Correctional Psychiatry
Topics of relevance as identified by the
American Board of Psychiatry & Neurology Board Certification Examination Content Outline.
Learn Forensic Psychiatry is not affiliated with nor endorsed by ABPN.
Epidemiology
Population Demographics
2022 Data from the Bureau of Justice Statistics (BJS) indicates that females made up about 7% of the prison population, and 14% of the local jail population.
Minorities are disproportionately impacted. According to the NAACP,
56% of the incarcerated population is made up of African Americans and Hispanics, versus 32% of the general population.
African Americans are incarcerated at more than 5 times the rate of whites.
African American children make up 14% of the population, but 32% of arrests.
Prevalence of Mental Health & Substance Use Disorders
Data from a 2011 survey conducted by the BJS indicates:
37% of prisoners and 44% of jail inmates had a history of a mental health problem.
The most commonly reported diagnosis was MDD, followed by bipolar disorder and schizophrenia.
14% of prisoners and 26% of jail inmates reported severe psychological distress within the past 30 days.
Females had higher rates than males
According to the National Institute on Drug Abuse (NIDA), 85% of the prison population has an active substance use disorder or were incarcerated for a crime involving drugs or alcohol.
Correctional Facilities
Types of Correctional Facilities
Lockup
Local, often within a police department
Temporary holding facility for inmates pending bail or transfer to jail, holds usually <48 hours
Jail
Local or State facilities
Hold inmates before or after trial.
Short-term facilities; inmates are typically serving a sentence of less than 1 year for misdemeanor charges.
Prison
State or Federal facilities
Hold individuals who are serving a sentence after conviction.
Longer-term facilities; prisoners are typically serving a sentence of at least 1 year for felony charges.
Prison Security Levels (per BOP)
Camps/ Minimum Security
Minimum security institutions
Nonviolent offenders
Dorm housing, low staffing ratio, & limited perimeter fencing
Low Security
Dorm or cubicle housing, higher staffing ratios, double perimeter fencing
Medium Security
Cell-type housing, higher staffing ratios, greater controls & strengthened perimeters
More likely to have violent offenders
High Security
Cell-type housing, highest staffing ratios, strict controls & highly secured perimeters
Administrative
Specialized facilities (medical or psychiatric conditions, disruptive/dangerous/high violence risk)
Includes Administrative Maximum Security Penitentiary “Supermax”
Located in Colorado (ADX Florence)
Extreme security for the most dangerous offenders, often with history of violence towards inmates/officers
23 hours/day of solitary confinement
Probation/ Parole
Probation
Punishment served in the community rather than in a correctional facility.
Under supervision of a probation officer.
Parole
Conditional, supervised early release from prison.
Under supervision of a parole officer.
Both probation and parole require that certain specific conditions be followed, examples of which may include reporting to probation/parole officer, abstaining from criminal activity, curfew, travel restriction, not possessing firearms, no contact with victims, random drug testing, & mental health treatment.
Right to Medical Treatment
Under the 8th Amendment, prisoners have a constitutional right to protection from “deliberate indifference” to serious medical needs..(Estelle v. Gamble, 1976)
The test for deliberate indifference is “subjective awareness” (Farmer v. Brennan, 1994)
Subjective Awareness: Actual knowledge of a specific risk of harm, with failure to acknowledge and take reasonable steps to abate. (Recklessness required; negligence is insufficient)
Inadequate medical care in prison constitutes Cruel & Unusual Punishment, however, medical malpractice doesn’t rise to the level of Cruel & Unusual Punishment simply because the patient is a prisoner.. (Estelle v. Gamble, 1976)
Practice Guidelines in Corrections
The American Psychiatric Association (APA) and National Commission on Correctional Healthcare (NCCHC) provide clinical guidelines of relevance to correctional psychiatry.
Specific Guidelines of Relevance to Exams
Suicide Prevention
Suicide in Corrections
According to the Suicide Risk Prevention Center (SRPC):
Suicide is the leading cause of death in jails, and the third leading cause of death in prisons
The suicide rate in local jails is 4x that of the general population
The most frequent method is hanging
Warning signs:
Verbal warnings (expressions of suicidal thoughts)
Depression
Psychosis
Reaction to incarceration
Precipitating factors (legal setbacks, isolation, sexual or physical abuse, bad news, drug withdrawal)
Suicide Prevention Measures
Formal suicide prevention plans
Universal mental health screening at intake
Suicide-resistant cells
Protocols for those at increased risk
Prison Rape Elimination Act (PREA)
PREA is a 2003 federal law intended to “provide information, resources, recommendations, and funding to protect individuals from prison rape”.
