In response to my previous post, I received a number of comments and feedback which included assertions that individuals who engage in repetitive self-injury in correctional settings are “doing it for attention.” That got me thinking. And the more thinking I did, the more I realized that these statements are likely true. But, not necessarily in the way one would think. Let me explain.
A few weeks ago, I received a request from a psychiatry resident working at a state prison about the use of restraints with patients who engage in severe self-injury. He was looking for guidance on the use of physical restraints with this population in prison. He noted that his role of ordering and monitoring patients in restraints caused him to feel more like a provider for the facility, rather than for the patient. I shared with him with the best resources I know – Resource Document on the Use of Restraint and Seclusion in Correctional Mental Health Care (http://jaapl.org/content/35/4/417) as well as Dr. Applebaum’s commentary on the same (http://jaapl.org/content/jaapl/35/4/431.full.pdf). As I sat down to write this, I intended to discuss the rules and regulations surrounding restraint (e.g., Center for Medicare and Medicaid Services (CMS) 42 CFR § 482.13) but I stopped myself.
The inquiry was not about regulations and requirements for the use of restraints. The question was about patient care.
According to the fitness tracker I wear on my wrist, I slept for 7 hours and 13 minutes last night. I was restless eight times and woke up twice. What does that tell me? No idea. The Centers for Disease Control tell us that adults need seven or more hours of sleep each night. But what if I feel refreshed after five hours? Am I unhealthy? What if I slept 10 hours, am I super healthy?
At the risk of oversimplifying, many incarcerated patients come to us with some manifestation of the following (or a combination of these):
It is important to work with the patient to understand which of these issues is experienced by the patient as most distressing and in need of change. I think back to a patient I once saw who was diagnosed with schizophrenia. She had significant trouble with tangential and disorganized thinking but what she wanted more than anything was having cigarettes at the end of the month. (This was back when inmates could still smoke in the prison.) She often smoked all her cigarettes prior to the end of the month and then had to borrow cigarettes “2-for-1” for the remainder of the month, putting her at a deficit at the start of the next month…you see the cycle. She did not have any interest in meeting with me to improve her thinking. She wanted her cigarettes.
This morning, inmate Gibbs had a visit. The nurse passing medications in the housing unit noticed that he was not ready when his name was called. Unusual. Mr. Gibbs is typically aware of his visits and is up and ready at least five minutes before it’s time to go. The nurse asked Mr. Gibbs if he was feeling ok. Mr. Gibbs just shrugged and left the unit for his visit. Later that day, the nurse noticed that Mr. Gibbs was not out in the day room playing cards with others, like he usually is. The nurse walked by Mr. Gibbs’ cell and noticed he was just lying on his bunk looking at the ceiling. The nurse asked again if everything was ok and Mr. Gibbs stated, “Just not my day. Things aren’t working out for me. That’s the problem with hope, you always get disappointed.” “Anything I can do?” the nurse asked. “No, man. Thanks. Just gotta do what I gotta do.”
Every individual who works in a correctional setting has unique experiences with inmates. Based on your role, your personality, your style of interaction and how others perceive you, you are likely to see and hear things that others do not see and hear. In the above example, the nurse has a unique perspective on what’s happening with Mr. Gibbs.
Do not underestimate the value and importance of what you see and hear.
When you notice things are out of the ordinary, ask questions. If the answers leave you feeling unsure, make a referral.
It’s September, which is National Suicide Prevention Awareness Month. Let’s start with awareness. According to the Centers for Disease Control, rates of death by suicide have increased in this country by 35% from 1999 to 2018. More specifically, the rate has increased by 2% every year from 2006 to 2018. The overall rate of death by suicide in 2018 was 14.2 people per 100,000. For men, the rate is higher than the rate for women, with a suicide rate of 22.8 per 100,000 for men and 6.2 per 100,000 for women. The rate for women, however, increased by 55% between 1999 and 2018.
According to the most recent data released by the Bureau of Justice Statistics, the rate of death by suicide in state prisons was 21 per 100,000 up from 14 per 100,000 in 2001. In federal prisons the rate in 2016 was 12 per 100, 000 down from 13 per 100,000 in 2001. In local jails, the rate of death by suicide in 2016 was 46 per 100,000 down from 48 per 100,000 in 2000.
