Correctional facilities are not just places of confinement; they are also intense environments where mental health crises can erupt unexpectedly. You’ll encounter some crises similar to those in inpatient psychiatric units, like self-injurious behaviors, suicide attempts, and psychotic or impulsive aggression. But in correctional facilities, you’re likely to see these alongside more frequent cases of predatory aggression towards staff, sexual misconduct, and unique challenges like hunger strikes. These situations are difficult to manage even for the most seasoned psychiatrists. To help navigate these challenges, here’s a primer on managing behavioral crises in jails and prisons.

Balancing security and mental health care
In correctional settings, the primary focus is on maintaining security for both inmates and staff, not providing mental health care. This priority can complicate the management of behavioral emergencies and requires a delicate balance between security measures and mental health interventions. Clear, respectful, and bi-directional communication with custody staff is essential. Sometimes correctional staff may disagree with your recommendations and prioritize safety measures, like the use of protective gear, riot shields, or stun grenades. These measures can traumatize and harm patients. By educating staff on mental health strategies and developing joint protocols, you can foster cooperation and improve the effectiveness of interventions while minimizing harm.

However, correctional facilities also provide unique resources that can aid in managing these complex situations. Custody staff are often better trained and equipped to handle violent individuals than psychiatric nurses or technicians in traditional settings. Additionally, some correctional facilities, including county jails, have inpatient psychiatric units that can manage acutely violent, suicidal, or self-injurious patients. Facilities without these units often provide specialized cells, such as ligature-resistant cells for suicide watch or damage-resistant cells for seclusion. 

In addition to these resources, correctional settings often have unique legal and procedural processes for obtaining treatment for individuals who refuse psychiatric care. Some jurisdictions may authorize involuntary antipsychotic treatment for patients found incompetent to stand trial by the court and/or involuntary psychotropic treatment for patients who are gravely disabled or dangerous due to their condition. One example of the latter is California’s Penal Code section 2603, which outlines procedures and criteria for providing involuntary treatment to incarcerated patients. This framework, effective since 2018, ensures that incarcerated individuals receive necessary care regardless of whether they refuse. Due to the varying availability of psychiatric services and custody resources, however, some county jails may lack the capacity to safely and effectively administer involuntary treatment, regardless of active court orders.

Responding to acute behavioral crises
The first step when responding to a behavioral crisis in custody is to utilize de-escalation techniques to help calm the patient and avoid the use of force (for more, see “Principles of Verbal De-escalation” in CHPR Jan/Feb/Mar 2022). Key strategies include:

Respecting personal space

Avoiding postures or statements that might be perceived as threatening

Allowing the patient to voice their concerns freely without receiving critical responses

Once the patient is calm, they may be open to taking oral medication to reduce distress, which can prevent the need for restraints or emergent intramuscular medication. While a recent Cochrane review noted that de-escalation lacks strong empirical support, it is widely accepted as good clinical practice (Du M et al, Cochrane Database Syst Revs 2017;4:CD009922). 

Predatory aggression and solitary confinement
Treating incarcerated patients differs significantly from treating those in the community due to the high prevalence of antisocial personality disorder (ASPD) and psychopathic traits, which affect up to 75% of the prison population (Zeier JD et al, Personal Disord 2012;3(3):283–293). These individuals often deny responsibility, blame others, dissemble, or exhibit hostility and aggression, making them particularly challenging to treat. Co-occurring primary psychotic or mood disorders can further complicate treatment. 

Patients with ASPD or psychopathic traits may engage in predatory aggression towards staff, such as fashioning weapons from toothbrushes or “gassing” staff with bodily fluids. Such behaviors often result in the use of force by custody staff, and emergency psychotropic medication may be required to prevent harm when these individuals become agitated.

Clinicians should stay alert to their physical surroundings at all times. Position yourself near exits, avoid turning your back on patients, and ensure custody staff are present during high-risk encounters. It’s essential to communicate any concerns and the patient’s aggression risk clearly with custody staff. When possible, building rapport with patients can help reduce the likelihood of violent incidents.

