health care practitioner to inject the antiemetic – an active involvement that would cross the line into euthanasia.

With regard to institutionalized patients, psychiatrists would be in a particularly challenging position. Presently, all patients admitted to hospitals are offered an opportunity to sign medical advance directives. At our forensic hospital in Maryland, admitting physicians assess the patient’s capacity to sign these directives. In theory, an insanity acquittee or long-term patient with a serious medical illness could request assisted suicide if competent. By law, the primary physician – a ward psychiatrist – would ultimately be required to write the lethal prescription or refer to another physician who would. If the patient were incompetent to request assisted suicide, the ward psychiatrist would be required to treat the mental illness knowing that it could eventually lead to the patient’s death. This situation is analogous to the dilemma of the correctional psychiatrist who treats an incompetent death row inmate.

 

There are many other problems with assisted-suicide legislation. At the very least, states should require a formal certification process to ensure that physicians who provide lethal medication have adequate training and experience to administer and interpret screening tests for psychiatric disorders, to do capacity assessments, and to make prognostic decisions relevant to their board certification and training. In all existing assisted-suicide bills and laws, the only requirement for a physician to provide lethal medication is that he or she must have the “qualifications and experience” to make a diagnosis and prognosis. There is no specific requirement that the attending or consulting physician actually be board certified to treat the illness in question. Thus, in theory, an attending or consulting physician could certify terminal illness without proven competence to do so.

Also, no clear safeguard exists to detect, investigate, and prosecute a hypothetical malicious or unscrupulous physician. In Oregon, three physicians write 20% of lethal prescriptions. It only takes one physician to do a lot of harm.

The American Medical Association has had a position statement on this topic for more than 20 years. The AMA takes the position that physician-assisted suicide is categorically unethical and bars doctors from participation. This, from the standpoint of a state health department, is probably the key issue: Should a legislature have the authority to allow physician behavior that a licensing board and professional organizations already have held to be unethical and not the practice of medicine? One of the core characteristics of a profession is the ability to monitor, police, and ensure the integrity of its members. Legislatures are unwise to undermine this.

Dr. Hanson is a forensic psychiatrist and co-author of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, bills aimed at allowing for physician-assisted suicide – also referred to as “Death With Dignity” laws – have been introduced in New Jersey, the District of Columbia, Maryland, Colorado, California, and Hawaii. Debates over the issue of end-of-life care are contentious and distressing, often accompanied by the tearful testimony of those who have cared for a family member throughout a long terminal illness. It’s hard to listen to these stories and not be moved personally, and to draw upon one’s own life experience with bereavement after a loved one’s suicide or disease.

For psychiatrists, the challenge is to think about assisted suicide not in terms of what we would want for ourselves, but what is best for our patients and the medical profession. Proponents argue that respect for patient autonomy should take priority, even if by respecting autonomy the end result is death. Opponents believe that by granting a request to die to a few people, many more vulnerable people may be abused or harmed inadvertently.

In my opinion, after extensive review of the bills and the effects of existing laws in Oregon and Washington, there are too many problems with assisted-suicide laws to safeguard or regulate this practice effectively.

The chief issue is that there is no mandate for any mental health evaluation for any qualified patient who requests assisted suicide. The primary physician and consulting physicians who certify competence may refer to a psychiatrist or psychologist, but this is only if there is a suspicion of incapacity. In Oregon, where this has been legal for 18 years, less than 5% of patients are referred for a competency assessment by a mental health professional although as many as 25% of terminally ill individuals may be suffering from clinical depression. In Oregon, individuals with HIV are 18 times more likely to die of assisted suicide than natural illness, which is particularly concerning given that HIV is known to affect the brain, and is associated with an increased risk of clinical depression and mania. The law allows a qualified patient to bar physicians from contacting or notifying family, which would make a psychiatrist’s competency assessment difficult if not impossible when the patient is suffering from a condition like dementia and can’t give a history himself.

The assisted-suicide process contains no mechanism to challenge the adequacy of the nonpsychiatrist’s assessment of capacity and noncoercion. There is no mechanism for judicial oversight, no mechanism to allow an interested party to raise the question of incompetence, and no existing standard of care for the assessment of capacity in this situation. Some bills protect the identity of the physicians and the patient, or bar medical records from subpoena or discovery, which would make any investigation for civil or criminal purposes difficult. In Oregon, 18 physicians were referred for board investigation, but none were sanctioned because the law required no more than “good faith” compliance with procedures – essentially only a requirement that the proper forms be filled out and filed promptly. This level of review is clearly inadequate when the process involves the death of an individual.

Some evidence suggests that having a physician-assisted law on the books may affect suicide rates in the general population. In Oregon, the suicide rate has risen out of proportion to the rest of the country, even excluding assisted-suicide deaths. (All laws require that assisted deaths be reported as a death from natural illness rather than suicide.) No formal study has been made of this issue, but there should be some provision to review and suspend the practice if this turns out to be the case.

All existing assisted-suicide laws recommend but do not require that a death be attended. Thus, despite the intent of the law, there is no way to ensure that the suicide is actually voluntary once the lethal medication is in hand. The law allows a physician to dispense medications to facilitate the ingestion of pentobarbital. This is necessary, because some patients have been unable to ingest the volume of liquid necessary to take the whole dose and have regurgitated the medication. Allowing premedication with an antiemetic is sometimes necessary. In theory, this aspect of the law could allow a health care practitioner to inject the antiemetic – an active involvement that would cross the line into euthanasia.

With regard to institutionalized patients, psychiatrists would be in a particularly challenging position. Presently, all patients admitted to hospitals are offered an opportunity to sign medical advance directives. At our forensic hospital in Maryland, admitting physicians assess the patient’s capacity to sign these directives. In theory, an insanity acquittee or long-term patient with a serious medical illness could request assisted suicide if competent. By law, the primary physician – a ward psychiatrist – would ultimately be required to write the lethal prescription or refer to another physician who would. If the patient were incompetent to request assisted suicide, the ward psychiatrist would be required to treat the mental illness knowing that it could eventually lead to the patient’s death. This situation is analogous to the dilemma of the correctional psychiatrist who treats an incompetent death row inmate.

 

There are many other problems with assisted-suicide legislation. At the very least, states should require a formal certification process to ensure that physicians who provide lethal medication have adequate training and experience to administer and interpret screening tests for psychiatric disorders, to do capacity assessments, and to make prognostic decisions relevant to their board certification and training. In all existing assisted-suicide bills and laws, the only requirement for a physician to provide lethal medication is that he or she must have the “qualifications and experience” to make a diagnosis and prognosis. There is no specific requirement that the attending or consulting physician actually be board certified to treat the illness in question. Thus, in theory, an attending or consulting physician could certify terminal illness without proven competence to do so.

Also, no clear safeguard exists to detect, investigate, and prosecute a hypothetical malicious or unscrupulous physician. In Oregon, three physicians write 20% of lethal prescriptions. It only takes one physician to do a lot of harm.

The American Medical Association has had a position statement on this topic for more than 20 years. The AMA takes the position that physician-assisted suicide is categorically unethical and bars doctors from participation. This, from the standpoint of a state health department, is probably the key issue: Should a legislature have the authority to allow physician behavior that a licensing board and professional organizations already have held to be unethical and not the practice of medicine? One of the core characteristics of a profession is the ability to monitor, police, and ensure the integrity of its members. Legislatures are unwise to undermine this.

Dr. Hanson is a forensic psychiatrist and co-author of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, bills aimed at allowing for physician-assisted suicide – also referred to as “Death With Dignity” laws – have been introduced in New Jersey, the District of Columbia, Maryland, Colorado, California, and Hawaii. Debates over the issue of end-of-life care are contentious and distressing, often accompanied by the tearful testimony of those who have cared for a family member throughout a long terminal illness. It’s hard to listen to these stories and not be moved personally, and to draw upon one’s own life experience with bereavement after a loved one’s suicide or disease.

For psychiatrists, the challenge is to think about assisted suicide not in terms of what we would want for ourselves, but what is best for our patients and the medical profession. Proponents argue that respect for patient autonomy should take priority, even if by respecting autonomy the end result is death. Opponents believe that by granting a request to die to a few people, many more vulnerable people may be abused or harmed inadvertently.

In my opinion, after extensive review of the bills and the effects of existing laws in Oregon and Washington, there are too many problems with assisted-suicide laws to safeguard or regulate this practice effectively.

The chief issue is that there is no mandate for any mental health evaluation for any qualified patient who requests assisted suicide. The primary physician and consulting physicians who certify competence may refer to a psychiatrist or psychologist, but this is only if there is a suspicion of incapacity. In Oregon, where this has been legal for 18 years, less than 5% of patients are referred for a competency assessment by a mental health professional although as many as 25% of terminally ill individuals may be suffering from clinical depression. In Oregon, individuals with HIV are 18 times more likely to die of assisted suicide than natural illness, which is particularly concerning given that HIV is known to affect the brain, and is associated with an increased risk of clinical depression and mania. The law allows a qualified patient to bar physicians from contacting or notifying family, which would make a psychiatrist’s competency assessment difficult if not impossible when the patient is suffering from a condition like dementia and can’t give a history himself.

