Annette Hanson, MD

Nonforensic psychiatrists in private practice rarely expect to be dealing with patients involved in the correctional system, but unexpected things happen even with the most carefully chosen patients. I’m writing this column to offer guidance to clinicians facing this situation for the first time, based upon the most common questions I get asked.

The most common situation I hear about is that a patient has missed an appointment, and the clinician hears from a family member that the patient has been arrested. The conscientious doctor wants to make sure that his seriously mentally ill client doesn’t experience an interruption in treatment, and that an appointment will be ready after release. The first challenge is to locate the patient.

In small communities, or when a family member was present at the time of arrest, it’s relatively easy to figure out which detention center or jail the patient was taken to. If the patient was arrested in a large urban area, or even out of state, this can be more of a challenge. Fortunately, many states and even now some local county or city jurisdictions have inmate locator web pages. The website will provide search capabilities to identify anyone currently in custody, and will generally provide a unique booking or inmate number that should be used in any facility communication, along with a date of birth and the address of the facility. Be aware that a large jail with high turnover may not have real-time data capability, meaning that new arrests may not show up on the website for 24 hours.

For psychiatrists who spend a lot of time tracking down their patients in custody, there is even an iPhone- and Android-compatible app called MobilePatrol, which provides a convenient interface to many inmate locator databases nationwide. MobilePatrol does not provide information about charges or date of birth, so it’s mainly useful if the patient can be identified by age and has a unique name.

The next step is to ensure that the patient has been identified as needing psychiatric care within the facility. Almost all jails and prisons now have routine multilevel screens to identify arrestees with chronic medical or mental health needs, and to assess suicide risk at intake. This is required by any jail or prison accredited by the National Commission on Correctional Health Care. Nevertheless, some patients are reluctant to self-identify out of fear they might be inappropriately or precipitously thrown into a suicide observation cell.

When it comes to transmitting information to a correctional facility, don’t rely on custody staff. They aren’t clinicians, they change with every shift, and they won’t know what questions to ask about the patient. This includes the warden’s office. The best thing to do is call the psychology department to transmit the patient’s name, date of birth, jail or prison number, and any pertinent clinical information. Don’t rely on an administrative assistant or nonmedical therapist to do this for you – I can’t tell you the number of times I’ve gotten a message that "...John Doe is in your jail and he needs to be seen..." with absolutely no information about medication names, dosage, and frequency, or even a diagnosis! An initial phone call will ensure that the patient is found within the facility and scheduled to see the institutional psychiatrist.

Follow the phone call up with a letter. This will ensure that the clinical information is still available on the day the psychiatrist comes in, and for the next institutional physician if the patient is transferred to another facility. The letter should summarize pertinent symptoms, violence or suicide risk factors, and previous medication trials. The past med trial information is particularly important for correctional psychiatrists, given that many jails and prisons require "fail-first" prescribing policies. Outside documentation that supports a current nonformulary medication regimen can be crucial to ensuring a smooth transition of care. But please, resist the temptation to reprimand the correctional psychiatrist in advance for making a medication change – there are many valid clinical reasons for a correctional psychiatrist to alter a treatment regimen upon arrest that have nothing to do with formulary issues.

Finally, encourage the patient’s family members to maintain contact with their incarcerated loved one if that relationship is healthy and supportive. No one knows a patient better than those in his own household, and a family member can be particularly sensitive to early signs of relapse sometimes through nothing more than a patient’s tone of voice during a phone call. Give the primary caregivers contact information for the institutional psychology department and encourage them to call if they observe anything concerning during a visit or court appearance. Court dates are particularly stressful times and may serve as a crisis point for a suicidal inmate. Having an extra pair of eyes on the scene could be lifesaving.

Once the patient has been identified and referred, and treatment started, your job is done until release. For misdemeanor offenders in local detention, this could take place within days or a few weeks, or even the day of arrest if the patient is able to make bail. Following the steps I’ve recommended to ensure continuity of care will help your patient return to you in at least as good a condition as when he came in.

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.

Nonforensic psychiatrists in private practice rarely expect to be dealing with patients involved in the correctional system, but unexpected things happen even with the most carefully chosen patients. I’m writing this column to offer guidance to clinicians facing this situation for the first time, based upon the most common questions I get asked.

The most common situation I hear about is that a patient has missed an appointment, and the clinician hears from a family member that the patient has been arrested. The conscientious doctor wants to make sure that his seriously mentally ill client doesn’t experience an interruption in treatment, and that an appointment will be ready after release. The first challenge is to locate the patient.

In small communities, or when a family member was present at the time of arrest, it’s relatively easy to figure out which detention center or jail the patient was taken to. If the patient was arrested in a large urban area, or even out of state, this can be more of a challenge. Fortunately, many states and even now some local county or city jurisdictions have inmate locator web pages. The website will provide search capabilities to identify anyone currently in custody, and will generally provide a unique booking or inmate number that should be used in any facility communication, along with a date of birth and the address of the facility. Be aware that a large jail with high turnover may not have real-time data capability, meaning that new arrests may not show up on the website for 24 hours.

For psychiatrists who spend a lot of time tracking down their patients in custody, there is even an iPhone- and Android-compatible app called MobilePatrol, which provides a convenient interface to many inmate locator databases nationwide. MobilePatrol does not provide information about charges or date of birth, so it’s mainly useful if the patient can be identified by age and has a unique name.

The next step is to ensure that the patient has been identified as needing psychiatric care within the facility. Almost all jails and prisons now have routine multilevel screens to identify arrestees with chronic medical or mental health needs, and to assess suicide risk at intake. This is required by any jail or prison accredited by the National Commission on Correctional Health Care. Nevertheless, some patients are reluctant to self-identify out of fear they might be inappropriately or precipitously thrown into a suicide observation cell.

When it comes to transmitting information to a correctional facility, don’t rely on custody staff. They aren’t clinicians, they change with every shift, and they won’t know what questions to ask about the patient. This includes the warden’s office. The best thing to do is call the psychology department to transmit the patient’s name, date of birth, jail or prison number, and any pertinent clinical information. Don’t rely on an administrative assistant or nonmedical therapist to do this for you – I can’t tell you the number of times I’ve gotten a message that "...John Doe is in your jail and he needs to be seen..." with absolutely no information about medication names, dosage, and frequency, or even a diagnosis! An initial phone call will ensure that the patient is found within the facility and scheduled to see the institutional psychiatrist.

Follow the phone call up with a letter. This will ensure that the clinical information is still available on the day the psychiatrist comes in, and for the next institutional physician if the patient is transferred to another facility. The letter should summarize pertinent symptoms, violence or suicide risk factors, and previous medication trials. The past med trial information is particularly important for correctional psychiatrists, given that many jails and prisons require "fail-first" prescribing policies. Outside documentation that supports a current nonformulary medication regimen can be crucial to ensuring a smooth transition of care. But please, resist the temptation to reprimand the correctional psychiatrist in advance for making a medication change – there are many valid clinical reasons for a correctional psychiatrist to alter a treatment regimen upon arrest that have nothing to do with formulary issues.

