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UDC 340.63:614.29:61:004
BecTHMK CTörY Me^MHa. 2020. T. 15. Bwn. 4
Organizational issues of re-socialization in penitentiary psychiatry (analytical review)
A. S. Fedonnikov, A. S. Nilova, E. A. Andriyanova
Saratov State Medical University named after V. I. Razumovsky of the Ministry of the Health of the Russian Federation, 112, B. Kazachya ul., Saratov, 410012, Russian Federation
For citation: Fedonnikov A. S., Nilova A. S., Andriyanova E. A. Organizational issues of re-socialization in penitentiary psychiatry (analytical review). Vestnik of Saint Petersburg University. Medicine, 2020, vol. 15, issue 4, pp. 246-255. https://doi.org/10.21638/spbu11.2020.403
The article deals with the medical and social rehabilitation and resocialization provision for persons in the space of penitentiary psychiatry. The article analyzes the data of Russian and foreign sources, including the regulatory framework, considers the principles of providing psychiatric care to persons who commit socially dangerous acts (SDA) and suffering from mental disorders. The existing approaches to resocialization and adaptation of persons after serving a sentence in the form of imprisonment in the post-penitentiary space are analyzed. The principles of providing psychiatric care in correctional institutions with the use of regulations governing the appointment and implementation of compulsory medical treatment measures (CMTM) in correctional institutions are noted. The data reflecting the organizational approaches and possibilities of medical and social rehabilitation and resocialization for the studied category of persons on the basis of legal, medical and social criteria are analyzed and presented in the form of the author's matrix. The need to develop and use tools for online communication based on digital technologies in the process of organizing psychiatric care for the specified contingent of persons is substantiated in order to create conditions for effective medical and social rehabilitation as well as re-socialization in the post-penitentiary space.
Keywords: mental disorders, penitentiary psychiatry, rehabilitation, re-socialization, digital health, online communication.
The mental health retention of the working-age population remains an urgent medical and social problem therefore the issues of mental disorders prevention do not lose it importance. Protection of mental health is a special direction of state policy which guarantees the protection of personal interests and observation of citizens' right to health protection. The state implements this direction including the establishment of mechanisms for the disorders prevention and rehabilitation of the concerned citizens [1; 2].
Preserving the health of convicts suffering from mental disorders is not only relevant for public health issues but also requiring its own promotion as there are national particular qualities of criminal punishment execution and approaches to reintegration into society (re-socialization) and medical rehabilitation management in the post-penitentiary space. Practically this is manifested in the following: changes in national legislation; reforms in the penal system; the state of penitentiary medicine; epidemiological data of convicts suffering from socially significant diseases; prevalence of psychiatric diseases among
© St. Petersburg State University, 2020
convicts (in particular an increase in the number of persons convicted of crimes related to drug trafficking) [3; 4].
There're specific characteristics of convicts suffering from mental disorders. In particular this contingent requires a comprehensive approach on the part of the penal system institutions — educational, psychological and other special services. At the same time a high level of various kinds of disciplinary violations remains which are committed by this category of convicts in all types of penal institutions, including educational colonies [5].
It should be noted that there are serious differences between forensic psychiatry and social psychiatry. Despite the fact that the same principles are applied in forensic psychiatry the general developed system of scientific views on mental disorders and practical actions for it detection, prevention and treatment this industry is distinguished by its specificity [6; 7]. Forensic psychiatry as a branch of medical practice includes several independent areas. Each area is distinguished by its tasks, ways of it solving as well as legal forms:
• forensic psychiatry expert examinations in the framework of criminal and civil proceedings;
• implementation of medical measures in the form of compulsory medical treatment and supervision by a psychiatrist;
• involuntary psychiatric measures under psychiatric care providing;
• penitentiary psychiatry [8].
