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George Parker Psychiatric Services Impact of Mental Health Training Course for Guards on Shu 2009

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Impact of a Mental Health Training
Course for Correctional Officers
on a Special Housing Unit
George F. Parker, M.D.

Objective: This stud)' determined the impact of a len-hour mental
health training program developed by the Indiana chapter of the National Alliance on Mental illness (NAMI-Indiana) for correctional offi-

cers on a prison special housing ("supennax") unil. Methods: The training was delivered to all of the correctional officers on the unit in five
weekly sessions and was repeated 15 months later for new unit staff.
The number of incidents reported by unit sLaff' in standard monthly reports, consisting of use of force by the officers and battery by bodily
waste on the officers by the offenders, was compared for the nine
months before and after both training sessions. Results: Attendance at
the initial training ranged from 48 to 57 officers per session, and on the
basis of Likert ratings. training was well received by the officers. The total number of incidents, the use of force by the officers, and battery by
bodily waste all declined Significantly after the first mental bealth training, and the total number of incidents and battery by bodily waste declined significantly aner lhe second training. Conclusions: The provision of len hours of mental heallh training to correctional officers was

associated with a Significant decline in use of force and ballery by bodily waste. (Psychiatric Services 60:64~5, 2(09)

n the past two decades the concept of Ule control unit, or secure
housing unit, popularly known as
"'supermax," has become popular
among U.S. correctional authorities.
Although there is some debate as to
what constitutes a supermax unit, in
2006 the Urban Institute reported
that 95% of prison wardens surveyed
agreed that a supennax: unit consisted
of "a stand-alone unit or part of another faCility and is designated for violent or disruptive inmates. It typically involves single-ceU confinement for
up to 23 hours per day for ,ll) indefinite period of time. Inmates in supermax housing have minimal contact
\loth still and other inmates" (1).


Typically, the stated rationale for
such wlits is the need to house the
most difficult and dangerous offenders in an environment that minimizes
the risk of trouble for the other inmates and staff. Nearly every stale
now has at least one speCial housing
unit, and several states and the federal prison system have built entire facilities, C'alled supennax prisons, on
tillS model (2,3). Intended for tile
most dangerous offenders. special
housing units have become "home" to
many inmates with mental illness, despite tile efforts of mental healtll and
civil rights advocates. A polley paper
of tile National Institute of Corrections in 1999 stated. "Insofar as possi-

Dr. Parker is with the Depm1,,,umt ofPsychiatry. Imliima Uniucrsity School of Medicine,
1111 West 10th St.. Indianapolis. IN 46202 (e-mail: geoparke@l" A preliminanJ
version ofthis research was presentel! in !)OsterJomUlt at the annual meeting OJtfl€ American Academy of PsychiatnJ ami t!1e Uiw, October 27. 2006. Montreal. Canada.


hie, mentally ill imnates should be excluded from e,~ended control facilities ... much of the regime common
to extended control facilities may be
unnecessary, and even counter-productive, for this population" (4).
This recommendation was not followed, and tile reality of tile prevalence of offenders with mental illness
in special housing units was evident in
a 2004 monograph from the National
lnstirnte of Corrections. for it identified mental health as "the major issue
emerging in supennax litigation" (5).
The author of this report noted that in
California, Ohio, and 'Wisconsin
plaintiffs had successfully argued tI,at
some offenders should not be placed
in a special housing writ hecause of
mental illness and that placement in a
special housing unit could cause serious mental illness. The report identified several steps to prevent liability,
including screening out inmates with
serious mental illness before referral
to ti,e special housing unit, ongoing
monitoring of the mental starns of inmates on the special housing unit,
and the provision of adequate mental
health care on the unit.
Over ti,e past 20 years the prevalence of mental illness in jails and
prisons has been a growing concern
for st.:'1te correctional agencies, state
mental health agencies, and advocacy
organizations. Systematic examinations of mental illness among inmates
have reported a tlueefold greater
prevalenc.'e of psychotic and mood
disorders in ti,e population behind
bars, compared \loth the adult u.s.
population (6). Overall, 10% to 15%
of inmates are estimated Lo have a serious mental illness (7). AltlJOugh provision of general medical care is a

