Prison Psychiatrists Must Overcome Barriers to Effective Care
Lee Rome, M.D.: “It is a humbling experience to work in prisons.”
“It’s a self-contained society with its own language, customs, and rituals,” said Rome, noting that the customs and rituals are usually related to security measures that can seem daunting for many psychiatrists. “Some metal detectors can be so sensitive that you’d swear they were picking up the iron in your hemoglobin.”
Rome traveled to APA’s 2001 annual meeting in New Orleans in May to be part of a panel of experts discussing the most crucial issues in prison psychiatry.
Rome said he has seen unresolved issues relating to dependency or control emerge in practitioners unprepared for what can seem to them to be degrading practices. “It is a humbling experience to work in prisons,” said Rome, “and I have seen psychiatrists leave the prison setting for good because they have been narcissistically injured from having to surrender their wallet or be patted down.”
Countertransference is perhaps the most significant issue in prison psychiatry, according to Rome.
Psychiatrists often have emotional reactions that mirror the patient’s behavior and interpersonal style, Rome noted. He explained that they can serve as a barrier to appropriate diagnosis and treatment if acted out by the psychiatrist, or an opportunity to better understand the patient’s issues if appreciated as important clinical information.
In a prison setting, some prison patients may seem threatening to the psychiatrist, and others may appear helpless. The psychiatrist may feel fearful of the prisoner who seems threatening or may have fantasies of rescuing the patient who seems helpless, according to Rome. The psychiatrist may then unconsciously act out in a punitive manner toward the patient or in a way that inappropriately appeases the patient, Rome pointed out.
“If that happens,” said Rome, “the therapist can unconsciously withhold or provide treatment that isn’t clinically indicated. This, of course, can interfere with an objective diagnosis and treatment of behaviorally disordered prisoners,” said Rome.
He suggested that due to countertransference, it is possible for psychiatrists to “criminalize mentally ill behavior or medicalize criminal or antisocial behavior,” said Rome.
The prison psychiatrist must determine whether the prisoner’s maladaptive behavior relates to an underlying major mental disorder, which should respond to medication or psychotherapy, or is linked to personality disorders that don’t respond to psychiatric treatment, or both, said Rome.
In one instance, for example, the psychiatrist can misinterpret maladaptive behavior as an antisocial personality disorder when its underlying cause is a major mental illness—and then the patient doesn’t get the appropriate treatment. Instead the prisoner is placed in administrative segregation as a punitive measure, Rome noted.
In contrast, he said, if the psychiatrist places a psychiatric diagnosis on behavior that is purely predatory, narcissistic, and antisocial, obvious problems are created.
“The prisoner may be placed on a mental health unit [in the prison], and the antisocial behavior will continue—the prisoner won’t respond to medical treatment and may assault staff and mentally ill prisoners on the unit,” said Rome.
He noted that when the psychiatrist steps back from emotional reactions toward the prisoner such as fear, anger, and punitive feelings, he or she will be more effective at sorting out personality-disordered behavior from the elements of an Axis I major mental disorders.
Rome also focused on populations in prisons that need special treatment considerations. These include suicidal prisoners, prisoners who self-mutilate, women, juveniles, and prisoners with developmental disabilities.
Jeffrey Metzner, M.D., talks about the importance of discharge planning when treating inmates who have a mental illness.
Metzner, who is chair of APA’s Council on Psychiatry and Law and president of the American Academy of Psychiatry and the Law, said, “Discharge planning is an essential component of mental health treatment of the inmate.” He added that the extent of discharge-planning services provided to the inmate needs to be adjusted to the nature and severity of the inmate’s mental illness and his or her ability to function independently after release.
Metzner noted that key obstacles to an inmate’s effective transition into the community after release are homelessness, symptoms of mental illness, poor socialization skills, and cognitive deficits.
“Adequate discharge planning includes creating a written service plan that identifies the needs of the inmate and the appropriate resources available to him or her upon release,” said Metzner. He also suggested that psychiatrists refer inmates to community-based mental health services and provide inmates with a temporary supply of medication when clinically appropriate. ▪
