Ethics, Psychology, and the Prison Mess

Stephen A. Ragusea, PsyD, ABPP

Guest Blogger

Recently on one of my psychology list serves, one colleague posted the following, 

“I witnessed an inmate in a county jail who was acutely psychotic, and was kept in solitary confinement for almost two years, naked, lying in his/her own urine and feces. There was no heat in the cell, and the human wastes leaked into adjoining cells. Numerous official and professional persons were aware of this poor person's plight, and no one did anything (or at least anything that was within their ability and authority) to end the inmate's suffering. Apparently, this is acceptable practice here in Florida, as all persons were found to be practicing appropriately.”

Unfortunately, the situation described above by one of our colleagues is not uncommon.  In my many years of work in prisons I’ve observed similar scenarios many times.  I too have scene naked prisoners lying in their own filth.  I’ve seen prisons where an entire block of 40 men was on suicide watch.  I’ve seen a prisoner who was elderly, demented, and paranoid sent to prison repeatedly after being prosecuted for making “Terroristic Threats.”  I’ve seen a psychotic bipolar prisoner tied to a metal chair and drenched with a fire hose to make him “behave.”

Dr. Ragusea

As has been true for more than two decades, the United States incarcerates a higher percentage of its population than any other nation in the world.  Most prisoners are under the age of 30 and approximately 15% of the total are people who meet the DSM-IV criteria for a mental illness.  About half of that 15% are diagnosable as seriously mentally ill, suffering from problems like schizophrenia and bi-polar disorder.

According to a 215-page report (ISBN: 1564322904) by Human Rights Watch, “One in six U.S. prisoners is mentally ill. Many of them suffer from serious illnesses such as schizophrenia, bipolar disorder, and major depression. There are three times as many men and women with mental illness in U.S. prisons as in mental health hospitals.”  One of the report’s authors, Jamie Felner, observed, “Prisons have become the nation’s primary mental health facilities.” 

Prisons have become the nation’s primary mental health facilities.

How did we get into this mess?  Some of it started when politicians decided that they could get elected and stay elected by being “tough on crime.”  They voted for mandatory minimum sentences, taking discretion away from the judiciary.  And, although approximately half of these prisoners were convicted of non-violent, drug related offenses, rather than voting for funding to pay for alcohol and drug treatment, our elected officials decided to spend our hard-earned tax dollars on building more prisons.  The result of this national movement was that we currently incarcerate approximately 1% of our population.  More than 2.5 million Americans now live behind bars.  That’s the equivalent of every man, woman and child in the cities of Philadelphia, Columbus, and Seattle.

A few years ago the Tallahassee Democrat reported, “Florida's law enforcement and corrections systems are rapidly evolving into the state's de facto mental health treatment providers. More often than not, our law enforcement officers, prosecutors, defense attorneys, judges and parole officers are being forced to serve as the first responders and overseers of a system ill equipped to deal with an underfunded treatment system that's stretched beyond capacity.”

To a large degree, the tax money for building and operating prisons was stolen from our public mental health system.  Part of John Kennedy’s vision for Camelot included a national system of well-funded community mental health centers that would serve the mentally ill in their own hometowns, thereby permitting the closing of a well-developed system of state mental hospitals that had been providing inpatient treatment for the severely mentally ill.  Those of us old enough to remember the 1970s recall an era of widely available, well funded, mental health care provided through local Community Mental Health Centers.  Oddly enough, the systematic under-funding and disempowering of our Mental Health Centers coincided with the increase in funding of the prison system to support the “Get Tough on Crime” movement that spread like a well-intentioned plague from sea to shining sea.

Psychologists should be leading the battle for prison reform.  I would argue that we have an ethical obligation to do so.  Specifically I reference the preamble of our ethical code, which states:As doctors of behavior, academic psychologists should be researching new solutions to our social problem of crime and punishment.  Clinical psychologists who work in the system should be developing and implementing alternative treatment models for the imprisoned mentally ill.  And, all psychologists should be demanding government action to correct this inhumane, ill-conceived, foolishness.  Can you imagine a hundred thousand psychologists remaining passively silent as 275,000 mentally ill Americans are mistreated?   We are.   Can you imagine America’s psychologists saying nothing as prisons are turned into “the nation’s primary mental health facilities?”  We have.