Finally, encourage the patient’s family members to maintain contact with their incarcerated loved one if that relationship is healthy and supportive. No one knows a patient better than those in his own household, and a family member can be particularly sensitive to early signs of relapse sometimes through nothing more than a patient’s tone of voice during a phone call. Give the primary caregivers contact information for the institutional psychology department and encourage them to call if they observe anything concerning during a visit or court appearance. Court dates are particularly stressful times and may serve as a crisis point for a suicidal inmate. Having an extra pair of eyes on the scene could be lifesaving.

Once the patient has been identified and referred, and treatment started, your job is done until release. For misdemeanor offenders in local detention, this could take place within days or a few weeks, or even the day of arrest if the patient is able to make bail. Following the steps I’ve recommended to ensure continuity of care will help your patient return to you in at least as good a condition as when he came in.

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.

Nonforensic psychiatrists in private practice rarely expect to be dealing with patients involved in the correctional system, but unexpected things happen even with the most carefully chosen patients. I’m writing this column to offer guidance to clinicians facing this situation for the first time, based upon the most common questions I get asked.

The most common situation I hear about is that a patient has missed an appointment, and the clinician hears from a family member that the patient has been arrested. The conscientious doctor wants to make sure that his seriously mentally ill client doesn’t experience an interruption in treatment, and that an appointment will be ready after release. The first challenge is to locate the patient.

In small communities, or when a family member was present at the time of arrest, it’s relatively easy to figure out which detention center or jail the patient was taken to. If the patient was arrested in a large urban area, or even out of state, this can be more of a challenge. Fortunately, many states and even now some local county or city jurisdictions have inmate locator web pages. The website will provide search capabilities to identify anyone currently in custody, and will generally provide a unique booking or inmate number that should be used in any facility communication, along with a date of birth and the address of the facility. Be aware that a large jail with high turnover may not have real-time data capability, meaning that new arrests may not show up on the website for 24 hours.

For psychiatrists who spend a lot of time tracking down their patients in custody, there is even an iPhone- and Android-compatible app called MobilePatrol, which provides a convenient interface to many inmate locator databases nationwide. MobilePatrol does not provide information about charges or date of birth, so it’s mainly useful if the patient can be identified by age and has a unique name.

The next step is to ensure that the patient has been identified as needing psychiatric care within the facility. Almost all jails and prisons now have routine multilevel screens to identify arrestees with chronic medical or mental health needs, and to assess suicide risk at intake. This is required by any jail or prison accredited by the National Commission on Correctional Health Care. Nevertheless, some patients are reluctant to self-identify out of fear they might be inappropriately or precipitously thrown into a suicide observation cell.

When it comes to transmitting information to a correctional facility, don’t rely on custody staff. They aren’t clinicians, they change with every shift, and they won’t know what questions to ask about the patient. This includes the warden’s office. The best thing to do is call the psychology department to transmit the patient’s name, date of birth, jail or prison number, and any pertinent clinical information. Don’t rely on an administrative assistant or nonmedical therapist to do this for you – I can’t tell you the number of times I’ve gotten a message that "...John Doe is in your jail and he needs to be seen..." with absolutely no information about medication names, dosage, and frequency, or even a diagnosis! An initial phone call will ensure that the patient is found within the facility and scheduled to see the institutional psychiatrist.

Follow the phone call up with a letter. This will ensure that the clinical information is still available on the day the psychiatrist comes in, and for the next institutional physician if the patient is transferred to another facility. The letter should summarize pertinent symptoms, violence or suicide risk factors, and previous medication trials. The past med trial information is particularly important for correctional psychiatrists, given that many jails and prisons require "fail-first" prescribing policies. Outside documentation that supports a current nonformulary medication regimen can be crucial to ensuring a smooth transition of care. But please, resist the temptation to reprimand the correctional psychiatrist in advance for making a medication change – there are many valid clinical reasons for a correctional psychiatrist to alter a treatment regimen upon arrest that have nothing to do with formulary issues.

Finally, encourage the patient’s family members to maintain contact with their incarcerated loved one if that relationship is healthy and supportive. No one knows a patient better than those in his own household, and a family member can be particularly sensitive to early signs of relapse sometimes through nothing more than a patient’s tone of voice during a phone call. Give the primary caregivers contact information for the institutional psychology department and encourage them to call if they observe anything concerning during a visit or court appearance. Court dates are particularly stressful times and may serve as a crisis point for a suicidal inmate. Having an extra pair of eyes on the scene could be lifesaving.

Once the patient has been identified and referred, and treatment started, your job is done until release. For misdemeanor offenders in local detention, this could take place within days or a few weeks, or even the day of arrest if the patient is able to make bail. Following the steps I’ve recommended to ensure continuity of care will help your patient return to you in at least as good a condition as when he came in.

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.

Lately, I've been busy wading through a heavily publicized study that was published this month in the Lancet. In their paper, "Antipsychotics, mood stabilisers and risk of violent crime," Dr. Seena Fazel and his associates linked Swedish national registers to compare rates of violent crime among 82,647 male and female psychiatric patients to assess the effect of medication on this outcome.

The study made quite a splash in the news, because the outcome was almost too good to be true. There was a 64% reduction in violent crime among patients who had been prescribed any antipsychotic or mood stabilizer, compared with those taking other psychotropics. The reduction in violence for those taking neuroleptics and mood stabilizers was 45% and 24%, respectively. Selective serotonin reuptake inhibitors (SSRIs) had no apparent effect on crime (Lancet 2014 [doi:10.1016/S0140-6736(14)60379-2]).
Given our American anxiety over spree shooters and other high-profile crimes allegedly committed by untreated psychiatric patients, this study clearly deserves some scrutiny to thoroughly understand the findings, limitations, and other factors that could limit generalizability to the United States.

The authors compared mental health treatment registries with the national criminal history database. They looked at the rate and types of crimes committed by psychiatric patients when they were in and out of treatment. The "in-treatment" time interval was defined as the time between two or more prescriptions, as long as the prescriptions were no more than 4 months apart. Individuals who had only been given one script [prescription] were excluded. The outcome measure was any criminal conviction. The conviction outcome was based upon the date the offense took place, not the date of conviction. Individuals were excluded if the offense date was unknown.

A within-individual analysis showed significant reduction in all crimes, including violent crime, drug-related crime, and less severe crimes, during times when patients were prescribed medication, compared with medication-free intervals. When medicated, the rate of violent crime did not differ between patients with and without a history of violent offenses when diagnosis was not considered. When the analysis was limited to people with schizophrenia, bipolar disorder, or other psychotic disorders, the prescription of neuroleptics significantly reduced violent crime for both men and women.