In the Russian penitentiary system psychiatric care is provided both outpatient and inpatient. In accordance with the law compulsory medical treatment measures (CMTM) can be imposed by a decreet both on an outpatient and on an inpatient basis. In case of CMTM are carried out in institutions providing psychiatric assistance to citizens on the basis of decreet then a person who has committed a socially dangerous act (SDA) and suffers from a mental disorder is recognized as insane (non compos mentis) and is not subject of punishment in the form of imprisonment [9; 10]. Under the condition of correctional institutions the provision of psychiatric care is carried out in accordance with the legal status of the patient. In the event that the person who committed SDA is recognized as non compos mentis or in a state that does not exclude sanity and at the same time suffers from mental disorder the court may appoint CMTM outpatiently at the place of serving the sentence (part 1 of article 104 of the Criminal Code of the Russian Federation). In this case the appointment of the CMTM is the exclusive right of the court but it execution is regulated by the criminal-executive legislation (part 3 of article 97 of the Criminal Code of the Russian Federation) and by the concerned legal acts of the penal system.
There're two important issues of psychiatric care providing within the penal system: prevention of illegal acts commitment by persons suffering from mental disorders of various types; measures are taken to prevent the re-criminalization of patients who previously committed SDA [10; 11].
Penitentiary practice of foreign countries points that convicts suffering from mental disorders represent a diverse group which structure depends on the sentence imposed and not only on the psychiatric diagnosis [12]. In this regard certain categories of convicts have emerged, for example, "criminals suffering from psychopathy", "criminals convicted of sexual crimes" etc. Thereon various programs and methods of treatment are being actively developed and include not only medication but psychotherapeutic methods which are also being actively introduced [13].
Historically the penitentiary system doctrine in Russia includes correctional rehabilitation as its main goal. ^e solution is achieved through educational influence, the use of psychological methods of correction, improvement of educational methods including the establishing of educational colonies on the territory of correctional institutions. However, special educational measures are not applied directly to the category of persons belonging to the group of active dynamic observation or to persons who are at the CMTM. According to the Concept for the Penitentiary System Development in the Russian Federation until 2020 comprehensive rehabilitation programs focused on Western experience have been developed in the penitentiary system. Most of them were aimed at the rehabilitation of persons with addiction to psychoactive substances. With regard to persons suffering from mental disorders the effectiveness of such rehabilitation programs was not so good due to the fact that among convicts suffering from mental disorders and staying in penitentiary institutions violations of the detention regime and other types of maladaptive behavior are often noted [14].
There is a whole arsenal of works which reflect various nosological structures and their prevalence among convicts suffering from mental disorders [15; 16]. Models of diagnostics and groups of convicts examination with certain diagnoses have been developed [17]. A number of authors studying the structure of mental pathology in the population of the penitentiary institution note a high prevalence of depressive disorders (40.0-59.0 %) as well as a high percentage of the prevalence of dependence on psychoactive substances (33.3-65.3 %) [15; 18]. At the same time there're also works which represent draw attention to the high degree of compatibility of mental disorders [19; 20]. Didenko distinguishes a significant spread of borderline spectrum disorders or rather personality disorders [15; 21].
Some research of criminologists and sociologists attempt to destroy the template that convicts with mental disorders are always socially dangerous. With adjustment disorders or penitentiary stress some categories of convicts find support among friends, relatives, or put themselves into religion. But on the other hand difficulties in adaptation and manifestations of penitentiary stress can be accompanied by severe depressive reactions and psychopathological symptoms. These manifestations need to be corrected not only with medication but also with psychotherapeutic methods [22]. Studies have noted that depressive reactions commonly proceed as adjustment disorders in connection with penitentiary stress.
Convicted minors and women constitute a special category. Despite the periodic health examination many minors who have committed SDA are diagnosed with a mental illness in a correctional institution [20]. Psychophysiological characteristics and specificity of social conditions make this group of convicts more susceptible to penitentiary stress and impaired social adaptation [20; 23]. Accordingly this category of convicts needs a comprehensive approach that combines educational and medical segment of assistance especially in case of a tendency to re-commit SDA.
In penitentiary practice a special place is given to the category of a special contingent consisting of persons sentenced to imprisonment as well as in accordance with paragraph "d" part 1 of article 97 of the Criminal Code of the Russian Federation.
