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.
She missed his nonverbal hesitation, his wide eyes, and his fear of being honest. He was thinking about hurting or killing himself but the answer he gave was, “No.” And the interview moved on, more intimate questions being asked in a public space by a staff member looking at a screen and not at the person being asked. Exactly the wrong set up. No privacy. No confidentiality. Rapid paced yes or no questions. No interest in the person being interviewed, just focus on completing a required form.
Sound familiar? Unfortunately, it is likely all too familiar in jails and prisons across the country.
Screening is one of the most important steps in identifying the needs of individuals entering our jails and prisons. It is step number one in determining who needs to be seen for further follow up and how soon they need to be seen. Unlike physical wounds and abnormal vital signs, there are not always clear objective markers of risk for mental health emergencies or mental health needs. We must rely on patient self-report and on subtle cues, like pauses and hesitations.
I have three basic recommendations for a supporting a successful screening:
- Conduct the screening in a private, confidential area.
The space where the person is being interviewed should be safe from being overheard and ideally free from being observed by other inmates/detainees. Standard safety protocols should be in place to ensure protection for the staff member and the patient, but there are ways to set up spaces so that the patient’s back is to an open room and noise protections are in place.
- Engage with the patient.
The staff member conducting the interview needs to read the question then look at the individual during the response. Ideally, the staff member should read the question, remember the question, and then ask it while looking at the individual. This allows for observation of the patient’s reaction to the question, the nonverbal response in conjunction with the verbal response. Should the patient’s response reveal issues of concern, there needs to be follow up.
- Use open ended questions.
Whenever possible, ask “When is the last time you…” instead of “Have you ever…” Asking “When is the last time you took medications for a mental health condition?” makes what we call a gentle assumption. It assumes that something is true. In this case, that the patient has taken psychotropic medications. This gentle assumption provides permission for the individual to share the details of his/her experience rather than having to admit something in the first place. For patients who have not taken medications in the past, the answer will be “never” but for those who have, there is a sense that taking medications is the norm and therefore safe to reveal.
Screening is the gateway to services and interventions. It is the triage point and possibly one of the most important assessments conducted in our settings. Let’s set it up for success.
What I have shared here is my opinion, based on my training, research and experience. I could have missed something or just be plain wrong. If you think I’ve got it wrong, please let me know why in the Comments.
Do you have any recommendations for effective mental health intake screenings? Please feel free to share.
Cynical take: Are these problems solely due to operational difficulties, or could a desire not to know play a role in how jails set these up? More confidentiality and more careful observation mean more referrals and more medical care for the jail to provide. Neither physicians nor psychologists are particularly cheap, and hospitals are even less so. The screening system described here sounds like something a lawyer (which I am) might design — maximum chance to document negative results that could be very helpful in litigation if the inmate commits self-harm and decides to sue.
Interesting take, Jason. Thank you for your thoughts. In my experience, the issue commonly arises from the fact that including MH screening at intake was an after-thought and not part of the original design in booking areas of jails. This results in having to place staff in inappropriate locations for screenings. Also, I’ve seen the failure to identify needs result in litigation as well.