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1 Joseph D. Galanek Begun Center for Violence Prevention, Research, and Education Jack Joseph and Morton Mandel School of Applied Social Sciences Case Western Reserve University (E mail: email@example.com) Correctional Officers an d the Incarcerated Mentally Ill: Responses to Psychiatric Illness in Prison _____________________________________________________________________________ Based on ethnographic fieldwork in a U.S. men's prison, I investigate how this social and cultural context structures relations between correctional officers and inmates with severe mental illness. Utilizing interpretivist perspectives, I explor e how these relations are structured by trust, respect and meanings associated with mental illness. Officers' discretionary responses to mentally ill inmates included observations to ensure psychiatric stability and f lexibility in rule enforcement, and were enmeshed within their role to ensure staff and inmate safety. Officers identified housing, employment, and social support as important for inmates' psychiatric stability as medications. Inmates identified officers' observation and responsiveness to help seeking as assisting in institutional functioning. These findings demonstrate this prison's structures and values enable officers' discretion with mentally ill inmates, rath er than solely fostering custodial responses to these inmates' behaviors These officers' r esponses to inmates with mental illness concurrently support custodial control and the prison's order. [prison, mental illness, correctional officers, illness categories, illness construction] ______________________________________________________________________________ We spend more time with these inmates than any other staff. The mental health staff are in their offices seeing these guys, or they come down to the cell blocks for a few minutes to talk to them at their cells. But we spend 8 hours a day with them. We're with em all day. Correctional Officer, Pacific Northwest Penitentiary Introduction Over the past 30 years, psychiatric illness experiences, the professional constitution and treatment of mental illness, and the discursive practices regarding psychiatric illness categories have become inextricably enmeshed within correctional institutions rather than solely in the community or psychiatric hospitals (Applebaum 2010; Galanek 2013; Redlich and Cusak 2010; Rhodes 2001, 2004 ; Waldram 1997 2012). Published p revalence e stimates of serious mental illness in U.S. state prisons have varied due to diversity of measurements used to identify disorder s but ha ve nonetheless remained consistently higher than U.S. population samples ( James and Glaze 2006; Lamb and Weinberger 2005 ; Prins 2014 ) Lower end estimates of serious mental illness among state prisoners indicate 17% of the U.S. prison population have the presence of a serious DSM mental illness ( Lamb and Weinberger 200 5; National Commission on Correctional Health Care 200 2 ) W ithin these total institutions, individuals identified as mentally ill have compulsory interaction with prison inmates and corre ctional staff ( Adams and Ferandino
2 2 008; Dvoskin and Spiers 2004; Goffman 1961 ; Rhodes 2004 ). Among these staff, c orrectional officers are identified as having the most engagement with the incarcera ted mentally ill ( Applebaum et al 2001 ). Inmates with mental ill ness are disproportionat ely housed in state prison s disciplinary segregat ion and supermax units, reflecting an unyie lding c ontrol over disordered behaviors ( Fellner 2008 ; Haney 2008; Lovell 2008; Rhodes 2004). In California, documenta tion of systematic patterns of staff abuse toward mentally ill inmates reflect a system ill equipped to address the needs o f this incarcerated population, a lack of training for officers, and an inst itutional culture contributing "to the very problems they ostensibly seek to solve interpersonal violence" (Fellner 2008:1080 ; Rosen Bien Galvan & Grunfeld 2014 ). Prisons are embed ded within specific social, historical and cultural contexts, contributing to variations in their social and cultural processes such as staff inmate relations ( Fleisher 1989; Garland 1990 ; Liebling 2004 ) Given the heteroge neity of these institutions do these findings indicate a systematic and deliberate abuse of the incarcerated mentally ill? Or are there other institutional responses available to prison staff? Based on nine months of ethnographic fieldw ork in a U.S. state prison I invest i gate how institutional values and social structures enable correctional officers responses to mentally ill inmates. I focus on how officers' discretionary respons es are possible within a total institution, whose hierarchical structures limit agentive resp onses to disordered behavior (Foucault 1977; Goffman 1961; Rhodes 2001, 2004; Waldram 2012) Utilizing interpretivist and constructivist perspecti ves I identify how officers constitute the category of "mentally ill inm ate" and how a prison' s context enabl es and structures relations between officers and inmates with severe psychiatric disorde r. I attempt to answer several related questions. How do prison correctional officer s construct mental illne ss within an institution designed to correct disordered behavior and hold offenders accountable (Foucault 1977; Rhodes 2004 )? I s there a strict adherence to holding inmates accountable to all viol ations of prison rules ? Finally, how does this prison's cultural values structure hel p seeking ? I explore how the mentally ill engage with officers and how these officers, charged with overseeing convicted felons respond to prisoners identified within the illness category of mentally ill inmate By investigating these processes, I identify what m akes these inmates less susceptible to an inflexible use of power an d control by prison officers Prisons as Local Moral Worlds and the Construction of Illness Categories T here has been a decline in ethnographic resear ch in U.S. prisons over the past 30 years a lthough this methodology characterized the foundational sociolo gical penal research (Clemmer 1940; Irwin 1970; Rhodes 