For bipolar disorder, mood stabilizing medication reduced violent crime for men but not for women. The SSRI-medicated group was used as a control, to account for the general effect of contact with the mental health system and non-medication interventions related to this, and there was no effect on violent crime with this class of medication.

Now on to the limitations. Medication adherence was not assessed and could not be verified apart from patients given depot neuroleptics. The overall rate of violent crime was low, as would be expected. Only 6% of men and 1% of the women committed a violent crime. The numbers were so low that the study could not statistically assess the impact of violent crime history among patients diagnosed with psychosis. This is a small but crucial finding that did not make the traditional media coverage of this study.

Also, only 40% of those patients taking antipsychotics and mood stabilizers had a diagnosis of schizophrenia, other psychosis, or bipolar disorder, suggesting that, in Sweden, these medications might be prescribed for other indications such as characterologic low frustration tolerance or irritability. The analysis did not look at impact on violent crime by personality disorder diagnosis.

The authors acknowledged that their research could not prove a causal link between psychiatric illness and violence, another important conclusion that was not mentioned in traditional media coverage. In Sweden, mental illness cannot be used to prevent or mitigate a criminal conviction, so any connection between psychiatric symptoms and crime in this population can't be determined. The study also did not consider which subjects, if any, were taking medication or in treatment under court-mandated conditions.

As legislators and advocacy groups push to strengthen involuntary treatment laws, there is a risk that "bottom line" media coverage of research like this may inappropriately sway public opinion. Psychiatrists should be prepared to respond to proposed policies based on inaccurate interpretation of research.

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.

Lately, I've been busy wading through a heavily publicized study that was published this month in the Lancet. In their paper, "Antipsychotics, mood stabilisers and risk of violent crime," Dr. Seena Fazel and his associates linked Swedish national registers to compare rates of violent crime among 82,647 male and female psychiatric patients to assess the effect of medication on this outcome.

The study made quite a splash in the news, because the outcome was almost too good to be true. There was a 64% reduction in violent crime among patients who had been prescribed any antipsychotic or mood stabilizer, compared with those taking other psychotropics. The reduction in violence for those taking neuroleptics and mood stabilizers was 45% and 24%, respectively. Selective serotonin reuptake inhibitors (SSRIs) had no apparent effect on crime (Lancet 2014 [doi:10.1016/S0140-6736(14)60379-2]).
Given our American anxiety over spree shooters and other high-profile crimes allegedly committed by untreated psychiatric patients, this study clearly deserves some scrutiny to thoroughly understand the findings, limitations, and other factors that could limit generalizability to the United States.

The authors compared mental health treatment registries with the national criminal history database. They looked at the rate and types of crimes committed by psychiatric patients when they were in and out of treatment. The "in-treatment" time interval was defined as the time between two or more prescriptions, as long as the prescriptions were no more than 4 months apart. Individuals who had only been given one script [prescription] were excluded. The outcome measure was any criminal conviction. The conviction outcome was based upon the date the offense took place, not the date of conviction. Individuals were excluded if the offense date was unknown.

A within-individual analysis showed significant reduction in all crimes, including violent crime, drug-related crime, and less severe crimes, during times when patients were prescribed medication, compared with medication-free intervals. When medicated, the rate of violent crime did not differ between patients with and without a history of violent offenses when diagnosis was not considered. When the analysis was limited to people with schizophrenia, bipolar disorder, or other psychotic disorders, the prescription of neuroleptics significantly reduced violent crime for both men and women.

For bipolar disorder, mood stabilizing medication reduced violent crime for men but not for women. The SSRI-medicated group was used as a control, to account for the general effect of contact with the mental health system and non-medication interventions related to this, and there was no effect on violent crime with this class of medication.

Now on to the limitations. Medication adherence was not assessed and could not be verified apart from patients given depot neuroleptics. The overall rate of violent crime was low, as would be expected. Only 6% of men and 1% of the women committed a violent crime. The numbers were so low that the study could not statistically assess the impact of violent crime history among patients diagnosed with psychosis. This is a small but crucial finding that did not make the traditional media coverage of this study.

Also, only 40% of those patients taking antipsychotics and mood stabilizers had a diagnosis of schizophrenia, other psychosis, or bipolar disorder, suggesting that, in Sweden, these medications might be prescribed for other indications such as characterologic low frustration tolerance or irritability. The analysis did not look at impact on violent crime by personality disorder diagnosis.

The authors acknowledged that their research could not prove a causal link between psychiatric illness and violence, another important conclusion that was not mentioned in traditional media coverage. In Sweden, mental illness cannot be used to prevent or mitigate a criminal conviction, so any connection between psychiatric symptoms and crime in this population can't be determined. The study also did not consider which subjects, if any, were taking medication or in treatment under court-mandated conditions.

As legislators and advocacy groups push to strengthen involuntary treatment laws, there is a risk that "bottom line" media coverage of research like this may inappropriately sway public opinion. Psychiatrists should be prepared to respond to proposed policies based on inaccurate interpretation of research.

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.

Lately, I've been busy wading through a heavily publicized study that was published this month in the Lancet. In their paper, "Antipsychotics, mood stabilisers and risk of violent crime," Dr. Seena Fazel and his associates linked Swedish national registers to compare rates of violent crime among 82,647 male and female psychiatric patients to assess the effect of medication on this outcome.

The study made quite a splash in the news, because the outcome was almost too good to be true. There was a 64% reduction in violent crime among patients who had been prescribed any antipsychotic or mood stabilizer, compared with those taking other psychotropics. The reduction in violence for those taking neuroleptics and mood stabilizers was 45% and 24%, respectively. Selective serotonin reuptake inhibitors (SSRIs) had no apparent effect on crime (Lancet 2014 [doi:10.1016/S0140-6736(14)60379-2]).
Given our American anxiety over spree shooters and other high-profile crimes allegedly committed by untreated psychiatric patients, this study clearly deserves some scrutiny to thoroughly understand the findings, limitations, and other factors that could limit generalizability to the United States.

The authors compared mental health treatment registries with the national criminal history database. They looked at the rate and types of crimes committed by psychiatric patients when they were in and out of treatment. The "in-treatment" time interval was defined as the time between two or more prescriptions, as long as the prescriptions were no more than 4 months apart. Individuals who had only been given one script [prescription] were excluded. The outcome measure was any criminal conviction. The conviction outcome was based upon the date the offense took place, not the date of conviction. Individuals were excluded if the offense date was unknown.