Most of the convicts with this nosological unit serve their sentences in correctional institutions. According to some authors the purpose of punishment for this contingent should be not only isolation and development of therapeutic approaches to treatment but
also the prevention of repeated SDA [21; 24]. Thus for this category of convicts it's necessary to develop programs of medical and social rehabilitation.
A serious debatable problem remains the lack of a clear understanding of the behavior correction boundaries and the limits of psychiatric interventions in the process of correcting a convict [25].
In general the effectiveness of therapeutic interventions in the penitentiary system should be considered in relation to each prisoner [26].
The question of the potential danger (re-committing SDA) of the convict remains relevant in the conditions of a correctional institution as well as after the end of the criminal punishment due to the deterioration of the mental state. The literature describes various programs for drug correction and the use of psychotherapeutic techniques that reduced the likelihood of recurrence of SDA. Thus, Eamon [27] in his work described a program for the treatment of addiction to psychoactive substances and a program for reducing the level of aggression in the conditions of female correctional institutions. These programs included not only drug therapy but also psychotherapeutic rehabilitation. As a consequence there were obvious improvements in the form of a regimen violations decrease and a decrease in relapses [27].
In Western practice it has been developed a special attitude to the understanding of drug treatment of mental disorders of convicts. On the one hand the tactics, methods and goals of drug therapy should be determined strictly individually and based on the initial definition of the boundaries of personal pathology. On the other hand deviant behavioral traits are considered the most significant target of corrective action. Correction of such behavior in unity with social and psychological stability is the base of the repeated SDA prevention [28]. Moreover the literature reflects the opinion that the clinical goals of patients' treatment should be considered separately from criminological [29].
In studies concerning the relationship between the effectiveness of treatment and re-offending it was noted that diagnostics and frequent hospitalizations do not significantly contribute to the variation in rates of reoffending [30]. If we consider such a category of convicts as adolescents then in this case the psychotherapeutic approach and further rehabilitation after the end of punishment make a greater contribution to the prevention of repeated SDA. This applies primarily to the category of persons approaching puberty. For this category it's necessary to design innovative approaches for further medical rehabilitation and re-socialization in the post-penitentiary space due to their psychological characteristics. At the same time many authors note the ambiguity of the relationship between criminal behavior and mental disorders. Thus participants in various therapeutic programs to reduce interpersonal violence are not always patients with mental disorders [29; 31].
Various studies note the limitation of the drug approach because it doesn't always provide psychosocial behavior correction in isolation. The need to apply a comprehensive use of psychotherapeutic and psychological influence, in general, has a beneficial effect on the further adaptation of convicts. In the development of programs for the further rehabilitation of convicts suffering from mental disorders it should be borne in mind that in the penitentiary system not every convict suffering from mental disorders is assigned a CMTM [12]. Western scientists do not attribute borderline mental disorders to true pathology but regard them as dysfunctional behavioral patterns. This approach forms another goal of therapy and rehabilitation — the development of life skills in the presence
of difficult life situations. In this case comprehensive rehabilitation programs are formed which are applied both in the conditions of the penitentiary institution and in the post-penitentiary space [32; 33]. ^is approach gives an opportunity to clearly determine the effectiveness of treatment, the further prognosis of the patient's re-socialization, perception of treatment as well as the motivation for it.
A significant factor of the considered category of convicts re-socialization is the availability of sufficient resources for their social support after the end of criminal punishment. Definitely a sufficient effect of treatment should be determined not only by a decrease of repeated SDA but also by a change in the personal beliefs of this category of persons. ^us it is necessary not only to influence asocial traits but also to achieve the formation of the patient's motivation for observation and treatment (if necessary) in the post-penitentiary space.
In the organization of psychiatric care in the penitentiary system both in Russia and in foreign countries two directions have been formed: inpatient and outpatient [34].
At the outpatient basis in the departments of the medical service of correctional institutions psychiatric care is provided in differentiated forms. There are individual, group and systemic methods. For such groups of disorders as personality disorders, including disorders of sexual preference various treatment programs are offered, including different approaches. So, in the correctional institutions of the Netherlands it was previously used the correctional program "Preventing Recidivism" aimed to the formation of cognitive skills and of an attitude to solve various problems in an acceptable social way [29]. ^is type of program was applied after undergoing psychiatric treatment and before the end of criminal punishment. Within the framework of Russian legislation and the organization of the penal system it is not always possible to use such programs in a penitentiary institution.