ps.psychi3tr)'' May 2009 Vol. 60 No.5

constitutional duty of correctional autllOrities (8), inmates with serious

mental illness pose more challenges
to administrators, compared with inmates with other chronic illnesses,

because the symptoms of mental illness, especially psychosis, may cause
disruptive behavior. Because mainte-

nance of a secure and stable environment is a primal)' concern for correc-

and psychology services. However, assessments. monitoring, and programming were limited because of the

they affect the neurotransmitter systems, as well as discussion of psychological treatments. 111e fourth session
focused on how to interact efTectively

challenges of communicating tllrough
the food slot in the ceU door or by the
difficult Ingistics of arranging the

with people witll mental illness and

movement of an offender from his
ceD to another location either within

from NAMI's In Our Own Voice program (14). The curriculum concluded

or off the special housing unit.
The National A1~ance on Mentally
IUness (NAMl) is an advocacyorgan-

with a session that reviewed and inte-

incorporated a consumer-speaker

grated all of ti,e previous sessions and

typically results in administrative consequences, up to and including segregation. In state prisons, offenders
\\;th mental illness are more likely

ization dedicated to improving the

was co-led by a senior supelvisor
from the Department of Correction.

~ves of people aIllicted by serious and
persistent mental iUness (13). In 2003
an inmate at the Carlisle special hous-

The prepamtinn of the curriculum
was coordinated hy an administrator
from NAMI-Indiana. The curriculum

than those who do not have a mental
ilhless to be written up for breaking

ing unit wrote to the Indiana chapter

authors were

nf NAMI (NAMl-lndiana' to repolt
the difficult l'Onditinns faced by offenders with mental illness in the spe-

members and included medical
school psychiatry faculty, university

tional authorities, disruptive behavior

institutional rules (58% versus 43%),
and they are also more likely to be
charged with an assault (24% versus
14%) (9). Offenders with mental illness are thus more likely to be housed
in more restrictive settings. including

special housing units. Once ruisigned
to a speCial housing unit, offenders

typically do not do weU clinically, particularly if they have a mental illness
(10), and they also pose Significant
management challenges to staff of
special housing units; they often suffer additional administrative penalties
as a consequence.

The Indiana Department nf Correction has two special housing
wuts-the first opened in the \¥est-



in 1993, and the second,

the site of this project. opened in the

Carlisle facility in 1995 (11). The
Carlisle facility is currently classified
as high-medium security by ti,e Indiana Department of Correction, and it
has both minimum- and maximumsecurit)' wuts; the vVestville facility is

classified as medium security and has



basic sciences faculty, a prison admin-

cial housing unit. At the invitation of

istrator, family members, and con-

the superintendent, NAMI members
subsequently toured the facility. After

sumers. The curriculum was designed

further discussions, NAMI-Indiana
was invited to develop and provide a
training program on mental illness for
the correctional staff on the special
housing unit. This report discusses

encouraged questions and discussion-and role-playing exercises for

the effect of tills educational intervention on the number of incidents

reported hy correctional staff on ti,e
special housing unit in their monthly

reports, botll before and after the
NAMI training.
The training program consisted of
Rve two-hour sessions. given over Rve
consecutive weeks. The first session

introduced the correctional officers
to ti,e major categories of psychiatriC
disorders (substance abuse disorders.
personality disorders, mood disor-

ders, psychotic disorders, and anxiety
disorders) by describing ti,e diagnos-

to be interactive-all of tile speakers

ti,e participants were included. The
curriculum was field-tested before
tile Carlisle training at a meeting of
Indiana correctional officials and at a
tnlining conference hosted by NAMIIndiana.
At the invitation of the Carlisle superintendent, NAMI-Indiana pro-

vided tllis training in February and
March 2004 to aU of the correctional
officers assigned to ti,e Car~sle special housing unit. The trailung was
prOvided at the official training site