A within-individual analysis showed significant reduction in all crimes, including violent crime, drug-related crime, and less severe crimes, during times when patients were prescribed medication, compared with medication-free intervals. When medicated, the rate of violent crime did not differ between patients with and without a history of violent offenses when diagnosis was not considered. When the analysis was limited to people with schizophrenia, bipolar disorder, or other psychotic disorders, the prescription of neuroleptics significantly reduced violent crime for both men and women.

For bipolar disorder, mood stabilizing medication reduced violent crime for men but not for women. The SSRI-medicated group was used as a control, to account for the general effect of contact with the mental health system and non-medication interventions related to this, and there was no effect on violent crime with this class of medication.

Now on to the limitations. Medication adherence was not assessed and could not be verified apart from patients given depot neuroleptics. The overall rate of violent crime was low, as would be expected. Only 6% of men and 1% of the women committed a violent crime. The numbers were so low that the study could not statistically assess the impact of violent crime history among patients diagnosed with psychosis. This is a small but crucial finding that did not make the traditional media coverage of this study.

Also, only 40% of those patients taking antipsychotics and mood stabilizers had a diagnosis of schizophrenia, other psychosis, or bipolar disorder, suggesting that, in Sweden, these medications might be prescribed for other indications such as characterologic low frustration tolerance or irritability. The analysis did not look at impact on violent crime by personality disorder diagnosis.

The authors acknowledged that their research could not prove a causal link between psychiatric illness and violence, another important conclusion that was not mentioned in traditional media coverage. In Sweden, mental illness cannot be used to prevent or mitigate a criminal conviction, so any connection between psychiatric symptoms and crime in this population can't be determined. The study also did not consider which subjects, if any, were taking medication or in treatment under court-mandated conditions.

As legislators and advocacy groups push to strengthen involuntary treatment laws, there is a risk that "bottom line" media coverage of research like this may inappropriately sway public opinion. Psychiatrists should be prepared to respond to proposed policies based on inaccurate interpretation of research.

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.

The Treatment Advocacy Center has released an update of a national survey of prison and jail involuntary treatment policies in its 116-page report, "The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey."

The survey was a replication of a previous study done in 2008. The purpose of the study was to compare treatment bed capacity and the numbers of seriously mentally ill patients housed within a state’s correctional system versus its public mental health system, and to promote the use of involuntary treatment procedures within correctional facilities.

To prepare the report, the center gathered data from each state prison system, as well as from non–randomly selected jails, regarding total bed capacity and the percentage of seriously mentally ill prisoners housed in the correctional system. Information about nonemergency involuntary medication procedures was gathered from prison websites or through Freedom of Information requests. For jails, some policies were obtained or clarified from administrative personnel or mental health professionals within the facility. Information about available psychiatric state hospital beds was gathered from a previous TAC report on state per-capita treatment capacity.

The new report found that the ratio of seriously mentally ill patients housed in correctional facilities versus state hospitals has increased substantially since 2008. Then, the ratio was 3:1. Currently, the ratio is 10 patients held in jail or prison for every single patient in a state hospital. This is clearly a significant change, which TAC attributes to closure of state hospital beds and failure to implement outpatient commitment laws.

As I’ve said in previous columns, I’m reluctant to attribute the incarceration of mentally ill people solely to mental illness. I’m uncomfortable with a reductionist hypothesis that overlooks the whole person. All of my prison patients have challenges common to many non–mentally ill prisoners: substance abuse, lack of social supports, illiteracy, poor vocational skills, and poverty. Psychiatric patients also suffer the baser instincts common to all humanity: fear, greed, and jealous rage. Changes in laws governing sentencing also will affect all offenders, regardless of psychiatric status. Psychiatric medication, voluntary or involuntary, is not the sole answer to the problem of criminality and will do nothing to address these other issues.

Nevertheless, I agree with the majority of the TAC report recommendations, and I applaud the emphasis placed upon expanded use of mental health courts and crisis intervention teams (CIT) to avert incarceration. The recommendation to screen prisoners for mental illness is already mandated by the National Commission on Correctional Health Care (NCCHC) for any accredited facility. According to a 1994 national survey by Dr. Jeffrey L. Metzner and associates, all prisons systems provided either reception or prompt intake mental health screening to all newly admitted intakes (Bull. Am. Acad. Psychiatry Law 1994;22:451-7). Twenty-six percent of the prison systems exceeded screening standards recommended by the American Psychiatric Association. This is good news.

The TAC report also recommended mandatory release planning. Systematic release planning is a challenge to implement for most correctional systems for several reasons. In jail, release may be contingent upon the outcome of a trial and is therefore unpredictable. If the trial is postponed, a valuable community treatment slot is tied up for a patient who will never arrive. Conversely, failure to plan prior to a court date might leave a prisoner on the street directly from court with no aftercare. Nevertheless, states are beginning to realize the cost and public safety benefit of release plans that integrate medical, mental health, and substance abuse services.

One recent outcome study showed that more than half of released prisoners stayed in treatment in the community when an in-reach program provided integrated release planning services, and that annual criminal charges dropped by more than 50% in the year following engagement. More good news.

Finally, a minor quibble. My own state, Maryland, was cited in the report as one of the few states in which the involuntary treatment of inmates is most difficult because of the requirement to transfer the inmate to a hospital first. What the TAC failed to mention was that, in Maryland, the involuntary medication process was substantially undermined by case law. In 2006, the Maryland Court of Appeals decided in Department of Health and Mental Hygiene v. Anthony Kelly that involuntary medication only can be administered if the patient demonstrates dangerousness within the institution. Given this restriction, involuntary medication could not be administered on a nonemergency basis even in a correctional facility.

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.

The Treatment Advocacy Center has released an update of a national survey of prison and jail involuntary treatment policies in its 116-page report, "The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey."

The survey was a replication of a previous study done in 2008. The purpose of the study was to compare treatment bed capacity and the numbers of seriously mentally ill patients housed within a state’s correctional system versus its public mental health system, and to promote the use of involuntary treatment procedures within correctional facilities.

To prepare the report, the center gathered data from each state prison system, as well as from non–randomly selected jails, regarding total bed capacity and the percentage of seriously mentally ill prisoners housed in the correctional system. Information about nonemergency involuntary medication procedures was gathered from prison websites or through Freedom of Information requests. For jails, some policies were obtained or clarified from administrative personnel or mental health professionals within the facility. Information about available psychiatric state hospital beds was gathered from a previous TAC report on state per-capita treatment capacity.

The new report found that the ratio of seriously mentally ill patients housed in correctional facilities versus state hospitals has increased substantially since 2008. Then, the ratio was 3:1. Currently, the ratio is 10 patients held in jail or prison for every single patient in a state hospital. This is clearly a significant change, which TAC attributes to closure of state hospital beds and failure to implement outpatient commitment laws.

