Correctional violence: Mental illness or institutional failure?

Prison violence has been on my mind recently due to an article in my local newspaper about the high rate of homicide in the Maryland prison system, which has one of the highest rates in the country –  although assault rates between prisoners has actually decreased by 47% over the last 6 years. Inevitably, people link prison violence either to some failure in prison administration or to a lack of correctional mental health services. In my experience, neither explanation alone suffices.

While most people imagine a prison as a “Lord of the Flies” environment where the fittest survive and rule, in fact, there are strict principles of etiquette that every experienced inmate lives by. These are: keep your cell or “home” clean, pay back your debts to your cellmate, wipe the toilet clean after each use, don’t talk too much, and always apologize after any burp or fart. And as much as possible, try not to snore.

Prison etiquette isn't followed out of courtesy so much as out of a mutual desire to avoid confrontations that could lead to fights and disciplinary segregation. Newly received inmates generally have experience in a local detention center first, where they learn this etiquette. They also learn that a correctional facility has rules and expectations, and that violating those rules through violence will have clearly spelled out consequences.

The most common cause of violence between inmates that I’ve seen is a persistent failure to follow prison courtesy between cellmates. This has very little to do with prison administration, and it’s nothing that your average correctional officer on the tier can predict or prevent.

In addition to lifestyle or etiquette-based conflicts, there are other rational motives for violence. Certain aggressive behaviors, such as throwing urine or feces or making violent threats, are a standard form of protest behavior within the correctional environment. These behaviors are so commonly accepted as “normal” prison aggression that they typically don’t trigger a referral for mental health evaluation and are handled entirely within the prison disciplinary process.

When a small inmate ”proves” his toughness by assaulting a larger and physically more imposing inmate, violence can be adaptive and protective by deterring harassment from others. By demonstrating a willingness to stand up for oneself, the inmate also increases his status on the tier, which in turn will improve his access to privileges and resources such as telephone calls and paid jobs within the facility.

Similarly, violence between neighborhood rivals or known prison gang members is typical of instrumental aggression to maintain order on a tier or to further criminal activities within the facility. If these rivalries are known to investigators, the violent prisoner would not typically be referred for psychiatric evaluation.

In contrast, sexually threatening behavior or repetitively assaultive behavior, or assaults that are indiscriminately directed against both officers and inmates, could trigger a consult to the prison psychology department.

The key to determining rational or instrumental violence from symptomatic violence is a careful mental status examination and history. Some violence-related questions that are unique to correctional practice are:

• Is the victim known to the inmate? What is their previous relationship? Do they have known gang or neighborhood rivalries and affiliations?

• What is the inmate’s previous adjustment history? Has he been moved to the facility from a lower security setting and if so, why? Does he have identified enemies within the facility?

• What is the inmate’s preferred housing status? Does he have a history of requesting segregated confinement voluntarily?

• Where is the inmate’s family? Is there a higher security facility located closer to them, and would a disciplinary transfer facilitate family contact?

• Does the inmate have a history of aggression directed toward authority figures, particularly in early development?

• Does the inmate have a history of persecution by other inmates? Is he a known informant or drug user within the facility? Does he owe gambling or other debts?

New onset violence is of particular concern, and may indicate a recent psychosocial stressor, mental illness, substance intoxication, or an undetected medical condition. While substance abuse is less likely in the correctional environment, use of stimulants or hallucinations, or even the newer synthetic cannabinoids, has been known to trigger aggression in previously well-adjusted inmates.

The cause of violent behavior and any related diagnosis usually can be identified through careful history and observation. Rarely, a transfer for admission or diagnostic work-up may be indicated. There is a substantial body of literature on the pharmacologic management of violence, and most medication interventions are available in a standard correctional formulary.

Anticonvulsants or lithium are commonly used, with the short-term addition of a neuroleptic if the violence is due to a primary psychotic disorder or mania. Regardless of the medication choice, it is important to clearly document the condition and indication for the medication to avoid allegations that pharmacologic interventions are being used for disciplinary reasons or merely to “keep the inmate quiet.”

After the acute crisis is resolved, the inmate can be offered additional follow-up for supportive counseling, crisis intervention as needed, as well as education about anger management skills.

The use of behavior modification plans, while helpful, can be somewhat controversial if the terms are overly restrictive or harsh. Such plans have led to court challenges over legal and ethical concerns. The plan should be carefully constructed to allow for inmate input into the terms and conditions, and explained in detail along with the rationale for each contingency. Voluntary participation in plan development is more likely to lead to a successful outcome and to withstand challenge by outside agencies.

The use of solitary confinement or segregated housing is controversial. However, when used temporarily in conjunction with psychiatric evaluation and intervention, solitary confinement can be an essential tool to protect both staff and other prisoners.

