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Brief Report   |    
Jail Administrators' Perceptions of the Use of Psychiatric Advance Directives in Jails
Anna M. Scheyett, Ph.D., M.S.W.; Jennifer S. Vaughn, M.S.W.; Annie M. Francis, B.S.Ed.
Psychiatric Services 2010; doi: 10.1176/appi.ps.61.4.409
View Author and Article Information

The authors are affiliated with the School of Social Work, University of North Carolina at Chapel Hill, 325 Pittsboro St., CB 3550, Chapel Hill, NC 27599-3550 (e-mail: amscheye@email.unc.edu).

Abstract

Objective: Individuals with serious mental illnesses are at high risk of incarceration. Jails are often unable to obtain information needed to provide appropriate care. Psychiatric advance directives may be useful tools to communicate treatment information to jails. This study explored their use as a novel intervention for individuals with mental illnesses in jails. Methods: Eighty jail administrators in North Carolina were surveyed to determine their support for psychiatric advance directives in jails. Relationships between respondents' job type (jail administrator or medical administrator) or jail census and support for the directives were examined by using chi square tests. Open-ended responses were analyzed using qualitative methods. Results: Seventy-three percent of respondents indicated they supported psychiatric advance directives. Respondents from jails at or below a median census of 120 were significantly more likely to support psychiatric advance directives than those from larger jails. Conclusions: Psychiatric advance directives' informational function may prove valuable in jail settings. Additional research assessing directives as interventions for individuals with mental illnesses at risk of incarceration is needed. (Psychiatric Services 61:409–411, 2010)

Abstract Teaser
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Individuals with serious mental illnesses have high incarceration rates (1). A recent study estimated that approximately 15% of male and 31% of female jail inmates have mental disorders (2). Individuals with mental illnesses often receive little treatment while incarcerated (2,3,4). Jails face multiple challenges in providing these individuals with adequate care: lack of knowledge of treatment histories or medications, no access to medical records, and inability to communicate with providers because of confidentiality restrictions (5). This results in challenges both to treatment while in jail and to coordination with providers upon release, increasing an individual's likelihood of instability, hospitalization, or recidivism.

Psychiatric advance directives are legal documents allowing individuals with mental illnesses, when they are competent, to state wishes for psychiatric treatment during crisis times when they may no longer be able to communicate preferences or information. These documents allow individuals to identify proxy decision makers for their care during these crisis times as well. Psychiatric advance directives are also used as a record of treatment and a limited waiver of confidentiality (6,7). Individuals with mental illnesses at high risk of incarceration may be able, when well, to create psychiatric advance directives as a way to communicate treatment information to jails, to identify a surrogate decision maker to share information and consult regarding treatment, and to allow communication between jails and providers, thus increasing the likelihood of psychiatric stability and successful community tenure upon release.

Despite this potential, there has been no published research assessing directives' utility in jail settings, and only one study has discussed them in any criminal justice setting (8). In that study the author examined cases where individuals with mental illnesses were in prison and required medication, but because of symptomatology they were no longer able to provide consent. As a result, cumbersome legal processes needed to be followed, resulting in serious delays before medication could be administered. The author proposed using psychiatric advance directives as a way to obtain prior consent for medication and avoid lengthy legal processes when treatment was needed.

This study assessed jail administrators' perspectives on psychiatric advance directives as a novel intervention for persons with mental illnesses. Using telephone surveys, we examined both familiarity with psychiatric advance directives and views of their utility for individuals with mental illness in jails.

Study data were part of a larger phone survey of North Carolina jail administrators regarding mental illness, completed between July and November 2006 (9). Letters describing the study were sent to jail administrators in each of the state's 93 active jails; they were then contacted by telephone and asked to participate in the interview. Some administrators designated a jail medical official to complete the interview. Interviews began with a review of the purpose, voluntary nature, and confidentiality of the study and a request for verbal consent to participate. Interviews were approximately 60 minutes in length. All responses were entered directly into an electronic record during the interview. This study was approved by the University of North Carolina Institutional Review Board.

Eighty (86%) jail administrators or designees participated in the study. Of these, 65 (81%) were jail administrators and 15 (19%) were medical administrators within the jail. Fifty-one respondents (64%) were male. Daily jail census ranged from eight to 2,700 (mean=195±332, median=120).