As I’ve said in previous columns, I’m reluctant to attribute the incarceration of mentally ill people solely to mental illness. I’m uncomfortable with a reductionist hypothesis that overlooks the whole person. All of my prison patients have challenges common to many non–mentally ill prisoners: substance abuse, lack of social supports, illiteracy, poor vocational skills, and poverty. Psychiatric patients also suffer the baser instincts common to all humanity: fear, greed, and jealous rage. Changes in laws governing sentencing also will affect all offenders, regardless of psychiatric status. Psychiatric medication, voluntary or involuntary, is not the sole answer to the problem of criminality and will do nothing to address these other issues.

Nevertheless, I agree with the majority of the TAC report recommendations, and I applaud the emphasis placed upon expanded use of mental health courts and crisis intervention teams (CIT) to avert incarceration. The recommendation to screen prisoners for mental illness is already mandated by the National Commission on Correctional Health Care (NCCHC) for any accredited facility. According to a 1994 national survey by Dr. Jeffrey L. Metzner and associates, all prisons systems provided either reception or prompt intake mental health screening to all newly admitted intakes (Bull. Am. Acad. Psychiatry Law 1994;22:451-7). Twenty-six percent of the prison systems exceeded screening standards recommended by the American Psychiatric Association. This is good news.

The TAC report also recommended mandatory release planning. Systematic release planning is a challenge to implement for most correctional systems for several reasons. In jail, release may be contingent upon the outcome of a trial and is therefore unpredictable. If the trial is postponed, a valuable community treatment slot is tied up for a patient who will never arrive. Conversely, failure to plan prior to a court date might leave a prisoner on the street directly from court with no aftercare. Nevertheless, states are beginning to realize the cost and public safety benefit of release plans that integrate medical, mental health, and substance abuse services.

One recent outcome study showed that more than half of released prisoners stayed in treatment in the community when an in-reach program provided integrated release planning services, and that annual criminal charges dropped by more than 50% in the year following engagement. More good news.

Finally, a minor quibble. My own state, Maryland, was cited in the report as one of the few states in which the involuntary treatment of inmates is most difficult because of the requirement to transfer the inmate to a hospital first. What the TAC failed to mention was that, in Maryland, the involuntary medication process was substantially undermined by case law. In 2006, the Maryland Court of Appeals decided in Department of Health and Mental Hygiene v. Anthony Kelly that involuntary medication only can be administered if the patient demonstrates dangerousness within the institution. Given this restriction, involuntary medication could not be administered on a nonemergency basis even in a correctional facility.

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.

The Treatment Advocacy Center has released an update of a national survey of prison and jail involuntary treatment policies in its 116-page report, "The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey."

The survey was a replication of a previous study done in 2008. The purpose of the study was to compare treatment bed capacity and the numbers of seriously mentally ill patients housed within a state’s correctional system versus its public mental health system, and to promote the use of involuntary treatment procedures within correctional facilities.

To prepare the report, the center gathered data from each state prison system, as well as from non–randomly selected jails, regarding total bed capacity and the percentage of seriously mentally ill prisoners housed in the correctional system. Information about nonemergency involuntary medication procedures was gathered from prison websites or through Freedom of Information requests. For jails, some policies were obtained or clarified from administrative personnel or mental health professionals within the facility. Information about available psychiatric state hospital beds was gathered from a previous TAC report on state per-capita treatment capacity.

The new report found that the ratio of seriously mentally ill patients housed in correctional facilities versus state hospitals has increased substantially since 2008. Then, the ratio was 3:1. Currently, the ratio is 10 patients held in jail or prison for every single patient in a state hospital. This is clearly a significant change, which TAC attributes to closure of state hospital beds and failure to implement outpatient commitment laws.

As I’ve said in previous columns, I’m reluctant to attribute the incarceration of mentally ill people solely to mental illness. I’m uncomfortable with a reductionist hypothesis that overlooks the whole person. All of my prison patients have challenges common to many non–mentally ill prisoners: substance abuse, lack of social supports, illiteracy, poor vocational skills, and poverty. Psychiatric patients also suffer the baser instincts common to all humanity: fear, greed, and jealous rage. Changes in laws governing sentencing also will affect all offenders, regardless of psychiatric status. Psychiatric medication, voluntary or involuntary, is not the sole answer to the problem of criminality and will do nothing to address these other issues.

Nevertheless, I agree with the majority of the TAC report recommendations, and I applaud the emphasis placed upon expanded use of mental health courts and crisis intervention teams (CIT) to avert incarceration. The recommendation to screen prisoners for mental illness is already mandated by the National Commission on Correctional Health Care (NCCHC) for any accredited facility. According to a 1994 national survey by Dr. Jeffrey L. Metzner and associates, all prisons systems provided either reception or prompt intake mental health screening to all newly admitted intakes (Bull. Am. Acad. Psychiatry Law 1994;22:451-7). Twenty-six percent of the prison systems exceeded screening standards recommended by the American Psychiatric Association. This is good news.

The TAC report also recommended mandatory release planning. Systematic release planning is a challenge to implement for most correctional systems for several reasons. In jail, release may be contingent upon the outcome of a trial and is therefore unpredictable. If the trial is postponed, a valuable community treatment slot is tied up for a patient who will never arrive. Conversely, failure to plan prior to a court date might leave a prisoner on the street directly from court with no aftercare. Nevertheless, states are beginning to realize the cost and public safety benefit of release plans that integrate medical, mental health, and substance abuse services.

One recent outcome study showed that more than half of released prisoners stayed in treatment in the community when an in-reach program provided integrated release planning services, and that annual criminal charges dropped by more than 50% in the year following engagement. More good news.

Finally, a minor quibble. My own state, Maryland, was cited in the report as one of the few states in which the involuntary treatment of inmates is most difficult because of the requirement to transfer the inmate to a hospital first. What the TAC failed to mention was that, in Maryland, the involuntary medication process was substantially undermined by case law. In 2006, the Maryland Court of Appeals decided in Department of Health and Mental Hygiene v. Anthony Kelly that involuntary medication only can be administered if the patient demonstrates dangerousness within the institution. Given this restriction, involuntary medication could not be administered on a nonemergency basis even in a correctional facility.

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.

In the jail cell I had appropriated as an office, the toilet was broken. The metal toilet bowl was wrapped carelessly in heavy plastic and the plastic was anchored in place by gray duct tape. The window opened hopefully to about 4 inches, just enough to let in the August humidity. Outside, the temperature reached 90 F. Inside the cell, the temperature was easily over 100° F. I was wilting, my patients were wilting, and I left the building at the end of the morning soaked in sweat carrying stacks of damp paper. For the first time since I was an intern, I donned a pair of surgical scrubs because the building was too intolerable for wearing street clothes. This was the legacy of my jail. The facility was opened in 1859, well before the invention of modern heating and air conditioning.