for the facility, which was located
outside the walls of the prison. The
speCial housing unit staff was sp~t in
half for the training, and each of ti,e
five sessions was prOvided twice each

week. The NAMI members who developed each portion of the curricu-

miuimwn-, medium-, and maximWll-

tic criteria for these disorders in clear

lum proVided the training in person,

security units (12). The nWllber of offenders Witll mental illness in the
Carlisle special housing unit, which
has a capacity of 280, was tracked
from 1996 to 2003; the number in-

language, using illustrative examples
from clinical practice and popular

\vitll ti,e assistance of the NAMI-Indiana conrdinator and the Carlisle

movies, and encouraging questions
and discussion. Session 2 built on the
first session by focusing on the biolo-

closely monitored by ti,e Depart-

creased stendily since it opened, from

gy of mental illness; the speaker used

49 (18% of capacity) in 1996 to 173
(62% of capacity) in 2003 (persnnal

clear diagrams and neuroimaging to
outline how brain cells communicate
using neurotransmitters and how
mental illness affects the cllemistry,
structure, and metabolism of the
brain. Session 3 provided an overview

conununication. Carlisle Department
of Correction superintendent, 2006).

Throughout ti,e study, mental healtll
cnre to offenders housed on the

Carlisle special housing unit was pro\;ded by a Department of Correction
contractor and included psychiatric

training supervisor. Attendance was
ment of Correction with sign-in
sheets, because the training was

deemed mandatory hy the prison administration. The correctional officers came in before shift change,

stayed after the end of tlleir shift, or
came in on da),s off to attend the
training. and they were paid accord-

of the treatment of mental illness,

ingly. Each attendee was asked to

with discussions of the major groups

complete anonymously a pretest before each session and a posttest and a

of psychiatriC medications and how

PSYCJ:llATR.IC SERVICES ' ps.psychi:nryonIine.o~ , May 2009 Vol. 60 No.;


Table 1

tial training. the special housing unit

Evaluation of the first mental health training sessions (February and March
2004) for correctional officers working on a prison special housing unit

was over census for two months, and
the mean±SD monthly census was

Content ratinga












275.7±5.1 (98.5% of capacity). The

Presenter ratinga



special housing unit was over census

• As measured by a Lil,-eTt scale. Possible scores range from 1. poor. 105. excellent.

feedback form at the end of each ses-

incidents of battery by bodily waste

sion. The training was repeated by
videoconference in June and July
2005. and all staff who had joined

were then statistically compared for

the special housing unit since the ini-

ing Studenfs t test (15).

tial training attended. along with

This research project was granted
exempt status by the Indiana Univer-

staff from other units at the Carlisle

The administrators at the Carllsle
special housing unit routinely prepared standard monthly quallty assurance reports, which included a summary sheet noting the unit census, the
total number of incidents for the

month, the number of times force
was used by unit staff on ofTenders,
and the number of incidents of battery by bodily waste on custody staff.
The Carllsle superintendent shared
the summary sheets with NAMI-Indiana, beginning nine months before

the start of the first training and continuing until the special housing unit
undenvent a major reorganization
nearly two years later. Although the
full reports generated by the facility
included specific information about
the circwnstances of each incident
and the inmates and correctional officers involved, the research presented

here was based only on the summary

the nine months before and after
each of the two training sessions, us-

Sity-Purdue University Indianapobs
Institutional Review Board.

for eight of the nine months after the
initial training, with a mean monthly
census of 282.4±2.7 (100.9% of capacity). The monthly census was lower in the nine months before the sec-

ond training (273.3±6.0. 97.6% of capacity) and decllned further in the
nine months after the second training

(243.6±29.1. 87.0% of capacity). As
noted above, the prevalence of mental illness on the speCial housing unit
was 62% in 2003; however, this statistic was not determined in subsequent
years, because of a change in supervisory staff (personal communication,

Carbsle Department of Correction
superintendeot. 2008).
In the nine months after the 6rst
training, the number of total incidents, number of incidentr iAH9H.1lg

use~f force. and i;~l::~ ?,f ~~:;;



