Spread of infectious diseases, such as COVID-19, can be amplified in jails and prisons because social distancing is nearly impossible inside those facilities. Last week, at least 21 inmates in the Tuscaloosa County Jail tested positive for the virus, according to the Tuscaloosa Mayor’s Office, and only one of those inmates showed any symptoms.
Dr. Marisa Giggie is a child, adolescent, general and forensic psychiatrist who practices at University Medical Center. She is also an associate professor of psychiatry and behavioral medicine at The University of Alabama College of Community Health Sciences, which operates UMC.
One of the populations of patients that Giggie provides mental health care for are inmates at the Tuscaloosa County Jail.
What is a forensic psychiatrist?
Giggie said a forensic psychiatrist works at the “intersection of psychiatry and the law.” She said forensic psychiatrists might evaluate people to determine if they are competent to stand trial, or if they might be not guilty by reason of insanity. Forensic psychiatrists also work with lawyers in court to assist in cases that involve mental health issues, she said
Does this bring you into the prison system?
Giggie said correctional psychiatry, which is working with inmates in prisons and jails, is part of forensic psychiatry. “That is how I got interested into this population,” she said.
Why is this an important service?
“Unfortunately, our jails and prisons, and specifically our jails, have become our new mental health hospitals,” Giggie said. As state hospital and outpatient services for the mentally ill have been dramatically reduced over the past several years, “so many people who should be getting treatment are often on the streets and are arrested for minor charges.” She said many inmates arrested for misdemeanors and minor crimes “have serious mental illnesses, like schizophrenia and severe depression. They should be getting treatment, but they end up getting arrested.” Giggie said approximately 30% of the U.S. inmate population has a serious mental illness; add addiction, general anxiety and depression and that number rises to 90%.
What exactly is schizophrenia?
Giggie said schizophrenia is a serious mental illness that leaves people “out of touch with reality. It’s a neurodevelopmental disorder so their cognitive function, their ability to make decisions, deteriorates. They become paranoid. They can also hear voices that aren’t there and become disorganized.” She said people who suffer from schizophrenia, if left untreated, can become homeless, living on the streets or in group homes. “Many can do well if they get treatment, but many of those services have been cut because of cuts in funding for mental health services. So many of them end up on the streets and, unfortunately, end up in jail. We just are very poor on resources for the seriously mentally ill.”
How did you get involved in this kind of work?
Giggie said her involvement in correctional psychiatry evolved over time. She completed a forensic psychiatry fellowship, and when she moved to Tuscaloosa, worked for two years at Taylor Hardin Secure Medical Facility, the forensic hospital that provides treatment for male inmates in Alabama found guilty by reason of insanity who need to be restored to competency.
“We (had clients) who came from the jails, and I became interested in what was going on at the jails. When I started working for the University, the opportunity came up at the (Tuscaloosa County) jail. It’s such a high-need population and you can make such a big impact working in that location and that’s why I was interested in working there.
How is what you’re doing there different from private practice?
Correctional psychiatry is community-based psychiatry and works with a specific population, Giggie said. “You’re also working in an organization, the jail, where you also have to work with the courts and the sheriff.” In private practice, psychiatrists can care for anyone in the community, she said.
Are there specific challenges that present in jails that you wouldn’t have in a private practice population?
“Absolutely, and a big challenge is resources,” Giggie said. She is limited on the kinds of medications she can prescribe, and she has to be aware of issues related to medications and jail, such as drug diversion and drug abuse. In addition, jails are correctional settings where people go after they have been arrested; they’re not therapeutic settings. “It’s not supposed to be a hospital, so if someone is very (mentally) ill, it’s not set up like a psychiatric therapeutic hospital setting and that poses lots of challenges.”
How has COVID-19 affected jails and how is the jail system working to keep everyone safe?
At the Tuscaloosa County Jail, COVID-19 has prevented Giggie from going into the facility to provide mental health services; she now uses Zoom. Group therapy services have been paused. All incoming inmates, as well as guards and other employees, are screened before entering the facility, and employees wear personal protective equipment. “The other big change is that the prisoners can’t get visitors like they used to, so that’s been hard,” she said. A quarantine area has been set up within the jail for inmates who test positive for the virus, “and we have identified high-risk inmates who have predisposing conditions that would place them at higher risk for contracting COVID-19,” she said.
What would be an example of conditions that might make them high risk for contracting COVID-19 and possibly becoming seriously ill?