The assisted-suicide process contains no mechanism to challenge the adequacy of the nonpsychiatrist’s assessment of capacity and noncoercion. There is no mechanism for judicial oversight, no mechanism to allow an interested party to raise the question of incompetence, and no existing standard of care for the assessment of capacity in this situation. Some bills protect the identity of the physicians and the patient, or bar medical records from subpoena or discovery, which would make any investigation for civil or criminal purposes difficult. In Oregon, 18 physicians were referred for board investigation, but none were sanctioned because the law required no more than “good faith” compliance with procedures – essentially only a requirement that the proper forms be filled out and filed promptly. This level of review is clearly inadequate when the process involves the death of an individual.

Some evidence suggests that having a physician-assisted law on the books may affect suicide rates in the general population. In Oregon, the suicide rate has risen out of proportion to the rest of the country, even excluding assisted-suicide deaths. (All laws require that assisted deaths be reported as a death from natural illness rather than suicide.) No formal study has been made of this issue, but there should be some provision to review and suspend the practice if this turns out to be the case.

All existing assisted-suicide laws recommend but do not require that a death be attended. Thus, despite the intent of the law, there is no way to ensure that the suicide is actually voluntary once the lethal medication is in hand. The law allows a physician to dispense medications to facilitate the ingestion of pentobarbital. This is necessary, because some patients have been unable to ingest the volume of liquid necessary to take the whole dose and have regurgitated the medication. Allowing premedication with an antiemetic is sometimes necessary. In theory, this aspect of the law could allow a health care practitioner to inject the antiemetic – an active involvement that would cross the line into euthanasia.

With regard to institutionalized patients, psychiatrists would be in a particularly challenging position. Presently, all patients admitted to hospitals are offered an opportunity to sign medical advance directives. At our forensic hospital in Maryland, admitting physicians assess the patient’s capacity to sign these directives. In theory, an insanity acquittee or long-term patient with a serious medical illness could request assisted suicide if competent. By law, the primary physician – a ward psychiatrist – would ultimately be required to write the lethal prescription or refer to another physician who would. If the patient were incompetent to request assisted suicide, the ward psychiatrist would be required to treat the mental illness knowing that it could eventually lead to the patient’s death. This situation is analogous to the dilemma of the correctional psychiatrist who treats an incompetent death row inmate.

 

There are many other problems with assisted-suicide legislation. At the very least, states should require a formal certification process to ensure that physicians who provide lethal medication have adequate training and experience to administer and interpret screening tests for psychiatric disorders, to do capacity assessments, and to make prognostic decisions relevant to their board certification and training. In all existing assisted-suicide bills and laws, the only requirement for a physician to provide lethal medication is that he or she must have the “qualifications and experience” to make a diagnosis and prognosis. There is no specific requirement that the attending or consulting physician actually be board certified to treat the illness in question. Thus, in theory, an attending or consulting physician could certify terminal illness without proven competence to do so.

Also, no clear safeguard exists to detect, investigate, and prosecute a hypothetical malicious or unscrupulous physician. In Oregon, three physicians write 20% of lethal prescriptions. It only takes one physician to do a lot of harm.

The American Medical Association has had a position statement on this topic for more than 20 years. The AMA takes the position that physician-assisted suicide is categorically unethical and bars doctors from participation. This, from the standpoint of a state health department, is probably the key issue: Should a legislature have the authority to allow physician behavior that a licensing board and professional organizations already have held to be unethical and not the practice of medicine? One of the core characteristics of a profession is the ability to monitor, police, and ensure the integrity of its members. Legislatures are unwise to undermine this.

Dr. Hanson is a forensic psychiatrist and co-author of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

In a study published in the December 2014 issue of American Journal of Public Health, Jennifer M. Reingle Gonzalez, Ph.D., and Nadine M. Connell, Ph.D., of the University of Texas Health Science Center at Houston interviewed a nationally representative sample of all state and federal prisoners with psychiatric disorders to determine whether they had been screened for services at intake and to assess whether screening led to continuity of community treatment.

The subjects were chosen first by selecting a random sample of correctional facilities of varying sizes, from diverse geographic regions. From those facilities, 18,185 prisoners were chosen from among all those incarcerated on a single day in September 2002. Each subject was interviewed personally but also given computer-assisted interviews at different times to ensure recollection accuracy and the confidentiality of clinical data (Am. J. Public Health 2014;104:2328-33).

In the direct interview, each prisoner was asked if he or she had ever been diagnosed with a mental health condition such as depression, bipolar disorder, schizophrenia, posttraumatic stress disorder, an anxiety disorder, or a personality disorder. If any condition had ever been diagnosed, the inmates were then asked if they were taking a psychiatric medication upon admission to the facility. If they were in treatment at intake, they were asked if they had ever been on medication since that time. Finally, they were asked if they had had a medical examination while incarcerated.

Almost all prisoners (90%) were screened at intake and received a medical evaluation. The researchers found that 5,207 (26.2%) of the inmates received at least one lifetime mental health diagnosis, with depression being the most common. Eighteen percent reported taking medication for a psychiatric disorder at the time of intake, but of these, only about half were taking medication after incarceration. Medication continuance was twice as likely for schizophrenia as for depression, and those who received an intake screen were significantly more likely to be referred to a physician and receive medication. Notably, 27% of state and 16% of federal prisoners received medication only in prison.

The investigators attributed the discontinuity in treatment after incarceration to a lack of trained mental health professionals to diagnose and treat psychiatric disorders, and to a rise in prison populations out of proportion to available treatment services. The findings of this study supported the investigators’ recommendation for all facilities to employ intake screening to identify and refer prisoners in need of psychiatric care.

This research is important to forensic psychiatrists working in correctional systems and to those working as administrators or external court-appointed monitors, because it highlights the importance and efficacy of intake screening for prisoners with psychiatric disorders.

Unfortunately, traditional media coverage of this research was predictably provocative. Headlines blared: “Mental health care lacking in state and federal prisons.” The researchers themselves also implied that failure to continue medication in prison indicated some systemic deficiency. While an evaluation by a physician was correlated with the prescription of medication, this was not a perfect correlation. The authors did not discuss any of the valid reasons why medication might not be continued in prison.

The most common reason medication is not continued is that inmates are more likely to be abstinent from drugs and alcohol, and thus may require less or even no antidepressant medication after detoxification. This could account for as much as half of the treatment discontinuity, because as many as 20% of the prisoners had been diagnosed with depression. Also, evidence is mounting that indefinite medication may not be necessary for all conditions. Following a clinical assessment, a correctional physician may have determined that the prisoner had successfully completed maintenance therapy. The final reason why medication is not continued is that the inmate may simply have refused the offered treatment; some prisoners do choose to go without medication completely rather than risk a change to a different regimen.

All of this assumes that the subjects accurately reported both their psychiatric history and their mental health service contact following incarceration. Without access to current records or past documentation, this remains an open question. In my prison system, our electronic health record does contain some data provided by the public health care system. In rare cases, this information is consistent with what the patient reports, but this is the exception rather than the rule.

Finally, the most telling aspect of this research is what it reveals about free society care: A quarter of the inmates received treatment only in prison. That is the real finding worthy of a headline.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.


In a study published in the December 2014 issue of American Journal of Public Health, Jennifer M. Reingle Gonzalez, Ph.D., and Nadine M. Connell, Ph.D., of the University of Texas Health Science Center at Houston interviewed a nationally representative sample of all state and federal prisoners with psychiatric disorders to determine whether they had been screened for services at intake and to assess whether screening led to continuity of community treatment.

The subjects were chosen first by selecting a random sample of correctional facilities of varying sizes, from diverse geographic regions. From those facilities, 18,185 prisoners were chosen from among all those incarcerated on a single day in September 2002. Each subject was interviewed personally but also given computer-assisted interviews at different times to ensure recollection accuracy and the confidentiality of clinical data (Am. J. Public Health 2014;104:2328-33).

In the direct interview, each prisoner was asked if he or she had ever been diagnosed with a mental health condition such as depression, bipolar disorder, schizophrenia, posttraumatic stress disorder, an anxiety disorder, or a personality disorder. If any condition had ever been diagnosed, the inmates were then asked if they were taking a psychiatric medication upon admission to the facility. If they were in treatment at intake, they were asked if they had ever been on medication since that time. Finally, they were asked if they had had a medical examination while incarcerated.

Almost all prisoners (90%) were screened at intake and received a medical evaluation. The researchers found that 5,207 (26.2%) of the inmates received at least one lifetime mental health diagnosis, with depression being the most common. Eighteen percent reported taking medication for a psychiatric disorder at the time of intake, but of these, only about half were taking medication after incarceration. Medication continuance was twice as likely for schizophrenia as for depression, and those who received an intake screen were significantly more likely to be referred to a physician and receive medication. Notably, 27% of state and 16% of federal prisoners received medication only in prison.

The investigators attributed the discontinuity in treatment after incarceration to a lack of trained mental health professionals to diagnose and treat psychiatric disorders, and to a rise in prison populations out of proportion to available treatment services. The findings of this study supported the investigators’ recommendation for all facilities to employ intake screening to identify and refer prisoners in need of psychiatric care.

This research is important to forensic psychiatrists working in correctional systems and to those working as administrators or external court-appointed monitors, because it highlights the importance and efficacy of intake screening for prisoners with psychiatric disorders.

