7 Week 623 Clinical Psychopharmacology in Correctional Settings

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clearly that such placement will be contingent on bed space and that the inmate can expect the ability to use this strategy to become less frequent.

Another strategy is to make adjustments to segregation times, whether through reductions or staggered segregation schedules. Many disruptive inmates owe tremendous amounts of segregation time that have been accumulated over time. For these inmates, it may be helpful to make a deal whereby 15 days could be completed rather than 6 months. Such reward would be contingent on an absence of the maladaptive behaviors for that time period. Allowing inmates to receive 2 or 3 days' credit for each adaptive day is also an option. Effectiveness has also been shown in allowing inmates to be housed in segregation during the week and in general population during the weekend.

All of these strategies are designed to instill a sense of control within the inmate-patient based on behaving appropriately, that is, as specified in the treatment plan. With an opportunity to achieve rewards, the inmate-patient will learn how to control some features of his or her environment appropriately, which will lead to a reduction in the experience of punishment and perhaps generalize to other situations. Table 14.3 contains a sample BTP that incorporates a sampling of the strategies described above.

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Table 14.3

Combined Interventions Although BTPs can be effective, their effectiveness may be increased substantially when they are combined with other treatment modalities including medication and more cognitively oriented interventions. These additional treatment strategies might be helpful in increasing impulse control, in overcoming skill deficits, or in addressing underlying mental health issues. For example, breathing exercises, deep muscle relaxation, challenging irrational assumptions, and/or behavioral skills training (e.g., social skill training or assertiveness training) may each assist the inmate in gaining more control over impulses. Pharmacological interventions with or without hospitalization might be appropriate where psychosis is involved, especially when command hallucinations to act aggressively towards oneself and/or others are involved (see Chapter 7 for more information about psychopharmacological interventions). Linehan's (1993) book, Cognitive-Behavioral Treatment of Borderline Personality Disorder, provides an excellent conceptual integration of a range of cognitive and behavioral interventions, as well as the

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use of psychotropic medications, for patients with borderline personality disorder, although the practical applicability of this treatment-intensive approach to a general population correctional setting is questionable.

Obstacles to Best Practice In this section, some of the potential obstacles to developing and implementing BTPs are discussed.

Past Practices: Finding an Alternative to Punishment Consistent with the admonition to be firm, fair, and consistent in the treatment of inmates, correctional systems have guidelines that mandate specific, standardized procedures, including the imposition of penalties, in response to institutional rule violations. This approach works in most situations with most inmates, at least over the short term (Byrne & Hummer, 2007). However, it is well documented that punishment is not effective for promoting long-term behavioral changes (e.g., Amos, 2004).

In fact, punishment of disruptive institutional behaviors sometimes results in an ongoing power struggle and an escalation of the problem behaviors. This has largely to do with the emphasis on controlling the behavior of an unwilling participant and/or the emphasis on punishing unwanted behavior rather than rewarding appropriate behavior. Toch (2008) suggests that behavioral management plans (i.e., behavior control strategies implemented by staff without inmate consent) that emphasize punishment serve to intensify inmates' resentment and solidify their resistance, even when they lead to surface compliance. There certainly is little reason to expect an “ah-ha” moment with the extremely disruptive or aggressive inmate unless the situational circumstances within the institution change for the inmate.

Therefore, in planning behavioral interventions, it is the task of the mental health professional to consult with and convince wardens and other staff stakeholders that the inmate is ultimately controlling things through disruptive behaviors, and that a departure from traditional responses, that is, a collaborative approach that emphasizes positive reinforcement, is necessary. Standards of care, such as those offered by NCCHC (2008) and the American Correctional Association (2004), as well as features of settlement agreements and consent decrees from other jurisdictions, provide useful leverage for moving correctional systems away from sole reliance on traditional punitive custodial practices and toward the development of more flexible and effective behavioral treatment strategies. A collaborative approach that appreciates and incorporates both effective custody and mental health practices tailored to the inmate's functional level can result in successful and long-lasting behavioral change for the inmate and a smoother, more efficient correctional operation.

Staff Resistance

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There may be potential differences between the assumptions under which mental health providers approach offenders and the standard correctional management approach. The former focuses on individual differences, whereas the latter stresses uniformity (i.e., equal standards and treatment for all). These philosophies can sometimes be difficult to reconcile in practice; it is often difficult for correctional workers to serve mental health care and correctional functions simultaneously. In particular, mental health care providers are likely to prioritize the institution's rehabilitation mission and a positive approach (as consistent with the learning theory emphasis on reward rather than punishment), broadly speaking. Most staff, particularly those in custody, must consider safety and security as paramount. As a result, they are likely to rely on short-term, punishment-oriented approaches, as dictated by institutional policy and applied consistently and objectively; and they are likely to resist deviations from these policies suggested by mental health clinicians.

