Paperwork

Doin’ the weasel

It’s usually sad to see a guy come back to prison, often for some stupid reason.  But for today’s returnee, I’ll make an exception.

He’d have better luck on selling me his hard-luck story if I hadn’t been the one who researched and wrote up his social history the last time he came through here.  It’s still in the files.  In the twenty-odd years in which he’s been bouncing in and out of prison, he’s also been in and out of the prison mental health system, which he has historically used to manage his comfort level in prison.  There’s not the slightest iota of evidence that he has ever had any commitment to personal change, and no evidence that he’s bothered with mental health in the community either.  Why should he?  Like most antisocial types, he doesn’t think there’s anything wrong with him; it’s the system that needs to change to accommodate his wishes.

Even if I didn’t know his history,  I’d be suspicious. For one thing, he’s lying to me about why he’s back in prison; he says it’s because he missed a curfew — a minor technical violation of probation — but he admitted to Classification that he’s in because he stole a car from his employer.  Nice guy; that’s one more bridge burned, not to mention that he’s just made it that much tougher for the next ex-con who needs a job to find one.  Then there’s the way he’s presenting.  He’s over-dramatic and much too invested in trying to sell me on his “problems,” for reasons that rapidly become apparent — he wants me to intervene and ensure that he won’t go to a particular prison where he’s had trouble before.  No dice.  That’s Classification’s bailiwick, not mine; they don’t take recommendations, let alone orders, from Mental Health.  Besides, if he’s telling the truth about the investigation and its outcome, there will be a flag on his file to ensure that he doesn’t come in contact with the same people again.  If he’s lying, tough; it’s still not my problem.

He also wants me to get him into an inpatient mental health facility when he is released 18 months from now, and I know perfectly well why — he has absolutely no intention of changing his ways and figures he’ll get more lenient treatment in a mental hospital than he would continuing his predatory ways on the street, which will bring him right back to prison.  I have all I can do not to laugh in his face.  We can’t even get chronic schizophrenics into the state hospital and out of the prison system, and he thinks they’re going to admit him because that’s the way he wants it?  I tell him as nicely as I can that inpatient placement isn’t a realistic option and he would be better off talking to the transitions officer about a halfway house placement when the time comes for him to prepare for release.  He doesn’t like that; he could use the support, all right, but halfway houses have strict rules, and he doesn’t want to deal with that.  But he also guesses — correctly — that I’m not going to give this issue any more time today.  Even if what he wanted was a legitimate option, it’s far too early to get into pre-release planning.

He’s watching me intently; his head weaves from side to side, but his eyes are steady as rocks and about as expressive.  In fact, his whole upper face is a mask, contrasting sharply with his emotional speech and mobile mouth.  He reminds me of one of those nature films in which a weasel is getting ready to strike a mouse.  I’ve seen this behavior plenty of times before, and in my experience it’s invariably the mark of a sociopath who’s trying to run something past me.  Not today.  I wrap up the needed business and get him out of my office.  Fortunately for me, he’ll be someone else’s problem soon; he’s been on a caseload here before, so his former counselor will be picking him back up.  I silently wish my colleague luck; he’s going to need it.  And a lot of patience.

Penny wise, pound foolish

Budget cuts are a grim reality in my state, as in many.  But cutting prison substance abuse programs isn’t where I’d want to do it.  I’m seeing too many guys who should be in treatment declared ineligible — especially first-time offenders, often young, who have histories indicating heavy use of alcohol, marijuana, or both.

I suppose some people figure these are relatively “minor” drugs — shoot, alcohol is even legal, at least as long as you’re over 21 — and not worthy of that much concern.  Perhaps they need to read the recent news releases about binge drinkers and how often they get behind the wheel while sloshed.  According to a September 1 article by the Associated Press, a survey of 14,000 binge drinkers (those who admit to consuming five or more drinks at a sitting at least once a month) revealed that 12% of them admitted to getting behind the wheel and driving after their last binge.  That alone ought to be reason for some concern.  Too, alcohol serves as “courage in a bottle” or a convenient excuse for a lot of crimes ranging from robbery to date rape to partner abuse.  Then there’s the lovely health effects of chronic drinking — cirrhosis of the liver, elevated risk of GI tract cancers, premature aging.  (In the mental health population, heavy drinkers are notoriously easy to spot by the time they’re in their mid-thirties or so; they usually look at least 10 years older than their stated ages, especially if they also smoke.)