Set standards for staff training, inmate education, sexual abuse investigations, and protection.
Establishes a zero-tolerance policy for sexual abuse and harassment in correctional facilities
Requires collection of data on sexual abuse in correctional facilities via the Bureau of Justice Statistics
Due Process Issues
Involuntary Hospitalization
Prior to involuntary transfer from prison to a psychiatric hospital, prisoners have a right to Due Process protections, including: (Vitek v. Jones, 1980)
Notice
Legal counsel
Adversarial hearing with an independent decision maker & opportunity to present evidence and testimony
Involuntary Medication
Under the Due Process Clause of the 14th Amendment, a prisoner with a serious mental disorder may receive antipsychotic medication over objection if he represents a danger to self or others, and the medication is in his best interest. (Washington v. Harper, 1990)
Prisoners’ liberty interests must be balanced with prison safety and security.
A formal judicial hearing is not required prior to overriding treatment refusal, medical professionals may serves as the decision-makers for involuntary medication.
Undue Hardship
Correctional facilities cannot discriminate against prisoners with disabilities, and must provide reasonable accommodations to facilitate access to a program, service, or benefit, unless such accommodation would impose undue hardship, or fundamentally alter the nature of the program.
US v. Georgia, 2006 extended ADA protections to state prisons
Civil Commitment Following Incarceration
Under the Equal Protection Clause of the 14th Amendment, prisoners facing civil commitment following incarceration have the right to a jury trial to determine presence of mental illness. (Baxstrom v. Herold, 1966)
Class Actions/ Consent Decrees in Corrections
Class Actions in Corrections
Class Action Lawsuit: a civil lawsuit in which a group of people who suffered harm by the same entity are represented by a member(s) of the group.
In correctional settings, prisoners (as well as public defenders and advocacy groups on their behalf) often file class action lawsuits in response to mistreatment or deprivation of constitutional rights.
Frequently involve complaints related to lack of access to medical treatment, overcrowding/inhumane conditions, excessive use of force or abuse, and mistreatment of vulnerable populations (juveniles, inmates with disabilities or mental health conditions)
Violations of the 8th Amendment (protection from Cruel & Unusual Punishment) and 14th Amendment (Due Process) frequently serve as the basis for these suits.
Class action suits may lead to a consent decree, a negotiated settlement between the parties involved.
Class action suits filed by prisoners are subject to procedural requirements established by the Prison Litigation Reform Act (PLRA)
Consent Decrees
Consent Decree: a negotiated settlement between the parties involved in a class action lawsuit.
In correctional settings, consent decrees often involve an agreement to improve conditions or implement reforms.
Under the PLRA, consent decrees require evidence of unconstitutional conditions.
Paraphilias & Sex Offenders
Paraphilic Disorders
Voyeuristic Disorder
Fantasies, urges, or behaviors related to recurrent and intense sexual arousal from observing an unsuspecting person who is naked, disrobing, or engaging in sexual activity.
Urges or fantasies must cause distress or functional impairment, or the individual has acted on urges with a non consenting person.
Exhibitionistic Disorder
Fantasies, urges, or behaviors related to recurrent and intense sexual arousal from exposure of one’s genitals to an unsuspecting person.
Urges or fantasies must cause distress or functional impairment, or the individual has acted on urges with a non consenting person.
Frotteuristic Disorder
Fantasies, urges, or behaviors related to recurrent and intense sexual arousal from touching or rubbing against a non consenting person.
Urges or fantasies must cause distress or functional impairment, or the individual has acted on urges with a non consenting person.
Sexual Masochism Disorder
Fantasies, urges, or behaviors related to recurrent and intense sexual arousal from the act of being made to suffer.
Urges or fantasies must cause distress or functional impairment.
Sexual Sadism Disorder
Fantasies, urges, or behaviors related to recurrent and intense sexual arousal from the physical or mental suffering of another.
