Telehealth and Incarceration: Expanding Mental Health Care in Jails and Prisons
This is a student blog piece by Stephanie Miodus, a third-year doctoral student in the School Psychology Ph.D. program at Temple University.
According to the U.S. Department of Justice (Bronson & Berzofsky, 2017), 14% of individuals who are incarcerated in prisons and 26% of those in jails met criteria for serious psychological distress, and 37% in prisons and 44% in jails had a history of mental illness. In addition, individuals who are incarcerated are more likely to die by suicide than individuals in the general population (e.g., Fazel et al., 2011). For individuals with serious mental illnesses, there is a greater risk of recidivism after their release (Baillargeon et al., 2010), resulting in jails and prisons serving as the primary source for mental health services for those individuals who spend more time in facilities than in the community.
Thus, access to high quality mental health services for individuals who are incarcerated is imperative (Kupers & Toch, 1999). Yet, mental health services in jails and prisons are not meeting the need (i.e., only 36% of those who met criteria for serious psychological distress in prisons and 30% of those who met criteria in jails were currently receiving treatment; Bronson & Berzofsky, 2017). Mental health needs are left unrecognized (Trestman et al., 2007) and unaddressed (Bronson & Berzofsky, 2017). Many barriers, including a lack of providers (e.g., Leonard, 2004), insufficient resources for training (Birmingham et al., 2000), privacy and safety concerns (Lexcen et al., 2006), and time constraints (Deslich et al., 2013), exist due to the nature of jails and prisons (e.g., physically distant from populated areas; punitive environment).
Telemental health, or the delivery of mental health services over technological platforms, can be leveraged to address these barriers and expand access to mental health care for individuals who are incarcerated. First, telehealth addresses one of the major constraints to care for individuals who are incarcerated, the limited number of clinicians (e.g., Leonard, 2004). Since service providers would not need to live near facilities, telehealth offers an opportunity to expand the network of clinicians who can provide mental health care. This is especially crucial in rural areas, where there is a lack of providers in the general population (Holzer III et al., 2000), as well as in jails and prisons (Ruddell & Mays, 2007). Some facilities in rural areas have already implemented telehealth for mental health services and preliminary results show positive outcomes (Manfredi et al., 2005). Additionally, in all geographic areas, having a connection to an outside provider over telehealth offers the opportunity to continue care with the same clinician upon reentry, addressing the issue of a gap in care between incarceration and reentry (Baillargeon et al. 2010).
Using outside providers through telehealth services can also help address the lack of resources for training clinicians in jails and prisons (Birmingham et al., 2000). Clinicians cannot specialize in treating all disorders and all treatment modalities, and with the small number of mental health staff in jails and prisons (e.g., Leonard, 2004), this means that there is a limited number of areas that are these clinicians’ areas of expertise. With the expansion of the clinical network through telehealth, there is an opportunity for more individualized, specialized care that can best fit the needs of clients (Levant & Shlien, 1984). This vision for care does not negate the training that in-person providers in jails and prisons have, especially their specialized expertise for care in forensic settings, so it is essential that telehealth providers that plan to work with incarcerated populations receive training in this area prior to delivering services.
Another concern in facilities is safety. This may be especially true for those with a mental health concern, as they are more likely to be written up for or charged with either a verbal or physical assault of correctional staff or another incarcerated individual than the rest of the population in jails and prisons (Bronson & Berzofsky, 2017). Due to these safety concerns, individuals who are incarcerated are often shackled and accompanied from their housing to the location where they will receive treatment. This process takes time, which takes away from time spent in care and the number of individuals which can be seen (Deslich et al., 2013). In cases where telehealth is provided over the incarcerated individual’s own personal tablet, individuals can receive faster access to care, and it can be on their own schedule as planned with their clinician. This provides the clinical benefit of a greater sense of autonomy for individuals (e.g., Ryan & Deci, 2008) who are incarcerated, which is often devoid in jails and prisons.
Another response to safety concerns is correctional officers remaining nearby during sessions, creating privacy concerns when individuals are sharing confidential information with their clinicians (Lexcen et al., 2006). As there are reduced safety concerns when a telehealth platform is used, correctional officers should not need to monitor as closely, allowing for more privacy in sessions.
There is the valid question of the efficacy of care over these platforms when compared to in-person treatment. Overall, the literature shows telemental health in the general population is an effective way of delivering treatment (e.g., Hilty et al., 2013). In addition, research on services for individuals who are incarcerated show that they found their therapeutic relationships over telehealth services just as positive as in-person services (Morgan et al., 2008).
This proposed approach does not suggest an end to in-person mental health services in jails and prisons. Rather, these considerations suggest the value of incorporating telehealth services in tandem with the current in-person treatment. In-person services are especially critical for emergency situations, such as suicide risk. A strong working relationship between in-person and telehealth providers is beneficial to meet the needs of all incarcerated individuals, especially under such emergency circumstances, while expanding access to care and addressing current barriers. Overall, the considerations explored call for further examination of implementing telemental health care in jails and prisons. By leveraging this technology to offer access to high quality services, jails and prisons can provide an expanded avenue for clinicians to meet the mental health needs of individuals who are incarcerated.
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