Attendance at the first mental health
training. which took place in Februmy mld March 2004. ranged from 48
to 57 staff per session (Table I). At-

by1X>dilywaste on
unit all declined sjff'iR~iilPtly com- >
pared with the nine months before ...

tendance was determined by a count

total number of incidents and the

of the pre- and posttests turned in

number of incidents of battery hy
bodily waste decllned Significantly.

for each session; these tests were required for participants to receive
training credit from the Department
of Correction. Participants were also
asked to rate anonymously the content of eacll session and the presenter, as well as the overall course, us-

ing a Likert scale; possible scores
ranged from I. poor. to 5. excellent.
The initial training was well received
by the correctional officers, with a
mean rating of 4.15 for the course
presenters and a mean rating of 3.57
for the overall course content. A to-

tI~ng (Table 2). In ti,e nine
months after ti,e second traiuing. the

compared with the nine months


fore ti,e training (Table 3). Similar
data were sought for the entire

Carlisle facility. hut ouly battery by
hodily waste was tracked during the
study period; all but one battery by

bodily waste incident occurred on the
special housing unit.

Role and training of
correctional officers
Correctional officers can play a vital

sheets, because of concerns about
confidentiality and informed consent.
As a result, it could not be determined whether any given incident involved an inmate with a serious mental illness or a particular correctional

tal of 34 staff from the Carlisle facility attended the second training in
June and July 2005. The attendance

role in ensuring appropriate treatment of offenders widl mental illness,

numbers, evaluations, and test per-

ing in mental health issues and have a

formances of the staff of the special
housing unit for this training could


not be determined, because the staff
of the special housing unit were part

professional culture that is quite different from tllat of mental health professionals (16.17). The NAMI-Indiana training program attempted to
bridge tllis cultural gap by educating

The overall number of incidents
and the number of each type of inci-

dent. dating from July 2003 to April
2006, were entered into an electronic

spreadsheet. The numher of total incidents, incidents of use of force, and

nf a larger group from the Carlisle
facility and the attendance sheets did
not note each officer's unit assignment.
In the nine months before the ini-

but they generally receive little train-

the correctional officers asSigned to a
secure housing unit about mental ill-

ness. On ti,e basis of the decline in
dle number of incidents after the

PSYCHIATRIC SERVlCfS ' , May 2009 Vol. 60 No.5

Table 2

\"olent incidents before and after the first set of mental health training sessions (February and March 2004) for
correctional officers working on a prison

special housing unit

9 months before training

9 months after training











All incidents
Use of ro~officers




12.75 to 23.25
11.48 to 21.41






4.19 to 14.70
4.03 '0 13.97




.80 to 2.31




-.31 '01.20

Battery by
. }' waste
by offenders

training, the NAMI-Indiann program
was successful in reducing both the
use of force by the correctional officers, as well as the number of assaults

by bodily waste on the officers. The
training was also well received by the
staff of the special housing unit, despite their initial reluctance to partic-

ipate in the training.
Little has been written on the role
of correctional officers in the man-

agement of offenders with mental illness in jails and prisons. Kropp and
cnlleagues (IG), in a 1989 article,
found that the correctional offieers
assigned to a maximum-security pretrial unit felt that working with offenders with mental illness added
stress to their jobs, and although they
were confident i.n their abilities to
handle the general population in the
jail, nearly all of them were interested
in further training on how work with
offenders with mental illness.
In recent years, only two articles
have been published on the specific
topic of mental bealth training for
correctional officers. Appelbaum and

colleagues (17), writing ahout working in the Massachusetts state prison
system, noted the difficult working
conditions faced by correctiooal officers, particularly the threat of violence, and identified the differing
professional cultures of security staff
and mental health staff as a major issue. They also observed that many
correctional officers and many mental
bealth staff work together effectively
and share common goals nf decent
and humane treatment of inmates.
They emphasized that correctional
officers could and should be recognized as members of tl,e multidisciplinary treabllent team for offenders
with mental illness, particularly au
residential treatment units. Massachusetts offers (,'otlaborative training
sessions for correctional officers
about suicide prevention and mental
illness, hut tltis program was not described in detail and no outcomes
were described.
Dvoskin and Spiers (18) described
the culture of the community inside
prison walls and argued that correc-










