When my clinic manager told me that prison may be the best place to practice psychiatry nowadays, I didn’t believe him. After all, prisons often seem like a world apart, often in isolated rural areas or in windowless, nondescript urban buildings.

Some mental health professionals feel that working in a prison is for second-rate clinicians who can’t get better work, as I once did, or that typical prisoners are sociopaths who cannot be treated successfully.

However, after working in prison psychiatry for six months now, I must say that my clinic manager may just be right, at least for this medium-security men’s prison in Wisconsin. There is much that the rest of our mental healthcare system, especially community mental health, can learn from what is in place in some prisons today.

Better access to care
Take access, for instance. Inadequate access for care has been a chronic problem in mental health, not only for the uninsured, but also for the minimally insured or those in tightly administered managed-care programs. As the current economic crisis reduces state Medicaid funding, more patients can’t find services and become progressively more dangerous, often ending up in jails or prison. This has been dubbed the “criminalization of mental illness.”

Once these individuals reach the prison system, however, access to mental healthcare is no longer a problem. In fact, access is easier for mental healthcare than for medical healthcare. There is no fee for mental healthcare, but there is a fee equivalent to a day’s work for non-emergency medical care. Mental health is a priority in prisons, in part because mental health conditions often connect to the behaviors that caused incarceration in the first place. Inmates identified as being “mentally ill” may also offer an alternative, and perhaps more acceptable, explanation to others regarding their criminal past.

Not only do prisoners who recognize they need mental healthcare have easy access, but those with undiagnosed mental health problems are more readily recognized by others because inmates are under constant observation. Of course, mental disorders can be viewed as an excuse for criminal behavior and a means of being “soft” toward prisoners, who are known to manipulate the system. Occasionally, this thinking results in an inmate with a mental health problem, such as impulsive ADHD behavior, ending up in the segregation unit instead of the psychiatrist’s office.

Access is especially important in prison due to the prevalence of mental health disorders. Up to 50 percent of inmates are thought to have some diagnosable psychiatric disorder, including alcohol and substance abuse disorders.

Safety and security
Of course, access is meaningless unless both clinicians and patients feel-and are-safe. Clinicians can and do get hurt, or worse: Wayne Fenton, MD, was killed in 2006 while assessing a paranoid psychotic patient in his empty, private practice office on a weekend.

Though infrequent, there have also been violent incidents in the community mental health centers where I have worked, both in the clinic and outside in the parking lot. When funds were available, we hired a security guard, but often we couldn’t afford it. I had assumed that working in a prison would be more risky, and I worried that my counter-transference of feelings of fear for my patients could limit my responsiveness to them.

However, security is the first priority of prisons, and, as it turns out, there hasn’t been a dangerous incident involving a healthcare clinician in more than 20 years. The prior psychiatrist warned me that deer jumping on the roadway are more dangerous to me than the inmates visiting the prison medical office.

Throughout my 35-year career, I’ve sought to find a practice setting where family practitioners, psychiatrists, and other mental healthcare clinicians work together. And, to my surprise, here it is-in prison!

The quality of all the staff seems equivalent to what I’ve known outside of prison. Among the psychiatrists in this Wisconsin system are two former department chairs of well-known medical schools. One is known for his work with the homeless, and the other for his work with aggressive behavior.

Our salary meets or exceeds that of facilities outside the prison system. Productivity standards are not excessive, as they sometimes are in community mental health settings.

The prison population
Despite the high level of security, everything is in place to provide competent treatment. Among the disorders that a prison psychiatrist sees are:

•Antisocial personality disorder, which is clearly associated with criminal behavior and a lack of remorse. Psychiatrists don’t see many cases outside of prison because patients with this disorder don’t feel they need help or manipulate their way out of treatment.
•Malingering, a diagnosis often associated with antisocial personality disorder in the DSM-IV, which I have never considered as often as I do now.
•Post-traumatic stress disorder (PTSD). I have found that a significant percentage of those thought to be primarily sociopathic often have an extensive history of trauma and a subsequent onset of post-traumatic stress disorder. The trauma is especially common in African-American males, who are heavily overrepresented in prison systems. One has to be careful here because it is so hard to be sure that reported trauma actually took place due to the possibility of fabrication and limited access to information from family and friends.
•Narcissistic personality disorder appears to be quite common among prisoners as well.
•A large group of prisoners also have the expected alcohol and substance abuse disorders, which are often at the root of their criminal behavior and subsequent imprisonment.
•Bipolar disorder. This is sometimes seen after prisoners get “clean” from substance abuse for the first time in many years. Manic behavior associated with bipolar disorder sometimes led to substance abuse as the individual attempted to self-medicate the mood swings.
•ADHD is overrepresented in prisoners, and is frequently seen in the core symptom of impulsivity. Another ADHD symptom-poor concentration at work and school-often contributes to subsequent crime.
•Schizophrenia. There seems to be a smaller, but still significant, percentage of the chronic and severely mentally ill inmates, including schizophrenics. In many cases, prisons have assumed the role once held by state hospitals, from which schizophrenic patients were discharged in the 1970s into often inadequate community-based treatment.

