The U.S. correctional system is facing a mental health crisis. Among its prisons and jails, it houses 10 times more people with mental illnesses than all of the country’s mental health hospitals combined. The rate of serious mental illnesses in the jail population is between 3 to 6 times higher than the normal population.
Statistics like these are hard to fathom out of context, but I see these challenges firsthand at my clinical practice. For about a week a month I work at a maximum security jail in the Bay Area, where I treat inmates with severe mental illness. I spend the rest of time as a director of digital health at Brain Power, a mental-health focused technology startup. These worlds might seem far apart, but I’ve often thought about how we can utilize cutting-edge innovations in technology to help some of our most disenfranchised communities, especially those wrapped up in the judicial system.
My major takeaway thus far is that our correctional system has become our mental health system. And our correctional mental health care is for many people their only source of care. I see huge opportunities for technology to help address some key issues in correctional institutions, and more specifically jail mental health. But there are three challenges that are really important to understand before we swoop in with a trendy new telemedicine app or wearable.
Jail administrators and medical personal have their work cut out for them. While delivering mental health and medical care is normally no mean feat, the added restrictions and protocol associated with safety and security within a correctional facility add several layers of complexity. The movement of inmates and personnel is closely regulated (and occasionally halted in an event of a security issue), meaning that running a clinic inside a facility can be much more time-consuming. You must also be careful in what you physically hand to inmates, even pieces of paper can be made into deadly weapons. Lastly, the gang culture in facilities causes some inmates to decline psychiatric help for fear of being judged to be “weak” and risk being ostracized from their gang.
Secondly, when we consider a piece of technology that helps us assess a person’s behavior in real time, or predict that person’s behavior (including risk of suicide or violence), we must clearly outline to whom that information is available, how it will be used, and whether the incarcerated person needs to consent to that technology being used. Unless court-ordered, people have the right to decline routine medical or psychiatric treatment.
Finally, we need to think bigger about the purpose of our correctional system. Is it aimed at rehabilitating, punishing, or a combination of the two? I think about this when considering the role of technologies such as virtual reality, which could be used for inmates to temporarily escape the harsh physical and sensory environments of the jail or prison. But is that what we’re trying to achieve?
It’s a no-brainer, but an area ripe for innovation is the design of communication systems to facilitate the transfer of health information between health care providers inside and outside of the jail. But this is much easier said than done. Many electronic health care record systems are not cross-compatible, and even fewer are specifically designed for use in the correctional environment. Oftentimes fax machines and phone calls are being used to attempt to confirm medication use, a tricky area given that some psychiatric medications are also commonly abused due to their addictive qualities. In some instances, despite considerable detective work, I have found it to be near impossible to piece together a person’s recent use of mental or medical services, especially when they themselves cannot remember their medications, physicians, or diagnoses.
As a result, mental health workers like myself who see patients newly incarcerated in a jail may also have very limited information on a patient’s behavior, mental health history, and prior suicidal risk factors. The suicide rate in jails is three times greater than our prisons. From a technology standpoint, a number of recent papers have highlighted the ability to accurately identify people at high risk of a suicide attempt by using machine-learning approaches on big data sets. One could conceive that such an approach would be very helpful to supporting the proactive work of correctional mental health services, especially if we could access all this information in one place.
Smartphones are also not an immediately obvious answer. I’ve found that the “digital divide” between the technology use inside and outside of jail has never been greater. The reduced access to information is an additional source of uncertainty for those who I work with, especially those whose mental health challenges reduce their ability to remember, understand, and navigate the judicial and legal processes that they are involved in. Frequently, patients ask me about the judicial process, their court dates, or if I can help them in obtaining housing or social security assistance. In many situations, the questions are beyond the scope of my medical/psychiatric expertise. I wonder whether a simple piece of technology could be made accessible to inmates to enable them to gather basic information about their legal situation. Is there a role for conversational Siri-like agents, to help address some of the inmates’ basic questions about the jail/correctional process and facilities?
Obviously there are a range of safety and security implications that need to be carefully and thoroughly evaluated. One concern I have is that some patients might have a toxic digital environment that gravitates them toward worsening mental health, drug and alcohol use, and repeat involvement with the judicial system.
There could also be an opportunity to use computer vision to analyze audio and video from an incarcerated patient, as well as sensors, in a manner that will aid in the early identification of a potential mental health crisis. Parameters such as physical activity, sleep, and speech and acoustic information could help generate a personal digital mental state assessment for patients. But we have to also ensure such that such technologies are developed in the context of medical/psychiatric care, the collected data are appropriately protected, and incarcerated patients consent to their use.
One might also hope that neuroscience-based mental health research would help address some of the challenges we see in the correctional system. In particular, we have seen a range of startling, and sometimes overhyped, reports of the advances in our understanding of mental health and the human brain. Unfortunately, much of this research has focused on recruiting patients with clear-cut symptoms, or those who neatly fit into single categorical diagnoses. Most people in correctional settings who have had a mental illness would seldom meet the eligibility criteria to get into many of these research studies, being excluded because of their multiple diagnoses, unstable housing, legal or drug issues, or an inability to follow up.
As such, many research findings on carefully screened research subjects may simply not be applicable to the needs and challenges that face real-world people with multiple serious mental illnesses, drug addiction, unstable housing and finances, as well as poorly treated medical issues. The same could be said of the rapidly rising number of mental health or wellness startups, which focus on developing products for the general population, leaving niche groups like prison populations unaccounted for.
I fear that technological innovation in our correctional system is being hampered by a lack of interest, understanding, and quite frankly a discomfort in acknowledging the immense social, cultural, and economic chasm that exists in the Bay Area between the haves and have nots. Unfortunately, what happens in the technology hub of Silicon Valley, or in this case, doesn’t happen, will be felt nationwide.
Arshya Vahabzadeh M.D. is a subspecialist-trained psychiatrist, and is the director of Digital Health at neurotechnology company Brain Power. He holds faculty positions at Massachusetts General Hospital and Harvard Medical School, and is an investigator on privately and federally funded research into experimental technologies for mental health and brain conditions. For those who want to get involved, contact him at firstname.lastname@example.org or email@example.com