The moral battleground of a prison psychiatrist

Abstract

Objective

Moral distress occurs when we know what the right thing to do is in accordance with our ethical principles and values, but institutional or other constraints make this difficult¹. As psychiatrists and psychiatry trainees, we are asked to assume responsibilities and balance competing obligations to our patients, organisations, and the public. I offer a first-person narrative of the moral distress experienced by a prison psychiatrist. I hope it resonates with other psychiatrists and psychiatry trainees dedicated to addressing the moral challenges in mental health and inspires those to harness the moral courage to improve the broken systems in which we work.

Conclusions

Forensic psychiatrists who practice in the carceral system, a low resourced and punitive environment, encounter unique structural and institutional constraints on their moral judgement. These include the inequivalence of care, coercive practices, role conflicts, hierarchical power structures, and punitive laws. Such constraints on our moral agency invoke a complicity of wrongdoing and generate feelings of powerlessness where our moral intuitions are not heard or taken seriously. Moral distress is not unique to forensic psychiatry, but the sub-speciality is exemplary of the concept and offers fertile learning opportunities for other areas of psychiatric practice.

Australian prisons are places of punishment and fundamentally incompatible with good mental health. They have become both our largest and our most underfunded providers of mental healthcare for the severely mentally ill. ¹ Restrictive practices for the mentally disturbed are ubiquitous. The provision of mental healthcare under these conditions means that moral events are common. This leaves many well-meaning prison psychiatrists struggling to do what they know is right ² ; and it is the ensuing psychological distress of questioning whether they are complicit in wrongdoing and contributing to patient harm which causes moral distress. ³ But for some, harnessing such distress can lead to a transformative journey of building courage ⁴ and seeking justice for their patients.

In the beginning I was bright eyed, full of enthusiasm, and ready to make a difference for the least well off in society. Like many other forensic mental health clinicians with an ambition to improve prisoner health, it was a moral duty that led me to the prison gates. The fortified sandstone facade of the Victorian era penitentiary designed to keep people out, and the guard patrolling from the prison wall with rifle in hand made for an imposing welcome.

The sheer volume of mental ill health in prison quickly confronted me. Correctional trucks 20 prisoners deep would arrive at the reception pod one after the other. The endless banging, yelling, and clashing between patients and officers gave new meaning to the term ‘frontline’ worker. My battle against the never-ending waitlists, teething with trauma, psychosis, and general suffering had begun. More worryingly were the patients not on the waitlist, those who I would never know about, often forgotten because their suffering was less obvious amongst the chaos. For others, including those with personality disorder, neurodiversity and cognitive impairment, effective treatments, and services were simply not available. Prioritising between the high-risk patients most in need felt like a game of Russian roulette. I juggled rationing my time between doing everything I could for the few or doing the little I could for the many. With little more than a script pad in my arsenal, I witnessed patients become increasingly disturbed under the conditions of oppression. Faecal smearing, flooded cells, hunger strikes, and severe self-harm were often how their distress was communicated. My naïve aspirations to do good were becoming increasingly distant as the uneasy realisation of being complicit in the widening disparities for mentally ill prisoners set in ⁵.

The rules of engagement for the incarcerated are harsh, and the system quickly overcomes those who fail to adapt. People with schizophrenia are outnumbered and stand little chance against being victimised by career criminals for their food, money, and medications. Heightened threat perceptions due to paranoia, misperception of the surroundings from hallucinations, institutional mistrust due to past traumas, and disinhibition and impulsivity from cognitive impairment, all make people with severe mental illness vulnerable in confronting situations. Failure to maintain composure or comprehend instructions from officers can result in the ‘use of force’ or being ‘gassed’ with chemical munition by ‘the squad’. As health service employees and ‘visitors’ to the custodial environment, clinicians have little power to intervene and must simply bear witness. Appeals to the officers are often dismissed with an air of justified retribution. At first, there is shock, and then there is helplessness.

For further punishment, many patients are segregated from the prison milieu, work, programs, or education, and housed in solitary confinement. They are confined to their cell for up to 24 hours a day and see little natural light outside of the brief periods of ‘exercise’ in just another small open-air cell. Weeks of confinement can turn into months, and sometimes years. The sensory deprivation serves as another form of confinement, but for the mind. Panic attacks, intrusive thoughts, dissociative experiences, confusion, and worsening psychosis set in ⁶.