2001 ; Sykes 1958 ; Wacqua nt 2002). This has been largely attributed to perceptions of ethnographers being r isks within these controlled environments and bureaucratic response s to inc reasing prison populations (Di L u l lo 1987; Rhodes 20 09; Simon 2000; Waldram 2009). R esearch within U K prison s remains prevalent particularly in exploration of the prison's social structu res and value systems through descriptive accounts of staff inmate relations However, ther e has not been ethnographic research on U K officers' work with severe ly mental ly ill inmates (Crawley 2004; Genders and Players 1995; Liebling 2004; Morris and Morris 1963:196; Sparks et al. 1996). Recent approaches const itute the prison as a local moral world with values and cultural meanings arising from interactions within the hierarchically structured compulsory sociality of institutional actors ( Galanek 2013 ; Kleinman 1992; Liebling 2004 ; Rhodes 2004 ; Waldram
3 2012:97 ). I nteractional processes embedded with in local social and cultural contexts construct psychiatric illness categories t hrough interpretive activities of professional p sychiatric sys tems and social networks, such as families and peers (Brown 1995 ; Kirmayer 1989; Kleinman 1988 ; Lurhmann 2000; Rhodes 2004 ). These int er pretive activities imbue illness es with cultural meanings which in turn structure responses to individuals identified within illness categories ( Jenkins 1988 ; Rhodes 2004 ; Waxler 1974). For example, clinicians may ascribe more personal blame and culp ability to U.S. patients exhibiting DSM Axis II personality disorders; Axis I disorder s presumed to be b iologically based, are out of the patients' control ( Luh rmann 2000 ) D escriptive accounts of the prison indicate that construction of psychiatric illness does not occur solely through the work of mental health practitioners (Fou cault 1977 ). I nteractions among mental health p rofessionals, correctional officers and prisoners within these local moral worlds construct illness categories and structure culturally mediated institutional responses to these categories ( Galanek 2013 ; Rhod es 2004). As large numbe rs of individuals with mental ill ness sh ift into institutions of punishment and incapacitation, what are the responses of those charged in overseeing their lives? Correctional Officers : People Work and the Incarcerated Mentally Ill Correctional offi cers are a heterogeneous group who engage in "people work" ( Crawley 2004 ; Liebling 2004 ) Officers have variably characterize d their work as congruent with re habilitative goals merely sat isfying basic job requirements or con flicted in their professional role and relations with inmates; others display ed cynicism regarding rehabilitative efforts in prison (Crawley 2004 ; Tait 2011; Toch 19 7 8). Toch (1978 :27 ) has noted that exclusive characterization of officers as custodians did not take into account their exercise of discretion in "working with" inmates This perspective, that officers work with inmates rather than s olely using coercive measures, is key to understanding how correctional officers maintain order and conduct the ir work (Crawley 2004; Farkas 1999; Fleisher 1989; Johnson and Price 1981; Leibling 2004; Liebling et al. 2011; Lombardo 1981; Shapira and Navon 1985; Spark s et al. 1996 ). O fficers may seek bureaucratic loopholes in response to inmates' needs, listen to inmates' concerns, and rely on verbal skills to de escalate potential violence (Fleisher 1989:1 74; Gilbert 1997; Liebling 2004; Liebling et al. 2011; Lombardo 19 81; Owen 1988; Rhodes 2004 ; Sparks et al. 1996 ). Prisoners have also identified how these relationships may be mutually beneficial (Liebling 2004; Sp arks et al. 1996). O fficers are iden tified as having the most contact with mentally ill inmates housed in the gener al prison population and as having potential ly positive impa cts on treatment and illness outcomes (Apple baum et al 2001; Dvoskin and Spiers 2004). R esearch in Canada and the U nited States suggests officers' negative attitudes about inmates identified as mentally ill, with receipt of training contributing to positi ve perspectives and officers being supportive of treatment even potentially coercive measures ( Callahan 2004; Kropp et al 1989; Lavoie et al 2006). Officer s have opportunities to work collaboratively with mental health staff in ens uring treatment ; c ustodial roles and support of treatme nt are not mutually exclusive as suggested by a treatment custody division model of prison staffing (Apple baum et al 2001; Callahan 2004; Dvoskin and Spiers 2004 ; Rhodes 2004:152 153; Tait 2011 ). Rhodes demonstrated t hat w ithin a U.S. prison's inpatient psychiatric and supermax unit, mentally ill prisoners may be "partially exempted from custodial expectations" thro ugh officers' use of discretion (2004: 103) However, Rhodes did not p rovide accounts of whether
4 officers' discretion was widespread Additionally, b oth custodial and treatment staff may be "capable of performing the role usually attribute d to the other" (Rhodes 20 0 4 :152 ). Rhodes states that officers in the supermax unit may take time to listen to inmates' concerns, speak with them humanely, and even "asked if they skip ped their meds but does not suggest there are institutional v alues or illness categories that mediate staff responses to mentally ill inmates ( Rhodes 2004 :120 121 ) Investigation of the institutional values that structure social relati ons provides continued analysis of prison s a s a local moral world s and how culturally mediated relations structure responses to the illness c ategory of mentally ill inmate Qu est ions remain as to how these unique institutional contexts and sites of interpreti ve activities shape responses to illness categories. The Research Context Pacific Northwest Penitentiary Pacific Northwest Penitentiary ( PNP ) 1 houses 2 000 male inmates ; a ppr oximately 1 000 of this population are in two massive cell blo cks. These cell blocks are composed of five tiers with two rows of 50 5x8 cells ; inmates are housed alone or are doubly housed. F our correctional officers oversee the activities of