If we consider inpatient psychiatric care then in foreign practice a direction of labor rehabilitation for convicts with "limited sanity" is widely developed. Directly in the hospital they are involved in light labor practice. Among such a contingent various mental disorders are often found in combination with comorbid pathologies. As a rule these are addictions to various psychoactive substances. Due to a long stay in such institutions it is possible to conduct both drug treatment and psychotherapeutic in the format of cognitive-behavioral therapy. Research has shown that this approach can help reduce patient aggression. They develop attitudes towards treatment but there is not enough convincing data on the stimulation of social behavior after serving a sentence [29]. ^us both outpatient and inpatient types of therapeutic care organization are unequal and should be used depending on the severity of clinical symptoms, the dynamic state of personality disorder and a number of other conditions.
In Western penitentiary psychiatry there has long been an interest in convicts suffering from mental disorders studied from the standpoint of dialectical behavioral therapy, aggression replacement therapy and focused therapy schemes. This type of therapy includes a comprehensive approach in the form of supervisory programs as well as intensive training. This approach is most common to convicts suffering from personality disorders. ^e effectiveness of the approach confirmed by control studies in the framework of international projects [35].
Thus in the center of foreign studies of re-socialization and adaptation of persons serving a criminal sentence are the individual characteristics of the convict as well as the presence of comorbid pathologies [36]. Social support for convicts is based on age and
personal factors. The use of drug treatment in work with convicts is carried out strictly according to indications in combination with psychotherapeutic methods.
Analysis of foreign experience in organizing the practice of re-socialization showed that preference is given to centers of social rehabilitation and adaptation (Kazakhstan), hostels in order to restore social skills and more successful integration into society (Japan). At the same time different countries have different approaches to resolving issues of employment in the post-penitentiary space [35].
The peculiarities of Russian legal system, approaches to the organization of social and medical services as well as to monitoring and, in general, rehabilitation of convicts suffering from mental disorders differ from foreign models significantly.
In the Russian Federation outpatient medical care is provided in correctional institutions (CI) in the medical unit and outpatient psychiatric care is provided directly through the psychiatric office of the branch of the medical unit. Medical activity is carried out in draded forms.
Treatment and rehabilitation programs predominantly depend on nosological characteristics as well as it is actively encouraged an interagency cooperation in the conditions of a correctional institution. The convicts involved in work provided not only by the psychiatric service but also by the psychological one. This is especially regard to the contingent suffering from disorders of the neurotic register [20].
In Russian penitentiary psychiatry the treatment and organization of the psychiatric service in general has a number of tasks and unresolved issues. The reform of the penitentiary system is carried out constantly including the development of rehabilitation programs for this category of convicts but, as a rule, these programs are of an individual nature and are mainly aimed at re-socialization [36]. The system of social support in the post-penitentiary period is insufficiently developed which leads to the decompensation of mental disorders, repeated commission of SDA and repeated internment in the conditions of the penitentiary system. There is no monitoring identifying criminal remission in the context of mental health. This is primarily due to legislative gaps.
The data presented in the literature keeps up to date the need for the development of comprehensive medical and social programs based on psychotherapy in a penitentiary institution. These programs increase the adaptation of the convict, make it possible to reduce violations in correctional institutions and also prepare the convict to rehabilitation in the post-penitentiary period [37].
It should be noted that a comprehensive therapeutic approach includes taking into account the following factors:
• mandatory consideration of the patient's clinical and neurophysiological parameters;
• strict individualization of each case of personality disorder;
• assessment of the typological personality structure;
• providing a comprehensive effect on individual links of pathogenesis;
• accounting for concomitant and predisposing pathogenic, somatogenic and exogenous-organic indicators;
• assessment of age and evolutionary stage;
• stages and sequence of psychotherapeutic and medication measures aimed at social readaptation and re-socialization of patients.
