A significant number of inmates in US prisons have been wrongfully convicted and incarcerated as a result of forced confessions, perjury, official misconduct, eyewitness misidentification, and poor forensic science1-3; 2.3% to 5% of people currently in correctional facilities (as many as 100,000 inmates) are actually innocent.3 Inmates who think they are wrongfully convicted face not only the mental health challenges common to other prisoners but also an additional burden of struggling with a sense of injustice, which can foster or exacerbate mental health problems.4

To gain deeper insight into the unique challenges facing psychiatrists working with inmates on death row, Psychiatry Advisor interviewed 3 individuals, each with his own individual experience and expertise: Daryl Matthews, MD, PhD, Forensic Psychiatrist, Park Dietz and Associates, Inc., and Clinical Professor of Psychiatry, University of Hawaii at Manoa; Joseph Simpson, MD, PhD, Supervising Psychiatrist, Correctional Health Services, Los Angeles County Department of Health Services, California; and Jarvis Jay Masters, an inmate on death row at the San Quentin facility in California.

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Interview with Dr Daryl Matthews

Psychiatry Advisor: What is your experience working in correctional settings?

Dr Matthews: I worked with detainees at Guantanamo. Perhaps this has colored my view of correctional psychiatry, because the psychiatry practiced there was at its worst. Many of the problems I encountered there were common in an ordinary prison setting as well, but in Guantanamo they were greatly magnified. I have not personally worked in death row settings, since Hawaii doesn’t have the death penalty. But my understanding is that being on death row also magnifies problems that appear in other correctional situations.

Psychiatry Advisor: What might exacerbate problems on death row that are encountered in other correctional settings?

Dr Matthews: Having a “Sword of Damocles” hanging over one’s head the way death row inmates do is extremely stressful. In fact, it is hard to imagine anything more stressful than that, especially when the process stretches on for years or decades.

Psychiatry Advisor: What are your perspectives on what was once called “solitary confinement” but today is usually referred to as the “adjustment center” or “segregation?”

Dr Matthews: I think that solitary confinement is cruel and unusual punishment. Although there is a minority of people who may benefit from the solitude and may also receive a reprieve from violence at the hands of other inmates, the majority of people do very poorly. Being isolated exacerbates their preexisting mental health issues. Combined with the impending specter of execution, this type of treatment is abhorrent to me.

Psychiatry Advisor: What do you think the role of a psychiatrist is in prison settings in general and on death row in particular?

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Dr Matthews: The role of a psychiatrist is somewhat tricky. It is all too easy for psychiatrists to be coopted by the system and essentially become guards with prescription pads. Of course, you need to have a good relationship with the officers to facilitate treatment, but it is a delicate balance to make sure you do not compromise your recognition that the inmate and not the system is your patient, and you are in service to that patient.

This challenge can arise in connection with medications, for example. It can be tempting for medications to be used to control people behaviorally at the wishes of the officers. On the other hand, withholding medications can be the flip side of the problem. Medications that are used to treat insomnia or anxiety are sometimes withheld because they are regarded as potential risks for abuse. So psychiatrists do not always prescribe much-needed medications that would be offered to patients in other mental health settings.

Beyond the deleterious impact of these issues on the inmates, it can be very demoralizing for psychiatrists to realize that they are tools of the system. After all, this is not why we attended medical school. It is one of the reasons for burnout or a high turnover rate in these settings.

Psychiatry Advisor: What role can psychiatrists play in improving matters for death row inmates?

Dr Matthews: Beyond providing the most expert and compassionate care possible, I think that as psychiatrists, we can try to liaise as much as possible with the officers. The training and education of officers vary from state to state. But in Hawaii, for example, all a person needs in order to become an officer is a high school diploma and 3 months of training. This type of minimal education will lead to minimal professionalism. Part of the psychiatrist’s role is to educate and work with officers as much as possible so that they understand the realities of the mental health challenges facing inmates and so that they can develop more compassionate and targeted skills.