each block I n 2009, approximately 10% of PNP 's inmate population was diagnosed with severe psychiatric disorder, which incl udes schizophrenia spectrum disorders, bipolar disorder, any psychotic disorder, and major depression (severe, recurrent). Since the mi d 1990 s, a team of mental health professionals have been embedded within the prison conduct ing assessment and diagnost ic services, and pharmacological, psychosocial, and therapeutic treatment inter ventions An inpatient psychiatric unit (IPU) provid es acute inpatient cri sis services The majority of mentally ill inmates live and work within the general prison population, dispersed in the major housing units Fifty severely mentally ill inmates live in a specially designated tier i n one of the large c ell blocks termed the "mental heal th tier Mental health staff, in conjun ction with correctional staff, determine the appropriateness of housing severely men tally ill men there, providing institutional clinicians opportunities to engage with officers. O ffice rs working the mental health tier know these inmates have a di sorder that warrants treatment, alth ough they do not have access t o confidential medical files which are HIPPA pr otected Ment al health staff meet with officers to discuss "warning signs" of increased symptoms for specific inma tes, such as poor sleep, difficulty concentrating or bizarre speech. In this manner, officers, in conjunction with departmental training, assignment to units such as the IPU, and collaborations with mental health sta ff were prepared to work with inmates with severe mental illness. Methods All research protocols were approved by the State Department of Corrections and the university's institutional review board (IRB) Approximately 430 hours of observations o f the prison and interviews with 23 staff and 20 inmates were collecte d during fieldwork. Written informe d consent was obtained for all participants with o ngoing informed consent obtained for inmate participants. Semi structured, open ended interviews of 45 60 minutes in length were conducted in a private office four times with s taff and seven times with inmates and transcribed verbatim I had status as a volunteer and successf ully negotiated for access throughout the institution. Establishing credibi li ty as a participating observer hinge d on maintaining visibility
5 interacting with staff and inmates, comm unicating the study's goals and maintaining routinized observation in cell blocks and common areas to accustom staff and inmates to my presence (Ber nard 2011: 34 59 ) No formal, recorded interviews were conducted in public institutional spaces. Field notes were taken during or immediately after observation periods. Observations and interactions among staff and inmates consisted largely of the cell block that contained the mental health tier St aff participants included seven correctional officers three prison administrators six mental health staff two medical staff three correctional counselors one ed ucation staff and one work supervisor All PNP staff self identified as having long term experiences working with inmates with seve re psychiatric disorders and knowledge of instit utional practices related to this prisoner population. For inmate recruitment, a purposeful sampling strategy was employed to access experiences of psychiatrically stable inmates who were function ing well in the prison to answer this study 's broader questions o n psychiatric recovery ( Ulin e t a l 2005 ). Inclusion criteria included: ( 1) diagnosis of severe psychiatri c disorder; ( 2) living in general prison population; ( 3) assessed by mental health providers as psychiatric ally sta ble to provide informed consent, pa rticipate in research ; ( 4) low number or no days in disc iplinary segregation or IPU past 12 months; and ( 5) a dherence to programming (education, mental health, employment) in the preceding 12 months. Inmates who were symptomatic were identified as not being able to participate in informed consent processes by the IRB and the DOC's office of research. P articipati on could also potentially int erfere with treatment A list of 51 eligible inmates was created by mental health staff, with 22 declining participation and 9 dropping from the study due to disin terest in continuing (2), work schedule confl icts (4), increas ed symptoms (2), or transfer to another prison (1) A private office was provided to discuss details of the re search, informed consent and conduct interviews Staff were not present during inmate recruitment n or were they informed of inmates' participation or refusal to participate. The inmate sample characteristics are presented in Table 1. Consenting inmates also signed a HIPPA waiver, providing access to diagnosis to ens ure eligibility requirements Diagnoses and treatm ent need s were arrived at through clinical judgment of PNP mental health staff and through consultations with other DOC mental health profe ssionals Due to length of incarcerations and time in treatment, diagnoses were assessed as accurate, although no formal diagnostic interview schedules were used All inmates reported to taking psychiatric medications. A ll data were analyzed using Atlas.ti (version 5.5), a quali tative analysis software Data for this article wer e derived from two questions for inmates: ( 1) Can you describe your relationship with correctional of ficers? ( 2) Have these relationships have helped you cope with living in prison or with your mental illness? Data were also derived from one question for s taff: Can you describe what it is like to interact and work with inmates with mental illness? The open ended questions allowed for exploration of non security staff's experiences and observations of officers' work with mentally ill inmates. A priori codes were utilized along with codes derived from an iterative i nductive and deductive process Compiling coded sorts of interview and observational data allowed for review of discrepancies and generalizations in data. Conclusions were drawn from triangulation o f observational data, and i nterview data, contributing to credibility and dependability of findings (Ulin et al 2005 ).