Mental health care providers should bear in mind that BTPs depend on the cooperation of other staff, for whom the concept of the prisoner as patient, or healthcare consumer, may be utterly foreign. Hence, in formulating BTPs, it is vital to bear in mind that staff must be persuaded that BTPs have value and will benefit both the inmate and the institution. Additionally, staff must be reinforced for their cooperation. Ideally, wardens and other high-level administrators support these programs and recognize staff for their contributions.

Mental health, medical, and correctional staff may express apprehension that meeting one inmate's needs and making exceptions to standard correctional practices via BTPs will result in other inmates doing the same thing, the perceived failure of the system, the perception of inmates being in control, and the perception of giving in. However, this apprehension can easily be countered with the notion that when these behaviors are not properly treated, they can have a dramatic impact on facility operations, including increased staff injury and the canceling of visits, programs, recreation, and other activities important to inmates. Additionally, with regard to control issues, it is the chronically disruptive inmate who ultimately controls things anyway (e.g., provoking use of force, compelling staff to expend more time in paperwork) through his or her behavior. The key is to accept that current punitive strategies are not effective with this group of disruptive offenders and to attempt strategies that may prove more effective.

Cost-Benefit The time and labor investments in BTPs are greater over the short term, that is, during the baseline and early implementation phases, whereas the reward to staff, in terms of improved behavior, may take considerable time. For example, assessment is continuous and requires ongoing observation and recording of the target behavior(s), so that the effectiveness of the intervention, once introduced, can be determined. During the earlier phases of the program, there may be no improvement in behavior or even an exacerbation of the problem, until and unless the inmate-patient responds favorably to the changed circumstances, that is, the intervention. Hence, staff should be prepared to exercise patience and consistency, and rewards (positive reinforcement) for staff involvement (e.g.,

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through awards, letters of commendation placed in personnel files) should be built into these programs.

Obtaining Informed Consent Finally, there is the challenge of obtaining the inmate-patient's cooperation in the BTP. Without the inmate's cooperation, any attempt at behavioral change would be considered a traditional behavior management plan, and as previously noted, with such plans there is the danger of increasing inmate resistance, the frequency of disruptive behaviors, and an adversarial relationship between staff and inmates. If the inmate can be persuaded to become an active partner in the treatment process; can see value in developing alternative, more acceptable behavioral patterns; and can be convinced to work collaboratively with staff, then behavioral change through BTPs becomes possible and more likely to succeed. Hence, if the inmate's cooperation cannot be obtained, perhaps because maintaining the control that exercising the problem behavior affords him or her is extremely reinforcing, or because no adequate reinforcement for more appropriate behavior can be found, it is recommended that a BTP be introduced on a much smaller scale. Perhaps in this instance, a first step would be to build trust through a small verbal agreement such as providing out- of-cell time for a shift of adaptive behaviors. Whereas formal signed contracts may not be needed if a verbal agreement can be obtained, it is important to ensure that the inmate is involved in the plan. As previously noted, improperly designed behavioral interventions can exacerbate problem behaviors.

Summary and Conclusions This chapter has focused on disruptive inmate behaviors as well as possible motivations for these behaviors. It has reviewed treatment strategies designed to ensure safety and security through a collaborative approach designed to reduce these behaviors. The challenge for correctional staff is to reshape inmate demands into something acceptable to the institution through the reinforcement of appropriate, adaptive behaviors. Most systems can find the balance between care and safety in the service of change and good outcomes, as long as there is collaboration and clear communication. It is clear that in addition to those who meet typical criteria for serious mental illness, there is a small group of inmates with personality disorders or other mental health symptoms whose extreme behaviors require unique interventions based on behavioral principles. Although these interventions may be time- and labor-intensive and may meet initial resistance from correctional staff, their long-term benefits may warrant their use with some offenders when more traditional correctional management techniques prove ineffective.

While the “mad” versus “bad” dilemma has a long history in corrections, behaviors attributed to either must be addressed collaboratively and based, at least in part, on behavioral principles. Recent standards of care, legal cases, and heightened awareness are moving correctional facilities toward making accommodations for those whose mental illness or symptoms (e.g., impulsivity) prohibit them from progressing within the framework of traditional correctional practices. This is leading to best practices as detailed in this chapter. Although several obstacles still exist, mental health professiona

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