Marijuana is not exactly harmless either, no matter what its advocates think.  I’m not talking about casual use of a few joints a week, which I suppose can be compared to having one or two beers or a glass of wine every so often; people may disapprove for various reasons, but at that level it’s not likely to hurt you.  And I will admit right now that it is high time (excuse the pun) that medical research got back to exploring the possible benefits and uses of cannabinoids.  But heavy, regular consumption of marijuana is something else again.  There’s a fair amount of research indicating that this stuff can trigger psychosis in vulnerable individuals; the smoke is loaded with cancer-causing agents; and in my experience, chronic users tend to be either pretty irritable or highly anxious, especially when they can’t get their weed any more.  (Of course, this could be a chicken-and-the-egg thing, but even if the mood symptoms came first, the pot sure isn’t helping the person learn how to manage them effectively.)  Not to mention that anything bought on the street isn’t exactly standardized, so unless you grow your own, you’re taking your chances as to both the potency of the weed and what else may be included in your toke — a little insecticide, maybe, some oregano for filler, or maybe even a little cocaine or PCP to give it some added kick.

That’s not all there is to it.  A lot of my inmates started using alcohol, marijuana, or both in their early teens, and a fair minority indicate that they started using before the age of 10.  I’ve met a few who’ve told me that their parents or other caretakers used to put booze in their bottles when they were just tots.  Now, you can argue that social use of these substances by responsible adults is no big deal, but I don’t know of anyone who thinks exposing a child’s developing brain to powerful psychoactive substances on a regular basis is a terribly good idea except by prescription and under a doctor’s supervision.  (And you can find plenty of debate out there on whether even that’s a good idea; the use of medication for pediatric mental health issues, especially off-label use, is a hot topic indeed.)  In teenagers, the development isn’t quite as rapid, but the risk of harm to developing areas of the brain is still there.

Treating these inmates has more importance than helping steer them away from repeat trips through prison, though it surely helps even that.  Most of these first-timers will be fathers and mothers someday, if they aren’t already.  Helping them deal with their substance abuse issues isn’t just for their own sakes, but for those of their future or existing families, so that the cycle of abuse and damage is less likely to be passed on.  And that reduces everyone’s costs, personal and financial, in the long run.  Isn’t that worth spending some money on here and now?

Bad news, big time

The news from Florida’s prison system is all over the Internet.  One inmate is in an outside hospital, fighting for his life.  He was allegedly beaten over a two-day period after flinging feces on a correctional sergeant.  Seven officers — including the aggrieved sergeant and a lieutenant — are on administrative leave pending the outcome of investigations by the state of Florida and the FBI.  Even more shocking, four nurses were fired for failure to report the alleged abuse.  By the time the investigations are finished, more people may be facing criminal prosecution.  The newspapers, needless to say, are having a field day.

For correctional officers in any state to do what these men are accused of doing is inexcusable.  It may be unpleasant and disgusting to be the target of flung feces, but there are appropriate ways to respond to an agitated inmate and legitimate channels for disciplinary action.  Beating an inmate within an inch of his life does not come under either heading.  It is doubly inexcusable for a senior officer, one entrusted with the supervision of others and with setting the example, to be involved in such a breach of the regulations governing a prison.  The grim symmetry to the situation is that, if convicted, these officers will find themselves at risk of the same treatment they have allegedly dished out — quite possibly from the other inmates.  As the old saw says, what goes around comes around.

Yet, as horrible as the alleged actions of the accused officers were, the fired nurses failed at an even more fundamental level.  By profession and oath, they are bound to work for the health of all the human beings who come within their circle of care.  To ignore that obligation for whatever reasons and to fail to take whatever action was possible are sins of omission every whit as culpable as the officers’ alleged sins of commission.  Not one of the four fired nurses laid a finger on the injured inmate, but should he die, they will bear part of the responsibility for his death.  Even if it turns out that the officers are exonerated, the nurses still had a duty to see to it that the inmate received appropriate care for his injuries and to make any needed reports regarding a use of force.

