Department of Corrections EOP malingering.... Any advice?

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carlosc1dbz

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I am currently doing some work in the correctional system. EOP stands for enhanced outpatient program which is like a partial hospitalization program, (daily groups, individual therapy weekly, monthly meeting with psychiatry). There is also CCCMS which is Correctional Case Management System, which pretty much is just standard outpatient, (no groups, see psychiatry once every 3 months). There is also a department called Crisis Bed which are like inpatient beds. Lastly there is the General Population.

There usually is no mixing of the general population which includes CCCMS and patients in the EOP program. They have different buildings, different yard times, different lunch times and so on. Many inmates want to be EOP because there are many advantages such as being out of the cell more often, having one on one with therapist some of which are female, correctional officers are "nicer," some fun groups like painting, movies sometimes, stuff like that and lastly there is less of a risk of violence.

So who gets to be a part of EOP? Great question. Patients with significant psychiatric symptoms including mostly mood and psychotic disorders. The thing is, there is so much litigation by inmates that it has lead to over reacting to inmate reports, thus allowing people to get easily get into EOP and say whatever they need to stay in EOP. If someone says they are suicidal, they get taken to the Crisis Bed (inpatient) right away. Some inmates are indeed suffering for MDD and are having worsening SI, but others just want a change of setting or are in trouble with other inmates and need a quick out. There is no system in place to evaluate SI and suicide risk assessments allowing for increased monitoring, suicide precautions, increased visits with psychology and psychiatry, they just get sent to Crisis Bed (inpatient). It also does not help that inmates know to "go suicidal," after 5pm. When I have seen inmates really want to get out to Crisis Bed, but denied, they start superficially cutting arm saying "you see I am suicidal." Psychology evaluate the inmates when they say they are suicidal and most of the time, they send them out to Crisis Bed (inpatient).

In addition many inmates use drugs and become psychotic or manic and get schizophrenia diagnosis and to EOP they are sent. When they try to graduate them out of the program, every 90 days, the inmates "decompensate," reporting increased psychosis, depression or SI. Despite functioning just well in other aspects of their day, like socializing with other inmates, participating effectively in groups, and overall doing well. They end up staying, because EOP is a great place to be an inmate.

My question is if anyone has had this experience in the correctional system? If so, are there any good systems out there that might reduce the way the institution responds to inmate malingering?

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I'd be interested to see what others offer because I gots nothing. The corrections population is one I have enjoyed at times although our present lack of ability to set any boundaries, society in general, has made it unmanageable in my opinion. Inmates largely run the show and the lawsuits successfully dragging everyone from the psychiatrist to the janitor who dumped the trashcans into court because someone with antisocial personality disorder didn't get their Wellbutrin and Seroquel for their "bipolar" which they didn't even have is disgusting. I loved the very few who were interested in learning nonpharm coping skills as I reduced the excessive substance-abuse-clusterB cocktails their OP docs wrote because they were intimidated by them but having to constantly be in a pissing match with the other 19 patients that day wore me out.
 
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Not a healthcare professional, but could you implement some sort of tiered or step program, have those who you suspect of, or who are clearly malingering placed in a different program level and make it as soul suckingly boring and frustrating as possible for them to be there?
 
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I used to moonlight at a jail, and interestingly their first step in reported SI was to put someone in a locked padded room. No bed. No toilet. Just a hole in the floor. They would be left there until the therapist (or occasionally psychologist) came to eval and clear them. Interestingly after some time in there the malingerers would openly recant, admitting they were lying.
 
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I think cekes post, and nitemagi's, makes the most sense. If there were levels the inmates worked through, starting at extremely boring and something a mentally stable person would be averse to, progressing to more and more privileges/interesting/rewarding as the inmate's symptoms improved, you would have some leverage for the inmate to get better. If the inmate suddenly decompensated the day prior to discharge they would get sent back to the very beginning. IF there is convincing evidence for malingering, you could keep them in the early level entirely until they improve to the point of discharge. This way you avoid the rewarding aspects of the program. You will probably still get burned, but once the inmate has shown themselves to malinger, you can no longer trust them and they will know faking SI again will only get them stuck in the boring early level of the mental health program.
 
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I know this doesn't help you, but apart from seeing a psychiatrist, it seems like they should just change the general population program to be what you describe the EOP program as. Guards should be nice; there should be something to do in the day; there should be rehabilitation work; there should be safety from violence.

The EOP program isn't too rewarding; the alternative is too unsafe and meaningless.
 
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MHCBs aren't really like inpt beds its more like a PES/CSU as if they need inpt level of care they get shipped out to DSH (where there is again a lot of malingering; in fact not uncommon for pts to admit they were malingering when they get there).

What is challenging is that these malingerers often do have a lot of suicide risk factors, and often do engage in self-injurious behavior. CDCR is quite ridiculous and has certainly become all about the paperwork and created a ridiculous system that encourages malingering post coleman. But you are not going to be able to change the system. these are total institutions, and the dysfunction goes beyond the individual prison (though some prisons in CDCR are definitely worse than others). You as an individual practitioner, do have some choice in how you respond to it, balancing the fact that these inmates do have risk factors and can up the ante, with not reinforcing the dysfunctional behavior of antisocials and psychopaths. This includes documenting well, with good reasoning and explanation, doing and documenting your own risk assessment, making sensible diagnoses (and undiagnosing), and taking them of drugs they don't need or likely won't benefit from. It may also mean souring the milk. i do have some sympathy for the prisoners; malingering may well be an adaptive and sane response to the very maladaptive and insane prison-industrial complex. I don't see it as my job to get the goods on them, to act as their custodians, tormentors, or abusers but rather do the best I can. I think it's a pretty interesting population to work with it, and as nitemagi alludes, the county jails in california tend to deal with inmates much more harshly. The flip side is that not only do the jails disincentivize malingering, they may also disincentivize people who are actually in need of help from getting it.
 
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I think cekes post, and nitemagi's, makes the most sense. If there were levels the inmates worked through, starting at extremely boring and something a mentally stable person would be averse to, progressing to more and more privileges/interesting/rewarding as the inmate's symptoms improved, you would have some leverage for the inmate to get better. If the inmate suddenly decompensated the day prior to discharge they would get sent back to the very beginning. IF there is convincing evidence for malingering, you could keep them in the early level entirely until they improve to the point of discharge. This way you avoid the rewarding aspects of the program. You will probably still get burned, but once the inmate has shown themselves to malinger, you can no longer trust them and they will know faking SI again will only get them stuck in the boring early level of the mental health program.

Everyone is making great points. I like the idea of rewarding people that get better. It seems like here people get rewarded for getting worse. Almost like the VA and service connection. (don't get me started on that.) This is a big system and it appears that most of the policies come from Sacramento and are not adaptive to the individual institution.
 
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