Position Statements

Correctional Health Care and the Prevention of Violence

Background
In the last ten years, interpersonal violence (i.e., homicide, rape, robbery, aggravated assault, abuse and neglect of young and old people) has grown to epidemic proportions. In 1990, there were more than 23,200 homicides in America. In comparison to other industrialized countries, the United States 1990 murder rate was 11 times that of Japan, nearly 9 times that of England, over 4 times that of Italy, and 9 times that of Egypt and Greece. Our nation's youth and young adults, particularly among minority groups, are frequently involved in acts of interpersonal violence. During the 1980s alone, over 48,000 people were murdered by youth and young adults in the 12 to 24 year age range. Homicide is now the second leading cause of death among 15 to 24 year olds and the leading cause of death among 15 to 34 year old black American males. It's also been demonstrated that the effects of violence on youth increase the odds of their future delinquency and adult criminality overall by 40%. Victims of violence, in other words, are likely to become victimizers in future years.

As violence grows in America, a number of different agencies are responding in a number of different ways. The justice system's long range plans address reducing violent crime, improving the effectiveness of law-enforcement agencies to combat violence, providing assistance to victims, and crime prevention programs. The medical and mental health professions have joined with the Centers for Disease Control and Prevention (CDC) in an initiative intended to treat violence as a major public health problem. Such an approach has an objective of preventing violence through surveillance, epidemiological analysis, and the evaluation of various intervention techniques. An important emphasis of this initiative has been to involve the health care community in the identification of victims of abuse and violence.

Very little emphasis has yet to be placed upon the use of intervention techniques that teach individuals alternatives to violence as a behavioral response. This would appear to be a particularly appropriate technique for use within correctional facilities where increasing numbers are now being incarcerated for violent crimes. This further suggests an important role for correctional health programs that might begin to address violent behavior within the correctional environment as a public health problem. Perhaps an equally important role for correctional health programs is the identification and treatment of the incarcerated who have lived with violence in their lives. Some experts believe that certain kinds of violent behaviors can be effectively treated enabling people to better cope with violence in their lives. Since most of those who are incarcerated eventually return to their communities, these kinds of intervention and treatment techniques might have a positive effect on reducing violence in the community.

Violence can be characterized in several ways. For example, Jenkins and Bell characterizes expressive violence as that which grows out of some kind of interpersonal altercation in which one person intends harm on another. Persons involved in expressive violence typically know each other, are similar in age, and frequently share the same race and ethnic background.

Instrumental violence, in contrast, is usually premeditated and motive-driven (e.g., acquire property or economic gain). Typically, parties involved do not know one another and the harm caused is secondary to the motive. Finally, gang-related violence results from gang membership and related membership activities involving retaliation or revenge. These distinctions imply that different intervention strategies may be required to effectively prevent the various kinds of violent behavior.  Further, experts believe that expressive violence may be appropriately treated through public health intervention techniques, as opposed to socio-economic interventions for instrumental violence and political interventions for gang violence. All three kinds of violent behaviors are prevalent in society and, too, in correctional facility populations.

Position Statement
Correctional health programs are an important public health resource in the identification, care, and treatment of individuals who have been involved in violent acts. The National Commission heartily endorses the CDC's position that violence is a public health problem and calls upon correctional health programs to join with the CDC, and other professional groups, in addressing violence within the incarcerated population. It is the National Commission's position that standards for correctional health services should be used as the basis for correctional health services violence prevention, treatment, and education in these settings. Specifically, correctional health services should:

1. Incorporate violence risk assessment—including child and domestic abuse, sexual abuse, and any personal victimization—into receiving screening undertaken of all inmates upon intake,  all inmate health assessments, and mental health evaluations.
2. Refer as appropriate all inmates with violent histories (i.e. those with expressive violence), including those who exhibit violent behaviors that place the safety and welfare of themselves or others in jeopardy, to treatment by appropriately trained health care providers. Treatment should not consist of only placing the inmate on medication, but should take a balanced biopsychosocial approach to the treatment of inmate violence.
3. Protocols and guidelines for violence prevention, intervention, and follow-up should be developed for use by qualified health professionals treating inmates. In addition, health care providers should receive training in these areas. Training should include information on policies and practices designed to prevent violence, non-physical methods for preventing and/or controlling disruptive behaviors, appropriate use of medical restraints, and effective techniques for personal safety.
4. Correctional officer training should include prevention of expressive violence and non-physical methods for prevention and/or controlling disruptive behaviors stemming from expressive violence.  Correctional officer training should continue to address security issues designed to inhibit instrumental and gang-related violence.
5. All correctional facilities should establish contacts with community-based organizations able to assist in the treatment and continuity of care upon the inmate's release from the correctional facility.

Adopted by the National Commission on Correctional Health Care  Board of Directors
September 19, 1993
Last Amended:  April 10, 1994

References
Hollinger, P. C., Offer, D., Barter J. T., & Bell, C. C. (1994). Suicide and homicide among adolescents. New York: Guilford Press.

Introduction of resolution establishing select committee on violence. (March 1992). Congressional Record, Vol. 138, No. 30.

Rosenberg, Mark.  (1992). Youth violence: A public health problem. Juvenile Justice Digest, 20(17)

National Commission on Correctional Health Care standards for health services manuals include the following:

• Standards for Health Services in Jails (1996)
• Standards for Health Services in Prisons (1997)
• Standards for Health Services in Juvenile Detention and Confinement Facilities (1995)