Severe predatory violence can lead to placement in solitary confinement or intensive management units (IMUs), where access to peers, staff, and stimulation is severely restricted. Incarcerated individuals in IMUs often report social isolation, sensory hypersensitivity, and loss of identity (Reiter K et al, AM J Public Health 2020;110(S1):S56–S62). While one study found no difference in psychiatric symptoms between those still in or released from IMUs after one year, other research shows that solitary confinement significantly increases the risk of suicide and self-injury, prompting some to advocate for its abolition (Dellazizzo L et al, Int J Ment Health Nurs 2020;29(4):576–589). Understanding the psychological toll of such deprivation is key to managing patient care effectively in correctional settings.

Sexual misconduct
Mental health staff play an important role in the assessment of sexual misconduct in custody. The Prison Rape Elimination Act (2003) mandates training, prevention, screening, and response to sexual assault allegations, including those involving staff. If an inmate reports sexual misconduct by staff, it’s important to ensure their immediate safety, initiate an investigation, and provide emotional support.

Conversely, if an inmate is the perpetrator and the staff member is the victim, the focus should shift to ensuring staff safety, providing appropriate support, and promptly reporting the incident for investigation. Facilities must offer medical and mental health evaluations to all victims of sexual abuse and attempt to evaluate abusers within 60 days of the incident.

Sexual misconduct can include sexually explicit statements, genital exposure, sexual touching, and penetrative acts. Incarcerated individuals may engage in such behaviors for a host of reasons, including protest, antisocial opportunism, aggressiveness, paraphilic exhibitionism, neurodevelopmental impairments, psychotic disorganization, or delusional motivations. 

You might be asked to evaluate patients who have engaged in sexual misconduct to help formulate a diagnosis and treatment plan aimed at reducing future incidents. In cases of sexual violence, especially involving psychotic individuals refusing care, the behavior can support the need for treatment over objection. 

Certain populations—including women, bisexual or gay individuals, sexual offenders, and those with mental illness—are at higher risk for sexual victimization in custody (Beck AJ and Johnson C. National Former Prisoner Survey, 2008. Washington, D.C.: Bureau of Justice Statistics; 2012). Understanding these risk factors allows you to advocate for appropriate housing and safety monitoring to protect vulnerable individuals.

Managing hunger strikes
Hunger strikes are relatively common in correctional settings. Sometimes they are coordinated and massive, such as the 2013 hunger strike involving about 30,000 people incarcerated in the California prison system. More often, they involve a single individual. Typically, hunger strikes involve a “total fast” (avoiding food only) rather than a “dry fast” (avoiding both food and water), as dry fasts can be fatal within a few days, often before the person can draw attention to their cause. Genuine hunger strikers refuse food to make a statement, whereas “food refusers” may not intend to risk their health for their purported cause.

Most hunger strikes resolve without significant risk to the patient’s health, but some require medical and psychiatric intervention. A 2017 study on characteristics of hunger strikers in the New Jersey prison system from 2005–2015 found that 71% lasted three days or fewer, while 5% lasted beyond 30 days. The longest lasted 395 days, but longer strikes typically involved individuals consuming liquid nutritional supplements.  Notably, 45% of hunger strikers had a mental health special needs designation. Compared to other incarcerated individuals, hunger strikers were more likely to have a mental health special needs designation or a diagnosis of personality disorder, antisocial personality disorder, or a psychotic disorder (Reeves R et al, J Am Acad Psychiatry Law 2017;45:302–310). You may need to assess an individual’s mental state and determine if their hunger strike is related to a mental disorder.

Patients who are psychotic, delusional, or lack the capacity to engage in a hunger strike may require psychiatric treatment over their objection. Psychosis that prevents a patient from meeting their nutritional needs can be considered a form of grave disability. While the Supreme Court’s ruling in Cruzan v. Director allows competent adults to refuse force-feeding, close medical monitoring of fluid consumption and metabolic parameters is essential, and additional laws and regulations provide guidance on when and how force-feeding may be implemented to ensure the safety and well-being of the individual.

Carlat Verdict: Treating patients in correctional settings presents unique challenges and emergencies. Along with the more familiar psychiatric crises like self-injury and violence, you’re also likely to encounter hunger strikes, sexual misconduct, and predatory aggression. Being aware of available resources—like trained custody staff and specialized housing units—is critical for managing these behaviors effectively. Work closely with custody staff to ensure that interventions not only address the immediate crisis but also support individuals’ long-term mental health. Your role is to help navigate these emergencies while advocating for humane, thoughtful practices in what can be a very controlled and high-stress environment.