Unfortunately, traditional media coverage of this research was predictably provocative. Headlines blared: “Mental health care lacking in state and federal prisons.” The researchers themselves also implied that failure to continue medication in prison indicated some systemic deficiency. While an evaluation by a physician was correlated with the prescription of medication, this was not a perfect correlation. The authors did not discuss any of the valid reasons why medication might not be continued in prison.

The most common reason medication is not continued is that inmates are more likely to be abstinent from drugs and alcohol, and thus may require less or even no antidepressant medication after detoxification. This could account for as much as half of the treatment discontinuity, because as many as 20% of the prisoners had been diagnosed with depression. Also, evidence is mounting that indefinite medication may not be necessary for all conditions. Following a clinical assessment, a correctional physician may have determined that the prisoner had successfully completed maintenance therapy. The final reason why medication is not continued is that the inmate may simply have refused the offered treatment; some prisoners do choose to go without medication completely rather than risk a change to a different regimen.

All of this assumes that the subjects accurately reported both their psychiatric history and their mental health service contact following incarceration. Without access to current records or past documentation, this remains an open question. In my prison system, our electronic health record does contain some data provided by the public health care system. In rare cases, this information is consistent with what the patient reports, but this is the exception rather than the rule.

Finally, the most telling aspect of this research is what it reveals about free society care: A quarter of the inmates received treatment only in prison. That is the real finding worthy of a headline.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.


In a study published in the December 2014 issue of American Journal of Public Health, Jennifer M. Reingle Gonzalez, Ph.D., and Nadine M. Connell, Ph.D., of the University of Texas Health Science Center at Houston interviewed a nationally representative sample of all state and federal prisoners with psychiatric disorders to determine whether they had been screened for services at intake and to assess whether screening led to continuity of community treatment.

The subjects were chosen first by selecting a random sample of correctional facilities of varying sizes, from diverse geographic regions. From those facilities, 18,185 prisoners were chosen from among all those incarcerated on a single day in September 2002. Each subject was interviewed personally but also given computer-assisted interviews at different times to ensure recollection accuracy and the confidentiality of clinical data (Am. J. Public Health 2014;104:2328-33).

In the direct interview, each prisoner was asked if he or she had ever been diagnosed with a mental health condition such as depression, bipolar disorder, schizophrenia, posttraumatic stress disorder, an anxiety disorder, or a personality disorder. If any condition had ever been diagnosed, the inmates were then asked if they were taking a psychiatric medication upon admission to the facility. If they were in treatment at intake, they were asked if they had ever been on medication since that time. Finally, they were asked if they had had a medical examination while incarcerated.

Almost all prisoners (90%) were screened at intake and received a medical evaluation. The researchers found that 5,207 (26.2%) of the inmates received at least one lifetime mental health diagnosis, with depression being the most common. Eighteen percent reported taking medication for a psychiatric disorder at the time of intake, but of these, only about half were taking medication after incarceration. Medication continuance was twice as likely for schizophrenia as for depression, and those who received an intake screen were significantly more likely to be referred to a physician and receive medication. Notably, 27% of state and 16% of federal prisoners received medication only in prison.

The investigators attributed the discontinuity in treatment after incarceration to a lack of trained mental health professionals to diagnose and treat psychiatric disorders, and to a rise in prison populations out of proportion to available treatment services. The findings of this study supported the investigators’ recommendation for all facilities to employ intake screening to identify and refer prisoners in need of psychiatric care.

This research is important to forensic psychiatrists working in correctional systems and to those working as administrators or external court-appointed monitors, because it highlights the importance and efficacy of intake screening for prisoners with psychiatric disorders.

Unfortunately, traditional media coverage of this research was predictably provocative. Headlines blared: “Mental health care lacking in state and federal prisons.” The researchers themselves also implied that failure to continue medication in prison indicated some systemic deficiency. While an evaluation by a physician was correlated with the prescription of medication, this was not a perfect correlation. The authors did not discuss any of the valid reasons why medication might not be continued in prison.

The most common reason medication is not continued is that inmates are more likely to be abstinent from drugs and alcohol, and thus may require less or even no antidepressant medication after detoxification. This could account for as much as half of the treatment discontinuity, because as many as 20% of the prisoners had been diagnosed with depression. Also, evidence is mounting that indefinite medication may not be necessary for all conditions. Following a clinical assessment, a correctional physician may have determined that the prisoner had successfully completed maintenance therapy. The final reason why medication is not continued is that the inmate may simply have refused the offered treatment; some prisoners do choose to go without medication completely rather than risk a change to a different regimen.

All of this assumes that the subjects accurately reported both their psychiatric history and their mental health service contact following incarceration. Without access to current records or past documentation, this remains an open question. In my prison system, our electronic health record does contain some data provided by the public health care system. In rare cases, this information is consistent with what the patient reports, but this is the exception rather than the rule.

Finally, the most telling aspect of this research is what it reveals about free society care: A quarter of the inmates received treatment only in prison. That is the real finding worthy of a headline.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.


According to the last Gallup poll, most Americans still favor the death penalty. Nevertheless, over the years, the number of capital-eligible defendants has been gradually whittled down because of challenges over the execution of juveniles, the intellectually disabled, and for defendants guilty of crimes other than murder. The latest challenge came up again in December, when lawyers for Texas death row inmate Scott Panetti sought a reprievealleging that he was incompetent to understand the reason for his execution.

Scott Panetti had a longstanding history of schizoaffective disorder dating back to the age of 20 years and had been hospitalized for treatment of his hallucinations and delusions at least 14 times. He once was convinced that the devil had possessed his home and had buried several valuables next to the house to “cleanse” it. His wife sought emergency intervention once when he threatened to kill her. In 1992, dressed in camouflage, he broke into the home of his estranged wife’s parents and killed them in front of her. He took his wife and young daughter hostage overnight but eventually surrendered to police.

At trial he wanted to represent himself, so the court ordered an evaluation of his competence to waive counsel. He was found competent and proceeded to present his own insanity defense to a jury. By the time of trial, he had been off medication for 2 months, and his behavior during the hearing was later described as bizarre and confusing at best. He came to court dressed in a cowboy suit, referred to himself as his alter-ego “Sarge,” and attempted to subpoena the Pope. He was convicted, in part, because jurors feared his behavior enough that they wanted to ensure he would never be released. He was sentenced to death.

Panetti received appointed counsel for his appeal after he was found incompetent to waive representation. His execution date was set in 2003, but the defense filed a motion alleging that he was incompetent to be put to death. The motion was accompanied by supporting documentation from a psychologist that Panetti did not understand the reasons for his punishment. The court appointed two experts who disagreed, stating that Panetti knew that he was about to be put to death and that he had the ability to understand the reason for the execution. They also implied that Panetti’s bizarre behavior in court was a calculated plan to present himself as insane.

Without a hearing, the court found Panetti competent. Panetti appealed to the Supreme Court, stating that under an earlier Supreme Court case, Ford v. Wainwright, he had a right to have a hearing on the competency issue, which would allow him to challenge the state’s experts and to present contrary medical evidence. The question at appeal was not whether execution of the mentally ill per se was cruel and unusual, but what standard should be applied to determine competency, and whether Texas followed the proper procedure to determine it.

Under Ford v. Wainwright, the bar was set extremely low. In order to be competent for execution, a defendant had only to know that he was being put to death, and that the death sentence was a punishment for a crime he had committed. This was a standard that required no more than intellectual or factual knowledge. Panetti was found competent to be executed because he could recite these facts. However, he disagreed with the facts: He believed that he was being executed by the state to prevent him from preaching the gospel. The Court of Appeals held that delusions alone would not necessarily mean that someone was incompetent. In 2007, the Supreme Court held in Panetti v. Quartermanthat competency requires a prisoner to have a rational as well as a factual understanding of the execution.

The American Psychiatric Association, the American Psychological Association, and the National Alliance on Mental Illness all joined to file an amicus brief on the case. In the brief, all the organizations agreed that “a prisoner is not competent to be executed if he ‘has a mental disorder or disability that significantly impairs his or her capacity to understand the nature and purpose of the punishment, or to appreciate the reason for its imposition in the prisoner’s own case.’ ” In other words, punishment is futile if the person in question doesn’t have the ability to understand that he is being punished.

The case was sent back for a formal hearing, and Panetti was again found competent. This time, the Supreme Court refused to hear his appeal. An execution date was set for Dec. 3 but was stayed 7 hours before he was to be put to death. Another competency assessment is probably on the horizon, given that 7 years have passed since the last one. The outcome this time will probably be the same, since Panetti reportedly has been on no medications for most of the last 20 years, and he has not been diagnosed with a psychotic illness in the prison system by any of the 14 mental health staff who have evaluated him.

 

Of course, none of this litigation to date settles the question of whether our judiciary should be executing anyone, with or without a mental illness. But until that question is settled, psychiatry will struggle along with the courts to decide exactly how ill is too ill to die.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

According to the last Gallup poll, most Americans still favor the death penalty. Nevertheless, over the years, the number of capital-eligible defendants has been gradually whittled down because of challenges over the execution of juveniles, the intellectually disabled, and for defendants guilty of crimes other than murder. The latest challenge came up again in December, when lawyers for Texas death row inmate Scott Panetti sought a reprievealleging that he was incompetent to understand the reason for his execution.