6 Table 1: Pacific Northwest Penitentiary Inmate Sample Characteristics ( n =20 ) Mean Age = 46 Age Range = 26 57 Diagnosis Frequency Percent Schizophrenia 9 45 Schizo Affective D/O 4 20 Bi Polar D/O 2 10 Psychotic D/O NOS 1 5 Major Depression 2 10 Mood D/O NOS 2 10 Total 20 100 Race/Ethnicity Anglo/Euro 12 60 African American 7 35 Native American 1 5 Total 20 100 Number of Years at Pacific Northwest Penitentiary 1 month 2 Y ears 4 20 3 5 Years 4 20 6 10 Y ears 4 20 11 15 Y ears 3 15 More than 15 years 5 25 Total 20 100 Relationships b etween Staff and Inmates The DOC identifies off icers as positive ly impact ing inma te behavior while concurrently maintaining institutional safety and security Participants discussed that opportunities to p ositively i nfluence behavior resulted from officers and inmates establishing working relationships within the context of officers' custodial work An inmate livin g on the mental health tier discussed how officers needed to establish and mai ntain a relationship with inmates to run the housing unit : You have to have a relationship with others. It's not all, Get in your cell!'A lot of that goes on, but the sergeant working that block every day has to develop some type of relationship with the inmates. Intensive interactions, encouraged and structured through PNP 's administrative policies, enabled w orking relationships between inmates and correctiona l officers. In th e late 1990 s, t he s tate DOC implemented the Accountability Model based on social learning theory and cognitive behavioral princip les. This policy mandated high level s of staff in mate interactions, providing opportunities for staff to model pro social behavior, reinforce inmates' positive behaviors and redirect negative behaviors while maint ain ing institutional safety. Following from the DOC's p aramilitary organization t hese statewide policies were implemented through formal meetin gs with institutional and state administrators among correctional staff. R anking officers (captains, sergeants, and lieutenants) were expected to use this model to structure the day to day management of the inmate population through communication of expectations with officers during shift change meetings and inf ormal interactions. A lieutenant told me : Staff inmate interaction is basically treating the inmate like
7 how you want to be treated I think staff were doing it a long time before the state put a name on i t These comments refer to PNP 's institutional culture: P risoners and staff engaged with each other to manage the prison's day to day activities and to maintain order (Liebling 2004). A cell block sergeant reflected this, stating : "We all have to communic ate to make things run smoothly around here Staff and inmate participants acknowledged that respectful interaction mandated by the accountability model, w as absolutely necessary for the in stitution to run effectively safely Officer and inmate participants acknowledged that this mandate for pro social interaction was differentially enacted by inmates and staff P articipants identified portions of correctional staff and PNP inmates as "never getting it" and not understanding the benefits of man ag ing the prison in this manner. PNP's physical structure cont ributed to the informal interactions which enabled staff to engage in the accountability model's tenets; common areas and open institutional spaces provide d opportunities for communication and informal requests out side of official channels (Galanek 2013). For example, c ell block and common area observations revealed that officers and inmates engage in idle conversation, inmates interact with officers to make requests, and officers speak with inm ates to maintain the housing unit's operations The prison's par amilitary culture gives these interactions a brusque flavor, but as often, inmate s and staff attempt to neutrally engage to maintain order within the cell block. Heated exchanges also occur between staff and inmates, and inmates are written up for disrespecting officers. A n officer commented on how PNP 's institutional social structure and culture may be unique among state prisons: In some institutions, like in California, inmates have to wal k on a painted line, or they get take n to the hole, taken down, or shot. I think that's why there's less assaults on staff. We listen to the inmates. A rapport, you might call it. This comment reflects acknowledgment that U.S. prisons are not uniform in i nmate management due to diverse institutional cultural values that structure staff inmate interactions Prisons a re low trust environments, but within particular prisons staff prisoner relations may be structured through institutional cultural values of trust and respect (Fleisher 1989; Libeling 2004; Owen 1988 ). Liebling ( 2004) identifies that trust within U K prison s is not an either or proposition; gradations of trust may exist between prisoners and staff Given that the social structure of PNP enco urages sustained levels of interaction, gradati o ns of prisoner staff trust are enabled through demonstration of character traits within institutional interactions An officer explained how mutual respect and trust is based on consistency of behavior and f ollowing through on your word: If you prove yourself to them [inmates], being straightforward and true to your word, not lying to them, doing your job the inmates will come to respect you. And that's when it'll work well for you if they respect you. A mental health staff discussed how inmates assess trustworthiness of staff of being trustworthy, and ultimately worthy of respect : Trust works experientially. That's about when staff follows through with what they say they're going to do. It commands respect. Inmates respect that. There's some staff who won't do it and the inmates don't respect that. T he trust that gets built is a trust of being who you are I trust you're going to do what you're supposed to do, and I'm going to do what I'm supposed to do.
8 Consist ent behav ior indicates who can be trusted and whether an individual's "word" has cr edibility, contributing to gradation s of trust in institutional relationships However, t hree inmate characterized officers as being there solely to guard over the inm ates, officers' livelihoods were dependent on imprisonment of citizens, and these inmates verbalized resentment that officers ultimately have control over them. One inmate indicate d that his symptoms interfered with interact ions with staff. I nmates perceived officers variably which limited working relations and opportunities to establish gradation s of trust and res pect "Mentally Ill Inmate": Institutional Illness Category Officers discussed how increasing identification of mentally ill inmat es necessitated knowledge acquisition to effec tively work within the prison M ental health staff and correctional officers discussed that rotat i ng through various posts such as the IPU or mental health tier allowed officers to acquire experience and training on how to work with mentally ill inmates The looping effects of the prison (Goffman 1961) enabled observation of inmates across institutional contexts, providing opportunities to observe psychiatr ic symptoms firsthand, or as one officer noted, "people talking to the walls and inmates' psychiatric recovery. This demonstrated to offic e rs that psychiatric illness was present in the prison and treatable. Mental health staff also have interactio ns with officers, providing on the job training about behaviors that are warning signs of psy