Besides the disorders that inmates have upon arrival, there are other disorders that tend to develop within the prison environment. Depressive disorders secondary to loss and separation from the outside world are common. Anxiety related to fears about prison life and the future are also common. Inmates traumatized by other inmates may experience PTSD or a triggering of memories of earlier trauma.

Treating inmate disorders
Several common challenges must be overcome before effective treatment can be provided. Prisoners tend to mistrust authority figures, including clinicians. Given that clinicians desire to help people and be healers, working with those who have done the opposite can elicit intense feelings such as antipathy or even horror. For clinicians, those feelings must be processed and accepted.

Nowadays, the application of psychotherapy is as limited in prison as it is outside. Medication is the mainstay of treatment, though any medications that can be abused or diverted to other prisoners are strictly limited. In Wisconsin many medications are prohibited, including benzodiazepines and stimulants. Seroquel, which I had not realized was subject to abuse, is another prohibited medication.

Given the high costs of housing and securing prisoners, states seek to control other costs, including medication. Thus, less expensive, generic medications are always preferred, as their usage has less suicide risks and fewer metabolic side effects.

For the treatment of those with substance abuse disorders, we have a four-month residential facility. Such settings are virtually unavailable nowadays outside of a prison, except for the very expensive celebrity rehab facilities.

The treatment of schizophrenic patients can be especially distressing in prison. Fortunately, the rest of the inmates tend to leave these “crazies” alone rather than victimize them. Some schizophrenic inmates don’t seem to mind staying in prison. One such patient said to me: “Doc, I like it here. I hope I don’t have to leave. I wouldn’t mind coming back if I do. I have a place to stay, three squares, and medical care.” Finding adequate community mental health resources for inmates who complete their sentences is perhaps our greatest challenge in planning discharges.

I find that some of the most difficult prisoners to treat are those with Adult ADHD, since the best ADHD medication has very limited availability due to its potential for abuse. Some have suggested that separate housing units be developed for such inmates. However, earlier diagnosis and better treatment options outside of prison can help reduce the impulsivity, substance abuse, or social exclusion that leads to criminal behavior in the first place.

Conclusions
So, are those with mental illness better off in prison? Given the various states of prisons in the U.S. and the world, ranging from the bare-bones barracks and occasional riots in California to the hotel-like settings and services in Austrian prisons, some patients are and some patients aren’t.

Am I, and other clinicians like me, better off in prison? As of now, it certainly seems so. I not only can provide as high or higher quality treatment in the prison setting, but I’ve been challenged by situations that I’ve never encountered before and learned things I couldn’t have learned anywhere else.

Helping those who have hurt others can be the ultimate test for a healer. When my treatment is successful, I have the satisfaction of knowing that I may have reduced the typical 70 percent recidivism rate by motivating a former inmate to change his life’s course, perhaps in a way that saves the lives or property of other citizens. This feeling makes me wonder if most mental health clinicians or administrators wouldn’t be better off after spending a little time in prison.

Comparing prison psychiatry and community psychiatry

Prison

Community

Access to care

No insurance required; rapid access with little or no cost

Coverage required; significant waiting times are common

Integrated primary/mental healthcare, with on-site psychiatrist

Sometimes available

Rarely available

Productivity expectations

Generally appropriate

Sometimes excessive, especially under tightly managed plans

Medication availability

Generally limited, includes only generics and medications with low abuse potential

Unlimited, based on prescriber’s preference, formulary provided in coverage, or patient ability to pay

Substance abuse treatment

Long-term, residential treatment often available on site without long waits

Off-site residential treatment may require wait time and significant out-of-pocket costs

Vulnerability to violent behavior

Extremely low due to high security, constant observation, and prior knowledge of violent patients’ histories

Varied, based on funding for on-site security, knowledge of patient history, office staffing, and layout

[Ed Note: This article, originally published in Behavioral Healthcare (2010;30:26-29), has been chosen as a finalist for NIHCM Foundation’s Seventeenth Annual Health Care Journalism Awards. For the Behavioral Healthcare Web site and article, clickhere. For a related blog by Dr Moffic, see Wrestling With Evil in Prison Psychiatry.]