To ensure consistent understanding of psychiatric advance directives among respondents, they were read a standard description and allowed to ask clarifying questions. Respondents were then asked the following questions: Have you ever seen a jail inmate with a psychiatric advance directive? Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that psychiatric advance directives are a good idea for people with mental illness? Please explain your views on psychiatric advance directives.

Descriptive statistical analyses summarized responses, and relationships between respondents' job type or jail census and support for psychiatric advance directives were examined using chi square tests with SAS, version 9.1. Qualitative data were analyzed by two researchers with open and then axial coding for identification and interpretation of major themes.

No respondent reported seeing a jail inmate with a psychiatric advance directive; eight (10%) reported any knowledge of them at all. Overall, respondents were supportive of directives: when asked whether psychiatric advance directives were a good idea, 28 (35%) responded strongly agree, 30 (38%) responded agree, six (8%) responded somewhat disagree, eight (10%) responded strongly disagree, and eight (10%) said they were unsure and could not respond. As shown in Table 1, chi square tests showed respondents from jails at or below the median daily census of 120 were significantly more likely than those from larger jails to think psychiatric advance directives were a good idea, and jail administrators were more likely than medical administrators to support directives, although this trend was not significant.

Qualitative analyses revealed several themes. Psychiatric advance directives were seen as positive because they gave jails needed information. One respondent stated, "[Psychiatric advance directives] would make it a whole lot easier to get something done for them … this would mean we could do more [regarding treatment]." Another commented, "Anything that establishes a course of action for us to follow … is a good idea." One respondent reported, "A lot of times we have people who come in, and we don't know anything about their family or their past, and they can't give us any information … . The doctor might prescribe medications that are totally different than what they were taking before … having psychiatric advance directives would be a good idea."

In addition, directives were considered positive because they helped individuals with mental illnesses get care and become stable. One respondent said, "Psychiatric advance directives are a good idea if they help a person with mental illness keep it in check in a lawful way." Directives were also seen as a way of providing consumer voice. One respondent noted, "I know if I was going up the wall, I'd want them [jail staff] to know what to do with me—wouldn't you?"

Some respondents were not in favor of psychiatric advance directives because of jail limitations. Several noted that stating preferences in a directive would be meaningless in jails because "they don't have a choice when they go in here. They can refuse or request meds when they come, but they lost freedom when they came." Others stated that irrespective of individual's preferences, "in jail we have guidelines we must go by [referring to jail-developed protocols for management of inmates]." A few respondents expressed concern that jails would be unable to use psychiatric advance directives because they had limited staffing and resources or because individuals would not be in jail long enough for directives to be utilized.

A second concern voiced had to do with the competence of persons with mental illness when they created the psychiatric advance directive. One respondent commented, "Sometimes people just don't know what they're writing out," and another reported, "I have dealt with some schizophrenics who thought they were fine and cured, and I wouldn't trust them." Several respondents thought directives would be helpful only if certain they were created while the individual "fully understood this and had all their right sense about them."

Participant responses suggest that psychiatric advance directives, particularly their informational function, may be useful for jail-involved individuals with mental illnesses. Directives were seen as a way to provide jails with needed information about the presence of mental illness and about treatment. However, regulatory and other restrictions in jails were seen by some as limits to their utility.

Respondents' statements regarding the rights of individuals with mental illnesses regarding treatment raised some interesting questions and concerns. A number of administrators who did not support directives saw them as conflicting with jail protocols, wherein inmates had no rights or choices and must accept the medications dispensed by the jail. More nuanced and informed thinking regarding inmates' right to appropriate treatment or right to refuse treatment was not evident among these respondents. These comments thus suggest that if psychiatric advance directives hold any promise as an intervention for individuals with mental illnesses in jails, there must first be larger discussions regarding jail administrators' understanding of the treatment rights of inmates with mental illnesses.

Of interest, some jail administrators seemed more open to psychiatric advance directives than others. Those in smaller jails were significantly more likely to be supportive of psychiatric advance directives, and general jail administrators were more likely than those without a medical role to be supportive, although this finding was not significant. Reasons for these differences were not made clear in qualitative comments and could be due to a number of factors, such as jail and community resources or lack of mental health knowledge of some jail administrators. Additional exploration is needed here.