chiatric decompensation, s trateg ies that work best with inmates and how t o minimize risks of decompensation (Applebaum 2010 ). This knowledge contributed to officers' constructions of inmate s' psychiatric disorder. As front line staff, they saw the immediate effects of, for example, medications and the prison environment on an individual's symptoms. A n officer who wo rked on the mental health tier emphasized that medications were an importan t part of treatment, but th at environment also played a cruc ial role in inmates psychi atric stability : I worked in disciplinary segregation I've seen these guys improve. Guys used to be smeared with feces, fighting you. They were warehoused. Now they're in general population, doing well, on meds. If someone needs their anti psychotic meds, I'll make sure they get em. I've seen the meds work. This one inmate is on his meds now, living on the mental health tier, and he's adjusted and doing well. The enviro nment is equally, if not more important, than meds. You could give someone all the meds in the world, but if you put them in a hostile part of the cell block, it won't work. Pharmacological treatments had become part of the institutional culture since the implementation of the mental health program and all officers indicated that medi cati ons were a critical aspect of inma te s' psychiatric stab ility Observat ions revealed that t hree times a day, inmates lined up in a common area by the cell blocks for "pill line This medication distribution from nurses demonstrated to officers that large numbers of inmates were assessed as needing psychi atric medications to function in the prison. However, r ather than a biological reductionist account of psychia tric illne ss (Lurhmann 2000), officers understood mental illness as being significantly affected by pharmacological treatments and social context Consequently, o fficers were attentive to the significance of inmates' context including housing assignments, inter actions with other inmates, and activit ies
9 such as employment Of the latter, a n officer commented : It keeps their mind off of things, gives them some self worth. Cell time is bad. I t gives them more time to think, problems with hearing voices. The more they're out, thinking, getting daily stimulus from their job, the better. Officers acknowledged that keeping busy, by focusing on external tasks could contribute to most inmates maintaining positive functioning in the prison, but viewed this coping strategy as particularly applicable to mentally ill inmates. Inmates discussed how offi cers' acknowledgment of mental illness positively structured their working rel ationships with officers An inmate stated: There's certain security that work with you better. Sergeant Smith 2 is one of the few that know about menta l health. When they work in the cell block it makes a d ifference. They know about it [ mental illness], and they know some of the things that people go through. They'll just come down and talk to you at the cell. T his inmate discusses how mental health knowledge structured of fice rs' interactions with him, such as taking time to talk by the cell during his shift. An officer emphasized that these responses wer e mostly voluntary, as o fficers could treat mentally ill inmates as any other inmate ( i.e. not utilize additional time to observe or engage with them ) "You have to want to work with them this officer noted, which suggests tha t this prison's structure allowed agentive responses to individual inmate needs. The inmate quoted above discusses that s ome office rs work better with inmates than others suggesting that the category of "mentally ill inmate" was still contested among correctional officers. Interviews wit h staff indicated variability among PNP officers' knowledge of mental health from disinterest in working with these inmates, to assessing all mentally ill inmates as potential m alingerers (Rhodes 2004 ). There was also variability in how officers understood mentally ill inmates. While acknowledging the presence and severity of mental illness in PNP, officers emphasized that even the mentally ill engage in manipulative behaviors and discuss how mentally ill inmates "turn it on" ( exag gerate symptoms) when they want something such as unwarranted phone calls to mental health staff. A l though acknowledging the illness, officers may still take custodial a pproaches to their interactions O fficers and staff also indicated that at tentiveness to the mentally ill was simply "part of the job and discussed responsiveness to mentally ill inmates as demonstrating thei r credibility Assuring that menta lly ill inmates' needs were met contributed to the order of housing units; highly sy mptomatic inmates are perceived as unpredictable threats by other inmates. In this way officers' responses were intertwined with responsibilities to maintain safety and security and "keep the peace" within the cell bloc ks. Correctional Officers' Respo nses to Mentally Ill Inmates Observation Officers' work consists of observing inmates as they go to and from cell blocks, recreate on th e yard, o r work B ehavior al changes are used in officers' assessments as to whether a mentall y ill inmate needs c risis intervention and are predicated on getting to know inmates firsthand Officers were discussed as being first responders and crucial in heading off decompen sation through communication with mental health staff Psychiatric sy mptoms such as hallucin ations or
10 paranoid ideations, create risk s for mentally ill inmates to be eithe r victimized or to harm others. Disruption in prison also creates further risks. Officers' inattentiveness to other inmates while breaking up an assault increases risks for escalating disorder and decreasing safety for staff and inmates within the institution Although officers' observations, reports to mental health staff and checking in with menta lly ill inmates are understood a s ensuring treatment it also serves a dual purpose of maintaining the prison's safety and sec urity Similar to Rho des' s (2004) finding of custodial and mental health staff roles converging in the r esponse to mentally ill inmates officers in PNP embedded their work with mentally ill inmates in maintain ing safety and security. An officer who had worked at PNP for 15 years discussed h ow checking in with mentally ill inmates mai ntained security made his work days easier and enabled inmates' access to crisis services. It's like five dollars in the bank every week. It keeps you from having to deal with them later. They're just waiting for that 5 minutes of your time, and you get to know just where they're at, and if they're getting to the point of where they'r e going to cycle [decompensate] 3 or if they're just angry at that moment. But you just find out where they're at, take some time to find out how their day is going. You can cut if off if they're starting to spin [decompensate] and call mental health. You have the same individuals you see every day. I tell new staff spending some time with this individual is going to save you a lot of time and frustration when he's gone off his meds or cycling or whatever. If you go by the administrative rules, this is jus t doing your job. Attentiveness to mental status through supportive checking in with mentally ill inmates c ontributes to the officers' primary responsibility of maintaining safety and security of the institution, and of the inmates themsel ves The mental health tier was embedded within a 500 man cell block that also housed non mentally ill