Any one who has ever heard me complaining about the ethical and quality of care issues that arise from my work with inmates in prisons and jails, the elderly in nursing homes, and with the disabled with brain trauma, know I have to include my rants on these issues and populations. But before you click away from this page because ‘Who cares about those people?’ consider this:
‘For I was one hungered, and ye gave me meat;I was thirsty, and you gave me drink;
I was a stranger, and you took me in.
Naked, and ye clothed me;
I was sick, and ye visited me;
I was in prison, and ye came onto me.
.And the King shall answer and say onto them,
Verily I say unto you,
Inasmuch as ye have done it to one of the least of these my brethren,
Ye have done it unto me!’
Christian New Testament, Matthew 25, 35-40.
I have some strong opinions on this issue, because I do a lot of work in prisons and jails, as well as in nursing homes and hospitals. Almost all are overcrowded, under-funded and under-resourced, and none of them is a top priority for anyone but those who have to live there. And I must tell you now: there is no easy answer! I’m not going to sugarcoat these issues. I take my ethics as a licensed psychologist and my oath as a forensic examiner seriously.
Maybe I’ll start a web page about dealing with obnoxious people in general, whether they’re at work or a relative or whatever. But what I’d like to do on this web page is have a forum to discuss how we treat the ‘least’ among us, and whether the abuses in the system aren’t draining our community resources as well as hurting the very people who need help so much.
Sometimes I get referrals because somebody is a problem to other people, not just having a problem to his/herself. People incarcerated for a crime are a good example, as are people whose obnoxious behavior disrupts or threatens other nursing home residents, Nobody, especially not me, is saying that these populations are easy or pleasant to deal with. But they are still human beings, and how we treat them affects us all the long run.
As anybody in the business world knows, it’s often tempting to save money by cutting costs in quality or service. But it never works! If you cut quality, you do everybody (including you and me!) a disservice. The people who need the most and need help of the best and most effective kind seem to get the worst care! And in the cases we are discussing here, increased violence, more victims, and increased overall despair are the end-result.
Over and over, in different parts of this website, I will return to the theme of consequences and trade-offs, because in this world, there are few easy solutions. And the more we refuse to consider the impacts and the trade-offs involved in our choices, the more damaging and dangerous consequences we will see. So always keep in mind that I am trying to consider the practical impact of not giving these problems our full attention and rational consideration.
I think it is important to immediately introduce the concept of ‘dual client responsibility.’ This is the standard that even when seeing an individual client, a clinician continues to have fundamental ethical and professional responsibilities to other groups, including the greater community and the overall society, including potential victims. This is why clinicians are mandated reporters of child or elder abuse, must give warning if a credible threat is made regarding a specific victim(s), and why Medicare, EAP and other similar group providers claim a right to monitor what is done is therapy.
Let’s start with my complaints about mental health in the correctional system. Anyone who reads the paper knows that the California prison system is in ‘a state of disaster. Many of its facilities are horrifically overcrowded, recidivism rates are high, and its health services are so bad that a federal judge has put them in receivership.’ (CN&R, 10/5/2006) And this appears to be the direction much of the country’s correctional system is heading!
Sometimes I am infuriated because it seems as though the MHSDS (Mental Health Services Delivery System) in the California Department of Corrections is making a mockery of psychology and psychotherapy, and it is doing it in a place that will have the worst and the greatest impact on our communities and our society.
I don’t mean to denigrate those clinicians, psychologists and social workers, who are trying to do a good job. And certainly the correctional officers with whom I have worked can attest to the respect I give to those men and women in uniform who daily risk their emotional well-being and physical life to guard, protect, and serve both us and the inmates in their custody. No, rather I am upset with those bureaucrats who could care less about safety or improvement and give the majority of their attention to maintaining the status quo, working to keep their job and preserving their right to get a pension when they retire.
Some of them even used to be clinicians. But once having reached the level of a Senior Supervisor they are often removed from actual clinical contact with patients and the day-to-day questions that bedevil actual therapists. They cease to worry about ethics and competency, and focus instead on making up records to meet the requirements of court-ordered compliance to minimal standards.
But all this attention to the letter (or numbers!) of the law doesn’t touch the spirit of these complaints about poor care. All these lawsuits against CDC (popularly known as Plata, Davis, Coleman, etc. — there are many at present.) exist because something was being doing that damaged somebody, either the inmate or their next victim. What could be an exciting and fascinating field of new discoveries in psychology and innovations in treatment has become a place where too little effort goes into being effective.
A whole new generation of psychologists and social workers are getting their training and early experiences in a setting that encourages cynicism, incompetence, sloppy therapy practices, and little understanding of human behavior. Without previous training, without yet having earned their professional license or even doctoral degree, they can be at the mercy of those supervisors who, when asked how to deal with ethical questions or problems in delivering good treatment, give the advice to ‘Ignore it.’
This makes a mockery of mental health for those young clinicians. Worse yet, the inmate population is already prone to making a mockery of the values and systems that are characteristic of our society, So what behaviors are getting reinforced when they see the attitudes of exhausted, jaded, and badly guided interns? Cynicism, lack of prosocial values, and the unimportance of ethical beliefs — exactly those pathologies that are already epidemic among inmates! (Think about it! That’s why most of them are in prison already!) .
In case you think I’m making a fuss over people who can’t be saved anyway, consider this critical ethical issue: If you don’t believe this population can be helped, is it ethical for you to be working with them? Since our expectations of people have an enormous effect on what they learn, what are we teaching them in prisons?
This isn’t just some esoteric mental health argument; this is about something that affects our very communities through parolees, families and friends of prisoners, and anyone coming into contact with them. It isn’t enough to lock up those who have committed criminal acts if you’re not worked to prevent the cynicism and selfishness that encourages them!