Clinical Alternatives to Punitive Segregation: Reducing self-harm for incarcerated patients with mental illness

Within the NYC jail system, the Department of Health and Mental Hygiene (DOHMH) is responsible for health care while the Department of Correction is responsible for custody and security. We (DOHMH) recently reported that the policy of placing incarcerated patients in solitary confinement for violation of jail rules was associated with increased risk of self-harm. As a result, we worked with DOC to design an alternative unit for seriously mentally ill patients who are found to have violated jail rules. This unit, called Clinical Alternatives to Punitive Segregation (CAPS) has been in existence for one year and is based on a mental health treatment model, rather than punishment via solitary confinement. One of the primary indicators of this unit’s success is the rate of self-harm among patients, a practice that can range from trivial to fatal. We reviewed data form the first 8 months of the CAPS unit (December 1 2013-August 31 2014), including 185 patients who were ever in this unit. We compared rates of self-harm for these patients to those for patients with mental illness who are still held in solitary confinement, known as the Restrictive Housing Units. The programmatic distinction between the two units is that patients with serious mental illness are directed to CAPS, while patients with less serious mental illness are directed to RHU. Rates of self-harm were compared among 185 CAPS and 1,399 RHU patients. The incidence rate of self-harm was 0.27 per 100 person-days for patients on the CAPS unit and 2.52 per 100 person days for patients housed on the RHU units. Because there were baseline differences between the admission criteria of these units (Serious mental illness was present in 84.3% of CAPS patients but only 29.9% of RHU patients), we then analyzed records of patients who were in both units (n=57). The rate of injury for these patients was significantly lower for their time on CAPS than RHU (0.48 vs. 0.97 per 100 person days, P<0.001) as was the rate of self-harm (0.18 vs. 0.76 per 100 person days, P<0.001). Data from the CAPS unit provides support for transitioning away from a punishment model towards a treatment approach for incarcerated persons with mental illness.