Thanks to the intervention of the Department of Justice, some improvements were made. Certain tiers were given air-conditioning units and designated for the housing of inmates vulnerable to heat exhaustion. Intake procedures were modified to identify and stratify new detainees according to their medical needs and heat tolerance. Inmates were given education on the symptoms of heat exhaustion and how to prevent it. Eventually summer passed, and I was able to lose the surgical scrubs and slip back into street clothes.

Yet the remaining need for a new jail was obvious to anyone working in the facility or incarcerated there. A recent legislative inquiry pointed out the security risks posed by the antiquated tier structures and other hazards. In the report published later, the cost of a new jail was estimated to be $553 million.

The protest started almost immediately. People wrote to the local newspaper to object to the idea of spending money on incarceration rather than crime prevention. Advocacy groups carved out territorial niches to promote diversion of juveniles, pregnant women, and the mentally ill, apparently leaving any prisoner who didn’t fit into one of those categories to fend for himself. In the end, the jail – which opened at a time when there were only 33 states in the union, the year that "A Tale of Two Cities" and "On the Origin of Species" were published, and when the works of Johannes Brahms were being heard for the first time – remained untouched.

These memories returned quickly after reading a recent New York Times story about a homeless veteran with mental illness who died in his jail cell, presumably because of excessive heat. The man had been incarcerated for a misdemeanor and held only because he couldn’t make bail. The fact that this happened in winter tells me a lot about the nature of the facility’s heating and ventilation system.

The first thing that struck me about this story was the need to invoke certain adjectives, as though readers would not care about the story if the prisoner who died was not mentally ill or was not a veteran. There may be some truth to that concern. When it comes to prison reform, I’ve seen the tendency within psychiatry to limit discussions only to conditions as they affect the mentally ill. This was not always the case. Dr. Benjamin Rush, founder of Pennsylvania Hospital, also founded one of the first prison reformation societies. He advocated humane care for everyone in the facility, not just a certain faction.

Unless someone figures out how to "cure" crime, we will always need jails and prisons. Building a new facility is neither a failure nor a waste of resources. It may be the beginning of a long-term commitment to rehabilitation.

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 the jail cell I had appropriated as an office, the toilet was broken. The metal toilet bowl was wrapped carelessly in heavy plastic and the plastic was anchored in place by gray duct tape. The window opened hopefully to about 4 inches, just enough to let in the August humidity. Outside, the temperature reached 90 F. Inside the cell, the temperature was easily over 100° F. I was wilting, my patients were wilting, and I left the building at the end of the morning soaked in sweat carrying stacks of damp paper. For the first time since I was an intern, I donned a pair of surgical scrubs because the building was too intolerable for wearing street clothes. This was the legacy of my jail. The facility was opened in 1859, well before the invention of modern heating and air conditioning.

Thanks to the intervention of the Department of Justice, some improvements were made. Certain tiers were given air-conditioning units and designated for the housing of inmates vulnerable to heat exhaustion. Intake procedures were modified to identify and stratify new detainees according to their medical needs and heat tolerance. Inmates were given education on the symptoms of heat exhaustion and how to prevent it. Eventually summer passed, and I was able to lose the surgical scrubs and slip back into street clothes.

Yet the remaining need for a new jail was obvious to anyone working in the facility or incarcerated there. A recent legislative inquiry pointed out the security risks posed by the antiquated tier structures and other hazards. In the report published later, the cost of a new jail was estimated to be $553 million.

The protest started almost immediately. People wrote to the local newspaper to object to the idea of spending money on incarceration rather than crime prevention. Advocacy groups carved out territorial niches to promote diversion of juveniles, pregnant women, and the mentally ill, apparently leaving any prisoner who didn’t fit into one of those categories to fend for himself. In the end, the jail – which opened at a time when there were only 33 states in the union, the year that "A Tale of Two Cities" and "On the Origin of Species" were published, and when the works of Johannes Brahms were being heard for the first time – remained untouched.

These memories returned quickly after reading a recent New York Times story about a homeless veteran with mental illness who died in his jail cell, presumably because of excessive heat. The man had been incarcerated for a misdemeanor and held only because he couldn’t make bail. The fact that this happened in winter tells me a lot about the nature of the facility’s heating and ventilation system.

The first thing that struck me about this story was the need to invoke certain adjectives, as though readers would not care about the story if the prisoner who died was not mentally ill or was not a veteran. There may be some truth to that concern. When it comes to prison reform, I’ve seen the tendency within psychiatry to limit discussions only to conditions as they affect the mentally ill. This was not always the case. Dr. Benjamin Rush, founder of Pennsylvania Hospital, also founded one of the first prison reformation societies. He advocated humane care for everyone in the facility, not just a certain faction.

Unless someone figures out how to "cure" crime, we will always need jails and prisons. Building a new facility is neither a failure nor a waste of resources. It may be the beginning of a long-term commitment to rehabilitation.

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 the jail cell I had appropriated as an office, the toilet was broken. The metal toilet bowl was wrapped carelessly in heavy plastic and the plastic was anchored in place by gray duct tape. The window opened hopefully to about 4 inches, just enough to let in the August humidity. Outside, the temperature reached 90 F. Inside the cell, the temperature was easily over 100° F. I was wilting, my patients were wilting, and I left the building at the end of the morning soaked in sweat carrying stacks of damp paper. For the first time since I was an intern, I donned a pair of surgical scrubs because the building was too intolerable for wearing street clothes. This was the legacy of my jail. The facility was opened in 1859, well before the invention of modern heating and air conditioning.

Thanks to the intervention of the Department of Justice, some improvements were made. Certain tiers were given air-conditioning units and designated for the housing of inmates vulnerable to heat exhaustion. Intake procedures were modified to identify and stratify new detainees according to their medical needs and heat tolerance. Inmates were given education on the symptoms of heat exhaustion and how to prevent it. Eventually summer passed, and I was able to lose the surgical scrubs and slip back into street clothes.

Yet the remaining need for a new jail was obvious to anyone working in the facility or incarcerated there. A recent legislative inquiry pointed out the security risks posed by the antiquated tier structures and other hazards. In the report published later, the cost of a new jail was estimated to be $553 million.

The protest started almost immediately. People wrote to the local newspaper to object to the idea of spending money on incarceration rather than crime prevention. Advocacy groups carved out territorial niches to promote diversion of juveniles, pregnant women, and the mentally ill, apparently leaving any prisoner who didn’t fit into one of those categories to fend for himself. In the end, the jail – which opened at a time when there were only 33 states in the union, the year that "A Tale of Two Cities" and "On the Origin of Species" were published, and when the works of Johannes Brahms were being heard for the first time – remained untouched.

These memories returned quickly after reading a recent New York Times story about a homeless veteran with mental illness who died in his jail cell, presumably because of excessive heat. The man had been incarcerated for a misdemeanor and held only because he couldn’t make bail. The fact that this happened in winter tells me a lot about the nature of the facility’s heating and ventilation system.