tional officers could pia)' important
roles in the provision of mental bealth
setvices to offenders, including talking with offenders in a therapeutic
manner, talking about the offenders
as part of tl,e mental healtll consultation process, and obsetving medication effects and side effects. The autllDrs specifically identified special
housing programs, including administration segregation units, as places
where correctional officers could play
a vital role in the identification and
management of mental illness; they
also emphasized the importance of
training to improve tlle relationship
between custody staff and mental
health professionals. The autllDrs included descriptions of programs that
successfully involved correctional officers in mental health roles, but none
of tllese were accompanied by a reference to a published article that described the program or its outcomes.
Correctional officers play a vital
role in maintaining safety and security in prisons, and tlley are subject to
many stresses, including long hours,

Table 3
Violent incidents before and after 'he second set of mental healtll training sessions (June and July 2005) for C"Orrectional
officers working on a prison special housing unit

All incidents
Use of fort.'e by officers
Battery by bodily waste
by offenders

9 months before training

9 months after training















8.3G '0 13.64
7.43 to 12.57




4.43 to 9.57







-.50 to.50


'0 1.50

1'5\'CIllATRlC SERVICES ' ps.psychlalryonline.0r& ' May 2009 Vol. 60 No. ;

4.3G '0 9.84










low pay, and the risk of violeoce,
which is their highest concern (19). In
addition, correctional officer.; have
reported higb psychological demands
00 the job, accompanied by low social

en to skills in interaction with people

Carlisle Department of Correction

with mental illness helped in this
area as well. Since battery by hodily

administrative staff, 2006). The ad-

support, a low sense of control, and

waste is one of the few fOnTIS of retaliation available to offenders on
special housing units, it is pOSSible

feelings of insecurity (20). When one
coosiders the challenges of their work

ers with more understanding, may

environment, it is perhaps not surprising that correctional officers who

have decreased the frustration and
anger that lead to battery by bodily

work on special housing wlits have


that the officers, hy treating offend-

heen reported to he physically and
psychologically abusive to inmates

StrengtIJs and limitations

under their supervision (2,3).
The U.S. Bureau of Labor Statistics

The strengths of this study include

notes, "Correctional officers learn

Illost of what they need to know for
their work through on-the-job train-

ing" (21). Indiana requires only that
correctional officer.; be high school
graduates and have three years of
work e"'"perience; as a result, the re-

cruits generally have little experience with or knowledge about working with people with serious mental

the training of the entire staff of a
special housing unit and the avail-

ability of objective data directly related to safety issues from hefore and
after the traioing. Weaknesses of the
study include the retrospective nature of the study and the lack of a
control population. Although the
NAMI-lndiana team that created

ilhless, even after completing the

the curriculum was interested in outcomes, the initial focus was on the
response of the officers to the train-

presenrice academy. At the time of

ing itself;

the study, Indiana correctional offi-

not become available until well after

cers received only a very basic OJientation to mental health issues in the
presen'ice academy, consisting of 2.5
to 3.0 hours, out of more than three
weeks of training. on working with



incident reports did

training had been completed.

The 'Vestville special housing unit

could have heen a good cootrol population for ~lis study, hut this facility
declioed to respood to a request for

offender.; 'vith mental illness, sub-

data on incidents of use of force and

stance abuse, and developmental

hattery by bodily waste. The overall
Carlisle faCility could also have

ministration of the unit changed before the training. as the sergeants
were rotated off the unit and a new
captain was assigned. In the months

immediately after ~,e training (April
to Juoe 2004), the Department of
Correction gradually transferred selected offender.; from the special
housing unit to a new program at tlle
prison psychiatriC faCility, dUring
which time some offenders became
more disruptive in all attempt to be
placed on the transfer list; as a result, there were high numbers of use
of force in nvo of these three
months. However, Carlisle Depart-

