The Vera Institute of Justice's Safe Alternatives to Segregation (SAS) Initiative recently began highlighting PA DOC's Diversionary Treatment Units that was provided by Dr. Lucas D. Malishchak, DBA, who serves as director of the DOC's Psychology Office.
History & Brief Summary
Historically, in the Pennsylvania Department of Corrections (DOC), when an individual committed a serious institutional rule infraction, that person would be swiftly removed from the general population and placed into a segregated Restricted Housing Unit (RHU), until seen by a hearing examiner for disposition of the allegations or charges. Depending on the severity of the infraction and if found guilty of the rule infraction, the individual could be sentenced to reside in the RHU for up to 90 days per rule infraction. For example, if an individual was asked by a corrections officer to return to their cell and the individual refused the order, insulted the corrections officer by using foul language, and then banged his head on the floor once the corrections officers attempted to restrain him and resisted the restraints being applied, that individual could be sanctioned to 360 days in the RHU, due to four institutional rule infractions (that's correct, we used to punish individuals who self-injured themselves or attempted suicide).
Once placed into an RHU, the individual would be restricted to 23-hours-per-day, in-cell restriction five days per week (i.e., most weekends, individuals were locked down for 24-hours-per-day), with movement and privileges severely restricted. Individuals housed in RHUs were afforded three showers per week and an hour of exercise out of the cell per day, with only several other basic privileges required through constitutional case law. Conditions within RHUs were typically drab, uninspiring, dark and populated with an institution's most incorrigible, disruptive, shrewd and dangerous individuals that presented the most significant security concerns to the overall institutional operations. Mental health contacts occurred at reception and then every 30 days thereafter and as needed. However, these contacts were very generic and not very focused. A brief suicide risk screen was also completed by the lead corrections officer (i.e., typically a lieutenant). As such, all mental health services were basically provided on a crisis intervention basis to all individuals admitted and confined to RHUs; all were basically "treated" the same from a mental health perspective, in that, all received monthly contacts whether or not they were currently receiving mental health treatment, diagnosed with a mental illness, or prescribed psychotropic medications.
Unfortunately, what was discovered was that individuals admitted and confined under these conditions, did not typically improve and many times decompensated even further. It was discovered that many times, individuals initially confined to an RHU for 30 or 60 days ended up confined to the RHU for several years at a time due to the aggregate accrual of institutional infractions received while in the RHU. It was not uncommon for individuals housed in RHUs to have disciplinary custody time that exceeded their formal sentence, for which they were incarcerated. Historically, any individual could be admitted to the RHU, if they were charged with a serious enough disciplinary infraction or the institutional administration requested enhanced administrative or security measures (i.e., administrative segregation/custody). Placement into RHUs was indiscriminate, in that any individual charged or sanctioned with a disciplinary or administrative sanction would be confined in the RHU, regardless of their mental health status, diagnoses, suicide history or individual treatment plan. Alternative housing units for individuals sanctioned for disciplinary reasons did not exist.
In 2016, the DOC made reforms to its use of segregation for treatment of people with serious mental illness, after a federal investigation. Although there is limited data on the DOC's use of segregation, the Department of Justice officially ended its investigation in 2016 after the DOC implemented reforms.
The Goal
After much reflection, consideration, and advocacy, the DOC developed Diversionary Treatment Units (DTUs). DTUs were developed to supplant RHUs and to divert individuals diagnosed with serious mental illnesses, significant functional impairments and intellectual disabilities to an enriched treatment unit, where the individual's mental health treatment needs and security needs would both be met, without sacrificing one or the other. DTUs were not RHUs. DTUs were brightly painted treatment units, with inspirational quotes, murals, motivational landscapes and recovery oriented language that aimed to persuade and influence those individuals receiving treatment therein. Indeed, the basic premise of DTUs was to create a treatment unit that could meet the needs of seriously mentally ill individuals who have recently been sanctioned for a serious institutional rule infraction. DTUs were not only equipped with televisions, radios, clocks and bright lights, but also a variety of secure cubicles, individual treatment chairs and secure group treatment tables. The goal of the DTU was to provide individualized mental health care treatment to seriously mentally ill individuals that recently demonstrated an enhanced security need and enhanced need for mental health treatment.
The Process
However, the difference between DTUs and RHUs is far more than simply appearance. Processes, treatment planning, out-of-cell time and staff training requirements and selection criteria specific to the new treatment unit were established. Staff members selected to work on DTUs were required to receive several specialized trainings in order to qualify for DTU posts. The training requirements to work on DTUs for correctional officers included completion of the eight-hour Mental Health First Aid course and the 40-hour Crisis Intervention Team (CIT) Training course. Other new processes that were developed for this solution were treatment plans based on the recovery model, out-of-cell treatment service delivery and strategically placed mental health contacts associated with the disciplinary process. Additionally, DTU policy revisions created enhanced safeguards for seriously mentally ill individuals, which creatively crafted, still held individuals accountable for their actions (i.e., seriously mentally ill or not) and encouraged the use of the informal disciplinary process for less serious infractions, which resulted in far less individuals being sent to a restrictive setting like an RHU.
