International
Conference: Joint meeting between Tri State Chapter of the American
Academy of Psychiatry and the Law and the Forensic Psychiatry
Faculty of the Royal College of Psychiatrists
As part of the ongoing commitment of the Forensic Psychiatry
Faculty of the Royal College to develop international relationships,
the Faculty held a joint meeting with the Tri State Chapter
of American Academy of Psychiatry and Law (AAPL) in New York
between 22-24 April 2004.
The programme included a visit to Rikers Island Jail and a
visit to Kirby Forensic Psychiatric Centre, Wards Island.
Rikers Island Jail.
The main detention centre in New York is based on Rikers Island.
The average daily inmate population of New York City
Department of Correction (DOC) fluctuates between 14,000 and
18,000. Its 10 major
jails have a combined capacity of more than 16,000 inmates. Among the Rikers Facilities are a jail for sentenced males, another
for sentenced and detainee females and a detention centre for
adolescent males. The
7 other jails on the island house adult male detainees.
Two floating detention centres are docked off the island
and are kept in reserve for temporary use in the event that
the inmate population needs them.
Jail Mental Health Service.
On reception inmates are screened using a brief questionnaire
and enquiries are made about risk of suicide and self harm. There is one main mental health centre with
320 beds. Seriously
ill inmates and those requiring intensive psychiatric observation
are held in prison wards that the department operates in city
hospitals such as the Forensic Psychiatric In-patient Service,
Bellevue Hospital and the Kirby Forensic Psychiatric Centre
(see below). Each month
approximately 20-30 inmates are transferred to hospital.
As in Ireland and the UK it is not legal to administer medication
to inmates on a compulsory basis.
We were told that the suicide rate in Rikers Island is
less than that in the general population.
They had 5 suicides last year which was more than the
previous 11 years. This has prompted a move to a more intense
monitoring of inmates. There
is an ‘Enhanced Suicide Observation’ (ESO) policy
in place. Essentially, this consists of 47 inmates place in one large dormitory
under the supervision of 2 officers.
In the prison there is a Methadone Programme and approximately
900 inmates are receiving Methadone on any one day, with half
on detox and half on maintenance.
There is a large emphasis on ‘Discharge Planning’. A New York Court recently found that the City
of New York was not meeting its aftercare obligations. Now there is a system to start discharging
planning at the outset of one’s incarceration.
Bearing in mind that this is a remand prison (known locally
as jail) there is a very high turn over and some inmates may
only be present for 2 to 3 days.
This makes discharge planning very difficult.
Problems with funding and strategic planning were referred
to, for example the lack of interface planning between the law
enforcement people and the social service people. The City Commissioners now see reception into
custody as being a public health opportunity. Issues such as sobriety, employment and support housing are addressed.
There is an employment programme in place for the first
2 weeks post release.
In relation to costs, we were informed that it costs approximately
$270.00 per night to house an inmate at Rikers Island.
High priority is given to charging inmates who assault other
inmates. This results
in arrest and charging. This
has resulted in a reduction of violent incidents of 200% over
the last year.
As in every other jurisdiction, public perception and political
influence are relevant when modernising facilities. The term ‘air-conditioning’ is
avoided as it is thought that this would invoke a negative voting
response from the public. It
has been replaced by the term ‘security ventilation’
in the tendering process.
Kirby
Forensic Psychiatric Centre
The Kirby Forensic Psychiatric Centre was opened in February
1985 by the New York State Office of Mental Health. The Kirby Forensic Centre is on Wards Island and from the outside
looks like a prisoner secure hospital.
It has 168 beds but usually has 110% to 120% capacity. All patients are involuntary commitment under
Criminal Procedure Law, Mental Hygiene Law or New York State
Regulations. As in Ireland
they also receive not only patients who are insanity acquitees
and those who are unfit to stand trial but also patients who
are transferred on civil commitment from non secure facilities
or upon release from jail or prison.
Care
Discharge Planning
Treatments
are provided to patients through a multidisciplinary team approach. Throughout a patient’s stay the multidisciplinary
team meet the patients regularly to develop, review and modify
treatment plans. All
services are based on particular needs and are individualised
in goal orientated treatment plans.
In addition to clinical and medical services, individuals
are entitled to various rehabilitation modalities and are involved
in educational, vocational, socialisation and recreational activities.
Patients are expected to be actively involved in their
treatment and to attend team meetings where their treatment
plans and progress are discussed. Each patient is advised that he or she is a
key member of their treatment multidisciplinary team which address
their treatment and personal needs.
Patients are actively involved in their own treatment
and in regular treatment planning sessions.
Upon admission each patient is given a page identifying the
names of his or her treatment plan members and a programme detailing
the general ward schedule.
Patients are also given a list of patients’ rights
upon admission and contact numbers of the Commission on quality
of Care in the event that standards are not to the patients’
satisfaction or should they wish to lodge a complaint. Clinical issues are similar to those encountered
at the Central Mental Hospital in Dundrum such as the treatment
of refractory psychosis, delusions interfering with fitness,
poor insight, sexual offences, borderline deliberate self harm
and malingering.
Compulsory
Clozapine
One notable area of difference in the treatment of refractory
psychosis is where a Court Order is sought for treatment. Treatment in this situation consists of inserting
a nasogastric tube for the purpose of administering Clozapine
on a compulsory basis.
Restraint
and seclusion
There has been a shift in policy in an effort to eliminate
restraint. We learned
that four plus five point restraint has been eliminated from
all wards except from the ‘highest acuity ward’.
Initially hospital management encountered
union opposition to the elimination of restraint.
This opposition has now been overcome.
The elimination of restraint has resulted in an increase
in the use of seclusion.
Treatment
Mall’s
Staff
accompany patients to the various activities outside of the
ward such as on the ‘Treatment Mall’ where there
are psycho-educational programmes given by members of the clinical
teams. We were informed
that the ‘Treatment Malls’
were described to
us as being ‘the next greatest change to anti-psychotics’.
In other words, by creating a structure involving interactive
therapies and discussion groups this has resulted in a dramatic
decrease in violent incidents and improvement in mental health
and well being of the patients.
Dr
Damian Mohan
Chairman, Faculty of Forensic Psychiatry