Psychologists are committed to increasing scientific and professional knowledge of behavior and people’s understanding of themselves and others and to the use of such knowledge to improve the condition of individuals, organizations, and society.  Psychologists respect and protect civil and human rights and the central importance of freedom of inquiry and expression in research, teaching, and publication.  They strive to help the public in developing informed judgments and choices concerning human behavior.

If you think these issues are important, say so to the leadership of your state and national Psychological Associations.  Talk to your elected representatives.  Contribute your time and energy to make things change.

We can do better. It is our ethical responsibility as psychologists to do better.

References

American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist,Vol. 57, 1060-1073. 

Johnson, Suzanne Bennett.  Quotation retrieved from her website at http://sbjforapa.com/statements/response-to-abpp.

If you have specific suggestions for topics to be covered in The Ethics Corner, please e-mail me with your suggestions.  My e-mail address is ragusea@aol.com. 

Data breach exposes 4.9 million Tricare patients

By Sig Christenson

San Antonio Express-News

One of the Pentagon's largest contractors said late Wednesday it had discovered a data breach affecting as many as 4.9 million patients who have received care from military facilities in San Antonio since 1992.

Science Applications International Corp. said the breach involved backup computer tapes from an electronic health care record. Some of the information included Social Security numbers, addresses, phone numbers and private health information for patients in 10 states.

A statement posted on the Defense Department's Tricare health system website said no credit card or bank account information was on the backup tapes.

Tricare covers military retirees as well as active-duty troops and their dependents.

“The risk of harm to patients is judged to be low despite the data elements involved since retrieving the data on the tapes would require knowledge of and access to specific hardware and software and knowledge of the system and data structure,” the website statement said.

Vernon Guidry, a spokesman for SAIC, a McLean, Va.-based scientific, engineering and technology applications firm, could not say when the data from the backup tapes was compromised.

The statement on Tricare's website, however, said the tapes contained information on patients visiting San Antonio military hospitals and clinics or had tests analyzed here from 1992 through Sept. 7. The San Antonio Military Medical Center, formerly BAMC, was apparently unaware of the breach.

The tapes held data on people living throughout Tricare's southern region, which includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee and Texas with the exception of El Paso.

The entire story can be read here.

IU medical school warns thief may have gained access to patient data of 3,000 people

The Chicago Tribune, as cited from The Associated Press

INDIANAPOLIS (AP) — The Indiana University School of Medicine says a thief who stole a physician's laptop computer may have gained access to the confidential patient information of more than 3,000 people.

The news release can be found here.

Texas Execution Stayed Based on Race Testimony

By Manny Fernandez
The New York Times
Published September 16, 2011

In May 1997, a psychologist took the stand in a courtroom here during the sentencing hearing of Duane E. Buck, a black man found guilty of killing his former girlfriend and her friend.

The psychologist, Walter Quijano, had been called by the defense, and he testified that he did not believe Mr. Buck would be dangerous in the future. But on cross-examination, the prosecutor asked Dr. Quijano more detailed questions about the factors used to determine whether Mr. Buck might be a danger later in life.

“You have determined that the sex factor, that a male is more violent than a female because that’s just the way it is, and that the race factor, black, increases the future dangerousness for various complicated reasons,” the prosecutor asked Dr. Quijano. “Is that correct?”

“Yes,” the psychologist replied.

That statement, and how it was handled by the Harris County District Attorney’s Office, helped spare Mr. Buck from the death chamber on Thursday, and has become the center of a case that has raised questions about the role of race in the Texas criminal justice system at a time when Gov. Rick Perry’s support of the death penalty has become a factor in his campaign for the Republican presidential nomination.

Mr. Buck, 48, had been scheduled to be executed on Thursday evening, but the Supreme Court intervened, granting a temporary stay of execution pending a decision about whether it will review an appeal of his case. Mr. Buck’s lawyers had argued that his death sentence was based, at least in part, on his race, and that in carrying out his execution, the state would violate the Equal Protection Clause of the Constitution, which prohibits discrimination by state governments.

At Mr. Buck’s sentencing hearing in 1997, the Harris County prosecutor told the jury in her closing argument to rely on the psychologist’s expert testimony, telling the jury: “You heard from Dr. Quijano, who had a lot of experience in the Texas Department of Corrections, who told you that there was a probability that the man would commit future acts of violence.”

In 2000, while the case was on appeal, the state attorney general at the time, John Cornyn, made an unusual announcement, conceding error in Mr. Buck’s case and six others in which the government had relied on race as a factor in sentencing. Mr. Cornyn, now a United States senator, stated that if the lawyers for the defendants in those cases challenged the government’s reliance on race at sentencing, he would not object. All of those cases centered on testimony from Dr. Quijano, a former chief psychologist for the state prison system.

