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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?

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.

I once asked them how they could be so cheerful, joke with one another, and seem not to have any depression. They were quiet for a few minutes and finally came up with one answer with which everyone agreed: "We have each other," they said. They are able to make a family out of fellow prisoners.

The complexity of the problems faced by those in prison is overwhelming. For example, one of the Lifers has shared with me the number of deaths of prisoners he has witnessed in his 40 years in the prison. So much is unknown about this population. How do they view the behaviors that landed them in prison for life?

The Lifers created PSI - the Public Service Initiative - of which I've become a big part. They train young men who will be discharged to be mentors of younger boys and men who are on the street selling drugs and getting into trouble. They report to us when discharged, and we put them in touch with a mentee and support them in other ways. This is another group of men who hopefully will not return to prison.

Currently about 50% recidivate, that is, they do return to prison. It is hard to resist the call of the streets. We try to get them jobs, which is extremely difficult. Because jobs are so hard to come by, they often end up committing criminal acts to generate income.

Race is another important issue that must be examined as we look at our prison populations. Hundreds of African American men are in prison for committing nonviolent, crack cocaine-related crimes, while their white counterparts who were arrested for offenses related to powder cocaine are not. Because of this double standard in our criminal justice system, the lives of thousands of African American families have been disrupted. Michelle Alexander, a longtime civil rights litigator, examines these issues in a book called "The New Jim Crow" (New York: The New Press, 2012), Instead of paying $30,000 to $40,000 per inmate per year to essentially warehouse human beings, why aren't we making sure that those with addictions get treatment?

Women in Prison

Women, particularly those of color, "represent the fastest growing segment of the US. prison population and their incarceration mirrors the ethnic and racial disparities of our larger society." In the area of mental illness, women prisoners have higher rates than do incarcerated men: 73% vs. 55% in state prisons; 75% vs. 63% in local jails icy, Politics & Nursing Practice 2011;12:119-25 [doi: 10.1177/1527154411412384]).

Yet, the lack of access to mental and physical health care by women who are incarcerated is well documented. One deterrent to health care in prisons is the practice of charging copayrnents. "Today, all U.S. federal prisons and about 70% of state prisons have a copayment, collecting a fee of between $2 and $10 for each request for health care made by a prisoner," wrote Anastasia A. Fisher and Diane C. Hatton (Women's Health Issues 2010;20:185-92). Ms. Fisher and Ms. Hat-ton studied three women's prisons in California that charge copayments for care, and the women resented paying for what they considered poor health care. As one woman said: "I've been in jail so many times that unless I'm deathly ill, I don't go. Water and Motrin are their answers for everything, they won't answer my questions. 1 don't go." Another woman described an experience with a doctor that should hit home for us: "I went to see the psychiatrist, I didn't get anything. I saw him through the glass barred window, and he asked me a couple of questions and that's it. It is $3 for that."

Just as they do in the general population, women in prison use health care and psychiatry much more than do male prisoners. Access to care is one of the most pressing problems facing women who are incarcerated.

Unfortunately, compassion is in short supply in prison. The prevailing attitude is that people who commit crimes don't deserve any consideration. However, psychiatrists are usually compassionate, and prisoners would thrive on a shred of kindness we would provide.

America has more people in prison than any other country in the world. Warehousing human beings is a complex enterprise, and those human beings are deeply affected by the process. I want to encourage every psychiatrist in America to spend time with the men and women in the local prison or jail and lend a hand. Those who are serving time are part of a community that is tremendously underserved. This work would open up a whole new vista for our specialty.

DR. FINK is a consultant and psychiatrist in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia. He can be reached at cpnews@elsevier.com.

PAUL J. FINK, M.D.
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Title Annotation:OPINION
Author:Fink, Paul J.
Publication:Clinical Psychiatry News
Date:Feb 1, 2012
Words:1483
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