Behavioral Health Brief: Finding Effective Treatment in the Criminal Justice System
By Sue Coyle, MSW
Social Work Today
Vol. 19 No. 6 P. 32

Correctional facilities—prisons and jails—are the largest mental health institutions in the United States. Incarcerated individuals struggle with a wide variety of mental health needs. In fact, according to a 2017 report from the Bureau of Justice Statistics, more than one-third of prison inmates and 44% of jail inmates have been told that they have a mental health disorder by a mental health professional.

This is widely known to those who work and live within jails and prisons. “I would talk to the wardens, and they knew they were running mental health treatment facilities. I talked to people at the state level, and they knew,” says Jennifer E. Johnson, PhD, C.S. Mott Endowed Professor of Public Health, a professor of OB/GYN, and professor of psychiatry and behavioral medicine in the division of public health in the College of Human Medicine at Michigan State University. “It’s the rule, not the exception.”

However, the treatment available to incarcerated individuals does not align with the level of need. “There were a handful of MSWs,” Johnson says of what she saw as a researcher entering the prison system. “All they had time to do was try to prevent suicides and address rape allegations. For the bulk of people with problems—if they were seeing anyone—they were seeing a bachelor’s-level mental health counselor.”

The Bureau of Justice Statistics affirms Johnson’s report, as they found that the most common type of treatment for inmates with a mental health indicator in jails and prisons was medication. Therapy and counseling services were considerably less common. And, all told, only about one-third of prison and jail inmates were receiving any type of treatment at the time of survey.

Fortunately, researchers (and practitioners) are looking for ways to effectively meet the mental health needs of incarcerated individuals.

MDD and IPT
In a study released early this year, Johnson and her team examined the impact of interpersonal psychotherapy (IPT) on prisoners diagnosed with major depressive disorder (MDD).

They chose to look at MDD because of its prevalence. “People in jails and prisons have elevated rates of all kinds of mental health and substance use disorders. Major depressive disorder is the most common, with up to 24% having lifetime major depression,” says Johnson of both male and female prisoners. “Depression also increases several areas of risk in prison—poor functioning, aggressively acting out, getting picked on. It makes it harder to function,” she says.

IPT was chosen because previous studies had shown that counselors at varying levels of education and experience could be trained in it. Additionally, IPT offers both structure, which can be beneficial to the individuals incarcerated, and the opportunity to address stressful life events.

Licensed clinicians, as well as non–specialist counselors, were trained in IPT and delivered it throughout the study. The individuals who received this treatment did so over the course of about 12 weeks, with 20 group sessions and four individual sessions. The treatment was provided as an add-on to what they already received, which ranged from nothing to medication to infrequent (monthly or even quarterly) counseling. The control group continued with their regular treatment only.

The study found that IPT reduced depressive and PTSD symptoms, and increased remission from major depression. The effects on suicidality were minimal. However, Johnson questions the accuracy of suicidal ideation reporting. “If they think you’re suicidal, they put you in isolation,” she says. “People tend not to report.” She looked instead at the prevalence of hopelessness, which strongly correlates to suicidality. “IPT dramatically reduced hopelessness,” she says.

The treatment did not, however, appear to have a significant impact on prison functioning. There was not much difference in the prevalence of events such as behavior leading to discipline reports.

Beyond Modality
While the study is promising and points toward an intervention that jails and prisons could implement, Johnson notes that identifying effective treatment measures is just one piece to a large, complicated puzzle. There are many other aspects that need to be addressed in tandem for incarcerated individuals to receive the care they need.

For one, within jails and prisons, communication and understanding surrounding mental health need to improve. Take for example, discharge planning within jails specifically. “Only 30% of people with serious mental illness have any kind of discharge planning. Forty-three percent of people are discharged between 5 pm and 8 am,” says Sheryl Kubiak, PhD, dean and professor at Wayne State University School of Social Work and director of the Center for Behavioral Health and Justice.

While the security team knows of releases ahead of time, she adds, it’s not unusual for the mental health team to be unaware. “The security and mental health sides of the house don’t really communicate that well,” Kubiak says. “If they don’t feel like it’s need to know, they don’t let the folks know. [Additionally], they use HIPAA as a shield to block what would be continuity of care: ‘We can’t flag individuals as mental health clients, because the security staff would know that they have mental health issues.’” Thus, even if the security team was apt to share discharge information with the mental health team, they may not know they should.

When care is given—whether assessment, medication, or ongoing counseling—there is a significant lack of standardization and continuity within jails and across systems. Kubiak points out that while jails must complete some type of mental health assessment, no one validated measure is used. “What they call screening really varies,” she says.

As does the medication management provided. Oftentimes, individuals must start a new medication once incarcerated. The change, as well as the time it may take for the new medication to take effect, can have negative results on both well-being and behavior.

Within prisons, similar obstacles exist. However, Kubiak notes that incarcerated individuals are not housed in prisons unless they have at least a 12-month sentence. Jails have a much more rapid cycle of turnover; therefore, prisons are often better able to achieve stabilization.

Addressing Policy
Addressing these challenges is, again, multifaceted. It’s not just the individuals who work within the jails who have to strive for change. Evidence-based practice, standardized tools, and increased communication will help but not solve the lack of quality mental health care. Both Kubiak and Johnson note that change has to happen at the policy level as well.

In fact, policy was influential in why Johnson chose to implement interpersonal psychotherapy as a part of her study. As a relatively inexpensive treatment modality (the cost per patient was just $575, not including staff training and supervision), IPT could be seen as more appealing to a system that already lacks funding for mental health care. Johnson also believes that positive results in prison functioning, though minimal, would appeal to the policy makers. After all, “ultimately, they’re [the legislators] answerable to the voters,” she says.

The hope is that studies such as Johnson’s will encourage legislators to support more and better mental health treatment within prisons and jails. But Johnson and Kubiak extend that hope even further with the goal of creating a system where individuals can receive needed treatment before they are incarcerated—a goal that requires well-trained, devoted mental health professionals, such as social workers.

“It’s really important for social workers to be at the nexus. We need to do a better job of training social workers on where the points of intervention along the criminal legal continuum are,” Kubiak explains. “It’s much harder to treat somebody inside,” she adds.

And despite all the challenges that exist, Kubiak believes change is possible. “You’re seeing bipartisan support for it. It’s amazing to me that this has been something that’s been swept under the carpet and all of a sudden there’s more attention paid to it,” she notes.

“I do find it [today] the most hopeful time.” But, she cautions, “It doesn’t mean we can sit down. It is an opportunity to create change.”

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.