ment of Correction staff noted that
the offenders who were transferred
were not those who had been involved in the incidents reported in
previous months. The transfers were
then replaced with new offenders
from the waiting list for the special

housing unit. Finally, in the fall of
2004, several months after the training, several unit staff received disciplinary action, including arrest, for
abusive behavior; this investigation

began months before the diSCipline

Clearly, each of these factors could

setved as a control population, even
though it housed both minimum and
maximum-security offenders. Unfor-

have had an impact. for better or for
worse. on the culture of the special
housing unit. The change in supervisory staff could have set tIle stage for
a positive response to the training;
although senior management sup-

tunately, ~le only data available for
~,e eotire facility for the study period covered just battery hy bodily

ported the training, the faculty noted
obvious difficulty in engaging the ofBe..,r.; in the training, particularly in

ing was associated with a Significant
decline in officers' use of force with

waste; tIlis report was not particular-

the early sessions, despite tIle posi-

ly useful for control purposes, he-

offender.; and in the number of attacks on the officers hy the offend-

cause over tIle course of more than

tive ratings given by attendees. The
change in offender population could

ers. Although it is not pOSSible to
state with certainty how the training

waste occurred ofT of the special
housing unit-which is clearly evi-

led to these beneficial results, the
NAMI team attributed the declioe in

dence of the troubled nature of ~,e

disabilities (22). The NAMl-lndiana
curriculum on mental illness was deSigned to address this knowledge
deficit and was well received by the
correctional officers who attended
the sessions.

More important, the NAMI train-

use of force to improved under-

standing of the offenders' mental illnesses and to the interacting skills
emphaSized in the latter part of the
training. The reason for the decline

in incideots of battery by bodily
waste is less obvious, but in discussions between the NAM I team and

two years, only one battery hy bodily

offenders on the unit. the disturbing
impact of the special housing unit it-

self, or both.
In addition, as should be e'1'ected
in a large prison facility, the NAMI
training was not the only factor at
work over the course of tlle study.
The Indiana special housing unit undenvent a number of changes he-

have removed the offenders who
were most involved in reported inci-

dents and thus "ffected the perceived effectiveness of tIle training,
but a unit administrator noted that
the transferred offenders were not
those involved in prior incidents. Finally, the investigation and later removal of officers on charges of abuse
could have affected the atmosphere
on the unit either poSitively (encouraging for more profeSSional behavior) or negatively (aggravating an al-

staff of the Department of Correc-

fore, dUring, and after the NAMI

ready difficult work environment).

tion, it was felt that the attention giv-

training (personal communication,

Although the officers who were re-


I , May 2009 Vol. 60 No.5

moved left the unit more than six
months after the initial training. the
numbers of incidents declined significan~y shortly after the first training ended and rose modes~y after
their departure. only to decline again
after ~,e second training of officers
new to the special housing unit. This
pattern suggests th~lt the removal of
the officers w~.. not the driving force
in the decrease in the nwnber of incidents on the special housing unit and
~mt the mental health training played
an important role in that decrease.

The NAMI training curriculum,
which provided ten hours of education on mental illness to all of the correctional officers who worked on an
Indiana special housing, or supennax.
unit, was associated with a significant
decrease in the use of force by the
correctional officers and battery by
bodily waste on the officers by offenders. These results suggest that
providing mental health training to all
ofthe correctional officers on a prison
Wlit can lead to safer working (.'(mditions for the correctional officers and
safer living conditions for offenders.

Acknowledgments and disclosures
The KAMI41nwana members who created and
pl'Q\ided the mental heahll lraining curriculum
were Kel1ie fI,·leyer. M.A.• Alan Schmetzer.
M.D.• Joan LaJi'uze. Ph.D.• Joseph Vanable. Ph.
D.• Alan Finnan. Ph.D.• Mike Kempr, Christine
Je\....ell. B.S., and Ceorge Parker. M.D.
The author reports no competing interests.

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