Tarasoff duties in prisons: community standards with certain twists

When security and medicine missions conflict: confidentiality in prison settings

Purpose - It is a simple fact that prisons cannot exist - practically, legally, ethically or morally - without the support of physicians and other health professionals. Access to adequate healthcare is one of the fundamental measures of the legitimacy of a jail or prison. At the same time, there is a fundamental tension in the missions of the prison and doctor. The primary mission of the prison is security and often punishment. Reform and rehabilitation have intermittently been stated goals of prisons in the last century, but in practice those humane goals have rarely governed prison administrative culture. The primary mission of the physician is to promote the health and welfare of his or her patient. The paper aims to discuss these issues. Design/methodology/approach - At times, what is required to serve the patient's best interest is at odds with the interests of security. Much of the work of the prison physician does not conflict with the operation of security. Indeed, much of the work of the prison physician is allowed to proceed without much interference from the security regime. But given the fundamental discord in the legitimate missions of security vs medicine, conflict between the doctor and the warden is inevitable. Findings - In this paper, the authors consider the example of patient confidentiality to illustrate this conflict, using case examples inspired by real cases from the experience of the authors. Originality/value - The authors provide an ethical and practical framework for health professionals to employ when confronting these inevitable conflicts in correctional settings.

Psychodynamic Treatment of the Criminal Offender: Making the Case for Longer-Term Treatment in a Longer-Term Setting

In recent years, prisons and jails have become de facto psychiatric hospitals, responsible for the care and treatment of individuals with serious mental illness. Historically, cognitive-behaviorally informed therapeutic approaches have been the treatment of choice among mental health practitioners in correctional settings. However, inmate-clients often present with complex diagnostic issues that are arguably better served by long-term treatment options, such as psychodynamic psychotherapy. We first review the nature of psychotherapy in the correctional setting, as well as treatment barriers and challenges faced by both mental health providers and inmate-clients. We then review treatment studies that examine the efficacy of various therapeutic techniques in correctional/forensic contexts. Finally, we argue that, due to the complex nature of psychopathology, average length of time incarcerated, and treatment issues that arise in this multifaceted and challenging setting, mental health treatment providers should consider providing psychodynamic treatment modalities when working with incarcerated individuals. We also argue that more research is needed to examine the efficacy of these treatment approaches with inmate-clients.

Informing patients about limits to confidentiality: A qualitative study in prisons

AIM

Confidentiality is important in healthcare practice, however, under certain circumstances, confidentiality is breached. In this paper, mental health professionals' (MHPs) practices related to informing imprisoned patients about confidentiality and its limits are presented.

METHODS

Twenty-four MHPs working in Swiss prisons were interviewed. Data analysis involved qualitative thematic coding and was validated by discussing results with external experts and study participants.

RESULTS

For expert evaluations and court-ordered therapies, participants informed patients that information revealed during these consultations is not bound by confidentiality rules. The practice of routinely informing patients about confidentiality and its limits became more complex in voluntary therapies, for which participants described four approaches and provided justifications in favour of or against their use.

CONCLUSIONS

Further training and continued education are needed to improve physicians' ethical and legal knowledge about confidentiality disclosures. In order to promote ethical practices, it is important to understand and address existing motivations, attitudes and behaviours that impede appropriate patient information. Our study adds important new knowledge about the limits to confidentiality, particularly for providers working with vulnerable populations. Results from this study reflect typical ethical and practical dilemmas faced by and of interest to physicians working in forensic medicine and other related settings.

Paternalistic breaches of confidentiality in prison: mental health professionals' attitudes and justifications

AIM

This manuscript presents mental health practitioners' (MHPs) practice, attitudes and justifications for breaching confidentiality when imprisoned patients disclose suicidal thoughts or abuse by others.

METHODS

24 MHPs working in Swiss prisons shared their experiences regarding confidentiality practices. The data were analysed qualitatively and MHPs' attitudes and course of action were identified.

RESULTS

Analysis revealed paternalistic breaches of confidentiality. When patients reported suicidal thoughts and abuse, MHPs believed that forgoing confidentiality is necessary to protect patients, providing several justifications for it. Patients were informed that such information will be transmitted without their consent to medical and non-medical prison personnel. With reference to suicidal attempts, MHPs resorted to methods that may reduce suicidal attempts such as transfer to hospital or internal changes in living arrangements, which would require provision of certain information to prison guards. In cases of abuse, some MHPs convinced patients to accept intervention or sometimes overrode competent patients' refusals to report. Also in the case of abuse, provision of limited information to other prison personnel was seen as an acceptable method to protect patients from further harm.