inmates offering a contrast in how officers engaged with mentally ill and non mentally ill inmates. Officers would walk on the non mentally ill inmate tiers in a cursory fashion, with checks to ensure safety or briefly respond to questions. Officers on the mental health tier checked in with inmates cell side, having brief conversations and noting any behavioral changes that would warrant contact with mental health staff An inmate discussed the importance of this checking in: The cops are treating us differently on the mental health tier. Most of the cops are showing us concern, checking up on us. They want to make sure were not distraught or suicidal. This quote reveals that inmates themselves identified positive benefit to off icers' interactions, interpreting this observation as supportive of their ment al health. Flexibility and Discretion Rhodes (2004) observed that prisoner accountability is a paramoun t concern for custodial staff Officers at PNP discussed, however, that strict enforcement of rules may not be the best approach in wo rking with mentally ill inmates. An officer stated: I think writing them up is the wrong thing to do in most cases for ment ally ill inmates. A lot of these guys, in dealing with them over the years
11 they're not aware of the consequences. It's much easier in the long run to work with them. When they do to disciplinary segregation, they go downhill. This quote reveals that off icers understood that mentally ill inmates had co gnitive deficits, and may not respond to dis ciplinary measures. Mentally ill inmates are admitted to disciplinary segregation but outcomes of these measures may be negoti ated between security and mental health staff ( Adams and Ferr andino 2008 ) An inmate diagnosed with bipolar disorder and living on the mental health tier discussed how an officer exercised discretion following an incident on the housing unit: A: Well, somebody left a note on my bunk, in my cell. Real fire and brimstone, that I was goin g to hell. So I threatened the person that I thought did it threate ned to beat him to a pulp. He told the sergeant The sergeant pulled me aside and said, Is there going to be a problem? And I told him, No. And I told him wh at happened and I talked to my case manager. Q: Could the sergeant have written you up? A: Yes Q: Did he cut you a break? A: Yeah. Q: Cause he could've just put you in the hole [disciplinary segregation unit] right? A: Yeah. He recognizes we're on the mental health tier. Here is a clear rule violation. The inmate threatened another inmate, but the officer, because of his int ensive in teraction with mental health tier residents decided to defuse the situation by not sending the in mate to the disciplinary segregat ion unit This placement creates risks for i ncreased symptoms due to this unit's noxious environment : l ocked down 23 hours per day and pervasive harassment from inmates The inmate could have lost his job, cell assignment or time in intensive programming. This reveals that PNP officers can take a n agentive, pragmatic approach to mentally ill inmates based on knowledge stemming from intensive interactions B lack and white perspectives, prevalent in the pa ramilitary prison structure, were not seen as appropriate when working with mentally ill inmates Discretion, or flexibility in approach was warranted. C hecking in on menta lly ill inmates in their cells and taking "that five minutes" is not th e standard work of officers T here is a boot camp mentality in the cell blocks, where inmates "do your own time without need ing to be "coddled I t is the inmate's responsibi lity to determine instit utional routines and conduct himself accordingly. Mitigation of this boot camp mentality, through officers' flexible approaches to mentally ill inmates, ( such as checking in and increased observations) was enabled by meanings associated with this institutional illnes s category. Mentally ill i nm ates were understood b y officers as needing more attention, more discretion, and a different approach to their management than general population inmates. Officers' a pproaches to worki ng with mentally ill inmates were observed one morning as I was talking to the sergeant of the cell block in which the mental health tier was housed. During his morning duties t he sergeant gruffly engages with inmates, f ielding and deflecting requests
12 when a n inmate approaches us The sergeant speaks softly to me that this is a mental health t ier resident indicating his appearance to confirm his illness. 4 The inmate appears visibly anxious, or "shell shocked" as some officers term the expre ssions of the mentally ill. The inmate has wide eyes and a flat expression, much diff erent from the serious, angered expression that inmates cultivate to detract exploitation from potential predators As we stand together, t he inmate keeps his distance and silence, but his presence indicates he wants to speak to the sergeant. I back away, givin g them room to speak, and they converse in h ushed tones to provide confidentiality After they finish and the inmate returns to his cell, t he sergeant tells me "He needed to see his counselor I'll call mental health for him If you tell him you're going to do something, you're only as good as your word Rather than tell the inmate to send a kite 5 to his counselor, the officer will intervene to ensure a more rapid communica tion to the mental health staff. Addi tionally, completing the call contributes to this officer' s credibility. Abruptly, the sergeant switches back to t he curt officer I' ve seen all morning, directing loitering inmates on the cell "What do you want!? Shouldn't you be at work?" he barks This interaction between the sergeant and this inm ate reflects an officer's discussion on effectively communicating with mentally ill inmates: You have to approach them differently. You can't bark at em or treat em like any other inmate. It ends up winding them up. Barking at them could set them off, cause a lot of them are on the edge anyway. Later that week, I observe officers on the cell block fielding requests from other inmates. Inmates make req uests to call a l ieutenant for a housing change or their correctional counselor to make a personal cal l These requests are uniformly responded to with a short reply that the inmate needs to go through the institutional c hannels, such as writing a kite. When an inmate asks for a form to have something fixed in his cell, the sergeant form states : "You know, you can ask for these things when it's not the busiest time of the day and with regard to a cell change : "You need to fill out the form and send it to the l ieutenant Later, I observe the cell block sergeant discussing th e mentally ill inmat e he assisted with other block officers, offering suggestions on how to assist him with his hygiene : "You gotta make sure he showers and you get him clean sheets. If not, he'll get stinky Obtaining linen is the inmate's responsibility. But officers takin g the time to ensure this inmate received clean bedding reflects the extra attention officers will provide to mentally ill inmates due to perceived cognitive deficits. These examples show that PNP officers' responses to mentally ill inmates are based on t hese inmates' inclusion in an illness category. Constituted as mentally ill, they are underst ood as needing extra attention. T hose extra 5 minutes of additional monitoring ensure s their psychiatric stability. The inmate on the cell block, with his history being housed on the mental health tier, is pragmatically deemed by the cell block sergeant as needing additional attent ion, and the boot camp approach to inmate management is mitigated b y identification of this inmate as severely mentally ill Help See king: Trust and Respect Officers' a cknowledgment of serio us mental illness in PNP 's population and discretion also structured responses to mentally ill inmates' help seeking Inma tes in treatment have scheduled appointments with mental health providers bu t may also request to see mental health staff on an emergency basis If inmates are not known as being mentally ill and they request an immediate appointment with a mental health provider, officers will frequently tell them to fill out a written request If officers kno w the inmate through personal experience or institutional memory they
