Challenges in the mental health care of older incarcerated persons

Background: The number of older incarcerated adults has exponentially risen within the past two decades. Even though they still represent a minority amongst the general prison population, they require vast amount of resources from prison mental health services. Their health needs are higher compared to the general population and to younger incarcerated adults. At the same time, we lack detailed knowledge on their needs and the applicability of current interventions to this particular subgroup. We therefore systematically explored their mental health needs profile with a specific focus on substance use issues. Moreover, a major limitation in the integration of literature on older incarcerated adults is the missing shared definition of this age group. For this reason, we assessed the problems of defining the older population and compared current understandings and arguments provided to support these choices.
In addition, in the Swiss prison context, the number of older adults mandated to psychotherapeutic treatment has risen the most drastically. The overall goal of these court-mandated treatment orders is to reduce risk of recidivism by treating mental health disorders that stand in direct connection with the crime committed. Such interventions come with specific challenges due to aspects such as the coercive and restrictive nature of prison environment, the involuntary admission to psychotherapeutic treatment, as well as the therapist’s dual role to care and control. To date, we lack research exploring these factors on psychotherapeutic interventions, which could support mental health professionals in integrating these challenges into their clinical practice. This thesis therefore investigated the experiences of older incarcerated adults and mental health professionals with court-mandated treatment orders to explore current challenges and shortcomings in the delivery of psychotherapeutic and psychiatric treatment.
Methods: Systematic reviews of current literature were performed with the aim to investigate prevalence rates of mental health disorders with a specific focus on substance use issues as well as to shed light into current ways of defining this older age group, arguments used to support this choice, and the empirical evidence to back these definitions. This research project further used a mixed-methods approach, collecting qualitative and quantitative data from incarcerated persons as well as mental health professionals working in Swiss and Canadian correctional contexts. Quantitative data collection mainly encompassed data extraction from medical records. Additionally, pilot studies for the applicability of the routine outcome measure HoNOS-secure, the screening tool PHQ-9, and the structural diagnostic interview MINI were conducted. For qualitative data collection, semi-structured interviews were performed with older incarcerated adults receiving mental health care as well as mental health professionals working with patients who offended.
Results: Systematic review methodology revealed that definitions of the older age group vary and hamper the integration of already limited research. Based on our findings, we suggest the use of age 50 as cut-off to define the older age group for research and health care planning on national levels. Additionally, we confirmed the high rates of mental health disorders amongst this subgroup with psychiatric diagnoses of cognitive issues, alcohol misuse, and affective disorders being relatively more common in comparison to younger incarcerated adults. Qualitative interviews showed that patients and mental health professionals likewise struggled with integrating the involvement of the justice system into their psychotherapeutic work. In particular, limits to confidentiality needed to be handled transparently. Patients accepted mental health professionals sharing information with judicial authorities, as long as their private details were protected that were of no relevance to authorities’ decision-making. Additionally, when mental health professionals accomplished to emphasize their caring role over their controlling responsibilities, patients reported beneficial treatment experiences. This was achieved by a supportive and respectful attitude that aimed at promoting the patient’s well-being and progress in life. Therapists needed to master the balancing act between responding to patient’s individual needs within the predefined framework of mandated interventions. When therapist managed to respond to these personal needs, relief from psychological burden and therefore positive effects from treatment participation motivated them to remain and engage in therapy. This psychological burden frequently originated in their difficulties in dealing with deprivation of freedom, harshness of prison environments, as well as accepting and understanding their crimes committed and their psychiatric diagnoses. Last, external pressures imposed by judicial authorities strongly affect patients’ experiences with psychotherapeutic treatment. Predefined goals and authorities’ decision-making currently lacks clarity and transparency. To augment patients’ motivation to participate in treatment, the application of these external motivators should be used more favorably.
Discussion: This research project contributes to much-needed research on mental health of older incarcerated adults and their experiences with court-mandated interventions. We confirmed high prevalence rates of older incarcerated persons’ mental health issues and outlined current definitions applied to this subgroup. This to advance a shared understanding of this population to facilitate the integration of available literature. Further, we showed that the involvement of the justice system substantially affects psychotherapeutic processes. We confirmed previous assumptions that the way MHPs integrate coercion and control in their clinical work, alters patients experiences with psychotherapy. We outline some pressing shortcomings of current treatment delivery and propose some strategies in alleviating the negative impact of external pressures. By this, we can potentially enhance patient motivation and alliance quality to improve clinical and criminal outcomes of incarcerated persons mandated to treatment. By increasing the effectiveness of such court-mandated treatments, we consequently not only enhance well-being of the individual patient but concurrently increase public’s safety.