“The people of Texas want and deserve a system that affords the same fairness to everyone,” Mr. Cornyn said then.

Of the defendants, all of whom were on death row, Mr. Buck was the only one who had not been granted a new sentencing hearing. The others were later re-sentenced to death.

The efforts to stop Mr. Buck’s execution drew widespread support. Linda Geffin, a former assistant district attorney in Harris County who helped prosecute Mr. Buck, wrote a letter to state officials, including Mr. Perry, asking them to halt the execution, writing that it was regrettable that “any race-based considerations were placed before Mr. Buck’s jury.” In addition, a survivor of Mr. Buck’s attack, Phyllis Taylor, had urged the Texas Board of Pardons and Paroles and the governor to halt the execution.

The entire article can be read here.

What if the Secret to Success Is Failure?

By Paul Tough
The New York Times Sunday Magazine
Published September 18, 2011

Dominic Randolph can seem a little out of place at Riverdale Country School — which is odd, because he’s the headmaster. Riverdale is one of New York City’s most prestigious private schools, with a 104-year-old campus that looks down grandly on Van Cortlandt Park from the top of a steep hill in the richest part of the Bronx. On the discussion boards of UrbanBaby.com, worked-up moms from the Upper East Side argue over whether Riverdale sends enough seniors to Harvard, Yale and Princeton to be considered truly “TT” (top-tier, in UrbanBabyese), or whether it is more accurately labeled “2T” (second-tier), but it is, certainly, part of the city’s private-school elite, a place members of the establishment send their kids to learn to be members of the establishment. Tuition starts at $38,500 a year, and that’s for prekindergarten.

Randolph, by contrast, comes across as an iconoclast, a disrupter, even a bit of an eccentric. He dresses for work every day in a black suit with a narrow tie, and the outfit, plus his cool demeanor and sweep of graying hair, makes you wonder, when you first meet him, if he might have played sax in a ska band in the ’80s. (The English accent helps.) He is a big thinker, always chasing new ideas, and a conversation with him can feel like a one-man TED conference, dotted with references to the latest work by behavioral psychologists and management gurus and design theorists. When he became headmaster in 2007, he swapped offices with his secretary, giving her the reclusive inner sanctum where previous headmasters sat and remodeling the small outer reception area into his own open-concept work space, its walls covered with whiteboard paint on which he sketches ideas and slogans. One day when I visited, one wall was bare except for a white sheet of paper. On it was printed a single black question mark.

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The most critical missing piece, Randolph explained as we sat in his office last fall, is character — those essential traits of mind and habit that were drilled into him at boarding school in England and that also have deep roots in American history. “Whether it’s the pioneer in the Conestoga wagon or someone coming here in the 1920s from southern Italy, there was this idea in America that if you worked hard and you showed real grit, that you could be successful,” he said. “Strangely, we’ve now forgotten that. People who have an easy time of things, who get 800s on their SAT’s, I worry that those people get feedback that everything they’re doing is great. And I think as a result, we are actually setting them up for long-term failure. When that person suddenly has to face up to a difficult moment, then I think they’re screwed, to be honest. I don’t think they’ve grown the capacities to be able to handle that.”

Randolph has been pondering throughout his 23-year career as an educator the question of whether and how schools should impart good character. It has often felt like a lonely quest, but it has led him in some interesting directions. In the winter of 2005, Randolph read “Learned Optimism,” a book by Martin Seligman, a psychology professor at the University of Pennsylvania who helped establish the Positive Psychology movement. Randolph found the book intriguing, and he arranged a meeting with the author. As it happened, on the morning that Randolph made the trip to Philadelphia, Seligman had scheduled a separate meeting with David Levin, the co-founder of theKIPP network of charter schools and the superintendent of the KIPP schools in New York City. Seligman decided he might as well combine the two meetings, and he invited Christopher Peterson, a psychology professor at the University of Michigan, who was also visiting Penn that day, to join him and Randolph and Levin in his office for a freewheeling discussion of psychology and schooling.