Scott Panetti had a longstanding history of schizoaffective disorder dating back to the age of 20 years and had been hospitalized for treatment of his hallucinations and delusions at least 14 times. He once was convinced that the devil had possessed his home and had buried several valuables next to the house to “cleanse” it. His wife sought emergency intervention once when he threatened to kill her. In 1992, dressed in camouflage, he broke into the home of his estranged wife’s parents and killed them in front of her. He took his wife and young daughter hostage overnight but eventually surrendered to police.

At trial he wanted to represent himself, so the court ordered an evaluation of his competence to waive counsel. He was found competent and proceeded to present his own insanity defense to a jury. By the time of trial, he had been off medication for 2 months, and his behavior during the hearing was later described as bizarre and confusing at best. He came to court dressed in a cowboy suit, referred to himself as his alter-ego “Sarge,” and attempted to subpoena the Pope. He was convicted, in part, because jurors feared his behavior enough that they wanted to ensure he would never be released. He was sentenced to death.

Panetti received appointed counsel for his appeal after he was found incompetent to waive representation. His execution date was set in 2003, but the defense filed a motion alleging that he was incompetent to be put to death. The motion was accompanied by supporting documentation from a psychologist that Panetti did not understand the reasons for his punishment. The court appointed two experts who disagreed, stating that Panetti knew that he was about to be put to death and that he had the ability to understand the reason for the execution. They also implied that Panetti’s bizarre behavior in court was a calculated plan to present himself as insane.

Without a hearing, the court found Panetti competent. Panetti appealed to the Supreme Court, stating that under an earlier Supreme Court case, Ford v. Wainwright, he had a right to have a hearing on the competency issue, which would allow him to challenge the state’s experts and to present contrary medical evidence. The question at appeal was not whether execution of the mentally ill per se was cruel and unusual, but what standard should be applied to determine competency, and whether Texas followed the proper procedure to determine it.

Under Ford v. Wainwright, the bar was set extremely low. In order to be competent for execution, a defendant had only to know that he was being put to death, and that the death sentence was a punishment for a crime he had committed. This was a standard that required no more than intellectual or factual knowledge. Panetti was found competent to be executed because he could recite these facts. However, he disagreed with the facts: He believed that he was being executed by the state to prevent him from preaching the gospel. The Court of Appeals held that delusions alone would not necessarily mean that someone was incompetent. In 2007, the Supreme Court held in Panetti v. Quartermanthat competency requires a prisoner to have a rational as well as a factual understanding of the execution.

The American Psychiatric Association, the American Psychological Association, and the National Alliance on Mental Illness all joined to file an amicus brief on the case. In the brief, all the organizations agreed that “a prisoner is not competent to be executed if he ‘has a mental disorder or disability that significantly impairs his or her capacity to understand the nature and purpose of the punishment, or to appreciate the reason for its imposition in the prisoner’s own case.’ ” In other words, punishment is futile if the person in question doesn’t have the ability to understand that he is being punished.

The case was sent back for a formal hearing, and Panetti was again found competent. This time, the Supreme Court refused to hear his appeal. An execution date was set for Dec. 3 but was stayed 7 hours before he was to be put to death. Another competency assessment is probably on the horizon, given that 7 years have passed since the last one. The outcome this time will probably be the same, since Panetti reportedly has been on no medications for most of the last 20 years, and he has not been diagnosed with a psychotic illness in the prison system by any of the 14 mental health staff who have evaluated him.

 

Of course, none of this litigation to date settles the question of whether our judiciary should be executing anyone, with or without a mental illness. But until that question is settled, psychiatry will struggle along with the courts to decide exactly how ill is too ill to die.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

According to the last Gallup poll, most Americans still favor the death penalty. Nevertheless, over the years, the number of capital-eligible defendants has been gradually whittled down because of challenges over the execution of juveniles, the intellectually disabled, and for defendants guilty of crimes other than murder. The latest challenge came up again in December, when lawyers for Texas death row inmate Scott Panetti sought a reprievealleging that he was incompetent to understand the reason for his execution.

Scott Panetti had a longstanding history of schizoaffective disorder dating back to the age of 20 years and had been hospitalized for treatment of his hallucinations and delusions at least 14 times. He once was convinced that the devil had possessed his home and had buried several valuables next to the house to “cleanse” it. His wife sought emergency intervention once when he threatened to kill her. In 1992, dressed in camouflage, he broke into the home of his estranged wife’s parents and killed them in front of her. He took his wife and young daughter hostage overnight but eventually surrendered to police.

At trial he wanted to represent himself, so the court ordered an evaluation of his competence to waive counsel. He was found competent and proceeded to present his own insanity defense to a jury. By the time of trial, he had been off medication for 2 months, and his behavior during the hearing was later described as bizarre and confusing at best. He came to court dressed in a cowboy suit, referred to himself as his alter-ego “Sarge,” and attempted to subpoena the Pope. He was convicted, in part, because jurors feared his behavior enough that they wanted to ensure he would never be released. He was sentenced to death.

Panetti received appointed counsel for his appeal after he was found incompetent to waive representation. His execution date was set in 2003, but the defense filed a motion alleging that he was incompetent to be put to death. The motion was accompanied by supporting documentation from a psychologist that Panetti did not understand the reasons for his punishment. The court appointed two experts who disagreed, stating that Panetti knew that he was about to be put to death and that he had the ability to understand the reason for the execution. They also implied that Panetti’s bizarre behavior in court was a calculated plan to present himself as insane.

Without a hearing, the court found Panetti competent. Panetti appealed to the Supreme Court, stating that under an earlier Supreme Court case, Ford v. Wainwright, he had a right to have a hearing on the competency issue, which would allow him to challenge the state’s experts and to present contrary medical evidence. The question at appeal was not whether execution of the mentally ill per se was cruel and unusual, but what standard should be applied to determine competency, and whether Texas followed the proper procedure to determine it.

Under Ford v. Wainwright, the bar was set extremely low. In order to be competent for execution, a defendant had only to know that he was being put to death, and that the death sentence was a punishment for a crime he had committed. This was a standard that required no more than intellectual or factual knowledge. Panetti was found competent to be executed because he could recite these facts. However, he disagreed with the facts: He believed that he was being executed by the state to prevent him from preaching the gospel. The Court of Appeals held that delusions alone would not necessarily mean that someone was incompetent. In 2007, the Supreme Court held in Panetti v. Quartermanthat competency requires a prisoner to have a rational as well as a factual understanding of the execution.

The American Psychiatric Association, the American Psychological Association, and the National Alliance on Mental Illness all joined to file an amicus brief on the case. In the brief, all the organizations agreed that “a prisoner is not competent to be executed if he ‘has a mental disorder or disability that significantly impairs his or her capacity to understand the nature and purpose of the punishment, or to appreciate the reason for its imposition in the prisoner’s own case.’ ” In other words, punishment is futile if the person in question doesn’t have the ability to understand that he is being punished.

The case was sent back for a formal hearing, and Panetti was again found competent. This time, the Supreme Court refused to hear his appeal. An execution date was set for Dec. 3 but was stayed 7 hours before he was to be put to death. Another competency assessment is probably on the horizon, given that 7 years have passed since the last one. The outcome this time will probably be the same, since Panetti reportedly has been on no medications for most of the last 20 years, and he has not been diagnosed with a psychotic illness in the prison system by any of the 14 mental health staff who have evaluated him.

 

Of course, none of this litigation to date settles the question of whether our judiciary should be executing anyone, with or without a mental illness. But until that question is settled, psychiatry will struggle along with the courts to decide exactly how ill is too ill to die.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One serious problem with being an advocate of correctional mental health services is that you run the risk of coming across as an apologist, a Pollyanna, or a defender of the status quo. This is true even though every week I meet someone with an addiction problem so severe that he’d be unable to voluntarily seek or stay in treatment in the community. For someone like that, an arrest can be lifesaving. But to point this out will lead people to believe that I must oppose ready access to community care, pretrial diversion, alternative sentencing, mental health courts, or anything related to alternatives to incarceration.

That isn’t the case. Many problems require more than one solution. What I oppose is the idea that the solution has to be a simple dichotomous choice between arrest and incarceration versus community care. I’ve found discussions about criminalization of people with mental illnesses to be polarizing and unproductive. There will always be people with mental illnesses in jail and prison, because – like people with diabetes, heart disease, or AIDS – they sometimes commit very serious crimes. As a care provider, my view is that a patient’s need for treatment is independent of criminal culpability. An ill person deserves appropriate and skilled health care, regardless of the treatment setting. Moving someone from an understaffed, overcrowded correctional facility to an understaffed, overcrowded state hospital hardly solves the problem.

People make the argument that money spent on corrections would be better spent elsewhere, on services for at-risk youth, or on community substance abuse and mental health programs. I agree that all these programs are needed, but what rarely gets mentioned is that when money is diverted from jails and prisons, part of that money also includes funding for inmate health care. Taking away this money is like stealing a coat from a blind beggar in the winter time. If you want to make a serious problem worse, by all means, take away what little we have.

How much money are we talking here, anyway?