13 will facilitate rapid access to mental health services Since a number of inmates were house d on the mental health tier and thus observable, this aided officers' assess men ts as to when to make calls to mental health. An inmate discussed this: You got to ask the officer. That's how it works on the cell block. The officer will call up to mental health, and write you a pass if it's alright for you to see them. If th ey say no, you got to write a ki t e and wait. You have to rely on the officer, especially if you need to talk to the mental health prescriber, like if you need your medication changed, or you have a problem like you're hearing voices, and you might actually feel l ike hurting yourself. If they know you, they'll help you. If they really don't know you, or think you're playin' [manipulating], they'll tell you to write a kit e. If the officer likes you, and you're for real with them [officers], they'll do you a favor, t hey'll help you. There's trust there. T he inmate discusses that some type of r elationship with an officer, and the officer s' knowledge of the inmate as critical in the help seeking process. If the officer questions whether the inmate is mentally ill o r is malingering, the officer will tell the inmate to go through the prison bure aucracy for an appointment. Of importanc e is the inmate being "real" with the officer, establishing trust between the officer and himself. I nm ates by virtue of their incarceration are construed as manipulative and deceitful In this prison however, some gradation of trust with officers is sought out and maintained by prisoners with mental illness T his inmate discuss es how help seeking behavio r is structured through relationship s of trust with officers. O fficers trust that inmates with serious mental illness are being truthful in their requests for emergency a ppointments with mental heal th staff. O fficers will also check in with mental health staff to ensure appropriate ness of req uests Officers had to judge the legitimacy of these help seeki ng requests. I nmat es who experienced increased symptoms could become aggressive, assaultive, or engage in self harm acts that would jeopardize institutional safety and security. It was in the officers' bes t interest to be responsive, having a gradation of t rust to inmates' reque sts for assistance, thus d ecreasing chances of inmates acting out due to psychiatric illness. I nmates discussed how being "up front and honest" about symptoms facilitate d relationships of trust and respect. For example, officers could trust in an inmate's word that he truly needed assistance and consistent help seeking without manipulation contributed to officers' respect of inmates with mental illness and these inmates' credibility. An other inmate living on the menta l health tier discussed how relationshi ps with officers structured reality checking: It does matter if you have a profes sional relationship with security staff Sometimes you might be having delusions ab out what reality is and you want an officer's perspective. Sometimes the officers w ill help, cause they'll say, T he situation is not that serious, look at it this way, and talk you out of doing something. I can work with the cops on the cell block if I have issues. This quote reveals that trusting in the officer's judgment and having a good working relationship to discuss delusional thoughts and "check" reality was an important aspect of this relationship.
14 T rust centering on consistent behavior and be ing as good as one's word was equally salient for inmates' assessments of officers' behaviors. An officer discussed how a working relationship and knowledge of a severely mentally ill inmate facilitated the inmate's admission to the psychiatric unit, and d ecreased the likelihood of the use of physical force, or extraction from the cell (Rhodes 2004 ): Why make things harder? It doesn't make any sense. Why extract this guy and risk getting hurt and the staff hurt when there's other ways to get him out of the cell? I knew an inmate, I had worked with him before I knew him from special housing and general pop. He was off his meds. He needed to go to the IPU and he wasn't backing up [in his cell] to get cuffed up, and they were going to call a cell extraction team. I said, Wait a minute, let me go talk to him. So I went down the tier, and I said, Hey man, just back up, or these guys are going to come and get you. Let's do this the easy way. Would I lie to you? C'mon. And he backed up and we cuffed him and t ook him to the IPU. We didn't need to extract him. You gotta use your head with these guys [mentally ill inmates]. It can't all be muscle. Back in the day, we'd just get him You can take that home with you you just can't hit the gate and forget that. Thi s officer reveals that his consistent behavior and relationship with the inmate headed off a volatile situation. Good as his word, he did not lie to inmates and was consistent in h is behavior so that even though severely ill and decompensated, the inmate c ould still have a gradation of trust to leave his cell and be escorted to the IP U. Of interest here is that the inmate would have been sent to the IPU regard less of the officer's attempts at negotiation I f the inmate did not leave his cell when directed an extraction team would have come to physically remove him from it, forcibly taking him to the IPU This possibility re fl ects the inherent power of prison s hiera rchy ; officers ultimately exercise total control of inmates, either through cooperative act ivity, or physical force. What is of importance is that an inflexible exercise of power is not the primary strategy in dealing with mentally ill prisoners disordered behavior Instead this officer aims to decrease the likelihood of making his complex and challenging job mor e difficult. He said that in the past, institutional responses may not have taken into account his relationship with the inmate or the possibility of mental illness In conclusion, he reflect ed that e ven in the PNP deemed the "toughest institution in the state officers could experience psychological repercussions from an inflexible exercise of control. Discussion This article contributes to the analysis of prisons as cultural contexts (Galanek 2013; Garland 1990; Waldram 2012), w hich directs attention to how meanings associated with institutional illness categories structure institutional staffs' responses. Within this frame work, prisons are cultural institutions, as much as medical systems and thus accessing institutional meaning s are paramount in analyzing this context's socia l processes (Gaines 1992; Garland 1990; Good 199 4; Kleinman 1988). From this perspective, prisons are not acultural ahistorical institutions, but are embedded within specific social, cultural, and hi storical contexts (Garland 1990 ) This heuristic provides a framework for understanding the observed variability across U.S. priso ns and offers an explanation for officers diverse response s to mentally ill inmates The social and cultural