These rates tell us despite our efforts in training, education and suicide prevention within our jails and prisons, people are still choosing to take their own lives.
Suicide is the intentional ending of one’s own life. Think about that. Just sit and think about the fact that thousands of individual human beings, every year, decide that the life they have should end. Many of these individuals experienced emotional and cognitive distress beyond what they believed they could handle and saw death as the best possible choice in the moment. They likely felt alone, isolated, trapped and hopeless. Like there was nowhere to turn. We can change that.
It was a holiday weekend in the middle of the night. The booking area of the jail was a big, open, noisy pit with people sitting in plastic chairs, watching TV or on phones and the officers either behind desks or circling the perimeter. It was filling up. A staff member was completing initial mental health screenings in a corner of the open room, up on a platform and behind a computer. She had the electronic health record open to the mental health screening form and she was going through each “yes/no” question, reading from the computer screen and not looking at the recently arrested individual, a young man picked up on a possession charge.
“Are you currently taking any medications for mental health problems?” “No.”
“Have you ever been hospitalized for mental health reasons?” “No.”
“Are you currently thinking about hurting or killing yourself?” Pause. Swallow. “No.”
“Have you ever been treated for withdrawal from drugs or alcohol?” “No.”
She missed it. She missed the pause; she missed the swallow.
I am pleased to be joined on JailMedicine by my colleague Dr. Sharen Barboza! Dr. Barboza has been providing correctional mental health care for more than 20 years. Her complete bio can be found in the About The Authors tab (here). Besides her broad experience, intelligence and common sense, Dr. Barboza is simply the best speaker I have heard at any correctional medicine conference. I am honored to have her as my co-editor at JailMedicine! Jeffrey Keller
I am truly honored, grateful and humbled to join Dr. Keller on JailMedicine.com. I think that now, more than any other time in the past, we are all realizing the impact that our mental health has on our ability to function in the world. For so many of us, we take the “health” part of our “mental health” for granted. We trust our thoughts to be based in reality; we rely on our emotions to adequately and appropriately meet the moment; and we have confidence in our ability to cope with what comes our way. Most days.
Continue readingConsider the case of a 60-year-old patient I will call “Library Man.” While at the public library, Library Man took off most of his clothes and was talking loudly to no one in particular. The police were called, of course. He was charged with disturbing the peace and brought to my jail.
Jails basically have three types of housing areas. First are dormitory-style rooms with 60-100 residents. Library Man cannot be housed there—the young aggressive inmates would prey on him. Second are smaller cells that hold two to four inmates. The problem with these cells is that even if the jail could guarantee gentle cell mates, it would be hard to monitor Library Man in such cells. Such cells tend to be in out-of-the-way places and have small windows on the doors. The only place that Library Man can be reasonably housed in most jails is “Special Housing,” which refers in this case to a single-man isolation cell with lots of plexiglass to allow easy observation. Such rooms are designed to have nothing that someone could use to harm themselves, so they are made entirely of concrete and steel—even the bed. This is where Library man ends up—basically in a large concrete box.
Unfortunately, this is not a good place for Library Man to be. You may have guessed that Library Man is a homeless schizophrenic who had gone off of his meds. He is harmless–certainly not a danger to himself or to others. In his psychotic state, he does not understand why he was arrested and jailed. Library Man would benefit from familiar surroundings and normal social interaction with people. He will get neither of these in the alien and sterile environment of his concrete isolation cell.
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I have a confession to make. Before I knew anything about Correctional Medicine, I had a bad opinion about it. I’m not proud of this. I even turned down my first opportunity to get into Correctional Medicine because of my preconceived prejudice. Thank goodness I got a second opportunity, because Correctional Medicine changed my life! Who knew that Correctional Medicine was such a great job and a great career?
Certainly not my colleagues. Back when I made the mid-life career change to jail medicine, my physician friends asked me, bewildered, “Why in the world would you want to work in a jail?” Without knowing anything about it, they had a preconceived notion of Correctional Medicine as being low skill and basically without redeeming features.
What a difference 15 years makes! 
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