By some estimates, the money spent on health care for all American prisons is about $7.7 billion per year. That includes physician and related health care professional costs, laboratory and diagnostic testing, hospitalization costs, as well as medications. Fourteen percent of that, or about $1 billion, goes to mental health care. Those costs are expected to rise as the prison population continues to age. Meanwhile, federal spending on mandatory health care programs in 2013 was about $1 trillion. When the prison health care budget represents less than 1% of health care spending nationally, this doesn’t seem to be enough to be quibbling about and certainly not enough to be cutting or diverting elsewhere.

But of course, the correctional nihilists will respond, “You get what you pay for.” Inevitably, low-cost care becomes equivalent to low-quality care in the eyes of many Americans. But if you compare American medical outcomes globally, it’s been well established that we have fallen behind many countries in life expectancy and infant mortality, despite heavy investment in a broad spectrum of services and interventions.

Let’s compare that to prison. Because of data gathered through the 2000 Federal Death in Custody Reporting Act, as well as other studies, prisons have been able to demonstrate reduced mortality, compared with age-matched men in free society, particularly for minorities. That mortality rate doubles after release. Clearly, prisons appear to be keeping people alive more efficiently and at a fraction of the cost of our community services.

This is not to imply that incarceration should be the answer to every social problem. This is my response to the naysayers and nihilists who believe that jails and prisons are so far gone they are not worth investing in. The lives of many prisoners depend on that investment.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One serious problem with being an advocate of correctional mental health services is that you run the risk of coming across as an apologist, a Pollyanna, or a defender of the status quo. This is true even though every week I meet someone with an addiction problem so severe that he’d be unable to voluntarily seek or stay in treatment in the community. For someone like that, an arrest can be lifesaving. But to point this out will lead people to believe that I must oppose ready access to community care, pretrial diversion, alternative sentencing, mental health courts, or anything related to alternatives to incarceration.

That isn’t the case. Many problems require more than one solution. What I oppose is the idea that the solution has to be a simple dichotomous choice between arrest and incarceration versus community care. I’ve found discussions about criminalization of people with mental illnesses to be polarizing and unproductive. There will always be people with mental illnesses in jail and prison, because – like people with diabetes, heart disease, or AIDS – they sometimes commit very serious crimes. As a care provider, my view is that a patient’s need for treatment is independent of criminal culpability. An ill person deserves appropriate and skilled health care, regardless of the treatment setting. Moving someone from an understaffed, overcrowded correctional facility to an understaffed, overcrowded state hospital hardly solves the problem.

People make the argument that money spent on corrections would be better spent elsewhere, on services for at-risk youth, or on community substance abuse and mental health programs. I agree that all these programs are needed, but what rarely gets mentioned is that when money is diverted from jails and prisons, part of that money also includes funding for inmate health care. Taking away this money is like stealing a coat from a blind beggar in the winter time. If you want to make a serious problem worse, by all means, take away what little we have.

How much money are we talking here, anyway?

By some estimates, the money spent on health care for all American prisons is about $7.7 billion per year. That includes physician and related health care professional costs, laboratory and diagnostic testing, hospitalization costs, as well as medications. Fourteen percent of that, or about $1 billion, goes to mental health care. Those costs are expected to rise as the prison population continues to age. Meanwhile, federal spending on mandatory health care programs in 2013 was about $1 trillion. When the prison health care budget represents less than 1% of health care spending nationally, this doesn’t seem to be enough to be quibbling about and certainly not enough to be cutting or diverting elsewhere.

But of course, the correctional nihilists will respond, “You get what you pay for.” Inevitably, low-cost care becomes equivalent to low-quality care in the eyes of many Americans. But if you compare American medical outcomes globally, it’s been well established that we have fallen behind many countries in life expectancy and infant mortality, despite heavy investment in a broad spectrum of services and interventions.

Let’s compare that to prison. Because of data gathered through the 2000 Federal Death in Custody Reporting Act, as well as other studies, prisons have been able to demonstrate reduced mortality, compared with age-matched men in free society, particularly for minorities. That mortality rate doubles after release. Clearly, prisons appear to be keeping people alive more efficiently and at a fraction of the cost of our community services.

This is not to imply that incarceration should be the answer to every social problem. This is my response to the naysayers and nihilists who believe that jails and prisons are so far gone they are not worth investing in. The lives of many prisoners depend on that investment.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One serious problem with being an advocate of correctional mental health services is that you run the risk of coming across as an apologist, a Pollyanna, or a defender of the status quo. This is true even though every week I meet someone with an addiction problem so severe that he’d be unable to voluntarily seek or stay in treatment in the community. For someone like that, an arrest can be lifesaving. But to point this out will lead people to believe that I must oppose ready access to community care, pretrial diversion, alternative sentencing, mental health courts, or anything related to alternatives to incarceration.

That isn’t the case. Many problems require more than one solution. What I oppose is the idea that the solution has to be a simple dichotomous choice between arrest and incarceration versus community care. I’ve found discussions about criminalization of people with mental illnesses to be polarizing and unproductive. There will always be people with mental illnesses in jail and prison, because – like people with diabetes, heart disease, or AIDS – they sometimes commit very serious crimes. As a care provider, my view is that a patient’s need for treatment is independent of criminal culpability. An ill person deserves appropriate and skilled health care, regardless of the treatment setting. Moving someone from an understaffed, overcrowded correctional facility to an understaffed, overcrowded state hospital hardly solves the problem.

People make the argument that money spent on corrections would be better spent elsewhere, on services for at-risk youth, or on community substance abuse and mental health programs. I agree that all these programs are needed, but what rarely gets mentioned is that when money is diverted from jails and prisons, part of that money also includes funding for inmate health care. Taking away this money is like stealing a coat from a blind beggar in the winter time. If you want to make a serious problem worse, by all means, take away what little we have.

How much money are we talking here, anyway?

By some estimates, the money spent on health care for all American prisons is about $7.7 billion per year. That includes physician and related health care professional costs, laboratory and diagnostic testing, hospitalization costs, as well as medications. Fourteen percent of that, or about $1 billion, goes to mental health care. Those costs are expected to rise as the prison population continues to age. Meanwhile, federal spending on mandatory health care programs in 2013 was about $1 trillion. When the prison health care budget represents less than 1% of health care spending nationally, this doesn’t seem to be enough to be quibbling about and certainly not enough to be cutting or diverting elsewhere.

But of course, the correctional nihilists will respond, “You get what you pay for.” Inevitably, low-cost care becomes equivalent to low-quality care in the eyes of many Americans. But if you compare American medical outcomes globally, it’s been well established that we have fallen behind many countries in life expectancy and infant mortality, despite heavy investment in a broad spectrum of services and interventions.

Let’s compare that to prison. Because of data gathered through the 2000 Federal Death in Custody Reporting Act, as well as other studies, prisons have been able to demonstrate reduced mortality, compared with age-matched men in free society, particularly for minorities. That mortality rate doubles after release. Clearly, prisons appear to be keeping people alive more efficiently and at a fraction of the cost of our community services.

This is not to imply that incarceration should be the answer to every social problem. This is my response to the naysayers and nihilists who believe that jails and prisons are so far gone they are not worth investing in. The lives of many prisoners depend on that investment.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

For a clinician working in a forensic setting, the assessment and management of violence is a core clinical skill. Unfortunately, evidence-based practices are often lacking for those patients with serious, treatment-resistant psychoses who defy current guidelines, or for those with severe personality disorders.

This is why I was pleased to see a new resource put out by the California Department of State Hospitals entitled, appropriately enough, the California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines (CNS Spectrums 2014;19:449-65). The authors, led by Dr. Stephen M. Stahl, are respected experts in forensic psychiatry, psychopharmacology, and psychology. The document is a thorough and thoughtfully organized work that can be employed in both forensic and nonforensic settings.

Too often, the general public will view violence as the sine qua non of mental illness. Rather, violence is often attributable to an amalgam of risk factors, and even the best psychiatrist can be hard-pressed to tease out which aspect is the predominant driving force behind aggressive behavior. Dr. Stahl and his colleagues do an excellent job laying out the most common etiologies: psychosis and disorders associated with impulsivity, psychopathy, medical conditions, and adverse reactions to medication. They provide a structured and logical approach to pharmacologic management, complete with flowcharts and a discussion of general treatment principles relevant to each etiology. They suggest both primary or acute pharmacologic interventions as well as adjunctive therapies and long-term treatment options.

Compared with other papers I’ve read related to the treatment of violence, the Cal-VAT provides a more comprehensive approach by also considering environmental and staffing factors that contribute to violence, and by outlining nonpharmacologic strategies. I found these additional considerations to be just as important as the prescribing recommendations, so much so that I wanted to emphasize them in this column. Understaffing, high staff turnover, inexperience, and inadequate staff training will affect both morale and unit safety. The Cal-VAT guidelines recommend peer support for colleagues as well as postincident opportunities for staff to process violent incidents by patients. Training in de-escalation techniques and violence prevention, as well as good communication between team members, also can minimize the level of tension on a ward.

I was somewhat more skeptical regarding recommendations for the management of predatory aggression, but again, the Cal-VAT cautions that treatment gains in this domain might be modest or nonexistent. I strongly agree with the need for treatment in a highly structured environment for patients high in sociopathy, along with consistent strong boundaries and close external supervision. Good communication between security and clinical staff is also essential.

