By Theresa M. Dronet, PhD
Posted on September 29, 2010 – As a result of an American Civil Liberties Union (ACLU) consent decree in Mississippi in 2005, severely mentally inmates located in a maximum-security unit, named Unit 32 of the Mississippi State Penitentiary at Parchman, MS, were given the opportunity to participate in a mental health step-down program. Prior to the implementation of the step-down program, services provided to the prisoners in administra-tive segregation were limited to routine psychiatric evaluations for those inmates on psychotropic medications, segregation rounds conducted daily or weekly by medical and mental health staff, and crisis intervention. Annual reviews were conducted on all segregated prisoners who did not require psychiatric treatment.
The Step-Down Unit was developed to treat both prisoners who had to remain segregated for the time being as well as open-population prisoners with serious mental illness at Unit 32. The unit occupies two tiers, each containing 16 cells: one tier being devoted to housing segregated prisoners, while the other is filled with open-population prisoners. The phases of the program begin in the segregated tier and progress through the open-population tier, until the prisoner graduates from the program and transfers to general population.
The Step-Down Unit program is modeled on the Assertive Community Treatment (ACT) approach (Marx, Stein, and Test, 2003; Drake et al, 1998; Scott et al, 1995). The aim is to provide mental health services to patients in vivo, or where the patients live and work. The ACT program was developed to meet the needs of patients who found that they were not capable of applying skills they had learned in inpatient treatment when they returned to living in their communities. The idea was to move intensive mental health services to the place where the patients live and work, and for staff—working as a team—to be assertive in gaining the patients’ cooperation in the treatment. The ACT approach is able to help people who have not gained effective treatment from traditional approaches to mental health treatment. The target population is patients who have the most serious and intractable symptoms of mental illness and experience the greatest impairment in functioning. Because they have difficulties with basic, everyday, self-preservation skills and are involved with substance abuse, they find their way into the criminal justice system. ACT seemed the right model for the new step-down program at Unit 32.
The treatment programming of the unit is divided into two levels, the focus being on remediation of a prisoner’s particular deficits in effective functioning rather than on a change of personality. The first level of treatment, which occurs while the prisoners remain segregated, is called Growth level, where prisoners learn about their illness and are educated on how to cope with anger, impulses and anxiety. It is an adjustment phase for the prisoner who has been segregated and has grown unaccustomed to freedom of movement, privileges and intensive individual and group therapy. They are monitored closely by psychiatrists, psychologists, mental health professionals and security staff for appropriate adjustment, stabilization on medication and compliance with their medication regimen.
The next phase of treatment is called the Excellence level, where programming is more peer-facilitated and interrelational issues are the focus of treatment. This phase of the program takes place on the open-custody tier. Topics addressed include domestic violence, mentorship, accountability and moral reasoning. Preferred candidates for the program are those whose symptoms are likely to be ameliorated with participation in individual and group treatment. For a prisoner to be admitted to the program there must be a diagnosis of serious mental illness, for example, schizophrenia or other psychotic disorder, bipolar disorder, major depressive disorder or other serious mood disorder, mental retardation, organic brain disorder, severe generalized anxiety disorder, posttraumatic stress disorder, or any disorder characterized by repetitive self-harm. Typically, prisoners admitted to the program are experiencing a relapse or decompensation, or they are having difficulty coping with prison life because of their psychiatric disorder. They often require close monitoring of their psychotropic medications.
Preference for admission is given to those willing to engage with the treatment services and who agree to the plan of care. Prisoners admitted to the program remain an average of three to six months within the step-down unit. They are considered ready for discharge from the program when their treatment plan has been accomplished and their condition has become stable. Before graduation can occur, the multidisciplinary team must unanimously determine that the prisoner has progressed to the point of remediation of deficits and can manage his mental illness in a corrections environment, with less intensive therapeutic interaction from mental health providers.
When prisoners complete the treatment program, a discharge summary including progress and accomplishments is forwarded to MDOC classification staff so they can consider upgrading the custody status. After being discharged, a prisoner may be readmitted if he experiences another relapse. If he is discharged for lack of compliance or behavioral issues, he may be considered for readmission following intensive individual treatment with mental health staff. He must improve his behavior and treatment compliance to the point where he will not disrupt the program or its participants.
There is a collaborative Treatment Team approach to treatment planning. A Risk Assessment Team (R.A.T.) was set up as an integrated, self-contained treatment group, a development that was unprecedented in the MDOC. Mental health staff and key security personnel come together on a weekly basis to communicate how to best implement treatment for the unit while furthering a shared interest in quality care as well as security. In line with the intention of the legal settlement, increased out-of-cell time for prisoners has become a significant topic of discussion for the R.A.T. The plan is to remove prisoners with serious mental illness from isolated confinement, but many have to be segregated initially because they have demonstrated an inability to get along with others, act appropriately or do not follow rules when they are included in congregate activities. For this subpopulation, an incentive plan for good behavior rewards them with incrementally more time in an activity treatment room where they can access media equipment, use a library of educational and fictional literature, and make use of drawing and writing materials. Because of the restrictive custody status of these prisoners, they are not allowed to mingle with other prisoners, but granting them increased freedom and space to move about allows them to gain more breathing room, and, one hopes, moves them further toward the treatment objective of appropriate participation in congregate activities.
A Custody Phase Program has also been designed and refined to allow more interconnectedness among prisoners who must remain separated until their behavior improves. The phases include introductory individual treatment sessions with the unit psychologist, followed by transition into a group of four prisoners who meet together for group treatment. The original plan for this group treatment was to construct modified holding cells or therapeutic cubicles (prisoners call them cages) in which the prisoners would sit during the sessions while remaining in the same room. However, the staff decided it would be more practical and therapeutic to have the prisoners free of any cubicle, but shackled and linked to floor-hook restraints so that, in case animosities escalate, they cannot reach each other.
A Positive Psychology approach has been used at a treatment module in the step-down program. In the early stages of the group program, a group of four inmates with four different gang affiliations were placed together as a treatment cohort. Not only were there no bhavioral incidents with this group, but the four inmates moved through the program and graduated together into a semi-open custody environment. As a result of this step-down program, behavioral incidents across all graduated participants were reduced by 89%.
Dr. Dronet is Associate Director, Mental Health Programs, at Wexford Health Sources, Inc. Readers may contact her at tdronet@wexfordhealth.com.