Given the potential utility of psychiatric advance directives in jail settings, strategies to increase jail administrators' awareness and understanding of these tools should be explored. Community-based providers could offer training on directives to jail administrators and staff. In addition, collaborative conversations among community providers and jail administrators could be arranged wherein the potential utility of directives would be explored.

Additional research is needed to inform these discussions. Studies should explore the utility of directives for various subsets of individuals with mental illnesses. Feasibility studies are needed to determine how collaborations regarding directives can best be established across mental health and criminal justice systems. Finally, studies are needed to determine the effectiveness of directives in increasing appropriate treatment for persons while incarcerated, linking individuals with community treatment at release, and decreasing crises after release.

Psychiatric advance directives have been seen primarily as tools supporting choice and autonomy, with less emphasis on their functions as informational records and communication links with providers. However, these functions may prove valuable in jail settings, as was indicated by a number of jail administrators in this study. Additional research assessing psychiatric advance directives as an intervention for individuals with mental illnesses at risk of incarceration is needed.

This study was funded in part by a grant from the North Carolina Governor's Advocacy Council for Persons With Disabilities.

The authors report no competing interests.

Theriot M, Segal S: Involvement with the criminal justice system among new clients at outpatient mental health agencies. Psychiatric Services 56:179–185, 2005
 
Steadman H, Osher F, Robbins P, et al: Prevalence of serious mental illness among jail inmates. Psychiatric Services 60:761–765, 2009
 
Lurigio A, Swartz J: Mental illness in correctional populations: the use of standardized screening tools for further evaluation or treatment. Federal Probation 70:29–35, 2006
 
Ditton P: Mental Health Treatment of Inmates and Probationers. Washington, DC, Bureau of Justice Statistics, 1999
 
Lamberti J, Weisman R: Persons with severe mental disorders in the criminal justice system: challenges and opportunities. Psychiatric Quarterly 75:151–164, 2004
 
Joshi K: Psychiatric advance directives. Journal of Psychiatric Practice 9:303–306, 2003
 
Swartz M, Swanson J, Elbogen E, et al: Psychiatrists' views and attitudes about psychiatric advance directives. International Journal of Forensic Mental Health 4:107–117, 2005
 
Thomas D: Advanced directives in a correctional setting. Psychology, Public Policy, and Law 4:878–900, 1998
 
Scheyett A, Vaughn J, Taylor MF: Screening and access to services for individuals with serious mental illnesses in jails. Community Mental Health Journal 45:439–446, 2009
 
Table 1  Rates of support for psychiatric advance directives among jail administrators
Table 1  Rates of support for psychiatric advance directives among jail administrators
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References

Theriot M, Segal S: Involvement with the criminal justice system among new clients at outpatient mental health agencies. Psychiatric Services 56:179–185, 2005
 
Steadman H, Osher F, Robbins P, et al: Prevalence of serious mental illness among jail inmates. Psychiatric Services 60:761–765, 2009
 
Lurigio A, Swartz J: Mental illness in correctional populations: the use of standardized screening tools for further evaluation or treatment. Federal Probation 70:29–35, 2006
 
Ditton P: Mental Health Treatment of Inmates and Probationers. Washington, DC, Bureau of Justice Statistics, 1999
 
Lamberti J, Weisman R: Persons with severe mental disorders in the criminal justice system: challenges and opportunities. Psychiatric Quarterly 75:151–164, 2004
 
Joshi K: Psychiatric advance directives. Journal of Psychiatric Practice 9:303–306, 2003
 
Swartz M, Swanson J, Elbogen E, et al: Psychiatrists' views and attitudes about psychiatric advance directives. International Journal of Forensic Mental Health 4:107–117, 2005
 
Thomas D: Advanced directives in a correctional setting. Psychology, Public Policy, and Law 4:878–900, 1998
 
Scheyett A, Vaughn J, Taylor MF: Screening and access to services for individuals with serious mental illnesses in jails. Community Mental Health Journal 45:439–446, 2009
 
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