Aside from the family of the injured inmate, the people who ought to be maddest of all about this are the correctional officers and prison health care staff across the country who carry out their duties to the best of their abilities within the scope of the law.  Once again, the actions of a few will taint the reputations of the many and make what’s usually a thankless job anyway that much more difficult.

A tale of three inmates

Depression and anxiety.  Depression and anxiety.  Some days it seems that those are all the problems I see.  Run of the mill stuff, really, when working in a prison.  You expect people to be depressed here.

Except it’s not quite as simple as that.  Three inmates come in, one after another.  They’re all being treated for depression and anxiety.  And they couldn’t be more different than morning, noon, and night.  The first is pretty routine; from what I’m reading in his records, the only time he ever complains about mental health stuff is when he’s in jail or prison.  Diagnosis:  “jail-itis.”  A habitual thief, he’s been in a few times before and knows the routine; he’ll be all right once he quits wasting time on feeling sorry for himself.  (He certainly hasn’t any sympathy to spare for his victims.)  Won’t hurt to keep an eye on him and give him a safe place to get things off his chest, but chances are he’ll be fine in a few weeks, and he admits as much.

The second has different problems.  He has high blood pressure and has started having chest pains recently.  He’s middle-aged, a bit overweight.  He’s been in prison before and can handle that; it’s his health that’s got him scared, legitimately so.  The question is whether his depression and anxiety are reactions to his health problems or is a direct result of them, since heart disease appears to have a physiological tie to both.  The psychiatrist has already put him on antidepressant medication to help take the edge off his emotions, but he’ll definitely need some supportive therapy.  If the medical department can help him get his blood pressure under control and work with him on losing some weight, that will probably help too.  The less helpless he feels about his health and the more he feels that he has some control over his condition, the better.  Since he’s indicated a religious preference, I suggest that he talk to a chaplain or volunteer from his faith as well; the more lines of support he has, the better.

The last of the trio is a 19-year-old, first time in prison.  That’s reason enough to be upset and scared, but there’s more going on with this youth than that.  He’s alleging that he was molested by his cellmate while in the county jail; the record indicates that his claim is being investigated.  If his story is true, there’s a serious lawsuit in the making — how could anyone have been so stupid as to pair a youthful offender (so designated by court order) with a 60-year-old with a previous history of sex offenses against younger males?  The teenager is now reporting symptoms consistent with posttraumatic stress disorder: not just depression and anxiety, but nightmares, intrusive memories, and inability to relax anywhere, any time.  The one bright spot in all this is that the molestation apparently happened only once and wasn’t all that long ago; it’s a lot easier to intervene under these circumstances than when there’s a long history of repeated traumas.  Fortunately, we have a counselor on staff who’s taken special training in the treatment of trauma; I refer this young man to him, hoping that if we can lay the groundwork now, the inmate will recover with relatively little long-term damage.

Whew.  And that’s just the morning’s schedule.  Wonder what the afternoon will bring?

Diagnosis

In these uncertain economic times, one way of getting the maximum out of every dollar spent on prison mental health would be to ensure correct diagnosis.  While I don’t have any scientific data on the matter, from my own personal experience, I would guess that we’re spending hundreds of thousands of dollars annually — if not more — on medications that are ineffective because they aren’t properly matched to the inmate’s actual conditions.

Unfortunately, we’re hampered by several barriers to getting started off with an accurate diagnosis, and the biggest single one is probably lack of time.  On first coming into the prison system, inmates are usually screened through an intake interview with a master’s level mental health specialist.  While the intake specialists are mostly experienced clinicians, the interview often lasts only 10 minutes, seldom more than 20; there’s too many people to be gotten through in a day to take more time than that.  Those identified as needing psychiatric evaluation, either because of the interview or because they were under mental health treatment while in the county jail, then see one of the psychiatrists.  These interviews are usually a little longer but seldom above 40 minutes.  And regulations require that a diagnosis be made within that time if the inmate is judged to need treatment  The long and the short of it is that in most cases, inmates are getting their diagnoses based on no more than an hour’s clinical contact, plus whatever records the county jail sent along.  Unfortunately, once a label is applied, it tends to stick whether it’s accurate or not.