—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

Prison violence has been on my mind recently due to an article in my local newspaper about the high rate of homicide in the Maryland prison system, which has one of the highest rates in the country –  although assault rates between prisoners has actually decreased by 47% over the last 6 years. Inevitably, people link prison violence either to some failure in prison administration or to a lack of correctional mental health services. In my experience, neither explanation alone suffices.

While most people imagine a prison as a “Lord of the Flies” environment where the fittest survive and rule, in fact, there are strict principles of etiquette that every experienced inmate lives by. These are: keep your cell or “home” clean, pay back your debts to your cellmate, wipe the toilet clean after each use, don’t talk too much, and always apologize after any burp or fart. And as much as possible, try not to snore.

Prison etiquette isn't followed out of courtesy so much as out of a mutual desire to avoid confrontations that could lead to fights and disciplinary segregation. Newly received inmates generally have experience in a local detention center first, where they learn this etiquette. They also learn that a correctional facility has rules and expectations, and that violating those rules through violence will have clearly spelled out consequences.

The most common cause of violence between inmates that I’ve seen is a persistent failure to follow prison courtesy between cellmates. This has very little to do with prison administration, and it’s nothing that your average correctional officer on the tier can predict or prevent.

In addition to lifestyle or etiquette-based conflicts, there are other rational motives for violence. Certain aggressive behaviors, such as throwing urine or feces or making violent threats, are a standard form of protest behavior within the correctional environment. These behaviors are so commonly accepted as “normal” prison aggression that they typically don’t trigger a referral for mental health evaluation and are handled entirely within the prison disciplinary process.

When a small inmate ”proves” his toughness by assaulting a larger and physically more imposing inmate, violence can be adaptive and protective by deterring harassment from others. By demonstrating a willingness to stand up for oneself, the inmate also increases his status on the tier, which in turn will improve his access to privileges and resources such as telephone calls and paid jobs within the facility.

Similarly, violence between neighborhood rivals or known prison gang members is typical of instrumental aggression to maintain order on a tier or to further criminal activities within the facility. If these rivalries are known to investigators, the violent prisoner would not typically be referred for psychiatric evaluation.

In contrast, sexually threatening behavior or repetitively assaultive behavior, or assaults that are indiscriminately directed against both officers and inmates, could trigger a consult to the prison psychology department.

The key to determining rational or instrumental violence from symptomatic violence is a careful mental status examination and history. Some violence-related questions that are unique to correctional practice are:

• Is the victim known to the inmate? What is their previous relationship? Do they have known gang or neighborhood rivalries and affiliations?

• What is the inmate’s previous adjustment history? Has he been moved to the facility from a lower security setting and if so, why? Does he have identified enemies within the facility?

• What is the inmate’s preferred housing status? Does he have a history of requesting segregated confinement voluntarily?

• Where is the inmate’s family? Is there a higher security facility located closer to them, and would a disciplinary transfer facilitate family contact?

• Does the inmate have a history of aggression directed toward authority figures, particularly in early development?

• Does the inmate have a history of persecution by other inmates? Is he a known informant or drug user within the facility? Does he owe gambling or other debts?

New onset violence is of particular concern, and may indicate a recent psychosocial stressor, mental illness, substance intoxication, or an undetected medical condition. While substance abuse is less likely in the correctional environment, use of stimulants or hallucinations, or even the newer synthetic cannabinoids, has been known to trigger aggression in previously well-adjusted inmates.

The cause of violent behavior and any related diagnosis usually can be identified through careful history and observation. Rarely, a transfer for admission or diagnostic work-up may be indicated. There is a substantial body of literature on the pharmacologic management of violence, and most medication interventions are available in a standard correctional formulary.

Anticonvulsants or lithium are commonly used, with the short-term addition of a neuroleptic if the violence is due to a primary psychotic disorder or mania. Regardless of the medication choice, it is important to clearly document the condition and indication for the medication to avoid allegations that pharmacologic interventions are being used for disciplinary reasons or merely to “keep the inmate quiet.”

After the acute crisis is resolved, the inmate can be offered additional follow-up for supportive counseling, crisis intervention as needed, as well as education about anger management skills.

The use of behavior modification plans, while helpful, can be somewhat controversial if the terms are overly restrictive or harsh. Such plans have led to court challenges over legal and ethical concerns. The plan should be carefully constructed to allow for inmate input into the terms and conditions, and explained in detail along with the rationale for each contingency. Voluntary participation in plan development is more likely to lead to a successful outcome and to withstand challenge by outside agencies.

The use of solitary confinement or segregated housing is controversial. However, when used temporarily in conjunction with psychiatric evaluation and intervention, solitary confinement can be an essential tool to protect both staff and other prisoners.