15 processes at wor k in PNP may indeed be unique to U.S. prisons, particularly when compared to conditions in California. The ethnographic specificity presented here provides evidence that U.S. prison staff do not respond uniformly to inmates identified as m entally ill. This article offer s insights into how there may be institutional spaces that allow for officers' discretionary agentive responses and how offi cers and mentally ill inmates have opportunities to engage in gradations of trust. Brodwin's (2013:56) discussion of workplace ethos or the "ideals woven into everyday action is particularly relevant here, as it enables officers' "standard r ecipes for action These ideals are reflected in the accountability model, a nd although differentially taken up by officers, the ethos this model endorses enable s staff to f ind their way through the extraordinary challenges in maintaining safety and security of the institution and mentally ill inmates. Correctional officers now p arallel community staffs' engagement with individual s with severe mental illness. Similar to fron t line clinicians, officers at PNP appear to display "ethics narrow or context specific decisions in the face of local constraints (Brodwin 2013:17). Officers' responses to mentally ill inmates are concurrentl y grounded within the meanings associated with this institutional illness category. This category offered officers an alternative responses to inmates' disordered behavior and the prison's "near at hand contingencies" (B rodwin 2013:19). L everaging personal relationships rather than using a singular strategy of physically coercive power to meet institutional needs demonstrates the alternative "tools in hand" available within the se officers' responses (Brodwin 2013:129). In con trast to community staff, office rs articulate d spe cific principles to maintain the psychiatric stability of inmates in their charge, and these actions were based on how they understood the m ental illness within the prison The hegemony of biopsychiatric's thinking" (Brodwin 2013:102) wa s no t challenged, but was complementary to officer s' pragmatic approach to effectively manage inmates. Ensuring inmates received medications was another tool, among managing other contextual factors, which contributed to mentally ill inmates' stability. PNP o fficers work with mentally ill inmates is ena bled by policies encouraging high levels of staff inmate interac tion and structured throu gh ideal institutional values of trust and respect (Fleisher 1989; Liebling 2004). Officers recognized that a particular illness category or prisoner role (Irwin 1970) was now prevalent and responses were pragmatic. Although officers were invested in maintaining these inmates' psychiatric stability through monitoring and facili tating help seeking this did not ci rcumvent or limit officers' options to enact force. Officers' constructions of inmates identified as severely mentally ill were based on exp eriences such as in the IPU and the mental health tier, and their interactions with mental health staff, ra ther tha n accessing mental health files (Foucault 1977; Waldram 2012). These processes contributed to a model of mental illness that identified contextual factors such as hous ing and employment as contributing to psychiatric stability, rather than solely on pharma cological treatments. It also demonstrates that officers' understanding and responses to mentally illness included possibilities for these men's psychiatric recovery Although mental illness was acknowledged in this prison, officers had differential respon ses to mentally ill i nmates, substantiating findings that officers respond variably to rehabilitative measures and the incarcerated mentally ill (Ta it 2011). O fficers discretion, generally display ed with non mentally ill prisoners was enacted by with mentally i ll inmates, but due to their inclusion in an illness category. PNP's social structure enabled agentive responses to inmates identified as mentally ill because of the meanings associated with this institutional i llness category. P resumed cognitiv e deficits warranted enhanced observation and intera ctions. Thus, o fficers denied be ing locked into
16 rigid roles or stringently responding to disordered behaviors, which enabled responses to these illness categories. Inmates discussed how officers' acknowle dgm ent of their illness, observations, and discretion in disciplinary matters also benefited their lives and illness. In particular, inmates identified that the relations with officers, structured on gradations of trust and respect, enabled the help seekin g with access to mental health services or to rea lity check troubling symptoms I nmates identified that being honest, not exaggerating symptoms, and allow ing officers knowledge of their illness operating within a relation of trust provided opportunities to access mental health services outside of the formal bureaucratic processes. Institutional values, whose maintenance is critical to the order of prisons (Liebling 2004), also structure and enable the relations between mentally ill inmates and officers. As in other contexts, officers' responses to mentally ill inmates were structured by meanings associated with psychiatric illness. Discretion was enacted due to perceived cognitive deficits and affective lability; observations ensured psychiatric stability ; and help seeking was facilitated. All of these processes were embedded within mandates to maintain safety and security, indicating the institutional context mediated officers' interpretations of their work with mentally ill inmates. Officers responses, contributing to mentally ill inmates stability also preserved institutional order. These intersecting goals safety and maintenance of inmates' mental health did not appear to be contradictory within this prison. Rather, responses to the incarcerated ment ally ill are structured at the intersection of s ystems of control and treatment Notes Acknowledgements. This research and the preparation of this manuscript was funded by the National Science Foundation ( DDIG 0823512 ) and t he National Institute of Mental Health ( 5T32 MH019960 19 ). I would like to acknowledge the participation of staff and inmates at Pacific Northwest Penitentiary I am deeply ind ebted to the men and women who live and work in this prison, and the time they offered in providing their valuable perspectives. This research could not have been conducted and completed without their interest, assistance, and effort. I would also like t o acknowledge the anonymous reviewers who provided comments and feedback on earlier drafts of this manuscript. 1. This is a pseudonym. For more detailed description s, see Galanek (2013). 2. This is a pseudonym 3. This refers to an inmate's increasing symptoms and precipitation to IPU admission. 4. This inmate was not a participant in this research, and I did not know his name, or his medical history. 5. This refers to w ritten inmate communication References Cited Adams, K and J Ferrandino 2008 Managing Mentally Ill Inmates i n Prisons. Criminal Justice and Behavior 35:913 927. Applebaum, K 2010 The Mental Health Professional in a Correctional Culture. In Handbook of Correctional
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