The first thing that struck me about this story was the need to invoke certain adjectives, as though readers would not care about the story if the prisoner who died was not mentally ill or was not a veteran. There may be some truth to that concern. When it comes to prison reform, I’ve seen the tendency within psychiatry to limit discussions only to conditions as they affect the mentally ill. This was not always the case. Dr. Benjamin Rush, founder of Pennsylvania Hospital, also founded one of the first prison reformation societies. He advocated humane care for everyone in the facility, not just a certain faction.

Unless someone figures out how to "cure" crime, we will always need jails and prisons. Building a new facility is neither a failure nor a waste of resources. It may be the beginning of a long-term commitment to rehabilitation.

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, the Senate Judiciary Committee heard testimony regarding the use of solitary confinement in the Federal Bureau of Prisons. This was the second hearing on this issue, which featured testimony from the director of the federal system, from several human rights organizations, from state prison officials, and from former inmates themselves. Although one of the main concerns of the hearing was the psychological effects of solitary confinement, only one of the 11 speakers was a mental health professional. Psychology professor Craig Haney, Ph.D., has spent 30 years studying the effects of solitary confinement; however, by his own testimony, he did this primarily as an expert witness retained in the context of correctional litigation. None of those offering testimony was a mental health professional actively involved in the treatment of segregated prisoners. In fact, according to the curriculum vitae that Dr. Haney filed in his capacity as an expert in the California prison overcrowding case, Dr. Haney has never worked in a jail or a prison.

During the hearing, Sen. Al Franken (D-Minn.) made a reference to the risks some inmates posed to prison "guards." For those readers who have never worked in corrections, this is a tremendous faux pas. A "guard" is a generic term for a civilian hired by a private company or business who is given minimal training, slapped into a uniform, and told to stand watch over something. A correctional officer is a law enforcement professional who is trained, regulated, and monitored by the state. A correctional officer is a professional with a code of ethics and who is granted police powers, including the right to use deadly force. Confusing a correctional officer with a "guard" is like mistaking a Navy Seal for a Boy Scout.

So we have a hearing about the psychological effects of confinement in which a psychologist with no correctional experience is testifying before a senator who is not familiar with even basic correctional training standards. What could possibly go wrong?

This topic is close to my heart lately, because there is a bill currently before the Maryland General Assembly to study the use of solitary confinement in our prison system. I’ve read the bill, I’ve listened to the testimony, and I have a few opinions on the issue myself.

First, a few stipulations and clarifications. People involved in this issue tend to confuse terminology related to restricted housing within a correctional facility. The term "solitary confinement" traditionally means a housing situation in which the inmate is placed alone in a cell. The term "administrative segregation" or "ad seg" is sometimes used interchangeably with "disciplinary segregation," although this is not accurate. Disciplinary segregation means that the inmate is removed from the general population because of a rule violation. Inmates on disciplinary segregation are often barred from owning certain property like a television or radio. Visiting privileges and phone calls may also be restricted as a punishment.

In contrast, an inmate could be placed on administrative segregation for nondisciplinary reasons if the prisoner requires medical isolation temporarily, if the inmate voluntarily requests special housing, or if there is a need for protective custody. In this case, the inmate is still allowed to own property, and he retains basic visiting and telephone privileges. In all cases, there is time allowed out of the cell for exercise and recreation. There is also still access to medical and mental health services.

Regarding the stipulations, I don’t question that the prevalence of mental illness among prisoners will be high in a facility that is designated as maximum security or in a control unit prison. I also agree that solitary confinement, or housing without a cellmate, is a bad idea for a prisoner who is deemed a high suicide risk. I agree that boredom and lack of activity are generally a very bad thing for anyone, prisoner or not, and that we shouldn’t keep prisoners on segregation status longer than is necessary to accomplish the intended purpose of the housing.

Here’s where the agreement ends: I don’t think restricted housing is automatically and consistently bad for everyone, and I certainly don’t agree that the segregated housing itself causes whatever mental disturbance may be present. Association does not prove cause and effect, and the number of well-designed, controlled studies of this issue are too few and far between to allow a causal link to be drawn. I realize that this goes against the grain of most court findings on this issue, but that’s the state of the science. I was not surprised to see that the proponents of the solitary confinement bill didn’t mention contradictory evidence. Few journalists in the traditional media have, either.

I think when it comes to dictating prison policy, our legislators need to realize how dangerous our prison systems have become. According to the Bureau of Justice Statistics, between 2001 and 2011, the number of murders in American prisons increased by 79%. During that time my own state ranked second in the country in per capita prison murders. According to the testimony by the federal prison director, 47% of the inmates confined in the Florence SuperMax facility – the institution at the heart of the latest class action suit over solitary confinement – are there for killing another prisoner or staff member while incarcerated. Some of them have killed more than once. If one of my patients tells me that he feels safer in segregated housing and wants to be there, I’m not going to question that, and I hope no outside politician or advocacy group is going to criticize that intervention.

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.

Recently, the Senate Judiciary Committee heard testimony regarding the use of solitary confinement in the Federal Bureau of Prisons. This was the second hearing on this issue, which featured testimony from the director of the federal system, from several human rights organizations, from state prison officials, and from former inmates themselves. Although one of the main concerns of the hearing was the psychological effects of solitary confinement, only one of the 11 speakers was a mental health professional. Psychology professor Craig Haney, Ph.D., has spent 30 years studying the effects of solitary confinement; however, by his own testimony, he did this primarily as an expert witness retained in the context of correctional litigation. None of those offering testimony was a mental health professional actively involved in the treatment of segregated prisoners. In fact, according to the curriculum vitae that Dr. Haney filed in his capacity as an expert in the California prison overcrowding case, Dr. Haney has never worked in a jail or a prison.

During the hearing, Sen. Al Franken (D-Minn.) made a reference to the risks some inmates posed to prison "guards." For those readers who have never worked in corrections, this is a tremendous faux pas. A "guard" is a generic term for a civilian hired by a private company or business who is given minimal training, slapped into a uniform, and told to stand watch over something. A correctional officer is a law enforcement professional who is trained, regulated, and monitored by the state. A correctional officer is a professional with a code of ethics and who is granted police powers, including the right to use deadly force. Confusing a correctional officer with a "guard" is like mistaking a Navy Seal for a Boy Scout.

So we have a hearing about the psychological effects of confinement in which a psychologist with no correctional experience is testifying before a senator who is not familiar with even basic correctional training standards. What could possibly go wrong?

This topic is close to my heart lately, because there is a bill currently before the Maryland General Assembly to study the use of solitary confinement in our prison system. I’ve read the bill, I’ve listened to the testimony, and I have a few opinions on the issue myself.