The pressure to move inmates through the mental health intake process fast is enormous.  Reception centers have only a limited capacity, and the longer inmates sit at these facilities, the greater the backlog grows at the county level.  As things now stand, there simply isn’t time to do structured interviews (which are themselves expensive in terms of staff time and the materials that have to be purchased), to do multiple interviews involving the full treatment team, to perform psychological testing beyond the quick screenings that are standard for all incoming inmates, or to request records from previous treatment providers and wait for them to arrive.  Yet all of these things would be extremely helpful, especially given the grim fact that, for many reasons, inmates aren’t always accurate historians.

Inmate diagnoses often aren’t cut-and-dried, either.  The most common complicating factor is substance abuse, and it’s usually abuse of multiple substances at that.  Lifestyle factors also have to be considered; if an inmate reports feeling “paranoid,” is he really reporting irrational fears or the results of 10 or 20 years of looking over his shoulder for the police and rivals?  Then there’s the medical side of the house.  Histories of head injuries are more common among inmates than in the general population; so are chronic conditions such as hepatitis C, poorly controlled diabetes and hypertension, and chronic pain conditions due to orthopedic and/or neurological injuries sustained in motor vehicle accidents, on-the-job accidents, and shootings.  All of these conditions can have a significant impact on mental health.

In an ideal world, we’d be able to spend all the time we need to get an accurate picture of what’s going on with an inmate.  Unfortunately, time is what the system doesn’t allow — a real irony in a system in which the inmates have, as they say, “nothing but time.”

Red flags

“It’s nothing to do with my situation,” the inmate insists.  “I got a lot of stress on me.  I just want to kill myself.”

Yeah, right, I’m thinking.  Thirteen years of working in prison mental health have taught me a lot about what’s live and what’s Memorex, so to speak.  This guy is about as genuine as a three-dollar bill.  For starters, he’s claiming to be so stressed that he’s feeling overwhelmed and suicidal.  I’d be more likely to believe him if he could give me some specifics about why he’s feeling stressed.  He can’t — or, more accurately, won’t.  He repeatedly ducks the question.  And then he tops off his evasiveness and refusal to give a straight answer by saying, “I know you see a lot of other guys who are just playing games.”  I have to bite my tongue to keep from replying, “Which is precisely why I’m not buying your act for a minute.”  Has it ever occurred to him that all the other guys have given me the very same line about how they’re not the ones playing games?

Naah, probably not.

He doesn’t look at all overwhelmed either.  People in that state usually look either desperately upset, numb, or scared half to death of their own out-of-control emotions; if they’re maintaining control, they’re doing so by the tips of their fingernails.  This inmate?  Not even close.  He’s mostly just plain mad, and I know perfectly well why, considering he just got gassed for yet another episode of acting up.  As if he didn’t have plenty before, at every facility he’s ever been to; he’s in close management status for good reason.  Too, I know the correctional lieutenant on this shift pretty well, and he’s not the kind to overreact and hand out punitive action indiscriminately; he’s usually as easygoing as the inmates will let him be.  If at all possible, he’d have given this man multiple chances to back down before ordering a spray.  And, of course, the whole incident is on videotape; the officer with the camera is only waiting for me to finish my interview (which, by law, cannot be recorded other than in my mental health notes) before resuming filming.

To top off his less-than convincing presentation, the inmate complains that he has put up repeated requests for mental health assistance and they have been ignored, intimating that this is the reason why he “lost it ” today.  Unfortunately for him, his claim is easily checked.  As a matter of fact, he was seen by one of my colleagues just four days ago and was referred to the psychiatrist for further evaluation; he has an appointment pending in just two days.  Legally, I could hit this loser with another disciplinary report for lying to staff, but there’s not much point to it; he’s already gotten himself sunk into about as much trouble as he can have short of picking up another criminal charge.  I content myself with confronting him on the fact that he obviously has had attention paid to his requests and ask him again what has changed since he was seen.  And, if course, he once again refuses to give me a straight answer.