Giggie said two that immediately come to mind are HIV and Hepatitis C, which are found in higher proportions in jails than in the general population. Another one is asthma. She said approximately 15% of the correctional population in the U.S. has asthma, which, is higher than the general population. Others are heart disease, diabetes and the age of inmates, she said.
Is COVID-19 also having a psychological effect on correctional officers?
Giggie said the virus and resulting changes at the jail are having an effect on everyone – correctional officers, staff and inmates. “There’s more anxiety, especially about the unknown and how serious the threat is,” she said. “It’s stressful because it’s hard to socially distance in jail. The way that the dorms are set up is with bunk beds and they are very close together, so it’s next to impossible to keep people be six feet apart.”
Are you seeing an increase of loneliness, depression or boredom because there are no visitors?
“I’ve actually seen a lot of frustration over the fact that they’re (inmates) not getting as much communication with their attorneys, and the (court) system seems to be moving at a much slower pace so they’re not sure what’s happening with their hearings. That seems to be a bigger anxiety producer than not getting visits,” Giggie said. An inability to get into addiction treatment programs is also producing frustration. “Often, what we do is recommend treatment as part of release, but many treatment programs aren’t taking people right now because of COVID-19.”
Any other observations about prison psychiatry that you have?
Giggie said there is such a need among this population and the work is rewarding. “Most of the inmates I work with are really appreciative of having someone listen to them because many of them have been disenfranchised and have not been listened to.”
You also have a background in child and adolescent psychiatry, and that brings you to Brewer-Porch Children’s Center here in Tuscaloosa. Tell us about your involvement there.
Giggie said she provides psychiatry services for both the residential and outpatient treatment programs at Brewer-Porch. Patients in the residential treatment program are children in foster care or in the custody of the Alabama Department of Human Resources who require long-term treatment for mental health issues. “I work with a treatment team and we try to get (the children) to a point where they can be back in the community, either in a foster home or with an adopted family,” she said. Currently, because of COVID-19, she is providing care to children in the outpatient program via Zoom. But for children in the residential program, care is being provided in person. “We do social distancing, we wear masks,” Giggie said. “When the children come in, we sit around a big conference table and we’re all six feet apart and we do our sessions that way.” She said the children vary in age from 6 to 17.
For the younger children, I imagine that human touch is an important piece. How do you deal with that and COVID-19?
“It’s a real challenge, but we’re working through it,” Giggie said. Staff are protected with masks and gloves. “It’s not easy, but I’m amazed, and the children are doing so much better than I expected; they’ve adapted fairly well. These kids have been through multiple placements, so they understand stressful times and they’ve mostly complied with what we’ve asked them to do.”
Have you seen a change in types of other responses the children might have with COVID-19? Are you seeing more anxiety, depression, acting out?
Giggie said in the last couple of weeks she has “noticed an uptick in some anxiety over not being able to see family as much as they would like. I think they’re feeling cooped up and starting to get frustrated, just like all of us, and they’re ready to get back to normal.” She said the children are also feeling frustrated because, while some have homes to go to, they can’t at this time because COVID-19 is hindering efforts to set up services in the community for the children once they are discharged. “We can’t release a child to a home, even with their family, unless we have all of the services for them in place – school, therapy and other outpatient services – and a lot of these places are closed or have limited access. It takes more time to get those things set up.”
Does the staff also feel frustrated, and are they having more anxiety?
Just like staff in most health-care facilities, they are anxious, Giggie said. They worry about possibly getting the virus from children returning from home visits, and with lower admissions numbers, are worried about their jobs, she said. “There’s a lot of anxiety about the unknown for the future.”
You are also medical director for Reprieve for Women? Tell us a little about that.
Giggie said Reprieve for Women is a residential addiction treatment program in Tuscaloosa for women that also has an outpatient sober living community. She said the program provides an intensive 12-step approach to recovery.
Has anything there changed because of COVID-19?
Giggie said there have been several changes. She now provides all patient visits viz Zoom and can no longer go to the residential facility or to the sobor living community. The other big change: “I have seen an increase in relapse rates because of the stress of COVID-19 and the social isolation. Some of the people in our community living, and some of the people who had been in our treatment program in the past, have relapsed. Whatever their drug of choice was in the past, that had been their coping mechanism for stress. With COVID-19, they can’t work, they’re stuck at home and they can’t have social connections like they had before. A lot of the women rely on their sponsors and going to meetings, and when those aren’t available there’s the risk that they could go back to the old coping mechanism. That’s what I’ve seen happening since COVID.”