The guidelines were developed for hospitals, and in a hospital setting, security measures like management of contraband or adequate security staff are just as important as in the correctional setting. However, some of the recommendations in the Cal-VAT may not be practical for a correctional setting, where formularies may be limited and there may not be a means for providing PRN medication. For example, the use of clozapine in a correctional setting may not be practical when weekly blood draws can’t be guaranteed. Nevertheless, the guidelines provide a useful framework for risk assessment and violence risk management.

The Cal-VAT assumes that there are options for moving a patient to a higher level of care within a facility when the violence risk becomes too great. Given that many public hospitals now have a high proportion of forensic patients, a change in ward may not be sufficient to manage this risk. As a profession, we can move violence management forward by addressing this last remaining barrier – the resistance some systems put up against accepting the difficult-to-treat patient. Correctional facilities should be willing to provide the treatment resources needed for mentally ill prisoners high in sociopathy, and hospitals must be equally willing to accept severely ill offenders who cannot be medicated within a jail or prison. For a full spectrum of care, violence management requires a system-level commitment by both public mental health and corrections.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

For a clinician working in a forensic setting, the assessment and management of violence is a core clinical skill. Unfortunately, evidence-based practices are often lacking for those patients with serious, treatment-resistant psychoses who defy current guidelines, or for those with severe personality disorders.

This is why I was pleased to see a new resource put out by the California Department of State Hospitals entitled, appropriately enough, the California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines (CNS Spectrums 2014;19:449-65). The authors, led by Dr. Stephen M. Stahl, are respected experts in forensic psychiatry, psychopharmacology, and psychology. The document is a thorough and thoughtfully organized work that can be employed in both forensic and nonforensic settings.

Too often, the general public will view violence as the sine qua non of mental illness. Rather, violence is often attributable to an amalgam of risk factors, and even the best psychiatrist can be hard-pressed to tease out which aspect is the predominant driving force behind aggressive behavior. Dr. Stahl and his colleagues do an excellent job laying out the most common etiologies: psychosis and disorders associated with impulsivity, psychopathy, medical conditions, and adverse reactions to medication. They provide a structured and logical approach to pharmacologic management, complete with flowcharts and a discussion of general treatment principles relevant to each etiology. They suggest both primary or acute pharmacologic interventions as well as adjunctive therapies and long-term treatment options.

Compared with other papers I’ve read related to the treatment of violence, the Cal-VAT provides a more comprehensive approach by also considering environmental and staffing factors that contribute to violence, and by outlining nonpharmacologic strategies. I found these additional considerations to be just as important as the prescribing recommendations, so much so that I wanted to emphasize them in this column. Understaffing, high staff turnover, inexperience, and inadequate staff training will affect both morale and unit safety. The Cal-VAT guidelines recommend peer support for colleagues as well as postincident opportunities for staff to process violent incidents by patients. Training in de-escalation techniques and violence prevention, as well as good communication between team members, also can minimize the level of tension on a ward.

I was somewhat more skeptical regarding recommendations for the management of predatory aggression, but again, the Cal-VAT cautions that treatment gains in this domain might be modest or nonexistent. I strongly agree with the need for treatment in a highly structured environment for patients high in sociopathy, along with consistent strong boundaries and close external supervision. Good communication between security and clinical staff is also essential.

The guidelines were developed for hospitals, and in a hospital setting, security measures like management of contraband or adequate security staff are just as important as in the correctional setting. However, some of the recommendations in the Cal-VAT may not be practical for a correctional setting, where formularies may be limited and there may not be a means for providing PRN medication. For example, the use of clozapine in a correctional setting may not be practical when weekly blood draws can’t be guaranteed. Nevertheless, the guidelines provide a useful framework for risk assessment and violence risk management.

The Cal-VAT assumes that there are options for moving a patient to a higher level of care within a facility when the violence risk becomes too great. Given that many public hospitals now have a high proportion of forensic patients, a change in ward may not be sufficient to manage this risk. As a profession, we can move violence management forward by addressing this last remaining barrier – the resistance some systems put up against accepting the difficult-to-treat patient. Correctional facilities should be willing to provide the treatment resources needed for mentally ill prisoners high in sociopathy, and hospitals must be equally willing to accept severely ill offenders who cannot be medicated within a jail or prison. For a full spectrum of care, violence management requires a system-level commitment by both public mental health and corrections.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

For a clinician working in a forensic setting, the assessment and management of violence is a core clinical skill. Unfortunately, evidence-based practices are often lacking for those patients with serious, treatment-resistant psychoses who defy current guidelines, or for those with severe personality disorders.

This is why I was pleased to see a new resource put out by the California Department of State Hospitals entitled, appropriately enough, the California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines (CNS Spectrums 2014;19:449-65). The authors, led by Dr. Stephen M. Stahl, are respected experts in forensic psychiatry, psychopharmacology, and psychology. The document is a thorough and thoughtfully organized work that can be employed in both forensic and nonforensic settings.

Too often, the general public will view violence as the sine qua non of mental illness. Rather, violence is often attributable to an amalgam of risk factors, and even the best psychiatrist can be hard-pressed to tease out which aspect is the predominant driving force behind aggressive behavior. Dr. Stahl and his colleagues do an excellent job laying out the most common etiologies: psychosis and disorders associated with impulsivity, psychopathy, medical conditions, and adverse reactions to medication. They provide a structured and logical approach to pharmacologic management, complete with flowcharts and a discussion of general treatment principles relevant to each etiology. They suggest both primary or acute pharmacologic interventions as well as adjunctive therapies and long-term treatment options.

Compared with other papers I’ve read related to the treatment of violence, the Cal-VAT provides a more comprehensive approach by also considering environmental and staffing factors that contribute to violence, and by outlining nonpharmacologic strategies. I found these additional considerations to be just as important as the prescribing recommendations, so much so that I wanted to emphasize them in this column. Understaffing, high staff turnover, inexperience, and inadequate staff training will affect both morale and unit safety. The Cal-VAT guidelines recommend peer support for colleagues as well as postincident opportunities for staff to process violent incidents by patients. Training in de-escalation techniques and violence prevention, as well as good communication between team members, also can minimize the level of tension on a ward.

I was somewhat more skeptical regarding recommendations for the management of predatory aggression, but again, the Cal-VAT cautions that treatment gains in this domain might be modest or nonexistent. I strongly agree with the need for treatment in a highly structured environment for patients high in sociopathy, along with consistent strong boundaries and close external supervision. Good communication between security and clinical staff is also essential.

The guidelines were developed for hospitals, and in a hospital setting, security measures like management of contraband or adequate security staff are just as important as in the correctional setting. However, some of the recommendations in the Cal-VAT may not be practical for a correctional setting, where formularies may be limited and there may not be a means for providing PRN medication. For example, the use of clozapine in a correctional setting may not be practical when weekly blood draws can’t be guaranteed. Nevertheless, the guidelines provide a useful framework for risk assessment and violence risk management.

The Cal-VAT assumes that there are options for moving a patient to a higher level of care within a facility when the violence risk becomes too great. Given that many public hospitals now have a high proportion of forensic patients, a change in ward may not be sufficient to manage this risk. As a profession, we can move violence management forward by addressing this last remaining barrier – the resistance some systems put up against accepting the difficult-to-treat patient. Correctional facilities should be willing to provide the treatment resources needed for mentally ill prisoners high in sociopathy, and hospitals must be equally willing to accept severely ill offenders who cannot be medicated within a jail or prison. For a full spectrum of care, violence management requires a system-level commitment by both public mental health and corrections.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The news has been filled lately with stories of violence within correctional facilities, often involving prisoners or detainees who are alleged to have mental illness. The California prison system recently announced an initiative to reduce the use of force against mentally ill prisoners and to require correctional officers to consider an inmate’s mental health status prior to any use of force.

This is an excellent initiative, and close collaboration between security and mental health services is crucial for effective treatment of some mentally ill offenders.

However, this would be a good time to remember that not all seriously mentally ill prisoners are disruptive and that violence is a behavior rather than a diagnostic criterion. The nonsymptomatic causes of violence are important to consider as well: Is the inmate defending himself from attack by more aggressive peers? Is he taking a stand and making a display of force in order to make the point that he won’t be intimidated? Is he delirious from an unrecognized or treated medical condition? Is he having a seizure, suffering from withdrawal, or medically compromised in some other way? Or is the violence instrumental, a means to an end by a sociopathic inmate who needs to enforce his chain of command or protect his prison drug distribution channels? While for some, violence may be an outward sign of psychosis, for others it’s part of the cost of doing business.

In addition to looking at violence on an individual level, we also need to consider it from an institutional perspective. Violence may be a sign that there are serious problems not only on an individual level but possibly on an institutional one as well. Increased sensitivity to the mental status of the prisoner is only one piece of the puzzle.

 

Correctional officers are exposed to an environment unlike anything most civilians can imagine. They are exposed daily to threats, actual or implied assault, harassment, and sometimes even flying bodily fluids. When the prison budget doesn’t keep up with the daily institutional census, they may be required to work repeated overtime shifts or to work on tiers in which they are greatly outnumbered by the prisoners they are supposed to supervise and protect. Even when a correctional officer is not directly the subject of violence, the officer is required to respond to traumatic events like inmate-on-inmate assaults or completed suicides.

