Volume 56, Number 1 - Winter 2010

 

By Eric Monthei, PsyD

Note: Dr. Monthei provided the following written answers in response to questions submitted by Marin Medicine.

I am the chief psychologist and also the chief of mental health for a department consisting of psychiatrists, psychiatry fellows, licensed clinical psychologists, social workers, psychiatric technicians, recreation therapists, mental health RNs, correctional counselors, and administrative assistants. 

I began my managerial career at the largest psychiatric hospital in the country at that time, which your readers might be surprised to learn was Mississippi State Hospital in Whitfield. After holding several administrative positions at the hospital, I returned to California to be near my family. 

I first joined the California Department of Corrections and Rehabilitation (CDCR) with a position at the California Medical Facility, a level III prison in Vacaville. I have since fulfilled other roles, including working for the CDCR Secretary to reform health care throughout the department. I began as the chief of mental health at San Quentin in November 2006. 

In general, how would you compare providing psychiatric care within San Quentin to providing care in the outside world? What are the biggest differences? The similarities? 

Starting with the similarities, psychiatric care at San Quentin is identical to the “outside world” in many aspects, including HIPAA, due process, community standards, best practice, treatment modalities, emergency and on-call services, crisis intervention, routine follow-up, hospital admission processes, discharge, qualifications of the staff providing services, and spectrum of psychiatric illness. 

There are, of course, many differences as well. The institutional setting itself plays a large part. There is an inherent complexity to providing services consistent with a model treatment approach while maintaining the safety and security of the institution. At times, there are institutional needs that must be accommodated. For example, in an outside treatment situation, the patient might call for an appointment or have a standing time available with a therapist. Within a CDCR institution there are intricacies such as lockdowns, custody count, bed changes, inmate/patient transfers and other health care needs that require constant coordination. 

The consistent presence of law enforcement and the fact that they are intimately integrated into the lives of our patients adds a dimension not often encountered on the “outside.” This provides a whole new rubric of possible treatment options when one considers that the inmate/patient’s treatment team consists of both health care and law enforcement representatives, all working toward a common goa1. Most notably, there are the challenges that are posed by providing services to patients on San Quentin’s death row. With a condemned population, our treatment providers face several unique challenges that have no real equivalent in the outside community. 

When there is a mental health issue of imminent concern, such as suicidality or florid psychosis, the interaction between health care staff at the relevant county jail and San Quentin is often coordinated prior to transfer. There are a number of screenings that occur as soon as the inmate/patients step off the bus at San Quentin, including medical, nursing, dental, custody, and mental health. 

While each discipline screens for any mental health concerns, the actual mental health screening consists of a multisystem review and screening process designed to identify any major or minor mental health concerns and to place the inmate/patient within the correct level of mental health care. There are a variety of databases at our disposal, including current parole records and archived prison records for those returning to custody. Regardless of whether the individual is a new commitment or a return to custody, every effort is made to solicit as much collateral data as possible. 

The vast majority of the conditions we see are no different and do not present differently than the outside community, although the willingness to engage in treatment is generally very different. In the correctional setting, treatment engagement and compliance is heavily influenced by environmental factors, race, gang affiliation, level of care, and custodial classification. While these factors undoubtedly impact treatment on the outside as well, within the closed environment of the prison system, they take on a new meaning and importance. The politics of prison are unlike any other outside environment. To a certain extent, it is only understandable from inside our walls. 

We tend to see a disproportionate rate of certain types of disorders within our population, including Axis II personality disorders, depressive disorders and substance abuse/dependence disorders. As one would expect, the complicating comorbidity of chronic medical illness, a heavily dual-diagnostic population, and the reality of a physically aging population serving time have led to challenging conditions layered upon one another. In part, this complex presentation is what has led the Mental Health Services Delivery System (MHSDS) at San Quentin to continuously recruit the best and brightest candidates; this also helps to explain why our management team is extremely proficient. 

What types of psychiatric treatments do the prisoners receive? How do those compare with standard treatments? 

Our treatments do not differ from what would be found in the outside community. 

How successful are the treatments that prisoners receive? 

Consistent with the newly restructured MHSDS at San Quentin, we have implemented a Recidivism Reduction Team (RRT) specializing in evidence-based treatment and inmate/patient reintegration into society. By design, this team serves as an internal outcome measure to determine what treatment is most efficient and effective. Keeping with the unique structure at San Quentin, we anticipate that our RRT will prove to be the next step in our evolvement into efficient and effective evidenced-based treatment with outcome measures. 

What happens after prisoners are released? 

Generally speaking, the vast majority of inmate/patients parole and reintegrate, with the exception of the condemned and life without parole inmate/patients, who compose a very small percentage of the total inmate population statewide. While paroling inmates will have scheduled visits with their parole officers, they will mostly be spending their time living among the rest of society. They will be in line at the supermarket, going to the movies, and living as your neighbors. Some will enter the job market, by continuing their GED or college programs, or work in a trade that was gained during incarceration. Others will have nowhere to go, paroling to the streets with no family, no source of income, and no support. Still others will return to life in their gang or turn to other illegal activities. 

Based on your experiences, how would you characterize psychiatric care in San Quentin? 

In my opinion, we are one of the most efficient and effective mental health departments. Our success can be directly attributed to the MHSDS management team, the individuals employed within the mental health department, local custody administration, and the professional working relationships with the Secretary’s Office, the Office of the Receiver, and the Division of Correctional Health Care Services. 

The MHSDS management team has been integral in researching, developing, and implementing a continuity of care organizational structure at San Quentin. Upon my arrival, we continued the straightforward medical model that was in place; however, upon analysis, we identified that management appeared to be disconnected from their respective employees and that many providers were unable to provide adequate continuity of care. We therefore created a robust business-minded organizational structure where the team leads were separated by function, knowledge and expertise. 

The individual treatment providers who work for the MHSDS at San Quentin are another critical key to our success. In order for the management team to adopt a business model emphasizing separate functions and expertise, the entire department had to be restructured. The providers were asked to choose an area of expertise, practice only that area of expertise, and follow the inmate/patients to wherever they were housed. This denotes a significant departure from the typical institutional treatment model where a clinician is assigned to a unit. In San Quentin’s restructured model, the multidisciplinary treatment team is not assigned to a location, but to their inmate/patients. We now have individual clinicians practicing in their areas of strength, rather than trying to provide every service. 

Working within an institution, local custody administration is an invaluable ally in the delivery of mental health services. Each peace officer—including the warden, chief deputy warden, associate wardens, captains, lieutenants, sergeants and officers—plays a critical role in our success. Local San Quentin custody ensures a safe working environment while serving as our access to providing care. Absent this safety or this access, our working environment would be much less efficient and effective. In part, our success is derived from our ability to provide services, and this function is uniquely tied to custody operations.

Finally, our professional relationship with various administrative bodies has led to our success via their unwavering support, including working relationships with the Secretary’s Office, the Office of the Receiver, and the Division of Correctional Health Care Services

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Dr. Monthei is the chief of mental health at San Quentin.