First, a few stipulations and clarifications. People involved in this issue tend to confuse terminology related to restricted housing within a correctional facility. The term "solitary confinement" traditionally means a housing situation in which the inmate is placed alone in a cell. The term "administrative segregation" or "ad seg" is sometimes used interchangeably with "disciplinary segregation," although this is not accurate. Disciplinary segregation means that the inmate is removed from the general population because of a rule violation. Inmates on disciplinary segregation are often barred from owning certain property like a television or radio. Visiting privileges and phone calls may also be restricted as a punishment.

In contrast, an inmate could be placed on administrative segregation for nondisciplinary reasons if the prisoner requires medical isolation temporarily, if the inmate voluntarily requests special housing, or if there is a need for protective custody. In this case, the inmate is still allowed to own property, and he retains basic visiting and telephone privileges. In all cases, there is time allowed out of the cell for exercise and recreation. There is also still access to medical and mental health services.

Regarding the stipulations, I don’t question that the prevalence of mental illness among prisoners will be high in a facility that is designated as maximum security or in a control unit prison. I also agree that solitary confinement, or housing without a cellmate, is a bad idea for a prisoner who is deemed a high suicide risk. I agree that boredom and lack of activity are generally a very bad thing for anyone, prisoner or not, and that we shouldn’t keep prisoners on segregation status longer than is necessary to accomplish the intended purpose of the housing.

Here’s where the agreement ends: I don’t think restricted housing is automatically and consistently bad for everyone, and I certainly don’t agree that the segregated housing itself causes whatever mental disturbance may be present. Association does not prove cause and effect, and the number of well-designed, controlled studies of this issue are too few and far between to allow a causal link to be drawn. I realize that this goes against the grain of most court findings on this issue, but that’s the state of the science. I was not surprised to see that the proponents of the solitary confinement bill didn’t mention contradictory evidence. Few journalists in the traditional media have, either.

I think when it comes to dictating prison policy, our legislators need to realize how dangerous our prison systems have become. According to the Bureau of Justice Statistics, between 2001 and 2011, the number of murders in American prisons increased by 79%. During that time my own state ranked second in the country in per capita prison murders. According to the testimony by the federal prison director, 47% of the inmates confined in the Florence SuperMax facility – the institution at the heart of the latest class action suit over solitary confinement – are there for killing another prisoner or staff member while incarcerated. Some of them have killed more than once. If one of my patients tells me that he feels safer in segregated housing and wants to be there, I’m not going to question that, and I hope no outside politician or advocacy group is going to criticize that intervention.

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.

Recently, the Senate Judiciary Committee heard testimony regarding the use of solitary confinement in the Federal Bureau of Prisons. This was the second hearing on this issue, which featured testimony from the director of the federal system, from several human rights organizations, from state prison officials, and from former inmates themselves. Although one of the main concerns of the hearing was the psychological effects of solitary confinement, only one of the 11 speakers was a mental health professional. Psychology professor Craig Haney, Ph.D., has spent 30 years studying the effects of solitary confinement; however, by his own testimony, he did this primarily as an expert witness retained in the context of correctional litigation. None of those offering testimony was a mental health professional actively involved in the treatment of segregated prisoners. In fact, according to the curriculum vitae that Dr. Haney filed in his capacity as an expert in the California prison overcrowding case, Dr. Haney has never worked in a jail or a prison.

During the hearing, Sen. Al Franken (D-Minn.) made a reference to the risks some inmates posed to prison "guards." For those readers who have never worked in corrections, this is a tremendous faux pas. A "guard" is a generic term for a civilian hired by a private company or business who is given minimal training, slapped into a uniform, and told to stand watch over something. A correctional officer is a law enforcement professional who is trained, regulated, and monitored by the state. A correctional officer is a professional with a code of ethics and who is granted police powers, including the right to use deadly force. Confusing a correctional officer with a "guard" is like mistaking a Navy Seal for a Boy Scout.

So we have a hearing about the psychological effects of confinement in which a psychologist with no correctional experience is testifying before a senator who is not familiar with even basic correctional training standards. What could possibly go wrong?

This topic is close to my heart lately, because there is a bill currently before the Maryland General Assembly to study the use of solitary confinement in our prison system. I’ve read the bill, I’ve listened to the testimony, and I have a few opinions on the issue myself.

First, a few stipulations and clarifications. People involved in this issue tend to confuse terminology related to restricted housing within a correctional facility. The term "solitary confinement" traditionally means a housing situation in which the inmate is placed alone in a cell. The term "administrative segregation" or "ad seg" is sometimes used interchangeably with "disciplinary segregation," although this is not accurate. Disciplinary segregation means that the inmate is removed from the general population because of a rule violation. Inmates on disciplinary segregation are often barred from owning certain property like a television or radio. Visiting privileges and phone calls may also be restricted as a punishment.

In contrast, an inmate could be placed on administrative segregation for nondisciplinary reasons if the prisoner requires medical isolation temporarily, if the inmate voluntarily requests special housing, or if there is a need for protective custody. In this case, the inmate is still allowed to own property, and he retains basic visiting and telephone privileges. In all cases, there is time allowed out of the cell for exercise and recreation. There is also still access to medical and mental health services.

Regarding the stipulations, I don’t question that the prevalence of mental illness among prisoners will be high in a facility that is designated as maximum security or in a control unit prison. I also agree that solitary confinement, or housing without a cellmate, is a bad idea for a prisoner who is deemed a high suicide risk. I agree that boredom and lack of activity are generally a very bad thing for anyone, prisoner or not, and that we shouldn’t keep prisoners on segregation status longer than is necessary to accomplish the intended purpose of the housing.

Here’s where the agreement ends: I don’t think restricted housing is automatically and consistently bad for everyone, and I certainly don’t agree that the segregated housing itself causes whatever mental disturbance may be present. Association does not prove cause and effect, and the number of well-designed, controlled studies of this issue are too few and far between to allow a causal link to be drawn. I realize that this goes against the grain of most court findings on this issue, but that’s the state of the science. I was not surprised to see that the proponents of the solitary confinement bill didn’t mention contradictory evidence. Few journalists in the traditional media have, either.

I think when it comes to dictating prison policy, our legislators need to realize how dangerous our prison systems have become. According to the Bureau of Justice Statistics, between 2001 and 2011, the number of murders in American prisons increased by 79%. During that time my own state ranked second in the country in per capita prison murders. According to the testimony by the federal prison director, 47% of the inmates confined in the Florence SuperMax facility – the institution at the heart of the latest class action suit over solitary confinement – are there for killing another prisoner or staff member while incarcerated. Some of them have killed more than once. If one of my patients tells me that he feels safer in segregated housing and wants to be there, I’m not going to question that, and I hope no outside politician or advocacy group is going to criticize that intervention.

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.