Correctional violence: Mental illness or institutional failure?

Anticonvulsants or lithium are commonly used, with the short-term addition of a neuroleptic if the violence is due to a primary psychotic disorder or mania. Regardless of the medication choice, it is important to clearly document the condition and indication for the medication to avoid allegations that pharmacologic interventions are being used for disciplinary reasons or merely to “keep the inmate quiet.”

After the acute crisis is resolved, the inmate can be offered additional follow-up for supportive counseling, crisis intervention as needed, as well as education about anger management skills.

The use of behavior modification plans, while helpful, can be somewhat controversial if the terms are overly restrictive or harsh. Such plans have led to court challenges over legal and ethical concerns. The plan should be carefully constructed to allow for inmate input into the terms and conditions, and explained in detail along with the rationale for each contingency. Voluntary participation in plan development is more likely to lead to a successful outcome and to withstand challenge by outside agencies.

The use of solitary confinement or segregated housing is controversial. However, when used temporarily in conjunction with psychiatric evaluation and intervention, solitary confinement can be an essential tool to protect both staff and other prisoners.

—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.