—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

Prison violence has been on my mind recently due to an article in my local newspaper about the high rate of homicide in the Maryland prison system, which has one of the highest rates in the country –  although assault rates between prisoners has actually decreased by 47% over the last 6 years. Inevitably, people link prison violence either to some failure in prison administration or to a lack of correctional mental health services. In my experience, neither explanation alone suffices.

While most people imagine a prison as a “Lord of the Flies” environment where the fittest survive and rule, in fact, there are strict principles of etiquette that every experienced inmate lives by. These are: keep your cell or “home” clean, pay back your debts to your cellmate, wipe the toilet clean after each use, don’t talk too much, and always apologize after any burp or fart. And as much as possible, try not to snore.

Prison etiquette isn't followed out of courtesy so much as out of a mutual desire to avoid confrontations that could lead to fights and disciplinary segregation. Newly received inmates generally have experience in a local detention center first, where they learn this etiquette. They also learn that a correctional facility has rules and expectations, and that violating those rules through violence will have clearly spelled out consequences.

The most common cause of violence between inmates that I’ve seen is a persistent failure to follow prison courtesy between cellmates. This has very little to do with prison administration, and it’s nothing that your average correctional officer on the tier can predict or prevent.

In addition to lifestyle or etiquette-based conflicts, there are other rational motives for violence. Certain aggressive behaviors, such as throwing urine or feces or making violent threats, are a standard form of protest behavior within the correctional environment. These behaviors are so commonly accepted as “normal” prison aggression that they typically don’t trigger a referral for mental health evaluation and are handled entirely within the prison disciplinary process.

When a small inmate ”proves” his toughness by assaulting a larger and physically more imposing inmate, violence can be adaptive and protective by deterring harassment from others. By demonstrating a willingness to stand up for oneself, the inmate also increases his status on the tier, which in turn will improve his access to privileges and resources such as telephone calls and paid jobs within the facility.

Similarly, violence between neighborhood rivals or known prison gang members is typical of instrumental aggression to maintain order on a tier or to further criminal activities within the facility. If these rivalries are known to investigators, the violent prisoner would not typically be referred for psychiatric evaluation.

In contrast, sexually threatening behavior or repetitively assaultive behavior, or assaults that are indiscriminately directed against both officers and inmates, could trigger a consult to the prison psychology department.

The key to determining rational or instrumental violence from symptomatic violence is a careful mental status examination and history. Some violence-related questions that are unique to correctional practice are:

• Is the victim known to the inmate? What is their previous relationship? Do they have known gang or neighborhood rivalries and affiliations?

• What is the inmate’s previous adjustment history? Has he been moved to the facility from a lower security setting and if so, why? Does he have identified enemies within the facility?

• What is the inmate’s preferred housing status? Does he have a history of requesting segregated confinement voluntarily?

• Where is the inmate’s family? Is there a higher security facility located closer to them, and would a disciplinary transfer facilitate family contact?

• Does the inmate have a history of aggression directed toward authority figures, particularly in early development?

• Does the inmate have a history of persecution by other inmates? Is he a known informant or drug user within the facility? Does he owe gambling or other debts?

New onset violence is of particular concern, and may indicate a recent psychosocial stressor, mental illness, substance intoxication, or an undetected medical condition. While substance abuse is less likely in the correctional environment, use of stimulants or hallucinations, or even the newer synthetic cannabinoids, has been known to trigger aggression in previously well-adjusted inmates.

The cause of violent behavior and any related diagnosis usually can be identified through careful history and observation. Rarely, a transfer for admission or diagnostic work-up may be indicated. There is a substantial body of literature on the pharmacologic management of violence, and most medication interventions are available in a standard correctional formulary.

Anticonvulsants or lithium are commonly used, with the short-term addition of a neuroleptic if the violence is due to a primary psychotic disorder or mania. Regardless of the medication choice, it is important to clearly document the condition and indication for the medication to avoid allegations that pharmacologic interventions are being used for disciplinary reasons or merely to “keep the inmate quiet.”

After the acute crisis is resolved, the inmate can be offered additional follow-up for supportive counseling, crisis intervention as needed, as well as education about anger management skills.

The use of behavior modification plans, while helpful, can be somewhat controversial if the terms are overly restrictive or harsh. Such plans have led to court challenges over legal and ethical concerns. The plan should be carefully constructed to allow for inmate input into the terms and conditions, and explained in detail along with the rationale for each contingency. Voluntary participation in plan development is more likely to lead to a successful outcome and to withstand challenge by outside agencies.

The use of solitary confinement or segregated housing is controversial. However, when used temporarily in conjunction with psychiatric evaluation and intervention, solitary confinement can be an essential tool to protect both staff and other prisoners.

—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.