It’s not surprising, then, that many new officers leave the profession within the first 5 years, and that those who stay longer may be prone to stress-related absenteeism, substance abuse, and depression. Officers (or "guards" as the traditional media repeatedly misidentifies them) who show a change in personality or an unusually low tolerance for inmate misbehavior may be showing early signs of posttraumatic stress disorder or clinical depression. If this is being taken out on an inmate, it may also be a problem at home, leading to relationship problems or domestic violence. Officers who are cruel to a prisoner may not be particularly pleasant to civilian staff, either.

Changing a violent prison environment requires more than additional staff training and another redundant prison directive about the use of force. It requires change in a prison culture that values toughness and bravado. Access to mental health should be rapid and confidential, and not seen as an indication that an officer wants an "easy way out" through medical retirement. Security and psychiatry must work together for the care of the prisoner, but they also need to work on behalf of one another.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health & Mental Hygiene or the Maryland State Division of Correction.

The news has been filled lately with stories of violence within correctional facilities, often involving prisoners or detainees who are alleged to have mental illness. The California prison system recently announced an initiative to reduce the use of force against mentally ill prisoners and to require correctional officers to consider an inmate’s mental health status prior to any use of force.

This is an excellent initiative, and close collaboration between security and mental health services is crucial for effective treatment of some mentally ill offenders.

However, this would be a good time to remember that not all seriously mentally ill prisoners are disruptive and that violence is a behavior rather than a diagnostic criterion. The nonsymptomatic causes of violence are important to consider as well: Is the inmate defending himself from attack by more aggressive peers? Is he taking a stand and making a display of force in order to make the point that he won’t be intimidated? Is he delirious from an unrecognized or treated medical condition? Is he having a seizure, suffering from withdrawal, or medically compromised in some other way? Or is the violence instrumental, a means to an end by a sociopathic inmate who needs to enforce his chain of command or protect his prison drug distribution channels? While for some, violence may be an outward sign of psychosis, for others it’s part of the cost of doing business.

In addition to looking at violence on an individual level, we also need to consider it from an institutional perspective. Violence may be a sign that there are serious problems not only on an individual level but possibly on an institutional one as well. Increased sensitivity to the mental status of the prisoner is only one piece of the puzzle.

 

Correctional officers are exposed to an environment unlike anything most civilians can imagine. They are exposed daily to threats, actual or implied assault, harassment, and sometimes even flying bodily fluids. When the prison budget doesn’t keep up with the daily institutional census, they may be required to work repeated overtime shifts or to work on tiers in which they are greatly outnumbered by the prisoners they are supposed to supervise and protect. Even when a correctional officer is not directly the subject of violence, the officer is required to respond to traumatic events like inmate-on-inmate assaults or completed suicides.

It’s not surprising, then, that many new officers leave the profession within the first 5 years, and that those who stay longer may be prone to stress-related absenteeism, substance abuse, and depression. Officers (or "guards" as the traditional media repeatedly misidentifies them) who show a change in personality or an unusually low tolerance for inmate misbehavior may be showing early signs of posttraumatic stress disorder or clinical depression. If this is being taken out on an inmate, it may also be a problem at home, leading to relationship problems or domestic violence. Officers who are cruel to a prisoner may not be particularly pleasant to civilian staff, either.

Changing a violent prison environment requires more than additional staff training and another redundant prison directive about the use of force. It requires change in a prison culture that values toughness and bravado. Access to mental health should be rapid and confidential, and not seen as an indication that an officer wants an "easy way out" through medical retirement. Security and psychiatry must work together for the care of the prisoner, but they also need to work on behalf of one another.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health & Mental Hygiene or the Maryland State Division of Correction.

The news has been filled lately with stories of violence within correctional facilities, often involving prisoners or detainees who are alleged to have mental illness. The California prison system recently announced an initiative to reduce the use of force against mentally ill prisoners and to require correctional officers to consider an inmate’s mental health status prior to any use of force.

This is an excellent initiative, and close collaboration between security and mental health services is crucial for effective treatment of some mentally ill offenders.

However, this would be a good time to remember that not all seriously mentally ill prisoners are disruptive and that violence is a behavior rather than a diagnostic criterion. The nonsymptomatic causes of violence are important to consider as well: Is the inmate defending himself from attack by more aggressive peers? Is he taking a stand and making a display of force in order to make the point that he won’t be intimidated? Is he delirious from an unrecognized or treated medical condition? Is he having a seizure, suffering from withdrawal, or medically compromised in some other way? Or is the violence instrumental, a means to an end by a sociopathic inmate who needs to enforce his chain of command or protect his prison drug distribution channels? While for some, violence may be an outward sign of psychosis, for others it’s part of the cost of doing business.

In addition to looking at violence on an individual level, we also need to consider it from an institutional perspective. Violence may be a sign that there are serious problems not only on an individual level but possibly on an institutional one as well. Increased sensitivity to the mental status of the prisoner is only one piece of the puzzle.

 

Correctional officers are exposed to an environment unlike anything most civilians can imagine. They are exposed daily to threats, actual or implied assault, harassment, and sometimes even flying bodily fluids. When the prison budget doesn’t keep up with the daily institutional census, they may be required to work repeated overtime shifts or to work on tiers in which they are greatly outnumbered by the prisoners they are supposed to supervise and protect. Even when a correctional officer is not directly the subject of violence, the officer is required to respond to traumatic events like inmate-on-inmate assaults or completed suicides.

It’s not surprising, then, that many new officers leave the profession within the first 5 years, and that those who stay longer may be prone to stress-related absenteeism, substance abuse, and depression. Officers (or "guards" as the traditional media repeatedly misidentifies them) who show a change in personality or an unusually low tolerance for inmate misbehavior may be showing early signs of posttraumatic stress disorder or clinical depression. If this is being taken out on an inmate, it may also be a problem at home, leading to relationship problems or domestic violence. Officers who are cruel to a prisoner may not be particularly pleasant to civilian staff, either.

Changing a violent prison environment requires more than additional staff training and another redundant prison directive about the use of force. It requires change in a prison culture that values toughness and bravado. Access to mental health should be rapid and confidential, and not seen as an indication that an officer wants an "easy way out" through medical retirement. Security and psychiatry must work together for the care of the prisoner, but they also need to work on behalf of one another.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health & Mental Hygiene or the Maryland State Division of Correction.

Under British common law, suicide was a felony if committed by a person "in the years of discretion," in other words, by an adult, who was "of sound mind." An adult who killed himself while insane was not considered a criminal. While the offender obviously could not be punished, he also could not be buried in hallowed ground, and all of his property was seized by the crown. Surviving family members were not allowed to inherit.

While no state defines suicide itself as a crime by statute, there are still common law and statutory prohibitions against aiding or abetting, or encouraging, a suicide. Laws surrounding assisted suicide might seem remote or irrelevant now, but clinicians should be aware that this is changing on an almost monthly basis, and impetus is building through the support of various advocacy groups, such as Compassion & Choices, Final Exit Network,and the Euthanasia Research and Guidance Organization (ERGO).

My own interest in this topic was spurred when a recent Maryland gubernatorial candidate ran on a platform that included a plan to introduce legislation to allow physician-assisted suicide. Presently, our state defines assisted suicide as a felony offense punishable by 1 year of incarceration and a $10,000 fine, and there have been two criminal prosecutions for assisted suicide in recent years.

Nationally, 39 states have prohibitions against assisted suicide defined either by specific statute or contained within the definition of manslaughter. Some states ban assisted suicide by case law, some through the adoption of common law. Presently, five states allow physician-assisted suicide. Oregon, Washington, and Montana were among the first states to allow this. New Mexico and Vermont adopted legislation this year in January and May, respectively.

Most states have modeled their laws after the original physician-assisted suicide law, Oregon’s Death With Dignity Act. For psychiatrists involved in legislative affairs, familiarity with this law is essential.

Under the Death With Dignity Act, a person might be eligible to request physician aid in dying if he is an adult resident of the state, is able to make and communicate medical decisions, and has a 6-month prognosis as medically confirmed by two physicians. The patient must make an initial oral and written request, then repeat the oral request no sooner than 15 days later. The written request must be submitted on a state-mandated form witnessed by two people who can neither be blood relatives nor estate benefactors.

There is a requirement for informed consent, specifically that the person must know his medical diagnosis as well as the risk of taking the life-ending medication and the expected result of this act. There must be documented consideration of alternatives to suicide.

While there is a statutory mandate to refer patients for counseling if depression is suspected, there is no requirement that the patient seeking suicide be screened for this disorder or even have a capacity assessment performed by a psychiatrist.

Out of curiosity, I copied the text of the physician-assisted suicide request form through two text analyzing applications to determine the readability of the document. My two tests revealed that the form required between a 12th grade to college-level reading comprehension level. For comparison purposes, my average prison clinic patient has a 9th-grade education with a 6th-grade reading level.

The most easily understood sentence in the entire document was the instruction at the bottom of the form: "PLEASE MAKE A COPY OF THIS FORM TO KEEP IN YOUR HOME."

This makes sense when you consider the demographics of those who seek physician-assisted suicide in Oregon. Most were white, college educated, over age 65 years, and suffered from cancer or chronic respiratory disease. Since the law was passed, 752 out of 1,173 people, or 64% of those given prescriptions, ended their lives. Only 2 of the 71 people who died in 2013 were referred for psychiatric or psychological evaluation. Most died of suicide within the year; however, some died the following year.

