Fink! Still at Large: Mental Illness Is a Risk Factor Incarceration, and Inmate Populations Are Rising in the United States. What Does This Mean for the Practice of Psychiatry?

Article excerpt

This means that we must refocus! We must realize that thousands of potential patients with mental illness are found in our jails and prisons - rather than in traditional places such as offices and hospitals.

The risk factors for incarceration include mental illnesses such as schizophrenia, bipolar disorder, or other psychotic disorder diagnoses; co-occurring substance-related diagnoses; homelessness; no Medicaid insurance; prior incarcerations; and being African American. More than 2 million people are incarcerated throughout the United States (Psychiatr. Serv. 2012;63:26-32).

These rising inmate populations are putting incredible pressure on mental health services within our prisons (Psychiatr. Serv. 2011;62:1121-3). All of us have heard it said that the largest mental hospital in America is a Los Angeles jail.

Yet, few psychiatrists in America have ever set foot in a prison, and I worry that few of us have empathy for incarcerated patients who suffer serious indignities and have little or no care. Our absence means that thousands arc being neglected.

The history of 20th century psychiatry is filled with instances in which our profession failed to pick up the ball, and allowed the care of populations or the practice of new and successful treatments to fall to nonpsychiatrists, such as psychologists, master's level social workers, and others. Well, we're well into the next century, and it's time for a change. Prisoners need sophisticated mental health care, and they aren't getting it. Volunteering, perhaps spending one day a week caring for prisoners, could make a difference.

The Life of a Lifer

As I've mentioned previously, for the last 4 years 1 have been going to the State Correctional Institution at Graterford, Pa., a maximum security prison, to meet with a group of men, all of them African American, who have been sentenced to life in prison. They call themselves the Lifers. All of the men have either murdered someone or participated in a crime in which someone got killed.

They invited me to be on their executive committee, and 1 gladly accepted. My role is not to serve these men as a psychiatrist or as a therapist, i observe them, and they ask me to do things on the outside of the walls, which I am happy to do.

I meet with the Lifers every 2 weeks to help them with issues and questions about real-life stabilization, how to deal with a wife and child, how to reintegrate into society, and how to look for a job.

Doing this work is not convenient. The prison is 30 miles from Philadelphia, and the rigmarole of getting into the prison (as a volunteer) is awful. The rules are very strict, and they give us a taste of what the prisoners go through. The entire experience is humbling, to say the least.

The men in my group are considered the elite among lifers at Graterford. They are highly motivated and thoughtful. Some of them have earned bachelor's degrees during their incarceration. They come together to plan meetings, pursue intellectual issues, and study.

For years, they have worked to develop concepts related to reducing the culture of crime and reaching out to young boys who are destined to be in prison (although they cannot get out and do the work themselves). Those who have been in prison for more than 30 years have had time to be transformed and put their crises behind them. They tolerate the daily ignominy of total loss of control over their movements and being watched, ordered around, and told when they're allowed to do every function. Many of them have rienced multiple days in the hole - a tiny space where they spend 23 hours of the day totally alone. It is hard for me to describe with any accuracy what living in prison is like.

These men have no problem reaching out for help. Right now, if a prisoner becomes psychotic, he receives antipsychotic medication - and little else. There are no personnel to listen to the prisoners and to help them clarify their feelings about their families, their children, and the hopelessness of their situation. …