Specialist psychiatric assessments are conducted behind a cage with little privacy or through a small hatch where patient and doctor kneel together, either side of the cell door, so their eyes meet. The inmate in the adjacent cell listens in without an offer of privacy. In the little time, you resort to a quickfire screen of symptoms and press for their most urgent needs. For most, it’s a rare encounter with a trusted professional, and issues other than mental health, such as contacting family or lawyers, are their priority.

Those who are weakened and overcome turn the punishment inwards. A wish to be dead instead of enduring further imprisonment results in the transfer to a 24-hour surveillance cell. Clothing and utensils are removed and ‘safety gown and blanket’ and ‘finger foods’ are issued. Alternatively, patients are given a cellmate who acts as de-facto ‘suicide watch’. You ask your patient why they are feeling depressed, and then you momentarily look around, and awkwardly try to move on. You teach controlled breathing and mindfulness but can’t help feeling condescending. You resort to the prescription of psychiatric drugs, which numbs their reality, helps them remain calm, and hopefully survive their confinement. For the patients who don’t survive, it’s a sobering moment to meet their families to explain why the system couldn’t keep them safe. You stay up at night and reflect on the hippocratic oath of first do no harm.

For a prison psychiatrist, it is hard to deliver quality care that is anywhere close to being equivalent to outside of the prison walls. Inside I witnessed the traumatised become re-traumatised, and the ill get punished. I grew despondent witnessing the well get released, only to be re-imprisoned unwell. I questioned the integrity of my practice, which I had believed was caring and benevolent, but in fact was complicit in doing harm. The looming inevitability of it being your turn to give evidence in front of the coroner breeds hesitation and medical defensiveness. I realised my skills and training were in fact being used to treat the resultant mental ill health the system was causing and perpetuating. Eventually the compassion fatigue set in, and the burnout took over.

I felt trapped between the constraints of the system and my obligation to my patients, the health service, the prison, the law, and public safety. Then there are the accusations from the media of human rights violations for the mentally ill in prison. I questioned whether identifying as a voiceless victim was self-regarding and simply a distraction from my ethical responsibilities as a clinician. I wondered if I’d be accused by colleagues of losing objectivity and crossing professional boundaries as a ‘moral advocate’. But understanding moral distress offered me a language to reflect upon and articulate my experiences in a morally complex world. I could no longer maintain the status quo of inaction as a bystander in the battleground. I had an obligation to seek out, restore, and fight for justice for my patients. Reform wasn’t going to be achieved overnight but my commitment towards seeking justice had been ignited.

The journey began at the bedside – from being that clinician who tells a mother their missing mentally ill son was in fact in prison, or insisting on having access to that last patient on your list before lock-in. By re-centring the moral obligations I had entered the profession with, I found my voice to speak up for what was right. It was about calling out unprofessional behaviour; it was recommending patients be diverted and treated in hospital under Mental Health legislation for the second and third time; and it was advocating for Aboriginal patients to stay on Country. Professionally, it was upholding the integrity and independence of prison psychiatry against the perversions of social control. It was about educating colleagues and trainees on the ethical dilemmas in prison psychiatry and establishing safe spaces to reflect on the moral challenges of their work; all of which supported them to remain resilient and resolute in their ambitions for change. As a collective, it was calling for policy and law reform, including for the abolition of solitary confinement for people with mental illness and indefinite detention of those unfit to stand trial.

After years of battles, it’s the victories which rejuvenate me with the optimism I enjoyed on that first day. I have realised I am not alone on the frontline and now share a language with my colleagues that accurately reflects the unique journeys of our moral experiences. We are armed with a newfound moral courage and resilience. We are not in a battle against our patients, or each other, but the injustices of the carceral system. It is the tension that burns within, that continues to fuel the need to get back out of the trenches, and keep on fighting for what is right, until the next battle begins.

ORCID iD

Trevor Ma https://orcid.org/0000-0003-1484-4469