One of the tasks of the penitentiary psychiatric service is the development of an innovative approach to the rehabilitation of convicts with mental disorders in the post-penitentiary space [32]. The penal system has developed an integrated approach to the correction of convicts and adaptation after serving a criminal sentence in the post-penitentiary space in the form of implementing employment programs, programs for re-socialization and psychological programs [38]. At the same time many issues of social adaptation, medical and social rehabilitation of patients with mental disorders have not found a proper organizational solution.
Currently a detailed rehabilitation program has been developed for patients who have served a criminal sentence and suffering from addictions and socially significant diseases, such as tuberculosis, HIV-infection etc. However it is necessary to develop medical rehabilitation programs taking into account the current situation of mental illness prevalence among convicts. The issue of organizational interaction between the penitentiary psychiatric service and the psychiatric service in the system of the Ministry of Health of Russia remains unresolved. At the same time intersectoral cooperation significantly increases the success of public health programs [39]. Existing approach to the organization and monitoring of the patient's social rehabilitation in the system of rehabilitation and re-socialization measures in the post-penitentiary space is not systemic. There is no full-fledged interaction between psychiatric services and social services in the aspect of preventing the repeated SDA [40].
The results of the considered theoretical approaches to the problem and its practice's state of the art analysis are presented by the authors graphically in the form of a matrix. This framework makes it possible to systematize and clearly present the organizational approaches and possibilities of medical and social rehabilitation and re-socialization in the post-penitentiary space for the studied category of persons (Fig.).
Organizational approaches Foreign countries _ .. . Russian Federation mentioned in the review
medical and social rehabilitation and resocialization programs comprehensive approach based on a drug correction and psychotherapy social support in a post-penitentiary space based on intersectoral cooperation
< \ use of medical and social rehabilitation programs f \ Insufficient use of re-socialization programs
r > use of comprehensive approach V r predominantly drug correction v y
dialectical behavioral model implemented by social and medical services V V ( lack of interaction between the penitentiary system, medical organizations and social services V J
Fig. Organizational approaches and possibilities of medical and social rehabilitation and re-socialization in the post-penitentiary space (graphic presentation of the review results in the form of a matrix)
In this regard it is relevant to develop and introduce into the psychiatric practice at the post-penitentiary stage tools of remote communication based on digital technologies which allows to monitor and manage the re-socialization process for the patients with mental disorders. Also digital technologies can also improve the safety of health care [41]. The introduction of digital technologies into practice will increase, first of all, the availability of qualified care, will reduce the problem of stigmatization of the population including the patients who are registered with a psychiatrist. The use of online communication technologies, particularly in penitentiary psychiatry, will provide an opportunity for interactive monitoring and feedback with persons receiving and receiving CMTM.
Also when using such technologies the possibility of timely informing both the doctor and the patient about changes in the mental state increases. It should be noted that such technologies have shown their effectiveness in other areas of medicine. So, these studies were carried out in the field of traumatology and orthopedics with the aim of monitoring and managing the rehabilitation measures which showed good results. The use of such IT product presented by the researchers has shown a high patient focus, high quality of information interaction as well as the receptivity of patients to this service [42; 43]. If we consider the use of information technologies in psychiatry, psychotherapy and narcology it can also be noted a positive experience. So, in psychotherapeutic practice it was proposed to introduce information technologies in the form of mobile applications for smartphones and other computer technologies as well as to adapt existing foreign IT products for use in domestic practice [44]. Some authors also note that the development and use of telemedicine in the field of psychiatry and drug addiction is an effective organizational approach [45].
Thus the use of online communication tools in psychiatry has significant potential for the development and implementation of modern and effective rehabilitation and re-socialization programs for persons who have committed SDA and suffering from mental disorders.
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Received: December 15, 2020 Accepted: December 29, 2020
Authors' information:
Alexander S. Fedonnikov — MD, PhD; fedonnikov@mail.ru Anzhelika S. Nilova — MD; lika_nilova@bk.ru
Elena A. Andriyanova — Dr. Sci., Professor; elena-andriyanova@yandex.ru