Without discussing the merits and controversy of physician-assisted suicide per se, we can at least identify some obvious weaknesses in copy-and-paste legislation between states. A law that appears tailored for an educated majority culture, which accepts capacity at face value despite clearly concerning circumstances, would at least require substantial revision for a region with high rates of illiteracy or mental illness.

Other questions also are looming on the horizon: Should qualifying conditions be limited to medical conditions only? Could an advance directive include an option to request assisted suicide proactively, prior to a 6-month prognosis, or could it be requested through a designated proxy? If a patient has both a psychiatric disorder and a terminal medical condition, should laws for involuntary psychiatric care still apply?

 

Dr. Lawrence Egbert, retired anesthesiologist and former medical director of Final Exit Network, foretold these questions in a Washington Post interview in which he stated he "is also willing, in extreme cases, he says, to serve as an ‘exit guide’ for patients who have suffered from depression for extended periods of time."

Only time will tell how these issues play out, but with some background on the topic our profession can at least begin the discussion.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Under British common law, suicide was a felony if committed by a person "in the years of discretion," in other words, by an adult, who was "of sound mind." An adult who killed himself while insane was not considered a criminal. While the offender obviously could not be punished, he also could not be buried in hallowed ground, and all of his property was seized by the crown. Surviving family members were not allowed to inherit.

While no state defines suicide itself as a crime by statute, there are still common law and statutory prohibitions against aiding or abetting, or encouraging, a suicide. Laws surrounding assisted suicide might seem remote or irrelevant now, but clinicians should be aware that this is changing on an almost monthly basis, and impetus is building through the support of various advocacy groups, such as Compassion & Choices, Final Exit Network,and the Euthanasia Research and Guidance Organization (ERGO).

My own interest in this topic was spurred when a recent Maryland gubernatorial candidate ran on a platform that included a plan to introduce legislation to allow physician-assisted suicide. Presently, our state defines assisted suicide as a felony offense punishable by 1 year of incarceration and a $10,000 fine, and there have been two criminal prosecutions for assisted suicide in recent years.

Nationally, 39 states have prohibitions against assisted suicide defined either by specific statute or contained within the definition of manslaughter. Some states ban assisted suicide by case law, some through the adoption of common law. Presently, five states allow physician-assisted suicide. Oregon, Washington, and Montana were among the first states to allow this. New Mexico and Vermont adopted legislation this year in January and May, respectively.

Most states have modeled their laws after the original physician-assisted suicide law, Oregon’s Death With Dignity Act. For psychiatrists involved in legislative affairs, familiarity with this law is essential.

Under the Death With Dignity Act, a person might be eligible to request physician aid in dying if he is an adult resident of the state, is able to make and communicate medical decisions, and has a 6-month prognosis as medically confirmed by two physicians. The patient must make an initial oral and written request, then repeat the oral request no sooner than 15 days later. The written request must be submitted on a state-mandated form witnessed by two people who can neither be blood relatives nor estate benefactors.

There is a requirement for informed consent, specifically that the person must know his medical diagnosis as well as the risk of taking the life-ending medication and the expected result of this act. There must be documented consideration of alternatives to suicide.

While there is a statutory mandate to refer patients for counseling if depression is suspected, there is no requirement that the patient seeking suicide be screened for this disorder or even have a capacity assessment performed by a psychiatrist.

Out of curiosity, I copied the text of the physician-assisted suicide request form through two text analyzing applications to determine the readability of the document. My two tests revealed that the form required between a 12th grade to college-level reading comprehension level. For comparison purposes, my average prison clinic patient has a 9th-grade education with a 6th-grade reading level.

The most easily understood sentence in the entire document was the instruction at the bottom of the form: "PLEASE MAKE A COPY OF THIS FORM TO KEEP IN YOUR HOME."

This makes sense when you consider the demographics of those who seek physician-assisted suicide in Oregon. Most were white, college educated, over age 65 years, and suffered from cancer or chronic respiratory disease. Since the law was passed, 752 out of 1,173 people, or 64% of those given prescriptions, ended their lives. Only 2 of the 71 people who died in 2013 were referred for psychiatric or psychological evaluation. Most died of suicide within the year; however, some died the following year.

Without discussing the merits and controversy of physician-assisted suicide per se, we can at least identify some obvious weaknesses in copy-and-paste legislation between states. A law that appears tailored for an educated majority culture, which accepts capacity at face value despite clearly concerning circumstances, would at least require substantial revision for a region with high rates of illiteracy or mental illness.

Other questions also are looming on the horizon: Should qualifying conditions be limited to medical conditions only? Could an advance directive include an option to request assisted suicide proactively, prior to a 6-month prognosis, or could it be requested through a designated proxy? If a patient has both a psychiatric disorder and a terminal medical condition, should laws for involuntary psychiatric care still apply?

 

Dr. Lawrence Egbert, retired anesthesiologist and former medical director of Final Exit Network, foretold these questions in a Washington Post interview in which he stated he "is also willing, in extreme cases, he says, to serve as an ‘exit guide’ for patients who have suffered from depression for extended periods of time."

Only time will tell how these issues play out, but with some background on the topic our profession can at least begin the discussion.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Under British common law, suicide was a felony if committed by a person "in the years of discretion," in other words, by an adult, who was "of sound mind." An adult who killed himself while insane was not considered a criminal. While the offender obviously could not be punished, he also could not be buried in hallowed ground, and all of his property was seized by the crown. Surviving family members were not allowed to inherit.

While no state defines suicide itself as a crime by statute, there are still common law and statutory prohibitions against aiding or abetting, or encouraging, a suicide. Laws surrounding assisted suicide might seem remote or irrelevant now, but clinicians should be aware that this is changing on an almost monthly basis, and impetus is building through the support of various advocacy groups, such as Compassion & Choices, Final Exit Network,and the Euthanasia Research and Guidance Organization (ERGO).

My own interest in this topic was spurred when a recent Maryland gubernatorial candidate ran on a platform that included a plan to introduce legislation to allow physician-assisted suicide. Presently, our state defines assisted suicide as a felony offense punishable by 1 year of incarceration and a $10,000 fine, and there have been two criminal prosecutions for assisted suicide in recent years.

Nationally, 39 states have prohibitions against assisted suicide defined either by specific statute or contained within the definition of manslaughter. Some states ban assisted suicide by case law, some through the adoption of common law. Presently, five states allow physician-assisted suicide. Oregon, Washington, and Montana were among the first states to allow this. New Mexico and Vermont adopted legislation this year in January and May, respectively.

Most states have modeled their laws after the original physician-assisted suicide law, Oregon’s Death With Dignity Act. For psychiatrists involved in legislative affairs, familiarity with this law is essential.

Under the Death With Dignity Act, a person might be eligible to request physician aid in dying if he is an adult resident of the state, is able to make and communicate medical decisions, and has a 6-month prognosis as medically confirmed by two physicians. The patient must make an initial oral and written request, then repeat the oral request no sooner than 15 days later. The written request must be submitted on a state-mandated form witnessed by two people who can neither be blood relatives nor estate benefactors.

There is a requirement for informed consent, specifically that the person must know his medical diagnosis as well as the risk of taking the life-ending medication and the expected result of this act. There must be documented consideration of alternatives to suicide.

While there is a statutory mandate to refer patients for counseling if depression is suspected, there is no requirement that the patient seeking suicide be screened for this disorder or even have a capacity assessment performed by a psychiatrist.

Out of curiosity, I copied the text of the physician-assisted suicide request form through two text analyzing applications to determine the readability of the document. My two tests revealed that the form required between a 12th grade to college-level reading comprehension level. For comparison purposes, my average prison clinic patient has a 9th-grade education with a 6th-grade reading level.

The most easily understood sentence in the entire document was the instruction at the bottom of the form: "PLEASE MAKE A COPY OF THIS FORM TO KEEP IN YOUR HOME."

This makes sense when you consider the demographics of those who seek physician-assisted suicide in Oregon. Most were white, college educated, over age 65 years, and suffered from cancer or chronic respiratory disease. Since the law was passed, 752 out of 1,173 people, or 64% of those given prescriptions, ended their lives. Only 2 of the 71 people who died in 2013 were referred for psychiatric or psychological evaluation. Most died of suicide within the year; however, some died the following year.

Without discussing the merits and controversy of physician-assisted suicide per se, we can at least identify some obvious weaknesses in copy-and-paste legislation between states. A law that appears tailored for an educated majority culture, which accepts capacity at face value despite clearly concerning circumstances, would at least require substantial revision for a region with high rates of illiteracy or mental illness.

Other questions also are looming on the horizon: Should qualifying conditions be limited to medical conditions only? Could an advance directive include an option to request assisted suicide proactively, prior to a 6-month prognosis, or could it be requested through a designated proxy? If a patient has both a psychiatric disorder and a terminal medical condition, should laws for involuntary psychiatric care still apply?

 

Dr. Lawrence Egbert, retired anesthesiologist and former medical director of Final Exit Network, foretold these questions in a Washington Post interview in which he stated he "is also willing, in extreme cases, he says, to serve as an ‘exit guide’ for patients who have suffered from depression for extended periods of time."

Only time will tell how these issues play out, but with some background on the topic our profession can at least begin the discussion.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.