Levin had also spent many years trying to figure out how to provide lessons in character to his students, who were almost all black or Latino and from low-income families. At the first KIPP school, in Houston, he and his co-founder, Michael Feinberg, filled the walls with slogans like “Work Hard” and “Be Nice” and “There Are No Shortcuts,” and they developed a system of rewards and demerits designed to train their students not only in fractions and algebra but also in perseverance and empathy. Like Randolph, Levin went to Seligman’s office expecting to talk about optimism. But Seligman surprised them both by pulling out a new and very different book, which he and Peterson had just finished:“Character Strengths and Virtues: A Handbook and Classification,” a scholarly, 800-page tome that weighed in at three and a half pounds. It was intended, according to the authors, as a “manual of the sanities,” an attempt to inaugurate what they described as a “science of good character.”

It was, in other words, exactly what Randolph and Levin had been looking for, separately, even if neither of them had quite known it. Seligman and Peterson consulted works from Aristotle to Confucius, from the Upanishads to the Torah, from the Boy Scout Handbook to profiles of Pokémon characters, and they settled on 24 character strengths common to all cultures and eras. The list included some we think of as traditional noble traits, like bravery, citizenship, fairness, wisdom and integrity; others that veer into the emotional realm, like love, humor, zest and appreciation of beauty; and still others that are more concerned with day-to-day human interactions: social intelligence (the ability to recognize interpersonal dynamics and adapt quickly to different social situations), kindness, self-regulation, gratitude.

The entire story can be found here.

Are Psychiatric Medications Making Us Sicker?

By John Horgan

The Chronicle of Higher Education

Three years ago, I was reminded in dramatic fashion of the chasm between psychiatry and more-effective branches of medicine. My 14-year-old son, Mac, while playing lacrosse, emerged from a collision with his right arm askew. I drove him to a local hospital, where an orthopedic surgeon on duty immediately diagnosed the injury: dislocated elbow. He gave Mac an oral and local anesthetic and put him in a portable X-ray machine that showed Mac's elbow joint on a screen, in real time. Watching the screen, the doctor quickly snapped Mac's elbow back into place.

Overcome with gratitude to the doctor, I was leading my groggy son out of the hospital when my cellphone rang. An old friend, whom I'll call Phil, was on the line. He was in the psychiatric ward of a New York hospital, to which his 16-year-old son had been committed. The boy, who was taking antidepressants for depression, had threatened to commit suicide, not for the first time. The doctors were recommending electroconvulsive therapy, or ECT. Knowing that I had written about shock therapy and other psychiatric treatments, Phil asked my opinion. The fact that Phil had called me, a mere journalist, for advice in such a dire situation spoke volumes about the troubles of modern psychiatry.

I first took a close look at treatments for mental illness 15 years ago while researching an article for Scientific American. At the time, sales of a new class of antidepressants, selective serotonin reuptake inhibitors, or SSRI's, were booming. The first SSRI, Prozac, had quickly become the most widely prescribed drug in the world. Many psychiatrists, notably Peter D. Kramer, author of the best seller Listening to Prozac, touted SSRI's as a revolutionary advance in the treatment of mental illness. Prozac, Kramer said in a phrase that I hope now haunts him, could make patients "better than well."

Clinical trials told a different story. SSRI's are no more effective than two older classes of antidepressants, tricyclics and monoamine oxidase inhibitors. What was even more surprising to me—given the rave reviews Prozac had received from Kramer and others—was that antidepressants as a whole were not more effective than so-called talking cures, whether cognitive behavioral therapy or even old-fashioned Freudian psychoanalysis. According to some investigators, treatments for depression and other common ailments work—if they do work—by harnessing the placebo effect, the tendency of a patient's expectation of improvement to become self-fulfilling. I titled my article "Why Freud Isn't Dead." Far from defending psychoanalysis, my point was that psychiatry has made disturbingly little progress since the heyday of Freudian theory.

The entire story can be read here.

In Deal, Hundreds of Mentally Ill People Will Leave Confinement of Nursing Home

By Anemona Hartcollis
The New York Times
Published September 12, 2011

Hundreds of mentally ill people who have been confined to nursing homes, sometimes in prisonlike conditions, would move to apartments or other housing within three years under a legal settlement with New York State.

The settlement resolved a case that was filed in Brooklyn federal court in 2006 and that accused the state of violating the spirit of its own longstanding rules for housing mentally ill people.

In researching the case, the plaintiffs found that psychiatric centers and nursing homes had developed “turnaround agreements, which essentially were written agreements to transfer patients back and forth,” Veronica S. Jung, senior staff attorney for New York Lawyers for the Public Interest, which helped to represent plaintiffs, said Monday.