Of course, I’m going to refer this inmate for further evaluation anyway.  It doesn’t matter if every clinical instinct I’ve got is screaming that this man’s a malingerer; he’s still insisting he’s suicidal, and that means he’ll be cluttering up a suicide observation cell tonight.  He won’t escape his disciplinary problems, though; they’ll all be waiting for him when he gets back out.  You’d think he’d learn, considering this isn’t the first time he’s tried this ploy.  But it seems that he and the others of his kind (antisocial personality disorder) never do.

Master count

Slow afternoon today thanks to a master count, which is what happens when the initial count and a recount still can’t get the number of inmates on the prison roster and the number of inmates actually counted to match up.  Most of the time, it’s either because of an error in counting or because an inmate wasn’t properly transferred from one housing unit to another.  It can take hours to sort out the latter situation.  One truly spectacular snafu happened years ago when an inmate dropped dead from a heart attack just before morning shift change; his body was properly checked into the prison morgue until the relatives could be notified, but someone forgot to take him off his dormitory’s roster.  Of course, by the time the next count rolled around, all the officers who knew he was in the morgue had gone home for the day.  It took literally all day for Security to realize that while the inmate had in a sense escaped, his body was still very much around and accounted for.

Master counts are a nuisance from a clinical perspective, since all inmates have to return to their assigned bunks for the count.  That means we don’t get much work done, since we can’t see inmates in our offices while the count is in progress.  But they are absolutely necessary from the viewpoint of prison security.  Frequent counts reduce both the chances for an escape and the chances that an inmate will get a substantial head start if he does get loose.  They also reduce the chances for inmates to hide out within the prison grounds where they can waylay staff or fellow inmates.  All things considered, I’d rather deal with the nuisance than the alternative.

What do you do?

Another day, another social dilemma.  This time it’s an inmate in the medical inpatient unit.  He’s got AIDs-related dementia; just to complicate things, he doesn’t speak English either.  The medical staff want him out of there; he isn’t sick enough physically to warrant inpatient care, and they’re tired of dealing with his agitated periods.  But he can’t manage on the compound, either, and he doesn’t really belong in the inpatient mental health units we have; they’re meant for treatment, not warehousing of a guy who isn’t going to get any better.

We’re seeing this problem more and more often with an inmate population that’s getting older and sicker.  Trouble is, there aren’t too many places on the outside willing to take a guy like this even if he does get a parole for medical reasons, and he doesn’t have any family left that’s willing to cope with him.  At least he wasn’t a violent sort before he got sick; he’d move from difficult to downright impossible to place in the community with that kind of record.  But what we’ll do with him for the long run I don’t know, and neither does much of anyone else.

Choices

It’s an old saying that if there’s one thing you can’t save a man from, it’s himself.  It’s also true.  The 21-year-old kid I’m facing through the bars at the confinement unit is a case in point.  He’s already told Classification that he doesn’t care about education or vocational training because he plans to go right back to dealing drugs as soon as he gets out.  If he’s lucky, he’ll be back in prison before too long.  If he isn’t, he’ll most likely be dead; violence and drugs go hand in hand.

I don’t really know why the psychiatrist is having us waste time on therapy for this kid.  He’s not interested, other than in having access to someone else he can try to con.  And he doesn’t think anything’s wrong with him anyway, other than being a little depressed about being locked up.  It’s next to impossible to do anything with someone who doesn’t feel that he has a problem.  He probably wouldn’t even bother with the antidepressant except that it has enough of a sedating effect to help him sleep better.

Harsh as it sounds, this young man isn’t worth our time as therapists.  Maybe someone could have done something had there been intervention while he was still little, before he became hardened into the mindset he has now.  If he survives, he may reach a crisis point twenty or thirty years from now, when he’s old enough and damaged enough to have lost any cocksure notions that he’s immortal and can make the world go the way he wants it to.  But there’s nothing that could reach him now, unless it’s divine intervention — and he probably isn’t amenable to that either.