DISCUSSION

Breaches of confidentiality, whether limited or full, remain unethical, when used for competent patients based solely on paternalistic justifications. Institutionalising ethical and legal procedures to address suicidal and abuse situations would be helpful. Education and training to help both medical and prison personnel to respond to such situations in an appropriate manner that ensures confidentiality and protects patients from suicide and abuse are necessary.

Disclosure of past crimes: an analysis of mental health professionals' attitudes towards breaching confidentiality

Ensuring confidentiality is the cornerstone of trust within the doctor-patient relationship. However, health care providers have an obligation to serve not only their patient's interests but also those of potential victims and society, resulting in circumstances where confidentiality must be breached. This article describes the attitudes of mental health professionals (MHPs) when patients disclose past crimes unknown to the justice system. Twenty-four MHPs working in Swiss prisons were interviewed. They shared their experiences concerning confidentiality practices and attitudes towards breaching confidentiality in prison. Qualitative analysis revealed that MHPs study different factors before deciding whether a past crime should be disclosed, including: (1) the type of therapy the prisoner-patient was seeking (i.e., whether it was court-ordered or voluntary), (2) the type of crime that is revealed (e.g., a serious crime, a crime of a similar nature to the original crime, or a minor crime), and (3) the danger posed by the prisoner-patient. Based on this study's findings, risk assessment of dangerousness was one of the most important factors determining disclosures of past crimes, taking into consideration both the type of therapy and the crime involved. Attitudes of MHPs varied with regard to confidentiality rules and when to breach confidentiality, and there was thus a lack of consensus as to when and whether past crimes should be reported. Hence, legal and ethical requirements concerning confidentiality breaches must be made clear and known to physicians in order to guide them with difficult cases.

Medical and legal professionals' attitudes towards confidentiality and disclosure of clinical information in forensic settings: a survey using case vignettes

OBJECTIVE

When potentially dangerous patients reveal criminal fantasies to their therapists, the latter must decide whether this information has to be transmitted to a third person in order to protect potential victims. We were interested in how medical and legal professionals handle such situations in the context of prison medicine and forensic evaluations. We aimed to explore the motives behind their actions and to compare these professional groups.

METHOD

A mail survey was conducted among medical and legal professionals using five fictitious case vignettes. For each vignette, participants were asked to answer questions exploring what the professional should do in the situation and to explain their justification for the chosen response.

RESULTS

A total of 147 questionnaires were analysed. Agreement between participants varied from one scenario to another. Overall, legal professionals tended to disclose information to a third party more easily than medical professionals, the latter tending to privilege confidentiality and patient autonomy over security. Perception of potential danger in a given situation was not consistently associated with actions.

CONCLUSION

Professionals' opinions and attitudes regarding the confidentiality of potentially dangerous patients differ widely and appear to be subjectively determined. Shared discussions about clinical situations could enhance knowledge and competencies and reduce differences between professional groups.

Prison psychiatry

PURPOSE OF REVIEW

Prison psychiatry is a secluded area of the psychiatric care system, which in fact often provides treatment for those who do not have access to community-based healthcare systems. The aim of this review is to give an impression of the special challenges of psychiatric work behind bars and to emphasize current trends in prison psychiatry.

RECENT FINDINGS

In prisoners, mental disorders are more common than in the general population. There is evidence that prison suicide rates do not reflect general population suicide rates, suggesting that variation in prison suicide rates possibly also reflects differences in the provision of psychiatric care. Good transitional preparation preceding release seems to be necessary to reduce the risk of poor health outcome, but is hard to achieve. Up to now, there is no clear decision on whether it is useful or possible to treat adult prisoners with attention-deficit/hyperactivity disorder with stimulants.

SUMMARY

Prison psychiatry has to deal with a disproportionate burden of psychiatric disease in prisoners. Adequate psychiatric treatment options may reduce suicide behind bars. Further research should focus on the special needs of individuals who are out of reach of the conventional community-based health system.