The Solution
The three most significant developments associated with the DTU were the minimum requirements for out-of-cell time, the utilization of crisis oriented treatment plans aimed at treating the individual for the underlying reasons they were sent to the DTU and the strategic placement of a focused mental health assessment prior to DTU or RHU placement. The purpose of the mental health assessment is for a mental health professional to determine whether the individual meets inpatient commitment criteria. After all, a sentinel event has presumably just occurred (i.e., a serious rule infraction) and determining the existence of a diagnosed serious mental illness, significant functional impairment or intellectual disability would suggest that placement into an RHU would be counterproductive. This assessment did not previously exist—instead, individuals that committed serious rule infractions were immediately segregated from the general population, as well as from the enhanced mental health services and other supports provided to those confined outside of the DTU or RHU. This occurred because we simply assumed that those people acted voluntarily in violence or aggression, rather than considering the potential impact of an existing serious mental illness, significant functional impairment or intellectual disability.
As a result of the implementation of these assessments, we saw a 10 percent rise in the number of people being committed to inpatient treatment. This suggests that the disciplinary processes previously in place resulted in the segregation of seriously mentally ill individuals who should have otherwise been placed at our highest and most acute level of inpatient mental health treatment.
Once cleared by the mental health assessment for placement into the DTU, the clinician immediately and collaboratively (i.e., with the individual) creates an Individual Recovery Plan (IRP), which serves to direct the individual's course of treatment during their time in the DTU. For example, if we consider the above original scenario involving a resistant inmate, and it was determined that the individual had Schizophrenia and that they were resisting because they believed the corrections officer was a ghost (a visual hallucination) that was attacking him because of his Catholic faith (paranoid delusion), then appropriate treatment goals for DTU placement would include learning to live with psychotic disorders, anger management and violence prevention. The basic premise is that the goals developed would be specific to the individual's needs and to the underlying incident in question. However, this is only part of the formula. Once the IRP was developed, treatment groups and settings also needed to be developed within DTUs to be able to deliver mental health treatment to individuals that presented with not only enhanced mental health needs but also enhanced security needs.
The Results
The result was the offering of a minimum of 20-hours-per-week of out-of-cell time for every individual housed in a DTU. In most cases, individuals are now offered far in excess of 20-hours-per-week out of cell, to participate in groups and programs directly related to their needs and identified through the IRP. The offering of these out-of-cell programs is completed by all disciplines involved in the multidisciplinary treatment team, referred to as the Psychiatric Review Team.
Lessons Learned
This DTU solution did not come easy. Before we could develop the processes, procedures, units and policy revisions associated with the DTUs, we needed to solidify the definition of serious mental illness, accurately identify those individuals that met the new definition of serious mental illness, recalibrate our mental health classification system, consolidate seriously mentally ill individuals to 14 specific state correctional institutions within our system, and augment staffing ratios of clinical, administrative and security professionals in order to meet the new programmatic, clinical and security needs of these units and individuals. Following these major conceptual and paradigmatic shifts, the DOC proceeded with implementing outpatient Residential Treatment Units (RTUs) that would serve as step-down units from DTUs. Accordingly, similarly missioned outpatient units, that provided enhanced outpatient mental health treatment in a far less secure setting than DTUs were created to complement the transitioning periods of individuals discharged from DTUs and those individuals that required enhanced outpatient mental health treatment needs. The RTUs and DTUs now function well together as a feeder and landing system for one another, meeting the enhanced security and mental health treatment needs of individuals diagnosed with serious mental illnesses and incarcerated in Pennsylvania state prisons.
All areas outlined above were extremely crucial to the department's success. Though it is not explicitly written above, culture change remains the single most important obstacle to our continued success. Changing the way that correctional professionals think about incarcerated individuals is essential to treatment outcomes being successful. Integrating correctional officers into the treatment teams was a key factor as well. It is no secret that these individuals spend far more time with our patients that we do as mental health professionals; their input, guidance and opinions should not be marginalized.
Please note that Vera and its partners do not specifically endorse the practices and policies included in the Promising Practices section. The Promising Practices section features segregation reforms being implemented in prisons and jails around the country. The goal is to serve as a resource to other jail and prison systems interested in implementing similar practices and policies by highlighting those jurisdictions that report successful reforms.