“This certainly raises broader, troubling questions about the role of nursing homes, and their financial stakes, within the mental health care system,” Ms. Jung said.

The settlement came as the judge in the case, Brian M. Cogan, set a trial date for early October, Ms. Jung said.

“It did seem pretty clear that the specter of going to trial in the next few days probably motivated the state to move more quickly in negotiations,” Ms. Jung said. The state has agreed to pay $2.5 million in legal fees and costs to the plaintiffs’ counsel.

Andrew J. Zambelli, counselor to Gov. Andrew M. Cuomo, said the state had settled the case because “it just jibed with our kind of policy viewpoint — care for the vulnerable, into the community, using money appropriately.”

Under longstanding legal principle in New York and elsewhere, the mentally ill cannot be confined unless they are considered a threat to themselves or others, and should be housed in the least restrictive setting appropriate for their needs.

Under the terms of the settlement, the Cuomo administration has agreed to reform the process used to assess whether patients are capable of living in the community and want to live there. The state has also promised to hire independent contractors who would be trained to make the assessments.

The entire story can be found here.

How An Ethically Challenged Researcher Found A Home at the University of Miami

By Paul Thacker

Forbes

Dr. Charles Nemeroff

Three weeks ago, the National Institutes of Health announced new rules to govern federally-funded researchers and their financial conflicts of interest. Three years in the making, the policy will affect over 38,000 scientists at 2000 organizations as the NIH attempts to ensure that biomedical research, paid with taxpayer dollars, remains objective.  (See our prior blog post.)

But none of these changes might have happened were it not for Dr. Charles Nemeroff.

A renowned chairman of psychiatry at Emory University, Nemeroff was a proponent for drugs sold by GlaxoSmithKline, such as the antidepressant Paxil. While earning hundreds of thousands of dollars jetting around the country and giving talks about Paxil to doctors at fancy restaurants, Nemeroff also managed a multi-million dollar grant from the NIH to research drugs under development by Glaxo.

The ensuing scandal became central to an investigation by Senator Charles Grassley into undisclosed payments from companies to prominent physicians—a practice that puts patients at risk and drives up healthcare costs. As Grassley’s lead investigator on the matter, I had a ringside seat as arguably the most powerful psychiatrist in the country was forced from prominence, eventually leaving Emory.

At my new job with the Project On Government Oversight (POGO), a government watchdog, I have continued to study the cozy relationships between physicians and corporations.  I also observed as Nemeroff left Emory for a new job at the University of Miami which has a medical school operating under financial strain. But why would this school snatch up a physician with such a history?

According to new emails and other materials shown to me, UM officials had serious concerns about Nemeroff’s history of ethical blunders. However, these emails suggest that Nemeroff’s perceived ability to raise money trumped those concerns. At one point while negotiating with UM for a job, Nemeroff even dangled the possibility of a new funder for the school if he was hired. These emails imply that, despite new federal rules, the public must remain vigilant to ensure that medicine is practiced with the highest regard for ethics and patient safety.

Officials at UM did not respond to detailed and repeated questions about the emails, which include communications by UM President Donna Shalala, who is now facing public scrutiny over a separate ethics scandal involving UM’s football program.

The entire story can be found here.

Maryland State Board of Physicians v. Eist

Patient Privacy vs. Disciplining Doctors

By Jonathan E. Montgomery

Martindale.com

Originally published June 21, 2011

This January, Maryland's highest court ruled in Board of Physicians v. Eist, that health care practitioners must timely disclose patient medical records to Maryland's Board of Physicians pursuant to a Board subpoena, or face sanctions, even if the patient involved objects to the disclosure.

In this case, Dr. Eist, a psychiatrist, became the subject of a Board investigation after the estranged husband of one of his patients accused Dr. Eist of, among other things, overmedicating the patient. The Board demanded the patient's medical records, but Dr. Eist initially withheld the records when his patient refused to give consent to the disclosure. Dr. Eist believed that he should wait until the Board and his patient settled their privacy dispute.

The entire summary of the case can be found here.

The entire opinion can be read here.

One issue from this case stems from the psychiatrist’s choice of counsel.  Apparently, though a competent attorney, Dr. Eist’s lawyer did not seem to grasp fully how to proceed when dealing with Maryland's Board of Physicians.

One major benefit to being a PPA member is to subscribe to our Legal Consultation Plan.  For $150 per year, a member has access to three hours of time from an attorney who is also a psychologist and understands the workings of the Pennsylvania State Board of Psychology.