Urges or fantasies must cause distress or functional impairment, or the individual has acted on urges with a non consenting person.
Pedophilic Disorder
Fantasies, urges, or behaviors related to recurrent and intense sexual arousal from the sexual activity with a prepubescent child.
Urges or fantasies must cause distress or functional impairment, or the individual has acted on urges.
Fetishistic Disorder
Fantasies, urges, or behaviors related to recurrent and intense sexual arousal from the use of nonliving objects or a highly specific focus of a non-genital body part.
Urges or fantasies must cause distress or functional impairment.
Fetish object is not limited to articles of clothing use in crossdressing, or specifically designed for purpose of genital stimulation.
Sex Offenders
Definitions:
Sex Offender: an individual convicted of a sexual offense.
In most jurisdictions, requires registration with law enforcement.
May be subject to restrictions on housing or being in the presence of minors
Sexually Violent Predator (SVP): an individual who has been convicted of a sexual offense, and has a psychiatric condition that:
Limits their ability to control their sexual behavior
Increases their risk for sexual offending
Key Distinctions
Diagnosis of a paraphilic disorder does NOT equate to being a sex offender
All SVPs are sex offenders, but all sex offenders are not SVPs
Sex Offender Treatment
Aim of treatment is reduction in recidivism risk
Requires an evidence-based, multidisciplinary approach.
Risk-Need-Responsivity Model
Risk: Treatments target dynamic risk factors linked to recidivism.
Need: The intensity of treatment is related to recidivism risk.
Responsivity: Treatment should be responsive to the individual’s needs.
Treatment modalities may include relapse prevention, CBT, motivational interviewing, and pharmacological interventions.
Medications may include SSRIs, naltrexone, medroxysprogesterone acetate, cyproterone acetate, & leuprolide.
The World Federation of Societies of Biological Psychiatry (WFSBP) has published treatment guidelines for the biological treatment of paraphilias in adults and adolescent sexual offenders.
Sex Offender Recidivism
Sexual offenses are underreported, and the definition of recidivism varies between studies.
Rates of sexual recidivism vary from 5% after 3 years to 24% after 15 years. (DOJ)
Rates of general recidivism are higher than rates for sexual offenses. (DOJ)
Tools for Assessing Recidivism Risk
Static-99: assesses the risk of sexual and violence recidivism in sexual offenders
Stable 2007: assesses dynamic risk factors of relevance to recidivism in adult male sexual offenders
Sex Offender Risk Appraisal Guide (SORAG): predicts sexual and violence recidivism in men with hands-on sexual offenses
Rapid Risk Assessment of Sexual Offender Recidivism (RRASOR): assess sexual recidivism in males with at least one sexual offense
Penile Plethysmography
Tool used to measure sexual arousal in response to stimuli using a pressure-sensitive device that detects changes in penile circumference and volume.
Used to measure deviant sexual arousal as part of sexual offense recidivism risk
Protective Custody Issues for Sexual Offenders
Inmates at higher risk of harm from others may require protective custody for their safety, with placement in a separate housing unit rather than general population, as well as enhanced monitoring and potentially limited access to programming.
Sex offenders may be disproportionately targeted by other inmates and subjected the physical and sexual assault, exploitation, and ostracism.
Due Process Protections for Sexual Offenders
Indefinite Commitment
Due Process requires criminal procedural safeguards for sexual offender commitment proceedings, including rights to a judicial hearing, to counsel, to present evidence & witnesses, to confront & cross-examine witnesses. (Specht v. Patterson, 1967)
Civil versus criminal proceedings
Civil commitment of sexual offenders is a civil, not criminal, proceeding, thus 5th Amendment protections from self-incrimination don’t apply. (Allen v. Illinois, 1986)
Definition of Mental Abnormality
Civil commitment statutes are not constitutionally required to use the term “mental illness.” (Kansas v. Hendricks, 1997)
Volitional Control
Civil commitment of sex offenders under Kansas’ SVPA does not require complete inability to control one’s behavior, only “serious difficulty.” (Kansas v. Crane, 2002)
Federal Sex Offender Commitment
The federal government has the authority to enact civil commitment statutes for sexually dangerous individuals in federal custody under the “Necessary and Proper” clause. (US v. Comstock, 2010)